Carotid cavernous fistula masquerading as orbital cellulitis

Abstract

We report a case of direct carotid cavernous fistula (CCF) in a patient of head injury due to road traffic accident who presented several weeks after the injury with sudden onset of pain, redness, and proptosis of right eye. A 56 years old male patient with no known comorbidities presented to ophthalmology OPD with acute onset of pain, redness, swelling, and proptosis of right eye of one week duration and visual acuity of 1/60. Initially he was misdiagnosed and treated as orbital cellulitis. However, digital subtraction angiography confirmed the diagnosis of right direct CCF. Patient underwent endovascular treatment with a good visual recovery post operatively. Ophthalmologists should keep CCF higher up in their differential diagnosis of patients with red edematous eyes, especially with a history of trauma and get thorough investigations in order to provide timely aggressive management to such patients.

Keywords: Direct carotid cavernous fistula; Endovascular treatment; Orbital cellulitis; Traumatic CCF.

Fig. 1

A 56-year-old man with redness, chemosis, and proptosis right eye (Fig. 1A), one month after sustaining head injury. DSA examination demonstrates right direct CCF with predominant drainage anteriorly into dilated SOV (arrow in 1B). The right vertebral artery injection precisely localized the site of fistula to the cavernous segment of right ICA (arrow in 1C). Following favourable results with balloon occlusion test, PAO was performed using detachable coils, resulting in complete cessation of the shunt (Fig. 1D) and preserved flow to the right cerebral circulation across ACOM. Local examination of the right eye following embolization demonstrates near complete resolution of redness and chemosis (Fig. 1E). SOV: superior ophthalmic vein, PAO: parent artery occlusion.