Giant traumatic false aneurysm of the internal carotid artery associated with a carotid-cavernous fistula

Case report

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✓ A case of giant traumatic false aneurysm of the intracranial internal carotid artery (ICA) with a concomitant carotid-cavernous fistula is reported. The fistula and the aneurysm persisted after ipsilateral cervical ICA ligation was performed elsewhere. Successful obliteration of the aneurysm and the fistula, with preservation of cross filling of the ipsilateral middle cerebral artery system, was accomplished by ligation of the intracranial ICA proximal to the origin of the posterior communicating artery with a 7–0 prolene suture, followed by transaneurysmal packing of the fistula.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Computerized tomography scan revealing a giant aneurysm of the left internal carotid artery.

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    Left carotid angiograms, lateral (left) and anteroposterior (right) views; subtraction films. A large lobulated aneurysm is seen arising from the intracranial right internal carotid artery (ICA) and extending superiorly into the interpeduncular cistern. The aneurysm is fed on the lateral side by the right ICA. No evidence of antegrade filling of the right middle cerebral artery is observed. There is a carotidcavernous fistula with rapid opacification of the cavernous sinus and the superior ophthalmic vein.

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    Diagrammatic representation of the operative procedure. A: The location of the aneurysm, the position of the patient for surgery, and the outline of craniotomy are shown. B: Closer view of the aneurysm and fistula. The aneurysm seemingly developed from a life-saving containment of the hemorrhage by the arachnoidal compartments surrounding the internal carotid artery (ICA). Note the occluded proximal middle cerebral artery (MCA). The fistulous opening into the cavernous sinus was located inferior and lateral to the ICA and medial to the third nerve. ACA = anterior cerebral artery. C: The wall of the aneurysm (thickened arachnoid) was dissected away from the ICA with the tip of a No. 11 blade knife and then retracted and elevated with a small spatula. Insufficient space to occlude the ICA with an aneurysm clip and yet preserve the posterior communicating artery made it necessary to ligate the ICA with a No. 7-0 prolene suture. D: Following ligation of the distal ICA, the aneurysm was opened and the sac emptied by a strong suction unit. Considerable bleeding occurred from this maneuver. E: The proximal ICA was clipped and the cavernous sinus packed with Surgicel.

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    Postoperative left carotid angiograms, lateral (left) and anteroposterior (right) views; subtraction films. The large false aneurysm of the internal carotid artery and the fistula are no longer visible. The right middle cerebral artery fills by cross flow from the right A1 segment.

References

  • 1.

    Benoit BGWortzman G: Traumatic cerebral aneurysms. Clinical features and natural history. J Neurol Neurosurg Psychiatry 36:1271381973Benoit BG Wortzman G: Traumatic cerebral aneurysms. Clinical features and natural history. J Neurol Neurosurg Psychiatry 36:127–138 1973

  • 2.

    Debrun GLacour PCaron JPet al: Detachable balloon and calibrated-leak balloon techniques in the treatment of cerebral vascular lesions. J Neurosurg 49:6356491978Debrun G Lacour P Caron JP et al: Detachable balloon and calibrated-leak balloon techniques in the treatment of cerebral vascular lesions. J Neurosurg 49:635–649 1978

  • 3.

    Fein JMFlamm E: Planned intracranial revascularization before proximal ligation for traumatic aneurysm. Neurosurgery 5:2542581979Fein JM Flamm E: Planned intracranial revascularization before proximal ligation for traumatic aneurysm. Neurosurgery 5:254–258 1979

  • 4.

    Gelber BRSundt TM Jr: Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass. J Neurosurg 52:1101980Gelber BR Sundt TM Jr: Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass. J Neurosurg 52:1–10 1980

  • 5.

    Handa H: Traumatic aneurysms of the intracranial portion of the internal carotid artery. Inst Neurol Madras Proc 6:2682811976 (Cited in Reference 21)Handa H: Traumatic aneurysms of the intracranial portion of the internal carotid artery. Inst Neurol Madras Proc 6:268–281 1976 (Cited in Reference 21)

  • 6.

    Handa JKikuchi HIwayama Ket al: Traumatic aneurysms of the internal carotid artery. Acta Neurochir 17:1611771967Handa J Kikuchi H Iwayama K et al: Traumatic aneurysms of the internal carotid artery. Acta Neurochir 17:161–177 1967

  • 7.

    Hosobuchi Y: Electrothrombosis of carotid-cavernous fistula. J Neurosurg 42:76851975Hosobuchi Y: Electrothrombosis of carotid-cavernous fistula. J Neurosurg 42:76–85 1975

  • 8.

    Kerber CWBank WOCromwell LD: Calibrated leak balloon microcatheter: a device for arterial exploration and occlusive therapy. AJR 132:2072121979Kerber CW Bank WO Cromwell LD: Calibrated leak balloon microcatheter: a device for arterial exploration and occlusive therapy. AJR 132:207–212 1979

  • 9.

    Lister JRSypert GW: Traumatic false aneurysm and carotid-cavernous fistula: a complication of sphenoidotomy. Neurosurgery 5:4734751979Lister JR Sypert GW: Traumatic false aneurysm and carotid-cavernous fistula: a complication of sphenoidotomy. Neurosurgery 5:473–475 1979

  • 10.

    McCormick WFBeals JD: Severe epistaxis caused by ruptured aneurysm of the internal carotid artery. J Neurosurg 21:6786861964McCormick WF Beals JD: Severe epistaxis caused by ruptured aneurysm of the internal carotid artery. J Neurosurg 21:678–686 1964

  • 11.

    Mullan S: Treatment of carotid-cavernous fistulas by cavernous sinus occlusion. J Neurosurg 50:1311441979Mullan S: Treatment of carotid-cavernous fistulas by cavernous sinus occlusion. J Neurosurg 50:131–144 1979

  • 12.

    Parkinson D: Carotid cavernous fistula: direct repair with preservation of the carotid artery. Technical note. J Neurosurg 38:991061973Parkinson D: Carotid cavernous fistula: direct repair with preservation of the carotid artery. Technical note. J Neurosurg 38:99–106 1973

  • 13.

    Paullus WS JrNorwood CWMorgan HW: False aneurysm of the cavernous carotid artery and progressive external ophthalmoplegia after transsphenoidal hypophysectomy. J Neurosurg 51:7077091979Paullus WS Jr Norwood CW Morgan HW: False aneurysm of the cavernous carotid artery and progressive external ophthalmoplegia after transsphenoidal hypophysectomy. J Neurosurg 51:707–709 1979

  • 14.

    Prolo DJHanbery JW: Intraluminal occlusion of a carotid-cavernous sinus fistula with a balloon catheter. Technical note. J Neurosurg 35:2372421971Prolo DJ Hanbery JW: Intraluminal occlusion of a carotid-cavernous sinus fistula with a balloon catheter. Technical note. J Neurosurg 35:237–242 1971

  • 15.

    Salar GMingrino S: Traumatic intracranial internal carotid aneurysm due to gunshot wound. Case report. J Neurosurg 49:1001021978Salar G Mingrino S: Traumatic intracranial internal carotid aneurysm due to gunshot wound. Case report. J Neurosurg 49:100–102 1978

  • 16.

    Sedzimir CBOccleshaw JVBuxton PH: False cerebral aneurysm. Case report. J Neurosurg 29:6366391968Sedzimir CB Occleshaw JV Buxton PH: False cerebral aneurysm. Case report. J Neurosurg 29:636–639 1968

  • 17.

    Serbinenko FA: Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 41:1251451974Serbinenko FA: Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 41:125–145 1974

  • 18.

    Shen AL: Superficial temporal-middle cerebral artery anastomoses in the treatment of a carotid-cavernous fistula. Case report. J Neurosurg 49:7607631978Shen AL: Superficial temporal-middle cerebral artery anastomoses in the treatment of a carotid-cavernous fistula. Case report. J Neurosurg 49:760–763 1978

  • 19.

    Shirai STomono YOwada Tet al: Traumatic aneurysm of the internal carotid artery. Report of a case with late severe epistaxis. Eur Neurol 15:2122161977Shirai S Tomono Y Owada T et al: Traumatic aneurysm of the internal carotid artery. Report of a case with late severe epistaxis. Eur Neurol 15:212–216 1977

  • 20.

    Smith DRKempe LG: Cerebral false aneurysm formation in closed head trauma. Case report. J Neurosurg 32:3573591970Smith DR Kempe LG: Cerebral false aneurysm formation in closed head trauma. Case report. J Neurosurg 32:357–359 1970

  • 21.

    Waga SKojima T: [Association of carotid-cavernous fistula and traumatic aneurysm of internal carotid artery. Report of two cases.] No Shinkei Geka 7:9339381979 (Jpn)Waga S Kojima T: [Association of carotid-cavernous fistula and traumatic aneurysm of internal carotid artery. Report of two cases.] No Shinkei Geka 7:933–938 1979 (Jpn)

  • 22.

    Waga SMorikawa AFujimoto K: Carotid-cavernous fistula associated with traumatic aneurysm of the internal carotid artery. Surg Neurol 9:3673691978Waga S Morikawa A Fujimoto K: Carotid-cavernous fistula associated with traumatic aneurysm of the internal carotid artery. Surg Neurol 9:367–369 1978

  • 23.

    Yaşargil MGKasdaglis KJain KKet al: Anatomical observations of the subarachnoid cisterns of the brain during surgery. J Neurosurg 44:2983021976Yaşargil MG Kasdaglis K Jain KK et al: Anatomical observations of the subarachnoid cisterns of the brain during surgery. J Neurosurg 44:298–302 1976

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