Endovascular management of a complex intracranial internal carotid artery dissection in an adolescent

• Internal carotid artery dissection with carotid-cavernous fistula and ophthalmic artery pseudo-aneurysm
• Few similar lesions described in the literature
• Endovascular parent vessel occlusion undertaken. Details of treatment are described.
• Evidence guiding treatment of complex intracranial dissections is limited
• Justification for parent vessel sacrifice in the face of increasingly complex stenting, coiling, and surgical solutions.

BackgroundBlunt cerebrovascular injury is an important cause of morbidity and mortality following head trauma. Intracranial vessel dissections, carotid-cavernous fistulae, and pseudo-aneurysms are uncommon traumatic vascular lesions with limited evidence to guide endovascular management.Case descriptionWe describe the case of a sixteen year old male patient suffering a traumatic paraclinoidal internal carotid artery (ICA) dissection with carotid-cavernous fistula and ophthalmic artery pseudo-aneurysm. Repeat angiography demonstrated worsening dissection prompting an endovascular parent vessel sacrifice following a passed balloon test occlusion. Relevant imaging is included.ConclusionsAmongst new and developing stenting technologies as well as complex surgical solutions, utilizing a modern endovascular adaptation of simple Hunterian ligation to treat a complex multi-pronged pathology may in some cases represent the best available option. Given the limited published literature, our diagnostic and treatment approach may be informative to clinicians as well as inform an evidence based management approach in similar complex intracranial vascular injuries.