Bilateral Intracavernous Carotid Artery Aneurysms Research Articles

両側内頚動脈海綿静脈洞部脳動脈瘤に対してバイパス術を併用した母血管閉塞および血管内治療にて両側とも治癒せしめた1例

Aneurysms arising from the intracavernous carotid artery account for 3-5% of all intracranial aneurysms. Bilateral intracavernous carotid artery aneurysms are rare, and there are few reported cases that have been treated surgically. Here, we present the case of a 65-year-old woman with bilateral giant and large aneurysms, who was successfully treated with surgery for bilateral aneurysms. The patient presented with progressive left oculomotor and abducens nerve palsies, and magnetic resonance imaging (MRI) showed bilateral intracavernous mass lesions. Cerebral angiography revealed left giant and right large aneurysms at the intracavernous carotid artery. As a treatment for the symptomatic left aneurysm, balloon test occlusion (BTO) of the left internal carotid artery (ICA) was performed using 15O gas positron emission tomography (PET). The PET study during the BTO showed slightly decreased cerebral blood flow (CBF) in the left hemisphere, without any neurological symptoms. Therefore, left ICA proximal ligation with low-flow bypass was performed. Just after the treatment, thrombosis of the aneurysm began, and the left cranial nerve palsies gradually improved. Three months after the surgery for the left aneurysm, the right aneurysm was treated by using endovascular coil embolization with a stent assist. The postoperative course was uneventful, and the PET study performed 6 months after surgery showed normal CBF, even in the left hemisphere. Bilateral intracavernous carotid artery aneurysms are rare, and surgical treatment is controversial because there is no strict indication for the treatment. However, surgical treatment for patients with progressive symptoms should be considered carefully.

Bilateral Intracavernous Carotid Artery Aneurysms Presenting as Diplopia in a Young Patient

Introduction. Bilateral intracavernous carotid artery aneurysms (ICAAs) are extremely rare and difficult to treat. Case Report. A 26-year-old female presented in our clinic with acute diplopia due to oculomotor nerve palsy on the left side. Magnetic resonance imaging of the brain showed two heterogeneously enhanced masses indicating bilateral ICAA. An endovascular coil embolization was performed on the left side successfully, resulting in resolution of her symptoms. Conclusion. Thorough systemic evaluation in young patients with diplopia can reveal life-threatening underlying pathology and prevent major complications.

Bilateral abducens nerve palsy by compression from bilateral anterior inferior cerebellar artery

Isolated abducens nerve palsy affects patients with various pathological conditions, including head trauma, brain tumor, and infection. Systemic conditions such as diabetes mellitus or hypertension are also risk factors for abducens nerve palsy and may cause ischemic neuropathy [1]. Furthermore, compression by vascular abnormalities such as dolichoectatic arteries or aneurysms may induce abducens nerve palsy at its long extracerebral segment [2–7]. However, bilateral cases of isolated abducens nerve palsy are rare. Such cases have been reported in patients with ruptured aneurysms of the anterior communicating [8] or vertebrobasilar artery [9, 10], bilateral intracavernous carotid artery aneurysms [7], or subarachnoid hemorrhage without aneurysm [9]. Here, we report a case of bilateral isolated abducens nerve palsy due to compression by the bilateral anterior inferior cerebellar artery (AICA). A 75-year-old man developed diplopia without ocular pain 6 months earlier. He had undergone surgeries for gastric ulcer 33 years earlier and lung adenocarcinoma 9 years earlier. Follow-up for lung cancer revealed no evidence of relapse or metastasis. Two months earlier, diplopia worsened without other symptoms. Neurological examination revealed left ptosis, which had previously been identified. Additionally, there was complete right, and moderate left, abducens nerve palsy, but no abnormalities in pupil size, light reflex, and vertical eye movement (Fig. 1a). Laboratory tests showed slightly elevated glycosylated hemoglobin Alc level (6.6%; normal range: 4.3–5.8%), but normal erythrocyte sedimentation rate and thyroid function. Anti-acetylcholine esterase antibody and edrophonium tests were negative. Cerebrospinal fluid analysis showed a mild increase in protein content (50 mg/dL) and normal cell count (1 lymphocyte/lL) without malignant cells. Positron emission tomography/computed tomography scan revealed no abnormalities. Brain magnetic resonance (MR) imaging, including with gadolinium enhancement, showed no brainstem or cavernous sinus lesions. MR angiography demonstrated dolichoectatic basilar and left vertebral arteries (Fig. 1b). MR 3D heavy T2-weighted imaging showed stretching of the right abducens nerve by the right AICA (Fig. 1c) and compression of the left abducens nerve at the point of its exit zone by the left AICA (Fig. 1d). The condition improved slightly over 4 months, and there was no evidence of focal or systemic recurrence of lung cancer at 25 months after the onset of diplopia. An anatomical study showed that the ventral surface of the abducens nerve was crossed by the AICA in 75% of autopsied brains and that, in the majority of cases, the AICA was in contact with the abducens nerve [11]. Another study showed the AICAs or their branches were in contact with it in all cases of 44 hemispheres, and pierced in 11.4% [12]. In this patient, the left vertebral artery and basilar arteries were dolichoectatic with a deviation to the right, and the bilateral abducens nerves were compressed by the A. Taniguchi (&) Y. Ii H. Tomimoto Department of Neurology, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan e-mail: a2005t@clin.medic.mie-u.ac.jp

Bilateral intracavernous carotid artery aneurysms presenting as progressive cranial nerve palsies

Bilateral intracavernous carotid artery aneurysms are rare and can present with different clinical findings. We report such a case presenting with progressive cranial nerve palsies due to gradual increase in the size of aneurysms. This case demonstrates the clinician’s difficulty in diagnosis when isolated cranial nerve palsy is the sole presenting sign.

Massive recurrent epistaxis from non-traumatic bilateral intracavernous carotid artery aneurysms.

Recurrent epistaxis may rarely follow traumatic intracavernous carotid artery aneurysm. This occurs nearly always after head injury and is usually associated with fracture of the skull base. Severe torrential epistaxis due to non-traumatic intracavernous carotid artery aneurysm is extremely uncommon and potentially fatal, with only a few cases having been reported in the literature. We present the case of a 23-year-old female with a history of recurrent severe epistaxis and otalgia due to bilateral intracavernous carotid artery aneurysms, illustrating the diagnostic difficulties. The radiological investigations and the management of the patient are discussed and relevant literature is reviewed.

Multiple “mirror” aneurysms involving intracavernous carotid arteries and vertebral arteries: case report

BACKGROUND Bilateral intracavernous carotid artery aneurysms are rare. Moreover, the proportion of vertebrobasilar aneurysms in association with multiple aneurysms is extremely low. We describe a rare case of “mirror” aneurysms on the bilateral intracavernous carotid and bilateral vertebral arteries. CASE DESCRIPTION A 54-year-old male suffered from ophthalmic pain and oculomotor palsy on the left side. Cerebral angiography disclosed a giant left cavernous aneurysm and large asymptomatic aneurysms on the right intracavernous carotid artery and bilateral vertebral arteries. The cavernous sinus syndrome on the left side was successfully treated by left carotid artery ligation. However, 2 years later, severe subarachnoid hemorrhage (SAH) occurred. Computed tomography revealed thick clots densely distributed in the basal cisterns and third and fourth ventricles, indicating that the SAH originated from one of the vertebral artery aneurysms. Consciousness disturbance progressed rapidly, leading to cardiopulmonary arrest. CONCLUSION The literature contains no case of mirror intracranial aneurysms involving both intracavernous carotid and vertebral arteries. Multi-staged surgical techniques with optimal combinations of direct clipping, ligation or trapping, and endovascular embolization may be essential for patients with multiple aneurysms to avoid SAH.

Aneurysms of the Intracavernous Carotid Artery: Clinical Presentation, Radiographic Features, and Pathogenesis

Thirty-seven patients with 44 intracavernous carotid artery aneurysms (ICCAAns) were seen at one institution from 1976 through 1988. Fifteen patients had multiple intracranial aneurysms and 7 had bilateral ICCAAns. Age at diagnosis ranged from 15 to 80 (median 61). Thirty patients were women. Sixteen had a history of hypertension. In 34% of patients the ICCAAns were asymptomatic at diagnosis, 36% were associated with headache, and 57% had associated signs or symptoms of mass effect including sixth nerve paresis (43%), trigeminal pain or sensory loss (32%), third nerve paresis (20%), decreased vision or visual field cut (18%), fourth nerve paresis (16%), and Horner's syndrome (7%). In 4 patients the ICCAAns ruptured, leading to subarachnoid hemorrhage in 3 and epistaxis in 1. Two patients with ICCAAns were seen with spontaneous thrombosis of the ipsilateral internal carotid artery leading to distal ischemic symptoms in 1. More than 90% of the ICCAAns were saccular. Thirty-four percent were small (less than 1 cm), 48% were large (1 to 2.5 cm), and 16% were giant (greater than 2.5 cm). The majority arose from the anterior genu of the intracavernous internal carotid artery, followed in frequency by the horizontal segment, and then the posterior genu. Magnetic resonance imaging is superior to computed tomography for diagnosing ICCAAns and is the screening procedure of choice. Angiography remains the "gold standard" for diagnosis and determining specific anatomic details necessary to plan therapy. Analyzing the radiographic anatomy of 44 ICCAAns. we conclude that theories attributing the origin of aneurysms to arterial bifurcations may be inadequate to explain the point of origin and direction of take off of up to one-fourth of ICCAAns.

Diagnosis of bilateral intracavernous carotid artery aneurysms by computed tomography

Unruptured bilateral intracavernous carotid artery aneurysms are very rare. Within the last 30 years only five cases have been diagnosed radiologically and reported in the medical literature. We wish to add an additional three cases diagnosed during life by computed tomography and confirmed by angiography.