Orbital compartment syndrome secondary to direct CCF after carotid-cavernous aneurysm rupture; Case Report and Review of Literature.

Carotid cavernous aneurysm (CCA) rupture is rare. However, it can result in various complications such as carotid cavernous fistula, epistaxis, spontaneous thrombosis, and subarachnoid hemorrhage.We reported a 65-year-old woman with a history of uncontrolled diabetes, who referred with a complaint of acute headache, diplopia, proptosis, and chemosis. Ophthalmic examination revealed elevated intraocular pressure in the right eye, optic disk edema, and retinal venous congestion. Canthotomy was performed based on a diagnosis of Orbital Compartment Syndrome (OCS). Further imaging revealed dilated superior ophthalmic vein, cavernous sinus, and extraocular muscles swelling in the right eye. Digital Subtraction Angiography (DSA) showed the fistulous connection between the cavernous part of the internal carotid and cavernous sinus (direct CCF) due to the large ruptured carotid-cavernous aneurysm resulting in retrograde flow through superior and inferior ophthalmic veins.Successful endovascular coiling of aneurysm resulted in complete occlusion of fistula. Post-intervention ophthalmic examinations revealed the progressive improvement of ophthalmic signs and symptoms; however, the patient's right eye remained blind.In patients with clinical manifestation of OCS with no history of any predisposing risk factors, diagnosis of ruptured cavernous sinus aneurysm and the resulting direct CCF should be considered. In such cases, emergent imaging beside early endovascular intervention can resolve OCS and prevent permanent ocular injury and vision loss.