• Wang Ting, Seidu A Richard, Zhang Changwei, Wang Chaohua, and Xie Xiaodong.
• Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China.
• Medicine (Baltimore). 2019 Nov 1; 98 (48): e18184e18184.

RationaleDual aneurysms arising from the internal cerotic artery (ICA) is a very rare occurrence. Clinoid segment aneurysms (CSAs) are often seen at the carotid dural rings while cavernous carotid aneurysms (CCAs) are often a direct communication between the ICA and the cavernous sinus (CS). We present a case of complex concomitant occurrence of a CSA and a CCA complicated with delay aneurysmal rupture (DAR) resulting in carotid cavernous fistula (CCF) after our initial treatment of the patient with pipeline embolization devices (PLEDs) PATIENT CONCERNS:: We present a 64-year old female who we admitted at our institution due to one-year history of double vision. Neurological examinations were unremarkable.DiagnosisMagnetic resonance imaging (MRI) and computer tomography (CT)-scan revealed dual aneurysms on the ICA. Digital subtracting angiogram (DSA) confirmed a small CSA and a large CCA on the right ICA.InterventionsWe treated both aneurysms with PLED and subsequently observed DAR of CCA as a complication.OutcomesWe successfully occluded the fistula with ONYX (ev3, Irvine, CA) via the trans-venous approach.LesionsPLED was the best endovascular treatment option though DAR was inevitable. Although the trans-arterial approach may be the gold standard for the managing of CCF, the complex nature of our case made us opt for trans-venous approach. The trans-venous route is very appropriate for fistulas with complex parent arteries.

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