We report a case of a 12-year-old boy with no significant past medical history who presented at Phoenix Children's Hospital Emergency Room following a motor vehicle accident (MVA). The patient was sharing a seatbelt with one other sibling in the back seat of a 4-door sedan. The vehicle was involved in a "T-bone" collision, which resulted in a temporal head injury against the side door. At the time of presentation, the patient complained of neck tenderness, pain at the right skull base, and nausea. The patient did have poor recollection of the accident; however, there was no indication of loss of consciousness. The patient denied any neck or head pain prior to the accident, and denied any fever, chills, emesis, or seizures. Prior to his presentation, the patient was otherwise healthy, performed well in school, has no family history of coagulopathies, was not taking any medications, and had a negative review of systems except what was discussed earlier. On physical examination, the patient was alert and oriented and appeared well nourished and well hydrated. His pupils were equal and reactive to light, extraocular movements were intact, his smile was symmetric and his hearing present in both ears. He had no otorrhea or rhinorrhea, but some ecchymosis was noted around the right ear. There was some neck tenderness at the level of C3, a neck brace was applied as a precautionary measure pending imaging results. He had full power and normal tone in his upper and lower extremities. His pulses were equal bilaterally to palpation. Overall, the patient was clinically stable but remained somewhat confused with a Glasgow coma scale (GCS) of 14. The patient was admitted to the pediatric intensive care unit pending imaging studies.
A computed tomography (CT) of the head [Figure 1a] on presentation revealed a small petrous bone fracture on the right side of the skull. Several small pneumocephalic collections were evident surrounding the fractured mastoid air cells. Bony fragments were visible within the vicinity of the sigmoid sinus. A magnetic resonance venography (MRV) [Figure 1b] was ordered to evaluate the cranial vascular integrity, which demonstrated a flow void of the right sigmoid sinus and the right external jugular vein.
The patient's coagulation profile was within normal limits, he was admitted and started on IV heparin and monitored with serial exam for changes in neurologic function. The patient remained stable and on the third day of admission, a repeat MRV [Figure 2] demonstrated persistent flow void of the sigmoid sinus, but improved flow through the external jugular sinus. At this point, the patient's nausea and headache had resolved and he was switched to low molecular weight heparin (enoxaparin) and transferred to the pediatric floor. The remainder of the hospitalization was uneventful, the patient was discharged on day 7 with 6 weeks of low-molecular weight heparin (LMWH) therapy with weekly clinical follow up.