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LETTER TO EDITOR
Year : 2022  |  Volume : 70  |  Issue : 4  |  Page : 1728--1730

Flow Diversion as Treatment of a Recurrent Traumatic Pseudoaneurysm of the Internal Carotid Artery Presenting as Coil Extrusion

Abhidha Shah1, Ravikiran Vutha1, Atul Goel2,  
1 Department, Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, Maharashtra, India
2 Department, Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel; Consultant Neurosurgeon, Lilavati Hospital and Research Centre, Bandra (E), Mumbai, Maharashtra, India

Correspondence Address:
Abhidha Shah
Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, Maharashtra - 400 012
India




How to cite this article:
Shah A, Vutha R, Goel A. Flow Diversion as Treatment of a Recurrent Traumatic Pseudoaneurysm of the Internal Carotid Artery Presenting as Coil Extrusion.Neurol India 2022;70:1728-1730


How to cite this URL:
Shah A, Vutha R, Goel A. Flow Diversion as Treatment of a Recurrent Traumatic Pseudoaneurysm of the Internal Carotid Artery Presenting as Coil Extrusion. Neurol India [serial online] 2022 [cited 2022 Dec 2 ];70:1728-1730
Available from: https://www.neurologyindia.com/text.asp?2022/70/4/1728/355158


Full Text



Sir,

Coil extrusion or migration is a relatively rare but ominous complication of coil embolization of aneurysms. We report a rare case of coil migration in a patient with a traumatic pseudoaneurysm of the internal carotid artery that was earlier treated by coiling. An 18-year-old young boy met with a bike accident 10 months before presenting for treatment. Fifteen days following the injury, he developed one episode of epistaxis accompanied by progressive deterioration of vision in left eye. A four-vessel DSA performed at another institute revealed a large pseudoaneurysm in the paraclinoid segment of the left ICA just proximal to the origin of the ophthalmic artery. The patient was treated with endovascular coil embolization with Guglielmi detachable coil (GDC) at the same institute. A parent artery occlusion was not performed. The patient was well after the procedure; however, there was no improvement in his vision. After 5 months of the procedure, he noticed a foreign body hair-like sensation at the back of his throat. He went to his local practitioner who on oral examination found a thin metallic strand prolapsing into the oropharynx. The practitioner knowing the history of the patient cut the piece of coil that was hanging in the back of the throat without pulling it. On presentation to us, the patient had no other complaints except an inability to see from the left eye and an abnormal sensation at the back of his throat. On examination, the visual acuity was 6/9 in the right eye, with no perception of light in the left eye. Fluoroscopy showed that the coil mass was pushed towards the fundus of the aneurysm, and a piece of untangled coil was seen to be coming out of the fundus of the aneurysm sac and extending from the posterior ethmoid cells into the nasopharynx [Figure 1]a and [Figure 1]b. A repeat DSA showed a residual neck with flow into the pseudoaneurysm with a pulsating coil mass [Figure 1]c, [Figure 1]d, [Figure 1]e. In view of the residual filling aneurysmal sac, it was decided to first treat the carotid pseudoaneurysm with flow diversion. Flow diversion was chosen as the treatment strategy with the aim of reconstruction of the traumatic portion of the vessel wall and to achieve thrombosis of the residual pseudoaneurysm. As per protocol, the patient was put on dual antiplatelet therapy consisting of 325 mg of acetylsalicylic acid and 75 mg of clopidogrel daily for 5 days prior to the procedure. A pipeline embolization device (ev3/Covidien, Plymouth, MN, USA) was deployed across the neck of the pseudoaneurysm. A femoral access was obtained, and a tri-axial system was established using a 6 French guide sheath, a 5 French flexible Navien intracranial guiding catheter, and a Marksman microcatheter. The appropriate sized device was then deployed across the neck of the pseudoaneurysm. During the procedure, the distal part of the device did not open well with inadequate opposition of the vessel wall. Hence, this distal end was reinforced with an intracranial stent. Post-procedure showed stasis in the aneurysm with good flow across the vessels [Figure 1]f, [Figure 1]g, [Figure 1]h. The patient was well after the procedure. A few days after the endovascular treatment, the patient was taken up for the endoscopic endonasal procedure for removal of the extruded coil. Intraoperatively, the coil was seen to be coming out from the posterior aspect of the ethmoid air cells into the nasopharynx. Coil was cut flush to skull base and retrieved [Figure 1]i and [Figure 1]j. The patient did well after the procedure and at a follow up of 14 months is back to his routine life.{Figure 1}

The unique morphology of the pseudoaneurysm, its friable nature, and the lack of a “true” neck renders it difficult for direct surgical clipping. The preferred surgical option for treatment of this entity would be an extracranial to intracranial high flow bypass.[1] Traditional endovascular treatment of pseudoaneurysms involves coil occlusion of the aneurysm with or without occlusion of the parent vessel or stent-assisted coiling, which preserves the vessel wall. Aneurysm recurrence rates after endovascular treatment range from 15 to 33%.[2],[3] Several studies reported that about 50–55% of these recurrences may be associated with coil extrusion or migration.[3] The advent of flow diversion devices is a “game changer” in the management of these traumatic pseudoaneurysm. They can be used singly or in combination with protecting coils in the aneurysmal sac in the acute phase. They function by altering intraaneurysmal hemodynamics causing flow stasis and ultimately causing thrombosis of the pseudoaneurysm while maintaining flow across the parent vessel by vascular remodeling and endothelialization. There is a paucity of literature of the use of flow diverting devices for the management of traumatic pseudoaneurysms.[4] The use of flow diversion for a recurrent pseudoaneurysm has not been previously reported to the best of our knowledge. Our patient was earlier treated with coil embolization of the traumatic pseudoaneurysm without a parent artery occlusion. A probable incomplete occlusion of the neck led to continued blood flow in the aneurysmal sac. This flow probably pushed the compact coil mass towards the fragile fundus and “false” wall of the pseudoaneurysm causing a part of the coil to puncture the thin wall of the sac and herniate outside. The coil can erode the inherently thin or damaged traumatic wall of the sphenoid or ethmoid sinus causing it to prolapse into the nasopharynx. As the continuity of this prolapsed coil wire was maintained with the parent compact coil mass, the pulsatile flow into the aneurysm caused it to herniate further downwards and thereby reaching the oropharynx.

Migration of coil after endovascular treatment is a rare event and can be catastrophic if the embolized part is not fully thrombosed. Coil extrusion in a traumatic pseudoaneurysm has been reported infrequently.[5],[6]

In our patient, the pseudoaneurysm was not completely occluded when the patient presented with extrusion of the coil. In this case, excision of extruded coil can destabilise the sac. So the residual/recurrent pseudoaneurysmal sac was treated first with a flow diverter before excising the extruded coil endoscopically.

Abbreviations

ICA = internal carotid artery, DSA = digital subtraction angiography, CT scan = computed tomography, GDC = Guglielmi detachable coil.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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4Sami MT, Gattozzi DA, Soliman HM, Reeves AR, Moran CJ, Camarata PJ, et al. Use of PipelineTM embolization device for the treatment of traumatic intracranial pseudoaneurysms: Case series and review of cases from literature. Clin Neurol Neurosurg 2018;169:154-60.
5Singh A, Sikka K, Jain N, Devarajan LJ. Delayed endovascular coil extrusion presenting as a foreign body of the throat: A case report. Neurointervention 2018;13:66-9.
6Kaushal A, Singh G, Singh S, Dube S. Delayed migration of coil into the nasopharynx following embolization of internal carotid artery pseudoaneurysm: A rare complication. Saudi J Anaesth 2018;12:144-5.