Abstract
BACKGROUND: The Belonidae family of fish has been implicated in various penetrating injuries; to date, however, there have been limited reports of brain injury due to this species. OBSERVATIONS: The authors present the case of a young patient who suffered an ocular penetrating injury from a needlefish with a resultant cavernous sinus thrombosis and concomitant carotid-cavernous fistula. This case highlights the interdisciplinary management of this rare condition through a strategy of anticoagulation titration to the endpoint of fistula closure. LESSONS: Through this report the importance of a high index of suspicion for neurovascular injury and fistula formation in penetrating ocular injuries is highlighted as well as the importance of interdisciplinary management of patients with such injuries and their sequelae.