a 69-year - old woman presented with a 4-month history of diplopia , 2 months of conjuntival injection , and exophthalmos . neurological examination showed normal consciousness and no cranial nerve deficits were observed . magnetic resonance imaging ( mri ) showed bulging of left cavernous sinus with internal signal void and distension of left superior ophthalmic vein . an angiogram showed left csdavf with arterial supplies from the middle meningeal artery and sphenopalatine artery arising both external carotid arteries and meningohypophyseal trunk arising both internal carotid arteries ( icas ) . there was venous drainage from the anterior cavernous sinus into the left superior ophthalmic vein ( fig . however , angiogram did not show both the inferior petrosal sinus and facial vein , which are the typical access routes for transvenous embolization . we accessed the right common femoral artery , and a 5 fr catheter ( bern ; boston scientific , natick , ma , u.s.a . ) was placed in the left external carotid artery . afterwards , the left eye region was prepped in sterile fashion by plastic surgeon and exposed the left superior ophthalmic vein through incision ( fig . 2 ) . after directly puncturing the superior ophthalmic vein with a 22 g needle , a 4 fr yellow sheath from the micropuncture set ( fig . was placed in the superior ophthalmic vein . after connecting 4 fr yellow sheath and 3-way , it was considered that both detachable and undetachable coil embolization would be needed simultaneously and a sufficiently wide microcatheter ( prowler 18 ; cordis , miami lakes , fl , u.s.a . ) and microguidewire ( synchro 14 ; boston scientific , natick , ma , u.s.a . ) were used to approach the cavernous sinus . the microcatheter was placed into cavernous sinus and a total of 10 detachable coils ( gdc 10 ; boston scientific , natick , ma , u.s.a . ) and indetachable coils ( tornado coils ; cook , bloomington , u.s.a . ) were used to perform coil embolization ( fig . after embolization , the patient 's diplopia and exophthalmos disappeared and there were no signs of cranial nerve palsy or additional neurological deficit . carotid - cavernous sinus fistulas ( ccfs ) can be classified into two main type . direct ccfs consist of a communication between the main trunk of the ica and venous channels within the cavernous sinus . csdavf is communications between the cavernous sinus and extradural branches of internal carotid artery , external carotid artery , or both . the direct ccfs are almost caused by severe trauma or rupture of an intracavernous carotid aneurysm , and are usually characterized hemodynamically by high flow . csdavf usually become symptomatic spontaneously and may be characterized hemodynamically by high or , more often , low flow . compared to other type davf , csdavf is known to have favorable prognosis and spontaneous regression rate of 10 - 73% in the literature . consequently , an initial conservative treatment such as manual compression of ipsilateral common carotid artery can be attempted . however , in cases of rapid deterioration of eye symptoms or cortical venous drainage occurrence , urgent interventional therapy is warranted . endovascular embolization can be done transarterial or transvenous approach . because transarterial embolization is difficult to embolize the entire supplying artery and frequent relapse , it is currently used as a main method to transvenous embolization . transfemoral venous approach reaches the cavernous sinus through inferior petrosal sinus , and is the most preferred method due to its anatomically short and straight course . however , if it is inaccessible due to thrombus in the inferior petrosal sinus , treatment can be attempted through the facial vein - superior ophthalmic vein route . if the facial vein is also inaccessible , direct superior ophthalmic vein approach can be tried instead . in this case , the bilateral inferior petrosal sinus and facial vein were not opacification on angiogram , and therefore transvenous embolization through direct superior ophthalmic vein approach was performed . direct superior ophthalmic vein approach has an anatomically short distance to the cavernous sinus , making it easily accessible . in this case , a 4 fr yellow sheath was placed in the superior ophthalmic vein and after connecting 4 fr yellow sheath and 3-way , continuous saline flushing was performed through 3-way . this procedures are allowed for a stable procedure and easily adjustable control of the microcatheter and microguidewire . we used a sufficiently wide microcatheter ( prowler 18 ; cordis , miami lakes , fl , u.s.a . ) compared previous study . however , this method is reported to cause in rare instances , bleeding and infection of the access area , damage to the trochlea area and orbital sulcus , nerve damage , dural complications such as laceration and penetration , diplopia , and prolonged ocular motor dysfunction . in this case , there was no complication during or post procedure and showed completed occlusion of the csdavf . in conclusion , transvenous coil embolization through direct superior ophthalmic vein approach can be good in treating csdavf cases where accessing the inferior petrosal sinus or facial vein are difficult or impossible .
transvenous coil embolization has been successfully applied for the treatment of cavernous sinus dural arteriovenous fistula ( csdavf ) . 
 unfortunately , the technique can not be applied in cases of poor or absent inferior petrosal sinus or facial venous access route to the fistula . 
 recently , we experienced a successful embolization using direct superior ophthalmic vein approach in cases of csdavf which were no opacification of inferior petrosal sinus or facial vein .