Internal Carotid Artery Pseudoaneurysm Research Articles

Temporoparietal Fascia Flap (TPFF) in Extended Endoscopic Transnasal Skull Base Surgery: Clinical Experience and Systematic Literature Review

Background and Objectives: The temporoparietal fascia flap (TPFF) has recently emerged as an option for skull base reconstruction in endoscopic transnasal surgery when vascularized nasal flaps are not available. This study provides a systematic literature review of its use in skull base surgery and describes a novel cohort of patients. Methods: PRISMA guidelines were used for the review. Patients undergoing skull base reconstruction with TPFF in our center from May 2022 to April 2024 were retrospectively included. Data were collected on pre- and post-operative clinical and radiological features, histology, surgical procedures, and complications. Results: Sixteen articles were selected, comprising 42 patients who underwent TPFF reconstruction for treatment of complex skull base pathologies. In total, 5 of 358 patients (0.9%) who underwent tumor resection via endoscopic transanal surgery in the study period in our institution required TPFF. All had been previously treated with surgery and radiation therapy for different pathologies (three chordomas, one giant pituitary neuroendocrine tumor (PitNET), and one sarcoma). Post-operative complications included CSF leak, which resolved after flap revision, and an internal carotid artery pseudoaneurysm requiring endovascular embolization. Conclusions: TPFF is an effective option for skull base reconstruction in complex cases and should be part of the armamentarium of the skull base surgeon.

Management of internal carotid artery pathology with a covered stent: illustrative cases.

Endovascular treatment of internal carotid artery (ICA) pathology includes reconstructive or deconstructive options. One reconstructive option is covered stent placement, although this is limited by a lack of devices designed specifically for neurointervention. The PK Papyrus is a balloon-mounted covered coronary stent that has a lower profile and is more flexible than other stent grafts, which makes it more suitable for treating ICA lesions. The PK Papyrus was used to treat patients with iatrogenic cavernous ICA injury and symptomatic cervical ICA pseudoaneurysms. In both cases, the stent could be easily delivered without the use of an intermediate catheter or stiff microwire. Stent deployment resulted in immediate angiographic resolution of the pathology, and there were no peri- or postoperative complications. The PK Papyrus covered coronary stent is a good option for treating cervical and cavernous carotid pathology. Its single-layer design makes it more flexible and deliverable than other stent grafts, but additional case series are needed. https://thejns.org/doi/10.3171/CASE24517.

Intracranial Internal Carotid Artery Pseudoaneurysm: A Narrative Review and Update for Otolaryngology Residents

Intracranial Internal Carotid Artery Pseudoaneurysm: A Narrative Review and Update for Otolaryngology Residents

PK Papyrus covered stent to treat traumatic pseudoaneurysm of the internal carotid artery – A technical note and review of the literature

Intracranial pseudoaneurysms account for approximately 1% of all intracranial aneurysms and are associated with high rebleeding risk and mortality. Traditional treatments of these lesions include microsurgical or endovascular reconstruction and parent vessel sacrifice. Reconstruction of the vessel is challenging due to poor vessel integrity and incomplete wall structure. An alternative endovascular reconstructive treatment includes deployment of a covered stent. Original covered stents such as the Jostent Graftmaster and the Willis stent suffer from stiff constructs that limit deployment in tortuous anatomy. The PK Papyrus covered coronary stent may be a satisfactory treatment alternative for these lesions. We present a case of an enlarging traumatic distal cavernous segment internal carotid artery pseudoaneurysm treated with trans-radial deployment of a PK Papyrus stent at our institution. We propose that the PK Papyrus covered stent may be an alternative reconstructive endovascular treatment for intracranial pseudoaneurysms. Further larger scale prospective case series would provide further support for this management strategy.

An unsuspected extracranial internal carotid pseudoaneurysm following dog bites: a case report and review of literature

BackgroundExtracranial internal carotid artery (ICA) pseudoaneurysm is a rare condition that can be caused either by penetrating or blunt trauma, including dog bites, which is an uncommon occurrence. Together with the possibility of no symptoms or nonspecific ones such as cervical pain, hematoma, swelling, or mass, considering ICA pseudoaneurysm following a dog attack is of paramount importance to avoid life-threatening complications.Case presentationWe present a rare case of a 17-year-old male with a history of dog bites three months prior, who presented to the emergency department with left-sided neck pain, dizziness, and several episodes of blurred vision and diplopia. On physical examination, a palpable mass measuring approximately 20 × 30 millimeters was identified in the left neck region and multiple superficial lacerations were observed in this area. Laboratory tests yielded normal results. Doppler ultrasound revealed a pseudoaneurysm in the left internal carotid artery. Because the great saphenous veins were insufficient, the patient was successfully treated with synthetic graft patch arterioplasty, and no complications were seen in his one-year follow-up with computed tomography (CT) angiography.ConclusionsThis report emphasizes the significance of thorough initial evaluation and imaging in cases of dog attacks, even without apparent significant trauma, to rule out hidden arterial injuries.

Giant cell arteritis as a cause of extracranial internal carotid artery aneurysm: a case report

BackgroundThis report presents the management of patient with extracranial internal carotid artery pseudoaneurysm due to giant cell arteritis.Case presentationLeft internal carotid artery pseudoaneurysm was diagnosed in a 57-year-old Ukrainian woman, which became a direct indication for surgical treatment involving aneurysm resection and internal carotid artery reimplantation. The used reconstruction technique with oblique cutting of internal carotid artery, aneurysm resection, ellipse-form anastomosis formation, and distal intima fixation prevents the dissection, restenosis, and aneurysm of anastomosis in the long-term postoperative period. Histopathological examination revealed the giant cell arteritis of the internal carotid artery.ConclusionThis case emphasizes the importance of open surgical treatment of extracranial carotid artery aneurysms, which allows to perform optimal carotid artery reconstruction and also define the rare etiology of disease.

Efficacy analysis of endovascular treatment for ruptured internal carotid artery pseudoaneurysm hemorrhage in patients with nasopharyngeal carcinoma after radiotherapy.

This study aims to evaluate the efficacy and complications of endovascular treatment for hemorrhage caused by ruptured internal carotid artery pseudoaneurysms following radiotherapy in nasopharyngeal carcinoma (NPC) patients. This study retrospectively analyzed NPC patients who underwent endovascular treatment for ruptured internal carotid artery pseudoaneurysm hemorrhage after radiotherapy at Zhongshan People's Hospital from January 2016 to December 2022. The study aims to assess the postoperative hemostasis rate, postoperative rebleeding rate, complication rate, and 1-year postoperative survival rate. During the study period, 36 patients underwent endovascular treatment, of which 24 patients underwent embolization of the internal carotid artery and 12 patients underwent stenting of the internal carotid artery. The procedure success rate was 100%. The rebleeding rate at 1 year after the procedure was 5.6% (2/36, one patient with stent placement and one patient with coil embolization), and the complication rate was 11.1% (4/36, four patients with coil embolization patients). Two patients developed large-area cerebral infarction after the procedure, and two patients had different degrees of neurological impairment after the procedure. The 1-year survival rate was 91.7% (33/36). Ruptured internal carotid artery pseudoaneurysm hemorrhage after radiotherapy is rare but life-threatening. Endovascular treatment with coil occlusion or stenting reconstruction of the internal carotid artery provides immediate hemostasis and elimination of the pseudoaneurysm with a low rate of recurrence, which may be effective in reducing patient mortality.

Rupture of Internal Carotid Artery Pseudoaneurysm into Oropharynx – An Unusual Cause of Hematemesis

Abstract A 60-year-old male presented with life-threatening hematemesis from spontaneous rupture of an aneurysm of the cervical internal carotid artery (ICA). The hemorrhage was controlled by emergency ligation of the ICA in the neck. The patient made an excellent recovery and 6 months later, no neurologic deficit was noted. The diagnosis of an extracranial carotid artery aneurysm without a pulsatile lump may be very deceptive.

Successful treatment of iatrogenic internal carotid artery pseudoaneurysm following carotid endarterectomy with thrombin injection: a case report

BackgroundIatrogenic pseudoaneurysms arising from the internal carotid artery subsequent to carotid endarterectomy are exceptionally infrequent. Herein, we present a case detailing an internal carotid artery pseudoaneurysm that manifested subsequent to a hybrid carotid endarterectomy and endovascular therapy intervention. Our approach to managing this condition involved a novel technique wherein thrombin was directly injected into the luminal cavity of the pseudoaneurysm under the guidance of a C-arm.Case presentationA 66-year-old male patient of Chinese ethnicity exhibited a 4-month history of headache and a 20-day history of gait disturbance. Digital subtraction angiography revealed occlusion in the cervical region of the left carotid artery. Following a hybrid surgical procedure, the patient reported mild pain and bruising surrounding the incision site of the left internal carotid artery endarterectomy. Subsequent angiography identified the presence of a carotid artery pseudoaneurysm. Utilizing C-arm guidance, thrombin was then directly injected into the luminal cavity of the pseudoaneurysm, resulting in complete healing during follow-up.ConclusionFor the management of pseudoaneurysms arising post carotid endarterectomy, the direct injection of thrombin into the aneurysm cavity under the guidance of a C-arm is deemed both safe and efficacious.

Postimplantation Syndrome after Traumatic Internal Carotid Artery Pseudoaneurysm Repair with Stent

AbstractEndovascular repair of traumatic internal carotid artery pseudoaneurysm (TICAP) with covered stents represents a safe treatment with few complications. However, the presence of foreign material used to treat TICAP and blood clots in the excluded pseudoaneurysms can trigger an acute systemic inflammatory response syndrome called postimplantation syndrome (PIS). To the best of our knowledge, PIS is described only after abdominal aortic endovascular aneurysm repair. Here, we report the case of PIS in a young, healthy, polytraumatized female patient with TICAP treated with endovascular covered stent.

Internal Carotid Artery Pseudoaneurysm in a Patient Presenting With Recurrent Epistaxis: A Case Report and Literature Review

Traumatic pseudoaneurysms are uncommon vascular lesions that can result from traumatic injuries to the nasal and facial areas. They pose a significant clinical challenge due to their potential to cause recurrent and life-threatening epistaxis. Understanding the underlying vascular anatomy, causes, and treatment options is essential for optimizing patient outcomes. In this case report, we present a 55-year-old man who developed a traumatic pseudoaneurysm of the sphenoid sinus, arising from the cavernous segment of the internal carotid artery following a traumatic incident. This case was successfully managed with stent-assisted coil embolization.

Stenting for Traumatic Pseudoaneurysms of the Cervical Internal Carotid Artery: Case Report and Systematic Review

The optimal stenting approach for traumatic pseudoaneurysms (PSA) of the extracranial internal carotid artery (ICA) remains underinvestigated. We present a case of a traumatic pseudoaneurysm of the extracranial ICA managed with stenting and review of prior published similar cases. The systematic review followed PRISMA-S guidelines and included studies that investigated traumatic pseudoaneurysms of the extracranial ICA managed by stent placement. Statistical analysis assessed the association between the type of injury and stent type, dual antiplatelet therapy (DAPT) duration, and clinical presentation, and the association between stent type and DAPT duration. Our search yielded 82 publications with 135 patients with extracranial ICA PSA treated with stenting. The odds of neck hematoma presentation was 12.2 times greater for patients with penetrating rather than blunt injuries (P= 0.000002). Covered stents had 2.02 times higher odds of use for penetrating rather than blunt injuries compared to bare metal stents. (P= 0.0029). Shorter duration DAPT was seen with bare metal stents having 1.25 higher odds of DAPT duration less than one month compared to covered (P= 0.001). In traumatic extracranial ICA pseudoaneurysms, covered stents are used more commonly for penetrating injuries compared to blunt injuries. Penetrating injuries are more strongly associated with the presentation of a hematoma compared to blunt injuries. Stent type may influence the recommended DAPT duration. Surgeons should consider these findings when selecting stent type and DAPT duration with patients presenting with traumatic extracranial ICA pseudoaneurysm.

Pseudoaneurysm of the Petrous Section Internal Carotid: A Co-incidence or a Complication of Chronic Otitis Media: A Case Report

Although rare, a Petrous Internal Carotid Artery (ICA) pseudoaneurysm is a possible complication following chronic otitis media. A 57-year-old woman was brought to the Emergency Department with multiple painless episodes of right ear bleeding and epistaxis over the last two months. Upon evaluation, bony dehiscence was observed over the petrous carotid’s first (proximal) genu, along with a pseudoaneurysm detected in the Magnetic Resonance Angiography (MR angiogram). The Balloon Occlusion Test (BTO) showed no cross-flow from the opposite side. Consequently, the patient was considered for high-flow bypass surgery between the external carotid artery and the M2 segment of the Middle Cerebral Artery (MCA), utilising a radial artery graft in the neurosurgery specialty. The present rare case report emphasises the significance of maintaining a high index of suspicion and implementing prompt intervention through a multidisciplinary approach. It also raises an open-ended question about whether the petrous carotid pseudoaneurysm is a complication of chronic otitis media or merely a co-incidence.

A case of a challenging diagnosis of radiation-induced extracranial internal carotid artery pseudoaneurysm: the importance of early DSA follow-up

A case of a challenging diagnosis of radiation-induced extracranial internal carotid artery pseudoaneurysm: the importance of early DSA follow-up

Willis covered stent treatment for internal carotid artery pseudoaneurysm: A meta-analysis of efficacy and safety

BackgroundPseudoaneurysm (PSA) of internal carotid artery is a rare but severe cerebrovascular disease and difficult to repair surgically. A novel medical device called Willis covered stent (WCS) has been created especially for the treatment of complex cerebrovascular diseases. However, the efficacy and safety of WCS therapy for PSA are still debatable. Additional substantial proof is needed. MethodsTo find research pertaining to WCS treatment for PSA, a systematic review of literature was conducted in the Medline, Embase, Web of Science, CNKI, Wanfang, and CBM databases. The results comprising the data of intraoperative situation, postoperative situation, and follow-up were then included in a meta-analysis. ResultsThe criteria were met by 11 noncomparative studies with 152 patients and 157 PSAs. Technical success rate was nearly 100 % (>0.999 (95 % confidence interval (CI), 0.958, 1.000)), complete occlusion rate was 97.8 % (95 % CI, 0.932, 1.000), and side branch occlusion rate was 0.5 % (95 % CI, 0.001, 0.045). The rates of acute in-stent thrombosis (<0.001 (95 % CI, 0.000, 0.013)) and hemorrhage (<0.001 (95 % CI, 0.000, 0.005)) were both less than 0.1 %. In postoperative situation, surgery-related mortality rate was less than 0.1 % (<0.001 (95 % CI, 0.000, 0.005)). The rates of recurrence (<0.001 (95 % CI, 0.000, 0.002)) and parent artery stenosis (<0.001 (95 % CI, 0.000, 0.008)) were both less than 0.1 %, while late in-stent stenosis occurred in 1.3 % (95 % CI, 0.000, 0.053) of patients. In the end, 98.5 % (95 % CI, 0.943, 1.000) of patients had a good outcome. ConclusionThe application of WCS could be effective and safe for PSAs. The findings of this study could serve as a reference for upcoming clinical trials.

Abstract 13325: Novel Heterozygous EFEMP2 Variant Detected in a Patient With Bilateral Internal Carotid Artery Dissection and Oligodontia

Cutis laxa is a rare connective tissue disorder characterized by sagging or inelastic skin. This phenotype is caused by multiple genotype variants. Biallelic variants in the EFEMP2 gene cause cutis laxa subtype IB characterized by aortic aneurysm, arterial tortuosity, arterial stenosis, joint laxity, arachnodactyly, emphysema, and retrognathia. EFEMP2 encodes fibulin-4, an extracellular matrix protein involved in elastogenesis and modulation of TGF-beta signaling. To date, monoallelic variants in EFEMP2 have not been described as pathogenic. Furthermore, oligodontia has not been associated previously with variants in EFEMP2 . We describe a 67-year-old male with a past medical history of left distal internal carotid artery (ICA) pseudoaneurysm and dissection, right distal ICA dissection, arterial tortuosity, and oligodontia who was found to have a heterozygous variant of uncertain significance in EFEMP2: c.1279_1289del11, p.Arg427CysfsX27. The variant has not been observed previously in large population cohorts and causes a shift in reading frame that substitutes the carboxyl terminal 17 amino acids with 26 alternative amino acids. This carboxyl terminal variant of EFEMP2 has been predicted to interact with PITX2 in yeast two-hybrid analyses. Furthermore, variants in PITX2 have been associated with dental agenesis, including oligodontia. We hypothesize that heterozygous variants in EFEMP2 represent a new syndrome characterized by arteriopathy and dental agenesis.

Safety and efficacy of the Pipeline Flex embolization device with Shield Technology for the acute treatment of ruptured internal carotid artery pseudoaneurysms: a multi-institution case series.

Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms. The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected. Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0-2. Complete occlusion at follow-up was observed in 82.6% of patients. PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

Lemierre syndrome associated Cavernous Sinus Thrombosis and Development of Internal Carotid Artery Narrowing: A Case Report and Review of Literature (P2-5.005)

<h3>Objective:</h3> To report a case of Lemierre syndrome complicated by cavernous sinus thrombosis (CST) and bilateral internal carotid artery (ICA) stenosis without cerebral infarction in a young woman and summarize the literature on Lemierre syndrome with arterial involvement. <h3>Background:</h3> Lemierre syndrome is a complication of oropharyngeal infection characterized by thrombosis of the internal jugular vein (IJV) with septic thrombophlebitis followed by bacteremia and septic emboli dissemination to distal organs, but arterial involvement is extremely rare. <h3>Design/Methods:</h3> A 24-year-old previously healthy woman presented to the hospital with one week of progressive jaw pain and neck swelling after recent tooth extraction. Physical examination showed left ptosis without other neurologic deficits. Computer tomography (CT) of the neck found multiple anterior neck abscesses. The patient underwent emergent incision and drainage of abscess at the left lateral pharyngeal, left masticator, and bilateral sublingual space. Vascular imaging revealed findings of non-occlusive thrombus in the left IJV, bilateral cavernous sinus thrombosis (CST), and septic emboli in bilateral apical lungs, consistent with Lemierre syndrome. Neuroimaging showed no cerebral infarction even though a digital subtraction angiogram (DSA) demonstrated bilateral ICA severe stenosis (&gt;70%) in both extracranial and intracranial segments. Cultures of abscess samples proved positive for <i>Candida albicans</i> and <i>Streptococcus constellatus</i>. The patient received treatment with full-coverage antibiotics and anticoagulation therapy resulting in an excellent outcome. <h3>Results:</h3> A literature search yielded 29 cases of Lemierre syndrome with arterial complications, which manifested as ICA occlusion or stenosis, or mycotic aneurysm development. Despite variable clinical symptoms, most patients developed CST and were all treated with antibiotics. Anticoagulation therapy is controversial given scarce and inconsistent evidence. <h3>Conclusions:</h3> The presented case and literature review emphasize the variability of the clinical course of Lemierre syndrome. Septic CST can be a rare cause of ICA occlusion, stenosis, or pseudoaneurysms because of arteritis, and thus expedited workup is necessary. <b>Disclosure:</b> Dr. Zhou has nothing to disclose. Dr. Malik has nothing to disclose.

Endoscopic Repair of Internal Carotid Artery Injury with a Lateral Tongue Muscle Patch Graft: Novel Technique and Literature Review.

Objectives Iatrogenic injury to the internal carotid artery (ICA) is one of the most catastrophic complications of endoscopic sinus and skull base surgery. Previous research has shown that packing with a crushed muscle graft at the injury site can be an effective management technique to control bleeding and prevent the need for ICA sacrifice. Here, we describe a novel and readily available repair donor site-an autologous lateral tongue muscle patch. Design Three representative cases of a successful repair of ICA injuries using a lateral tongue muscle patch are included in this study. The graft measured approximately 2 × 3 cm and was taken from the lateral intrinsic tongue musculature. We describe the harvest of the graft, its advantages, and the details of operative repair. Results The lateral tongue provides a large and readily accessible source of muscle within the surgical field that can be quickly harvested during an endoscopic procedure. For the first case, an expanding parasellar ICA pseudoaneurysm was managed with a tongue muscle patch and nasal packing. In the second case, a cavernous ICA injury was sustained during craniopharyngioma resection. Case three involved an ICA injury during endonasal debridement of invasive fungal rhinosinusitis. None of the patients required embolization or neurovascular stenting. Postoperative angiograms and serial computed tomography angiograms showed complete resolution of the pseudoaneurysm, and the patients continued to do well at least 1 year after repair. Conclusion Lateral tongue muscle graft is an effective and efficient method to manage ICA injuries during endoscopic endonasal surgery. Advantages include the speed of harvest, donor site being readily accessible in the surgical field, and low donor site morbidity. It should be added to the repertoire of possible donor sites for addressing catastrophic sinonasal bleeding.

Neurogenic Pulmonary Edema following Carotid Intervention: A Rare Case Report

Abstract Extracranial carotid artery aneurysms are rare complication of atherosclerotic degeneration or traumatic neck injury and are managed with interventional and open surgical approaches with variable results. In cases with technical difficulties rarely managed with parent artery embolization. We present a case of a 50-year-old male with prior history of blunt neck injury during road traffic accident and presented with left-sided neck swelling 8 years after injury, diagnosed with internal carotid artery pseudoaneurysm, managed with parent artery embolization, 3 days later presented with hemiplegia and sudden respiratory distress, evaluated and diagnosed as massive cerebral infarct and acute pulmonary edema, managed with ventilator support and improved clinically within 48 hours, extubated. However patient developed sepsis during the hospital stay and succumbed to disease after 20 days. We present this case in view of rare presentation of neurogenic pulmonary edema following carotid intervention.