Coexistence of extracranial internal carotid artery aneurysm and multiple intracranial aneurysms--case report.

A rare case of extracranial internal carotid artery (ICA) aneurysm coexisting with intracranial multiple aneurysms in a 64-year-old female is reported. The three intracranial aneurysms were clipped uneventfully by two-stage craniotomies. The extracranial ICA aneurysm at the infratemporal region was excised through a high cervical route and ICA was reconstructed by an end-to-end direct anastomosis. Ours is the first case reported of extra- and intracranial aneurysms surgically treated successfully.     

Tuberculous aneurysm of extracranial carotid artery.

Incidence of extracranial carotid aneurysm is rare and represents a challenge to treatment strategy. Two patients presented to us a couple of years apart with pulsatile neck swellings. We propose that the extracranial carotid artery pseudoaneurysm was as a result of direct extension from tuberculous lymphadenitis and discuss the management of these patients.     

颅外颈动脉瘤的外科治疗分析

目的探讨颅外颈动脉瘤外科诊断和治疗的经验。方法总结了１９８６年１月～１９９７年６月期间收治颅外颈动脉瘤６７例（７０个），其中颈总动脉瘤１０例，颈动脉分叉处动脉瘤５３例（５６个），颈内动脉瘤３例，颈外动脉瘤１例。结果术后死亡率为１．５％，偏瘫发生率为４．５％。结论颅外颈动脉瘤是外周动脉瘤中少见疾病，临床一般检查是发现该病的重要手段，血管造影对了解血管形态、功能及病理生理情况起决定作用。颅内侧支循环血供的评价及Ｍａｔａｓ实验地应用是预防术后脑缺血并发症的关键所在。正确的选择手术术式是治疗成功的有力保证。     

Surgical treatment of extracranial internal carotid artery aneurysm

Aneurysms of the extracranial internal carotid artery are rare but can be responsible for severe complications such as rupture, thrombosis, or embolism. Between 1961 and 1985 we operated on 38 aneurysms of the extracranial internal carotid artery in 35 patients, 22 males and 13 females, whose ages ranged from 6 to 73 years. The underlying causes of aneurysm included atherosclerosis (12 cases), fibromuscular dysplasia (eight cases), a congenital defect (five cases), infection (one case), and trauma (six cases); in six cases aneurysm was secondary to spontaneous dissection. Signs of cerebral ischemia were present in 26 (74%) patients and a cervical mass was found in six. The aneurysm was proximal (i.e., below the angle of the mandible) in 16 patients and distal (i.e., above the angle of the mandible) in 22. After resection of the aneurysm, arterial continuity was restored in 37 patients by resection and grafting (12 cases), resection and anastomosis (11 cases), or arteriorrhaphy (14 cases). One death occurred 13 days after operation due to myocardial infarction. Two patients experienced a reversible neurologic event. Transient paresis of cranial nerves was observed in eight patients. During a follow-up period that ranged from 6 to 30 years, four patients were lost to follow-up and 25 patients remained asymptomatic. Three patients had asymptomatic thrombosis of the carotid artery detected at follow-up investigations. The potential risks of cerebral ischemia and rupture and the satisfactory long-term results achieved with surgery are strong arguments in favor of surgical treatment for aneurysms of the extracranial internal carotid artery.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Reims, France, June 19– 20, 1992.     

Management of extracranial carotid stenosis and intracranial aneurysms.

Twenty patients with extracranial carotid stenosis and intracranial aneurysms are reviewed. Fifteen of these patients had transient ischemic attacks (TIA's) and incidental aneurysms. The other five presented with symptoms referrable to an aneurysm, and angiography revealed significant carotid stenosis. None of the patients who presented with TIA's and underwent endarterectomy suffered subarachnoid hemorrhage. However, those patients who presented with symptoms referrable to an aneurysm and underwent endarterectomy seem to be at greater risk for subarachnoid hemorrhage.     

Intracranial internal carotid artery aneurysm associated with extracranial occlusion of the ipsilateral internal carotid artery in a patient with polycystic kidney disease

We report a rare case with polycystic kidney disease (PKD) having an intracranial internal carotid artery aneurysm associated with extracranial occlusion of the ipsilateral internal carotid artery. A 55-year-old man with chronic renal failure due to PKD presented with headache. CT scan and MRI showed no abnormal findings. MRA showed cervical occlusion of the right internal carotid artery and an ipsilateral intracranial carotid aneurysm. At surgery, the saccular aneurysm protruded anterolaterally at the C2 portion of the right internal carotid and was clipped. Hemodynamic stress of the blood flow through the posterior communicating artery and the fragility of arteries because of PKD were considered to be two main causes of aneurysmal formation in this case.     

Raeder's syndrome associated with intracranial internal carotid artery aneurysm

Raeder's syndrome consists of oculosympathetic paresis and ipsilateral facial pain, with variable involvement of the trigeminal and oculomotor nerves. A 63-year-old woman experienced severe facial pain, a partial Horner's syndrome, and restriction of ocular movements on the left side. A left carotid angiogram disclosed a giant aneurysm of the cavernous portion of the internal carotid artery. This is the third reported case of Raeder's syndrome due to aneurysm of the intracranial internal carotid artery. Her facial pain was relieved by carotid ligation, and serial computed tomographic scans showed decrease of aneurysmal size.     

Current management of extracranial carotid artery disease

Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year; 80% are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter, randomized, controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis and compare these data to a critical analysis of the recent results of CAS.     

A case of radiation induced aneurysm of extracranial carotid artery

An unusual case of post-irradiation aneurysm of extracranial internal carotid artery is presented. A 70-year-old man, complaining of left cervical throbbing mass with focal pain, was admitted on February 8, 1985. It was noted, from his past history, that he had had surgery of the removal of cervical lymph-nodes and that unknown dosage of irradiation had been added to the cervical region 30 years before. Left carotid angiography (on admission) demonstrated a giant aneurysm in the cervical portion of internal carotid artery. Right carotid angiography with compression of left carotid artery revealed good cross filling through anterior communicating artery. Computed tomography with contrast media showed a ring like enhanced mass, which was thought to showed a ring like enhanced mass, which was thought to suggest that a large part of the aneurysm was filled with intraluminal thrombosis. During 30 days of evaluation, the aneurysm grew larger and his cervical pain became untolerable. Operation, the resection of the aneurysm and the reconstruction (of circulation) with vein graft, was challenged n March 12. It was so difficult with meticulous work that the ligation of left common carotid artery was performed after all. Seven days after the operation, he suffered from the gastrointestinal bleeding, which was enough to lead him to hypovolemic shock. Thereafter, right hemiparesis and aphasia were brought about. Two months later, he die of pneumonia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Improved quality of life among patients with symptomatic carotid artery disease undergoing carotid endarterectomy

BACKGROUND: Few studies have examined how carotid endarterectomy affects patients' view of their quality of life. METHODS: Patients undergoing carotid endarterectomy from January 1996 to March 1997 at the John Radcliffe Hospital completed the United Kingdom Short Form 36 (SF-36) Health Survey Questionnaire before undergoing the procedure and again at 3 months afterward. Scores were compared with population normal values. RESULTS: In 50 patients with symptomatic carotid artery disease, there was significant improvement in the SF-36 overall "change in health" score after the procedure compared with beforehand (61.0 +/- 3.7 vs 44.5 +/- 3.4, P =.003, Wilcoxon signed rank test). There were, however, no statistically significant differences in the group's mean SF-36 subscores after operation compared with before the procedure. The physical subscores were below age-adjusted healthy population means but similar to those for chronically ill patients (physical function subscore P =.015 vs normal, P =.89 vs ill; role limitation-physical subscore P =.007 vs normal, P =.89 vs ill). Patients with postoperative complications did not have an improved change in health score (-12.5 vs 22.0, P =.03, Mann-Whitney U test). There was no effect on change in health score because of other risk factors or in patients with contralateral carotid artery occlusion or a history of preoperative stroke. CONCLUSIONS: Patients with symptomatic carotid artery disease undergoing an uncomplicated carotid endarterectomy perceive improved quality of life and overall health. There is no perception of worsened pain, energy, or physical or mental function after the procedure. These results confirm that patients believe that performance of carotid endarterectomy improves their overall health, supporting the surgical approach to carotid artery disease.     

Autopsied case of an extracranial internal carotid artery dissecting aneurysm

An autopsy case of extracranial internal carotid artery (ICA) dissecting aneurysm due to atherosclerosis was reported. A 74-year-old man was admitted to our hospital with the chief complaints of hoarseness and a pulsatile mass below the left mandibular angle. Neurological examination showed no obvious deficits except left recurrent laryngeal nerve palsy. Angiography revealed narrowing of the original segment of left ICA with dissection and aneurysmal dilation at the level of C3 vertebra. Seven days after admission, the patient had a sudden onset of consciousness disturbance. The second angiography showed no obvious changes compared with the first findings except slight narrowing in the distal portion above the aneurysmal dilation. The possible mechanism was thought to be recanalization following transient occlusion of the left ICA caused by extension of dissection or intracranial embolism due to a thrombus within the aneurysm. He was managed conservatively, but unfortunately he died of pneumonia. Macroscopic autopsy showed that the aneurysm was fusiform. Histologically, it demonstrated dissection of the hematoma between the media and adventitia layer. Hemorrhage in the atheromatous plaque with disruption of the elastic lamina were observed along with severe degenerative changes of the intima, media and, in part, adventitia layer due to atherosclerosis. In addition, a dissecting aneurysm of the right iliac artery and severe arteriosclerosis were observed in the systemic arteries. On the basis of these findings, the dissecting aneurysm presumably developed after disruption of a weak portion of the atherosclerotic wall, where intraplaque hemorrhage occurred earlier. We suggest that atherosclerosis be regarded as one of the pathogenic factors capable of causing dissecting aneurysm of the extracranial ICA in elderly patients.     

Unbranched-site aneurysm of intracranial internal carotid artery]

Most intracranial saccular aneurysms arise from the angle between a parent vessel and an arterial branch. Saccular aneurysms without relation to any arterial branch are rare. During the last 24 years, 210 patients with intracranial internal carotid artery (ICA) aneurysms were directly operated on at our institution. We found eight saccular aneurysms arising from intracranial ICA without relation to any arterial branch. So we call them unbranched-site aneurysms of intracranial ICA, and describe their unique characteristics. Of the eight cases with unbranched-site aneurysm of intracranial ICA, three were men and five were women. The age ranged from 31 to 61 years with an average age of 48. Seven cases suffered a subarachnoid hemorrhage due to ruptured unbranched-site aneurysm, and the other case had been admitted to our department because of accompanying ruptured left internal carotid-posterior communicating aneurysm. All cases of unbranched-site aneurysm presented intraoperative and/or angiographic findings of arteriosclerosis, and five of the patients had a past history of hypertension. Of the four unbranched-site aneurysms at the C2 portion of ICA, two arose from the lateral wall, one arose from the superior wall and the other arose from the infero-lateral wall of ICA. Of the four unbranched-site aneurysms at the C1 portion of ICA, three arose from the superior wall and the other arose from the supero-medial wall of ICA. Radical operation was performed in all cases and intraoperative rupture occurred in two cases. It was suggested that arteriosclerotic change in the arterial wall, and local hemodynamic stress played important roles in the development of unbranched-site aneurysms of intracranial ICA.     

Computed tomographic evaluation of extracranial carotid artery disease

Axial computed tomographic (CT) scans after intravenous contrast infusion were used to image the cervical carotid arteries of patients with cerebral ischemic symptoms. Standard transfemoral cervical carotid and cerebral angiography was the principal diagnostic modality used in all patients studied. The angiographic results were compared to the CT images and to the gross and microscopic endarterectomy pathological specimens, when available. Examples of the various types of abnormalities that can be visualized using CT scans are presented. The CT scan was useful for determining the presence of degenerative atheromatous changes including carotid artery calcification, subintimal hemorrhage, carotid occlusion, carotid segmental occlusion, and carotid pseudoocclusion, as well as carotid artery dissection. The scans were particularly useful for identification of atheromatous carotid artery disease when the carotid angiogram appeared nearly normal and for identifying the cause of postoperative carotid stenosis. CT scanning allows visualization of the carotid artery wall and lumen rather than just the lumen and, consequently, can sometimes add helpful information about the pathological processes affecting this artery.     

Ruptured intracranial aneurysm associated with spontaneous occlusion of internal carotid artery

Summary Out of 921 patients diagnosed and treated for intracranial aneurysm in 5 cases (0,5%) the co-existence of ruptured aneurysm and occlusion of the internal carotid artery was found. 4 patients were treated surgically-aneurysm clipping-without serious post-operative complications and 6 months follow-up showed satisfactory results. In 4 of 5 cases the aneurysm was located on the anterior communicating artery (ACA); this fact may support the hypothesis concerning a possible role of enhanced blood flow in aneurysm formation and rupture. In cases with good collateral blood flow extra-/intracranial bypass before aneurysm occlusion seems not to be necessary. The risk of operation in those patients is not as high, as might be expected.