Intracavernous Carotid Aneurysm Research Articles

Case report of unilateral abducens nerve paresis: A common sign with an uncommon etiology

Sixth nerve paresis is a rare presentation of intracranial aneurysms. We report an uncommon case of unilateral sixth nerve paresis in a young adult as the main presenting feature of an intracavernous aneurysm. The patient presented with pain and double vision in the right eye for 1 month. Computerized Tomography scan brain done elsewhere was normal. Examination showed right sixth nerve paresis with sensory loss in the first and second divisions of the trigeminal nerve. We suspected a cavernous sinus lesion and conveyed the same to the radiologist who therefore did additional and appropriate imaging, which revealed an intracavernous carotid aneurysm. This case is unique as to the best of our knowledge, it is the first case of its kind reported from India.

Successful Endovascular Treatment for Recanalized Post-Traumatic Carotid-Cavernous Fistula

Carotid-cavernous fistulas (CCFs) are spontaneous or acquired communications between the internal carotid artery (ICA) and the cavernous sinus, which can be classified as direct or indirect. Direct fistulas between the ICA and the cavernous sinus can arise from injury, rupture of intracavernous carotid aneurysm, collagen deficiency syndrome, artery dissection, fibromuscular dysplasia, and direct surgical trauma. The symptoms caused by CCF are related to their size, duration, location, the direction of venous outflow, and the presence of arterial and venous collaterals. The goal of treatment for direct CCFs is to close the defect between the ICA and the cavernous sinus while maintaining the patency of the ICA. This goal can be achieved either by transarterial fistula occlusion using a removable balloon, transarterial or transvenous occlusion of the ipsilateral cavernous sinus with coils or other embolic material, or by implanting a covered stent in the fistula area. The choice of a method for CCF treatment remains relevant. The paper describes a clinical case of successful endovascular treatment for post-traumatic recanalized CCF in a patient with obvious ophthalmic manifestations as pulsating exophthalmos, conjunctival chemosis, and ischemic optic neuropathy of the right eye. Previously, the patient had undergone endovascular CCF embolization with coils and ICA reconstruction with flow diverting stents. Fistula embolization was performed with coils via transvenous access. In the opinion of the authors, the use of venous access in this case allowed them to perform total occlusion of the recanalized fistula and to achieve good angiographic and clinical results in the long-term period.

Epidemiologic and anatomic aspects comparing incidental and ruptured intracranial aneurysms: A single centre experience

The feasibility of multicentric international data such as integrated in the PHASES score for patient counseling in unruptured intracranial aneurysms has recently been challenged. To determine, whether this data is applicable to local populations in a restricted catchment area, we performed a retrospective mono-centric analysis comparing patients with ruptured aneurysms to patients with incidental aneurysms. 200 patients with unruptured aneurysms and 197 patients after aneurysmal subarachnoid hemorrhage were analyzed for risk factors differing between the groups and to the general German population. Subgroup analysis was performed for 25 patients harboring multiple aneurysms, in 19 patients with intracavernous aneurysms and in 77 women of childbearing potential. While the preponderance of female patients was confirmed, significantly more men figured in the patient group with subarachnoid hemorrhage (36.4%) than among unruptured aneurysms (25%). Patients with bleeding events were significantly younger (51.6 years) than patients with incidental aneurysms (57.8 years). The rupture risk prediction of the PHASES score concerning aneurysm size below 7 mm and patient age over 70 years could not be confirmed, instead score points correlated to the clinical outcome after rupture. In our population, pregnant women were not overrepresented. Intracavernous carotid aneurysms contributed to the low risk profile of giant aneurysms. Thus, recommendations from pooled international data have to be adapted cautiously to local circumstances. We retained seven items with predictive value for outpatient counseling: age, smoking, hypertonus and concurrent vascular aberrations as patient characteristics and irregular shape, (increasing) largest diameter and the harboring vessel for the aneurysm.

Collaborative retrospective multicentre series of giant intracavernous carotid aneurysms

Giant intracavernous carotid aneurysms (GICCA) occur with very unusual clinical symptoms often resulting from a compressive mechanism that may possibly resolve although seldom from a rupture or haemorrhage. In fact, due to their clinical presentation their treatment is different from that of the intracranial subarachnoid aneurysms. The aim of this study was to analyze the clinical symptoms, therapeutic decisions, and the clinical state at 6months follow up in a retrospective consecutive multicentre series of 27 GICCA between 2004 and 2008. All the patients in the series were female, mean age 65 years (21 to 82 years). A pseudo tumoural cavernous sinus syndrome revealed the disease in 25 patients (92.6%), an atypical headache in one patient, and in another patient an intraoperative haemorrhage led to the diagnosis. In most of the cases the aneurysms were sacciform in shape (89%), with a size between 25 and 30 millimeters (66.6%) and contained a blood clot due to intrasacular thrombosis (57.5%). An occlusion test of the internal carotid artery was performed during the diagnostic angiography in 24cases (88.8%) and good tolerance of occlusion was observed in 16of them. An endovascular procedure was performed in 21patients (77.7%): selective coiling of the aneurysm facilitated by stenting or by remodeling techniques in 2 cases, whereas internal carotid artery occlusion was performed on the 19 other cases. Among these latter patients, 2 of them (10.5%) presented with a poor tolerance during the pre-therapeutic carotid occlusion test, necessitating a surgical intra-extra cranial by-pass prior to the carotid endovascular occlusion. In 1 other case of these 19, the internal carotid endovascular occlusion was carried-out in emergency because the aneurysm was revealed by a major haemorrhage during the surgical transsphenoidal approach of a hypophyseal tumour. No treatment was decided in the remaining 6 cases of the series (22.2%). At 6months follow-up, 18 of the 21 treated patients experienced a clinical recovery of their symptoms and 10 of them (50%) had a complete clinical recovery. Among the 6 untreated patients, 4 had a partial recovery but no complete recovery of oculomotor deficits was observed in this group of patients. No clinical worsening was observed in the entire series, neither among the treated patients nor among the untreated patients. In conclusion, this study underlines the need of a treatment for symptomatic GICCA in order to achieve a complete clinical recovery of the symptoms due to intracavernous compression, although only partial recovery may be expected from spontaneous evolution.

Endovascular Treatment of a Mycotic Intracavernous Carotid Artery Aneurysm Using a Stent Graft

Intracavernous carotid artery mycotic aneurysms are rare and management is determined by clinical presentation. We describe the first documented proximal intracranial mycotic aneurysm treated by a balloon expandable Aneugraft PCS covered stent. An 11-year-old female child presented with acute onset fever, headache, chemosis followed by diplopia, right-sided ptosis with ophthalmoplegia. Magnetic resonance imaging revealed bilateral cavernous sinus thrombosis. Subsequent work-up included serial computed tomographic arteriography and digital subtraction angiography which revealed a progressively enlarging intracavernous carotid aneurysm. An Aneugraft PCS covered stent was successfully deployed endovascularly, and complete exclusion of the aneurysm was achieved while maintaining the patency of the parent artery. The use of covered stents in intracranial vasculature can be an effective and safe treatment modality for exclusion of the mycotic aneurysm in selected cases.

Fatal rhinocerebral mucormycosis with intracavernous carotid aneurysm and thrombosis: a late complication of transsphenoidal surgery?

Mucormycosis is a rare opportunistic fungal infection. Rhinocerebral form of the disease mainly affects diabetic or immunocompromised patients. Mucormycosis have specific tropism for blood vessels leading to mucorthrombosis and less often to mycotic aneurysms. We report on a patient initially presenting with a severe sphenoid sinusopathy, who progressively evolved to cavernous sinus syndrome, internal carotid aneurysm followed by spontaneous thrombosis, chronic meningitis and ultimately fatal hypertensive hydrocephalus. Necropsy revealed a purulent infiltrate containing thin-walled, aseptate, right-angle branching, hyphae consistent with mucormycosis. His only relevant previous medical history was a transsphenoidal surgery for pituitary macroadenoma 21years before. We hypothesize that post-surgical mucosal changes in the sphenoid sinus have been a favoring factor for delayed and invasive mucor infection.

A Case of Intracavernous Carotid Aneurysm Presenting with Visual Loss with No Oculomotor Disturbance

A Case of Intracavernous Carotid Aneurysm Presenting with Visual Loss with No Oculomotor Disturbance

Delayed caroticocavernous fistula after stent-assisted coil embolization of intracavernous carotid aneurysm: should we manage conservatively?

Constructive endovascular techniques remain the mainstay for the treatment of cavernous carotid aneurysms due to their efficacy. However, they do harbor risks of complications, such as thromboembolic events, arterial injuries, and vessel occlusions. A 58-year-old lady presented with delayed caroticocavernous fistula (CCF) 1month after stent-assisted coil embolization of a cavernous carotid aneurysm (CCA). Following this, her caroticocavernous fistula resolved spontaneously with no further intervention. Our case demonstrates a unique presentation of a CCF as a delayed complication of stent-assisted coil embolization of CCA and the spontaneous resolution of the CCF. Symptomatic CCFs are commonly treated as an emergency in many institutions and the question arises as to whether we should adopt a conservative policy in the light of this case report.

Giant intracavernous carotid aneurysm with intraorbital extension: an unusual cause of unilateral proptosis

Giant intracavernous carotid aneurysm with intraorbital extension: an unusual cause of unilateral proptosis

Direct Carotid-Cavernous Fistula following Intracavernous Carotid Aneurysm Treatment with a Flow-Diverter Stent

A 39-year-old woman presented with a right intra-cavernous carotid aneurysm measuring 1.76 cm×1.33 cm. The aneurysm was treated with a self-expandable flow-diverter stent. Follow-up MRI showed normal flow in the internal carotid artery with partial thrombosis of the aneurysmal sac. Two weeks later, the patient developed a right direct carotid-cavernous fistula. The fistula was treated by transvenous route. We concluded that rupture of a previously unruptured aneurysm can occur after treatment with a flow-diverter stent.

Treatment strategy for intracavernous aneurysms of internal carotid artery: report of 13 cases with extracranio-intracranial bypass

Objective To analyze the indications and factors that influence the effectiveness of the treatment of intracavernous internal carotid aneurysms. Method From Oct. 2006 to Mar. 2010,13 cases of intracavemous internal carotid aneurysms were operated with EC - IC bypass, sacrifice of the internal carotid artery,and trapping of the aneurysms. The age of these patients was from 11 to 69 years old( median age 55). 12 patients were female. Only ones aneurysm was moderate,and the others were large or giant Results The bypass grafts were patent in 12 cases by post-operative DSA or CTA. One patient was reoperated but the bypass vessel was occluded finally. 8 cases had very good results without any neural deficit. 5 cases had severe complications such as hemiplegia,aphasia and coma. Of these 5 cases,2 recovered to GOS 4 finally, and 3 remained GOS 3. Thrombosis was found in all aneurysms in CT scan and disappearance of aneurysms was confirmed by CTA or DSA. Conclusions In conjunction with bypass surgery, IC A trapping constitutes an effective treatment strategy. With continued improvement of bypass techniques and perioperative care to decrease the occurrence of ischemic complications, the cure ratio will be elevated obviously in the future. Key words: Intracranial aneurysm; Internal carotid artery; Cavernous sinus; EC -IC bypass

REPAIR OF AN ALARMING INTRAOPERATIVE INTRACAVERNOUS CAROTID ARTERY TEAR WITH ANASTOCLIPS

Surgical treatment of an intracavernous carotid aneurysm (ICCA) is difficult because of the close relationship to bone, dura, and neurovascular structures. Intraoperative rupture of an ICCA is challenging, especially if the site of rupture is at the base of the aneurysm. We present a case of intraoperative rupture of an ICCA caused by clinoidectomy. We repaired it by using a single-clamp applicator (AnastoClip Vessel Closure System, 1.4 mm; LeMaitre Vascular, Burlington, MA). In April 2007, a 40-year-old woman underwent neurosurgical treatment at another institution for a ruptured basilar bifurcation aneurysm, with good recovery. Digital subtraction angiography performed at this time showed the presence of left internal carotid artery aneurysms, 1 at the anterior wall of the paraclinoidal segment and 1 at the lateral wall of the intracavernous segment. In February 2008, the patient was referred from outside Finland to our department for microsurgical treatment of both aneurysms. A lateral supraorbital approach was used, and during extradural removal of the anterior clinoid with a rongeur, the ICCA ruptured. The base of the intracavernous aneurysm was involved in the rupture, and we used a single-clamp applicator to repair the internal carotid artery. Intraoperative digital subtraction angiography, indocyanine green video angiography, and Doppler ultrasonography showed a good flow in the artery. The paraclinoid aneurysm was uneventfully clipped during the same intervention. Intraoperative rupture of ICCA was repaired quickly and effectively by using a single-clamp applicator. Our case and experimental data from other microsurgical vascular experiences suggest that the future of intracranial vessel repair/anastomoses will be using microclips and other simpler devices more, allowing the neurosurgeon to perform fast and effective vessel repair.

High-flow bypassおよび近位側結紮術後に再発をきたし遠位側クリッピングを要した海綿静脈洞部内頚動脈巨大動脈瘤の1例

71歳,男性.視力視野障害で発症した左海綿静脈洞部巨大内頚動脈瘤で,proximal ligationにhigh-flow bypassを併用し,術中および術後1ヵ月目に完全閉塞を確認した.しかし2ヵ月後に左動眼神経麻痺が出現し,high-flow bypassを介して動脈瘤の再増大を認めた.遠位側クリッピングを行って動脈瘤は完全閉塞し,症状は改善した.海綿静脈洞部巨大脳動脈瘤はproximal ligation+high-flow bypassが一般的な治療だが,今回のようにいったん閉塞した動脈瘤がbypassを介して再増大をきたすこともあるため,初回よりトラッピングが理想的と考えられた.

Giant intracavernous carotid aneurysm presenting as isolated sixth nerve palsy in an infant

Giant intracavernous carotid aneurysms (ICCAA) are extremely rare in the paediatric population. Ophthalmic symptoms from ICCAA are caused by pressure of the aneurysm wall on surrounding structures and depend on...

A potential catastrophic trap: an unusually presenting sellar lesion

A 63-year-old man was admitted to our emergency unit complaining headache, vomit and vertigo. A MR of the brain showed an expanding lesion within the sellar region. A subsequent angio-MR excluded any intracranial vascular malformations. Surprisingly, a cerebral angiography performed later on the basis of worsening of neurological signs and symptoms, demonstrated an aneurysm of the internal carotid artery. At the best of our knowledge, this is the first case of a thrombosis of an intracavernous carotid aneurysm mimicking a pituitary apoplexy documented by MR and angio-MR. The treatment of a milder syndrome of pituitary apoplexy is still controversial. This case would favour conservative treatment opposed to surgery at least when an intracavernous extension or invasion of the adenoma would limit the opportunity of a complete tumour removal.

Endovascular treatment for bilateral mycotic intracavernous carotid aneurysms

Bilateral mycotic aneurysms of the intracavernous segment of the internal carotid artery (ICA) are exceedingly rare. The authors present the case of a 46-year-old man with bilateral mycotic intracavernous carotid aneurysms, which were treated with a stent-assisted vessel wall remodeling technique with preservation of the parent arteries. The patient recovered quite satisfactorily after completing the whole course of treatment. Based on an extensive review of the literature, no reported case of bilateral mycotic aneurysm of the intracavernous segment of the ICA has been treated with this mode of endovascular therapy. This mode of treatment could be a therapeutic alternative for intracavernous mycotic aneurysms.

Resolution of cranial nerve paresis after endovascular management of cerebral aneurysms

Background This work aimed to study the outcome of endovascular (coiling and balloon occlusion) treatment in patients with aneurysmal mass effect (ophthalmoplegia due to third, fourth, or sixth CN paresis) and to compare it with the outcome of clipping (from the international literature). We looked at the outcome of endovascular treatment of CNP (third, fourth, and sixth) due to aneurysmal mass effect (PcomA aneurysms and intracavernous carotid aneurysms). Methods Between January 1999 and December 2004, 820 patients presented with aneurysmal SAH and/or mass effect. Eleven of these patients (1%) presented with third, and/or fourth, and/or sixth nerve dysfunctions and underwent endovascular treatment. The degree of the ophthalmoplegia was recorded at presentation, 2 months, 6 months, and yearly intervals thereafter. We correlated recovery of CNP to SAH, duration of the symptoms, degree of CNP, type of CNP, microvascular risks (age, diabetes mellitus, hypertension, and smoking), aneurysm size, and degree of coiling or balloon occlusion. Results The study showed a favorable outcome of endovascular treatment in the majority of patients. Resolution of CN dysfunctions occurred in 7 (64%) of 11 patients. The late follow-up showed that all the 7 patients are resuming normal life activities. This compares favorably to the results after clipping in [Leivo, Hemesniemi, Luukkonen, & Vapalahti, 1996] (41%). Presentation with SAH and isolated third CNP correlated with a better resolution of CNP ( P < .05). Conclusion Although mass effect remains after endovascular packing, CNP improves comparably to the recovery observed after surgical clipping. It seems likely that the decrease in aneurysmal pulsatility is responsible for the improvement of the CNP. The relatively atraumatic approach associated with endovascular management explains the favorable results. All previous reports assessed the outcome of only the third CNP after endovascular treatment in a very limited number of cases. To the best of our knowledge, this is the first study to assess the outcome of various CNP after endovascular treatment.

Ophtalmoplégie extrinsèque pure douloureuse du nerf moteur oculaire commun révélant un anévrysme de la carotide

In third cranial nerve palsy, the lack of mydriasis evokes a noncompressive mechanism. Case report. We report a case of a slightly painful, pure extrinsic third-nerve palsy, complete except for the partial ptosis secondary to the compression by an intracavernous carotid aneurysm. Percutaneous endovascular embolization was followed by complete regression of the palsy within 4 weeks. The pupil may have been spared by the mechanism of compression after the separation of the pupillomotor and extrinsic fibers or the ischemia of the third nerve by its arterial trunk lesion. This case report underlines that brain radiological explorations are necessary in some third-nerve pupil-sparing palsies.

Abducens Nerve Palsy and Postganglionic Horner Syndrome with or without Severe Headache

To report the clinical features of 9 patients with both abducens nerve palsy and postganglionic Horner syndrome. Nine patients with this symptom combination were examined by our Neuro-ophthalmology Clinic in Nihon University Itabashi Hospital between 1978 and 2004. Patient ages ranged from 28 to 63 years (average 47.2+/-8.7 years). Six patients were males and 3 were females. Primary diseases, accompanying symptoms and prognoses were surveyed. In primary diseases, neoplasm in the cavernous sinus was observed in 2 patients, sphenoidal sinus cyst in 2, intra-cavernous carotid aneurysm in 2, epipharynx carcinoma in 1, chordoma in the base of the skull in 1, and meningioma in the middle cranial fossa in 1. Five patients with extra-cavernous sinus lesions; sphenoidal sinus cyst, epipharynx carcinoma, chordoma and meningioma, complained of severe headache. However, in patients without severe headache, intra-cavernous sinus lesions such as carotid aneurysm and metastatic carcinoma were detected. After therapy, abducens nerve palsy improved in 5 patients, however, Horner syndrome persisted in all patients. We emphasize that this symptom combination is an important sign of lesions in the posterior portion of the cavernous sinus or in its vicinity. Moreover, the presence or absence of severe headache depends on whether the lesion is in the intra-cavernous or extra-cavernous sinus.

Evaluation of ketogenic diet efficacy in patients with refractory epilepsy

A comprehensive, computer-based, online search ofthe world literature on the 3 DTCA was performed(MEDLINE, LILACS, EMBASE, COCHRANE LIBRARY). Allprobable terms for 3DTCA were determined from ini-tial experience with the literature on the topic. Theseincluded “CT angiography”, “computerized tomograph-ic angiography”, “computerized tomography angiogra-phy”, “computer tomography angiography”, “comput-er tomographic angiography”, “three dimensional com-puted angiography”; the relevant terms used were“subarachnoid hemorrhage” e “aneurysm(s)”. The ini-tial criteria for inclusion in the systematic review werestudy design and examination methodology, imagereview process and presentation of result data.The results demonstrated that the 26 studies iden-tified by using this search, with total of the 1.483 intracra-nial aneurysms diagnosed through the digital subtrac-tion angiography and 1.391 (94%) of these diagnosedat the 3DCTA and the smaller size was 2mm. The intra-cavernous carotid aneurysms were the majority of thefalse negative results. In conclusion, the sensitivity of the 3DCTA was the95% as 100% by 63% these studies and the specificitywas the 95% as 100% by 50% these studies. The small-er size of the intracranial aneurysms diagnosed was 2mm, with the false negative cases more frequents werethe intracavernous carotid aneurysms(25%) because ofthe proximity with bone structures; the middle cerebralartery aneurysms (19%) because of the presence the loopsand posterior communicating artery aneurysms becauseof the infundibular dilatation. KEY WORDS:cerebral aneurysms, angiotomography.