Regrowth of Internal Carotid Artery Aneurysm after Neck Clipping Surgery Presenting with Compressive Optic Neuropathy / 대한임상신경생리학회지

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Internal Carotid Artery Aneurysm Presenting with Unilateral Nasal Hemianopsia

PURPOSE: To report a case of unilateral nasal hemianopsia caused by a large internal carotid artery aneurysm. CASE SUMMARY: A 56-year-old female presented with large cupping in the left optic nerve head detected incidentally during a routine check-up. She had no underlying systemic disease except hypertension. The best corrected visual acuity was 20/20 in both eyes and a slit-lamp examination showed no abnormal findings. Ophthalmoscopy showed cup/disc ratios of 0.6 in the right eye and 0.75 in the left eye. Relative afferent papillary defect or color vision defect was not observed. A Humphrey visual-field test indicated unilateral nasal hemianopsia in the left eye. Brain CT and angiography revealed a large 2.2-cm aneurysm on the left internal carotid artery. CONCLUSIONS: Internal carotid artery aneurysm should be considered as a possible cause of unilateral nasal hemianopsia in patients without intraocular lesion.

A Case of Intracavernous Carotid Aneurysm Presenting with Visual Loss with No Oculomotor Disturbance

PURPOSE: Oculomotor disturbance is the common manifestation of intracavernous carotid aneurysm cases. Intracavernous carotid aneurysms causing compressive optic neuropathy with no oculomotor disturbance are relatively rare due to their anatomical characteristics. We experienced a case of intracavernous carotid aneurysm which resulted in a shifted supraclinoid segment of the internal carotid artery, presenting with visual loss and visual field defect with no oculomotor disturbance. CASE SUMMARY: A 40-year-old woman presented with loss of vision in the right eye. A relative afferent pupillary defect was observed in this eye. Visual field test showed quadranopsia in the right eye. Magnetic resonance imaging revealed that the intracavernous carotid aneurysm had shifted the supraclinoid segment of the internal carotid artery to the superomedial position. The right optic nerve was directly molded by the shifted supraclinoid segment of the internal carotid artery at the point of the bifurcation between the anterior cerebral artery and the middle cerebral artery. A Guglielmi detachable coil (GDC) embolization was performed successfully with no operational complications. Six months after coiling, best corrected visual acuity of the right eye was 1.0, and the visual field defect had recovered in all except the superior temporal field. CONCLUSIONS: Oculomotor disturbance is frequently associated with intracavernous carotid aneurysms. Nevertheless, optic neuropathy without oculomotor disturbance may be the only sign in patients with an intracavernous carotid aneurysm that causes shifting of the supraclinoid segment of the internal carotid artery.

A Case of Carotid Aneurysm in Familial Retinal Arterial Tortuosity

A 44-year-old woman who showed recurrent vitreous hemorrhages with vascular tortuosity received CT angiography which revealed an internal carotid artery aneurysm. A case of internal carotid aneurysm was associated with a pattern of retinal arteriolar tortuosity pathognomic for familial retinal arterial tortuosity (fRAT), suggesting possible involvement of the cerebral circulation. We present a case of internal carotid aneurysm associated with a pattern of retinal arteriolar tortuosity pathognomic for fRAT.

Severe hyperprolactinemia associated with internal carotid artery aneurysm: differential diagnosis between prolactinoma and hypothalamic-pituitary disconnection / Hiperprolactinemia severa associada a aneurisma interno da artéria carótida: diagnóstico diferencial entre prolactinoma e desconexão hipotálamo-hipofisária

Sellar and parasellar masses blocking inhibitory hypothalamic dopaminergic tonus can produce hyperprolactinemia. One of these conditions, seldom reported, is internal carotid artery aneurysm causing pituitary stalk compression and hyperprolactinemia, the majority of which is related to small increases in serum prolactin levels. The aim of this study is to report the case of a patient with an internal carotid aneurysm and severe hiperprolactinemia. A 72 years old female patient, on oncology follow-up for clinically controlled cervical carcinoma, was evaluated due to worsening chronic headaches. During the investigation, computed tomography and magnetic resonance imaging (MRI) showed a sellar mass associated with high prolactin level (1.403 µg/L) that initially was considered a macroprolactinoma, and treated with bromocriptine. However, subsequent pituitary MRI suggested an internal carotid aneurysm, which was confirmed by an angioresonance imaging of cerebral vessels. On low bromocriptine dose (1.25 mg/day), there was a prompt normalization of prolactin levels with a great increase (> 600 µg/L) after withdrawal, which was confirmed several times, suggesting HPD. We report a patient with internal carotid artery aneurysm with severe hyperprolactinemia never reported before in patients with HPD, and the need for a differential diagnosis with macroprolactinomas even considering high prolactin levels.

Massas selares e parasselares podem produzir hiperprolactinemia por bloquear o tônus inibitório hipotalâmico de dopamina. Uma destas condições, raramente reportada, é o aneurisma de artéria carótida interna causando compressão da haste hipofisária e hiperprolactinemia, a maioria com pequenas elevações da prolactina. O objetivo deste estudo é descrever o caso de uma paciente com aneurisma de carótida interna e grave hiperprolactinemia. Paciente feminina, 72 anos, em acompanhamento oncológico por carcinoma de colo de útero clinicamente controlado, avaliada por causa da piora de cefaléia crônica. Durante investigação, tomografia computadorizada e ressonância magnética (RM) de hipófise mostraram massa selar associada com altos níveis de prolactina (1.403 µg/L), sendo avaliado como macroprolactinoma e tratado com bromocriptina. Entretanto, RM subseqüente sugeriu aneurisma de carótida interna que foi confirmado por angiorressonância de vasos cerebrais. Em uso de baixas doses de bromocriptina (1,25 mg/dia), houve pronta normalização da prolactina com grande elevação (> 600 µg/L) após a retirada do medicamento, sendo confirmado por várias vezes sugerindo DHH. Reporta-se uma paciente com aneurisma de artéria carótida interna com grave hiperprolactinemia, nunca descrita anteriormente em pacientes com DHH, e a necessidade do diagnóstico diferencial com macroprolactinoma, mesmo considerando altos níveis de prolactina.

Internal Carotid Artery Trunk Aneurysms: Its Surgical Management and Complication Avoidance

OBJECTIVE: Aneurysms arising from the trunk of the supraclinoid internal carotid artery(ICA) unrelated to the branching are rare and treatment of these aneurysm is well known as difficult due to intraoperative premature rupture and postoperative bleeding. The authors report an analysis of 12 cases of ICA trunk aneurysms treated with transcranial or endovascular methods. METHODS: Between Mar. 1999 and Apr., 2001, 12 patients were treate for the ICA trunk aneurysms. The medical records and neuroimaging studies of the patients were reviewed retrospectively. RESULTS: These 11(92%) presented with symptoms related to intracranial hemorrhage. All aneurysms were small in size. Eleven patients(92%) were in good neurological status(Hunt Hess grade 0-III), one (8%) in poor grade(H-H grade IV). Eight patients were treated with transcranial surgery, operated on by the ipsilateral pterional approach and 4 patients were treated with endovascular surgery. Intraoperative premature rupture of the aneurysm occured in 6 cases(75%) with transcranial surgery and these were managed with ICA trapping in 4 cases, wrapping using temporalis fascia and clip in 1 and clipping with Sundt-Kee encircling clip in 1. The management outcome of the transcranial surgery was: 3(38%) Glasgow outcome scale(GOS) I, 1(12.5%) GOS II, 2(25%) GOS IV, and 2(25%) GOS V(death). The major causes of morbidity and mortality related to transcranial surgery were cerebral infarction and brain swelling due to intraoperative rupture and vasospasm. Four cases underwent endovascular surgery using Guglielmi detachable coils. The management outcome of the endovascular surgery was: 3(75%) GOS I and one GOS V 1(25%). The cause of mortality related to endosaccular coiling was brain swelling due to vasospasm. CONCLUSION: Treatment of the ICA trunk aneurysm, especially with blister-like nature, has high risk of the intraoperative rupture. Prevention and successful management of the intraoperative bleeding can be made by careful preoperative diagnosis of the aneurysm and preparation for the intraoperative rupture.

Surgical Consideration for Internal Carotid Superior Wall Aneurysm

Seven cases of aneurysm arising from the superior wall of the internal carotid artery were operated on from January 1993 through December 1997. They consist of 3.7% among 191 operated cases of the internal carotid artery aneurysms and 1.2% among 590 operated cases of total intracranial aneurysms. Aneurysmal adhesion to the optic nerve was observed in five cases and the arteriosclerotic change in two cases. Four aneurysms were blister-like and thin-walled, and the other two aneurysms were covered with thick hematoma. Premature rupture occurred in three cases, two cases during aneurysmal clipping and one case during aneurysmal dissection. In three cases the aneurysms were clipped, and in the other four cases the aneurysms were wrapped circumferentially with the dacron mesh silastic sheet and clipped. Among the four wrap-clipping cases, two cases were associated with very fragile aneurysmal walls. There were neither clip sliding nor the regrowth of aneurysms on the following angiograms. The Glasgow Outcome Scale at discharge showed good recovery in five cases, moderately disabled in one case, and severely disabled in one case. In conclusion, wrap-clipping with the silastic sheet is helpful for the superior wall aneurysms of internal carotid artery with very fragile and thin walls or avulsion of aneurysmal neck.

Internal Carotid Artery Aneurysms Arising Remote from Arterial Divisions: Dorsal and Medical ICAA

Aneurysms arising remote from arterial divisions are rare. From January 1981 to December 1993, We operated on 271 internal carotid artery aneurysms(ICAA). Among them, we found nine of such unusual aneurysms protruding from the dorsal(six cases) or medical wall(three cases) of the internal carotid artery. Angiographically, they were often misdiagnosed as the posterior communicating artery aneurysms or carotid artery bifurcation aneurysm due to small size and flat shape with broad neck. On operation, all three medical wall aneurysms showed severe atherosclerosis. and moderate to minimal atherosclerosis was found in four dorsal wall aneurysms. In four cases, we experienced intraoperative premature rupture of the aneurysm, one during retraction of the frontal lobe due to adhesion of the aneurysmal dome to the base of frontal lobe, two during aneurysmal neck dissection and the other one during clip application. These aneurysms were difficult to operate on because of their fragility(thin or atherosclerotic wall) and relatively board aneurysmal neck. In conclusion, these aneurysms presented with difficulties in preoperative diagnosis by angiography due to small size and flat shape. In operation, special care should be taken to avoid premature rupture of the aneurysm due to thin or atherosclerotic fragile wall.

Clinical Analysis of Internal Carotid Artery Aneurysms

The authors analyzed 60 cases of ruptured internal carotid artery(ICA) aneurysms admitted and operated at Department of Neurosurgery in Kyung Hee University Hospital during the period from July 1983 to June 1988. The results of analysis were summarized as follows; 1) Mean age of patients was 51 years. ICA aneurysms occurred more frequently in female(47) than male(13). 2) Distribution of ICA aneurysms were ophthalmic aneurysm 8 cases(13.3%), posterior communicating aneurysm 40 cases(66.6%), anterior choroidal aneurysm 7 cases(11.6%), bifurcation aneurysm 5 cases(8.3%). 3) Most common direction of aneurysmal dome in ophthalmic, anterior choroidal and posterior communicating aneurysm was posterior-inferior-lateral and in bifurcation aneurysm was posterior-superior. 4) Multiple aneurysm was 23 cases(38%). 5) Incidence of clinical vasospasm was 48.3% and that of rebleeding was 20%. 6) Clipping was done in all cases, 2 cases combined with wrapping and 2 cases with trapping. 7) Mortality rate was 21.6%.

Management of Aneurysm of the Petrous Portion of the Internal Carotid Artery by Balloon Technique: A Case Report

Authors report a case of intrapetrosal carotid aneurysm which was successfully treated with Debrun's detachable balloon technique. The patients was a 21 year-old female with headache, vertigo and left facial palsy in whom aneurysm arising from the intrapetrosal segment of internal carotid artery was demonstrated.