BMJ Case Reports 2017; doi:10.1136/bcr-2017-219662
  • Novel treatment (new drug/intervention; established drug/procedure in new situation)

Staged curative treatment of a complex direct carotid-cavernous fistula with a large arterial defect and an 'oversized' internal carotid artery

  1. Geoffrey P Colby1
  1. 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2Department of Neurosurgery, University of California Irvine School of Medicine, Irvine, California, USA
  1. Correspondence to Dr Geoffrey P Colby, gcolby1{at}
  • Accepted 2 June 2017
  • Published 14 June 2017


This is a case of a high-flow, post-traumatic direct carotid-cavernous fistula with a widened arterial defect and a large-diameter internal carotid artery (ICA). The unique aspect of this case is the oversized ICA, >8mm in diameter, which is both a pathological and a therapeutic challenge, given the lack of available neuroendovascular devices for full vessel reconstruction. We present a planned two-stage embolisation paradigm for definitive treatment. Transarterial coil embolisation is performed as the first stage to disconnect the fistula and normalise flow in the ICA. A 3-month recovery period is then allowed for reduction in carotid diameter. Repair of the large vessel defect and pseudoaneurysm is performed as a second stage in a delayed fashion with a flow-diverting device. Follow-up angiography at 6 months demonstrates obliteration of the fistula and curative ICA reconstruction to a diameter <5mm.


  • Contributors GPC conceived the manuscript. GPC and MTB performed data acquisition. All authors contributed to data analysis, drafting of the manuscript and critical analysis of the manuscript. All authors approved the final version of the manuscript.

  • Competing interests GPC: Participates in clinical trials for Medtronic, Stryker and MicroVention. Consultant for MicroVention. ALC: Participates in clinical trials for Medtronic and Microvention. Consultant and proctor for Medtronic, Stryker and MicroVention. LML: Participates in clinical trials for Medtronic and Stryker. Proctor for Medtronic.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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