Multitrauma with diffuse axonal injury, temporal bone fractures and traumatic caroticocavernous fistula

Case contributed by Heather Pascoe
Diagnosis certain


Pedestrian vs car at 80 kph.

Patient Data

Age: 20 years
Gender: Male

Brain and Skull

  • Scalp hematomas.
  • Diffuse sulcal effacement. No hydrocephalus.
  • Diffuse axonal injury (pons, body/splenium of corpus callosum).
  • Small posterior falcine subdural.
  • Subarachnoid hemorrhage.
  • Small volume of intraventricular hemorrhage.
  • Left temporal extradural hemorrhage and pneumocephalus.
  • Right longitudinally-oriented petrous temporal bone fracture sparing the otic capsule with ossicular chain disruption, haemomastoid and extension into the external auditory meatus. There is also extension into the right parietal and occipital bones.
  • Left parietal bone fracture extending through the mastoid air cells and petrous temporal bone into the external auditory meatus. Ossicular chain is intact. Otic capsule sparing.
  • Left base of skull fracture extending into the clivus, sphenoid bone, left foramen lacerum and left carotid canal. Possible extension into the right carotid canal. Haemosphenoid.
  • Fracture of the nasal septum.
  • Hard palate fracture.
  • Medial left maxillary antrum fracture.
  • Gas from the base of skull fracture in the soft tissues of the face.
  • Oral cavity packing material.


  • ETT, NGT, Guedels.
  • Subarachnoind blood in the superior cervical spine.
  • Gas from the base of skull fractures.
  • No cervical spine fracture.

Bilateral internal carotid artery dissection:

  • Right: small intraluminal flaps in the distal lacerum / ascending cavernous segment, horizontal cavernous segment / anterior genu, and supraclinoid segment.
  • Left: diffusely narrowed petrous temporal segment, large flap and intraluminal filling defects (probably thrombus) throughout the distal lacerum / ascending cavernous segments.

DSA was performed given the findings on CTA. This demonstrated a traumatic left caroticocavernous fistula and a large left ICA pseudoaneurysm.

Small traumatic pseudoaneurysms of the right cavernous ICA and carotid cave were also demonstrated (not shown).


  • Right scapula fracture.
  • Small right pneumothorax. The differential for this includes extrapleural air and small pneumomediastinum.
  • Extensive bilateral airspace consolidation, likely related to aspiration.
  • T1 superior endplate fracture, possibly old.


  • NGT in situ.
  • Mild diffuse mesenteric fat stranding. Mild peripancreatic/periduodenal fluid.   
  • Small intrarenal cystic lesion in the left midpole, rather than a laceration.

Incidental findings

  • Small ductus diverticulum.
  • Schmorls nodes L3,4,5.

Case Discussion

DAI should be considered if the clinical findings are disproportionate to the imaging findings. MRI is the modality of choice for assessing DAI as many patients with a normal CT will have DAI visible on MRI.

Caroticocavenous fistulas can be difficult to diagnose on CT. The clinical symptoms of pulsatile exophthalmos and progressive visual loss may raise the questions about the diagnosis. CT features included proptosis and enlarged superior ophthalmic veins. DSA is usually performed to confirm the diagnosis.

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