[Traumatic carotid-cavernous fistula presenting subarachnoid hemorrhage 5 years after head injury; case report]

A case of traumatic carotid-cavernous fistula (CCF) which presented subarachnoid hemorrhage long after the injury is reported. A 24-year-old male was admitted to the National Yokohama Hospital with complaints of severe headache and nausea. CT scan and cerebral angiography showed subarachnoid hemorrhage due to ruptured CCF. His right visual acuity has disappeared after a traffic accident 5 years before, and he had hit his forehead again 3 years previously. He experienced severe headache twice for 2 weeks after his admission. He was transferred to Kanagawa Rehabilitation Center to be treated with intravascular surgery. Plain CT showed high density areas in the basal cisterns. CT after contrast infusion disclosed a small enlarged high density area in the right cavernous sinus, and showed an enhanced mass lesion in contact with the right ventrolateral side of the midpons. The right internal carotid angiogram showed high flow CCF, fed only by the internal carotid artery. It drained mainly into the basilar plexus, partially into the basal vein of Rosenthal and the inferior petrosal sinus. The CCF was found at the C4 portion of the right internal carotid artery. CT and the angiogram revealed a part of the CCF developing into a varix in the ventral side of the prepontine cistern. It ruptured and the patient developed subarachnoid hemorrhage 5 years after the head injury. The CCF was intravascularly embolized by a detachable balloon. Early treatment for CCF is necessary to prevent the occurrence of subarachnoid hemorrhage if a part of the CCF develops into a varix.