The patient was operated by me 15-January-2015 for complete occlusion of the right ICA for repeated CVA attacks with left sided plegia. The patient came for follow up and MRA of the carotids performed 03-March-2015 showed acceptable circulation of the right ICA with improvement of the patient neurologic status. The patient then came 07-March-2019 telling that he got enlargement under the old incision site pulsating  with pain at the lesion for the last 10 days. The patient was neurologically free. He was sent for investigations. MRA of the carotids showed pseudo-aneurysm with dissection 16.8x7.4 mm at the right ICA with clot 41.5x21.4 mm multilobulated lateral to the artery. The right extracranial ICA is not seen but the cross circulation is filling the right infraclinoid, clinoid, supraclinoid, M1 and A1 from the left side.

The patient then came 01-May-2019 with oozing of the mass after manipulation by a doctor. The patient was advised to keep in conservative treatment. The patient then came 03-November-2019 telling that yesterday, he progressed loss of vision right eye for 30 minutes then recovered. He has small clot at the most upper anterior edge of the previous incision. He told me that all the period the wound was quite, and subcutaneous mass appeared at the center of the incision. It was pulsating, for what another MRI investigation was performed and MRA of the right carotid was showing an aneurysm at the bifurcation of the CCA. The patient was advised to stop plavix and baby aspirin and try conservative treatment. The patient then came to the emergency of Shmaisani hospital, transferred from other hospital after resuscitating him from massive bleeding with hypovolimic shock. When I saw him, he was alert and the bleeding was stopped and advised to have blood transfusion with FFP to prepare him to surgery. Before transfusion the Hb was 10.7 mg/dL.

The old incision was extended down to expose the right CCA. The vagus nerve was separated and the CCA was circumscribed by rubber to protect it in case of urgent escalation of complications. Using Inomed ISIS Neuroexplorer with SEP protocol for both hands, the activity of the brain was monitored during all stages of surgery. A clamp was applied to the right CCA without complication. Angiography of the right CCA was performed and the branches of ECA were seen. Step-wise upward dissection of the CCA until the graft was seen There was a huge clot over the upper and anterior border of the graft. The clot was removed and the defect of the graft which was located upper medial was seen. Massive bleeding took place from the back flow of the right ECA. Using nylon 4 zero the defect was repaired. The bleeding stopped and the clamp was removed from the right CCA. No active bleeding. Routine closure of the wound.

Smooth postoperative recovery. He was sent to the ward. The patient is neurologically free walking after 5 hours of surgery.

This case in one of the most challenging and difficult to perform.

ISIS SEP is an important part of surgery to know the condition of the brain after clamping of the CCA.

Anesthesia protocol is an important part to make the patient wake during surgery and to see the movement of the left upper and left lower limbs.

Angiography was important to evaluate the back flow of the right ECA. In this case, retrospectively, ligation of the CCA will not resolve his problem, and massive back flow of the right ECA will trigger second bleeding attacks.

Exploration of the defect and removing the clot and repairing the defect with 4 zero nylon, not only resolved the essential problem, but also made unnecessary to legate the right CCA.