The authors report the treatment of a rare type of dural arteriovenous fistula of the paracavernous venous plexus. These fistulas can mimic carotid-cavernous fistulas in both imaging characteristics and clinical presentation, but the anatomical differences require differences in management. The authors describe an integrated open surgical and direct endovascular embolization approach and review of the literature pertaining to the anatomy of and treatment options for paracavernous fistulas.