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Abstract Details

Carotid Cavernous Fistula Mimicking Hemicrania Continua
Headache
Headache Posters (7:00 AM-5:00 PM)
081
Hemicrania continua presents as a persistent, unilateral headache with ipsilateral cranial autonomic symptoms. It exquisitely responds to indomethacin, but a careful and thorough work-up for secondary causes needs to be performed both at the time of initial diagnosis and with subsequent evaluations.  
To showcase a cavernous carotid fistula mimicking hemicrania continua.
We report a 48 year old male who presented with sudden-onset, painless, horizontal diplopia. He was diagnosed by ophthalmology with a decompensated esotropia and improved with prism correction. Initial MRI brain was unremarkable. He then developed a new, persistent right-sided headache one month after resolution of his diplopia. The pain was predominantly in the right occipital region, squeezing in nature, with radiation to the right jaw. He also had a dull, pressure-like sensation over the top of his right head. He endorsed right sided lacrimation, rhinorrhea, and swelling over his right eye and cheek. He was started on Indomethacin for a presumed diagnosis of hemicrania continua, given the initially negative MRI brain. His pain improved dramatically, but he developed ptosis with re-emergence of horizontal diplopia. He was referred to neuro-ophthalmology and was found to have a pupil sparing right 3rd nerve palsy with significant proptosis and conjunctival irritation. MRI orbit, MRA, and MRV were urgently performed which revealed a right cavernous carotid fistula. 
The patient underwent embolization of the superior ophthalmic vein , using a direct approach with cutdown with detachable coils, with improvement in his vision, proptosis, and pain. 
Although initial imaging in a patient with hemicrania continua may be unremarkable, careful persistence is necessary on the part of the clinician to ensure a sinister cause is not in fact etiological. Emergence of new neurological symptoms can aid in this process, and should always be carefully considered in cases of presumed primary headache syndromes. 
Authors/Disclosures
Kendra K. Davis (Henry Ford Hospital)
PRESENTER
Ms. Davis has nothing to disclose.
Ashhar Ali, DO, FAAN (Henry Ford) Dr. Ali has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Pfizer. Dr. Ali has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Ebsco.
Poonam Bansal, MD (Henry Ford Health System) Dr. Bansal has nothing to disclose.