Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass

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✓ Ten patients with intracranial internal carotid artery (ICA) aneurysms were managed by combining ICA ligation with an extracranial to intracranial bypass procedure. Nine of these grafts were proven patent by angiogram. One patient was unable to return for postoperative angiograms; his graft had appeared patent on physical examination. Seven aneurysms were intracavernous, two were giant carotid-ophthalmic aneurysms, and one aneurysm was at the intracranial bifurcation of the ICA. Despite occlusion cerebral blood flow (CBF) measurements of 20 ml/100 gm/min or less in six patients, only one patient was unable to tolerate ICA ligation. Three patients developed transient aphasia, but there were no permanent neurological deficits associated with the carotid occlusion. Seven patients had improvement in pre-existing extraocular palsies or visual field defects. Others remained stable.

The combination of an extracranial to intracranial microvascular bypass procedure with ICA ligation seems to be an effective method of treatment for aneurysms near the base of the skull that cannot be obliterated by a direct intracranial approach. The addition of the bypass procedure permits ICA ligation in patients who would not otherwise have tolerated occlusion of that vessel. Intraoperative xenon CBF measurements are an important adjunct to the operation.

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Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Cerebrovascular Research Center, Room 4-437, Alfred Building, St. Mary's Hospital, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 5. Right carotid angiogram showing a fusiform aneurysm in the cavernous portion of the right internal carotid artery. The lateral view (left) does not delineate it as clearly as the anteroposterior projection (right). Note the small A1 segment of the anterior cerebral artery suggesting minimal cross flow.

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    Case 5. Postoperative angiogram showing nonfilling of the aneurysm and patency of the bypass graft.

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    Case 6. Left carotid subtraction angiogram showing nonfilling of the giant intracavernous aneurysm, patency of the left occipital to middle cerebral artery bypass, and collateral flow through the ophthalmic artery.

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    Case 8. Left: Submentovertex x-ray film showing the jaws of the Drake clip open 3 mm across the neck of the aneurysm. Upper Right: Left carotid angiogram showing persistent filling of the aneurysm. Lower Right: Left carotid angiogram after internal carotid artery ligation and superficial temporal-middle cerebral artery bypass. There is no filling of the aneurysm and the bypass graft is patent.

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    Case 10. Upper Left: Preoperative angiogram showing a large internal carotid artery bifurcation aneurysm. Note stenosis at the origin of the middle cerebral artery (MCA) and apparent thrombus in the aneurysm. Upper Right: Preoperative angiogram 3 weeks later. Note partial lysis of the clot in the aneurysm. Stenosis of the MCA persists. Lower: Postoperative angiogram showing nonfilling of the aneurysm. Arrows point to sites of anastomosis (double-barrel bypass).

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