Massive epistaxis after rupture of intracavernous carotid artery aneurysm. Case report

Cranial nerve palsies and intracranial aneurysms: A narrative review of patterns and outcomes

Background

Cranial nerve palsy (CNP) in patients with intracranial aneurysms (IAs) can impose significant burdens on a patient's quality of life. The literature has a paucity of reviews addressing patterns of overall reported cranial nerve (CN) involvement and outcomes in patients with IA.

Methods

The literature systematically reviewed CNP at presentation in the setting of IA using PubMed, Web-of-Science, and Scopus according to the PRISMA guidelines.

Results

Fifty-two studies reported a total of 513 patients with IA and 630 CNPs observed at presentation: oculomotor (58.25%), abducent (15.87%), optic (12.06%), trochlear (8.7%), and trigeminal (1.9%). Most common aneurysms are located in a posterior communicating artery (46%) and cavernous internal carotid artery (29.2%). Trends of CNP based on the rupture status of IAs showed that 80% were associated with unruptured IAs and 20% with ruptured IAs. Post-treatment of IA, 55% of patients had complete resolution of CNP, with most (89%; n = 134) resolving within the first 6 months. Stratified by CNP type: Complete resolution rate is 100% in CN VII-IX, 60% in CN VI, 59% in CN IV, 54% in CN III, 45% in CN V, and 43% in CN II.

Conclusion

In patients with cranial nerve palsies attributed to IAs, the location and rupture status of the aneurysm could determine the type and severity of the nerve palsy. Most patients experienced favorable outcomes in terms of their resolution and long-term function of the CNP after treatment of the IA.

Benign Natural Progression of Small Cavernous Carotid Aneurysms Suggests Limited Clinical Utility of Serial Longitudinal Follow-up

BACKGROUND AND OBJECTIVES

Aneurysms in the cavernous segment of the internal carotid artery (ICA) often present in an indolent fashion with limited morbidity. However, their growth progression and possible rupture over time remains poorly defined, thereby limiting optimization of serial follow-up. Thus, we aim to describe the progression of cavernous ICA aneurysms over time, as well as the patient and aneurysm characteristics associated with possible growth and rupture status.

METHODS

We identified a consecutive cohort of 157 patients from 2007 to 2021 with cavernous ICA aneurysms. Patient demographic data, possible risk factors, presenting symptoms, radiographic features of aneurysms, size progression, rupture status, and concomitant noncavernous aneurysm rupture data were manually extracted.

RESULTS

One hundred and fifty-seven patients (mean age at diagnosis 57.2 ± 15.6 years; 85.4% females) with 174 cavernous carotid aneurysms (CCAs) were followed for an average of 7.1 ± 4.8 years. 76.4% of aneurysms were identified incidentally, with predominantly ocular palsies as the presenting symptoms in remaining primary cases. Most aneurysms were small, and of the 168 aneurysms that were followed, 98.2% did not demonstrate appreciable growth. Of the aneurysms that grew, it took an average of 6.0 years to grow 1.6 ± 0.2 mm. Demographic data, hypertension, and smoking status were not associated with aneurysm growth. Most radiographic features also were not associated with growth, except long-axis diameter, which had an odds ratio of 1.4 (CI: 1.2, 1.8) on multivariable analysis. Presenting clinical symptoms were not associated with growth. No CCAs ruptured during follow-up.

CONCLUSION

Cavernous ICA aneurysms in our series demonstrate no rupture and limited growth over years of clinical follow-up. No radiographic or patient risk factors were associated with growth except initial aneurysm size. Hence, small CCAs may not require close follow-up over time.

Reconstruction of the sphenoid sinus erosion or dehiscence after treatment of unruptured intracavernous aneurysms with flow diverter stents

BACKGROUND

Intracavernous carotid aneurysms (ICCAs) are rare, frequently asymptomatic, with a low rupture risk, which, however, can lead to life-threatening epistaxis. The aim of this study was to assess the effect of the treatment of asymptomatic ICCAs with flow diverters (FD) on sphenoid bone erosion or dehiscence in a selected cohort of patients.

METHODS

We retrospectively reviewed all asymptomatic ICCAs with sphenoid bone erosion or dehiscence detected on cone beam CT (CBCT) and treated with FD between December 2018 and December 2022. Patients were followed-up with CBCT and bone reconstruction was blindly evaluated by two interventional neuroradiologists and classified as unchanged, partial, or complete.

RESULTS

A total of 10 patients (women: 90%, mean age 58 years) treated with an FD for an asymptomatic ICCA with associated sphenoid bone erosion or dehiscence were included in this cohort. Sphenoid bone erosion was present in seven patients and dehiscence was observed in the remaining three. After treatment with FD, complete reconstruction of the sphenoid sinus wall occurred in seven cases, and partial reconstruction in two cases. Sphenoid bone erosion remained unchanged after treatment in only one patient.

CONCLUSIONS

The decision to treat asymptomatic and unruptured ICCAs remains challenging due to their benign natural history and low hemorrhagic risk. The presence of sphenoid sinus erosion or dehiscence should not be overlooked since it could be considered as an indication for prophylactic treatment of life-threatening epistaxis. The mechanisms of bone erosion by the aneurysm and of reconstruction after treatment are still to be fully elucidated.

Nasopharyngeal Coil Dislocation of an Embolized Internal Carotid Artery Pseudoaneurysm

Objective

Severe epistaxis caused by ruptured intracranial pseudoaneurysms can be effectively treated by coil embolization. This is generally an efficient and safe procedure and provides sufficient protection recurrent epistaxis. However, complications such as aneurysm rupture, arterial dissection, bleeding, and emboli can occur. A dislocation of a nasopharyngeal coil is an extremely rare event. Patient. We present a case of a 61-year-old patient with a recurrent undifferentiated nasopharyngeal carcinoma (NPC) treated with severe epistaxis. Initially, epistaxis was successfully controlled by a nasal packing. Recurrent bleeding despite packing required a neuroradiological intervention. An intracranially ruptured pseudoaneurysm was detected by magnetic resonance imaging (MRI) and computed tomography (CT), originating from the internal carotid artery at the junction of the petrous part to the cavernous part. Coiling and endovascular plug embolization was performed for the treatment of aneurysm. Ten months later, the patient removed a foreign body out of his left nose. It was dislocated coil material due to radionecrosis. MRI confirmed sufficient embolization of the internal carotid artery.

Conclusions

This case report highlights the possibility of a nasopharyngeal coil dislocation of an embolized internal carotid artery aneurysm emerging as a nasal foreign body.

High-Flow Bypass with Radial Artery Graft for Cavernous Carotid Aneurysms: A Case Series

Background:

The incidence of cavernous carotid aneurysms (CCAs) of intracranial aneurysms is low. Majority of cases presented as incidental findings with benign natural progression. The most common presenting symptoms are multiple cranial neuropathies among symptomatic patients. The treatment modalities for symptomatic patients include direct surgical clipping, endovascular coil embolization, or placement of flow diverter, or indirect procedures such as occlusion of parent artery with and without revascularization techniques. The advancement in the microsurgical treatments and endovascular devices have enable a high success rate in the treatment of patients with CCAs with low morbidity and mortality rates.

Objective:

To study the surgical outcomes of patients with cavernous aneurysm who underwent high-flow bypass between 2015 and 2020 in our institution.

Materials and Methods:

A total of six patients in a single institution presented with CCAs who were treated with high-flow bypass surgery were included in this case-series. A single-case illustration was presented focusing on the details of surgical case management of CCA. The intraoperative middle cerebral artery (MCA) pressure monitoring during bypass surgery was also described.

Results:

All five female patients and one male patient who were diagnosed with cavernous carotid aneurysms were studied. The mean age was 68.8 years old (range: 24-84 years old) and the mean size of the aneurysm was 19.6mm (range: 9.7 – 30mm). There were successfully treated with high flow bypasses using radial artery graft without any neurological sequelae.

Conclusion:

The surgical treatments of cavernous carotid aneurysms should be limited to experienced neurosurgeons in view of significant risk of morbidity and mortality. Endovascular procedures may be the main stay of treatments. The success shown in this case series with parent artery occlusion and bypass surgery may provide an safe alternative to the endovascular treatment.

Cavernous carotid artery aneurysms: epidemiology, natural history, diagnostic and treatment. An experience of a single institution

BACKGROUND

Cavernous carotid aneurysms (CCA) account for 2-9% of all intracranial aneurysms. They have been considered benign lesions, most often asymptomatic, and to have a natural history with a low risk of life-threatening complications. These aneurysms are unique, their rupture can present in many different forms, they can suffer spontaneous thrombotic changes and the symptomatology related to the mass effect involves the neuro-ophthalmologic system. In this scenario the natural history and clinical presentation are largely different from other intracranial aneurysms. Some investigators advocate treatment of both symptomatic and asymptomatic CCAs, others recommend no treatment. The reason for this controversy relates to a lack of information on the long term natural history of these aneurysms, as well as on the long term results of treatment.

METHODS

In this article the authors discuss their single institution experience in diagnosis, natural history and management of 123 asymptomatic and oligosympotomatic aneurysms located in the cavernous portion of internal carotid artery.

CONCLUSIONS

According to our results asymptomatic or olygosymptomatic (pain) CCAs should be conservatively managed with serial images while the others presentations should be analyzed by a multidisciplinary team, involving the neuroendovascular and microsurgical services.

Giant cavernous carotid artery aneurysm mimicking a fungal granuloma and presenting with massive epistaxis

A 42-year-old man presented with frequent minor nasal bleeds since 1 month. He was undergoing chemotherapy for pulmonary tuberculosis. MRI brain revealed a space occupying lesion in the right cavernous sinus extending to sphenoid sinus, with T2 inversion. An initial diagnosis of fungal granuloma was made and endoscopic trans-nasal biopsy was attempted. During surgery, a pink pulsating mass was seen in the sphenoid sinus and the procedure was abandoned. A cerebral CT-angiography done subsequently revealed a giant right cavernous segment internal carotid artery (ICA) aneurysm. He was then referred to our centre and upon admission he collapsed secondary to a major bout of epistaxis. An emergency cervical carotid artery ligation resulted in transient control of epistaxis. Owing to recurrence of bleed, trapping of the aneurysm was done resulting in cure. The present case shows that a giant cavernous ICA aneurysm can occasionally be erroneously diagnosed as fungal granuloma.

Massive epistaxis from a thrombosed intracavernous internal carotid artery aneurysm 2 years after the initial diagnosis--case report

A 77-year-old woman presented with a rare case of nontraumatic intracavernous internal carotid artery (ICA) aneurysm causing epistaxis. The thrombosed aneurysm was discovered incidentally, and was not treated. However, she suffered massive nasal bleeding 22 months after the initial diagnosis. The lesion was successfully treated by endovascular coil embolization. The present case shows that thrombosed intracavernous ICA aneurysm may still carry the risk of rupture. Radiological evidence of erosion of the sphenoid sinus wall and repeated minor bleeding may be important predicting signs for massive nasal bleeding. Parent artery occlusion including the aneurysm may be the best treatment for intracavernous ICA aneurysms if sufficient collateral blood flow to the territory of the affected ICA is expected.

Cavernous carotid aneurysms: to treat or not to treat?

Most cavernous carotid aneurysms (CCAs) are considered benign lesions, most often asymptomatic, and to have a natural history with a low risk of life-threatening complications. However, several conditions may exist in which treatment of these aneurysms should be considered. Several options are currently available regarding the management of CCAs with resultant good outcomes, namely expectant management, luminal preservation strategies with or without addressing the aneurysm directly, and Hunterian strategies with or without revascularization procedures. In this article, we discuss the sometimes difficult decision regarding whether to treat CCAs. We consider the natural history of several types of CCAs, the clinical presentation, the current modalities of CCA management and their outcomes to aid in the management of this heterogeneous group of cerebral aneurysms.

Interventional Neuroradiology Adjuncts and Alternatives in Patients with Head and Neck Vascular Lesions

Vascular lesions of the head and neck can result from a variety of neoplastic and traumatic conditions that may cause local neurologic symptoms or may compromise the carotid or vertebral arteries, leading to ischemic deficits. Management of lesions involving vascular structures at the skull base may require a temporary balloon occlusion tolerance test or endovascular transarterial embolization as part of the preoperative management. Endovascular techniques can also be used as a salvage measure for severe head and neck bleeding and can assist with the management of vascular injury occurring in the operative or perioperative setting. Familiarity with the role of endovascular techniques in this group of patients may favorably influence patient management and outcome.