Management approach to an extracranial internal carotid artery aneurysm

Abstract

This patient is an 84-year-old female who presented with left-sided facial swelling and complaints of tightness in her throat for the past few months. On examination, she was noted to have a pulsatile mass in her left pharyngeal space. The patient denied any history of trauma or surgery to her left neck. She denied any cerebrovascular symptoms or history of recent fevers. Computed tomography revealed an extracranial internal carotid aneurysm (B). We performed a carotid arteriogram confirming a large saccular aneurysm at the very distal segment of the extracranial left internal carotid artery (C). Rotational angiography with three-dimensional reconstruction was performed to better visualize the exact anatomy (A and D). Given the tortuosity of the proximal common carotid artery and the internal carotid just proximal to the aneurysm, we did not believe a covered stent could be safely advanced to the area of concern. After consideration of endoluminal options and open repair, we proceeded with open surgical clipping of the aneurysm with 11.420-mm standard cerebral aneurysm clips. Though mandibular disarticulation can augment exposure of this segment of the carotid artery, it was not necessary in this case as we were able to expose the base of the aneurysm adequately. The patient’s recovery was uneventful. Extracranial carotid aneurysms are rare and have a relative incidence of about 1.25% among all peripheral aneurysms. Etiology is usually infection, atherosclerotic disease, trauma, dissection, previous carotid surgery, or connective tissue and vasculitis disorders. Devastating complications include hemorrhage and stroke, but the most common presenting symptoms are pain, a pulsatile mass in the neck or pharynx, or cranial nerve palsies. Treatment options depend largely on the aneurysm location and anatomy. Operative options are clipping, resection with patch repair, or resection with bypass. Endoluminal treatment by coil embolization or covered stent placement has also been described and is being employed with greater frequency. Though these newer options have shown promise, associated complications have also been reported and long-term results of these treatment modalities are not available. Treatment should, therefore, be individualized to the patient’s anatomy and overall medical condition.