Bilateral aneurysms of the cavernous internal carotid arteries following yttrium-90 implantation

Refractory De Novo Multiple Cerebral Aneurysms After Radiotherapy and Multistaged "Open" Surgical Treatment for Low-Grade Glioma During Long-Term Follow-Up: A Case Report and Review of the Literature

Background

Radiation-induced aneurysms have been previously reported; however, multiple and repeated de novo aneurysm formation chronologically and anatomically during long-term follow-up have not yet been observed. The pathogenesis of persistent radiation-induced vasculopathy is not fully understood.

Case Description

A 31-year-old woman presented with intraventricular hemorrhage due to rupture of a right internal carotid artery (ICA) aneurysm that developed 17 years after surgical resection of a low-grade glioma in the right frontal lobe and postoperative radiotherapy (focal, 50 Gy/25 fractions). During glioma follow-up, salvage surgery with adjuvant gamma knife therapy and chemotherapy (ranimustine, vincristine, temozolomide) were performed for recurrence of the glioma. The aneurysm was treated with endovascular coil embolization. However, she experienced repeated intraventricular hemorrhages, and angiography revealed a de novo ICA aneurysm. The de novo aneurysms were treated with endovascular surgery using coil embolization and stenting. At 2 years after the third hemorrhage, the surgical wound became dehiscent, probably due to wound infection, thus epicranial soft tissue reconstruction using vascularized skin flap was performed. Despite multistaged endovascular surgery for the ICA aneurysm, she experienced repeated subarachnoid and intraventricular hemorrhages. Angiography revealed a de novo aneurysm of the right posterior cerebral artery and basilar trunk. She underwent coil embolization and stenting. Despite active management with endovascular surgery and close follow-up, she died after an eighth consecutive intraventricular and intracerebral hemorrhage caused by a de novo large aneurysm of the posterior cerebral artery.

Conclusions

To the best of our knowledge, the present study is the first to report on of refractory and recurring de novo aneurysms treated by multistaged endovascular surgery during a long-term follow-up after radiotherapy and multistaged craniotomy for glioma.

Intracranial aneurysms formation after radiotherapy for head and neck cancer: a 10-year nationwide follow-up study

Background

Intracranial aneurysms after radiotherapy (RT) have previously been reported. However, the majority of studies were case reports. Therefore, we performed a nationwide study to explore the risk of radiation-induced intracranial aneurysms.

Methods

This study included patients diagnosed with head and neck cancer (ICD9: 140–149, 161). Intracranial aneurysms formation was identified using the following ICD9 codes: nonruptured cerebral aneurysm (ICD9:4373), aneurysm clipping (ICD9:3951). Patients who did not receive curative treatment and those with intracranial aneurysms before the diagnosis of head and neck cancer were excluded.

Results

In total, 70,691 patients were included in the final analysis; they were categorized into the following three groups: nasopharyngeal carcinoma (NPC) with RT, non-NPC with RT, and non-NPC without RT. Patients in the NPC with RT group had the highest risk of developing intracranial aneurysms (hazard ratio (HR) 2.57; P <  0.001). In addition, hypertension was also a risk factor of developing intracranial aneurysms (HR 2.14; P <  0.01). The mean time interval from cancer diagnosis to intracranial aneurysm formation in the NPC with RT group was 4.3 ± 3.1 years.

Conclusions

Compared with the non-NPC with RT and the non-NPC without RT groups, patients with NPC who received RT had a higher risk of developing intracranial aneurysms.

Endovascular glue embolization of a radiation-induced lenticulostriate artery pseudoaneurysm in a pediatric patient with optic pathway glioma: Case report and review of literature

Radiation-associated vascular changes most commonly present in the form of stenosis, thrombosis and occlusion. However, development of intracranial aneurysms secondary to radiation is far less common and often manifests with rupture. These aneurysms are difficult to treat and associated with high morbidity and mortality when ruptured compared with saccular aneurysms unrelated to radiation treatment. Both surgical and endovascular options are available for treatment of these aneurysms. We present a young patient with a radiation-induced intracranial pseudoaneurysm arising from the lenticulostriate branch of the left middle cerebral artery (MCA); this developed 1 year 4 months after 59.4 Gy of focused radiation to the suprasellar pilomyxoid astrocytoma. The patient successfully underwent endovascular glue embolization of the aneurysm and occlusion of the lenticulostriate artery after unsuccessful trapping of the aneurysm and occlusion of the parent artery using coils. She developed transient hemiparesis of the right side following the procedure, which was managed conservatively. We performed a complete review of the literature dealing with the radiation-induced intracranial aneurysms, their presentation, treatment and outcome.

Radiotherapy-related intracranial aneurysm: case presentation of a 17-year male and a meta-analysis based on individual patient data

PURPOSE

The aim of this study was to investigate the incidence, clinical profiles, latency, and outcomes of radiotherapy (RT)-related intracranial aneurysms, rare but often fatal complications of cranial irradiation.

METHODS

We reviewed all published individual patient data regardless of language, using survival analysis to make statistical inferences.

RESULTS

We examined a total of 58 patients with RT-related intracranial aneurysms, including one unpublished case presented here, of whom 74.1 % presented with rupture. In the study, 29.3 % were younger than 18 years. The mean age at which patients received the first course of RT was 34.8 ± 22.8 years old. The mean latency between initiating RT and presenting with aneurysm was 10.4 ± 8.5 years. Rapid death ensured in 24 % shortly after presentation. The only significant predictor of death was rupture. In those with a single aneurysm, 43.1 % were located at the internal carotid artery, while 15.5 % of patients had multiple aneurysms. A male-to-female ratio of 1.87, 0.5, and 1.32 was found in patients younger than age 52, 52 years of age or older, and all 58 patients, respectively. Older age when receiving RT and presentation with ruptured aneurysm were significantly associated with shorter latency.

CONCLUSIONS

RT-related intracranial aneurysms presented differently from classical ones based on age, sex, site, multiplicity, and type. Sex ratios differed with age. The younger age group showed a longer latency of occurrence of an aneurysm. Older patients and those who develop ruptured aneurysms presented earlier. Since rupture may affect outcome, early detection of aneurysms before rupture may save lives.

Ruptured internal carotid artery aneurysm presenting with catastrophic epistaxis after repeated stereotactic radiotherapies for anterior skull base tumor: case reports and review of the literature

Objectives Radiation-induced aneurysm is a rare complication for head and neck tumors. Only seven cases of an aneurysm after stereotactic radiosurgery and/or stereotactic radiotherapy (SRT) have been described. We report two patients with a ruptured internal carotid artery (ICA) aneurysm presenting with catastrophic epistaxis after repeated SRT for an anterior skull base tumor.

Results Two male patients received repeated SRT in various combinations following surgery for an anterior skull base tumor. They presented with significant epistaxis due to rupture of the aneurysm of the ICA 6 and 77 months after the final SRT, respectively. The aneurysms were located within the radiation field. Preoperative angiography had revealed no aneurysms. Thus the aneurysms in these cases were most likely induced by the repeated SRT.

Conclusions This is a proven report of aneurysm formation following repeated SRT without conventional radiotherapy. SRT may be very effective to control malignant skull base tumors. However, the possible development of radiation-induced aneurysm of the ICA should be considered in the case of repeated SRT. The surviving patients who have received SRT should undergo sequential follow-up for possible vascular involvement.

Radiation-induced cerebral aneurysm treated with endovascular coil embolization. A case report

Radiation-induced cerebral aneurysms are rare. We describe a case of radiation-induced cerebral aneurysm successfully treated with endovascular coil embolization. A 39-year-old man received 60 Gy of radiation to a pineal germinoma at eight years old. The left internal carotid artery (ICA) aneurysm which developed within the irradiated field and stenotic change in the left ICA due to radiation-induced vasculopathy were detected incidentally. Because these aneurysms show a high risk of rupture and mortality, and even small aneurysms are prone to rupture, any such suspected aneurysm should be treated with surgical or endovascular procedures. Endovascular treatment is probably useful if the aneurysm is inaccessible to direct surgery. Special attention must be paid to treatment because of stenotic changes in cerebral vessels within the irradiated field.

Evolution of management strategies for cavernous carotid aneurysms: a review

OBJECTIVE

Cavernous carotid aneurysms are considered benign lesions with indolent natural history. Apart from idiopathic aneurysms, traumatic, iatrogenic, and mycotic aneurysms are common in the cavernous segment of the carotid artery. With rapid advances in endovascular therapy, management of cavernous carotid aneurysms has evolved. Our aim was to review the management options available for cavernous carotid aneurysms.

METHODS

The English literature was searched for various studies describing the management of cavernous carotid aneurysms and the evolution of various treatments was studied.

RESULTS

Numerous treatment options are available such as conservative management, Hunterian ligation, surgical clipping, and endovascular therapy. The introduction of flow-diverting stents has revolutionized the management of these lesions. The evolution of various treatment strategies are described.

CONCLUSIONS

A thorough knowledge of all the options is paramount to individualize therapy. We discuss the indications of treatment, various management options for cavernous carotid aneurysms and their outcomes.

Ruptured pseudoaneurysm following Gamma Knife surgery for a vestibular schwannoma

A 75-year-old woman underwent Gamma Knife surgery (GKS) for a vestibular schwannoma. Eight years after GKS, she suffered sudden onset of headache. Computed tomography revealed diffuse subarachnoid hemorrhage around the cisterns of the posterior fossa. Right vertebral artery angiography showed an aneurysm arising from the lateral pontomedullary segment of the left anterior inferior cerebellar artery. The aneurysm was not located at a branching site. Trapping of the distal anterior inferior cerebellar artery aneurysm was performed, and the aneurysm was removed. The pathological features of this aneurysm are discussed. This aneurysm was diagnosed as a pseudoaneurysm pathologically. This is the first report of aneurysm formation with pathological findings following GKS for a vestibular schwannoma.

Bilateral intracavernous carotid artery aneurysms presenting as progressive cranial nerve palsies

Bilateral intracavernous carotid artery aneurysms are rare and can present with different clinical findings. We report such a case presenting with progressive cranial nerve palsies due to gradual increase in the size of aneurysms. This case demonstrates the clinician's difficulty in diagnosis when isolated cranial nerve palsy is the sole presenting sign.

Intracranial aneurysm following radiation therapy during childhood for a brain tumor. Case report and review of the literature

Ionizing radiation therapy is associated with pathological vascular changes in intracranial vessels, most commonly in the form of vessel thrombosis and occlusion. The development of an intracranial aneurysm following such therapy, however, is far less common. In this report the authors describe a 24-year-old man in whom a distal middle cerebral artery aneurysm developed 15 years after radiotherapy, which was given as adjuvant treatment following resection of a medulloblastoma. The patient underwent a craniotomy for microsurgical trapping of the aneurysm and was discharged without any neurological deficit. This case serves to remind clinicians of the possibility, albeit rare, that intracranial aneurysms may form following cranial radiotherapy.

Anterior communicating artery aneurysm following radiation therapy for optic glioma: report of a case and review of the literature

A 42-year-old female presented with subarachnoid hemorrhage (SAH), presumably from a radiation-induced anterior communicating artery aneurysm. Six years earlier, she had undergone radiation treatment for an optic glioma that was diagnosed based on imaging criteria. The aneurysm was successfully clipped, and the optic glioma was biopsied to verify the diagnosis histologically. Radiation-induced cerebral aneurysms often manifest with a fatal SAH. These aneurysms typically develop in the field of radiation and are diagnosed a mean of 8.52 years after radiation. Rarely, the aneurysm sac thromboses spontaneously. Clipping or coiling of the aneurysm can be an effective treatment.

Magnetic resonance imaging features of pituitary yttrium-90 rod implantation

Intersellar implantation of yttrium-90 rods was a common treatment for a variety of pituitary tumours in the 1960s and 1970s. The magnetic resonance (MR) imaging features in three patients with implants (two for growth hormone-secreting and one for prolactin-secreting pituitary adenomas) are presented: the implants appeared as low signal cylinders with no image distortion, in contradistinction to CT where the implants generate beam hardening and back projection artefacts. Confident evaluation of the pituitary fossa for residential tumour and sequelae of therapy could be made on MR. It is the imaging technique of choice in the follow-up of patients treated with yttrium-90 implants.

Rapid saccular aneurysm induction by elastase application in vitro

OBJECTIVE

To develop a new saccular aneurysm model in vitro using elastase to study aneurysm initiation, growth, and rupture and to create a new in vivo aneurysm model to test endovascular therapies.

METHODS

Seventeen common carotid arteries excised from freshly killed pigs and sheep were treated with seven different methods of elastase delivery. The arteries were mounted in a saline-filled flow chamber. They received pulsatile flow for 48 hours, or until the resulting aneurysms ruptured. Changes were continuously monitored with video camera recordings and validated with histological sections.

RESULTS

All eight arteries treated topically, either on the intimal or on the adventitial surface, with elastase concentrations greater than 1 U/mm2, developed saccular aneurysms; five of them ruptured within 48 hours. All four arteries treated with surface concentrations of 0.1 U/mm2 via microcatheter infusion into the lumen developed fusiform aneurysms. None of the arteries that received surface concentrations less than 0.1 U/mm2 developed aneurysms. Histological sections revealed a reduced number of cellular element in a stretched collagen matrix at the dome of the saccular aneurysms.

CONCLUSION

After empirically testing several methods of elastase delivery, we were able to induce saccular, bifurcation-type aneurysms in animal arterial specimens. These aneurysms are histologically similar and more authentic than surgical models. The procedure is easy and reproducible. Our results suggest a possible enzymatic role in aneurysm formation and highlight the dramatic effects of selective arterial elastic damage. Also, the rapid growth of our experimental aneurysms may reflect the speed of the natural process.

False aneurysms of the intracavernous carotid artery--report of 7 cases

We present 7 cases of false intracavernous carotid artery aneurysms. Four occurred after trauma and three were caused iatrogenically. Two of the latter occurred in patients with pituitary adenomas, one after transsphenoidal microsurgery and the other after yttrium [YI90] seed implantation into the sella. The third iatrogenic aneurysm was seen shortly after transcavernous tumour surgery. In five of our seven patients massive, delayed, life-threatening epistaxis was the leading symptom. All traumatic cases were associated with immediate unilateral blindness or blurred vision and with skull base fractures. One of these had a concomitant carotid cavernous fistula. Treatment of choice of our 5 recent cases was permanent balloon occlusion of the intracavernous carotid artery at the level of the lesion. Collateral circulation was evaluated prior to definitive carotid occlusion using a balloon test occlusion. During the balloon test adequate collateral circulation was defined as symmetric angiographic filling of both hemispheres. Awake patients were neurologically examined continuously. In unconscious patients transcranial Doppler sonography, electroencephalographic and somatosensory evoked potential monitoring was used in addition. Intra-operative heparin administration was not reversed with protamin. A postoperative continuous heparin infusion was not found necessary. In our two early cases this technique was not available: In the first case we accomplished aneurysm occlusion by a surgically introduced Fogarty balloon catheter. Our second patient needed surgical trapping of the involved carotid after early unsuccessful attempts of selective aneurysm occlusion. After treatment no further epistaxis occurred. Follow-up angiography showed persistent aneurysm occlusion. The results were excellent in 5 cases and good in 1 case. One patient with bilateral lesions suffered a stroke after occlusion of the second, remaining carotid artery, despite functioning bilateral extra-intracranial bypasses. Four years later there is a mild dysphasia still present in this patient. The mean follow-up time was 75.6 months.