Kaplan et al. International Journal of Emergency Medicine 2012, 5:10 http://www.intjem.com/content/5/1/10 His past medical history was significant for alcoholism and an old frontal bone fracture suffered as a child. He was not on any medications and had no significant family history. Comprehensive review of systems was otherwise noncontributory. On physical examination, the patient was wearing sun- glasses, in no acute distress. Vital signs were unremark- able. He appeared clinically sober. His visual acuity was 20/30 in each eye, and there were bilateral orbital bruits. The patient declined fundoscopic examination because of significant photophobia. The right eye exhibited: pto- sis, inability to adduct, limited elevation and depression. He also could not abduct his left eye. He had decreased sensation to soft touch over the entire forehead, nose, and left cheek, but his corneal reflexes were intact. There was no facial asymmetry. The rest of the cranial nerve examination was intact. Motor strength bilaterally did not reveal any focal neurological deficits, and deep tendon reflexes (DTRs) were 2/4 symmetrical in both the upper and lower extremities. The cerebellar Page 2 of 5 examination was unremarkable except for abnormal tan- dem gait. Other systemic examinations were unremark- able except for bilateral carotid bruits. The initial workup in the ED included a complete blood count (CBC), basic metabolic panel (BMP), coagu- lation studies [prothrombin time (PT), partial thrombo- plastin time (PTT), international normalization ratio (INR)], and a urine toxicology screen. Each of these stu- dies was without abnormality. A computed tomography (CT) scan of the head without contrast was performed, showing a significantly dilated left ophthalmic vein, seen in Figure 1. Subsequent brain magnetic resonance imaging (MRI) confirmed the suspicion of a carotid artery-cavernous sinus fistula (Figure 2). Neurosurgery was consulted. The following day, cerebral angiography with coil embo- lization of the carotid fistula was performed without complication (Figure 3). The patient was discharged the next day. An 8-month follow-up in the neurosurgery clinic revealed complete resolution of his symptoms. Figure 1 CT of the head without contrast. Left ophthalmic vein is dilated.