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●Abstract● Objective: We report a unique case of carotid cavernous fistula (CCF) with thrombosed draining vein, making usual transvenous approaches impossible. Case presentation: This 69-year-old male patient presented with typical symptoms of CCF. Cerebral angiography revealed left CCF being fed by bilateral meningohypophyseal trunks (MHTs). Presumably due to anatomical variations of the cavernous sinus, attempts to access the shunting point by using the usual inferior petrosal sinus route failed. Thereafter peripheral draining vein thromboses might cause paradoxical worsening. Since urgent treatment appeared necessary, a transvenous coil embolization via direct puncture of the superior ophthalmic vein (SOV) was performed to obliterate the shunting point. Postoperatively that patient's visual symptoms recovered well. Conclusion: Direct puncture of the SOV to obliterate CCF is a possible alternative choice of treatment when the usual transvenous access route was available. To reduce risk of complications we believe biplane angiographical devices, preparation of liquid embolic material, 20G elastic needles, and prevention of heparinization are necessary. ●Key Words● carotid-cavernous fistula (CCF), direct puncture, thrombosed SOV

A case of carotid cavernous sinus fistula treated with a direct puncture to the thrombosed superior ophthalmic vein