Multiple "mirror" aneurysms involving intracavernous carotid arteries and vertebral arteries: case report

BACKGROUND: Bilateral intracavernous carotid artery aneurysms are rare. Moreover, the proportion of vertebrobasilar aneurysms in association with multiple aneurysms is extremely low. We describe a rare case of "mirror" aneurysms on the bilateral intracavernous carotid and bilateral vertebral arteries. CASE DESCRIPTION: A 54-year-old male suffered from ophthalmic pain and oculomotor palsy on the left side. Cerebral angiography disclosed a giant left cavernous aneurysm and large asymptomatic aneurysms on the right intracavernous carotid artery and bilateral vertebral arteries. The cavernous sinus syndrome on the left side was successfully treated by left carotid artery ligation. However, 2 years later, severe subarachnoid hemorrhage (SAH) occurred. Computed tomography revealed thick clots densely distributed in the basal cisterns and third and fourth ventricles, indicating that the SAH originated from one of the vertebral artery aneurysms. Consciousness disturbance progressed rapidly, leading to cardiopulmonary arrest. CONCLUSION: The literature contains no case of mirror intracranial aneurysms involving both intracavernous carotid and vertebral arteries. Multi-staged surgical techniques with optimal combinations of direct clipping, ligation or trapping, and endovascular embolization may be essential for patients with multiple aneurysms to avoid SAH.     

Evaluation of intra-aneurysmal blood flow by digital subtraction angiography: blood flow change after coil embolization

BACKGROUND: The natural course of cerebral aneurysms is related to many factors, and it is very important that intra-aneurysmal blood flow is considered. Our group developed a method that allowed the simultaneous evaluation of blood flow in human cerebral aneurysms using digital subtraction angiography (DSA) with no special devices. The intra-aneurysmal blood flow measurement would also be very useful for coil embolization. Since the Guglielmi detachable coil (GDC) was developed, many patients with cerebral aneurysm have been treated with GDC, but coil compaction has sometimes caused a problem after the coil embolization of a cerebral aneurysm. We believed that an intra-aneurysmal flow measurement would suggest the final result of embolization during the procedure. METHODS: We performed DSA to examine 17 aneurysms in 17 patients. The video signal of serial DSA images was stored on a personal computer, and time-density curves were obtained for each individual pixel. The formula, determined by a two-exponential model, was fitted to the time-density curve 1000 times by least square approximation for each individual pixel. We indirectly substituted the coefficient of the flow-in curve for the blood flow. We were therefore able to display the distribution of intra-aneurysmal blood flow in color. We could compare the blood flow in each portion of the cerebral aneurysm and parent artery during coil embolization. RESULTS: The blood flow k(a) in a small aneurysm was faster than that in a large aneurysm, and it slowed in accordance with the coil embolization. The blood flow in a large aneurysm was sometimes accelerated by incomplete coil embolization. CONCLUSION: We can detect the flow distribution in cerebral aneurysms and the flow change during coil embolization, using existing equipment. Our method would be useful in elucidating the natural history of cerebral aneurysms, treating cerebral aneurysms with coils, and following patients after treatment.     

Parent vessel Guglielmi detachable coil herniation during wide-necked aneurysm embolization: treatment with intracranial stent placement: two technical case reports

OBJECTIVE AND IMPORTANCE: Despite recent advances in technology, parent vessel coil herniation occasionally complicates successful Guglielmi detachable coil embolization, particularly in wide-necked aneurysms. We report endovascular stent deployment performed in two patients specifically to treat this complication. CLINICAL PRESENTATION: Two patients underwent Guglielmi detachable coil embolization of cavernous segment aneurysms. Both developed coil herniation into the internal carotid artery. In one patient, the herniation occurred during the initial procedure; in the other, it was discovered in a delayed fashion during a follow-up examination for ocular symptoms. INTERVENTION: In both patients, endovascular stent deployment was performed to isolate the herniated portion of the coil from the internal carotid lumen. Follow-up angiography at 6 months demonstrated no aneurysm recanalization and no stenosis of the parent internal carotid artery in the stented region in either patient. CONCLUSION: The use of intraluminal stents has been reported to be a helpful technical adjunct to the conventional endovascular treatment of aneurysms and balloon angioplasty. One additional indication for the use of this technology is sequestering herniated coils from the lumen of the parent artery to reduce potential embolic or occlusive sequelae.     

Cavernous carotid artery aneurysm associated with Marfan's syndrome: treatment by balloon embolization therapy

Intracranial aneurysms arising in the region of the cavernous carotid artery are difficult to manage surgically because of the surrounding cavernous sinus. With recent advances in microballoon technology and permanent solidification agents, it is now possible to treat certain intracranial aneurysms by detachable balloons and preserve the parent vessel. A patient with Marfan's syndrome presented with severe retroorbital pain, ophthalmoplegia, and headaches. Cerebral angiography demonstrated a large cavernous carotid artery aneurysm measuring 17 X 9 X 6 mm. This was successfully treated by placing three detachable balloons within the aneurysm and preserving the carotid artery via a transvascular approach. Intravascular detachable balloon embolization may offer a form of alternative therapy for the management of surgically difficult aneurysms.     

Follow-up study of inaccessible giant aneurysms of the intracranial internal carotid artery

Inaccessible giant aneurysms of the internal carotid artery had been treated with various methods. But these results are not always satisfactory. To determine the optimal treatment for these aneurysms, long-term follow-up study was carried out in 8 patients. They included 7 females and one male with ages ranging from 18 to 72 years. The aneurysms arose at the cavernous portion in 6 patients, at bifurcation of the posterior communicating artery and the ophthalmic artery in 2 patients. All but 2 patients had multiple cranial nerve palsies before admission. Those patients younger than 60 years had the ligation of the internal or common carotid arteries with or without EC-IC bypass. The others had conservative treatments including repeated Matas test. Follow-up period was 17 to 112 months after discharge. Follow-up results showed gradual decrease of the size of the aneurysms on CT scan and improvement of signs in all 3 operated cases. But only one aged patient who had repeated Matas maneuver had spontaneous improvement of her signs. There was no improvements in the others with conservative treatment. From the results of the present study, we would like to recommend carotid ligation with EC-IC bypass for the patients younger than 60 years after preoperative balloon occlusion test. When the patients were intolerable in temporary balloon occlusion of the internal carotid artery, detachable balloon embolization or electrothrombosis with copper wire also will be the treatment of choice. In the aged patients with high surgical risk, repeated balloon occlusion test or Matas test seems to be effective to promote intra-aneurysmal thrombosis.     

Case of direct carotid-cavernous fistula presenting with subarachnoid hemorrhage

We report a case of longstanding asymptomatic direct carotid-cavernous fistula (CCF) which caused fatal subarachnoid hemorrhage (SAH). A 91-year-old female with no history of previous head trauma and optic symptoms presented acute subarachnoid hemorrhage. Angiography revealed a left direct carotid-cavernous fistula draining only into the contralateral cavernous sinus with leptomeningeal venous reflux and small varix on the pontine bridging vein. The affected cavernous sinus was markedly dilated and there was no septum between the left cavernous sinus and the internal carotid artery. The patient underwent transvenous coil embolization for intercavernous sinus and leptomeningeal venous reflux was successfully obliterated and opacification of the varix was diminished. The past history of this patient and angiographical findings strongly suggest long standing asymptomatic CCF caused SAH.     

Surgical alternatives in the treatment of cavernous sinus aneurysms

Direct surgery on aneurysms in the cavernous sinus is a formidable technical procedure. The intimate relationship of the intracavernous carotid artery to the venous structures and to the cranial nerves make surgical access difficult at best. Thirty-two of 356 aneurysm patients presented with symptomatic aneurysms originating from the intracavernous internal carotid artery. Twenty-one patients had aneurysms contained entirely within the cavernous sinus, and in 11 others the aneurysms arose within the cavernous sinus and extended into the subarachnoid space. Of the purely intracavernous aneurysms there were five small aneurysms (less than 25 mm) and 16 giant (greater than or equal to 25 mm) aneurysms. Fifteen patients with purely intracavernous lesions had a superior orbital fissure syndrome, and six had a variety of other symptoms. Of 11 patients with subarachnoid extension, five had a subarachnoid hemorrhage (Grade I or II), five had ipsilateral visual loss, and one had periorbital pain. The aneurysms were treated as follows: Group 1 received progressive ligation of the internal carotid artery in the neck with a Selverstone clamp and a surface superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis (purely intracavernous in nine, and with subarachnoid extension in one); Group 2 underwent trapping of the internal carotid artery and a deep STA-MCA anastomosis (purely intracavernous in seven); and Group 3 had direct clipping of the aneurysm (purely intracavernous in five, and with subarachnoid extension in 10). The cavernous sinus was entered directly through its roof by a pterional craniotomy with radical removal of the optic canal, lesser sphenoid wing, and lateral and superior orbital walls. Proximal control of the internal carotid artery was obtained through a cervical incision. Two patients in Group 1 developed transient neurological deficits, which resolved. Two patients in Group 2 developed a cerebral infarction, one of whom died; in both of these patients, the anastomosis was completed after the internal carotid artery occlusion. Two patients in Group 3 progressed from marked visual loss to blindness of the same side, and one developed an intraventricular hemorrhage during induction of anesthesia and died without surgery. It is proposed that a direct approach to symptomatic aneurysms in the cavernous sinus is the best initial alternative. When this approach is not feasible, a trapping procedure preceded by a high-flow extracranial-intracranial anastomosis may be considered. Although the authors have been able to clip aneurysms of various sizes, this has not been possible in all patients. Further work is needed in this area.     

Parent Artery Occlusion for Unruptured Cerebral Aneurysms: The Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2

Parent artery occlusion (PAO) is an alternative to surgical clipping or endovascular endosaccular coil embolization for the management of cerebral aneurysms. Most giant and fusiform aneurysms are not amenable to endosaccular coil embolization due to anatomical considerations, such as a broad-neck. However, majority of reports regarding the safety of PAO are based on case series involving a relatively small number of patients. In the present study, a total of 381 consecutive patients with unruptured cerebral aneurysms who were treated with PAO were extracted from the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and JR-NET2 database, which are nationwide surveys conducted by the Japanese Society of Neuroendovascular Therapy. The mean age of the 381 patients was 58.1 years, and 59.3% were female. The aneurysmal location included the vertebral artery (42%) and the cavernous portion of internal carotid artery (32%). The aneurysm size and shape consisted of fusiform (45%), giant (25%), and large (22%). Symptomatic lesions were present in 59.8% of the population. Technical success was achieved in 98.4%. The 30-day morbidity and mortality rates were 3.1% and 1.0%, respectively. The most frequent procedure-related complication was ischemic stroke, which occurred in 12.9% (distal embolism, 6.0%; branch occlusion, 3.9%). The 30-day morbidity and mortality rates related to ischemic strokes were 2.1% and 0.3%, respectively. PAO for unruptured aneurysms is feasible with a high technical success rate. Peri-procedural management of ischemic stroke is the key to enhance the safety of this treatment option.     

Long-term follow-up study of patients with cavernous sinus aneurysm treated by proximal occlusion

Proximal occlusion of the internal carotid artery (ICA) is still the treatment of choice for a large cavernous sinus aneurysm. Endovascular occlusion or trapping of the ICA with or without an extracranial-intracranial bypass is sometimes performed. We analyzed the results of the long-term follow up of 11 patients with a giant or large cavernous sinus aneurysm treated by only proximal occlusion between 1975 and 1989. Proximal occlusion of the carotid artery was performed by Selverstone clamping. The follow-up period ranged from 6 to 21 years (mean 13.9 years). Eight of the 11 patients showed improvement of cranial nerves paresis or headache, and four became asymptomatic. None of the original aneurysms ruptured. The final outcomes were nine good recovery, one moderately disabled, and one severely disabled by the Glasgow Outcome Scale. The causes of morbidity were early ischemia and subarachnoid hemorrhage from a newly formed aneurysm. Late complications included ischemia in two patients, and new formation and enlargement of aneurysms at a site other than the original aneurysm in two patients, 13 and 17 years later. Therapeutic carotid artery occlusion requires strict test ICA occlusion. In addition, long-term follow up by periodical cerebral angiography using magnetic resonance, computed tomography, or digital subtraction angiography is necessary, and postoperative medical treatment is important to reduce the risk of late complications.     

A giant aneurysm of the internal carotid artery treated by intracranial direct surgery--with a special reference to the anatomical relationship between the cavernous sinus and the internal carotid artery (author's transl)]

There have been a few reports about intracranial giant aneurysms treated by intracranial direct approaches. Especially, for giant aneurysms of the internal carotid artery, direct operation has been thought to be difficult to perform because of the anatomical particularity and the danger of rupture during surgery. So the cervical carotid ligation has frequently been indicated. However, the carotid ligation does not relieve the symptoms caused by the giant aneurysm as an "intracranial mass lesion". The authors have reported here, a cured case of a giant aneurysm of the intracavernous portion of the internal carotid artery, to which, as the first step, ligation of the internal carotid artery in the cervical region was performed, and as the second step, endaneurysmorrhaphy was carried out for the remaining symptoms caused by the "intracranial mass lesion". Furthermore, the surgical techniques for treatment of giant aneurysms of the internal carotid artery were discussed citing literatures, and the authors concluded that the combined operation of carotid ligation and endane-urysmorrhaphy could be effective to giant aneurysms in this region. Meanwhile, a new concept concerning the anatomy of the carotid-cavernous region already proposed by Bedford, was confirmed by our observation at operation. It may be considered that the intracranial direct approach to aneurysms in this region and also to carotid cavernous fistulae should more frequently be indicated than ever performed, according to the new concept of the anatomy in this region.     

Giant carotid-ophthalmic artery aneurysms: direct clipping utilizing the "trapping-evacuation" technique

The authors have devised a "trapping-evacuation" technique to facilitate direct clipping of giant aneurysms in the paraophthalmic region of the internal carotid artery (ICA). The giant aneurysm is collapsed by first trapping the aneurysm by temporary occlusion of the cervical common carotid and external carotid arteries, along with temporary clipping of the intracranial ICA distal to the aneurysm. Thereafter, intra-aneurysmal blood is simultaneously aspirated through a catheter placed in the cervical ICA. Exposure of the proximal end of the aneurysm neck is mandatory for successful clipping. This is accomplished by extensive unroofing of the optic canal, removal of the anterior clinoid process, opening of the anterior part of the cavernous sinus, and exposure of the most proximal intradural (C2) and genu (C3) portions of the ICA. Four cases of giant aneurysms of the paraophthalmic ICA were successfully treated by this technique and the postoperative outcome was good in all cases. Preoperative magnetic resonance imaging for evaluation of the anatomical details, balloon occlusion test of the ICA, and intraoperative measurement of cortical blood flow were important to the success of the operation. Intraoperative digital subtraction angiography via the catheter placed in the cervical ICA was useful in confirming successful clipping.     

Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases

Interventional neurovascular techniques for treating patients with intracranial aneurysms are now being performed in selected cases. In certain anatomical locations that are difficult to reach surgically, such as the cavernous portion of the internal carotid artery (ICA), this technique may be especially useful. The procedure is performed from a transfemoral approach, using local anesthesia, thus permitting continuous neurological monitoring. Between 1981 and 1989, 87 patients diagnosed as having an intracavernous aneurysm were treated with endovascular detachable balloon embolization techniques. The patients ranged in age from 11 to 84 years. The presenting symptom was mass effect in 69 cases (79.3%), rupture of a preexisting aneurysm resulting in a carotid-cavernous sinus fistula in eight cases (9.2%), trauma resulting in a cavernous pseudoaneurysm in seven cases (8.0%), and hemorrhage in three cases (3.4%). Therapeutic occlusion of the ICA across or just proximal to the aneurysm neck was performed in 68 patients (78.2%). Since 1984, with the development of a permanent solidifying agent (2-hydroxyethyl methacrylate) to fill the balloon, it is now feasible in some cases to guide the balloon directly into the aneurysm and preserve the parent artery; this was achieved in 19 cases (22%). Follow-up examination has demonstrated complete thrombosis with partial or total alleviation of symptoms in all patients with therapeutic occlusion of the parent vessel. Of the 19 patients with preservation of the parent artery, follow-up studies have demonstrated total exclusion in 12 cases (63%) and subtotal occlusion of greater than 85% in seven cases (37%), with clinical improvement in all cases. Complications from therapy included transient cerebral ischemia during or after therapy requiring volume expansion in seven cases, embolic symptoms requiring antiplatelet medication in two cases, and stroke in four cases; there were no deaths. Detachable balloon embolization therapy, particularly for large and giant symptomatic aneurysms of the cavernous ICA, can be an effective mode of treatment.     

Alcohol embolization of carotid-cavernous indirect fistulae

OBJECTIVE: Carotid-cavernous fistulae (CCFs) are abnormal communications between the carotid artery and cavernous sinus that may present with rapid visual deterioration and extraocular paresis as a result of increasing intraocular pressure requiring emergent treatment to preserve vision. We present a technique of balloon-assisted ethanol embolization of the cavernous carotid artery supply to indirect CCFs providing immediate reduction in intraocular pressure with symptomatic improvement. METHODS: We reviewed clinical and angiographic data and present a retrospective case series illustrating six patients who underwent endovascular embolization because of worsening visual acuity and extraocular motility disorder caused by CCFs. Cerebral angiography revealed significant blood supply from the cavernous carotid artery to these CCFs. We performed ethanol embolization of these branches with distal balloon protection. RESULTS: Five of the six patients experienced immediate and sustained (mean follow-up, 21 mo) decreases in intraocular pressure, with significant symptom improvement. One patient experienced cavernous sinus thrombosis after conclusion of embolization, which caused a temporary worsening of symptoms that improved gradually over time. CONCLUSION: Many surgical and endovascular options are available to treat indirect CCFs. Absolute ethanol is a liquid agent that causes immediate vessel sclerosis and occlusion, which makes it a dangerous but potent liquid embolic agent. With distal temporary balloon protection to prevent migration of ethanol, we achieved excellent clinical and angiographic results using absolute ethanol to embolize the cavernous carotid supply to indirect CCFs. This represents a safe and effective method of endovascular management of this complex vascular anomaly.     

Sudden appearance of a mycotic aneurysm of the intracavernous carotid artery after symptoms resembling cluster headache: case report

Acute cavernous sinus syndrome developed in a 44-year-old man after he had experienced symptoms resembling cluster headache for 3 weeks. The cause was determined to be the sudden appearance of a large saccular aneurysm of the intracavernous portion of the left carotid artery secondary to an acute inflammation of the left cavernous sinus. The absence of this aneurysm before the onset of the ophthalmoplegia was confirmed by a computed tomographic scan and angiogram performed only 1 week earlier. The patient was treated with antibiotics in combination with a short regimen of steroids, which resulted in a slowly developing thrombosis of the aneurysm, although the cavernous sinus syndrome remained. This case suggests several important aspects regarding the pathogenesis of mycotic intracavernous carotid aneurysms, the mechanism of an acute manifestation of the cavernous sinus syndrome by an intracavernous carotid aneurysm, and the relation of the intracavernous portion of the carotid artery to cluster headache.     

Percutaneous intracranial stent placement for aneurysms

OBJECT: Intracranial stent placement combined with coil embolization is an emerging procedure for the treatment of intracranial aneurysms. The authors report their results using intracranial stents for the treatment of intracranial aneurysms. METHODS: A prospectively maintained database was reviewed to identify all patients with intracranial aneurysms that were treated with intracranial stents. Ten lesions, including eight broad-based aneurysms and two dissecting aneurysms, were treated in 10 patients. Four lesions were located in the cavernous segment of the internal carotid artery, two at the vertebrobasilar junction, two at the basilar trunk, one at the basilar apex, and one in the intracranial vertebral artery. Attempts were made to place stents in 13 patients, but in three the stents could not be delivered. Altogether, intracranial stents were placed in 10 patients for 10 lesions. Results that were determined to be satisfactory angiographically were achieved in all 10 lesions. Two patients suffered permanent neurological deterioration related to stent placement. In two patients, the aneurysm recurred after stent-assisted coil embolization. In one case of recurrence a second attempt at coil embolization was successful, whereas in the second case of recurrence parent vessel occlusion was required and well tolerated. CONCLUSIONS: Intracranial stents can be a useful addition to coil embolization by providing mechanical, hemodynamic, and visual benefits in the treatment of complex, broad-based aneurysms.     

A case of high flow CCF with congestive hemorrhage

The authors report a case of high flow CCF with intracerebral hemorrhage during treatment with endovascular coil embolization. A 52-year-old woman had been in good health until a sudden onset of orbital bruit and left orbital tinnitus occurred. Conjunctival chemosis and diplopia caused by left abducens palsy gradually progressed. Left internal carotid arteriography revealed a carotid-cavernous sinus fistula with direct high-flow shunt. The fistula drained into the superior orbital vein, inferior petrosal sinus, intercavernous sinus and sphenoparietal sinus with significant cortical reflux. The attempt at transarterial balloon occlusion failed. Then transvenous coil embolization was performed. During the course of endovascular treatment, follow up CT depicted intracerebral hemorrhage. Intracerebral hemorrhage was asymptomatic and thought to be caused by venous hypertension from cortical reflux. The patient underwent direct occlusion of the left sphenoparietal sinus for prevention of further hemorrhage via craniotomy. Lastly, the cavernous sinus was completely occluded by transvenous coil embolization. The signs and symptoms resolved 3 months after the procedures.     

Stent-Assisted Coil Embolization for Cavernous Carotid Artery Aneurysms

Internal carotid artery (ICA) occlusion with or without a bypass surgery is the traditional treatment for cavernous sinus (CS) aneurysms with cranial nerve (CN) dysfunction. Coil embolization without stents frequently requires retreatment because of the large size of CS aneurysms. We report the mid-term results of six unruptured CS aneurysms treated with stent-assisted coil embolization (SACE). The mean age of the patients was 72 years. The mean size of the aneurysms was 19.8 mm (range: 13–26 mm). Before treatment, four patients presented with CN dysfunction and two patients had no symptoms. SACE was performed under local or general anesthesia in three patients each. Mean packing density was 29.1% and tight packing was achieved. There were no neurological complications. CN dysfunction was cured in three patients (75%) and partly resolved in one patient (25%). Transient new CN dysfunction was observed in two patients (33%). Clinical and imaging follow-up ranged from 6 to 26 months (median: 16 months). Recanalization was observed in three patients (50%; neck remnant in two patients and dome filling in one patient), but no retreatment has yet been required. No recurrence of CN dysfunction has occurred yet. In summary, SACE increases packing density and may reduce requirement of retreatment with an acceptable cure rate of CN dysfunction. SACE may be a superior treatment for coiling without stents and be an alternative treatment of ICA occlusion for selected patients, such as older patients and those who require a high-flow bypass surgeryor cannot receive general anesthesia.     

Balloon-assisted coil placement in wide-necked cerebral aneurysms: preliminary clinical experience

Endovascular treatment of wide-necked cerebral aneurysms with Guglielmi detachable coils (GDCs) has been limited due to coil protrusion into the artery. Seven patients with wide-necked cerebral aneurysms were treated with GDCs with temporary balloon inflation for mechanical protection during coil placement. Transarterial embolization of the aneurysm with GDCs had failed due to coil protrusion into the parent artery. The use of simultaneous temporary balloon protection achieved more dense intra-aneurysmal coil packing, especially in the neck, without compromising the parent artery.     

Management strategies for unruptured cerebral aneurysms]

We discussed management strategies for unruptured aneurysms by an analysis of 62 treated and 48 untreated cases. The treated cases were divided into the following two groups; Group A consisted of 38 patients with 46 aneurysms treated during our initial 13 years (7 males, 31 females, 54 +/- 9 years old), and Group B of 24 patients with 32 aneurysms (8 males, females 16, 57 +/- 9 years old) during the last 3 years. In Group A, 36 patients were treated with neck clipping, except for two patients, who had giant aneurysms treated with internal carotid ligation and bypass surgery. All the patients in Group B were treated with either clipping or endovascular coil embolization. Our indications for coil embolization include patients with aneurysms located in paraclinoid internal carotid or basilar arteries, or with multiple aneurysms requiring more than one operation, or with a systemic risky disease for general anesthesia. In group A, 2.6% of cases resulted in death during operation and 10.3% of cases resulted in morbidity, while in group B, there was neither mortality nor morbidity caused by clipping, except for a patient with mild hemiparesis who had been treated with clipping for SAH caused by a procedure of coil embolization. The 50 aneurysms of 48 untreated patients have been observed without any neurosurgical treatment during periods of 6 months to 10 years with a mean of 2 years 7 months. Eventually, four aneurysms resulted in SAH, which cases were treated with emergency clipping or coil embolization. The high rupture rate (3.1% per year) in the natural history may suggest that some aneurysms are more likely to rupture than generally considered. We also reviewed operative findings of all entry clipping cases; more than 80 percent of aneurysms, including those measuring less than 5 mm in diameter, had red colored, thin wall domes with or without bleb. Our conclusion is that surgical indications are for a complementary use of clipping and coil embolization.     

Giant infectious intracavernous carotid artery aneurysm presenting as intractable epistaxis

Infectious intracavernous carotid artery aneurysms usually present with ophthalmoplegia and/or signs of cavernous sinus thrombosis. We report an unusual case in which a patient with AIDS presented with intractable epistaxis secondary to rupture of a giant infectious intra-cavernous carotid artery aneurysm. Culture of the aneurysm grew mycobacterium avium intracellulare (MAI). The patient was treated successfully by excision of the aneurysm and reconstruction of the internal carotid artery with a saphenous vein interposition graft.