Right ICA Aneurysm/Arteritis

Contributor:

Dr. Krishna Kumar

Case 17

Age: 59

Sex: Female

History: Dec 18, 2002: Sudden severe headache & decreased level of conciousness. Past history of temporal arteritis. Examination showed neck stiffness and GCS of 15. No neurological deficit.

Questions:

Now what?

Dr. Chris Ekong, Neurosurgeon, Regina

To Neurovascular Internet Rounds Group:

Dear Bob, Mike, Mike_T, Chris, Fred, Max, Joe, Cameron, Renn, etc.

This 59 year old lady with a past history of temporal arteritis which responded well to steroids over the years...Now presents (Dec 18, 2002) with extensive S.A.H on CT. Her GCS is 15 and she has no deficit.

Angio shows a very unusual aneurysm of the right ICA. I think it is an aneurysmal dilatation due to vascular rather than a true berry aneurysm. I do not see a neck in the 3Ds therefore I do not that surgery or coiling has a place here. Is there room for stenting? Would anybody clip or coil this?

Chris.

Dr. Renn Holness, Neurosurgeon, Halifax - December 23, 2002

Chris --

this is a real challenge & I have encountered a few of these over the years .The approach would use our full armamentarium -ie prep for a bypass,prepare the neck for a "Dallas type" procedure ,give barbiturates then "trap" the lesion with an attempt a reconstruction with R-angled,fenestrated clips or a Sundt clip depending on the exact configuration at exploration.I have had success with the former in 2 cases .I have seen a disaster on another as the vessel was so ratty it tore apart.

Some would want to do the bypass 1st and consider carotid sacrifice or stenting(looks too wide & near the bifurcation to stent but we have no experience with stents).In THIS case the temporal arteritis (?biopsied)precludes STA/MCA so a saphenous graft would be needed.

Renn

Dr. Walter Montanera , Neuroradiologist, Toronto - December 23, 2002

Chris:

I could not get all of the images, only the 3D surface rendered images.

Wide-neck aneurysmal expansion of the distal ICA. There is a small lobule

on the posterior convexity of the aneurysm (or is this the origin of PComm).

Not a candidate for GDC. Carotid balloon occlusion could be considered if

there is no good direct surgical option for repair.

Best Regards over the holidays.

Dr. Mike Tymianski, Neurosurgeon, Toronto - December 26, 2002

Chris:

Last time I had one of these, it was in a 25yr old with Ehler's Danlos. I believe that these strange aneurysms, associated with vascular diseases (arteritis, collagen vascular disease) are not the same disease as saccular ones.

I would not advocate direct surgical or endovascular attack on this lesion without having a better understanding of the diagnosis.

Surgically, some of these aneurysms are extremely fragile, and as they are dissecting in nature, do not lend themselves to easy reconstruction. Rate of intra-op rupture is high, and loss of the ipsilateral carotid is a likely outcome.

From an endovascular standpoint, I think that getting a stent up there (with current stents) will still be a challenge. I would defer to our endovascular colleagues for a definitive opinion, but my guess is that we would not be so keen to fiddle around deploying stents in a lestion that might be so fragile that it could break down due to the manipulation.

My approach would be as follows:

I think she needs treatment. Before doing so, I would try to learn a bit more about the lesion by doing an MRI, to see 1. whether there is more to the aneurysm than fills and 2. whether this is a dissection vs. saccular lesion (sometimes not possible, but sometimes is quite clear).

Next, I would do a test balloon occlusion to see whether she would tolerate temporary loss of her carotid (in the event of aneurysm rupture and the need for carotid sacrifice).

Next, even if she tolerates baloon occlusion, I would NOT treat this aneurysm solely with carotid sacrifice. Once she runs into vasospasm (highly likely from CT), there will be no way to treat her with angioplasty.

I would explore this aneurysm to see what it looks like. I would be set-up to do a long vein bypass, and if this aneurysm cannot be primarily surgically reconstructed, I would treat this lady with a long-vein bypass, followed by trapping (proximal and distal) of the aneurysm. - PLEASE SEE CASE #1 in your atlas series for a somewhat analogous case of a lady with a SAH who was treated with a similar bypass to avoud spasm-related complications...

Tough case.

Lemme know if we can help with either case 17 or 18, or update us about the outcomes.

Best,

M. Tymianski

A Project of The Emmanuel Charitable Foundation