A 21-year-old man presented with a 3-year history of bulging and redness of his right eye associated with double vision. He had a history of facial trauma 5 years previously. These symptoms, which had progressed over the year preceding the presentation, were accompanied by a bilateral pounding headache and gait unsteadiness with veering to the right. On examination, he had bilateral pulsating exophthalmos that was more marked on the right with a loudly audible orbital bruit. Mild soft tissue swelling of the right eyelid along with dilated veins in the right conjunctival fornices was observed. His visual acuity was 20/20 and there was no papilloedema. Eye movement examination showed restricted up-gaze, in conjunction with skew deviation, the right eye being hypertropic. Although impaired convergence was observed, there was no convergence retraction nystagmus. Right lateral rectus palsy and right sensorineural hearing loss were noted. Coordination testing revealed right finger to nose and heel to shin ataxia associated with a slightly wide based gait. The magnetic resonance images showed several findings of interest. There was a massive right cerebellar arteriovenous malformation, with a large tangle of vessels extending into the quadrigeminal plate and perimesencephalic cistern with mass effect on the right aspect of the midbrain (Figure 1). There was bilateral proptosis, significantly more pronounced on the right, with enlargement of the left lateral rectus muscle and bulging of the right cavernous sinus. Surprisingly, no significant enlargement of the right superior ophthalmic vein was noted (Figure 2). Cerebral angiography showed a massive right cerebellar arteriovenous malformation, fed by the bilateral posterior inferior cerebellar arteries, anterior inferior cerebellar arteries and superior cerebellar arteries, as well as direct branches from the basilar artery and right posterior cerebral artery. Superficial venous drainage was observed directly to the right transverse and sigmoid sinuses, as well as to the deep venous system, with an enlarged straight sinus, vein of Galen and internal cerebral veins. There was also retrograde forward-directed venous flow filling the right cavernous sinus and the inferior petrosal sinus. Emanating from the right cavernous sinus (Figure 3), there were two anterior directed veins: a smaller superior one, representing a cortical vein and a larger inferior vein, representing the right superior ophthalmic vein, which was only mildly dilated. The inferior ophthalmic vein was not visualized. No fistulous communication between the carotid artery and cavernous sinus was seen.