OHSU

Case of the Month

January 2011 by Aclan Dogan, M.D.


Right Cavernous ICA Giant Aneurysm

 

Patient history and diagnosis

A 54 year-old female was admitted with: 3 weeks of severe headache, progressive double vision and severe retro orbital pain. Past medical history included: shingles and osteonecrosis. Past surgical history included: an appendectomy, and a hip replacement.

Brain magnetic resonance imaging revealed:

? 2.1 x 2.2 cm saccular right cavernous internal carotid artery (ICA) aneurysm2D and 3D cerebral angiogram images show a right giant cavernous ICA

? mass effect on the adjacent cavernous sinus, Meckel’s cave, and right temporal lobe

Neurological Examination Results:

  • Mental status: Normal consciousness, orientation, affect and fluency
  • Cranial Nerves: 2nd-12th intact on detailed examination
  • Motor: Normal strength, muscle bulk, and tone
  • Sensory: Intact to pinprick and light touch
  • Cerebellar: Normal finger-to-nose and rapid alternating movements
  • Gait: Normal, Tandem and Romberg negative
  • Deep Tendon Reflexes: Present and normoactive
  • Pathologic Reflexes: Absent

Plan and Surgical Treatment


Indications for cavernous ICA aneurysms are:

? Debilitating pain

? Vision loss

? Diplopia

? Sphenoid sinus erosion

Treatment of giant cavernous aneurysms includes:

? ICA occlusion after balloon test occlusion

? Occlusion of the aneurysm with a covered stent

? Coil embolization of the aneurysm with/without stent

? Occlusion of the ICA with extracranial to intracranial (EC/IC) bypass

The patient tolerated the balloon test occlusion, however since there is 5-22% delayed ischemic complication and 5% mortality risk after a successful balloon test occlusion, an ICA occlusion with EC/IC bypass was selected.

The patient was taken to the operating room and a radial artery graft was harvested and right external carotid artery to middle cerebral artery by-pass surgery using the radial artery graft was performed without complication. Immediately after surgery the patient was taken to the angio-suite and the right ICA and aneurysm occluded with coils.

radial_graft_web

Outcome

The patient tolerated the procedures well without complication and was discharged home on postoperative day three.

Download .pdf files that include pre- and postoperative imaging.