Recurrent Embolic Stroke Caused by Large Cavernous Carotid Aneurysm: Stroke Recurrence Prevention with High-Flow Bypass Followed by Proximal Occlusion

Spontaneous Thrombosis of a Giant Cavernous Internal Carotid Artery Aneurysm and Parent Vessel Occlusion in a Patient With Bilateral Cavernous Internal Carotid Artery Aneurysms

Spontaneous thrombosis of giant aneurysms is a well-reported phenomenon. However, reports of complete occlusion of the aneurysm and parent vessel are scarce. Here, we describe the case of a patient with spontaneous thrombosis of a giant cavernous internal carotid artery (ICA) aneurysm and occlusion of the ICA. A 59-year-old female initially presented with frequent headaches and was otherwise completely neurologically intact. Magnetic resonance angiography (MRA) demonstrated a giant, partially thrombosed right cavernous ICA aneurysm. She was also found to have a contralateral left-sided intracavernous aneurysm. Cerebral angiogram revealed a giant, partially thrombosed right cavernous segment ICA aneurysm measuring 27.1 x 32.4 mm with slow, turbulent flow within the lesion. The patient was started on aspirin 325 mg and a dexamethasone taper with plans for follow-up flow diversion for treatment of the right cavernous ICA aneurysm. The patient presented three months later with worsening headaches, and on examination was found to have anisocoria (right > left) with a nonreactive right pupil as well as cranial nerve III/IV palsies, and facial edema. There was no evidence of intracranial hemorrhage or ischemia seen on head computed tomography (HCT). The diagnostic cerebral angiogram demonstrated complete occlusion of the right ICA at the carotid bifurcation with no filling of the giant right cavernous ICA aneurysm and a stable left cavernous ICA aneurysm. Although the exact mechanism of simultaneous thrombosis of the aneurysm and its parent artery remains unclear, it is likely due to stagnant flow. The presence of cranial nerve palsies was most likely secondary to acute edema of the lesion after thrombus formation. There was no evidence of ischemic symptoms due to collateral flow across a patent anterior communicating artery.