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 » Introduction
 » Case Report
 » Discussion
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CASE REPORT
Year : 2012  |  Volume : 60  |  Issue : 5  |  Page : 517-519

A surgical case of paraclinoid carotid aneurysm associated with ipsilateral cervical internal carotid artery dissection


Department of Neurosurgery, National Defense Medical College, Saitama, Japan

Date of Submission04-Jun-2012
Date of Decision04-Jul-2012
Date of Acceptance03-Aug-2012
Date of Web Publication03-Nov-2012

Correspondence Address:
Satoru Takeuchi
Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.103203

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 » Abstract 

This report presents a 60-year-old with a large paraclinoid carotid aneurysm associated with cervical interal carotid artery (ICA) dissection (CICAD). She had a fall while riding a bicycle and hit her head on the ground. Computed tomography scan done at another facility showed a round mass lesion near the sella. Her medical history revealed gradual decrease in left eye vision since two years. Left carotid artery digital subtraction angiography demonstrated a CICAD with an intimal flap and a large paraclinoid aneurysm (15.5 mm in size). She underwent a high-flow bypass with a so-called double-insurance bypass and proximal ligation of the cervical ICA and the postoperative course was uneventful. She was discharged without any new neurological deficits. We suggest that the possible nature of carotid artery dissection (CAD)-related hemodynamic changes should be taken into consideration in cases of intracranial aneurysm associated with CAD.


Keywords: Cerebral aneurysm, cervical, dissection, internal carotid artery, paraclinoid


How to cite this article:
Takeuchi S, Wada K, Sakakibara F, Mori K. A surgical case of paraclinoid carotid aneurysm associated with ipsilateral cervical internal carotid artery dissection. Neurol India 2012;60:517-9

How to cite this URL:
Takeuchi S, Wada K, Sakakibara F, Mori K. A surgical case of paraclinoid carotid aneurysm associated with ipsilateral cervical internal carotid artery dissection. Neurol India [serial online] 2012 [cited 2019 Sep 17];60:517-9. Available from: http://www.neurologyindia.com/text.asp?2012/60/5/517/103203



 » Introduction Top


Cervical artery dissection (CAD) is increasingly diagnosed as a cause of transient ischemic attacks, ischemic stroke, unilateral headache with ipsilateral oculosympathetic palsy and/or pulsatile tinnitus, as well as lower cranial nerve palsies. The reported predisposing factors include inherited connective tissue disorders, trauma, and respiratory tract infections. [1] Rarely, CAD has been reported with associated intracranial aneurysms. [2],[3],[4] Hemodynamic changes associated with CAD may increase the risk of intracranial aneurysm enlargement or even rupture. [2] Standard treatment for CAD is medical (antiplatelet agents or anticoagulants) and surgical or endovascular treatment is reserved for patients who have persistent symptoms of ischemia despite adequate medical treatment. [1] However, the treatment approaches remain unclear when intracranial aneurysms are associated with CAD. We present a case of large paraclinoid carotid aneurysm associated with CAD and discuss the treatment strategy.


 » Case Report Top


A 60-year-old female fell down while riding a bicycle and hit her head on the ground. She had no other symptoms and was conscious and alert. Computed tomography (CT) scan performed at another facility showed a round mass lesion near the sella area. Her medical history revealed hypertension, hyperlipidemia, and gradual decreased vision in left eye since two years. Neurological examination was normal except for decreased vision in left eye, 0.02. Brain magnetic resonance imaging (MRI) revealed a hypointense mass near the sella on T1-weighted images [Figure 1]. Left carotid artery digital subtraction angiography demonstrated a cervical internal carotid artery (ICA) dissection (CICAD) with an intimal flap and a large paraclinoid aneurysm (15.5 mm in size) [Figure 2]. Right A1 portion of the anterior cerebral artery was hypoplastic and balloon occlusion test was not performed.
Figure 1: T1-weighted magnetic resonance image revealing a hypointense mass near the sella

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She had a high-flow bypass with a so-called double-insurance bypass, [5] and proximal ligation of the cervical ICA. Briefly, the procedure included: after the double anastomoses were placed between the left frontal and parietal branches of the superficial temporal arteries (STA) and the frontal and temporal branches of the left M4 portion of the middle cerebral arteries (MCA), a high-flow bypass with anastomosis of the right radial artery (RA) to the left M2 portion of the MCA was performed.During occlusion of the M2 portion for anastomosis of the RA to the M2, blood flow to the distal MCA territory was secured via anastomoses between the STA and the M4 portion of the MCA. Thus anastomosis of the proximal end of the RA and the external carotid artery (ECA) was performed and then the ICA was ligated just distal to the cervical bifurcation.
Figure 2: Left carotid artery digital subtraction angiograms (a) left anterior oblique view, (b) lateral view, (c) antero-posterior view of the 3-dimensional image) demonstrating a cervical internal carotid artery dissection with an intimal flap (arrowheads) and a large paraclinoid aneurysm (15.5 mm in size) (arrows)

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Follow-up MR-angiogram showed good patency of the STA-MCA and the ECA-RA-MCA anastomosis [Figure 3]a. MR imaging revealed a hyperintense signal near the sella on T1-weighted images, indicating thrombosis of the paraclinoid aneurysm [Figure 3]b. The patient's postoperative course was uneventful, and she was discharged without any new neurological deficits.
Figure 3: (a) A follow-up magnetic resonance angiogram showing the patency of the superficial temporal artery-middle cerebral artery (arrow) and the external carotid artery-radial artery-middle cerebral artery anastomosis (arrowheads). (b) A follow-up T1-weighted magnetic resonance image showing a hyperintense signal near the sella

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 » Discussion Top


CAD in association with intracranial aneurysms has been reported in the literature. [1],[2],[3],[4] Mazighi et al., [3] described the association of CAD with intracranial aneurysmal rupture. Of the 133 patients with ruptured intracranial aneurysms, there were 7 (5.3%) cases of CAD.In the series by Schievink et al., [4] of the 164 patients with CAD, there were 9 (5.5%) patients with 13 intracranial aneurysms. The frequency of associated intracranial aneurysm in patients with CAD in this cohort was higher compared to the general population (1.1%). These may suggest a relationship between CAD and intracranial aneurysms. CAD is considered to be a dynamic disease process and the radiographic findings may change dramatically over time, sometimes within a period of days or even hours. [1],[2],[3] Therefore, several authors have suggested that CAD-related hemodynamic changes might play a role in the development, growth and rupture of intracranial aneurysms. [2],[3] In our patient, it is possible that CAD-related hemodynamic changes might have resulted in the development of intracranial aneurysm.However, it is more likely that CAD was caused by minor head trauma and that the association of CAD and intracranial aneurysm was coincidental.

Controversy exists regarding the management of CAD. Most clinicians agree that either anticoagulant or antiplatelet agents should be instituted to prevent ischemic events. [1],[2] As the incidence of recurrent ischemic events on appropriate medical treatment is low and overall outcomes are favorable,surgery or endovascular (angioplasty and stenting) treatment has been reserved for patients failing to respond to medical therapy or demonstrating significant progression of dissection. [1],[2],[6] Direct surgery consists of ligation of the ICA, combined with an in situ or extracranial-to-intracranial bypass. [1],[6]

The treatment of paraclinoid aneurysms remains a major challenge for neurosurgeons because of the complex topographical anatomical relationship between the neurovascular dural structures and bone structures. [7] Although endovascular techniques have improved, large and giant aneurysms at this site are often incompletely treated even after the best endovascular treatment. [7] Additionally, direct microsurgery remains the definitive treatment for large and giant paraclinoid aneurysms, however, these are unclippable in some cases because of broad neck, calcification or partial thrombosis. [7] Surgical ligation of the ICA proximal to the aneurysm with vascular reconstruction is one of the alternative procedures used for such aneurysms and the RA bypass to the MCA is a well-established procedure, that has been reported to have long-term patency. [5]

We had to treat the paraclinoid aneurysm surgically to prevent further worsening of her vision. We were concerned that if the aneurysm was clipped incompletely and a remnant neck was formed, CAD-related hemodynamic changes might result in aneurysmal development. We therefore elected to perform a ligation of the ICA with a high-flow bypass. We suggest that the possible nature of CAD-related hemodynamic changes should be taken into consideration in cases of intracranial aneurysm associated with CAD.

 
 » References Top

1.Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 2001;344:898-906.  Back to cited text no. 1
[PUBMED]    
2.Esposito G, Sabatino G, Lofrese G, Albanese A. Carotid artery dissection-related intracranial aneurysm development. Neurosurgery 2011;70:E511-5.  Back to cited text no. 2
    
3.Mazighi M, Saint Maurice JP, Rogopoulos A, Houdart E. Extracranial vertebral and carotid dissection occurring in the course of subarachnoid hemorrhage. Neurology 2005;65:1471-3.  Back to cited text no. 3
    
4.Schievink WI, Mokri B, Piepgras DG. Angiographic frequency of saccular intracranial aneurysms in patients with spontaneous cervical artery dissection. J Neurosurg 1992;76:62-6.  Back to cited text no. 4
[PUBMED]    
5.Hongo K, Horiuchi T, Nitta J, Tanaka Y, Tada T, Kobayashi S. Double-insurance bypass for internal carotid artery aneurysm surgery. Neurosurgery 2003;52:597-602.  Back to cited text no. 5
[PUBMED]    
6.Schievink WI, Piepgras DG, McCaffrey TV, Mokri B. Surgical treatment of extracranial internal carotid artery dissecting aneurysms. Neurosurgery 1994;35:809-16.  Back to cited text no. 6
    
7.Javalkar V, Banerjee AD, Nanda A. Paraclinoid carotid aneurysms. J ClinNeurosci 2011;18:13-22.  Back to cited text no. 7
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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