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) aneurysm

− 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.

Outcome

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

• June 2009: Occipital artery to PICA bypass for treatment of VA-PICA aneurysm
• July 2009: 12^th cranial nerve schwanomma
• August 2009: Large Fusiform Aneurysm of P1-P2 segment
• September 2009: Large Intraventricular Mass
• October 2009: Left frontotemporoinsular Mass
• December 2009: Right Frontotemporal Mass-Giant Aneurysm
• January 2011: Right Cavernous ICA Giant Aneurysm