Surgical Trapping With Revascularization of Concomitant Cervical and Petrous Internal Carotid Artery Aneurysms: 2-Dimensional Operative Video.

Abstract

Petrous internal carotid artery (ICA) aneurysms are rare, complicated lesions to treat. The management paradigms include observation, endovascular exclusion, or surgical trapping with or without revascularization. The case described in this video involved a 67-yr-old woman with a known history of chronic lymphocytic leukemia, who presented after a mechanical ground-level fall. Clinically, she had a nasal deformity and resolving epistaxis consistent with mild facial trauma. Computed tomography (CT) revealed a comminuted nasal bone fracture and an incidental 3-cm right petrous ICA aneurysm. Subsequent vascular imaging demonstrated a concurrent 1.5-cm right cervical ICA dissecting pseudoaneurysm. Flow diversion with a Pipeline stent (Medtronic, Dublin, Ireland) was unsuccessful because the aneurysm's size precluded microcatheter selection of the ICA distal to the lesion. When the patient did not tolerate balloon test occlusion of the ICA, we proceeded with surgical trapping of both aneurysms and high-flow extracranial-to-intracranial bypass. The patient underwent a right frontotemporal craniotomy and an external carotid artery-to-frontal M2 middle cerebral artery bypass with a radial artery graft. Following a clinoidectomy, an aneurysm clip was applied to the paraclinoid ICA, and the cervical ICA was ligated just distal to the bifurcation, effectively trapping both aneurysms. The patient tolerated the procedure well. Postoperatively, she experienced symptomatic hypotension requiring vasopressor therapy and a transient partial oculomotor palsy that resolved during her hospital course. She was discharged home without neurological sequelae. Postoperative CT angiography demonstrated complete exclusion of the ICA aneurysms and a patent radial bypass graft after surgery and at 6-month follow-up. The patient provided consent for publication.