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Year : 2017  |  Volume : 65  |  Issue : 6  |  Page : 1430--1433

Giant bilateral cavernous segment internal carotid artery aneurysms

Mohammad Iqbal, Sumaiya Irfan, Hukum Singh, M Ajay, Daljit Singh 
 Department of Neurosurgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi, India

Correspondence Address:
Dr. Mohammad Iqbal
Department of Neurosurgery, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, New Delhi

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;65:1430-1433

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 2023 Mar 21 ];65:1430-1433
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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}{Figure 2}{Figure 3}

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}{Figure 5}

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}

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1Lv 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.
2Slaba 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.
3Faria MA Jr, Fleischer AS, Spector RH. Bilateral giant intracavernous carotid aneurysms treated by bilateral carotid ligation. Surg Neurol 1980;14:207-10.
4Whittle 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.
5Biondi 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.
6Lv X, Jiang C, Li Y, Yang X, Zhang J, Wu Z. Treatment of giant intracranial aneurysms. Interv Neuroradiol 2009;15:135-44.
7Díaz MB, Mercado FC, Lemme Plaghos LA. “Mirror-image” bilateral giants: Intracavernous carotid artery aneurysms. Interv Neuroradiol 2006;12:251-6.
8Bodla AA, Ablett M, Inglis A. Bilateral intracavernous carotid artery aneurysms presenting as progressive cranial nerve palsies. Clin Exp Optom 2007,90;207-8.
9Berhouma 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.
10Allen 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.
11Rehman 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.
12Kopsachilis 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.
13Fujimura 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.
14Okauchi 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.
15Misra BK. Treatment of giant intracranial aneurysms: What is the best option? Neurol India 2015;63:138-41.
16Kumar 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.
17Zhang 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.