Intracavernous Internal Carotid Artery Aneurysm Research Articles

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

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.

海綿静脈洞部大型・巨大内頚動脈瘤に対する頭蓋外内バイパス術とそのピットフォール

Our treatment modalities and techniques for intracavernous large or giant internal carotid artery (ICA) aneurysms have been changed based on past clinical experience. We report clinical results and pitfalls of bypass surgery for intracavernous ICA aneurysms. This study included unruptured symptomatic 37 intracavernous ICA aneurysms in 36 patients. Treatment methods were selected based on the anatomical features of the aneurysm and neurological/hemodynamic conditions during balloon test occlusion (BTO). Eleven aneurysms were treated without bypass surgery. Low flow bypass (STA-MCA anastomosis) was performed for 18 aneurysms, and eight aneurysms were treated with high flow bypass. A saphenous vein graft was originally used for high flow bypass, but it was changed with a radial artery because of the problem of long-term patency. ICA occlusion was accomplished by ligation of the cervical ICA alone in the early cases until we encountered a case with brain infarction due to emboli from the aneurysm after ICA ligation. Accordingly, ICA occlusion was performed by endovascular internal trapping two days after bypass surgery. There was, however, a case of graft thrombosis before ICA occlusion. We now occlude ICA by surgical trapping between the neck and the intracranial ICA immediately after revascularization. No patients had permanent ischemic neurological deficits due to cerebral hypoperfusion after ICA occlusion. Our treatment algorithm based on BTO was reliable. When the patients undergo bypass surgery, we perform ICA occlusion by surgical trapping between the neck and the intracranial portion.

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.

Massive Epistaxis From a Thrombosed Intracavernous Internal Carotid Artery Aneurysm 2 Years After the Initial Diagnosis -Case Report-

A 77-year-old woman presented with a rare case of nontraumatic intracavernous internal carotid artery (ICA) aneurysm causing epistaxis. The thrombosed aneurysm was discovered incidentally, and was not treated. However, she suffered massive nasal bleeding 22 months after the initial diagnosis. The lesion was successfully treated by endovascular coil embolization. The present case shows that thrombosed intracavernous ICA aneurysm may still carry the risk of rupture. Radiological evidence of erosion of the sphenoid sinus wall and repeated minor bleeding may be important predicting signs for massive nasal bleeding. Parent artery occlusion including the aneurysm may be the best treatment for intracavernous ICA aneurysms if sufficient collateral blood flow to the territory of the affected ICA is expected.

BILATERAL INTERNAL CAROTID ARTERY ANEURYSM SIMULATING PITUITARY APOPLEXY

Intracavernous internal carotid artery (ICA) aneurysms can extend into the sella and simulate pituitary adenomas. However, they are rarely associated with pituitary apoplexy. We present a rare case of bilateral intracavernous ICA aneurysms simulating a sellar mass with the clinical picture of a pituitary apoplexy. An 82-year-old woman presented with a classic case of pituitary apoplexy with a history of headache, nausea, vomiting, and diplopia. She was found to have an intrasellar mass simulating a large and invasive pituitary adenoma. The patient had a medical history positive for breast cancer. Because of the presentation with apoplexy and the possibility of metastatic breast cancer or pituitary adenoma, the patient was explored transsphenoidally to obtain pathological verification and possibly resect the tumor. Unusual intraoperative findings led to a microDoppler evaluation, suggesting a vascular lesion. Intraoperatively, an angiogram confirmed the presence of bilateral ICA giant aneurysms involving the ICA intracavernous component extending into the sella turcica. The patient refused further treatment. The present case indicates that an intrasellar ICA aneurysm can be misdiagnosed as a macroadenoma and even present through pituitary apoplexy. When treating intrasellar masses with the slightest suspicion of a nonpituitary origin, further workup should be considered. The possibility of a vascular lesion simulating a pituitary adenoma should always be considered by neurosurgeons and ear, nose, and throat surgeons operating in the sellar region.

Introduction: Surgery of the Central Skull Base

With his anatomical studies of the parasellar space, the so-called cavernous sinus (CS), Taptas opened Pandora's box more than 60 years ago. Parkinson continued the anatomical studies, and operated on vascular lesions in the CS with the help of extracorporeal circulation. The need for endovascular treatment of intracavernous internal carotid artery (ICA) aneurysms, as well as carotid-cavernous fistulas (CCFs), was obvious. Serbinenko started with the endovascular treatment of CCFs and ICA aneurysms using a balloon. At nearly the same time, Hakuba undertook surgical treatment of tumorous lesions in the region. Glascock studied the ICA in relation to the petrous bone, and with his studies of the ICA and this artery's relationship to the other structures, it became clear that further understanding of the pathological entities in the parasellar space hinged on additional microanatomical studies.

Tension pneumocephalus following pterional craniotomy for treatment of intracavernous internal carotid artery aneurysm

The occurrence of tension pneumocephalus following intracranial aneurysm surgery is a rare event. Here, we present a case of extradural tension pneumocephalus following pterional craniotomy for the treatment of intracavernous internal carotid artery aneurysm. It has been caused by a fistulous communication between the posterior wall of the frontal sinus and the extradural space. Successful obliteration of this aberrant communication tract was performed using fibrin glue, with complete resolution of the pneumocephalus.

脳動脈瘤の複合手術 内頸動脈海綿静脈洞部巨大・大型動脈瘤に対する複合治療

脳動脈瘤の複合手術 内頸動脈海綿静脈洞部巨大・大型動脈瘤に対する複合治療

MRI finding of simultaneous coexistence of growth hormone-secreting pituitary adenoma with intracranial meningioma and carotid artery aneurysms: report of a case

Coexistence of pituitary adenoma, intracranial meningioma and cerebral aneurysm has never been described. We report on a patient with GH-secreting pituitary macroadenoma associated with a right frontal meningioma and with two intracavernous asymptomatic aneurisms. A 61-year-old woman was referred to our Endocrine Unit 13 years after a right frontal craniotomy for a pituitary tumour. Endocrine investigation showed high levels of IGF-1 (560 ng/ml) and increased basal serum GH (56 ng/ml) levels, not suppressed after OGTT. MRI showed persistence of a homogeneously enhancing intra- and suprasellar lesion, compressing the visual pathways, with bilateral intracavernous invasion and simultaneous coexistence of a right intracavernous internal carotid artery (ICA) aneurysm in direct contact with the pituitary tumour. Somatostatin analog treatment normalized GH and IGF-1 levels. Eight months later, the patient underwent a balloon ICA occlusion with disappearance of the right ICA aneurysm. One year later, a new MRI confirmed the presence of the pituitary mass showing also a right intracranial frontal meningioma and a new ICA aneurysm on the left side. Previous studies have suggested that prolonged GH hypersecretion could play a role in the genesis of intracranial aneurysms, inducing atherosclerotic and/or degenerative modification of the arterial walls. Other aetiological factors include a mechanical effect due to a direct contact between adenoma and aneurysm. Coexistence of pituitary adenoma and intracranial meningioma is a rare event, but also for this association it has been suggested that GH or other growth factors could play a role in appearance or in growth of meningioma. In our case, meningioma appeared and grew, despite the effective treatment of acromegaly.

困難を極めた症例・特別なテクニックを要した症例 特異な内頚動脈りゅうに対する術中の工夫

We present 3 patients with unusual internal carotid artery (ICA) aneurysms who underwent neck clipping with various intraoperative adjuncts. Case 1. A 64-year-old female underwent surgery of a large intracavernous ICA aneurysm because it enlarged significantly after 4 years of observation. Suction decompression via the catheter for intraoperative angiography was quite effective to dissect and clip the large aneurysm in the cavernous sinus. Case 2. A 74-year-old male with a re-grown aneurysm on the anterior wall of the ICA. The ruptured aneurysm had initially been clipped 3 years before. The follow-up angiography revealed that a slight neck remnant became prominent. A balloon test occlusion resulted in no neurological deficits. Because of the severe adhesion between the frontal lobe and aneurysm with the previous clips, we dissected the aneurysm and clips subpially from the brain. Then during the temporary trapping of the ICA, clips were applied parallel to the ICA, catching the normal wall of the ICA under the enlarged monitoring view of the endoscope. Case 3. A 41-year-old female with an angiographically occult ruptured aneurysm at the ICA-posterior communicating artery (PcomA). The aneurysm reruptured during the surgery on the ipsilateral unruptured carotid cave aneurysm that had been supposed as the ruptured aneurysm before surgery. The aneurysm was blind under the microscope because the aneurysm was tiny and located posteriorly. Therefore, the aneurysm was clipped by catching the intact wall of the ICA and PComA beyond the lesion under the simultaneous monitoring of microscope and endoscope. None of the 3 cases showed postoperative morbidity. In conclusion, we should anticipate all intraoperative problems in treating cerebral aneurysms and prepare all adjuncts for surgery previously.

Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization.

Certain intracranial aneurysms, because of their fusiform or complex wide-necked structure, giant size, or involvement with critical perforating or branch vessels. are unamenable to direct surgical clipping or endovascular coil treatment. Management of such lesions requires alternative or novel treatment strategies. Proximal and distal occlusion (trapping) is the most effective strategy. In lesions that cannot be trapped, alteration in blood flow to the "inflow zone," the site most vulnerable to aneurysm growth and rupture, is used. From 1991 to 1999 the combined neurosurgical-neuroendovascular team at the Massachusetts General Hospital (MGH) managed 48 intracranial aneurysms that could not be clipped or occluded. Intracavernous internal carotid artery aneurysms were excluded from this analysis. By applying a previously described aneurysm rupture risk classification system (MGH Grades 0-5) based on the age of the patient, aneurysm size, Hunt and Hess grade, Fisher grade, and whether the aneurysm was a giant lesion located in the posterior circulation, the authors found that a significant number of patients were at moderate risk (MGH Grade 2; 31.3% of patients) and at high risk (MGH Grades 3 or 4; 22.9%) for treatment-related morbidity. The lesions were treated using a variety of strategies--surgical, endovascular, or a combination of modalities. Aneurysms that could not be trapped or occluded were treated using a paradigm of flow alteration, with flow redirected from either native collateral networks or from a surgically performed vascular bypass. Overall clinical outcomes were determined using the Glasgow Outcome Scale (GOS). A GOS score of 5 or 4 was achieved in 77.1%, a GOS score of 3 or 2 in 8.3%, and death (GOS 1) occurred in 14.6% of the patients. Procedure-related complications occurred in 27.1% of cases; the major morbidity rate was 6.3% and the mortality rate was 10.4%. Three patients experienced aneurysmal hemorrhage posttreatment; in two patients this event proved to be fatal. Aneurysms with MGH Grades 0, 1, 2, 3, and 4 were associated with favorable outcomes (GOS scores of 5 or 4) in 100%, 92.8%, 71.4%, 50%, and 0% of instances, respectively. Despite a high incidence of transient complications, intracranial aneurysms that cannot be clipped or occluded require alternative surgical and endovascular treatment strategies. In those aneurysms that cannot safely be trapped or occluded, one approach is the treatment strategy of flow alteration.

塞栓術後の過剰な抗凝固療法により一過性にCCFを生じたと考えられた海綿静脈洞部未破裂内頸動脈瘤の1例 : GDCを用いた塞栓術における抗凝固療法の問題点

Guglielmi detachable coil(GDC)を用いて塞栓術を行い, follow-upの血管撮影で, 術直後にはみられなかったcarotid cavernous fistula(CCF)の一過性の出現を認めた海綿静脈洞部未破裂内頸動脈瘤の1例を経験した.Activated clotting time(ACT)を指標に, 術中, 術後の抗凝固療法を行ったが, ACT以外の検査値から術後に抗凝固活性が非常に高まっていた可能性があり, CCFが出現した後抗凝固療法を中止するとCCFは消失した.このことから過剰な抗凝固療法が, 一過性のCCF出現の要因になっていたと考えられ, 未破裂脳動脈瘤であっても塞栓術施行時の過度の抗凝固療法には潜在的な危険が伴い, 脳動脈瘤の形態あるいは塞栓状況に適した抗凝固療法を行うことが重要であると考えられた.

Unusual cranial nerve palsy caused by cavernous sinus aneurysms: Clinical and anatomical considerations reviewed

BACKGROUND Two cases of intracavernous internal carotid artery aneurysm with unusual clinical findings are reported. The pathomechanism and clinical significance are discussed. CASE DESCRIPTION The first patient was a 49-year-old woman who presented with 6th nerve palsy and Horner’s syndrome caused by a posteriorly located intracavernous aneurysm. The symptoms improved gradually in proportion to the size of the aneurysm. The second patient was a 69-year-old woman with isolated oculomotor superior division palsy caused by an anteriorly located large aneurysm. CONCLUSION In the first case, a local aneurysmal compression at both the 6th nerve and the sympathetic fibers sent from the plexus on the intracavernous internal carotid artery is the most probable explanation. In the second case, the aneurysm might have selectively compressed the superior division of the oculomotor nerve at the anterior cavernous sinus. Clinical recognition of these syndromes results in a better diagnostic orientation. The authors discuss the pertinent anatomy and pathophysiology of the lesions because these findings are rarely seen clinically or in the literature.

Extradural approach to intracavernous ICA aneurysms.

A series of 115 intracavernous internal carotid artery (ICA) aneurysms have been treated by a direct surgical approach during the past 15 years. Sixty-eight aneurysms were small. Of these 11 were traumatic; nine caused by severe head injury and 2 by ICA injury during transsphenoidal surgery. Twenty-six aneurysms were large and 21 were giant. Thirty-eight aneurysms were clipped, 46 were treated by resection followed by ICA wall reconstruction with interrupted sutures, 16 by excision and proximal/distal ICA end-to-end anastomosis and 15 by resection/grafting. Postoperative angiography was performed in 107 cases and the ICA was found to be patent in 100 of these. Three patients died after surgery, two (with traumatic aneurysms) from associated brain injury and 1 from pulmonary embolism. Oculomotor palsy was present in the immediate postoperative period in 104 patients. However, six months after surgery only 7 patients had residual palsy. The direct surgical approach to intracavernous ICA aneurysms has constantly been changed and improved. The approach in its original version [6] was mainly intradural, whereas its contemporary version in most cases is extradural [10, 11]. The latter approach provides complete exposure of the entire parasellar region, good proximal control of the ICA [13], and good access to the cavernous sinus through the individual "corridors" between the cranial nerves [7]. In the author's opinion the direct surgical approach provides better results than endovascular treatment with regard to patency of the ICA [11].

内頸動脈海綿静脈洞部動脈瘤に対するバイパス手術(<特集>海綿静脈洞病変をどう治療するか)

症候性内頸動脈海綿静脈洞部動脈瘤12例に,バイパス手術を併用した外科治療を行った.年齢は43〜73歳(平均58歳),男1例,女11例で,女性に多かった.このうち巨大動脈瘤が9例であった.術前に側副血行路の血管造影所見,マタステストによる神経症状の評価や脳波分析,SPECTによる脳血流検査を行った.その結果側副血行が良好であり,一時的に内頸動脈を閉塞しても神経脱落症状が出現せず,脳血流も十分保たれている症例ではSTA-MCA吻合術,マタステスト陽性の症例には橈骨動脈を用いたhigh-flow bypassを施行した.全例頸部内頸動脈の結紮を行い,そのうち4例で動脈瘤のトラッピングが可能であった.術後脳神経症状の回復は良好であり,バイパス手術を併用した外科治療は海綿静脈洞部動脈瘤に対して有用な治療法と考えられる.

Management of giant intracranial ICA aneurysms with combined extracranial-intracranial anastomosis and endovascular occlusion

Nine patients with giant internal carotid artery (ICA) aneurysms (greater than 2.5 cm in diameter) were subjected to a combined extracranial-intracranial (EC-IC) bypass procedure and endovascular ICA occlusion during 1987 and 1988. The procedures were performed under one anesthetic. In all cases the collateral circulation had been judged insufficient on the basis of a strict preoperative testing protocol including: cerebral panangiography, electroencephalography, somatosensory potential recording, and cerebral blood flow monitoring during manual compression of the ICA in the neck. There were four intracavernous ICA aneurysms, four carotid-ophthalmic artery aneurysms, and one supraclinoid ICA aneurysm. All patients showed symptoms and signs of compression of the surrounding nervous structures. In the five cases of intradural lesions, the artery was occluded at the level of the aneurysm neck, so the ophthalmic artery had to be occluded. There was, nevertheless, no case of worsening of vision following surgery, and all nine patients showed significant improvement following the combined procedure. A combined EC-IC bypass procedure and endovascular ICA occlusion allows for immediate verification of the surgical results and appears to be a worthwhile method for treating giant intracranial aneurysms.

Saphenous vein graft bypass of the cavernous internal carotid artery

Saphenous vein graft reconstruction was performed from the petrous to the supraclinoid internal carotid artery (ICA) to replace the cavernous ICA in six patients during direct intracavernous operations. Four of these patients had intracavernous neoplasms with invasion of the ICA and two had intracavernous ICA aneurysms that could not be clipped or occluded with intraluminal balloons. All but one patient had evidence of poor collateral flow reserve in a balloon occlusion test of the ICA. The superficial temporal artery was not present in four patients, was minuscule in one, and was damaged during the initial dissection in another, making it unsuitable for superficial temporal-to-middle cerebral artery branch anastomosis. Blood flow within the graft could not be established intraoperatively in one patient (who had excellent collateral circulation) due to the small size of the vein (3 mm). In all others, the grafts were patent on follow-up arteriography and transcranial Doppler studies. Three patients who had severe reduction of cerebral blood flow during test occlusion of the ICA exhibited temporary hemispheric neurological deficits postoperatively; the deficits were related to the duration of temporary ICA occlusion. All three recovered completely without evidence of infarction on computerized tomography (CT). One patient who clinically could not tolerate the balloon occlusion test of the ICA also had temporary neurological deficits with good recovery but showed evidence of border-zone infarction on CT scans. The present role of saphenous vein graft bypass of the cavernous ICA is discussed.