Extracranial internal carotid artery aneurysm in a child: a diagnostic and surgical challenge

Hybrid vascular intervention for a giant cervical carotid artery aneurysm in a clopidogrel-hyporesponsive child

Aneurysms of the extracranial internal carotid artery (ICA) in pediatric patients are rare and mostly treated surgically. The authors present the case of a child with a giant extracranial ICA aneurysm presenting with gradual airway compression. A plan was made to explore the aneurysm surgically and straighten the associated carotid artery kinks during the operation to enable further endovascular treatment if primary reconstruction of the carotid artery proved not to be possible. Finally, the aneurysm was successfully treated with staged hybrid intervention, which consisted of surgical correction of parent artery kinks followed by endovascular implantation of stent grafts. The child tolerated the procedure well without adverse events. A craniocervical CT angiogram at 5 months showed patency of the stent construct and relief of airway compression. However, a follow-up CT angiogram at 14 months showed total occlusion of the ipsilateral carotid artery without clinical sequelae and complete cessation of airway compression. The management of this was unique since the patient is the first reported case of clopidogrel hyporesponsiveness in a child undergoing neurovascular intervention with prasugrel monotherapy. Point-of-care testing-based adjustment of prasugrel necessitated education of the patient's family regarding the loss of effect of the prasugrel tablets upon crushing and contact with air.

True extracranial carotid artery aneurysm in a child

Isolated true aneurysm of the extracranial carotid artery is a rare entity in the pediatric population, with nine reported cases found in the literature. Contrary to adult carotid aneurysms, which are often due to atherosclerotic disease, pediatric aneurysms are more likely to be the result of congenital malformations, connective tissue diseases, or systemic inflammatory conditions. We present the case of a 10-year-old boy with an isolated true aneurysm of the internal carotid artery and a review of the literature.

Histological analysis of extracranial carotid artery aneurysms

Introduction

Extracranial carotid artery aneurysms (ECAA) are rare but may be accompanied with significant morbidity. Previous studies mostly focused on diagnostic imaging and treatment. In contrast, the pathophysiological mechanisms and natural course of ECAA are largely unknown. Understanding the pathophysiological background may add to prediction of risk for adverse outcome and need for surgical exclusion. The aim of this study was to investigate the histopathological characteristics of ECAA in patients who underwent complete surgical ECAA resection.

Material and Methods

From March 2004 till June 2013, 13 patients were treated with open ECAA repair. During surgery the aneurysm sac was resected and processed for standardized histological analysis. Sections were stained with routine hematoxylin and eosin and special stains to detect elastin, collagen, different types of inflammatory cells, vascular smooth muscle cells and endothelial cells.

Results

Histopathological characterization revealed two distinct categories: dissection (abrupt interruption of the media; n = 3) and degeneration (general loss of elastin fibers in the media; n = 10). In the degenerative samples the elastin fibers in the media were fragmented and were partly absent. Inflammatory cells were observed in the vessel wall of the aneurysms.

Conclusion

Histological analysis in this small sample size revealed dissection and degeneration as the two distinct underlying mechanisms in ECAA formation.

Extracranial carotid arteries aneurysms in children: single-center experiences in 4 patients and review of the literature

BACKGROUND

Extracranial carotid artery aneurysms (ECAAs) are very rare conditions in children but carry a great potential of thromboembolic episodes and ruptures.

METHODS

To determine the clinical and therapeutic characteristics of ECAA in children in our department, we reviewed the patients' records and completed the data from phone correspondence, written survey, and clinical examination.

RESULTS

From January 1981 to June 2006, 4 patients younger than 18 years were surgically treated for ECAA in our department. They were 3 boys and 1 girl. A medical history of tonsillectomy was reported in 3 patients. The aneurysm was symptomatic in all of the patients, local signs being present in every patient. The aneurysm caused hemispheric symptoms in 1 patient and finally stroke. The aneurysms were located in the common carotid artery, in the external carotid artery, and 2 in the internal carotid artery. The cause was congenital, mycotic, and traumatic (post tonsillectomy); for 1 patient, the etiology remained unknown. Aneurysm resection and interposition with vein graft were performed in 3 patients. The external carotid artery aneurysm was resected without reconstruction. There was no perioperative death or stroke. During the early follow-up period, 1 patient had a transient dysphagia and another a transient facial palsy. The patient with preoperative stroke remained with a neurologic deficit. All these patients were followed since the operation. The patient operated on in 1981 is asymptomatic after 25 years, but the graft became occluded 3 years after the operation. The patient who had recurrent attacks is still with residual neurologic deficit. The 2 other patients are without complains; the reconstructions remain patent.

CONCLUSION

Although very rare, ECAA can be encountered even in the pediatric population. The past medical history may reveal a tonsillectomy, although the relation may not be easy to establish. Local signs may be accompanied by hemispheric thromboembolic complications, rupture, and bleeding. Therefore, surgical treatment is indicated, but can be challenging according to the anatomical location of the aneurysm.

Aneurysma verum der Arteria carotis im Kindesalter

Extracranial aneurysms of the carotid artery in childhood are rare, and we found just nine cases described in the literature within the last 20 years. We report on the clinical appearance, diagnosis, and therapy of a carotid artery aneurysm in a 12-year-old girl and review the literature.

Anévrysme de l’artère carotide interne dans sa portion extracrânienne

INTRODUCTION

Extracranial aneurysm of the internal carotid artery is an exceptional finding.

CASE REPORT

An 89-year-old woman consulted for a peritonsillar mass. Physical examination revealed a parapharyngeal pulsatile mass in the oropharynx. Computed tomography (CT) provided the diagnosis of extracranial internal carotid artery aneurysm. Endovascular or surgical treatment were declined. Anticoagulation medication was given.

DISCUSSION

We reviewed the CT and magnetic resonance imaging findings and the clinical manifestations of extracranial internal artery aneurysm. Endovascular treatment is an alternative to open surgery.