High-flow direct carotid-cavernous fistula following craniofacial trauma: endovascular management and clinical outcome

Background: Direct carotid-cavernous fistulas (CCFs) are uncommon but potentially devastating vascular lesions resulting from an abnormal communication between the intracavernous internal carotid artery and the cavernous sinus. Most direct CCFs are traumatic and may lead to progressive visual impairment, cranial nerve dysfunction, and intracranial complications if left untreated.
Case Description: We report the case of a 25-year-old man who developed a high-flow direct carotid-cavernous fistula following craniofacial trauma secondary to physical assault. Clinical examination revealed pulsatile left-sided exophthalmos, orbital bruit, conjunctival congestion, eyelid edema, and severe visual impairment with visual acuity limited to 1/10. Cerebro-orbital computed tomography and digital subtraction angiography confirmed a Barrow type A direct carotid-cavernous fistula arising from the C3 segment of the left internal carotid artery. Endovascular embolization using detachable platinum coils achieved complete angiographic occlusion of the fistula. At six-month follow-up, visual acuity improved to 8/10 with marked regression of orbital symptoms.
Conclusion: Early diagnosis and prompt endovascular intervention remain the cornerstone of management for high-flow traumatic carotid-cavernous fistulas. Endovascular embolization offers excellent angiographic and functional outcomes while minimizing treatment-related morbidity.