case_images: PMC9240585_01
case_images: Cross-sectional imaging workup. (a) Initial non-contrast head CT excluded
  intracranial hemorrhage, enlarged ventricles, and intracranial mass; (b) CT
  angiogram demonstrates early enhancement of prominent cavernous sinuses and
  enlarged facial veins; (c) T2-weighted Magnetic Resonance (MR) image shows
  prominent flow voids in both cavernous sinuses suggestive of high blood
  flow; and (d) time-of-flight MR angiogram demonstrates flow signal in both
  cavernous sinuses.
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case_images: Computreized Tomography (CT) head without contrast showed no intracranial hemorrhage, enlarged ventricles, and no intracranial mass (Figure 1A). CT angiogram of head demonstrated findings typical for carotid-cavernous fistula (CCF) that included prominent cavernous sinuses with convex margins, early enhancement of both cavernous sinuses, enlargement of both superior ophthalmic veins (SOVs), prominent angular and facial veins, proptosis, and mild retro bulbar fat stranding in both orbits (Figure 1B). T2-weighted MR image showed prominent flow voids in both cavernous sinuses suggestive of high blood flow with additional note made of focal tenting of the left posterior globe secondary to stretching of the left optic nerve (Figure 1C). Time-of-flight Magnetic Resonance (MR) angiogram demonstrated flow signal in both cavernous sinuses (Figure 1D).
case_images: Pre-embolization selective catheter angiogram. (a and b) Right and left ICA
  injections demonstrate early filling of cavernous sinuses fed by the
  cavernous branches of both ICAs. (c and d) Right and left ECA injections
  demonstrate early filling of cavernous sinuses fed by the meningeal branches
  of both ECAs.. Abbreviations: ICA, internal carotid artery; ECA, external carotid
  artery.
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case_images: Catheter angiogram showed indirect (Barrow type D) bilateral CCFs fed by meningeal branches of both external carotid arteries and cavernous branches of both internal carotid arteries (Figure 2).
case_images: Frontal fluoroscopic images. Radiodense coils in both cavernous sinuses, both
  superior ophthalmic veins, and inter-cavernous sinus.
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case_images: Subsequent to multidisciplinary team discussion, the patient underwent endovascular treatment that comprised trans venous coil embolization of both cavernous sinuses and both SOVs using detachable coils (87 detachable coils, Figure 3).
case_images: One-month post-endovascular coil embolization follow-up catheter angiogram.
  Right and left ICA injections demonstrate no residual early filling of the
  cavernous sinuses.Abbreviation: ICA, internal carotid artery.
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case_images: She had remarkable improvement of the exophthalmos, conjunctival chemosis and injection in both eyes (Figure 4B).
case_images: (a) Pre-embolization image demonstrates exophthalmos, periorbital edema and
  erythema, and conjunctival chemosis and injection in both eyes; (b)
  post-embolization day 1 images show remarkable improvement with resolution
  of the prior findings.
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case_images: The conjunctiva showed chemosis and conjunctival injection in both eyes (Figure 5A). One-month follow-up catheter angiogram demonstrated complete resolution of CCFs, with no residual arteriovenous shunting (Figure 5).