Systemic multiple aneurysms of the extracranial internal carotid artery, intracranial vertebral artery, and visceral arteries: case report.

A rare case of systemic multiple aneurysms located in the extracranial internal carotid artery, intracranial vertebral artery, and intraperitonial arteries is described. A 56-year-old woman was referred to our hospital with suspected rupture of an aneurysm of the right extracranial internal carotid artery. Digital subtraction angiography demonstrated a giant aneurysm in the right extracranial internal carotid artery and an aneurysm of fusiform type of the left intracranial vertebral artery. The extracranial carotid artery aneurysm was successfully resected, with end-to-end anastomosis of the internal carotid artery, preserving the cranial nerves. Five days later, an aneurysm of the left hepatic artery ruptured unexpectedly and was treated with emergency surgery. Other aneurysms in the liver and spleen were identified on postoperative celiac angiography. The patient subsequently underwent an operation for a left intracranial vertebral artery aneurysm by proximal clipping.     

Management of inoperable cerebral aneurysms by the navigational balloon technique

Intravascular navigation with nondetachable balloons is a safe, effective method of treatment for inaccessible aneurysms of the internal carotid artery. The rate of ischemic complications is lower than that associated with carotid ligation, and the rate of subsequent hemorrhage is lower than that associated with either carotid ligation or direct clipping. Therefore, for many internal carotid artery aneurysms that originate at or proximal to the ophthalmic artery, the nondetachable balloon technique is an alternative treatment choice. During a 7-year period, 21 aneurysms of the internal carotid artery were treated by the nondetachable balloon technique. All 21 aneurysms were successfully excluded from the circulatory system by either proximal occlusion or trapping of the aneurysm neck. This series consisted of 8 carotid-ophthalmic artery aneurysms, 11 carotid-cavernous aneurysms (6 spontaneous, 5 traumatic), 1 petrous segment aneurysm, and 1 cervical segment aneurysm. At 3 years of follow-up, the following incidences were noted: transient ischemia, 4.7%; infarction, 9.6%; and hemorrhage, 0%. The complications were 1 case of transient hemiparesis and 2 late ischemic events. Fifty per cent of the patients underwent follow-up computed tomography, and thrombosis of the aneurysm was confirmed in all except one case, which was partially thrombosed.     

An operative complication in a patient with a true posterior communicating artery aneurysm: case report and review of the literature

Intraoperative oculomotor nerve injury in a patient with a true posterior communicating artery aneurysm is reported in detail. A comparison of internal carotid artery aneurysms at the posterior communicating artery junction with true posterior communicating artery aneurysms deserves special attention, because the vascular relationships of the aneurysm are more complex. A clip along the internal carotid artery does not occlude blood flow to the aneurysm, and the aneurysmal neck and the distal posterior communicating artery are closer to the oculomotor nerve. This is the 27th reported case of a true posterior communicating artery aneurysm. The incidence of true posterior communicating artery aneurysms ranges from 0.1 to 2.8% of all aneurysm patients. Such aneurysms constitute 4.6 and 11% of so-called posterior communicating aneurysms in two series. Difficulty associated with a preoperative diagnosis has been documented in at least 4 cases. An awareness of this rare aneurysm is stressed in order to avoid operative complications.     

Direct surgery for carotid bifurcation artery aneurysms

Eighteen patients with bifurcation of internal carotid artery aneurysms were treated with direct surgery. In all cases the pterional approach was used. The strategy used in dissecting the aneurysm depends on the size of the aneurysm and the length of the intracranial internal carotid artery. When the aneurysm is small, the bifurcation of the internal carotid artery can be exposed by dissecting along the internal carotid artery from a proximal-to-distal direction. The aneurysm and the perforating vessels adjacent to it are identified before the aneurysm is clipped. When the aneurysm is not small or if the intracranial segment of the internal carotid artery is long, the sylvian fissure has to be dissected open before dissection of the aneurysm and perforators is undertaken. Using this dissection strategy, 18 bifurcations of internal carotid artery aneurysms were clipped with 16 excellent, one good, and one fair result. There was no mortality.     

Bilateral internal carotid artery aneurysms.

Two patients were treated for bilateral internal carotid artery aneurysms. One had resection and restoration of continuity on the right side nine years after ligation of the left internal carotid artery. The second had sequential resection and reconstruction of both vessels. Complications of carotid aneurysms include embolization, rupture, and thrombosis. Preferred treatment is resection with reconstitution of the flow. Patients with carotid aneurysms should be investigated for similar lesions on the opposite side. Patients who have had one carotid aneurysm treated should be followed up for the possible occurrence of a contralateral aneurysm.     

Follow-up study of unruptured aneurysms arising from the C3 and C4 segments of the internal carotid artery

A follow-up study of unruptured aneurysms arising from the C3 and C4 segments of the internal carotid artery was performed. During the 10-year period from 1979 to 1989, there were 22 patients with 24 aneurysms arising from the C3 or C4 segment of the internal carotid artery. All 24 aneurysms were unruptured. They represented 3% of all intracranial aneurysms and 11% of all internal carotid artery aneurysms diagnosed at the hospital during the 10-year period. Eighteen patients were women and 4 were men. Their ages ranged from 34 to 82 years (mean 63.3 years). Of the 22 patients, 12 (55%) had multiple aneurysms. A follow-up study without treatment was made in 15 of the 22 patients who had a total of 16 unruptured aneurysms arising from the C3 or C4 segment of the internal carotid artery. This study excluded 7 of the 22 patients with a total of eight aneurysms because of operation or death soon after diagnosis. The average maximal dimension of the 16 aneurysms was 5 mm, with a range of 2-17 mm. Follow-up periods varied from 11 months to 10.5 years, with an average of 4.7 years. During this period, none of the 16 aneurysms ruptured, and they remained asymptomatic, except for one aneurysm that had been discovered as a result of the cavernous sinus syndrome. Some surgeons are now attempting direct operations on intracavernous carotid artery aneurysms, even if the aneurysms are unruptured and relatively small.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical treatment and radiological consideration of supergiant cerebral aneurysms

We have collected four cases of supergiant cerebral aneurysm, each greater than 6.0 cm in diameter. Two of these cases were saccular aneurysms of the anterior communicating artery and middle cerebral artery, of which the necks were clipped with resection of the aneurysms. Another patient had a fusiform aneurysm of the middle cerebral artery, which was resected accompanied by a reconstructive procedure of cerebral blood flow. The last patient had a fusiform aneurysm of the internal carotid artery. Following internal carotid artery occlusion surgery with superficial temporal artery-middle cerebral artery anastomosis, the aneurysm completely disappeared radiologically within several months.     

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.     

Autologous repair of an internal carotid artery aneurysm by resection, caliber reduction, and external mesh tube reinforcement in a 9-year-old boy

Extracranial internal carotid artery aneurysms in children are rare, with a reported incidence of 0.5% to 1.9% in internal carotid artery aneurysm operations compared with all carotid operations in adult patients. We report a case of surgical reconstruction of an extracranial internal carotid artery aneurysm in a 9-year-old boy. Our patient complained of episodic neck pain on the left site under the mastoid process for the last year. The child was otherwise healthy. Autologous reconstruction without graft interposition was planned. Surgical repair was performed by resection of the main body of the aneurysm and restoration of the arterial continuity with end-to-end anastomosis. Because nondilated proximal and distal vessels could not be approximated, the most distal end of the aneurysm was tapered over a mandril. To prevent redilation, a tubular polyester external stent was fitted around the diseased segment.     

Some observations on aneurysms of the proximal internal carotid artery.

The author reports on 41 aneurysms of the proximal internal carotid artery (PICA) demonstrated in 36 patients with subarachnoid hemorrhage. The patients included a striking preponderance of women, and there was a high incidence of multiple aneurysms. In cases with multiple aneurysms the PICA aneurysm was usually found incidentally, a more distal aneurysm on the internal carotid artery being the source of hemorrhage. An infundibulum at the origin of a posterior communicating artery was unusually common in these patients. The origin of the ophthalmic artery is proposed as the angiographic landmark of the level at which the internal carotid artery penetrates the dura mater.     

Surgical management of aneurysms in the cavernous sinus

Summary A series of 32 patients with aneuryms in the cavernous sinus region is presented. All of them have been operated upon through an intradural pterional approach and the aneurysms directly attacked. Only in 6 patients was the complete dissection of the internal carotid artery and of the aneurysm impossible because of the size of the aneurysms. In these cases the aneurysm has been traped by ligation of the internal carotid artery in the neck and its supraclinoid course and at the same time and extracranial intracranial anastomosis performed. One patient died from massive cerebral infarction after a trapping procedure and another died from a transoperative haemorrhage; another two developed a moderate hemiparesis which resolved within the first six postoperative weeks, and in two patients a preoperative severe visual impairment progressed postoperatively to complete visual loss. All others had a complete resolution of their preoperative symptoms and remained well.The advantages and disadvantages of the different approaches to intracavernous carotid artery aneurysms are discussed and the related literature reviewed.Presented at the European Congress of Neurosurgery, Barcelona, September 1987.     

Surgical management of carotid artery aneurysm with ball valve thrombus

Operative repair of extracranial carotid artery aneurysms has been infrequently reported. A unique case is presented in which an aneurysm of the cervical internal carotid artery contained a ball valve thrombus. The patient experienced transient ischemic attacks whenever a position was assumed which permitted occlusion of the internal carotid artery by the free floating thrombus. The aneurysm and thrombus were successfully resected and primary anastomosis of the internal carotid artery carried out to the common carotid artery. The patient has remained free of cerebrovascular ischemic symptoms for 18 months following operative repair. The previously reported surgical experience with extracranial carotid artery aneurysms is reviewed.     

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.     

Port wine nevus associated with ipsilateral saccular aneurysms: treatment by intraarterial balloon trapping

A 21-year-old woman with a port wine nevus presented with ipsilateral monocular visual loss. A computed tomography scan of the brain revealed a round suprasellar mass. Angiography demonstrated aneurysm of the right external carotid artery, and petrous, cavernous, and giant ophthalmic internal carotid aneurysms. Four detachable balloons were deployed with arteriographic guidance, resulting in occlusion of the right carotid artery. The association of aneurysms and phakomatoses is discussed. The use of detachable balloons in the treatment of nonresectable aneurysms represents a safe and advantageous option. The use of detachable balloons for carotid occlusion has proven to be an effective modality in the treatment of giant supraclinoid and carotid-cavernous aneurysms. Giant intracranial aneurysms have been surgically treated with carotid ligation proximal to the aneurysm and by direct approach using microsurgical technique. In cases in which direct ligation is not possible balloon occlusion represents an effective alternative. This case illustrates treatment by carotid trapping performed entirely with intraarterial balloons. In addition the association of saccular aneurysms in a patient with a port wine facial nevus is reported.     

Treatment of intracranial aneurysms by combined proximal ligation and extracranial-intracranial bypass with vein graft

Seven patients with internal carotid artery aneurysms, and one patient with a middle cerebral artery aneurysm, were managed by combining proximal ligation with an extracranial-intracranial bypass procedure. Five bypasses were done with an interposed vein graft between the external carotid artery and the distal middle cerebral artery (vein graft), and three were superficial temporal-middle cerebral artery bypasses (superficial temporal artery grafts). As demonstrated in postoperative angiograms, all eight patients had patent bypasses with nonfilling of the aneurysm. One patient developed transient dysphasia, but there were no permanent neurological deficits associated with carotid occlusion. Four patients had resolution of their neurological problems, and another three patients improved. The distribution of flow from vein grafts is more extensive than from superficial temporal artery grafts. This offers increased protection against ischemia, and increases the likelihood of internal carotid artery aneurysm thrombosis by reducing the turbulence in the distal internal carotid artery.     

Thrombosis of difficult intracranial aneurysms by the endovascular placement of platinum-Dacron microcoils.

Patients with symptomatic aneurysms that are not excluded from the cerebral circulation have a poor prognosis. Standard treatment is surgical exploration with direct clipping of the aneurysm. Because of their large size or relationship to the base of the skull, some aneurysms may not be suitable for direct surgical clipping and may require alternative treatment modalities. A prospective clinical and radiological study of seven patients treated with the endovascular placement of platinum-Dacron microcoils to exclude the aneurysm from the cerebral circulation is reported. The seven patients ranged in age from 37 to 63 years; four were women. At completion of the endovascular procedure, total occlusion of the aneurysm with preservation of the parent artery had been achieved in four patients and 90% occlusion of the aneurysm in two. In the seventh patient, occlusion of the internal carotid artery resulted in the patient's death. At the 6-month follow-up review, both patients with an aneurysm less than 20 mm in size had persistent aneurysm thrombosis; however, the two patients with giant aneurysms had partial recanalization. Both required repeat thrombosis of their aneurysm with the placement of additional microcoils, one at 6 weeks and one at 6 months. These two patients have persistent aneurysm thrombosis at 12 months following their second procedure. The patient mortality rate for this study was 14%, while the procedure mortality/morbidity rate was 9%. It is concluded that thrombotic aneurysm therapy of difficult aneurysms is a safe procedure and will have a place in the treatment of selected aneurysms.     

Aneurysm of the extracranial internal carotid artery

Aneurysm of the extracranial internal carotid artery is a rarely observed condition. Intra-aneurysmatic thrombosis, cerebral embolism with possible neurological consequences, and rupture are the most common complications. Operations were performed on 20 patients for aneurysm of the internal carotid artery. The cases included 14 "genuine" arteriosclerotic aneurysms and seven "false" aneurysms in the wake of shell splinter injuries, tonsillectomy, thrombo-arteriectomy, and blunt traumata. Pulsating tumour was the most important clinical symptom in all aneurysm cases. Arterial continuity was restored by resection of aneurysm in all cases. Sixteen patients were dehospitalised without any complaint. Two patients with preoperative cerebral infarction were left with residual paresis. One patient died of pulmonary embolism, and one patient operated on for rupture died in shock.     

Balloon-assisted microvascular clipping of paraclinoid aneurysms. Technical note

Paraclinoid aneurysms represent a significant surgical challenge. Multiple techniques have been developed to maximize the effectiveness and safety of excluding these aneurysms from the cerebral circulation. Endovascular balloons have been used for proximal control of parent arteries during the treatment of aneurysms. In this report the authors describe the technique of navigating an endovascular balloon across the neck of paraclinoid aneurysms in four patients to gain proximal control, improve the accuracy of clip placement, and reduce the risk of distal embolization of intraluminal thrombus. Six consecutive patients with giant or complex aneurysms of the ophthalmic or paraclinoid internal carotid artery that were not amenable to endovascular obliteration were retrospectively analyzed. In all six patients, the aneurysm was exposed and dissected for microsurgical clipping, and attempts were made to navigate a nondetachable, compliant silicone balloon across the neck of the aneurysm. If successfully placed, the balloon was inflated during clip placement. In four patients, the balloon was successfully navigated across the neck of the aneurysm and was inflated during clip application. Internal carotid artery tortuosity precluded navigation of the balloon into the intracranial circulation in two patients. All aneurysms were completely excluded from the parent vessel according to postoperative angiography studies. No complication occurred as a direct result of the endovascular portion of the procedure. Endovascular balloon stenting of complex paraclinoid aneurysms during microvascular clipping may provide an adjunctive therapy that facilitates safe and accurate clip placement.     

Endovascular treatment of large petrous internal carotid artery aneurysm associated with chronic otitis media: case report

Aneurysms of the petrous internal carotid artery are rare, and surgical treatment of the aneurysm in the petrous bone carries high risk with procedure. We report a case of large petrous internal carotid artery aneurysm associated with otitis media. A 58-year-old female was admitted to our institution with left hearing loss and facial palsy. She had 4-year history of left exudative otitis media. Imaging studies demonstrated a 17 mm left petrous internal carotid artery aneurysm, destroying osseous partition between carotid canal and Eustachian tube, and protruding into left middle cranial fossa. Endosaccular coil embolization with balloon assist technique was performed successfully without neurological deficit. Follow up magnetic resonance angiogram demonstrated complete obliteration of the aneurysm without parent artery occlusion. Traumatic, mycotic, radiation, and congenital origin have been implicated for petrous internal carotid artery aneurysm. In a review of the literature, 11 cases of mycotic aneurysms in this location were reported and all of them were complicated with chronic otitis media. Because of its close proximity of middle ear and Eustachian tube, adventitial infection of the artery weakens the arterial wall, and gives rise to formation of aneurysm. We conclude that our case is of mycotic origin, and endosaccular coil embolization is effective and less invasive treatment.     

Surgical treatment of atherosclerotic and dysplastic aneurysms of the extracranial internal carotid artery.

Atherosclerotic and dysplastic aneurysms of the extracranial internal carotid artery are rare in Japan. We have experienced only four cases since 1982. The patients were two men and two women with a mean age of 67 years (range 51 to 82 years). All four patients had a saccular type aneurysm; sizes ranged from 30 to 75 mm. Aneurysmectomy and end-to-end anastomosis of the internal carotid artery could be performed in two patients. One patient underwent aneurysmorrhaphy followed by primary closure of the internal carotid artery, and the remaining patient underwent aneurysmectomy followed by a prosthetic graft replacement (6 mm-PTFE graft). During aneurysm repair, simple arterial cross-clamping (time 18 to 57 min; mean +/- SD: 31.3 +/- 18.0 min) was used in all patients. During arterial clamping of the carotid artery in two patients, somatosensory evoked potentials and regional cerebral oxygen saturation detected by near-infrared spectroscopy remained within normal ranges. All patients survived without neurologic deficits. These findings indicate that intraluminal shunting may be unnecessary during aneurysm repair if the patient does not have obstructive disease in the contralateral carotid artery and if no somatosensory evoked potentials or regional cerebral oxygen saturation abnormalities occur during proximal arterial clamping. After aneurysmectomy, end-to-end anastomosis of the internal carotid artery is the preferred method of repair if the length of the distal internal carotid artery permits.