Hybrid treatment of large extracranial carotid artery aneurysm

An extracranial carotid artery aneurysm (ECAA) is a rare condition. The major complications are rupture and thromboembolism. Therefore, treatment is generally recommended. We report the case of a young woman affected by an ECAA, with a cervical pulsatile mass. A multidisciplinary evaluation was performed to ensure the best treatment in terms of safety and efficacy, and the patient underwent hybrid treatment. The 6-month computed tomography angiogram revealed patency of the carotid artery stents and the venous graft, in the absence of any relevant complications. An ECAA is a serious clinical condition. The treatment is challenging, and a multidisciplinary evaluation and precise planning are recommended.

Influence of postural changes on haemodynamics in internal carotid artery bifurcation aneurysm using numerical methods

Cerebral intracranial aneurysms are serious problems that can lead to stroke, coma, and even death. The effect of blood flow on cerebral aneurysms and their relationship with rupture are unknown. In addition, postural changes and their relevance to haemodynamics of blood flow are difficult to measure in vivo using clinical imaging alone. Computational simulations investigating the detailed haemodynamics in cerebral aneurysms have been developed in recent times not only to understand the progression and rupture but also for clinical evaluation and treatment. In the present study, the haemodynamics of a patient-specific case of a large aneurysm on the left side internal carotid bifurcation (LICA) and no aneurysm on the right side internal carotid bifurcation (RICA) was investigated. The simulation of these patient-specific models using fluid–structure interaction provides a valuable comparison of flow behavior between normal and aneurysm models. The influences of postural changes were investigated during standing, sleeping, and head-down (HD) position. Significant changes in flow were observed during the HD position and quit high arterial blood pressure in the internal carotid artery (ICA) aneurysm model was established when compared to the normal ICA model. The velocity increased abruptly during the HD position by more than four times (LICA and RICA) and wall shear stress by four times (LICA) to ten times (RICA). The complex spiral flow and higher pressures prevailing within the dome increase the risk of aneurysm rupture.

Purtscher-like retinopathy after a stent implant for the treatment of carotid aneurysm

Purtscher retinopathy is an occlusive microangiopathy associated with traumatic causes and usually causes visual impairment. For non-traumatic origins, it is called Purtscher-like retinopathy (PLR). A 26-year-old man reported loss of vision in his left eye after the implantation of a telescoping stent for the treatment of an intracranial carotid aneurysm. The fundus of the eye showed numerous cotton-wool spots and superficial haemorrhages. The spontaneous evolution was favourable, with almost complete resolution, except for an inferior residual scotoma. The appearance of PLR may be associated with the implantation of an endovascular stent for the treatment of intracranial aneurysms.

Etiology and treatment patterns of ruptured extracranial carotid artery aneurysm

OBJECTIVE

Rupture of an extracranial carotid artery aneurysm (ECAA) is a very rare and life-threatening condition. To obtain a comprehensive view of previous and current management of ruptured ECAAs (rECAAs), we analyzed all cases reported since 1940 and two of our own cases.

METHODS

We performed a comprehensive literature review of reports from the MEDLINE database on rECAAs and included two patients treated in our department.

RESULTS

A total 58 reports of 74 rECAAs in 74 patients were analyzed. Their mean age was 50 years, and the male/female ratio was 2.2:1. Infection was the most common reported etiology (19 of 74; 26%), followed by connective tissue disorder (13 of 74; 18%), atherosclerosis (9 of 74; 12%), and previous trauma (5 of 74; 7%). For 28 patients (38%), information on the etiology was not available. Of the 74 patients, 24 (32%) had undergone reconstructive surgery, 10 (14%) had undergone endovascular treatment, 17 (23%) had undergone ligation, 2 (3%) had been treated conservatively, and 1 (1%) had died before receiving definite treatment. For 20 patients (27%), information on the treatment received was not available. The complications after reconstruction included carotid blowout (3 of 24 patients; 13%) and cranial nerve deficit (3 of 24 patients; 13%). Two patients (8%) had died of unrelated ECAA causes during long-term follow-up, and one patient (4%) had died of an ECAA-related cause within 30 days. After an endovascular approach, 1 of the 10 patients had developed a cranial nerve deficit. After ligation, five patients (29%) had experienced stroke, three of which were fatal. One conservatively treated patient had experienced no complications and one had died of an ECAA-related cause.

CONCLUSIONS

The most common reported etiology for rECAA was infection. Reconstructive surgery was the most common approach and was safer than ligation, which carried a high risk of stroke. Endovascular treatment showed promising results, especially for distally located aneurysms; however, the number of patients has remained low.

Ischemic stroke and retinal artery occlusion after carotid aneurysm embolization

We present the case of a 72-year-old male with a right carotid aneurysm incidentally discovered after an ischemic stroke. After management of the stroke, stent-assisted coil embolization was performed to treat the aneurysm. Two simultaneous and early complications occurred: new ischemic strokes and branch retinal artery occlusions, respectively in the right occipital lobe and in the right eye. Treatment of unruptured carotid aneurysm using stent-assisted coil embolization can lead to severe complications involving both the brain and the retina. Multidisciplinary and close surveillance of patients should be performed to diagnose adverse effects of this endovascular treatment.

Endovascular techniques in the treatment of extracranial carotid artery aneurysms

OBJECTIVE

Carotid artery aneurysms and pseudoaneurysms (extracranial carotid artery aneurysm [ECCAs]) are relatively rare. The gold standard treatment has historically been open repair; however, there is increasing evidence of successful treatment of ECCAs with endovascular techniques. Our study examines the evolving experience with endovascular management of ECCAs at a tertiary care center.

METHODS

We performed a retrospective analysis of patients with ECCAs who underwent endovascular interventions at a single institution from 2010 to 2020. With increasing experience, the techniques evolved from covered stents to stent-assisted coil embolization and finally to braided stents and overlapping closed cell stents.

RESULTS

There were 18 ECCAs in 17 patients treated with endovascular modalities. The average age was 65.9 years. There were 11 males (64.7%). Seven aneurysms (38.9%) were symptomatic: three patients had painless pulsatile masses, three patients had painful pulsatile masses, and one had transient ischemia attacks. Two (11.1%) were treated with covered stents, 2 (11.1%) were treated with stent-assisted embolization, 2 (11.1%) were treated with flow-diverting braided stents, 10 (55.6%) were treated with overlapping bare metal stents, and 2 (11.1%) were treated with embolization or ligation alone. Technical success was achieved in all patients. The mean duration of follow up was 338 days (range, 8-3039 days). No perioperative or postoperative complications were encountered, including no neurologic deficits and no embolic events. All patients were discharged on postoperative day 1 or 2. All 16 stents (100%) retained vessel patency on follow-up imaging and exclusion of ECCAs was confirmed on postprocedure surveillance imaging.

CONCLUSIONS

Endovascular modalities for the management of ECCAs have evolved with experience. Our study suggests that endovascular management is technically feasible as well as clinically effective and suggests an algorithm for navigating the various treatment modalities.

Massive Epistaxis from Nontraumatic Cavernous Carotid Aneurysm Treated by High-Flow Bypass and Cervical Internal Carotid Artery Ligation: A Case Report and Review of the Literature

BACKGROUND

Epistaxis is a rare presentation of the ruptured cavernous carotid aneurysm, especially the nontraumatic type. Both endovascular therapies and open surgeries have a role in the treatment with various outcomes, but the standard procedure is not well established. We report a successful high-flow bypass with cervical internal carotid artery ligation for aneurysm repair and review the related literature.

CASE DESCRIPTION

An 81-year-old man presented with massive epistaxis from the left nostril. The epistaxis was controlled by nasal packing. A saccular aneurysm of the cavernous segment of the left internal carotid artery projecting into the sphenoid sinus was revealed using computed tomography angiography. We treated this patient with high-flow bypass with ligation of the cervical internal carotid artery. Immediate postoperative computed tomography angiography showed complete disappearance of the aneurysm. Nasal packing was removed without further bleeding. No neurological deficit or complications were detected in the postoperative period.

CONCLUSIONS

In cases of massive or recurrent epistaxis without coagulopathy or nasal pathology, a cavernous carotid aneurysm should be considered. Immediate cessation of the bleeding is necessary. Flow-preservation bypass with proximal ligation of the parent artery is 1 of the effective procedures for the treatment of this condition with low morbidity.

Transradial stenting of a carotid pseudoaneurysm

Carotid pseudoaneurysms are rare and, if treated endovascularly, are usually approached via the femoral artery. We report the case of transradial stenting of an anastomotic carotid pseudoaneurysm secondary to vertebral transposition through an existing carotid-subclavian bypass.

Comparability of semiautomatic tortuosity measurements in the carotid artery

Purpose

Increased arterial tortuosity has been suggested as a predisposing factor for carotid artery dissection, which is an important risk factor for development of extracranial carotid artery aneurysms (ECAA). Prior to comparison with non-ECAA controls, the optimal measurement technique should be defined. This study describes the difference between software packages in terms of reproducibility and absolute outcome of arterial tortuosity measurements in ECAA patients.

Methods

CT-angiography analysis was performed on 12 ECAA patients selected from our registry, using four software packages: 3mensio Vascular, TeraRecon, Vital Images, and Aycan OsiriX PRO. The tortuosity index (TI) was calculated from the skull base until the carotid bifurcation and aortic arch, and was defined as the centerline’s true length divided by the straight line distance. Intraclass correlation coefficients (ICC) with 95% confidence intervals were calculated to quantify inter- and intra-observer variability within one software package, and differences in measured TI between packages.

Results

Inter-observer agreement was nearly perfect for 3mensio, excellent for Vital Images and OsiriX, and substantial for TeraRecon, with ICC 0.99 (0.96–1.0), 0.90 (0.69–0.97), 0.84 (0.53–0.95), and 0.72 (0.28–0.91), respectively. Intra-observer agreement ranged from ICC 1.0 for 3mensio to 0.91 for TeraRecon. Agreements in TI ranged from ICC 0.99 (0.98–1.0) for 3mensio vs. OsiriX, to 0.95 (0.82–0.98) for 3mensio vs. TeraRecon. Median time needed to complete one round of measurements was highest for OsiriX (p = 0.013).

Conclusions

Carotid artery tortuosity measurements are reproducible and comparable between current commercially available software packages, with high intra-observer agreement. Although the reproducibility differed per software packages, all packages scored an acceptable inter-observer agreement.

Intra cavernous aneurysm of internal carotid artery masquerading as a pituitary adenoma: a case report

Background

Pituitary dysfunction in adults are often associated with tumors of the gland and manifests with mass effects and hypopituitarism. MRI of pituitary region often provides confirmation of the diagnosis and assists in planning neurosurgery.

Case presentation

A 69 years old female evaluated for chronic headache was found to have a supra-sellar mass lesion that mimicked a pituitary tumor, with biochemical evidence of hypopituitarism. Cerebral angiogram confirmed the diagnosis of an aneurysm of the intracavernous internal carotid artery. She was successfully treated with coil embolization of the aneurysm and achieved resolution of symptoms and return of biochemistries to normal.

Conclusion

Carotid aneurysm can mimc pituitary tumours clinically and radiologically on MRI scan. This rare possibility should be considered in evaluating supra-sellar masses to avoid catastrophic consequences.

[False aneurysm of the carotid artery revealing Behçet disease]

Vascular involvement in Behçet's disease often present as venous thrombosis. Arterial damage is rare. We report a case of Behçet's disease occurring in a 40-year-old woman revealed by a false aneurysm of the left common carotid artery. The intervention consisted in a prosthetic graft after endovascular control. After a 2-year follow-up period, the patient did not develop any postoperative complication.

Ruptured left external carotid artery aneurysm presenting as upper airway obstruction in von Recklinghausen's disease

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Vascular abnormalities are recognized but rare manifestations of Neurofibromatosis type 1.

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Stenoses, aneurysms and pseudoaneurysm are the most common vascular abnormalities.

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External carotid aneurysm has not been reported before in the litterature.

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The most common clinical presentation of aneurysms is their spontaneous rupture.

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Carotid aneurysm rupture can cause a life-threatening upper airway obstruction.

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Carotid aneurysm in NF-1 can be treated by surgical or endovascular approach or combination of the both.

Introduction

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by café-au-lait macules, neurofibromas, and iris hamartomas. Carotid artery aneurysms rarely affect patients with NF-1 but may be associated with rupture. We report the first episode of a ruptured external carotid aneurysm with severe life-threatening airway obstruction in a NF-1 patient.

Presentation of case

We report a case of NF-1 32-year-old woman admitted to our department for life-threatening upper airway obstruction caused by spontaneous expanding swelling in the left sided neck. The diagnosis of ruptured aneurysm was suspected clinically and confirmed by computed tomography of the neck. The patient required tracheotomy for breathing difficulties and hemostasis was assured surgically by ligation of the external carotid artery.

Discussion

Vascular abnormalities are rare but recognized manifestation of type NF-1. They often affect medium and large sized vessels. Carotid aneurysms are asymptomatic in most patients; they are subject to sudden rupture with potentially devastating consequences. CT angiography is the gold standard for diagnosis of an aneurysmal rupture in NF-1 patients. Treatment consists on surgical ligation, resection and reconstruction or on percutaneous embolization.

Conclusion

Patients with NF-I have a wide spectrum of vascular abnormalities. Particularly, aneurysms can be life-threatening for these patients; their surgical management must be urgent in these situations.

Endovascular repair for an extracranial internal carotid aneurysm with cervical access: A case report

BACKGROUND

Carotid aneurysms are a rare pathology. This vascular disorder can be asymptomatic or it can cause local compression. The disorder poses a high risk of embolization and rupture.

PRESENTATION OF CASE

A 79 years old female, presents with a right internal carotid fusiform aneurysm, approximately 3.8cm in diameter, localized 3.30cm from the common carotid artery bifurcation with an extremely tortuous common carotid artery.

DISCUSSION

Surgical management of the extracranial internal carotid artery remains varying and challenging, particularly with a distal internal carotid aneurysm and with anatomical difficulties.

CONCLUSION

Endovascular management of an internal carotid aneurysm with cervical access using an expanded polytetrafluoroethylene covered stent with Heparin Bioactive Surface in the carotid area, is safe and effective.

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.