Carotid cavernous fistula complicated by contralateral abducens palsy and optic neuropathy

Carotid-cavernous fistulas (CCFs) occur rarely in children. We present the second known case of a pediatric CCF complicated by contralateral cranial nerve palsies. A 9-year-old boy developed a left CCF after falling onto a plastic stick. He underwent stenting of the internal carotid artery and transvenous coil embolization of the left superior ophthalmic vein and left sides of the cavernous and circular sinuses. Six weeks after repair, he demonstrated right periorbital edema, proptosis, and engorged conjunctival vessels, a right abducens nerve palsy, and a right relative afferent pupillary defect. Repeat angiogram showed shunting from the left CCF across the circular sinus and into the right superior ophthalmic vein. The patient underwent coil embolization of the circular sinus and right superior ophthalmic vein and cavernous sinus. This case underscores the importance of monitoring both eyes for signs of orbital congestion and cranial nerve palsies in patients with CCFs.