A rare brainstem hemorrhage during transvenous embolization of a cavernous dural arteriovenous fistula

Intravascular treatment of cavernous dural arteriovenous fistula (dAVF) is usually safe and effective. However, we describe a patient with a rare brainstem hemorrhage during transvenous embolization (TVE). A 79-year-old woman suffered from left chemosis and diplopia. Cerebral angiography revealed a left cavernous dAVF with cortical venous drainage. The patient underwent TVE of the cavernous sinus (CS) via the left inferior petrosal sinus. Superior petrosal sinus (SPS) outflow occlusion was performed to avoid venous congestion, followed by superficial middle cerebral vein outflow occlusion, selective shunt occlusion of the middle meningeal artery, and superior orbital vein outflow occlusion. The patient’s condition suddenly deteriorated during CS packing. A CT scan revealed a massive brainstem hemorrhage. Cerebral angiography did not show SPS reopening or redistributed drainage to the posterior fossa. Thus, TVE for cavernous dAVF can result in life-threatening vascular complications. Well-planned treatment strategies could avert this rare complication.