E-007 Unusual Two Cases of Dissecting Cervical Internal Carotid Artery Pseudo-aneurysm with Symptomatic Intracranial Aneurysm
Authors: Lodi Y , Reddy V , Devasenapathy A , Chou J , Shehades K , Sethi K , Galyon D , Bajwa S 
Published: July 2014

Background

The incidence and the relationship between the symptomatic cervical internal carotid artery dissecting pseudoaneurysm (DP) and the presence of intracranial aneurysm in the same ICA distribution is unknown.

Objective

To describe two patients who underwent treatment of their both symptomatic cervical DP and intracranial aneurysm using endovascular strategies.

Methods

Retrospective review from a prospectively maintained aneurysm database.

Results

Case one is a 48 years old woman with history of smoking and uncontrolled blood pressure presented with 3 months progressive left sided headache and neck pain. Magnetic resonance angiography (MRA) demonstrated a 9 mm anterior communication artery (AComA) wide neck aneurysm. Catheter angiography revealed an unusual tortuosity in cervical ICA and presence of 8 mm DP in cervical ICA. Both aneurysms were considered to be symptomatic and an urgent endovascular repair was offered for both aneurysms; for AComA, stent-assisted coiling and for cervical ICA stenting. Patient underwent successful stent-assisted repair of AComA aneurysm. Due to the extreme tortuosity a self-deployable stent couldn’t be used. Therefore, a balloon-mounted stent-assisted coiling of the cervical DP was performed successfully and patient discharged home with strict blood pressure, and smoking cessation advice. Patient’s symptoms resolve in 4 weeks and 6 months follow up angiogram revealed complete obliteration of the AComA aneurysm and near-complete obliteration of the cervical DA. However, further tortuous remodeling of the cervical ICA was observed.

Case two is a 61 years old man with history of smoking and hypertension presented with 6 weeks progressive worsening left petrous area headache. MRA revealed suspected 7 mm aneurysm in the left ICA. Catheter angiogram demonstrated a 23 mm DP in the left petro-cavernous ICA measured 23 mm with 7 mm protruding sack.

Additionally, unusual tortuosity was present in the left proximal ICA with the presence of a 6 mm DP. A successful placement of 39 mm Enterprise stent and coiling of the daughter lobe was achieved. A self-deployable stent delivery system couldn’t be navigated resulting in placement of a balloon mounted stent. Patient symptoms improved and discharged home. A 6 weeks catheter angiogram revealed improved petro-cavernous aneurysm with obliteration of daughter aneurysm. Patient symptoms returned and a 3 months cerebral angiography revealed significant growth on of DP and worsening angulation of cervical ICA. Neither a guide nor a micro-catheter could be advanced. Therefore, a neurosurgical EC-IC bypassed followed by occluding of the left ICA below the PComA was offered. Extensive dissection made difficulties in proper placement of clip. Patient sustained malignant stroke leading to brain herniation and death.

Conclusions

In the evaluation of suspected intracranial aneurysm who present with headache with neck pain, a catheter cerebral angiogram not only will clearly define the correct morphology of intracranial aneurysm but also will appropriately identify the presence of life threatening cervical ICA abnormalities. Additionally, presence of an unusual cervical ICA anatomy with DP may warrant further evaluation of intracranial blood vessel of same territory. Using endovascular strategies, both extracranial and intracranial DP could be treated. However, long-term follow-up and outcome is unknown. Further studies are required.

Disclosures

Y. Lodi: None. V. Reddy: None. A. Devasenapathy: None. J. Chou: None. K. Shehades: None. K. Sethi: None. D. Galyon: None. S. Bajwa: None.