Direct carotid-cavernous sinus fistula

A 40-year-old man presented with decreased vision and redness in his left eye. He had a significant trauma to the left side of his face about one year ago, but did not seek medical attention. External examination showed significant proptosis of the left eye (Figure 1) and conjunctival injection and corkscrew episcleral vessels (Figure 2). Ocular motility was full in both eyes (Figure 3) and dilated examination showed left optic disc pallor, tortuous venules, and attenuated arterioles (Figure 4). CT scan of the orbits showed left proptosis (Figure 5), enlarged cavernous sinuses, superior ophthalmic veins, and extraocular muscles on the left (Figure 6). Similar findings were seen on coronal (Figure 7) and sagittal slices (Figure 8). A catheter angiogram was performed and showed evidence of Borden type II direct left carotid-cavernous sinus fistula shunting into bilateral cavernous sinuses (Figure 9). He was treated with transarterial coil embolization (Figure 10) and post-coiling catheter angiogram showed complete obliteration of the carotid cavernous sinus fistula without residual arteriovenous shunting (Figures 11 and 12).