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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 6  |  Page : 1633-1634

Smoking Guns

Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA

Date of Submission26-Feb-2021
Date of Decision05-May-2021
Date of Acceptance15-May-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Dr. Mithun G Sattur
Department of Neurosurgery, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 301 CSB, Charleston, SC 29425
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.333467

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How to cite this article:
Sattur MG, Lajthia O, Lena JR. Smoking Guns. Neurol India 2021;69:1633-4

How to cite this URL:
Sattur MG, Lajthia O, Lena JR. Smoking Guns. Neurol India [serial online] 2021 [cited 2022 Jan 26];69:1633-4. Available from:

A 24-year-old pedestrian was rendered unconscious after being struck by a speeding car at 90 kmph. She was intubated at the scene and transferred to our trauma center. She was hypotensive and tachycardic, with a Glasgow Coma Score (GCS) of 3 and massive epistaxis that was managed on scene with packing. The pupils were dilated and fixed and she had a weak cough and gag reflex. Computed Tomography (CT) brain revealed severe diffuse edema, pneumocephalus and air in ventricles, bilateral basal ganglia hemorrhages, and extensive skull fractures extending into the skull base [Figure 1]a and [Figure 1]b. CT spine showed atlanto-occipital dislocation. CT angiography (CTA) of the head and neck revealed two sites of dramatic contrast extravasation: (1) the right internal carotid artery (ICA) region near the intracranial bifurcation [Figure 2]a and [Figure 2]b and (2) the basilar bifurcation near from the left posterior cerebral artery (PCA, P1 segment) [Figure 2]c and [Figure 2]d, reminiscent of the 'smoking gun' sign. Despite aggressive resuscitative measures, she succumbed to her devastating injuries. Active contrast extravasation from intracranial arteries on diagnostic angiography (catheter or CTA) in a jet-like or smoking gun pattern has a dramatic appearance. It is typically described in studies performed for ruptured intracranial aneurysms[1],[2] or trauma.[3]
Figure 1: (a) CT brain showing severe edema, intracranial air, and bilateral deep hemorrhages (b) CT bone windows showing extensive skull fractures extending into anterior and middle cranial fossa

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Figure 2: (a) Sagittal CTA shows contrast jet from right ICA bifurcation, projecting anteroinferiorly (b) Oblique CTA showing contrast jet from right ICA into the sphenoid sinus (c) Axial CTA shows contrast jet from basilar apex region toward left PCA (d) Oblique CTA showing basilar apex and extravasation from left P1 (e) Coronal CTA shows a rare view of simultaneous contrast jets (“smoking guns”) from right ICA and left PCA

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To our knowledge, simultaneous extravasation from both anterior and posterior circulation [[Figure 2]e, [Video 1]a and [Video 1]b] has not been previously described. Unfortunately, but not surprisingly, the circumstances associated with these imaging findings proved to be fatal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Tsuang FY, Su IC, Chen JY, Lee JE, Lai DM, Tu YK, et al. Hyperacute cerebral aneurysm rerupture during CT angiography. J Neurosurg 2012;116:1244-50.  Back to cited text no. 1
Nehls DG, Flom RA, Carter LP, Spetzler RF. Multiple intracranial aneurysms: Determining the site of rupture. J Neurosurg 1985;63:342-8.  Back to cited text no. 2
Sim KB, Park SQ, Choi HA, Kim DH. Demonstration of traumatic subarachnoid hemorrhage from the anterior choroidal artery. J Korean Neurosurg Soc 2014;56:531-3.  Back to cited text no. 3


  [Figure 1], [Figure 2]


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