Traumatic Carotid Cavernous Fistula with a Connection between the Supraclinoid Internal Carotid Artery and Cavernous Sinus via a Pseudoaneurysm Presenting with Delayed Life-threatening Epistaxis

Traumatic carotid cavernous fistula (CCF) presents most commonly as a direct connection between the cavernous segment of internal carotid artery (ICA) and cavernous sinus (CS), and often accompanies basal skull fracture (BSF). The most frequently reported signs and symptoms are proptosis, chemosis, and bruit. Epistaxis is uncommon symptom of CCF. A 63-year-old man with a history of BSF due to blunt head trauma eight months previously was referred to our emergency room for massive epistaxis. Cerebral angiography demonstrated a high-flow CCF with a connection between the supraclinoid portion of left ICA and CS via a pseudoaneurysm, suggesting the life-threatening epistaxis had been caused by high-flow shunting, through the gap created by the BSF. After the complete obliteration of the pseudoaneurysm arising from the supraclinoid ICA by stent-assisted coil embolization, the CCF was no longer evident and epistaxis ceased. To the best of our knowledge, this is the first case of a traumatic CCF with a connection between the supraclinoid ICA and CS via a pseudoaneurysm, presenting with delayed life-threatening epistaxis.