Transverse transsphenoidal basilar skull fractures with carotid-cavernous fistula
Presentation
Motor vehicle accident
Patient Data
Anterior transverse transsphenoidal fracture, extending in a coronal plane into the sphenoid sinuses, associated with right lateral and left medial pterygoid plate fractures (without Le Fort fracture)
Posterior transverse transphenoid fracture, including bilateral otic-capsule sparing temporal bone fractures with ossicular chain disruption (bilateral incudomalleolar joint separation, right malleus neck fracture, left malleus manubrium fracture), involvement of the tegmen (without a large defect), involvement of the carotid canals, involvement of the external auditory canals, and possible but not definite involvement of the perigeniculate/tympanic segment of the facial nerve canals.
CTA
- Subarachnoid hemorrhage and pneumocephalus
- Epidural hematoma or expansile thrombus involving the right cavernous sinus
- Pseudoaneurysm of the right cavernous internal carotid artery
- Thrombosis of the right superior ophthalmic vein
- Intracranial pressure monitor in the right frontal lobe
- Normal neck CTA
- Right internal carotid artery dissecting pseudoaneurysm with carotid-cavernous fistula, Barrow type A (direct)
- Early filling but partial thrombosis of the right superior ophthalmic vein
- Early filling of the right middle cerebral vein
Case Discussion
The patient had bilateral hearing loss; right facial paralysis; and right ophthalmoplegia, chemosis, and proptosis. There was fluid drainage from the ears that may have represented CSF leak.
Skull base fractures, particularly those that involve the carotid canal, merit CT angiography for evaluation of arterial injury. The vascular finding in this case can be classified as a Barrow type A (direct) caroticocavernous fistula. Where an arteriovenous fistula fits into the Biffl scale for blunt cerebrovascular injury is not entirely clear but may be considered grade V.
The vascular injury was treated across multiple stages with Pipeline embolization of the right internal carotid artery pseudaneurysm and coil embolization of the right cavernous sinus and major tributaries. The CSF leak resolved without intervention.
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