Neglected Superior Ophthalmic Vein Enlargement Before Delayed Symptom of Carotid-Cavernous Fistula in a Blow-Out Fracture: A Case Report and Literature Review

Abstract

Carotid-cavernous fistula (CCF) is rare condition. However, it should be suspected when there are traumatic facial fractures, because if not diagnosed, it can lead to permanent damage such as blindness. Traumatic CCF often presents delayed symptoms, and delayed diagnosis without prompt treatment can lead to permanent injuries in optic and cranial nerves III, IV, V, and VI as well as intracranial hemorrhage. The routine initial modality for patients with suspected facial bone fractures is non-contrast computed tomography (CT) to identify any fracture lines and check for intracranial hemorrhage. We report a post-traumatic CCF case with a 4-day symptom delay, where left superior ophthalmic vein enlargement was observed on the routine non-contrast facial CT with ipsilateral orbital wall fracture. When the patient first presented to the emergency room, we did not detect vein enlargement on CT. Afterwards, the patient developed delayed symptoms of CCF and was re-admitted to the emergency room. When we re-analyzed the first CT scan, an enlarged superior ophthalmic vein was confirmed. The diagnosis was confirmed via magnetic resonance imaging angiography, and the patient was successfully treated with embolization of the fistula. Thus, we recommend reviewing ophthalmic vein enlargement that is readily identifiable through non-contrast CT for patients injured by craniofacial trauma to suspect the presence of delayed CCF at their initial presentation.