Intra-operative visualization of the superior ophthalmic vein in carotid-cavernous fistula

This 55-year-old woman with grade III invasive ductal carcinoma in remission on letrozole and hypertension presented with 4 months of headaches, diplopia, and a left eye with proptosis and circumferential corkscrew vessels extending to the limbus. Computed tomography imaging demonstrated a dilated superior ophthalmic vein consistent with a carotid-cavernous fistula (CCF). Diagnostic direct catheter angiography confirmed a CCF supplied by the left and right meningo-hypophyseal trunks of the internal carotid artery, which is type B by Barrow's classification. Oculoplastic surgery obtained access to the superior ophthalmic vein for direct catheterization on request from the interventional neuroradiology team as demonstrated in the image. Upon catheterization, the fistula had spontaneously thrombosed. Post-procedure, the patient had improved injection and proptosis of the left eye. She was started on apixaban to treat a presumed cavernous sinus thrombosis. She continues to do well at her follow up examinations.