Introduction : Carotid-cavernous fistulas (CCF) are abnormal communications between the venous cavernous sinus and the carotid artery. These may occur spontaneously but are usually caused by significant head trauma. Timing of presentation following injury can vary from one day to up to 2 years according to literature. CCFs are classified according to the anatomy of vessels involved. Presentation and treatment modality of different types can vary. A direct, high flow fistula between the cavernous internal carotid artery and the cavernous sinus, is the most common CCF following head trauma. A triad of clinical findings has been described as chemosis, pulsatile exophthalmos and orbital bruit.

Case histories : We present two cases of carotid-cavernous fistulas recently diagnosed in our unit over the last four months. The timing and presentation of these cases were different, demonstrating the variable nature of the condition. Difference in subsequent treatment options and recovery will be discussed. A video of pulsatile exophthalmos will be shown during the presentation.

Clinical relevance : Direct fistulas always require treatment, these ranges from transarterial or transvenous embolization with coils, liquid embolic agents, balloon embolization and stent placement. Surgical ligation of the internal carotid artery or packing of the cavernous sinus is occasionally used as a last treatment resort. High index of suspicious to this diagnosis is required, especially in the intubated polytrauma patients who are incapable to present symptoms. It is important for clinicians to recognise the clinical signs to avoid delays in the appropriate treatment hence preventing significant long term morbidity and mortality.