Fig. 2. A 91-year-old female with traumatic direct CCFs. (A) Coronal view on 3D-TOF MRA showing the high signal intensity of the bilateral CS and the right SOV. (B, C) Frontal (B) and lateral (C) views on right internal carotid angiography showing the high-flow CCF at the right cavernous portion. The direct CCF drained into the right CS to the contralateral CS, the bilateral inferior petrosal sinus, the bilateral pterygoid plexus, and the bilateral SOVs. (D, E) Axial (D) and coronal (E) reconstructed 3D angiography images of the right ICA clearly depicting the location of the fistula (yellow arrows) and fistulous venous pouch medially to the ICA. The direct CCF was treated by balloon-assisted coil embolization. A micro balloon catheter was placed crossing over the fistula in the cavernous portion of the right ICA and a microcatheter was advanced transarterially into the fistula via the orifice. Via the transvenous approach, two microcatheters were advanced into the same fistulous pouch via the right inferior petrosal sinus. 3D-TOF: 3D time of flight; CCF: carotid cavernous fistula; CS: cavernous sinus; ICA: internal carotid artery; SOV: superior ophthalmic vein; (The color version is available online.) (F) Fluoroscopic image showing three microcoils from three different microcatheters that were deployed into the fistula compartment under balloon inflation. (G) The fistulous pouch was packed with nine coils. (H) Right internal carotid angiography after selective embolization showing complete occlusion of the CCF. CCF: carotid cavernous fistula;