An unusual complication of mourning.

The emotional trauma of bereavement can, on occasion, be translated into physical trauma. Phrases such as "grinding of teeth", "breast-beating" and "tearing one's hair out" have a traditional association with mourning and lamentation.' We report a case where bereavement led directly to an uncommon neurological complication of blunt trauma. A forty year old housewife from the United Arab Emirates presented with a three week history of nausea, headache, pain in the right eye and a persistent throbbing in the head. Her nineteen year old son had been killed in a road traffic accident one month before presentation, and her relatives reported that in the few days between his death and the onset of the symptoms she had been seen repeatedly striking her head against a wall in her grief. Physical examination revealed pulsating exophthalmos of the right eye accompanied by a supraorbital bruit. A diagnosis of carotid cavernous fistula was made, and carotid angiography under general anaesthesia confirmed the diagnosis (fig). As part of the same procedure she underwent balloon occlusion of the fistula with preservation of carotid blood flow. Her subsequent recovery was complete and uneventful. Carotid cavernous fistula is an uncommon condition in which an abnormal communication exists between the carotid artery and the cavernous sinus at the base of the skull. This produces a characteristic syndrome of severe unilateral headache accompanied by ipsilateral carotid and supraorbital bruits, progressive pulsatile exophthalmos, usually ipsilateral, but not infrequently bilateral or even contralateral only, with chemosis, retinal haemorrhages, and variable degrees of ophthalmoplegia and loss of visual acuity which may progress to blindness. Approximately 750(of such fistulae are thought to be of traumatic origin, often found in association with a basal skull fracture, while the remainder are spontaneous, presumably arising from .r ~ ~~ ... Vertebral angiogram, lateral projection. There is retrograde filling of the internal carotid artery as far as afistula, which is outlined (arrow) by contrast medium shunting into the cavernousfistula. the rupture of a previously diseased carotid arterial wall. The majority of the post traumatic group are due to blunt trauma, usually following a head injury violent enough to produce unconsciousness, although some follow surgical procedures to the head and neck.23 Rarely, penetrating trauma is responsible, caused by such diverse items as knives,4 air rifle pellets5 and fish.6 The aetiology of the carotid cavernous fistula in the patient we describe was almost certainly blunt trauma from the repeated …