Petrous carotid artery pseudoaneurysm in bilateral carotid fibromuscular dysplasia: treatment by means of self-expanding covered stent

Petrous internal carotid artery aneurysm rupture induced by Eustachian tube catheterisation: case report

BACKGROUND

Petrous internal carotid artery aneurysms are very rare vascular lesions, which may present with otalgia and life-threatening massive otorrhoea.

CASE REPORT

An 84-year-old woman presented at a local otolaryngology clinic with progressive otalgia due to an acute exacerbation of chronic otitis media. She was referred with left-sided massive otorrhoea following Eustachian tube catheterisation. She suffered another massive otorrhoea with epistaxis during left-sided ear cleaning at a clinic visit. Contrast-enhanced computed tomography and computed tomography angiography revealed a left-sided aneurysm and adjacent stenosis at the left internal carotid artery. Coil embolisation of the petrous internal carotid artery aneurysm was performed with percutaneous transluminal angioplasty followed by dilatation of the stenosis.

CONCLUSION

Computed tomography angiography should be performed immediately when a patient reports massive otorrhoea. Endovascular occlusion is a treatment option as it avoids complications of open surgical ligation procedures.

Treatment of Intracranial Pseudoaneurysms With a Novel Covered Stent: A Series of 19 Patients With Midterm Follow-Up

Background: The optimal treatment for intracranial pseudoaneurysm is unclear. This study aims to analyze the outcome of treating intracranial pseudoaneurysm with a novel covered stent.

Materials and Methods: The institutional imaging and clinical databases were retrospectively reviewed for patients with intracranial pseudoaneurysms treated with Willis covered stent from January 2017 to December 2019. The clinical presentations, etiology, intraoperative complications, and immediate and follow-up outcomes were analyzed.

Results: A total of 19 patients with 20 pseudoaneurysms were enrolled for analysis. Seventeen patients presented with vision loss and two with epistaxis. Nineteen Willis covered stents were used with one for each patient without technical failure. Intraoperative thrombosis was encountered in one patient (5.3%), which was recanalized by tirofiban. During clinical follow-up, no further epistaxis occurred, and visual acuity improved in three (17.6%) patients. Endoleak occurred in seven (36.8%) patients after the initial balloon inflation and persisted in one (5.3%) patient after balloon re-inflation. This endoleak disappeared at 8 month follow-up. Finally, during angiographic follow-up (median 13 months), parent artery occlusion and in-stent stenosis occurred in one (5.3%) patient. No stent-related ischemic event was encountered.

Conclusions: The Willis covered stent is feasible, safe, and efficient in treating intracranial pseudoaneurysms.

Flow Diversion for the Treatment of Petrous Internal Carotid Artery Aneurysms

Petrous internal carotid artery (ICA) aneurysms are rare and pose a unique management dilemma. They are most commonly fusiform. They are difficult to treat surgically and typically not amenable to selective aneurysmal obliteration. The advent of flow diverters, such as the Pipeline endovascular device, has offered a new approach to these historically challenging lesions. The unique utility of flow diversion in treatment of petrous ICA aneurysms is reviewed and discussed.

Endovascular management of a giant petrous internal carotid artery aneurysm in a child. Case report and literature review

BACKGROUND

Aneurysms of the petrosal segment of the internal carotid artery are rare in children and are usually found secondary to trauma and infection or can have a congenital origin. Management includes endovascular therapy, surgery, and in rare cases observation.

DISCUSSION

Here, we report our experience with a giant petrous internal carotid artery aneurysm in a 16-year-old boy successfully managed endovascularly by parent artery occlusion.

The treatment of pseudoaneurysms with flow diverters after malignant otitis externa

Background We report a case of bilateral malignant otitis externa complicated with bilateral petrous internal carotid artery pseudoaneurysms and their successful treatment with a flow diverter. Case report A 68-year-old woman with serious complications of type II diabetes mellitus had malignant otitis externa on the right side. She was treated with combined antibiotic therapy and underwent mastoidectomy for mastoiditis. She presented at our hospital with acute hemorrhage from the right external auditory canal. The emergency computed tomography (CT) angiography revealed a multiobulated pseudoaneurysm at the petrous segment of the right internal carotid artery. The pseudoaneurysm was treated with a 5 × 40-mm Surpass flow diverter. Three months later, she developed a malignant external otitis on the left side. As the infection progressed, a left-sided mastoiditis, a brain abscess, and a pseudoaneurysm at the petrous segment of the left internal carotid artery developed. The pseudoaneurysm caused bleeding from the left ear, and was treated with a 5 × 50-mm Surpass flow diverter. No recurrent bleeding was observed. Four months later, a follow-up angiography showed complete occlusion of the pseudoaneurysm on the left side, but a residual aneurysm could be detected on the right side. One year after the first intervention, the follow-up CT and magnetic resonance angiography revealed the complete occlusion of the aneurysms bilaterally. Conclusion The use of a flow diverter appears to be an efficient and safe method to occlude carotid pseudoaneurysms even in an inflammatory milieu.

A rare but morbid neurosurgical target: petrous aneurysms and their endovascular management in the stent/flow diverter era

Background/objective

The rarity of petrous internal carotid artery (ICA) aneurysms has largely precluded analyses of their presentation and management in case series format.

Methods

We performed a retrospective analysis of our endovascular database of patients treated from January 2001 to May 2016 to identify patients with petrous ICA aneurysms. We evaluated the treatment approach and results for patients managed in the era of dedicated intracranial stents and flow diverters, noting clinical and angiographic results.

Results

Our database search identified 10 patients with petrous ICA aneurysms. Six aneurysms were managed in the era of dedicated intracranial stents and flow diverters. Two patients presented with cranial nerve palsies, two with incidental but enlarging aneurysms that had completely eroded through the petrous bone, one with transient ischemic attacks, and one with pulsatile tinnitus. Five aneurysms were large and one was small but symptomatic. In three cases the aneurysm was treated by flow diversion with adjunctive coiling; two patients with at least 4-month follow-up had complete occlusion of their aneurysm and significant improvement of mass effect symptoms. In one case the aneurysm was treated with balloon-assisted coiling with resultant near-complete occlusion. In two cases, prior to the introduction of flow diverters, the aneurysm was treated via stent-assisted coiling with resultant near-complete obliteration; one patient had resolution of pretreatment pulsatile tinnitus. There were no intraprocedural or postprocedural complications; no patients underwent retreatment.

Conclusions

Endovascular treatment of large or symptomatic petrous ICA aneurysms, in the era of flow diversion, is associated with excellent angiographic and clinical outcomes.

Stent-assisted Coil Embolization of Petrous ICA in a Teenager with Neurofibromatosis

We herein report on a patient with a cerebral aneurysm located at the petrous portion of the internal carotid artery (ICA). An 18-year-old male, previously diagnosed with neurofibromatosis, was referred to our emergency service complaining of severe headache, pulsatile tinnitus, nausea, and vomiting which occurred suddenly. Neuro-radiological studies including computed tomography and magnetic resonance imaging of the cerebral artery showed a large aneurysm arising from the petrous segment of the left ICA. He was treated with a neuro-interventional technique such as intra-arterial stenting and coil embolization for the aneurysm. Several days after the interventional treatment, his symptoms were resolved gradually except for a mild headache. Symptomatic unruptured aneurysm at the petrous portion of the ICA is rare, and our patient was treated successfully using a neuro-intervention technique. Therefore, we describe a case of a petrous aneurysm treated with endovascular coils without compromising the ICA flow, and review the literature.

Cervical-petrous internal carotid artery pseudoaneurysm presenting with otorrhagia treated with endovascular techniques

Cervical-petrous internal carotid artery (CP-ICA) pseudoaneurysms are rare and have different etiologies, presentations, and treatment options. A middle-aged patient with a history of chronic otitis media presented with acute otorrhagia and was found to have a left-sided CP-ICA pseudoaneurysm. The patient was a poor surgical candidate with difficult arterial access. The pseudoaneurysm was treated with stand-alone coiling via a left brachial approach with persistent contrast filling seen only in the aneurysm neck at the end of the procedure. The patient re-presented 12 days later with repeat hemorrhage and rapid enlargement of the neck remnant, and was treated with a covered stent via a transcervical common carotid artery cut-down. A covered stent may provide a more definitive treatment for CP-ICA pseudoaneurysms compared with standalone coiling.

Cervical-petrous internal carotid artery pseudoaneurysm presenting with otorrhagia treated with endovascular techniques

Cervical-petrous internal carotid artery (CP-ICA) pseudoaneurysms are rare and have different etiologies, presentations, and treatment options. A middle-aged patient with a history of chronic otitis media presented with acute otorrhagia and was found to have a left-sided CP-ICA pseudoaneurysm. The patient was a poor surgical candidate with difficult arterial access. The pseudoaneurysm was treated with stand-alone coiling via a left brachial approach with persistent contrast filling seen only in the aneurysm neck at the end of the procedure. The patient re-presented 12 days later with repeat hemorrhage and rapid enlargement of the neck remnant, and was treated with a covered stent via a transcervical common carotid artery cut-down. A covered stent may provide a more definitive treatment for CP-ICA pseudoaneurysms compared with standalone coiling.

Peripheral facial paralysis and bilateral carotid pseudoaneurysms of petrous localization: a case report

Carotid pseudoaneurysms of petrous localization are rare. They are mostly due to trauma, tumoral or infectious diseases, or a result of iatrogenic complications after skull base surgery. Symptoms such as facial paralysis are exceptional and have rarely been described in the literature until now. We report the case of a 64-year-old woman, who developed left peripheral facial paralysis induced by two carotid pseudoaneurysms in their intrapetrous section. The treatment is endovascular, despite the high morbidity rate. She was first put on antiplatelet medications, before the left carotid aneurysm was bypassed thanks to a self-expanding pipeline-type stent with flow diversion. The left peripheral facial paralysis was due to the compression exerted by the left carotid aneurysm, probably a congenital malformation. The progressive palsy recovery was fist due to the aneurysmal thrombosis, then to the secondary fibrosis.

Covered Stent Implantation for the Treatment of Direct Carotid-Cavernous Fistula and Its Mid-Term Follow-up

SUMMARY

Carotid-cavernous fistulas are abnormal arteriovenous communications either directly between the internal carotid artery and the cavernous sinus or between the dural branches of the internal and external carotid arteries. These fistulas predominantly present with ocular manifestations and they are treated mainly by endovascular techniques in most cases. A detailed review of the literature allowed us to make a complete analysis of the information available on the topic. We describe a case of a direct carotid-cavernous fistula occluded by endovascular implantation of a covered stent, showing the persistence of results after three years.

Placement of covered stents for the treatment of direct carotid cavernous fistulas

BACKGROUND AND PURPOSE

Endovascular detachable balloon occlusion and coil occlusion are 2 well-established options for the treatment of direct carotid cavernous fistulas (DCCFs). In recent years, covered stents have been applied in the treatment of neurovascular pathologies such as aneurysms, pseudoaneurysms, arterial dissections, and DCCFs. The purpose of this study was to investigate the clinical efficacy of covered stents for the treatment of DCCFs.

MATERIALS AND METHODS

Ten consecutive patients underwent covered-stent placement after failure of detachable balloon occlusion for the treatment of their DCCFs. Clinical and angiographic follow-up ranged from 5 to 48 months (mean, 18.2 months) after stent placement.

RESULTS

Stent placement was technically successful in all except 1 patient. In this patient, stent placement failed after multiple attempts because of rigidity of the Jostent GraftMaster Coronary Stent Graft and the tortuous anatomy of the internal carotid artery (ICA). Complete exclusion of the fistula was achieved in 6 patients immediately after stent deployment. Endoleak was observed in 3 patients. Re-dilation of the stent avoided the endoleak in 2 patients; in 1 of these 2 patients, formerly improved symptoms recurred the next morning and the ipsilateral ICA was occluded with detachable balloons. Spasm of the ICA was observed in most of the patients after stent placement; however, angioplasty was not required. Symptoms improved in all patients after treatment, without thromboembolic events. Follow-up cerebral angiography showed complete exclusion of all DCCFs and stent patency without intrastent stenosis in the 8 patients who had successful deployment of the stent.

CONCLUSIONS

Although a larger sample and expanded follow-up are needed, our series shows that covered stents can be used in the treatment of DCCFs with symptomatic relief.

Iatrogenic carotid artery pseudoaneurysm presenting with conductive hearing loss

Pseudoaneurysms of the intracranial internal carotid artery may occur in the setting of carotid artery dehiscence, due to trauma, invasive tumors, or as a complication of surgery. The rare surgical complication of carotid artery laceration in the petrous segment may occur during myringotomy procedures, middle ear operations, or petrous temporal bone surgery. We report a 28-year-old female patient, a case of internal carotid artery pseudoaneurysm as a complication of middle ear surgery. On her follow-up, computed tomography of the temporal bone demonstrated a dehiscent carotid artery, and a pseudoaneurysm involving the left petrous internal carotid artery was found in the cerebral angiography. She was managed by endovascular means.

Intracranial pseudoaneurysms, fusiform aneurysms and carotid-cavernous fistulas. Repair with percutaneous implantation of endovascular covered stents

The study assessed the effectiveness and safety of endovascular covered stents in the management of intracranial pseudoaneurysms, fusiform aneurysms and direct carotid-cavernous fistulas. Fourteen endovascular covered stents were used to repair three pseudoaneurysms, six fusiform aneurysms and six direct carotid-cavernous fistulas. Aneurysms were in the carotid artery in seven cases, in the vertebral artery two cases. It was not possible to treat two additional cases transcutaneously for technical reasons (2/15). Percutaneous closure of the lesions with an endovascular covered stent was successful in 13 of 15 cases. Initial follow-up showed good stent patency. No complications were observed after stent implantation. During follow-up, stent thromboses were detected in two of nine patients with follow-up digital subtracted angiography. One carotid-cavernous fistula of Barrow Type A transformed into Barrow Type D at nine month follow-up study was cured with a procudure of Onyx-18 injection. Endovascular covered stents may be an option for percutaneous closure of intracranial pseudoaneurysms, fusiform aneurysms and direct carotid-cavernous fistulas. Endoluminal vascular repair with covered stents offers an alternative therapeutic approach to conventional modalities.