title: Urgent treatment of severe symptomatic direct carotid cavernous fistula caused by ruptured cavernous internal carotid artery aneurysm using high-flow bypass, proximal ligation, and direct distal clipping: Technical case report.
abstract: BACKGROUND
  Direct carotid cavernous fistula (CCF) secondary to ruptured carotid cavernous aneurysms (CCAs) is rare, but patients with this condition who develop acutely worsening and severe neuro-ophthalmic symptoms require urgent treatment. Endovascular methods are the first-line option, but this modality may not be available on an urgent basis.
  
  
  METHODS
  In this article, we report a 45-year-old female with severe direct CCF due to rupture of the CCA. She presented with intractable headache and acute worsening of double vision and visual acuity. Emergent radiographic study revealed high-flow fistula tracked from the CCA toward the contralateral cavernous sinus and drained into the engorged left superior orbital vein. To prevent permanent devastating neuro-ophthalmic damages, urgent high-flow bypass with placement of a radial artery graft was performed followed by right cervical internal carotid artery (ICA) ligation and the clipping of the ICA at the C3 portion, proximal to the ophthalmic artery. In the immediate postoperative period, her symptoms resolved and angiography confirmed patency of the high-flow bypass and complete occlusion of the CCF.
  
  
  CONCLUSIONS
  With due consideration of strategy and techniques to secure safety, open surgical intervention with trapping and bypass is a good treatment option for direct severe CCF when the endovascular method is not available, not possible, or is unsuccessful.
authors.affiliation: Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya shi, Shizuoka 418-0021, Japan.
authors.forename: Hirotaka
authors.initials: H
authors.lastname: Hasegawa
authors.affiliation: Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya shi, Shizuoka 418-0021, Japan.
authors.forename: Tomohiro
authors.initials: T
authors.lastname: Inoue
authors.affiliation: Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya shi, Shizuoka 418-0021, Japan.
authors.forename: Akira
authors.initials: A
authors.lastname: Tamura
authors.affiliation: Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya shi, Shizuoka 418-0021, Japan.
authors.forename: Isamu
authors.initials: I
authors.lastname: Saito
keywords: Carotid cavernous aneurysm; carotid cavernous fistula; high-flow bypass; intracranial aneurysm