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Contributor:
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Dr. Chris Ekong
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Consultants:
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Dr. Mike Tymianski
Dr. Renn Holness
Dr. Joseph Buwembo
Dr. Krishna Kumar
Dr. R Willinsky
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Age: 67
Sex: Female
History: April 2001: While in Calgary, she developed sudden dysphasia and right hemiplegia. CT head showed left frontal haematoma. Angiogram was normal. April 2002: Almost completely recovered clinically. Carotid angiogram repeated. Only abnormailty in left Carotid at the ophthalmic.
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Now What?
Nothing?
Clip?
Coil?
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Dear Mike, Max, Chris, Bob, Philippe, Genevieve etc.:
Thank you all for taking great care of case #13. That patient went to Toronto the next day and was coiled and has done very well. We now have a 67-year-old lady who had a left intracerebral bleed in June 2001 while in Calgary. She had dysphasia and right hemiparesis. Angiogram at that time showed no aneurysm. She has recovered completely. A recent angiogram has now shown a small ophthalmic aneurysm measuring about 4 to 5mm. The films are shown below in case #14.
Questions: Should we leave it alone, clip it or coil it? Your opinion would be greatly appreciated.
Thank you.
Yours sincerely,
Chris
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Hi Chris et al.
Looks like a carotid cave aneurysm. I have never been convinced that I have seen one bleed. It is armored anteriorly by the carotid ring, superiorly by the clinoid, medially by the cavernous sinus dura, and laterally by the carotid. It is, however, subarachnoid in location. Patient is 67, and a year out from her event. If she bled from this thing, she is now back to the natural Hx of a small, unruptured aneurysm. I'd be inclined to leave it alone at this stage. I'm even more inclined to leave it be given that I'm not convinced that this is the cause of her initial bleed. Hope this helps.
Best
Mike T
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Chris,
we need to see the original CTs ..was the clot contiguous to the site of this Car/oph/cave aneurysm? If so & there was truly NO aneurysm on a good quality angio then the most likely thing is that the lesion we see now DID bleed (rather than "suddenly" appears now!) & should be treated (looks easy enough to coil but these little buggers can be troublesome & eventually require clipping)
Forward to the others .
Renn
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Chris,
Just returned from holiday...... I believe that this small carotid cave
aneurysm likely did not account for the initial bleed (although we did not
see the original CT). I would not recommend treatment of this asymptomatic
(or less likely "cold") cave anuerysm in a 67 y.o. These aneurysms rarely
bleed and all treatments carry a risk. The aneurysm is not suitable for
coiling (wide neck).
Best regards,
Bob
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Hi Chris,
This ophthalmic artery aneurysm is not likely to cause subarachnoid
heamorrhage.The intracerebral heamatoma was likely due to another
aetiology. Regarding treatment, I will inform the patient re: risk of
rupturing, which is about 1% per year; the effects of subarachnoid
heamorrhage; and the risks of intervention. She will have to make the choice
between observation and intervention, and if she chose intervention i would
recommend microsurgical clipping as it appears to me on these images that
the aneurysm has a broad neck.
Joe
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Thank you all. You have been very constructive and helpful.
Chris
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Mike Tymianski felt that this is a carotid cave aneurysm and therefore is not supposed to bleed. (see case 3 http://www.medi-fax.com/atlas/brainaneurysms/case3.html)
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Anatomy of carotid cave, courtesy of Dr. Mike Tymianski
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Renn was skeptical about the loation of the ipsilateral bleed and its relationship to the aneurysm. He wanted to see the films "with his own eyeballs". Calgary could not locate them but they finally did...... The haematoma is NOT contiguous with the aneurysm.
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1. This Carotid cave aneurysm did not bleed.
2. Aneurysm is being treated conservatively.
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