PMC4014831_01
MR angiography performed 5 years before admission revealed a right carotid cavernous aneurysm (15 mm in diameter)
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F1
She had a history of a right CCA (15 mm in diameter) [Figure 1] that was diagnosed at our hospital 5 years earlier when she presented with transient right third nerve palsy.
On the day of admission, MR imaging (a), right carotid angiogram (b), and CT (c) revealed an engorged right SOV (yellow arrows) due to direct CCF secondary to ruptured right CCA. Postoperatively, MR imaging (d), right carotid angiogram (e) and CT (f) revealed disappearance of the engorged SOV and no sign of CCF. White arrowheads indicate the patent radial artery graft
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F2
The fistula tracked toward the contralateral (left) cavernous sinus and drained into the left SOV [Figure 2a-c]. MR imaging revealed no significant cerebral infarction in the revascularized distal right ICA area and showed marked shrinkage of the formerly engorged left SOV [Figure 2d-f].
The upper picture is the final view of operation and the lower is its illustration. After removing the anterior clinoid process and opening the cavernous sinus, internal carotid artery was able to be trapped between cervical and C3 portion and the ruptured aneurysm got isolated from the circulation. Flow of the ipsilateral ICA was replaced with that of the ECA-RA-M2 bypass. The "insurance" STA-M3 bypass was performed to minimize ischemic damages during the RA-M2 bypass procedure
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F3
The C3 portion of the ICA was finally clipped [Figure 3].