Traumatic Direct Carotid-Cavernous Fistula Presenting with Delayed Epistaxis and Visual Loss Managed by Parent Artery Occlusion: A Case Report

Background: A high-flow arteriovenous connection between the internal carotid artery (ICA) and the cavernous sinus is known as a direct carotid-cavernous fistula (CCF). The most common cause of direct CCF is trauma, and the current standard of care is endovascular therapy. Visual impairment and severe epistaxis are rare but dangerous presentations that may require immediate, effective treatment. Case: About a month after a fall from a height that resulted in right-eye blindness, a 29-year-old man developed acute nasal bleeding after sneezing. A direct right CCF was confirmed by digital subtraction angiography (DSA), which showed a significant rent between the right cavernous ICA and cavernous sinus with no distal flow into the right anterior and middle cerebral arteries. Deconstructive right ICA parent artery blockage with coils was used to treat the fistula as there was no distal right ICA flow and collateral cerebral circulation. Complete right ICA occlusion, no residual CCF, and collateral supply to the right hemisphere via the anterior and posterior communication channels were all shown by follow-up angiography. Conclusion: In conclusion, this case demonstrates delayed post-traumatic direct CCF that mostly manifests as epistaxis and visual loss instead of the traditional ocular triad. When reconstructive preservation of the wounded ICA was not possible, angiographic evaluation of collateral circulation was essential to safely choosing parent artery closure.