This case demonstrates an indirect caroticocavernous fistula with feeders from bilateral ICA and ECAs. Prominence of the superior ophthalmic veins indicative of the increased, retrograde flow was a key diagnostic feature on the CT.
Erosion of the sella by the expanding cavernous sinus in an unusual feature, probably indicating chronicity of this fistula. The fistula was successfully treated angiographically.
A caroticocavernous fistula (CCF) may be due to either a direct connection between the cavernous ICA and the cavernous sinus (and present acutely), or due to an indirect connection via small branches of the ICA, ECA, or as in this case - both. In an indirect CCF, presentation may be more insidious.