Direct carotid-cavernous fistula presenting with minimal symptoms and rapid angiographic progression

Most patients with direct carotid-cavernous fistulas (CCFs) present with dramatic symptoms including proptosis, chemosis, and diplopia. We report a patient with a direct/high-flow CCF whose only initial symptom was pulse-synchronous tinnitus. Following diagnostic angiography, she developed mild symptoms and dramatic angiographic changes over a period of 3 days. Complete occlusion of the CCF and resolution of her symptoms were achieved by performing a stent-assisted coil embolization.