The Journal of the Arkansas Medical Society Issue 4 Volume 115 | Page 21
auscultation. Urgent CTA of the head was ordered
based on exam findings that revealed interval de-
velopment of right CCF, with marked exophthal-
mos and dilated orbital veins.
Interventional radiology performed endovas-
cular embolization with multiple coils 22 days
post-injury. Immediate improvement in orbital
swelling and proptosis occurred after interven-
tional procedure. She was admitted to acute reha-
bilitation for traumatic brain injury 27 days post-
injury, where she continued to progress. At the
time of discharge to a post-acute neurorestorative
rehabilitation center, 50 days post-injury, patient’s
proptosis had resolved, and she had improving
exotropia and right ptosis.
Discussion
We present a case of extradural, inferior cli-
noid pseudoaneurysm rupture resulting in insidi-
ous onset CCF. This is a rare condition (incidence
of 0.17% to 1.01%) due to an abnormal connec-
tion between the cavernous sinus and carotid
artery or its branches. 1 The Barrow CCF clas-
sification is the most widely used classification
system for CCF. According to the Barrow clas-
sification, there are two large categories of CCF:
direct (type A) and indirect (Types B-D). Direct
CCF formation, most likely secondary to trauma,
is the result of an abnormal connection between
the internal carotid artery and the cavernous
sinus. Direct fistulas are high-flow lesions and
are the most common type of CCF, accounting
for 75-80% of CCFs overall. 2 In contrast, indirect
CCFs are most commonly low-flow lesions and
develop when the meningeal branches of the ICA
or ECA form an abnormal connection with the
cavernous sinus. 3 CCF formation as a result of
a ruptured infraclinoid aneurysm may account
for one-quarter of all symptomatic cavernous
sinus aneurysms. 4 Traumatic intracranial aneu-
rysms represent 0.15 to 0.4% of all intracranial
aneurysms, and most commonly affect young
males. These traumatic aneurysms are often
pseudoaneurysms and are typically found in the
anterior circulation where vessels are vulnerable
to injury from adjacent fractures, supporting the
association between traumatic CCFs with closed
head injuries that involve a fracture of the basi-
lar skull. 5,3 Risk of hemorrhage in post-traumatic
aneurysms is 19% with mortality 32-54%. 5
Infraclinoid aneurysms present rapidly with
cranial nerve palsy, massive epistaxis, and cav-
ernous sinus syndrome. Cavernous sinus syn-
drome will result in multiple cranial neuropathies
Figure 2: Interventional Radiology cerebral angiogram showing right internal CCF with
opacification of cavernous sinus as well as superior and inferior ophthalmic veins.
which may include Horner’s Syndrome, impair-
ment of ocular motor nerves, and loss of sen-
sory ability in trigeminal nerve first and second
division. 6 Typically, symptoms from high-flow,
direct CCFs present acutely and progress rap-
idly, thus necessitating urgent treatment. Dan-
dy’s Triad are the classic symptoms seen in the
development of a direct CCF. The triad includes:
Exophthalmos, cephalic bruit, and conjunctival
congestion. Venous hypertension is often the
result of CCF, and is the cause of ophthalmic
manifestations including proptosis, injection of
the conjunctiva, decreased vision, and chemo-
sis. Venous hypertension in this case, is a result
of shunting of pressurized arterial blood into the
cavernous sinus and ophthalmic veins. 3 As a
result, ocular symptom severity correlates with
the venous drainage capacity and the intensity
of flow. 7 Many of these ocular symptoms were
seen in our patient, however, they did not appear
until three weeks after the hemi-craniectomy.
This supports the need for long term follow up
of trauma patients as certain complications from
facial trauma may not be clear until late.
Catheter cerebral angiography is the gold
standard imaging modality for diagnosis of
CCF. Patients might undergo noninvasive cere-
bral imaging with CT scanning, MRI, or CT/MR
angiography first. Evidence of cavernous sinus
enlargement, proptosis, extraocular muscle en-
largement, superior ophthalmic vein dilation, or
dilation of cortical or leptomeningeal vessels, as
well as associated skull fractures, may be seen
on CT or MRI and are suggestive of CCF. 2 Due
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