Traumatic carotid-cavernous fistula combined with pseudoaneurysm requires immediate treatment.

To cite: Koekkoek JAF, Lycklama à Nijeholt GJ, Jellema K, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013009013 DESCRIPTION A 69-year-old woman presented with recurrent episodes of heavy epistaxis after previous head trauma. She reported a slowly progressive left-sided headache, a slightly swollen left eye and pulsatile tinnitus for 3 weeks. Her medical history showed a cerebral concussion with multiple facial fractures after a fall from her bicycle 3 months ago. On neurological examination, she had slight chemosis and proptosis of the left eye, an intracranial bruit on auscultation over the left orbit and bilateral extensor plantar responses. CT of the brain showed obliteration of the left sphenoid sinus with a small defect in its lateral wall and dilation of the left superior ophthalmic vein (SOV). Contrastenhanced CTangiography (CT-A) clearly confirmed the dilation of the left SOV and enlargement of the left cavernous sinus. Furthermore, there was a pseudoaneurysm extending into the left sphenoid sinus (figure 1). Diagnostic cerebral angiography confirmed the diagnosis of a direct carotid-cavernous fistula (CCF). Because the patient did not tolerate an occlusion of the ipsilateral internal carotid artery (ICA) due to an insufficient anterior communicating artery, stent-assisted coiling of the left cavernous sinus was performed, after which the patient’s symptoms improved and the pseudoaneurysm was obliterated (figure 2). The most common type of CCF is the one connecting the ICA directly to the cavernous sinus, often caused by traumatic rupture of the ICA. SOV dilation, combined with bone fractures and obliteration of the sphenoid sinus, is a key radiological feature that can often be recognised on non-contrast-enhanced CT. Strong enhancement and enlargement of the cavernous sinus and SOV on CT-A, as well as the presence of a pseudoaneurysm, additionally support the diagnosis. Current