Carotid cavernous fistulas (CCF) are abnormal communications inducing shunting of blood between the carotid arterial system and the cavernous sinus (CS), resulting in flow reversal in the veins draining through the CS.1 CCFs can be classified as spontaneous or traumatic according to the etiology and direct or indirect (dural) according to the anatomical features2. The authors have dealt a case of a spontaneous indirect Carotid-Cavernous Fistula in a young male of 30 on the right side. The patient presented with headache and bulging of right eye. On examination there was pulsatile proptosis on the right side with conjunctival congestion. CT angiography revealed CCF on the right side with dilated, tortuous right ophthalmic and common facial vein. DSA revealed indirect Carotid-Cavernous Fistula fed by right middle meningeal artery (MMA), accessory meningeal artery and branch of right ophthalmic artery(OA) drained by right ophthalmic vein with abnormal communication via right common facial vein. Patient underwent transarterial embolization with ONYXR . DSA revealed total obliteration of fistula. Headache subsided and proptosis reduced immediately after embolization on procedure table with intact neurology. Almost two months down the follow up revealed complete recovery of proptosis and conjunctival congestion with no further headache. Bang. J Neurosurgery 2022; 11(2): 128-133

Introduction: Endovascular treatment offers different technique (Balloon assisted coiling / simple coiling, glue embolization) to treat Carotid Cavernous Fistula (CCF). This less invasive approach avoids morbidity and residual fistulas. The choice of treatment depends on the anatomy of the fistulas and cost effectiveness. Objective: To describe different endovascular treatment option of Carotid Cavernous fistulas (CCF), its short term outcome (clinical and angiographical) and to compare between trans-venous coiling and trans-arterial balloon assisted sinus coiling. Method: We have treated nine (9) cases of CCF during a period of three years. Out of them eight patients had direct CCF and one had indirect CCF. In two patients simple coiling done through trans-venous route and in another three patients through trans-arterial route. Balloon assisted coiling through trans-arterial route done in three patients. In two patients trans-arterial glue embolization was done. Results: Successful obliteration of fistula was achieved in all cases. Vision was improved in eight (8) patients. Postoperatively some proptosis remains in two patients. In one patient there was reappearance of proptosis two months after treatment, then balloon assisted coiling was done. One patient died from complication of glue (NBCA). Conclusion: Endovascular treatment is the mainstay of treatment in CCF. Trans-venous is the treatment of choice but recently balloon assisted sinus coiling through trans-arterial route is adopted. Bang. J Neurosurgery 2019; 8(2): 68-76