Central hypothyroidism as a rare sequela of traumatic carotid cavernous fistula in a pediatric patient.

PURPOSE: Direct carotid-cavernous fistulas (CCFs) are rare, high-flow shunts between the cavernous internal carotid artery and cavernous sinus, classified as Barrow Type A lesions. They commonly cause orbital venous congestion and cranial neuropathies, whereas endocrine dysfunction is exceedingly uncommon. We present the first case of a traumatic CCF in a pediatric patient complicated by transient central hypothyroidism, exploring whether severe venous congestion can impair hypothalamic-pituitary perfusion and emphasizing the importance of early vascular imaging and hormonal monitoring.

METHODS

Retrospective review of a 4-year-old female presenting with progressive proptosis, chemosis, elevated intraocular pressure, and central hypothyroidism after facial trauma.

RESULTS

Initially treated for concussion, the patient developed persistent ocular pain and swelling during a 7-day admission. Delayed CTA demonstrated a direct right ICA-cavernous sinus fistula with bilateral superior ophthalmic vein engorgement and cortical venous reflux. Digital subtraction angiography confirmed a high-flow Barrow Type A CCF caused by cavernous ICA dissection and pseudoaneurysm rupture. Low TSH was observed. Initial transarterial coil embolization reduced shunting but left residual filling. Follow-up angiography showed improved ICA flow and resolution of cortical reflux, though persistent drainage remained. Due to ongoing symptoms, combined transvenous and transarterial embolization achieved near-complete occlusion while preserving carotid patency. At follow-up, complete interval thrombosis was observed with stable ICA, healing pseudoaneurysms, normalized venous drainage, and no recurrent shunting; hypothyroidism resolved at follow-up.

CONCLUSION

Early vascular imaging is essential after craniofacial trauma with persistent orbital findings. Multimodal endovascular therapy can restore cavernous circulation and endocrine function while maintaining carotid integrity.