Endovascular management of carotid blowout syndrome is one of the most urgent experiences for a neurointerventionist who must make fast and critical decisions under suboptimal conditions. The patient is usually chronically ill and may be vitally unstable due to the bleeding. There is a lack of information on the vascular anatomy, and usually no premedication has been prescribed. Deconstructive parent vessel occlusion or reconstructive stent-graft placement can be endovascular options for treating carotid blowout syndrome with regards to the anatomy and collateral circulation [2-4]. An ischemic complication is a concern related to the endovascular treatment and may be related to hemodynamic insufficiency following deconstructive treatment or thrombo- embolic complications caused by the reconstructive treatment without sufficient pre/post antiplatelet medications [2]. Intra-procedural embolic stroke from migration of the embolic materials or thrombus formed during deconstructive treatment can be another potential complication as seen in this report [1].

Similar to the carotid stump syndrome, a thrombus formed from stasis of blood in the internal carotid artery (ICA) with distal migration by antegrade/collateral flow or migration of thrombus formed in the common carotid artery/external carotid artery (ECA) through ECA-ICA anastomosis can be potential mechanisms [1,5]. For prevention of this complication, ICA sacrifice from the level proximal to the ophthalmic artery to the site of carotid rupture may be considered to prevent potential petrocavernous ECAICA collateral flow related to thrombus migration. Some physicians advocate the use of dual lumen balloons for antegrade flow arrest during embolization [6].

In this study, endovascular management of an intracranial occlusion was complicated because the parent vessel was sacrificed. Thrombolytic drugs were not an option due to concerns of hemorrhage. In this regard, direct carotid puncture is a technique that has regained interest as a feasible intracranial access option for patients with a poor vascular anatomy [7]. Despite the added difficulties of an occluded proximal parent vessel (ICA) and the irradiated neck in this patient, the authors have successfully bailed out of a difficult situation by judiciously executing the carotid access technique under fluoroscopic guidance and achieving timely mechanical recanalization of the intracranial occlusion.