A 40-year-old male with a history of accident 2 days back presented to the ER with complaints of redness of eye, diplopia, decreased vision and facial pain in the distribution of ophthalmic division of trigeminal nerve. On examination, Bruit was heard over the eyes Proptosis Ocular pulsations Exposure keratopathy Pulsating exophthalmos MRI brain The aery involved in the above condition passes from which of the following structures: –

**Core Concept**
The patient is presenting with symptoms of orbital involvement, including redness of the eye, diplopia, decreased vision, and facial pain in the distribution of the ophthalmic division of the trigeminal nerve. The presence of a bruit, proptosis, ocular pulsations, and exposure keratopathy suggests a vascular lesion in the orbit.

**Why the Correct Answer is Right**
The patient's symptoms are consistent with a carotid-cavernous fistula (CCF), a direct communication between the carotid arterial system and the cavernous sinus. The involved artery is likely the internal carotid artery, which passes through the cavernous sinus. In a CCF, the abnormal communication between the carotid artery and the cavernous sinus leads to increased pressure and pulsatile flow into the orbital veins, resulting in the observed symptoms.

**Why Each Wrong Option is Incorrect**
* **Option A:** This option is not relevant to the patient's presentation. The middle meningeal artery is involved in conditions such as epidural hematoma, not carotid-cavernous fistula.
* **Option B:** The ophthalmic artery is a branch of the internal carotid artery but does not pass through the cavernous sinus. It is involved in conditions such as ophthalmic artery occlusion.
* **Option D:** The maxillary artery is a branch of the external carotid artery and is not involved in the pathophysiology of carotid-cavernous fistula.

**Clinical Pearl / High-Yield Fact**
Carotid-cavernous fistula should be suspected in patients with orbital symptoms and a bruit over the eye. It is essential to perform imaging studies, such as MRI or CT angiography, to confirm the diagnosis and plan treatment.

**Correct Answer:** C.