Traumatic Carotid-Cavernous Fistula in a Child with Nasal Penetrating Injury

BACKGROUND: Traumatic penetrating carotid-cavernous fistula (CCF) is an uncommon complication of craniofacial trauma, particularly in pediatric patients. Prompt recognition is essential to prevent irreversible visual and neurological deficits. CASE PRESENTATION: We describe a 2.5-year-old boy who sustained a penetrating nasal injury caused by a screwdriver. He initially presented with epistaxis and subsequently developed left-sided proptosis, chemosis, and restricted ocular motility. Early imaging studies were inconclusive, and orbital cellulitis was initially suspected. DIAGNOSIS AND MANAGEMENT: A delayed diagnosis of a direct (Type A) CCF was ultimately confirmed using digital subtraction angiography (DSA). The patient underwent successful endovascular embolization combined with internal carotid artery (ICA) stenting. CONCLUSION: This case highlights the need for a high index of suspicion for CCF in children presenting with atypical orbital findings following facial trauma, even when initial imaging doesn't reveal definitive pathology.