Rare case of carotid artery occlusion due to thrombosis of a giant cerebral aneurysm: the role of cerebral revascularization

Caso raro de oclusão da artéria carótida devido à trombose de um aneurisma cerebral gigante: o papel da revascularização cerebral

LETTERS

Rare case of carotid artery occlusion due to thrombosis of a giant cerebral aneurysm. The role of cerebral revascularization

Caso raro de oclusão da artéria carótida devido à trombose de um aneurisma cerebral gigante. O papel da revascularização cerebral

Rafael de Oliveira Sillero^I; Valter José Sillero Filho^II; Gislaine Priscila Momm Zimmermann^III

^IMD, Neurosurgeon-in-chief, Neurosurgery Unit, Regional Hospital of São José, São José SC, Brazil

^IIMD, Neurosurgeon, Neurosurgery Unit, Regional Hospital of São José, São José SC, Brazil

^IIIMD, Ophthalmologist, Regional Hospital of São José, São José SC, Brazil

^{Correspondence}

Spontaneous thrombosis of a giant cerebral aneurysm is a recognized phenomenon, however it becomes rare when the thrombosed aneurysm is associated with the occlusion of its parent artery^1,2. The best management strategy is not defined yet. Theoretically, it should be directed to alleviating mass effect related symptoms caused by the aneurysm itself and to preventing cerebral ischemia.

We describe a case of carotid artery occlusion and discuss the role of cerebral revascularization.

CASE REPORT

A 69-year-old woman had suffered from left painful ophthalmoplegia with a sudden onset. She had consulted her ophthalmologist, who suspected a left cavernous sinus syndrome. A computed tomography of the head was obtained, and the patient was referred to our service with a diagnosis of brain tumor.

On admission, the patient was conscious and the left cavernous sinus syndrome was confirmed. The initial computed tomography (CT) scan showed a high-density parasellar round lesion extending to the left middle cranial fossa. Magnetic resonance imaging revealed a giant thrombosed aneurysm of the left cavernous internal carotid artery (Fig 1). Further investigation with a four-vessel cerebral angiography (Fig 2) obtained 10 days after the onset of presentation revealed the finding of left internal carotid artery (ICA) occlusion with good cross filling in the left-side circulation through the anterior communicating artery. The patient was treated conservatively and her symptoms gradually improved. She was discharged on antiplatelet treatment.

At the 3-month follow-up consultation, the patient was complaining of some brief episodes of language disturbance related to verbal expression.

After demonstration of cerebral flow asymmetry by a single photon emission computed tomography (SPECT) study, the patient underwent extra-intracranial bypass surgery using the technique described by Yasargil³ to anastomose the left superficial temporal artery to the middle cerebral artery. Postoperative course was uneventful and control cerebral angiography confirmed bypass patency.

At follow-up consultation 3-years later, the patient was asymptomatic and CT angiography (Fig 3) showed that the bypass remained patent.

DISCUSSION

The angiographic finding of an ICA occlusion in the case of a parasellar cerebral aneurysm is very fortunate if there is good cross filling to the contralateral side and the patient is asymptomatic. We suggest that it cannot be considered a "self-treated lesion" unless a functional cerebral blood flow study (transcranial Doppler, positron emission tomography or SPECT) is within normal limits. When considering the indication of bypass surgery for the aim of flow augmentation, patient selection includes clinical criteria, such as recurrent transient ischemic attack and cerebral fluid flow study criteria of reduced cerebrovascular reserve capacity⁴.

A report has been published in which aneurysmotomy and thrombectomy of a thrombosed giant intracavernous carotid aneurysm were performed and produced mass effect relief with symptomatic improvement². Similarly, our patient had remission of mass effect symptoms, but with conservative management.

Our experience with this case has convinced us that a close follow-up is paramount in a patient with an occluded internal carotid artery since surgical intervention may be necessary.

Conflict of interest:

There is no conflict of interest to declare.

Received 16 August 2011

Received in final for 06 September 2011

Accepted 13 September 2011

• 1. Sato K, Fujiwara S, Yoshimoto T, Onuma T. Two cases of spontaneous internal carotid artery occlusion due to giant intracranial carotid artery aneurysm. Stroke 1990;21:1506-1509.
• 2. Whittle IR, Williams DB, Halmagyi GM, Besser M. Spontaneous thrombosis of a giant intracranial aneurysm and ipsilateral internal carotid artery. Case report. J Neurosurg 1982;56:287-289.
• 3. Yasargil MG. Microsurgery applied to neurosurgery. Stuttgart: Georg Thieme; 1969:60-81.
• 4. Vajkoczy P. Revival of extra-intracranial bypass surgery. Curr Opin Neurol 2009;22:90-95.

Publication Dates

• Publication in this collection
  01 Feb 2012
• Date of issue
  Feb 2012