csf leak vs sinus infection

[soniaa]

Hi. I was in a terrible car accident on Nov 9, 2007. I lost conciousnes for a few minutes. I had an imediate headache, felt like my spine was hit by a 2 x 4 and had facial brusing and swelling. A CT scan on 11/13 showed "air fluid level with in the spheniod sinus". I had an MRI on 1/21 that also showed the air fluid level stating also that the signal intesities are not typical and a tramatic etiology cannot be excluded. I have severe headaces that started on the top of my head and are now also behind my left eye. I have blurred vision at times and early on could not use my right foot at times even thought there was no injury to that area. I feel like something is very wrong but with many neuro surgeons not seeing car accident victims around here, noone except my family doctor has seen the results of my ct and mri. Some days it is so bad I feel the need to go to the er but am trying to hold out. How urgent is it to be seen whether it is an infalamatory process or of tramatic etiology?
Thank you so very much for any info you can give me.
There is also white matter signal changes deep in the white matter bilaterally, don't know if this has anything to do with the accident or not.
I am 38 yrs old. This is the 3rd car accident in the last 10 years where I have lost consciousness (none my fault in case you were wondering:-))

[RobynLee]

Dr. Taub,

I wondered if you could tell me if an artery disection - etither vertebral or carotid might be consistent with an elevated C Reactive Protein (highly specific) of 26.

I was in  an auto accident ( hit from benind by dwi) this past summer and have been left with neck/jaw pain - loss of equillibrium - and disturbed vision.  I've been attributing many of the symptoms to pathology of the cervical spine, however recent blood work came back with the C Reactive Protein elevated to 26, and TPO antibodies elevated to 550.  

The bloodwork was done because of recent onset of very severe 24/7 skull/head pain.  All other symptoms were there prior to the headpain (neck pain, jaw pain, shoulder pain, disequillibrium, problem vision etc.).  The head pain onset was 6 months after the accident and unlike any headache I've had in the past - currently taking round the clock Ibuprophen and sudafed for partial relief.

Any insight you might lend would be wonderful.  I am scheduled to see a neurologist next week and am going to have an MRI Brain w/o contrast prior to that.  

Best Regards, RobynLee

[CCFNeuroMD JT, MD]

Dear Soniaa,

Thank you very much for your question. I am happy to address the issues that you pose, although it is important that you recognize that my impression is based entirely on the information you have provided in your posting and is by no means a replacement for an office visit with a neurologist.  Diagnosis is contingent on detailed history and physical exam and as such, the following information should be considered solely for educational purposes.

Please allow me to summarize your history/symptoms: You  are a 38 year old female with a hx/o 3 motor vehicle accidents over the past 10 years, the most recent in  November 2007.  Of late, you have been experiencing severe headaches at the top of your head and behind the left eye associated with blurred vision and intermittent weakness of the right foot.  Although these could represent a migraine variant, given your recent history of an acceleration/deceleration injury from your accident, my biggest concern would be for a carotid artery dissection.  Essentially, what this means is that the layers within the artery have torn and eventually over time, blood flow may propogate that tear which can result in either blockage of the artery, formation of non-obstructive blood clots, and aneurysm formation.

Symptoms associated with arterial dissection include stroke like symptoms.  The fact that you are experiencing pain behind your left eye, blurry vision, and right-sided foot symptoms suggest that if you do in fact have a dissection, the left carotid artery is the one of concern.  Indeed, your symptoms all seem to fit this picture.  To further evaluate for a carotid artery dissection, a special test similar to an MRI called an MRA (magnetic resonance angiography) can be done to evaluate the blood vessels using special a window known as "fat sats" which optimizes visualization of a dissection.  Alternatively, a CT angiogram can be useful.  If these two studies are normal, ultimately, the gold-standard for diagnosis is a conventional angiogram which is an invasive test and is thus reserved for imaging-negative cases with high clinical suspicion.

Treatment of carotid artery dissection is variable depending on the location of the dissection and other comorbid factors.  Most patients are generally treated for about 6 months of blood thinning medicine called coumadin. If there is a contraindication to the use of coumadin, some neurologists may opt to use a medication like aspirin or clopidogrel.  Occasionally, the dissection is repaired endovascularly (i.e. during the angiogram) although this, too is not without risk and is often not optimal for the patient.

After this long-winded answer, my recommendation for you is that you see a good neurologist at a larger academic hospital.  An untreated carotid artery dissection carries a high risk of stroke which can be devastating.  I obviously am unable to make this diagnosis without seeing you and reviewing your records, but given the substantial risk of not conducting a thorough work-up, I urge you to see someone sooner than later.

Thanks again for your question, and best of luck.

Sincerely,
JBT, MD