Carotid-Cavernous Sinus Fistula: NEJM case report
A healthy 18-year-old man was in a motor vehicle accident and sustained a head injury that resulted in intracranial bleeding at multiple sites, fractures of facial bones, and immediate traumatic mydriasis and ptosis in the left eye. Two weeks later, he had recurrent profuse epistaxis from the left side of his nose.

Examination was notable for normal results of nasal endoscopy. However, in the left eye, he had complete ophthalmoplegia, ptosis (Panel A and Video), and mild exophthalmos, and vision was restricted to perception of light. The left eye showed no chemosis, pulsation, or bruit. Ophthalmologic examination of the left eye revealed traumatic optic neuropathy.

Because vascular injury was suspected, computed tomographic angiography was performed, which revealed a carotid–cavernous sinus fistula and pseudoaneurysm in the fractured sphenoid sinus (Panels B and C, arrows).

The patient subsequently underwent endovascular intervention, and the intracavernous internal carotid artery was successfully occluded with a detachable balloon. No further epistaxis occurred, but the neurologic deficit in the left eye remained unchanged.

Source: https://www.nejm.org/doi/full/10.1056/NEJMicm1509943
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