| Summary: | Background and importance: Iatrogenic Direct carotid-cavernous fistulas (CCFs) are uncommon complications of intracranial endovascular rescue. We describe the first reported case of an intraprocedural direct carotid cavernous fistula that developed immediately after flow restoration during treatment of an acute left M1 occlusion utilizing a stentriever. Clinical presentation: This was an 86 year old right handed Caucasian woman who presented with acute onset of aphasia, right sided weakness, and right facial droop. The time of onset was unknown. NIHSS scale on arrival to the ED was 16. Stroke protocol CT Perfusion imaging demonstrated a large region of ischemic penumbra within the left MCA distribution. Occlusion of the left M1 segment with collaterals to a limited number of opercular, insular, and cortical branches was noted on CT Angiography. Successful TICI 3 endovascular rescue of the left M1 occlusion was obtained. Later attempts at embolizing the iatrogenic left CC Fistula were abandoned for patient safety. Conclusion: While CCFs are not life threatening, the morbidity from ocular complications can be high. Each Carotid Cavernous Fistula should be reviewed as a unique case and the optimal treatment should be selected to decrease risk to the patient. Careful Endovascular navigation and device deployment of the retriever under full inspection of the roadmap may prevent or reduce the incidence of direct CCFs; however, sometimes it may become necessary to choose the potential complication to save a patient's life as was the case described in this report. Keywords: Iatrogenic Direct carotid-cavernous fistulas, CCF, Intracranial endovascular rescue, Stentriever, Stroke, Mechanical embolectomy
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