Left Internal Carotid Artery Aneurysm Research Articles

Anesthetic management of a patient posted for ruptured aneurysm repair with asymptomatic atrial myxoma

Abstract Atrial myxomas are rare cardiac tumors. It has to be surgically resected early when diagnosed, due to possible complications such as intracardiac obstruction, embolus, and metastasis. It becomes more challenging when found as an incidental finding in routine evaluation for a case of a ruptured aneurysm. Atrial myxoma is a common cause of ischemic and hemorrhagic strokes, but in 10%–15% of cases, it is associated with the development of metastatic intracranial aneurysms which is a rare complication of myxomatous emboli. We report the case of a 42-year-old female patient presented with subarachnoid hemorrhage, posted for the repair of left paraclinoid internal carotid artery aneurysm under general anesthesia with left interatrial septum myxoma.

Letter: Transradial Flow-Diverting Stent Placement Through an Arteria Lusoria: 2-Dimensional Operative Video.

To the Editor: We read with great interest the article “Transradial Flow-Diverting Stent Placement Through an Arteria Lusoria: 2-Dimensional Operative Video” by Hackett et al.1 The authors present a case of a patient with an arteria lusoria who received effective flow-diverting stent therapy for a large left internal carotid artery (ICA) aneurysm using a large bore guide catheter through right transradial access (TRA). Diagnostic angiography showed that the left ICA could be accessed through the right TRA. A 6F radial sheath was introduced into the right radial artery, and the sheath was then exchanged over a 0.035″ guidewire for an 8F 90-cm guide catheter (Infinity; Stryker Neurovascular). After navigating a 5F 130-cm Simmons catheter into the left common carotid artery through the arteria lusoria, the 8F guide catheter was delivered into the left ICA using the telescoping technique. The large left ICA-ophthalmic artery aneurysm was successfully treated with a pipeline embolization device (Medtronic). The importance of evaluating transradial diagnostic angiography to determine whether a catheter system can safely track into the target supra-aortic vessels is critical for successful transradial neurointervention in patients with arteria lusoria, and we wholeheartedly concur with the authors' conclusion on this point. Cannulation into the supra-aortic vessels through right TRA can be extremely challenging in patients with arteria lusoria because of unfavorable catheter trajectory.2 In addition, the right TRA can cause fatal arteria lusoria dissection.3 Therefore, transfemoral access is frequently employed as first-line access if neurointerventionalists encounter arteria lusoria.2 Previous study reported that left TRA is a technically feasible alternative in neurointerventions for patients with arteria lusoria.4 Nevertheless, a guide catheter may result in a failed TRA that necessitates a crossover to transfemoral access because of a failed cannulation, a kinked catheter, or an unstable system. We have used transradial access as the first-line access for neurointerventions.5-18 The first-line TRA using a 6F preshaped Simmons guiding sheath (outer diameter, 2.70 mm; inner diameter, 0.088″; usable length, 90 cm; 6F Axcelguide Stiff-J; Medikit) offers a large bore working channel and a high procedural success rate without catheter kinking or system instability even in patients with an unfavorable steep supra-aortic take-off.5-7,13 The 6F Simmons guiding sheath is fully engaged into the target common carotid artery with a pull-back maneuver (the pull-back technique) after reforming the Simmons curve within the ascending aorta. The Simmons curve can be reformed by anchoring the 6F Simmons guiding sheath to the descending aorta (the descending aorta anchoring technique) or contralateral subclavian artery (the subclavian artery anchoring technique) through the left TRA. Transradial carotid cannulation with the pull-back technique is technically simple and promising. As a result, left TRA with the 6F Simmons guiding sheath can be a beneficial treatment choice for performing anterior circulation procedures in patients with arteria lusoria. Finally, we would like to express our appreciation to the authors for their interesting article that advances the transradial neurointerventional method.

Transient Cortical Blindness Following Cerebral Angiography: A Case Report (P2-5.015)

<h3>Objective:</h3> We would like to report a case of Transient cortical blindness following cerebral angiography <h3>Background:</h3> Transient cortical blindness (TCB) is a rare complication following cerebral angiography. Its pathophysiology remains uncertain. We would like to report a case of TCB in a patient during follow up cerebral angiogram for post coil embolization of left internal carotid aneurysm. <h3>Design/Methods:</h3> 50-year-old woman with history of hypertension presents with bilateral vision loss during follow up cerebral angiography for ruptured left internal carotid artery aneurysm status post coiling. This was associated with headache, nausea, and emesis. No associated neurologic deficits. Review of symptoms was otherwise negative. CT Head and CTA showed no acute abnormalities. MRI done on admission showed no evidence of abnormalities. Ophthalmology saw the patient and exam was unrevealing. After 24 hours her vision gradually improved and was back to baseline after 48 hours with no intervention. <h3>Results:</h3> Transient Cortical Blindness is a rare but dramatic complication of cerebral angiogram. It is characterized by loss of perceived vision, normal fundi, normal papillary reflexes, and intact extraocular movements. Symptoms can occur at the start of the cerebral angiography procedure or until serval hours after. The recovery of normal vision may start within the first few hours, but may take as long as 5 days. Two hypothesis exist: could be due to a neurotoxic effect of contrast agent causing osmotic disruption of blood-brain barrier or could be the result of posterior reversible leukoencephalopathy syndrome leading to perivascular edema. There is no known treatment known to improve the condition. <h3>Conclusions:</h3> In summary, we reported a case of TCB following vertebral angiography, a rare but dramatic complication of cerebral angiography. Radiologists and clinicians should be aware of this complication. When it occurs, one should reassure the patient about the excellent prognosis of this condition. <b>Disclosure:</b> Dr. Gomez has nothing to disclose. Dr. Harris has nothing to disclose.

Recurrent Foreign Body Reactions to Neuroendovascular Polymers—A Clinicopathologic Case Study

Objective We provide histopathologic and neuroimaging evidence of recurrent foreign body reactions in a patient following separate stent-assisted coiling of two contralateral intracranial aneurysms a decade apart. Background Stent-assisted endovascular coiling for wide-neck cerebral aneurysms introduces permanent foreign materials into the cerebral vasculature. While foreign body reactions after endovascular coiling are increasingly reported in the literature, compelling histopathologic data remains very limited. Design/Methods Electronic medical record review for clinical details and neuroimaging. Histopathology was extensively reviewed with a neuropathologist. Results A 37-year-old woman presents with left arm weakness. Magnetic resonance imaging (MRI) shows numerous enhancing lesions with large multifocal T2 FLAIR changes in the right hemisphere. An extensive vascular, infectious, autoimmune, and neoplastic workup returns negative. Months earlier, she had undergone stent-assisted coiling of a right internal carotid artery (ICA) aneurysm. A decade prior, she had presented with focal right-sided seizures after coiling of a left ICA aneurysm; MRI brain at the time revealed two enhancing lesions in the left hemisphere of unclear etiology. A brain biopsy is performed, and histopathology reveals multifocal, chronic micro-abscesses characterized by collections of neutrophils surrounded by a rim of multinucleated giant cells and histiocytes which are in turn rimmed by fibrosis and granulation tissue. Staining is negative for neoplastic changes and infectious organisms. Rare filamentous structures are identified in association with the giant cells; these resemble coil polymers described in the endovascular literature and are highly suspicious for inducing a neuroinflammatory foreign body reaction. She improves following glucocorticoid treatment, and repeat imaging shows substantial reduction in parenchymal abnormalities. Conclusions Foreign body reactions are an uncommon complication of endovascular aneurysm coiling and can manifest as an embolic inflammatory phenomenon. These neuroinflammatory reactions are driven by endovascular polymers and responsive to glucocorticoid treatment. Heightened awareness can facilitate earlier diagnosis and treatment, with prompt neuroimmunology consultation for repeat endovascular procedures.

Acute middle cerebral artery occlusion caused by spontaneous thrombosis of a small internal carotid artery aneurysm: illustrative case

Spontaneous thrombosis of a saccular, unruptured, intracranial aneurysm is rare in nongiant aneurysms. Herein, the authors present a case of acute middle cerebral artery occlusion (MCO) caused by spontaneous thrombus of a small internal carotid artery (ICA) aneurysm. A 68-year-old woman presented with increased somnolence, right-sided hemiplegia, hemispatial neglect, and total aphagia. Left MCO and a small left ICA aneurysm were suspected based on magnetic resonance angiography (MRA). The authors detected early ischemic lesions from diffusion-weighted imaging (DWI). The DWI-Alberta Stroke Program Early Computed Tomography Score was 6. T2*-weighted imaging (T2*WI) showed a thrombus, the so-called susceptibility vessel sign, at the left MCO site. Another suspected thrombus was also found in the ipsilateral ICA aneurysm. The authors treated acute phase MCO with mechanical thrombectomy (MT), after which secondary stroke prophylaxis consisting of warfarin potassium was started. Since follow-up T2*WI showed the thrombus had disappeared from the left ICA aneurysm and the whole aneurysm was clarified by MRA, coil embolization was performed. After coil embolization, there was no ischemic recurrence. Aneurysms are infrequently found proximal to occlusion sites during MT. If the proximal aneurysm is a potential embolic source, treatment of the said aneurysm may prevent stroke.

Resection of an internal carotid artery aneurysm with extreme cranial exposure maneuvers

A 63-year-old woman presented with an enlarging lump below the angle of her left mandible. Neck computed tomography angiography revealed a 5 × 3 cm left internal carotid artery (ICA) aneurysm, arising 3 cm cranial to the carotid bifurcation and extending to the top of the second cervical vertebral body (Supplementary Video 1, online only), and this was confirmed on cervical angiography (Supplementary Video 2, online only). Initially, two overlapping flow-diverting stents were deployed leading to stagnant flow within the aneurysm sac (Supplementary Video 2, online only).

Flow diversion device for the management of an extracranial internal carotid artery aneurysm.

Our patient is a 60-year-old woman with a history of hypertension, hypothyroidism, and glossal hemangioma. She works as a standardized patient actor in our simulation center. A neck ultrasound scan performed during one of the simulation sessions demonstrated a left internal carotid artery aneurysm, which prompted a consultation with Vascular Surgery. She denied any symptoms associated with this aneurysm. On physical examination, there was a palpable pulsatile mass below the left mandibular angle. On computed tomography angiography, a 2.3- × 1.9- × 2.2-cm saccular aneurysm of the extracranial left internal carotid artery was noted (A). After multidisciplinary discussion, the decision was made to proceed with endovascular treatment using flow diversion due to the patient's desire of avoiding a scar in the neck, aneurysm size, and risk for thrombus formation and embolization. A 5.0- × 25-mm Pipeline flow-diversion device (PED; Medtronic) was deployed across the lesion with no event. The patient was observed overnight and discharged the following day with a normal neurological examination and on aspirin 81 mg and clopidogrel 75 mg daily as an antiplatelet regimen. On 1-month follow-up computed tomography angiography, the stent demonstrated excellent apposition to the wall of the artery and excellent flow through this vessel (B). Extracranial carotid artery aneurysm has a prevalence of 0.4%-1% among all peripheral artery aneurysms.1Qiu J. Zhou W. Zhu X. Zhou W. Zeng Q. Huang L. et al.Treatment of extracranial carotid artery aneurysm: fifteen years' experience at a single institution.Ann Vasc Surg. 2020; 69: 174-181Google Scholar The neurologic symptoms experienced by patients include transient ischemic attacks and ischemic strokes.2Welleweerd J.C. den Ruijter H.M. Nelissen B.G. Bots M.L. Kappelle L.J. Rinkel G.J. et al.Management of extracranial carotid artery aneurysm.Eur J Vasc Endovasc Surg. 2015; 50: 141-147Google Scholar The first successful treatment for an aneurysm in this location was performed by Sir Astley Cooper in 1808 through ligation of the proximal carotid artery.3Kraemer C.J.K. Zhou W. Carotid aneurysm review.Int J Angiol. 2019; 28: 17-19Google Scholar Then, in 1952, Dimtza4Dimtza A. Aneurysms of the carotid arteries; report of two cases.Angiology. 1956; 7: 218-227Google Scholar reported the first successful resection with end-to-end anastomosis. In the past 10 years, with the development of endovascular techniques, the treatment options of carotid artery aneurysms have included open surgery, endovascular procedures, and hybrid techniques.1Qiu J. Zhou W. Zhu X. Zhou W. Zeng Q. Huang L. et al.Treatment of extracranial carotid artery aneurysm: fifteen years' experience at a single institution.Ann Vasc Surg. 2020; 69: 174-181Google Scholar A review published by Qiu et al1Qiu J. Zhou W. Zhu X. Zhou W. Zeng Q. Huang L. et al.Treatment of extracranial carotid artery aneurysm: fifteen years' experience at a single institution.Ann Vasc Surg. 2020; 69: 174-181Google Scholar reports that the optimal management option for the treatment of carotid artery aneurysms is dependent on the morphology of the artery and the properties of the aneurysm. Recent advances in endovascular treatment allow for the utilization of flow diversion outside the skull, and treatment of extracranial internal carotid artery pseudoaneurysms with flow diversion has been shown to be safe and effective in selected patients.5Akinduro O.O. Gopal N. Hasan T.F. Nourollah-Zadeh E. Vakharia K. De Leacy R. et al.Pipeline embolization device for treatment of extracranial internal carotid artery pseudoaneurysms: a multicenter evaluation of safety and efficacy.Neurosurgery. 2020; 87: 770-778Google Scholar Informed consent was obtained from this patient for this publication.

Abstract #1003264: A Rare Case of Reversible Panhypopituitarism Secondary to Cavernous Internal Carotid Artery Aneurysm Successfully Treated with Pipeline Embolization

Large cavernous aneurysms are a rare cause of pituitary dysfunction (< 0.2%) due to mass effect and can mimic pituitary tumors. We present a case of hypopituitarism secondary to left Internal Carotid Artery (ICA) aneurysm treated with pipeline embolization, leading to complete recovery of pituitary function in 18 months.

Cerebral hypoperfusion necessitating additional bypass following hunterian ligation of the internal carotid artery despite reassuring intraoperative challenges: Video case report

Background: Hunterian ligation has been adapted for complex intracranial aneurysm repair when other, more modern techniques are insufficient. Before drastic alteration of cerebral blood flow dynamics, intraoperative challenges and consideration of blood flow dynamics must be completed to ensure adequate perfusion postligation. On satisfaction, ligation may proceed; however, subtle changes related to hypoperfusion may not be immediately observed during intraoperative challenge under general anesthesia and/or before onset of the vasospasm window.Case Description: In this report, we describe a patient who presented with a Hunt-Hess Grade III subarachnoid hemorrhage (SAH), with a right internal carotid artery (ICA) occlusion and a ruptured giant left ICA aneurysm. Endovascular treatment of the aneurysm was aborted because the nominal, 9 mm diameter of the ICA was too large for any intracranial balloon or stent. Three days later, she underwent a left-sided “insurance” extracranial-tointracranial arterial bypass (EIAB) using the superficial temporal artery simultaneously with hunterian ligation of the left ICA following reassuring results on intraoperative occlusion challenge. Over several days, her neurologic condition declined concurrent with the vasospasm window, and a right-sided EIAB was required to augment vascular supply. Following a protracted hospital course, the patient became progressively more independent and is currently residing in an assisted living facility.Conclusion: We illustrate an ultimately successful microsurgical treatment option in the setting of acute SAH that highlights the importance of cerebrovascular reserve and blood flow replacement in the setting of a compromised circle of Willis, especially during the vasospasm window.

Ruptured Giant Left Paraclinoid Internal Carotid Artery Aneurysm in a Patient with Right Aortic Arch Managed with Staged Endovascular Coiling and Flow Diversion

Ruptured Giant Left Paraclinoid Internal Carotid Artery Aneurysm in a Patient with Right Aortic Arch Managed with Staged Endovascular Coiling and Flow Diversion

Endovascular Reconstruction Utilizing Flow Diversion Stenting in a Patient With Bilateral Giant Cavernous Internal Carotid Artery Aneurysms

Bilateral giant cerebral aneurysms are exceedingly rare. Giant aneurysms of the internal carotid artery (ICA) carry a poor prognosis if untreated. Flow diversion is an endovascular technique whereby a device is placed in the parent blood vessel to divert blood flow away from the aneurysm and is an available treatment for giant aneurysms. A 69-year-old woman presented with progressive diplopia and was found to have bilateral ICA aneurysms. She had stenting of the left ICA aneurysm with improvement of her symptoms and no complications. Five years post procedure, she presented with recurrent diplopia and was found to have enlargement of the previously seen right-sided cavernous ICA aneurysm, which was treated with another flow diversion stent with no complications. Endoluminal reconstruction/flow diversion with Pipeline™ Embolization Device (PED) has emerged as an alternative to traditional endosaccular coiling and parent artery occlusion. We report a case of bilateral cavernous carotid giant aneurysms treated with flow diversion and demonstrate that flow diversion stenting using the PED is a safe and reliable treatment for bilateral giant ICA aneurysms. We encourage interventionists to consider this technique in patients with giant intracranial aneurysms. J Neurol Res. 2020;10(4):136-139 doi: https://doi.org/10.14740/jnr593

CME Test for Carotid Duplex Study of the Left External Carotid Artery Transposition for the Repair of the Left Internal Carotid Artery Aneurysm

CME Test for Carotid Duplex Study of the Left External Carotid Artery Transposition for the Repair of the Left Internal Carotid Artery Aneurysm

Coiling as a Rescue Strategy for Flow Diverter Prolapse into a Giant Intracranial Aneurysm

Up to 3.2% of the adult population has an unruptured intracranial aneurysm (IA). Flow diversion is a relatively new treatment technique that is especially useful for large and morphologically unfavorable IAs. A previously healthy woman aged 32 years presented with a 6-month history of ptosis and ophthalmoplegia of the left eye. A magnetic resonance imaging scan revealed a giant left internal carotid artery aneurysm. She was admitted for treatment using flow diversion. After delivery of the flow diverter (FD), prolapse of the proximal end of the stent into the aneurysmal sac was observed. FD stabilization was achieved by deploying multiple coils through a previously placed microcatheter to push the prolapsed end away from the aneurysmal lumen. The patient had a favorable outcome, with reduction of preoperative mass effect symptoms and complete obliteration of the aneurysm persisting at the 3-month follow-up. Giant IAs remain one of the most daunting clinical problems to treat. FD displacement is a rare (0.5%-0.75%) and possibly fatal complication. Currently, no clinical guidelines exist for its management. Adjunctive coiling is a possible rescue strategy for stabilizing an FD that foreshortened and prolapsed into the aneurysmal sac. Further studies are needed to identify the best approach to this complication.

Carotid Duplex Study of the Left External Carotid Artery Transposition for the Repair of the Left Internal Carotid Artery Aneurysm

This case study reports a carotid duplex study of a rare case of the extracranial internal carotid artery aneurysm, and an unconventional procedure for the repair, transposition of the external carotid artery into the internal carotid artery. The pre-operative and post-operative computed tomography images confirm these findings.

SUN-433 Pituitary Dysfunction Secondary to a Large Cavernous Internal Carotid Artery Aneurysm

Background: Intracranial aneurysms extending into the sellar space and leading to pituitary dysfunction are exceedingly rare. This type of vascular lesions may be responsible for less than 0.2% of cases of hypopituitarism. Herein, we present a case of hypopituitarism and hyperprolactinemia secondary to a large unruptured left cavernous internal carotid artery aneurysm with intra- and suprasellar extension. Clinical case: An 81-year-old woman with past medical history of long-standing primary hypothyroidism was noted to have a suppressed serum TSH (0.007 uU/mL [0.400 - 5.500]) on routine laboratory studies. Prior to this, she had been on a stable dose of levothyroxine replacement for several years and her TSH level had been maintained within the normal reference range. Subsequent laboratory studies showed an elevated prolactin level (173.4 ng/mL [4.5 - 26.8]), inappropriately low gonadotropin levels for a post-menopausal woman (FSH 4.4 mU/mL [20 - 100]; LH 0.8 mU/mL [>20]), normal IGF-1 (96 ng/mL [27 - 170]), and a low morning cortisol level (2.5 ug/dL (5.3 - 22.5)] with an inappropriately normal ACTH level (12 pg/mL [<47]). Her 60-minute cortisol level was <20 ug/dL during an ACTH stimulation test. The patient was started on steroid replacement and was continued on levothyroxine. A brain MRI was performed and demonstrated an area of heterogeneous unenhanced T1-weighted signal intensity and T2 signal void in the sellar space, measuring approximately 15 mm in diameter. The radiological differentials included a proteinaceous pituitary cyst or a vascular aneurysm. A brain MRA was then obtained for better characterization of the lesion, which revealed a large left cavernous internal carotid artery aneurysm (13 x 17 x 16 mm), completely filling the sellar space and extending into the suprasellar region. The patient was referred to neurosurgery and underwent a successful pipeline embolization of the aneurysm. At two months follow-up, her TSH was 0.159 uU/mL and her prolactin level was 140.3 ng/mL. Conclusion: Aneurysms with intrasellar extension should always be considered in the differential diagnosis of sellar lesions. When compared with cases of nonfunctioning pituitary macroadenomas, intrasellar aneurysms may result in comparable dysfunction in pituitary hormone production and hyperprolactinemia. Endocrine abnormalities are usually irreversible and permanent hormone replacement therapy is necessary. Long-term follow-up may elucidate pituitary function recovery after effective aneurysm treatment.

A case of pipeline migration in the cervical carotid

Since its emergence in 2011, the pipeline flow diversion (PFD) has gained recognition in the treatment of certain intracranial aneurysms. However, early or delayed pipeline migration (PM) and micro-catheter/guidewire retention have been infrequently reported. We report a case of PM and shortening in the treatment of a left cervical internal carotid artery (LICA) aneurysm. A middle-aged African-American patient presents for an off-label PFD treatment of an incidental 21 × 23 mm aneurysm at the sub-petrous segment of the left ICA. While the patient remained completely neuro-intact, a 6 months follow-up angiogram revealed a persisting filling of the cervical aneurysm with a foreshortening of the pipeline by 1/3 of its original 30 mm size and proximal migration into the aneurysmal sac. We opted to watch the aneurysm within 6 months especially that the aneurysm was extra-cranial and because of the potential risks involved in trying to re-access the device.

Limiting foetal doses during a four-vessel angiogram and endovascular stent-assisted berry aneurysm repair: A case report

A 36-year-old female patient, 20 weeks pregnant, was diagnosed with a left internal carotid artery aneurysm. Fluoroscopically guided repair was justified. A four-vessel cerebral angiogram was performed, and a left paraclinoid aneurysm was demonstrated. The patient subsequently underwent endovascular stent-assisted berry aneurysm repair. As the patient was pregnant, the procedure was preceded by consideration of the required radiation protection. The foetal dose was estimated as negligible. Active management of foetal exposures may improve radiation protection during pregnancy.

Acute distal migration of a flow diverting stent

The introduction of flow diverting stents, particularly for treatment of petrous to supraclinoid internal carotid artery aneurysms, has greatly impacted endovascular treatment of intracranial aneurysms. Despite their high efficacy, complications, such as ischemic events, distal hemorrhage, or problems with stent deployment, remain a significant concern. We present the first reported case of acute distal migration of a Pipeline Embolization Device (PED). A 24-year old female underwent elective placement of a PED for treatment of a left paraclinoid internal carotid artery aneurysm. Despite an uneventful intra-operative course, adequate stent placement and a normal neurologic examination immediately after placement, she demonstrated right hemiparesis shortly thereafter. Repeat angiography revealed acute distal migration of the PED and an occlusive thrombus. Thought to be secondary to chronic in-stent thrombosis, distal migration has been previously described in a delayed fashion over weeks to months. However, to our knowledge, this is the first reported case of distal flow diverter migration in an acute setting immediately following the procedure.

Nickel-associated delayed multiple white matter lesions after stent-assisted coil embolization of intracranial unruptured aneurysm

Metal-induced encephalopathy after stent-assisted coil embolization is extremely rare. The present report describes two patients who presented with symptomatic intracranial parenchymal edematous lesions after stent-assisted coil embolization. A 64-year-old woman...

Tuberous sclerosis with giant internal carotid artery aneurysm resulting left third nerve palsy: A case report

Tuberous sclerosis is an autosomal dominant hereditary condition with many varied forms of clinical presentation. The most frequent cutaneous findings in tuberous sclerosis include multiple angiofibromas, hypopigmented macules, periungual fibromas and shagreen patch. It is characterized by the development of hamartomatous growths in many organs. We present a case of tuberous sclerosis with a giant left internal carotid artery aneurysm causing pulsatile proptosis, left sided ptosis, anisocoria and papillary mydriasis indicative of left third cranial nerve palsy. DOI: http://dx.doi.org/10.3329/bmj.v43i2.21393 Bangladesh Med J. 2014 May; 43 (2): 103-105