Repeated Transient Ischemic Attacks Due to Cavernous Sinus Meningiomas and Associated A1 Radiation-Induced Vasculopathy: Report of a Case

Abstract

Stenosis and thrombosis of the cavernous ICA is well known in cavernous sinus meningiomas. Ischemic events following ICA thrombosis are rare because of the slow process of ICA stenosis and the progressive vascular supply provided by the circle of Willis. We report a case of a patient who developed repeated episodes of cerebral infarction due to left cavernous sinus meningiomas with ICA thrombosis and radiation-induced stenotic change of the left A1 segment. A 56-year-old woman with left intracavernous sinus meningiomas presented with a sudden onset of upper right arm paresis that recovered in 24 hours. She was treated 34 months prior to admission with fractionated stereotactic radiotherapy (50.4 Gy). The MRI size of the left cavernous sinus meningiomas was stable compared with the MRI performed before radiotherapy. However, a complete ICA thrombosis was detected. Several lacunar infarcts were identified in the left hemispheric white matter. Angiogram confirmed intracavernous ICA thrombosis and revealed isolated stenosis and irregularities of the left A1 segment immediately above the tumor, suggesting a radiation-induced vasculopathy. There was no filling of the posterior communicating artery. SPECT and measure of the vasoreactivity using perfusion of acetazolamide revealed a reduced perfusion capacity in the left hemisphere. The patient had no history or clinical or radiological signs of heart and vascular disease that could predispose to cerebrovascular disease. An EC-IC bypass between the left common carotid artery and the M2 segment of the left MCA using the radial artery was performed with good patient recovery.