Successful pain control with supraorbital nerve block and steroid in a patient with carotid-cavernous fistula

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Carotid-cavernous fistula (CCF) is an uncommon vascular condition characterized by chemosis, proptosis, bruit, and paralysis of structures innervated by the cranial nerves passing through the cavernous sinus. We describe a woman in her seventies woman with a 7-month history of headache, double vision, and tinnitus aurium, who was successfully treated with nerve blocks and transvenous endovascular occlusion. On initial examination, Tolosa-Hunt syndrome was suspected, and the patient was treated with supraorbital nerve block, near-infrared irradiation, and administration of betamethasone. The nerve blocks considerably improved her headache and tinnitus aurium, though her double vision persisted. Eventually, CCF was diagnosed based on MRI and cerebral angiography, and the patient underwent intravascular coil embolization, with nearly complete resolution of the remaining symptoms. Patients complaining of headache and unilateral ophthalmoplegia should be carefully examined for CCF.
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