Intracerebral hemorrhage and carotid-cavernous fistulas: a rare connection

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous shunts between the carotid arterial system and the cavernous sinus. They most frequently present with ocular symptoms, but intracerebral hemorrhage (ICH) as an initial manifestation is exceedingly rare. We report the case of a 41-year-old male with a progressive hemiparesis and a spontaneous CCF with atypical reflux into the deep cerebral veins and subsequent intracerebral hemorrhage, discuss the underlying pathomechanism, and provide an overview of the existing literature. CCFs should be included in the differential diagnosis of ICH, particularly when atypical venous drainage patterns are involved.