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Patrick J. Karas, Robert Y. North, Visish M. Srinivasan, Nathan R. Lindquist, K. Kelly Gallagher, Jan-Karl Burkhardt, Daniel Yoshor, and Peter Kan

The classic presentation of a carotid-cavernous fistula (CCF) is unilateral painful proptosis, chemosis, and vision loss. Just as the goal of treatment for a dural arteriovenous fistula (dAVF) is obliteration of the entire fistulous connection and the proximal draining vein, the modern treatment of CCF is endovascular occlusion of the cavernous sinus via a transvenous or transarterial route. Here, the authors present the case of a woman with a paracavernous dAVF mimicking the clinical and radiographic presentation of a CCF. Without any endovascular route available to access the fistulous connection and venous drainage, the authors devised a novel direct hybrid approach by performing an endoscopic endonasal transsphenoidal direct puncture and Onyx embolization of the fistula.