[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-435865-105":3,"doc-detail-435865-en":79,"detail-sidebar-cat-0-en-105":96},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":72,"head_meta":74,"extra_data":76,"updated_unix":78},105,"en","when-the-brain-fades-before-the-eye-encephalopathy-as-a-rare-presentation-of-direct-carotid-cavernous-fistula","When the brain fades before the eye: encephalopathy as a rare presentation of direct carotid-cavernous fistula","","Rare case report describing a 76-year-old man with progressive cognitive decline, acute encephalopathy, and visual symptoms occurring 6 months after cavernous internal carotid artery (ICA) stenting for intracranial stenosis. Initial workup was negative until neuroimaging revealed left temporal and orbital edema with cavernous sinus abnormalities. Ophthalmologic findings showed left cranial nerve VI palsy and elevated intraocular pressure. Cerebral angiography confirmed direct left type-A carotid-cavernous fistula with bilateral venous drainage; endovascular embolization improved the clinical course. Highlights atypical cognitive decline after ICA stenting as a vascular warning sign.",{"@graph":14,"@context":71},[15,34,54],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/when-the-brain-fades-before-the-eye-encephalopathy-as-a-rare-presentation-of-direct-carotid-cavernous-fistula/435865/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":48,"encodingFormat":47,"isAccessibleForFree":49,"interactionStatistic":50},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/when-the-brain-fades-before-the-eye-encephalopathy-as-a-rare-presentation-of-direct-carotid-cavernous-fistula/435865.png","ImageObject",300,407,{"name":42,"@type":43},"Logic","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-29",true,{"@type":51,"interactionType":52,"userInteractionCount":26},"InteractionCounter",{"@type":53},"ViewAction",{"@type":55,"mainEntity":56},"FAQPage",[57,63,67],{"name":58,"@type":59,"acceptedAnswer":60},"What symptoms were reported in the patient?","Question",{"text":61,"@type":62},"The patient developed progressive cognitive decline, acute encephalopathy, and visual symptoms.","Answer",{"name":64,"@type":59,"acceptedAnswer":65},"What imaging and diagnostic findings confirmed the condition?",{"text":66,"@type":62},"Neuroimaging showed left temporal and orbital edema with cavernous sinus abnormalities, and cerebral angiography confirmed a direct left type-A carotid-cavernous fistula with bilateral venous drainage.",{"name":68,"@type":59,"acceptedAnswer":69},"How was the carotid-cavernous fistula treated and what was the result?",{"text":70,"@type":62},"Endovascular embolization was performed, leading to clinical improvement.","https://schema.org",{"og:url":32,"og:type":73,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":75,"canonical":32},"index,follow",{"doc_id":77,"site_id":7},435865,1790716071,{"code":4,"msg":80,"data":81},"success",{"doc_id":77,"user_id":82,"nickname":42,"user_avatar":83,"doc_module":4,"category_id":84,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":85,"file_id":86,"file_url":87,"file_type":88,"file_size":89,"view_count":26,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":90,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":91,"faqs":92,"seo_title":93,"seo_description":12,"update_tm":94,"read_time":95},1099513958762,"https://ap-avatar.wpscdn.com/avatar/1000023916a998db790?x-image-process=image/resize,m_fixed,w_180,h_180&k=1784791008015729253",7,"Article published online: 2025-07-15  \nNeuroimaging 1  \nWhen the brain fades before the eye: encephalopathy asa rare presentation of direct carotid-cavernous fistula  \nLeonardo Furtado Freitas 1,2 Eduardo J. Labat 1,2 Robert T. Wicks3 Charif Sidani 1,2 Kevin J. Abrams 1,2  \n1 Baptist Health South Florida, Department of Radiology, Division of Clinical Neuroradiology, Miami FL, United States.  \n2 Florida International University, Herbert Wertheim College of Medicine, Miami FL, United States.  \n3 Baptist Health South Florida, Department of Cerebrovascular Neurosurgery, Miami FL, United States.  \nAddress for correspondence Leonardo Furtado Freitas (email: [drleonardofurtado@gmail.com](drleonardofurtado@gmail.com))  \nArq. Neuro-Psiquiatr. 2025;83(12):s00451809932 .  \nWe herein report a rare case ofa 76-year-old male patient with progressive cognitive decline, acute encephalopathy, and visual symptoms 6 months after cavernous internal carotid artery  \n(ICA) stenting for intracranial stenosis. The initial workup was negative. Neuroimaging ( ►Figure 1) showed left temporal and orbital edema with cavernous sinuses abnormalities. The  \nFigure 1 Axial non-contrast computed tomography (CT) scan (A, B) and CT angiography (CTA) (C) . Coronal orbit magnetic resonance imaging (MRI) scanon fluid-attenuated inversion recovery (FLAIR)-weighted images with fat suppression (D) and brain MRI scan on post-contrast axial T1 gradient echoweighted images (E,F) . Left temporal hypoattenuation with proptosis (black and orange arrows), dilation of the superior ophthalmic veins (white asterisks), and a stent in the cavernous segment of the left internal carotid artery (black asterisk) with cavernous sinuses engorgement (dashed blue circles). MRI scan showing prominent left temporal vasogenic edema extending to the subinsular region and putamen (black arrows), edema in the left extraocular muscles (green asterisks). There is also thick cortical enhancement in the left temporal pole and nodular enhancement in the ipsilateral putamen (white arrows) .  \nreceived April 7, 2025  \nreceived in its final form May 3, 2025  \naccepted May 7, 2025  \nDOI [https://doi.org/](https://doi.org/)[ ](https://doi.org/)10.1055/s-0045-1809932 . ISSN 0004-282X.  \nEditor-in-Chief: Hélio A. G. Teive.  \nAssociate Editor: Leandro Tavares Lucato.  \n© 2025 . The Author(s) .  \nThis is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit ([https://creativecommons.org/licenses/by/4.0/](https://creativecommons.org/licenses/by/4.0/))  \nThieme Revinter Publicações Ltda. , Rua Rego Freitas, 175, loja 1, República, São Paulo, SP, CEP 01220-010, Brazil  \n2 Neuroimaging  \nFigure 2 Cerebral angiogram. Left internal carotid artery, lateral projection (A), revealing direct carotid cavernous fistula with contrast opacification of the cavernous sinus (blue arrow). Left internal carotid artery injection, magnified lateral projection (B)– the solid arrow denotes dilated superior ophthalmic vein. The hollow and blue arrows show dilated inferior petrosal sinus and cavernous sinus, respectively. Left Internal carotid artery injection, unsubtracted lateral projection (C), which enables the visualization of internal carotid artery cavernous segment stent (white arrow). Left internal carotid artery injection, lateral projection (D) . Intraprocedural coiling of carotid cavernous fistula via the transvenous approach through the inferior petrosal sinus. Left internal carotid artery injection, unsubtracted lateral projection (E) . Posttransvenous coil embolization of carotid cavernous fistula. Left internal carotid artery injection, ateral projections (F), revealing complete coil embolization of the carotid cavernous fistula.  \nophthalmologic exam revealed palsy of the left cranial nerve VIand elevated intraocular pressure. Cerebral angiography ( ►Figure 2) confir","cbCaio11f0u4N3F7","https://ap.wps.com/l/cbCaio11f0u4N3F7","pdf",1520472,"English","# Case presentation\n## Clinical history and initial workup\n## Neuroimaging findings\n## Ophthalmologic and angiographic confirmation\n## Endovascular treatment and outcome\n# Authors’ information","[{\"question\":\"What symptoms were reported in the patient?\",\"answer\":\"The patient developed progressive cognitive decline, acute encephalopathy, and visual symptoms.\"},{\"question\":\"What imaging and diagnostic findings confirmed the condition?\",\"answer\":\"Neuroimaging showed left temporal and orbital edema with cavernous sinus abnormalities, and cerebral angiography confirmed a direct left type-A carotid-cavernous fistula with bilateral venous drainage.\"},{\"question\":\"How was the carotid-cavernous fistula treated and what was the result?\",\"answer\":\"Endovascular embolization was performed, leading to clinical improvement.\"}]","When the brain fades before the eye: encephalopathy as a rare presentation of direct carotid-cavernous fistula | PDF",1790675605,5,{"code":4,"msg":80,"data":97},[98,102,106,110,114,119,122,127,132,135,139],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":99,"show_sort_weight":100,"slug":101},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":107,"show_sort_weight":108,"slug":109},"Exam",70,"exam",{"id":95,"doc_module":4,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},"Comic",60,"comic",{"id":115,"doc_module":4,"doc_module_name":25,"category_name":116,"show_sort_weight":117,"slug":118},6,"Technology",50,"technology",{"id":84,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":120,"slug":121},40,"healthcare",{"id":123,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":125,"slug":126},8,"Research & Report",30,"research-report",{"id":128,"doc_module":4,"doc_module_name":25,"category_name":129,"show_sort_weight":130,"slug":131},9,"Religion & Spirituality",20,"religion-spirituality",{"id":130,"doc_module":4,"doc_module_name":25,"category_name":133,"show_sort_weight":130,"slug":134},"World Cup","world-cup",{"id":136,"doc_module":4,"doc_module_name":25,"category_name":137,"show_sort_weight":136,"slug":138},10,"Lifestyle","lifestyle",{"id":140,"doc_module":4,"doc_module_name":25,"category_name":141,"show_sort_weight":95,"slug":142},19,"General","general"]