Successful repair of spontaneous indirect bilateral carotid-cavernous fistula with coil embolization

Bilateral carotid-cavernous fistula (CCF) is a rare disease process, which portends poor visual outcome with delayed diagnosis and treatment. An 82-year-old woman presented with sudden onset of proptosis and decreased vision. A complete ophthalmologic examination along with magnetic resonance (MR) imaging of the brain and orbits, and MR angiography and venography of the brain confirmed the diagnosis of bilateral CCF. Diagnostic cerebral angiogram with concurrent coil embolization of the right cavernous sinus via left superior ophthalmic vein approach was performed. Bilateral indirect CCFs (type D CCF on the right and a type B CCF on the left) regressed completely after unilateral coil embolization. Visual acuity and limitation in extraocular movements significantly improved with complete resolution. In summary, we describe successful management of bilateral concurrent CCF with image-guided embolization and immediate recovery of vision and resolution of ophthalmological symptoms including proptosis and diplopia.