Post-traumatic carotid-cavernous fistula

A 46-year-old man attended the emergency department with a 24-hour history of sudden onset and progressive proptosis of the left eye. Over the previous days, he had experienced severe nausea and vomiting, causing multiple Valsalva manoeuvres. He had been discharged from hospital 12 days before after a severe head injury with skull base fractures affecting the central part of the sphenoid bone. On examination, he had a left exophthalmos, periorbital oedema with significant chemosis, with loss of all eye movements on the left (frozen eye), decreased visual acuity and elevated intraocular pressure (figure 1A,B)

Ateriography showed a direct left carotid–cavernous fistula (figure 2A,B), which was successfully occluded by embolisation (figure 3A,B). He improved almost immediately after the procedure (figure 4A) and at discharge, had normal eye movements but persisting minimal exophthalmos (figure 4B–E).

Carotid–cavernous fistula is an abnormal shunt from the carotid…

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