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BACKGROUND Carotid-cavernous fistula (CCF) is a rare complication after trans-sphenoidal surgery. METHODS The aim of this article is to report a case of CCF after the endoscopic resection of a growth hormone (GH) secreting pituitary microadenoma and to discuss and review all the cases of CCF secondary to trans-sphenoidal procedures described in literature. RESULTS A 74-year-old patient was operated for a GH-pituitary microadenoma through an endoscopic trans-sphenoidal surgery. During the procedure, a copious bleeding from the left cavernous sinus was managed with hemostatic material. A direct CCF was diagnosed and managed with transvenous and transarterial coiling. A complete exclusion of the fistula was possible and the patency of the internal carotid artery was maintained.A total of nine other cases have been reported. A trans-sphenoidal approach was performed for sellar tumors in six cases and for chronic sinusitis in two cases. In seven cases, intraoperative hemorrhage was reported, which could be controlled in five cases. The postoperative diagnosis of CCF was immediate in five cases. Patients presented with persistent bleeding after nasal unpacking or later with chemosis and proptosis. Cerebral angiography was the gold standard for the diagnosis. Eight cases were successfully treated through endovascular techniques with no recurrence observed at follow-up (mean of 15 months). No major neurological complications were observed. CONCLUSION CCF should be suspected with every abnormal bleeding after trans-sphenoidal surgeries, even when the symptoms are mild. Diagnostic arteriography and endovascular treatment represent the mainstay of the management and an early diagnosis strongly improves the prognosis.