Direct Carotid-Cavernous sinus Fistula Following Closed Head Injury

A case of direct carotid-cavernous sinus fistula (CCF) after closed head injury is presented. A
22-year-old male presented to the emergency department of Shohada Tajrish Hospital with the
chief complaint of blurred vision and pulsatile retro-orbital headache. The patient had closed head
injury due to car accident 2 month ago with lower limb fracture. After a 2-week symptom-free
period, he developed scalp and right facial tingling, along with pulsatile retro-orbital headache
and vision problems. His vital signs were within normal limits, but on primary evaluation
the patient orbital and carotid bruits could be recognized. Computed tomography (CT) scan
and magnetic resonance imaging (MRI) suggested the carotid-cavernous sinus fistula, which
was confirmed by brain angiographic imaging findings. Carotid-cavernous sinus fistula is an
uncommon condition that is usually caused by head trauma but can advance spontaneously in
about one fourth of patients with CCF. The connection between the carotid artery and cavernous
sinus leads to increased pressure in the cavernous sinus and compression of its contents, and
finally advances the clinical symptoms and signs seen. Diagnosis is based on clinical evaluation
and neuroimaging techniques. The target of management is to decrease the pressure within the
cavernous sinus, which results in gradual recovery of symptoms.