Intracavernous Carotid Artery Aneurysm Research Articles

Cavernous Carotid Aneurysm Presenting as Direct Carotid-Cavernous Fistula with Contralateral Ocular Symptoms: A Rare Case Report

ABSTRACT Carotid-cavernous fistula (CCF) resulting from intracavernous carotid artery aneurysms is uncommon. However, if rupture does occur, it can lead to a CCF, which causes sudden onset of unilateral ophthalmoplegia. In this report, we present a case of a ruptured giant intracavernous carotid artery aneurysm leading to a direct CCF with contralateral ocular features. The aim is to discuss the distinctiveness of this case and the most challenging aspects of identifying similar cases. A woman in her sixties developed a sudden direct CCF, resulting in proptosis in the opposite eye. Magnetic resonance angiography revealed that the left cavernous sinus (CS) and superior ophthalmic vein were dilated, whereas the right side was unaffected. However, digital subtraction angiography (DSA) revealed a large aneurysm in the right cavernous internal carotid artery (ICA) and a direct connection between the right ICA and CS, with venous drainage exclusively occurring in the opposite direction via the intercavernous sinus. To address the issue, the aneurysm and fistula underwent Coil and Onyx embolisation, successfully closing the fistula and leading to a regression in the orbital symptom. This presents a unique scenario of an unexpected unilateral CCF with contralateral symptoms in a direct CCF, which demands immediate attention. It is crucial to remain alert for CCF and verify the diagnosis through DSA when dealing with such patients to avoid severe outcomes. Prompt identification and intervention can enhance the patient’s chances of a positive outcome.

Microsurgical Treatment of a Giant Intracavernous Carotid Artery Aneurysm in a Pediatric Patient. Case Report and Literature Review

Introduction: Intracranial aneurysms in pediatric age represent 4 - 5% of all cases, and 20% are giant (>25mm). The main sites of occurrence are ICA and MCA; about 55% - 72.5% of cases present rupture and secondary SAH with a 10% - 23% mortality. Case Description: We report the case of a previously healthy nine-year-old woman that initiated severe right retroocular pain and holocraneal headache. Her relatives detected paresis of the III, IV, and VI cranial nerves three days later. After evaluation, an MRI showed the presence of a giant aneurysm in the cavernous portion of the internal carotid artery (ICA) with a mass effect. The patient was treated surgically through a high-flow bypass using a radial artery graft and trapping of the aneurysm. The patient had an uneventful postoperative course and was discharged three days after the operation to continue in follow-up at the outpatient clinic. Discussion: The options for treatment are endovascular treatment through flow diverters or stenting and coiling, with the risk of incomplete occlusion or thrombosis. On the other hand, the goal of surgery is the permanent occlusion through the proximal closure of the ICA if a balloon occlusion test shows good collateral circulation or by trapping the aneurysm combined with a high-flow bypass if the collateral circulation is not good or absent. Conclusion: Even when the surgical option was successful in this case, there is no consensus about the best treatment; the selection of the method to use in these aneurysms depends on the center´s experience when confronting this rare entity.

A Case of Large Intracavernous Internal Carotid Artery Aneurysm with Acute Spontaneous Thrombosis and Parent Artery Pseudo-occlusion

A Case of Large Intracavernous Internal Carotid Artery Aneurysm with Acute Spontaneous Thrombosis and Parent Artery Pseudo-occlusion

An unusual presentation of “Mirror-Image” bilateral giant carotid cavernous aneurysms: Case report and review of the literature

The almost asymptomatic “mirror-image” bilateral giant intracavernous carotid artery aneurysms are not common and its successful conservative management without further neurological complications is rarely reported. We report a case of a 64-year-old woman, admitted with a rapidly progressive headache, with no other signs or symptoms associated. The Head CT-Scan shows bilateral parasellar round hyperdense lesions and the Magnetic resonance angiography discloses bilateral giant intracavernous carotid artery aneurysms in detail. The clinical presentation of these types of lesions depends on their mass effect on the surrounding neurovascular structures. So, possibly no mass effect on any structure, then no obvious expected symptoms. A patient with these conditions and without neurological deficit should not be rushed to surgery or endovascular treatment.

Intracavernous Internal Carotid Artery Aneurysm Presenting as Acute Diplopia: A Case Report

IntroductionDiplopia is an uncommon emergency department (ED) complaint representing only 0.1% of visits, but it has a large differential. One cause is a cranial nerve palsy, which may be from a benign or life-threatening process.Case ReportA 69-year-old female presented to the ED with two days of diplopia and dizziness. The physical exam revealed a sixth cranial nerve palsy isolated to the left eye. Imaging demonstrated an intracavernous internal carotid artery aneurysm. The patient was treated with embolization by neurointerventional radiology.DiscussionThe evaluation of diplopia is initially divided into monocular, usually from a lens problem, or binocular, indicating an extraocular process. Microangiopathic disease is the most common cause of sixth nerve palsy; however, more serious etiologies may be present, such as an intracavernous internal carotid artery aneurysm, as in the patient described. Imaging modalities may include computed tomography or magnetic resonance imaging.ConclusionSome causes of sixth nerve palsy are benign, while others will require more urgent attention, such as consideration of an intracavernous internal carotid artery aneurysm.

Bilateral Giant Opthalmic Carotid Artery Aneurysms Presenting as Unilateral Diplopia: A Case Report

Introduction: The etiology of giant aneurysms is multifactorial. It becomes symptomatic in 9/100.000, most frequently in the fifth and sixth decades of the life. Intracavernous carotid artery aneurysms (ICAAs) represent less than 1% of intracranial aneurysms and show a slight female predominance. Case-Report: We report an interesting case of bilateral ICAA in 42-year-old female presented as acute diplopia and emphasize the need of a thorough systemic evaluation in young patients with diplopia and treated with endovascular coil embolization. A 42-year-old woman was admitted to the neurology department suffering from the unilateral diplopia. Neurological examination showed the left sixth cranial nerve palsy and had no further general motor or sensory symptoms. Digital Subtraction Angiogram (DSA) showed bilateral ophthalmic artery aneurysm. The patient was treated with endovascular loose packing coil embolization and Derivo 3.5x30mm flow diverter stent. Conclusion: It should be kept in mind that intracavernous carotid artery aneurysms may be bilateral in patients with unilateral cranial nerve symptoms.

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.

Causes of isolated recurrent ipsilateral sixth nerve palsies in older adults: a case series and review of the literature.

PurposeThe etiology of recurrent isolated sixth nerve palsies in older adults has not been well described in the literature. Sixth nerve palsies presenting with a chronic, relapsing, and remitting course are uncommon, but can herald a diagnosis of high morbidity and mortality in the older population.Patients and methodsOur method was a retrospective case series study. A review of clinical records of 782 patients ≥50 years of age diagnosed with recurrent sixth nerve palsies was performed over a 10-year period from 1995–2005 in a neuro-ophthalmology clinic in Reno, Nevada. A review of the current literature regarding similar cases was also performed on PubMed.ResultsSeven patients ≥50 years of age with chronic, recurrent sixth nerve palsies were identified. Five were males and two were females. Four of seven (57%) patients had structural lesions located in the parasellar or petrous apex cavernous sinus regions. One of seven (14.29%) had a recurrent painful ophthalmoplegic neuropathy (International Headache Society [IHS] 13.9), previously termed ophthalmoplegic migraine; one of seven (14.29%) presented with an intracavernous carotid artery aneurysm; and one of seven (14.29%) presented with microvascular disease.ConclusionThe clinical presentation of an isolated recurrent diplopia from a sixth nerve palsy should prompt the neurologist or ophthalmologist to order a magnetic resonance imaging (MRI) scan of the brain with and without gadolinium as part of the initial workup to rule out a non-microvascular cause, such as a compressive lesion, which can increase morbidity and mortality in adults >50 years of age.

Giant thrombosed intracavernous carotid artery aneurysm presenting as Tolosa–Hunt syndrome in a patient harboring a new pathogenic neurofibromatosis type 1 mutation: a case report and review of the literature

Neurofibromatosis type 1 (NF1) is a relatively common single-gene disorder, and is caused by heterozygous mutations in the NF1 gene that result in a loss of activity or in a nonfunctional neurofibromin protein. Despite the common association of NF1 with neurocutaneous features, its pathology can extend to numerous tissues not derived from the neural crest. Among the rare cerebrovascular abnormalities in NF1, more than 85% of cases are of purely occlusive or stenotic nature, with intracranial aneurysm being uncommon. Predominantly, the aneurysms are located in the internal carotid arteries (ICAs), being very rare bilateral aneurysms. This report describes a very unusual case of fusiform aneurysms of both ICAs in a Caucasian NF1 patient, with a new pathogenic intragenic heterozygous deletion of the NF1 gene, presenting at age 22 years with Tolosa–Hunt syndrome, because of partial thrombosis of the left giant intracavernous aneurysm. Medical treatment with anticoagulant therapy allowed a good outcome for the patient. In conclusion, early identification of cerebral arteriopathy in NF1 and close follow-up of its progression by neuroimaging may lead to early medical or surgical intervention and prevention of significant neurologic complications.

Therapeutic conundrum after diagnosis of Foix–/INS;Jefferson syndrome caused by intracavernous aneurysm

Introduction: Intracavernous carotid artery aneurysms are usually symptomatic in the form of several neurological deficits based on their anatomic location. They are rarely associated with life-threatening complications, such as thrombosis and hemorrhage, commonly found in a ruptured form.

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.

Delayed Branch Retinal Artery Occlusion and Partial Oculomotor Nerve Palsy Following Coiling of a Giant Intracavernous Carotid Artery Aneurysm

Delayed Branch Retinal Artery Occlusion and Partial Oculomotor Nerve Palsy Following Coiling of a Giant Intracavernous Carotid Artery Aneurysm

Atypical Presentation of Cavernous Sinus Infection with Intracavernous ICA Aneurysm

In a typical presentation of intracavernous internal carotid artery aneurysm and cavernous sinus infection there is involvement of 3rd, 4th and 6th cranial nerves along with 2nd and 5th cranial nerve. Here we present a case of a 32years old male with unilateral mycotic intracavernous internal carotid artery aneurysm with a history of head injury. Atypical features in this case was involvement of distantly situated multiple cranial nerves and sparing the 5th cranial nerve and optic nerve which are more near and commonly involved. Besides this patient has marked sphenoid sinusitis on left side but having no sign and symptoms.

Spontaneous rupture of an intra-cavernous internal carotid artery aneurysm presenting with massive epistaxis

We report a rare case of epistaxis resulting from a ruptured internal carotid artery aneurysm, and present a successful treatment method. A 72-year-old woman was admitted following recurrent massive epistaxis. There was no history of trauma or surgery. Radiographic imaging demonstrated a large internal carotid artery aneurysm. An attempt was made to occlude the aneurysm with endovascular coils. Despite this, the patient went on to have further epistaxis. Endovascular ablation of the feeding internal carotid artery led to complete resolution. This case demonstrates that spontaneous epistaxis from intra-cavernous carotid artery aneurysms can be managed using endovascular techniques. To our knowledge, we report the first use of interventional radiological techniques to assess the collateral circulation to the brain and subsequently undertake endovascular ablation of the internal carotid artery.

Cavernous sinus syndrome from an internal carotid artery aneurysm in an infant with tuberous sclerosis

Aneurysms are associated with tuberous sclerosis complex. We describe the first case of cavernous sinus syndrome from an intracavernous internal carotid artery aneurysm in a 9-month-old boy with tuberous sclerosis. The presence of an intracranial aneurysm should be considered in the differential diagnosis of children with tuberous sclerosis who develop cranial nerve deficits.

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

Controlateral cavernous syndrome, brainstem congestion and posterior fossa venous thrombosis with cerebellar hematoma related to a ruptured intracavernous carotid artery aneurysm

Intracavernous carotid artery aneurysms (ICCAs) are rarely associated with life-threatening complications. We describe a 55-year-old woman who, after the rupture of an intracavernous carotid artery aneurysm, presented with a contralateral cavernous sinus syndrome and severe posterior fossa and spinal cord symptoms. Following parent artery occlusion, thrombosis of the posterior fossa and spinal cord veins caused a progressive worsening of the neurological status to a "locked-in" state. The patient fully recovered with anticoagulation therapy. Comprehension of the pathophysiological mechanism associated with the rupture of ICCA and early diagnosis of the related symptoms are essential in order to plan a correct treatment that includes the management of the aneurysm rupture and of possible complications related to venous thrombosis.

Pseudoaneurysm Formation following Intrasphenoid Rupture of an Idiopathic Intracavernous Carotid Artery Aneurysm: Coil Migration and Early Recurrence after Endovascular Treatment

Intrasphenoid rupture of a non-traumatic aneurysm of the cavernous carotid artery is rare. We describe a patient in whom this condition manifested with epistaxis and led to the formation of a pseudoaneurysm occupying the right sphenoid sinus. The lesion recurred after repeated attempts at conservative endovascular therapy. Eventually the patient was treated with endovascular occlusion of the right internal carotid artery. Our report emphasizes the relapsing behaviour of a non-traumatic aneurysm of the cavernous portion of the internal carotid artery ruptured into the sphenoid sinus.

Subacute rupture of intracavernous carotid artery aneurysm with cavernous sinus thrombophlebitis: Potential diagnostic and therapeutic challenges

We report on a patient with subacute ruptured intracavernous carotid artery aneurysm presenting with nonspecific features of cavernous sinus thrombophlebitis initially, leading to delayed diagnosis. It alerts our awareness of the potential causes and consequences of cavernous sinus thrombophlebitis, in particular in the presence of complicating internal carotid artery aneurysm and hence, the importance of angiographic evaluation. The increased risk of thrombogenic event from coexisting inflammation raises difficulty in endovascular coiling of aneurysm, which would be further aggravated with presence of stent due to potential risk of stent infection from local spread, as demonstrated in our case with complicated parent artery occlusion due to in-stent thrombus formation during the procedure. Adequate antithrombotic therapy at both before and after the procedure is required and regular follow-up is mandatory.

Slowly progressive neuronal death associated with postischemic hyperperfusion in cortical laminar necrosis after high-flow bypass for a carotid intracavernous aneurysm

The authors report a rare case of slowly progressive neuronal death associated with postischemic hyperperfusion in cortical laminar necrosis after radial artery/external carotid artery-middle cerebral artery bypass graft surgery for an intracavernous carotid artery aneurysm. Under barbiturate protection, a 69-year-old man underwent high-flow bypass surgery combined with carotid artery sacrifice for a symptomatic intracavernous aneurysm. The patient became restless postoperatively, and this restlessness peaked on postoperative Day (POD) 7. Diffusion-weighted and FLAIR MR images obtained on PODs 1 and 7 revealed subtle cortical hyperintensity in the temporal cortex subjected to temporary occlusion. On POD 13, (123)I-iomazenil ((123)I-IMZ) SPECT clearly showed increased distribution on the early image and mildly decreased binding on the delayed image with count ratios of the affected-unaffected corresponding regions of interest of 1.23 and 0.84, respectively, suggesting postischemic hyperperfusion. This was consistent with the finding on (123)I-iodoamphetamine SPECT. Of note, neuronal density in the affected cortex on the delayed (123)I-IMZ image further decreased to the affected/unaffected ratio of 0.44 on POD 55 during the subacute stage when characteristic cortical hyperintensity on T1-weighted MR imaging, typical of cortical laminar necrosis, was emerging. The affected cortex showed marked atrophy 8 months after the operation despite complete neurological recovery. This report illustrates, for the first time, dynamic neuroradiological correlations between slowly progressive neuronal death shown by (123)I-IMZ SPECT and cortical laminar necrosis on MR imaging in human stroke.