BACKGROUND : Epistaxis is a rare presentation of the ruptured cavernous carotid aneurysm, especially the nontraumatic type. Both endovascular therapies and open surgeries have a role in the treatment with various outcomes, but the standard procedure is not well established. We report a successful high-flow bypass with cervical internal carotid artery ligation for aneurysm repair and review the related literature. METHODS : An 81-year-old man presented with massive epistaxis from the left nostril. The epistaxis was controlled by nasal packing. A saccular aneurysm of the cavernous segment of the left internal carotid artery projecting into the sphenoid sinus was revealed using computed tomography angiography. We treated this patient with high-flow bypass with ligation of the cervical internal carotid artery. Immediate postoperative computed tomography angiography showed complete disappearance of the aneurysm. Nasal packing was removed without further bleeding. No neurological deficit or complications were detected in the postoperative period. CONCLUSIONS : In cases of massive or recurrent epistaxis without coagulopathy or nasal pathology, a cavernous carotid aneurysm should be considered. Immediate cessation of the bleeding is necessary. Flow-preservation bypass with proximal ligation of the parent artery is 1 of the effective procedures for the treatment of this condition with low morbidity.