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
- Department of Neurosurgery, Research Institute i+12-CIBERESP, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Avda Cordoba SN, Madrid, Spain.
DOI:10.25259/SNI_597_2019Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ana M. Castaño-Leon, Jose F. Alen, Alfonso Lagares. 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. 04-Apr-2020;11:62
How to cite this URL: Ana M. Castaño-Leon, Jose F. Alen, Alfonso Lagares. 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. 04-Apr-2020;11:62. Available from: https://surgicalneurologyint.com/surgicalint-articles/9943/
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.
Keywords: Aneurysm, Collateral pathways, Intracavernous carotid artery, Parent artery occlusion
Intracavernous carotid artery (ICCA) aneurysms account for 3–5% of all intracranial aneurysms.[
In most centers, due to the challenging exposition of ICCA, these aneurysms are considered not amenable for clipping, and their management usually consists in coiling or flow-diverter placement. Parent artery occlusion (PAO) is a feasible alternative in those cases with intra-aneurysm or internal carotid artery (ICA) thrombosis, none or very wide neck, age or medical condition of the patient, and after failure of endovascular techniques. There are a number of alternatives according to the location (ICA or common carotid artery [CCA]), timing (abrupt ligation or prolonged closure with temporal clamps),[
The reported mortality and morbidity rates of surgical PAO range from 6–20% to 4–12%, respectively.[
Here, we present a rare case of a partially thrombosed ICCA aneurysm which early recanalized after surgical ligation of the cervical CCA via an unusual collateral pathway.
A 63-year-old woman, with arterial hypertension as the only relevant medical history, presented with a sudden binocular diplopia. Right 6th nerve palsy was evidenced on physical examination at admission. AngioCT revealed a right ICCA aneurysm with signs of partial thrombosis without evidence of rupture [
Admission AngioCT revealed a right intracavernous carotid artery (ICCA) aneurysm with signs of partial thrombosis without evidence of rupture (a). The patient experienced complete cavernous sinus syndrome in relation to progression of thrombosis of the ICCA aneurysm as a new AngioCT showed (b).
Right carotid angiography, anteroposterior (a) lateral (b) and oblique (c) projections, indicates a giant aneurysm (25 mm of main diameter, 9 mm neck width) at the cavernous segment of the right ICA. Left carotid angiography, anteroposterior projection, showing adequate collateral reserve via anterior communicating artery (d) and the aneurysm without filling of contrast after balloon occlusion at the proximal portion of the right ICA (e).
Nine months later, and without new neurological symptoms, signs of aneurysm growth were detected in a serial MRA [
Nine months after common carotid artery ligation, a right vertebral angiography (lateral projection) showed partial recanalization of the intracavernous carotid artery (ICCA) aneurysm (a). Collateral supply was explained from external carotid artery through the occipital artery with an inverse flow to the internal carotid artery (ICA) (arrowheads). After cervical ICA surgical ligation, a new right vertebral angiography confirmed total occlusion of the ICCA aneurysm (b).
In ICCA aneurysms, due to the small number and caliber of branching vessels, PAO is a feasible option for treatment.[
Even when similar rates of success have been reported, there is controversy about the best site of PAO.[
Although ischemic and thromboembolic complications after PAO have received the attention, delayed refilling of ICCA aneurysm could happen. Conventionally, collateral pathway development is based on the proliferation of vasa vasorum induced by neoangiogenic factors after progressive atherothrombotic ICA occlusion.[
According to the previous data, two main types of recanalization after PAO may occur:
Retrograde recanalization: backflow of the ophthalmic artery,[ Anterograde recanalization: vasa vasorum and collateral embryonal pathways between the ICA and ECA (in the case of CCA, meningohypophyseal branches, and inferior lateral trunk). Recently, Wang[
Retrograde recanalization: backflow of the ophthalmic artery,[
Anterograde recanalization: vasa vasorum and collateral embryonal pathways between the ICA and ECA (in the case of CCA, meningohypophyseal branches, and inferior lateral trunk). Recently, Wang[
In our opinion, some of the mechanisms that explain the lower risk of thromboembolism and ischemia after CCA occlusion are the same that influence the opening of unusual collaterals. The importance of the evaluation of proximal intracranial ICA branches during the planification of the site of PAO was described by Allen.[
Even with the mentioned multiple sources recanalization of ICCA aneurysms after PAO is a rare complication. If we review the literature of previously reported cases, we identify only seven studies [
Delayed refilling of ICCA aneurysms based on unusual collateral pathway opening after PAO may occur. Periodic long-term follow-up by neuroimaging is recommended, especially in those cases where potential collateral branches of have not been clearly identified in the preoperative studies.
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