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.