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Table of Contents    
LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 6  |  Page : 1430-1433

Giant bilateral cavernous segment internal carotid artery aneurysms


Department of Neurosurgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India

Date of Web Publication10-Nov-2017

Correspondence Address:
Mohammad Iqbal
Department of Neurosurgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.217960

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How to cite this article:
Iqbal M, Irfan S, Singh H, Ajay M, Singh D. Giant bilateral cavernous segment internal carotid artery aneurysms. Neurol India 2017;65:1430-3

How to cite this URL:
Iqbal M, Irfan S, Singh H, Ajay M, Singh D. Giant bilateral cavernous segment internal carotid artery aneurysms. Neurol India [serial online] 2017 [cited 2017 Nov 21];65:1430-3. Available from: http://www.neurologyindia.com/text.asp?2017/65/6/1430/217960


Sir,

The first giant intracranial aneurysm was described by Hutchinson in 1875. Giant intracranial aneurysms are defined to be having a minimum diameter of 25 mm. They represent 2–5% of all intracranial aneurysms. Bilateral giant intracavernous carotid artery aneurysms are extremely rare. Owing to their large size and anatomic complexity, they are challenging to treat; even with a multidisciplinary approach, outcome is not favorable.[1]

A 60-year old female patient presented with complaints of severe headache for 6 months, loss of vision in her left eye for 1 month, and drooping of the left eyelid for 15 days. Her examination revealed ptosis of the left eye. She also had no perception of light in the left eye with a dilated pupil, not reacting to light. There was left third, fourth, and sixth cranial nerve palsy. In the right eye, reaction to light was intact and the vision was 6/18. The right-sided cranial nerves were intact. On fundus examination, disc pallor was present in the left eye. Rest of the examination was within normal limits. There was no evidence to suggest the presence of other co-morbidities. The presence of diseases like the Ehlers–Danlos syndrome, Paget's disease, or Marfan's syndrome was also ruled out.

The computed tomographic (CT) angiography [Figure 1] showed a large, partially thrombosed saccular aneurysm of the cavernous segment of internal carotid artery on both the sides, measuring approximately 39 × 37 mm on the right side, and 48 × 39 mm on the left side. It was extending into the superior orbital fissure on both the sides along with thinning of the surrounding bone [Figure 2] and [Figure 3].
Figure 1: CT angiography showing a large, partially thrombosed saccular aneurysm of the cavernous segment of bilateral internal carotid arteries, measuring approximately 39 × 37 mm on the right side and 48 × 39 mm on the left side, extending into the superior orbital fissure on both the sides, along with thinning of the surrounding bone

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Figure 2: Three-dimensional reconstructed CT images, coronal section, showing large bilateral aneurysms

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Figure 3: CT angiography with reconstruction showing bilateral mirror-image intracavernous aneurysms

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Magnetic resonance imaging of the brain [Figure 4] showed a large, saccular, partially thrombosed aneurysm measuring 3.4 cm × 3 cm on the right side, and 3.8 cm × 3.6 cm on the left side in the cavernous segment of bilateral internal carotid arteries with mass effect on the intracranial portion of bilateral optic nerves, more on the left compared to the right side. Magnetic resonance angiography (MRA) [Figure 5] showed an aneurysm in the cavernous segment of bilateral internal carotid artery, partially filled with contrast due to the presence of thrombus within its lumen. A diagnosis of bilateral giant internal carotid artery aneurysm was made. Unfortunately, our patient did not opt for any intervention and was lost to follow-up.
Figure 4: Contrast enhanced axial sections of T1-weighted MRI of the brain showing a large, saccular, partially thrombosed aneurysm measuring 3.4cm × 3cm on the right side, and 3.8 cm × 3.6 cm on the left. Both are located in the cavernous segment of bilateral internal carotid arteries and are causing mass effect on the intracranial portions of bilateral optic nerves, more on the left compared to the right side

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Figure 5: MR angiogram showing the aneurysms in the cavernous segment of bilateral internal carotid arteries partially filled with contrast due to the thrombus present in their lumen

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Bilateral internal carotid artery aneurysms are rare [2],[3] and giant aneurysms are even rarer.

Spontaneous thrombosis in a giant aneurysm occurs in 13–20% of the cases.[4] Do we really need to perform any intervention in the light of associated morbidity and mortality as no successful treatment of bilateral giant cavernous segment aneurysms is documented in literature? One of the options available in the treatment of a single giant aneurysm with thrombosis is bypass surgery, which may include a superficial temporal artery-to-middle cerebral artery bypass. However, no single technique is effective in dealing with all giant aneurysms; therefore, a multidisciplinary approach is advocated in such cases but outcome is still not very satisfactory. [Table 1] shows the various treatment modalities used and the outcome in the earlier reported cases of giant aneurysms.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] When a giant aneurysm cannot be clipped directly, alternative endovascular techniques such as parent artery occlusion, coil embolization, stent-coil embolization, remodeling technique, or covered stent may be considered.[5] Lv et al., found out that parent artery occlusion, a covered stent, and coil occlusion provide an equally effective protection against bleeding.[6] A recent report has suggested that an endovascular pulmonary artery inflatable balloon-induced hypotension for clipping a giant intracranial aneurysms may be a useful technique to adopt.[16] Endovascular treatment of these lesions have relatively better results than the results obtained following their conservative management. However, the treatment is associated with high complication rates.[17] The risk of a major morbidity proportionately increases whenever an intervention for giant bilateral cavernous sinus aneurysms is contemplated.
Table 1: Summary of the previous reports

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lv X, Ge H, He H, Jiang C, Li Y. A systematic review of pipeline embolization device for giant intracranial aneurysms. Neurol India 2017;65:35-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Slaba S, Smayra T, Mohasseb G, Chédid G, Aoun N, Haddad S, et al. Mirror intracavernous aneuryms. Therapeutic dilemma apropos of a case with review of the literature. Neurochirurgie, 1997;43:325-9.  Back to cited text no. 2
    
3.
Faria MA Jr, Fleischer AS, Spector RH. Bilateral giant intracavernous carotid aneurysms treated by bilateral carotid ligation. Surg Neurol 1980;14:207-10.  Back to cited text no. 3
    
4.
Whittle IR, Williams DB, Halmagyi GM, Besser M. Spontaneous thrombosis of a giant intracranial aneurysm and ipsilateral internal carotid artery. J Neurosurg 1982;56:287-9.  Back to cited text no. 4
    
5.
Biondi A, Jean B, Vivas E, Le Jean L, Boch AL, Chiras J, et al. Giant and large peripheral cerebral aneurysms: Etiopathologic considerations, endovascular treatment, and long-term follow-up. Am J Neuroradiol 2006;27:1685-92.  Back to cited text no. 5
    
6.
Lv X, Jiang C, Li Y, Yang X, Zhang J, Wu Z. Treatment of giant intracranial aneurysms. Interv Neuroradiol 2009;15:135-44.  Back to cited text no. 6
    
7.
Díaz MB, Mercado FC, Lemme Plaghos LA. “Mirror-image” bilateral giants: Intracavernous carotid artery aneurysms. Interv Neuroradiol 2006;12:251-6.  Back to cited text no. 7
    
8.
Bodla AA, Ablett M, Inglis A. Bilateral intracavernous carotid artery aneurysms presenting as progressive cranial nerve palsies. Clin Exp Optom 2007,90;207-8.  Back to cited text no. 8
    
9.
Berhouma M, Chekili R, Jemel H, Khaldi M. A Foix's syndrome revealing “mirror” giant intracavernous aneurysms. An illustrative case report of a therapeutic dilemma. Acta Neurol Belg 2007;107:122-5.  Back to cited text no. 9
    
10.
Allen CA, Hart BL, Taylor CL, Clericuzio CL. Bilateral cavernous internal carotid aneurysms in a child with juvenile Paget disease and osteoprotegerin deficiency. AJNR Am J Neuroradiol 2008;29:5-8.  Back to cited text no. 10
    
11.
Rehman T, Ali R, Taylor C, Yonas H. Bilateral giant cavernous carotid artery aneurysms in a child with juvenile Paget's disease. World Neurosurg 2010;73:691-3.  Back to cited text no. 11
    
12.
Kopsachilis N, Pefkianaki M, Carifi G, Lialias I. Bilateral intracavernous carotid artery aneurysms presenting as diplopia in a young patient. Case Rep Med 2013;2013:209767.  Back to cited text no. 12
    
13.
Fujimura M, Sato K, Kimura N, Inoue T, Shimizu H, Tominaga T. A case of bilateral giant internal carotid artery aneurysms at the cavernous portion managed by 2-stage extracranial–intracranial bypass with parent artery occlusion: Consideration for bypass selection and timing of surgeries. J Stroke Cerebrovasc Dis 2014;23:393-8.  Back to cited text no. 13
    
14.
Okauchi M, Shindo A, Kawanishi M, Kawai N, Tamiya T. A case of bilateral intracavernous carotid artery aneurysms treated by using parent artery occlusion with bypass and endovascular therapy. Surg Cereb Stroke 2008;44:26-30.  Back to cited text no. 14
    
15.
Misra BK. Treatment of giant intracranial aneurysms: What is the best option? Neurol India 2015;63:138-41.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Kumar VR, Subramaniam SB, Murugan AB, Bapu KR. Endovascular pulmonary artery inflatable balloon-induced hypotension: A novel technique for clipping giant intracranial aneurysms. Neurol India 2017;65:566-9.  Back to cited text no. 16
[PUBMED]  [Full text]  
17.
Zhang Z, Lv X, Yang X, Shiqing MU, Wu Z, Shen C, Xu R. Endovascular management of giant aneurysms: An introspection. Neurol India 2015;63:184-9.  Back to cited text no. 17
[PUBMED]  [Full text]  


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