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. 2025 Oct 1;13(2):V6.
doi: 10.3171/2025.7.FOCVID25103. eCollection 2025 Oct.

Superior ophthalmic vein cutdown and craniotomy for sylvian vein access in the treatment of a bilateral spontaneous indirect carotid-cavernous fistula

Ross Greenberg #  1 , James Feghali #  1 , Risheng Xu  1 , Christopher M Jackson  1 , Justin M Caplan  1 , Nicholas R Mahoney  2 , Judy Huang  1 , Rafael J Tamargo  1 , L Fernando Gonzalez  1
Affiliations

Superior ophthalmic vein cutdown and craniotomy for sylvian vein access in the treatment of a bilateral spontaneous indirect carotid-cavernous fistula

Ross Greenberg et al. Neurosurg Focus Video. .

Abstract

The authors discuss the first reported case of bilateral spontaneous indirect carotid-cavernous fistula (CCF) treated by a hybrid open-endovascular approach bilaterally. A 74-year-old man presented to the emergency department following 1 month of progressive right-eye proptosis with increased intraocular pressure. Cerebral angiography confirmed bilateral indirect type D CCF. Attempts to access the cavernous sinus through the petrosal sinuses were unsuccessful. The right-sided CCF was successfully treated via surgical exposure of the superior ophthalmic vein for endovascular deployment of coils and liquid embolic agent. The left-sided CCF was similarly treated after gaining cavernous sinus access via craniotomy to catheterize the left sylvian vein. The video can be found here: https://stream.cadmore.media/r10.3171/2025.7.FOCVID25103.

Keywords: carotid-cavernous sinus fistula; cerebral arteries; embolization.

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Conflict of interest statement

Disclosures Dr. Huang reported stock ownership in Longeviti during the conduct of the study. Dr. Gonzalez reported being a consultant for Medtronic outside the submitted work. Dr. Huang reported stock ownership in Longeviti during the conduct of the study. Dr. Gonzalez reported being a consultant for Medtronic outside the submitted work.

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