Urgent treatment of severe subarachnoid hemorrhage caused by ruptured traumatic aneurysm of the cavernous internal carotid artery using coil embolization followed by superficial temporal artery-middle cerebral artery anastomosis: a case report

BACKGROUND: Traumatic aneurysm of the cavernous internal carotid artery (ICA) with extension into the subarachnoid space is associated with increased risk of fatality especially when it is accompanied by severe subarachnoid hemorrhage (SAH). Only cases of patients who survived the acute stage and who were treated in a delayed setting have been reported. There has been no successfully treated case immediately after an injury. CASE DESCRIPTION: We encountered a 48-year-old man who presented with dense SAH immediately after being involved in a motor vehicle accident. Emergent angiography revealed traumatic aneurysm of the left cavernous ICA with extension beyond the superior wall of the cavernous sinus into the subarachnoid space and concomitant direct high-flow carotid cavernous fistula. Detachable platinum coil occlusion of the cavernous ICA followed by superficial temporal artery-middle cerebral artery anastomosis on day 0 and aggressive therapy to SAH, including ventriculocisternal irrigation and drainage, was performed. The patient eventually made a good recovery. CONCLUSION: Considering the extremely poor prognosis and unstable nature of a ruptured traumatic aneurysm with extensive SAH in the acute stage, definitive and immediate prevention of rebleeding in conjunction with proper revascularization would be warranted, such as in the present case.