A 65-year-old woman with unknown past medical history presented after a motor vehicle rollover in which she was restrained with a seatbelt. The patient was intubated at the scene, stabilized at an outside hospital, and transferred to our hospital. She exhibited episodic bradycardia en route but retained reactive pupils. On arrival, the patient's Glasgow Coma Scale (GCS) score was 3T with progressive dilation of her right pupil. Computed tomography (CT) imaging showed a 1.8-cm right epidural hematoma (EDH) with 6-mm right-to-left shift but no acute skull-base fracture or injury in the area of the carotid canal [Figure 1a, b]. Other injuries included extensive osseous and soft tissue injuries in the thorax. The patient was treated with 3% hypertonic saline and mannitol before undergoing emergent hematoma decompression.
We completed evacuation of the EDH without difficulty; however, significant unexpected bleeding was uncovered from the skull-base and carotid-cavernous triangle. There was worsening bleeding from deep within the Sylvian fissure, prompting us to open the dura to achieve additional decompression. Extradural coagulation of the middle meningeal artery and ipsilateral neck pressure reduced the bleeding, but incompletely. We packed the wound and proceeded for emergent angiography to identify the source of bleeding.
Digital subtraction angiography (DSA) showed a large dissecting pseudoaneurysm of the cavernous segment of the right internal carotid artery (ICA), with arteriovenous shunting into the cavernous sinus consistent with a direct CCF. Outflow was noted through the bilateral inferior petrosal sinuses with no visualized cortical venous reflux [Figure 1c, d]. Flow in the right anterior (ACA) and middle (MCA) cerebral artery circulation was sluggish, and there was displacement of the right MCA branches because of mass effect from residual extra-axial blood and packing material. No abnormal fistula was seen during external carotid artery (ECA) injection (not shown). The left ICA demonstrated extensive dissection and arteriovenous shunting into the cavernous sinus, consistent with a direct CCF. Outflow from the left-sided CCF was noted into the petrosal sinuses and left external jugular veins [Figure 1e, f]. The left ACA and MCA flows were diminished, but no abnormality of the ECA was seen. Endovascular treatment and open surgical carotid bypass were discussed, but the patient proved to be hemodynamically unstable for treatment, and the family chose not to pursue further life-extending measures. This case report does not require patient consent per our institution.