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A 58-year old patient presented with diplopia in all directions of gaze for one week, disturbed vision and redness of his right eye as well as a bruit in his right ear for two days. Clinical examination revealed an incomplete oculomotor nerve palsy and decreased acuity of vision on his right eye. A pulsatile exophthalmus, conjunctival injections and chemosis of the right eye were seen (figure 1). CT angiography showed an enlarged superior ophthalmic vein (figure 2), the cerebral pan-angiography revealed an indirect carotid cavernous fistula (CCF) Barrow type D on the right side. The carotid cavernous fistula was successfully treated by coil embolisation. Afterwards the physical and functional signs resolved. Follow-up images showed no evidence of a persistent fistula.

Conclusion:
CCF results from an abnormal communication between the arterial and venous systems within the cavernous sinus in the skull. The majority of CCF occurs after a trauma, as others can develop spontaneously as suspected in this case. It is a rare condition, but should be considered in differential diagnosis of acute vision loss and gaze palsy. Suggestive clinical findings can lead to the appropriate diagnosis.