Unlocking the 'locked-in syndrome'.

Area of Science:

• Neurology
• Neurosurgery
• Vascular Imaging

Background:

• Brainstem stroke is a critical diagnosis with significant morbidity.
• Locked-in syndrome presents as severe immobility with preserved consciousness.
• Petrous apex dural arteriovenous fistulas are rare vascular malformations.

Observation:

• A 48-year-old male presented with symptoms mimicking a brainstem stroke, leading to a clinical diagnosis of locked-in syndrome.
• Initial investigations were insufficient to identify the underlying cause of the patient's neurological deficits.

Findings:

• Advanced imaging revealed a petrous apex dural arteriovenous fistula as the cause of the patient's condition.
• The fistula induced profound venous hypertension within the brainstem, explaining the neurological symptoms.

Implications:

• This case underscores the importance of considering rare vascular etiologies in patients presenting with locked-in syndrome.
• Surgical intervention, specifically clipping of the fistula, can lead to complete neurological recovery.
• Accurate diagnosis and timely management of petrous apex dural arteriovenous fistulas are crucial for favorable patient outcomes.