Ruptured Saccular Cavernous Carotid Aneurysm Presenting as a Rare Cause of Epistaxis: A Case Report and Comprehensive Literature Review

Introduction: Cavernous carotid aneurysm (CCA) is an uncommon pathological entity representing less than 2% of all intracranial aneurysms. Non-traumatic CCAs are extremely rare causes of epistaxis. Here we describe our experience in managing a left cavernous carotid aneurysm presented with massive recurrent life-threatening epistaxis.

Methods: A 71-year-old right-handed woman with a history of hypertension, type II diabetes, dyslipidemia, and a previously clipped right middle cerebral artery aneurysm (26 years ago) presented with multiple episodes of epistaxis and syncopal attacks over three days. Initial nasal packing controlled the bleeding, and blood tests revealed anemia requiring transfusion. Computed Tomography (CT) showed no subarachnoid hemorrhage, while Computed Tomography Angiography (CTA) identified a 7x7x5 mm saccular aneurysm on the left internal carotid artery (ICA), extending into the left sphenoid sinus, along with downstream stenosis.
Admitted to the ICU due to hemodynamic instability, a cerebral arteriogram confirmed the aneurysm. Embolization with balloon-assisted coiling was performed, achieving complete occlusion of the aneurysm without complications. The patient was discharged on day 5.

Results: Seven days later, she experienced massive recurrent epistaxis requiring resuscitation at another hospital. Repeat CTA indicated a hyperdense sphenoid sinus with a cervical ICA occlusion. Stable and neurologically intact, she underwent diagnostic angiography confirming left ICA occlusion with adequate collateral flow.
After a multidisciplinary discussion, given the life-threatening recurrent bleeding, a vessel sacrifice of the left ICA was deemed necessary. Repeat cerebral angiogram confirmed good collateral flow. Coil embolization of the left ICA was performed using 10 platinum coils, ensuring complete obliteration of the aneurysm. Post-procedure angiography showed effective cross-flow to the left anterior and middle cerebral arteries. The patient was discharged three days later with intact neurological function.

Conclusion : In cases of massive epistaxis, non-traumatic CCA should be considered in the differential diagnosis. Balloon-assisted coiling is an effective initial treatment for aneurysm management, but complications such as recurrent rupture and subsequent ICA occlusion may necessitate additional interventions. This case highlights the potential need for vessel sacrifice as a life-saving measure when recurrent bleeding persists.