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 NUMBER 4 > Continued on page 94. OCTOBER 2018 • 93