A 63-year-old woman with a direct carotid-cavernous fistula (CCF), manifesting as sudden onset of severe headache and pulsatile tinnitus suffered during coronary angiography, was successfully treated with transarterial embolization based on the anatomical information obtained from volume-rendered three-dimensional digital subtraction angiography (3D DSA) images. 3D DSA is useful for understanding the configuration of such fistulas accurately and devising a therapeutic strategy for the endovascular treatment of direct CCFs.