Spontaneous thrombosis of intracavernous internal carotid artery aneurysm and parent artery occlusion in patients with positive balloon test occlusion--two case reports

Spontaneous thrombosis and calcification of giant cavernous carotid artery aneurysm: A rare case and management insights

Background

Giant cavernous carotid artery aneurysms (>25 mm) are rare (3-5%), with some prone to spontaneous thrombosis (10-20% complete). We present a unique case of one of the largest aneurysms spontaneously thrombosing and calcifying.

Case Description

A 57-year-old with persistent right-sided headaches had a substantial hyperdense mass in the right middle cranial fossa, eroding petrous bone. Magnetic resonance imaging and digital subtraction angiography revealed a giant cavernous segment fusiform aneurysm of the right internal carotid artery (ICA) with spontaneous thrombosis and distal ICA occlusion. Collateral circulation maintains the cerebral blood supply. Despite anatomical challenges, conservative management was chosen due to the patient's stability.

Conclusion

This case highlights the complex interplay between thrombosed giant aneurysms and affected vessels, with unique features such as cross-flow, calcification, and bone erosion. We advocate conservative management for stable cases, supported by literature, emphasizing vigilant follow-up. This expands the spectrum of aneurysm presentations and encourages further research into their dynamics.

Spontaneous thrombosis of a giant cavernous-carotid aneurysm with simultaneous ipsilateral complete parent artery occlusion: a rare phenomenon and review of the literature

Cavernous-carotid artery (CCA) aneurysms represent about 3-5% of all intracranial aneurysms. Spontaneous thrombosis of a CCA aneurysm with simultaneous occlusion of its parent vessel is an extremely rare phenomenon with few reported cases in the literature offering different management strategies. A 54-year-old Asian female presented with a one day-history of painless left eye conjunctival injection, proptosis, and features of cavernous sinus syndrome (cranial nerve III, IV, V1, V2, and VI palsies). Imaging revealed a giant thrombosed CCA aneurysm measuring 3.6cmx3.4cm with complete thrombosis of the left cervical internal carotid artery (ICA) and adequate collaterals from the anterior and posterior communicating artery and branches of the left external carotid artery. Management was conservative with antiplatelet therapy and close clinical-radiological follow-ups. The outcome was satisfactory. Data in the literature on this condition is limited due to its exceedingly rare occurrence. The majority of patients do well via a conservative approach and surgery is rarely indicated. For clinically stable patients, especially those with adequate collateral circulation and tolerance to Balloon Test Occlusion, we advocate for a conservative approach and initiation of anti-platelet therapy to treat these patients. Emphasis is needed on close serial clinical-radiological surveillance in these cases to monitor the propagation of the thrombus as well as the development of new and/or enlarging pre-existing aneurysms in the contralateral ICA circulation.

Opening of unusual vascular collaterals leads to early recanalization of a giant intracavernous carotid artery aneurysm following common carotid artery occlusion: A Case report and literature review

Background:

Parent artery occlusion (PAO) with or without bypass surgery is a feasible treatment for large intracavernous carotid artery (ICCA) aneurysms. The ideal occlusion site (internal or common carotid artery [CCA]) and ischemic complications after PAO have received special attention since the description of the technique. Unfrequently, some patients can also develop unusual external carotid artery-internal carotid artery collateral pathways distal to the ligation site that can explain the failure to aneurysm size reduction.

Case Description:

We describe a rare case of delayed refilling of a large ICCA aneurysm partially thrombosed which early recanalized after surgical ligation of the cervical CCA through an unusual collateral pathway.

Conclusion:

Based on our experience, we recommend periodic long-term follow-up neuroimaging, especially in those cases where potential collateral branches have not been clearly identified in the preoperative studies.

Intraoperative Test Occlusion as Adjustment of Extracranial-to-Intracranial Bypass Strategy for Unclippable Giant Aneurysm of the Internal Carotid Artery

BACKGROUND

There is still a controversy for low-flow extracranial-intracranial or high-flow extracranial-intracranial bypass with proximal occlusion in the treatment of unclippable giant internal carotid artery aneurysms.

CASE DESCRIPTION

A 61-year-old woman presented with a 1-month history of double vision. Neuroimages revealed an unclippable giant internal carotid artery aneurysm located from the cavernous sinus to proximal site of the posterior communicating artery. Ipsilateral A1 of the anterior cerebral artery was hypoplastic, and posterior communicating artery was patent. Intraoperative proximal test occlusion at cervical internal carotid artery under neurophysiological monitoring, instead of preoperative balloon test occlusion, was performed to assess whether low-flow bypass was sufficient. The monitoring was unchanged during test occlusion, and the aneurysm was successfully trapped without high-flow bypass. Neither ischemic lesion nor neurologic deficits were found postoperatively.

CONCLUSIONS

Intraoperative proximal test occlusion is useful to decide on the surgical procedure of revascularization in patients with unclippable internal carotid aneurysm.

Completely Thrombosed Giant Intracranial Aneurysm with Spontaneous Thrombosis of the Parent Artery: Is It Nature's Divine Intervention and a Self-Cure?

BACKGROUND

Although partial thrombosis is common with intracranial aneurysms, complete aneurysmal thrombosis is extremely rare. An even rarer and seldom reported phenomenon is the spontaneous complete occlusion of the parent artery in the presence of a thrombosed aneurysm. Given the unclear natural history of this phenomenon, therapeutic decision making may be rather difficult. Here we report a case of right cavernous carotid artery aneurysm with spontaneous right internal carotid artery (ICA) thrombosis in a 45-year-old man.

CASE DESCRIPTION

Our patient presented almost 1 month after an episode of sudden-onset severe holocranial headache associated with vomiting that had resolved completely within 2 days. He was neurologically intact at the time of presentation. A computed tomography (CT) scan done at the time of ictus showed a rounded hyperdensity with the epicenter at the right parasellar region along with nonvisualization of the ipsilateral ICA on CT angiography. Magnetic resonance imaging (MRI) suggested a diagnosis of a completely thrombosed right cavernous segment ICA aneurysm. Intra-arterial angiography confirmed a complete ipsilateral ICA thrombosis and a good arterial cross-flow from the left side to the bilateral anterior and middle cerebral artery territories. We started the patient on oral aspirin and a close clinicoradiologic follow-up after having decided against any active intervention.

CONCLUSIONS

Spontaneous thrombosis of an intracranial aneurysm and the parent artery is rare, with only a few cases reported in the literature. In the absence of symptoms and adequate collateral circulation, these patients are perhaps best managed conservatively.

Parent vessel occlusion for treatment of cerebral aneurysms: Is there still an indication? A series of 17 patients

INTRODUCTION/PURPOSE

Flow diversion has allowed cerebrovascular neurosurgeons and neurointerventionalists to treat complex, large aneurysms, previously treated with trapping, bypass, and/or parent vessel sacrifice. However, a minority of aneurysms remain that cannot be treated endovascularly, and microsurgical treatment is too dangerous. However, balloon test occlusion (macro and micro), micro WADA testing, ICG, intra-angiography and intra-operative monitoring are all available to clinically test the hypothesis that vessel sacrifice is safe. We describe a dual-institution series of aneurysms successfully treated with parent vessel occlusion (PVO).

MATERIALS/METHODS

Prospectively collected databases of all endovascular and open cerebrovascular cases performed at Maine Medical Center and Vanderbilt University Medical Center from 2011 to 2013 were screened for patients treated with primary vessel sacrifice. A total of 817 patients were screened and 17 patients were identified who underwent parent vessel sacrifice as primary treatment.

RESULTS

All 17 patients primarily treated with PVO are described below. Nine patients presented with SAH, and 3/17 involved anterior circulation. Complete occlusion was achieved in 15/17 patients. In the remaining 2 patients, significant reduction in the aneurysm occurred. Modified Rankin Score (mRS) of 0, signifying complete independence, was achieved for 16/17 patients. One patient died due to an extracranial process.

CONCLUSIONS

Parent vessel sacrifice remains a viable and durable solution in select ruptured and unruptured intracranial aneurysms. Many adjuncts are available to aid in the decision making. In this small series, patients naturally divided into vertebral dissecting aneurysms, giant aneurysms and small distal aneurysms. Outcomes were favorable in this highly selected group.

Endovascular parent artery occlusion of proximal posterior cerebral artery aneurysms: a report of two cases

We report two cases of proximal posterior cerebral artery (PCA) aneurysms treated with endovascular parent artery occlusion (PAO) with coils. In both cases, selective injection from the 4 F distal access catheter clearly showed the perforating arteries arising from the PCA. Case No 1, a 49-year-old woman, was successfully treated with preservation of a paramedian artery. Case No 2, a 54-year-old woman, was treated in the same manner. The patient underwent extensive thalamic infarction after the procedure because of paramedian artery occlusion. Endovascular PAO with coils is feasible for proximal PCA aneurysms; however, preservation of perforating arteries arising from the PCA is mandatory.

Thrombosis and spontaneous recanalization of a giant intracranial aneurysm: diagnostic and management pearls in a pediatric patient

The authors present the case of a boy who was successfully managed through the spontaneous thrombosis of a cavernous internal carotid artery (ICA) aneurysm, the subsequent occlusion of the ICA, its recanalization, and ultimate endovascular sacrifice, using only two angiograms because of the diagnostic capability of CT angiography. Spontaneous recanalization of the ICA following occlusion in the setting of a giant aneurysm has not been previously reported.

Sphenoid sinus mucocele caused by a completely thrombosed intracavernous carotid artery aneurysm: an unusual association

Background Mucocele is an inflammatory disease caused by the retention of mucoid secretions within a paranasal sinus. Although rare, the presence of a vascular lesion inside the sphenoid sinus could determine ostium obstruction, thus causing mucocele development.

Clinical Presentation An 84-year-old woman was referred to our institution due to a lesion abutting into the sphenoid sinus; she was complaining of constrictive frontal headache, progressive worsening of visual acuity in the left eye; later, sudden homolateral ptosis and diplopia occurred. The radiologic evidence was consistent with the diagnosis of thrombosed aneurysm of the right intracavernous carotid artery, surrounded by sphenoidal mucocele. The patient underwent an endoscopic endonasal transsphenoidal approach exclusively for sphenoid mucocele drainage.

Conclusion Although rare, the presence of a vascular lesion inside the sphenoid sinus has to be considered among the possible diagnostic hypotheses of masses abutting in this cavity; the association with mucocele is even more rare and, to date, has not been described.

Giant cavernous carotid aneurysm with spontaneous ipsilateral ICA occlusion: Report of 2 cases and review of literature

Giant aneurysms of the cavernous carotid artery are rare entities which present predominantly with features of compression of the adjacent neural structures, most commonly the III, IV, VI and V cranial nerves. Historically, treatment options included occlusion of the feeding vessel, direct surgery on the aneurysm, bypass procedures and in recent times, the use of endovascular devices. While intramural thrombus formation is commonly seen in giant aneurysms, we present 2 cases of giant cavernous aneurysms which on evaluation were found to have spontaneous occlusion of the feeding internal carotid artery secondary to thrombus formation, and review the available literature regarding the same.

Intracavernous internal carotid artery mycotic aneurysms: comprehensive review and evaluation of the role of endovascular treatment

Mycotic aneurysms may arise in the setting of many local or systemic infections. Those of the intracranial circulation are especially worrisome due to their potential to compress vital neural structures and their propensity for rupture with consequent hemorrhage. Mycotic aneurysms of the intracavernous internal carotid artery (ICA) represent an exceedingly rare clinical entity, described in less than fifty published cases. Typically presenting as a cavernous sinus syndrome with signs and symptoms of the underlying infection, they are often missed initially, with diagnosis and treatment commencing for the triggering infection or confused with cavernous sinus thrombophlebitis, which may be additionally coexistent, confounding timely diagnosis of the aneurysmal disease. Compared to non-mycotic aneurysms of the intracavernous ICA, which typically have a benign course, the infectious etiology of the mycotic variety increases their tendency to rupture, precludes surgical clipping as a viable treatment option, and requires institution of prolonged antibiotic therapy prior to definitive intervention. Their critical location, friability, and propensity to occur bilaterally result in an unpredictable risk of rapid neurological decline and death, making the timing and specific nature of treatment a unique dilemma facing the treating physician. This review seeks to discuss the natural history of and management strategies for mycotic aneurysms of the intracavernous ICA with special emphasis on the role, safety, and efficacy of endovascular therapies.

Case report: Thrombosed giant cavernous carotid artery aneurysm secondary to cervical internal carotid artery dissection: An unusual entity

Spontaneous thrombosis of a giant intracranial aneurysm with parent artery occlusion is known. The exact mechanism is however unclear and various theories have been proposed. We present an unusual case of an angiographically documented cervical internal carotid artery (ICA) dissection, which led to total occlusion of the ICA distal to the dissected site, with acute cessation of forward blood flow. This resulted in acute upstream thrombosis of the giant cavernous carotid artery aneurysm and an acute cavernous sinus syndrome-like presentation.

Thromboembolic complication induced stable occlusion of a ruptured basilar tip aneurysm. Case report and review of the literature

We describe a case of a ruptured basilar bifurcation aneurysm that thrombosed during preparation for endovascular therapy as a complication of diagnostic angiogaphy, and showed a favorable evolution during long-term follow-up. Endogenous thrombosis of ruptured, non giant aneurysms is uncommon. The persistence of occlusion over time in such cases is not well established. Two weeks after rupture, a 6 x 8 mm basilar bifurcation aneurysm was referred for endovascular treatment. During preparation for endovascular coil occlusion, without having any endovascular material at the level of the basilar artery, a complete thrombotic occlusion of the basilar bifurcation and aneurysm was observed. Given the good collateral circulation for both posterior cerebral arteries no thrombolysis was undertaken. The early follow-up of seven days, three and six months showed a complete recanalization of the basilar artery and remodeling of the basilar bifurcation. The 20 months imaging follow-up demonstrated a small aneurysm regrowth at the prevoius location that remained stable during the follow-up of seven years. Unchanged biological and hemodynamic characteristics. however, may pose an elevated risk of a new aneurysm formation over time, making long-term imaging follow-up, and in case of progression, aneurysm occlusion necessary for the patient.

Disappearing saccular intracranial aneurysms: do they really disappear?

SUMMARY

Evolution and natural history of cerebral aneurysms is a dynamic process. Spontaneous regression in size or complete disappearance of an aneurysm is a known phenomenon, more commonly noted in giant intracranial aneurysms. However, reappearance or regrowth of such aneurysms is rare with few anecdotal reports. We report a series of four cases including one giant aneurysm, which either disappeared or regressed on sequential angiograms. Regrowth or reappearance of two of these previously disappeared or regressed aneurysms was noted and endovascularly treated while the other two cases are being followed up. The decision to follow up was crucial considering the nature of the aneurysms to change in morphology under the influence of various hemodynamic factors.