case_images: PMC6262944_01
case_images: Bilateral blunt cerebrovascular injury (BCVI) with associated high-flow caroticocavernous fistulas (CCFs) is shown. (a) Non-contrast axial CT demonstrates a 1.8-cm right EDH with 6 mm of right-to-left shift. (b) Axial bone window CT shows no acute skull-base fracture or injury in the area of the carotid canal. (c) Townes and (d) lateral digital subtraction angiographic (DSA) images during right internal carotid artery (ICA) injection undertaken after the patient continued to have uncontrolled bleeding intraoperatively show a direct CCF with drainage through the bilateral inferior petrosal sinuses. Flow through the anterior cerebral (ACA) and middle cerebral (MCA) arteries was significantly slow, with displacement of the MCA branches due to mass effect. (e) Townes and (f) lateral DSA images of a left ICA injection show a direct CCF with outflow through the inferior petrosal sinuses, as well as egress through the left external jugular system. Flow through the ACA and MCA was diminished
case_images: SNI-9-229-g001.jpg
case_images: PMC6262944_01_SNI-9-229-g001.jpg
case_images: F1
case_images: 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]. Outflow was noted through the bilateral inferior petrosal sinuses with no visualized cortical venous reflux [Figure 1c, d]. Outflow from the left-sided CCF was noted into the petrosal sinuses and left external jugular veins [Figure 1e, f].