Early Intracerebral Hemorrhage Complicating the Successful Occlusion of a Carotid-cavernous Fistula

A 74-year-old woman with a direct carotidcavernous fistula secondary to aneurysm rupture was treated by endovascular balloon occlusion of the fistula. Two days later, she suffered an intracerebral hemorrhage ipsilateral to the treated carotid cavernous fistula, perhaps due to normal perfusion pressure breakthrough. Normal perfusion pressure breakthrough has been described as a cause of hemorrhage following treatment of arteriovenous malformations (1) and carotid stenosis (2,3). We report an unusual case of therapeutic endovascular occlusion of a direct carotid-cavernous fistula complicated by hemorrhage presumably caused by normal pressure perfusion breakthrough.