Flow Diversion for the Treatment of Petrous Internal Carotid Artery Aneurysms

Petrous internal carotid artery aneurysm: A cause of chronic otitis

BACKGROUND

Aneurysm of the petrous segment of the internal carotid artery (pICA) is a rare pathology presenting with extracranial and especially oto-rhinological symptoms that can be misleading and delay diagnosis.

METHODS

We report the case of a giant pICA aneurysm compressing the Eustachian tube (ET), presenting with hearing loss due to chronic serous otitis. A PRISMA review of the literature was performed to find similar cases. In addition, relevant anatomical sources were screened.

RESULTS

Five reports about 7 cases of middle-ear effusion caused by pICA aneurysm compressing the ET were identified. Median age at diagnosis was 18.5 years. After endovascular treatment, overall outcome was favorable, with no mortality, although outcome was sometimes impaired by neurological comorbidities and unclear prognosis of hearing-loss recovery.

DISCUSSION

These reports, though rare, offer relevant insights into the poorly known regional anatomy of the pICA, in the borderland between neurosurgery and ENT. Within the petrous bone, the osseous separation between the ET and the pICA is narrow, when not dehiscent. This leads to a risk of any pathological process in either the pICA or the ET impinging on the other.

CONCLUSION

Giant pICA aneurysm is a rare cause of hearing loss, due to compression of the ET, leading to chronic serous otitis. This co-dependency between pICA and ET should be kept in mind, as it underlines the necessity of multidisciplinary management and could facilitate earlier diagnosis and therapeutic management when facing atypical clinical situations.

Neurosurgical Causes of Pulsatile Tinnitus: Contemporary Update

Traditionally in the domain of the otolaryngologist, pulsatile tinnitus (PT) has become increasingly relevant to neurosurgeons. PT may prove to be a harbinger of life-threatening pathology; however, often, it is a marker of a more benign process. Irrespectively, the neurosurgeon should be familiar with the many potential etiologies of this unique and challenging patient population. In this review, we discuss the myriad causes of PT, categorized by pulse-phase rhythmicity.

Endovascular Treatment of Aneurysms Using Flow-Diversion Embolization: 2-Dimensional Operative Video

Initially developed for large and giant wide-necked aneurysms of the internal carotid artery, flow diverter devices are now used in almost every location safely and with effectiveness.1-5 This video demonstrates a unique case of a giant aneurysm of the right petrous internal carotid artery in a 20-yr-old patient. This is an extremely rare location, and most of patients are asymptomatic.3-6 Signs of compression of the seventh and eight cranial nerves can be present and even Horner syndrome and lower cranial nerves neuropathies. Nevertheless, rupture can lead to epistaxis and otorrhagia, and ultimately to hemorrhagic shock. The patient in the current report was otherwise healthy but presented with lightheadedness and dizziness for 10 d. The patient consented to the procedure. There was no history of major trauma or head and neck infection. A transradial endovascular flow diversion embolization of a giant aneurysm of the petrous internal carotid artery is herein demonstrated in a stepwise manner. A triaxial system was used to deploy 3 overlapping devices. Concepts of J-wire technique, multiple coverage,1 and the so-called weld technique are emphasized. The role of adjunctive coiling and main reasons for failure are also discussed.7,8 Brief cases of flow diversion embolization of aneurysms of different morphologies at different locations are used to highlight the importance of assessing vessel wall apposition and follow-up imaging.

Carotid petrous segment aneurysm presenting as hypoglossal nerve palsy

Aneurysm in the petrous segment of the internal carotid artery is extremely rare, and symptoms are usually derived from compression of neighbor structures such as nerve palsies. Clinical symptoms can be nonspecific and imaging findings are complex, making the diagnosis of this kind of aneurysms extremely challenging. CT angiography is the best diagnostic tool, and treatment options include surgical and endovascular approaches, the latest being preferred. We report an extremely rare case of an aneurysm in the petrous apex presenting with hypoglossal nerve palsy. We document the aneurysm through CT and confirm it using angiography. We also describe the satisfactory management of this rare case. To the best of our knowledge this an extremely rare aneurism presenting with hypoglossal nerve palsy, in which successful interventional management was achieved through a specific and prompt diagnosis.