Severe Subacute Headache Two Months after Head Trauma
Author Affiliations
1 Department of Neurology, Virginia Commonwealth University, Richmond Virginia, United States
2 Department of Radiology, Drexel University, Philadelphia Pennsylvania, United States
Corresponding Author
Yasir Al-Khalili, Department of Neurology and Internal Medicine, Virginia, Commonwealth University, Richmond, VA, 1201 E Marshall St #4-100, Richmond Virginia, United States
Citation
© 2019 Yasir Al-Khalili, etal.
This is an open-access article distributed
under the terms of the Creative Commons
Attribution 4.0 international License, which
permits unrestricted use, distribution and
reproduction in any medium, provided the
original author and source are credited.
Clinical Background
A 59 year old presented unconscious with elevated blood alcohol level following
closed head injury as a result of pedestrian, hit by a car. CT head revealed fractures of
the left temporal and parietal bones as well as scattered subarachnoid and parenchymal
hemorrhage within the left temporal lobe. Keppra was started. Over 48 hours the patient
improved in orientation and neurologic exam and was discharged. 2 months later returned
with subacute headache. Imaging is shown in Figure 1.
Figure 1: Axial T2 MRI demonstrate increased number and size of tortuous cavernous
sinus flow voids bilaterally
Discussion
Vascular imaging, noted an enlarged right superior ophthalmic vein and increased number and size of tortuous flow voids in the bilateral cavernous sinuses. MRA revealed abnormal flow related enhancement of the prominent cavernous sinuses (right greater than left), right superior ophthalmic vein, right sphenoparietal sinus and bilateral petrosal sinuses.
Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus. This can be either due to a direct connection between the cavernous internal carotid artery and the cavernous sinus, or a communication between the cavernous sinus and a meningeal branch of the internal carotid artery or external carotid artery. The most common (70%-90%) etiology of direct CCF is trauma from a basal skull fracture. Symptoms include conjunctival chemosis, proptosis, pulsating exophthalmos, diplopia, ophthalmoplegia, orbital pain, audible bruits and blindness [1]. Our patient had subacute headache which prompted her visit to the emergency room. Treatment options for traumatic direct high flow CCF include endovascular embolization using liquid embolics, coils and, occasionally, parent artery sacrifice [2].
Figure 2: 3D MIP TOF MRA demonstrate increased number
and size of tortuous cavernous sinus flow voids bilaterally, right
greater than left
Figure 3: Lateral right ICA injection angiogram before
endovascular coil embolization of CCF demonstrate resolution
of enlarged right ophthalmic and cavernous sinus veins status
following embolization
Figure 4: Lateral right ICA injection angiogram after endovascular
coil embolization of CCF demonstrate resolution of enlarged
right ophthalmic and cavernous sinus veins status following
embolization
References
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- Chaudhry IA, Elkhamry SM, Al-Rashed W, Bosley TM. Carotidcavernous fistula: ophthalmological implications. Middle East AfrJ Ophthalmol. 2009 Apr;16(2):57-63.
- Shwe Y, Paramasivam S, Ortega-Gutierrez S, Altschul D, BerensteinA, etal. High-flow carotid cavernous fistula and the use of amicrovascular plug system: initial experience. Interv Neurol.2015 Mar;3(2):78-84.
