ArticleJournal of neuroendovascular therapy2026
Delayed Rupture Presenting as Direct Carotid-Cavernous Fistula after Flow Diversion for a Cavernous Internal Carotid Artery Aneurysm with Enlarging Blebs: A Case Report.
Article in Journal of neuroendovascular therapy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Objective: This study aimed to report a case of delayed rupture presenting as a direct carotid-cavernous fistula following flow diversion for a cavernous internal carotid artery aneurysm with enlarging blebs. Case Presentation: An 82-year-old woman with a progressively enlarging right cavernous internal carotid artery aneurysm and 2 enlarging blebs underwent flow diversion using a Pipeline embolization device (Medtronic, Irvine, CA, USA) under dual antiplatelet therapy. On postoperative day 1, diffusion-weighted MRI revealed a small right corona radiata infarction causing mild disorientation and left hemiparesis; the patient remained ambulatory. On postoperative day 6, she developed pulsatile tinnitus without headache. 3D-CTA and cerebral angiography revealed rupture of a neck-adjacent bleb, with the formation of a new direct carotid-cavernous fistula (Barrow type A). Because a balloon occlusion test performed prior to flow-diverter treatment demonstrated intolerance to parent artery occlusion, parent artery sacrifice was considered infeasible. A microcatheter was advanced transvenously into the cavernous sinus and subsequently into the aneurysm sac through the rupture site and coil embolization was performed, resulting in a marked reduction in shunt flow with disappearance of cortical venous reflux. The patient was transferred to a convalescent rehabilitation hospital for rehabilitation of left hemiparesis and was discharged home 3 months after onset with a modified Rankin Scale (mRS) score of 1. Conclusion: Even extradural cavernous internal carotid artery aneurysms may undergo delayed rupture following flow-diverter placement. In aneurysms with enlarging blebs, careful early surveillance is warranted, and transvenous intra-aneurysmal embolization may be an effective alternative when parent artery occlusion is not feasible.
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