Article Text

Download PDFPDF
High index of suspicion: diagnosing a carotid-cavernous fistula
  1. Yara Sarkis,
  2. Astin Worden,
  3. Torsten Schreiber and
  4. Alvaro Lapitz
  1. Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
  1. Correspondence to Dr Torsten Schreiber; tmschrei{at}


A woman in her 70s presented with acute bilateral retro-orbital headache, diplopia, chemosis and eye swelling. Ophthalmology and neurology were consulted after detailed physical examination and diagnostic workup including laboratory analysis, imaging and lumbar puncture. The patient was diagnosed with non-specific orbital inflammation and was started on methylprednisolone and dorzolamide–timolol for intraocular hypertension. The patient’s condition improved slightly, but a week later, she developed subconjunctival haemorrhage in the right eye, which prompted investigation for a low-flow carotid-cavernous fistula. Digital subtraction angiography showed bilateral indirect carotid-cavernous fistula (Barrow type D). The patient underwent bilateral carotid-cavernous fistula embolisation. Her swelling improved considerably on day 1 after the procedure and her diplopia improved over the following weeks.

  • Headache (including migraines)
  • Eye

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @yaransarkis

  • Contributors YS—acquisition of data and drafting of the article. TS, AW and AL—review and editing of the article. TS—legal documentation and consent form. All authors—final revision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.