PMC9884056_01
Anterior segment photograph at patient's presentation, demonstrating chemosis in the right eye (A) and left eye (B), and episcleral corkscrew vessels (yellow arrows) in the right eye (C) and left eye (D).
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There were significant chemosis and episcleral corkscrew vessels in both eyes (Figure 1).
Optical coherence tomography of the macula at presentation demonstrating normal thickness in the right (A) and left (B) eyes.
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Optical coherence tomography demonstrated normal thickness of the macula in each eye (Figure 2).
MRI and MRA of the brain and orbits, with gadolinium, at presentation. Axial DWI (A) and corresponding axial ADC (B) images demonstrating diffusion restriction (arrows in A) with corresponding reduced ADC (arrows in B) bilaterally along the entire orbital segment of the optic nerves. Axial MRA (C) image demonstrating arterialization of the bilateral cavernous sinuses (arrows). Axial MRA (D) image demonstrating arterialization of the bilateral SOVs (arrows).
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That is consistent with bilateral PION (Figures 3A and B). Magnetic resonance angiography (MRA) of the brain and orbits revealed arterialization of the bilateral cavernous sinuses and SOVs (Figures 3C and D). 
Pre-embolization of right ICA angiography (A) demonstrating a dural CCF with feeders from dural branches of the ICA (arrows). Bilateral SOVs (arrowheads) are opacified. Note that the left SOV is opacified through inter-cavernous communication. Pre-embolization of left ECA angiography (B) demonstrating a dural CCF with feeders from the dural branches of the ECA (arrows). Bilateral SOVs (arrowheads) are opacified. Note that the right SOV is opacified through inter-cavernous communication.
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The right dural CCF was fed by the dural branches of the ICA (right meningohypophyseal trunk, Figure 4A). ECA (left-middle meningeal artery and the left artery of the foramen rotundum, Figure 4B) and the dural branches of the ICA (left meningohypophyseal trunk). Each side of the dural CCF contributed arterial blood flow into the bilateral SOVs (contralateral SOV through inter-cavernous communication, Figures 4A and B).