Surgical management of aneurysms of the distal extracranial internal carotid artery

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✓ Results, complications, and operative techniques of the surgical management of 20 aneurysms of the distal extracranial internal carotid artery (ICA) in 19 patients are reviewed. The proximity of these aneurysms to the styloid process is not considered as a chance occurrence, and the possibility is raised that these lesions are related to trauma from that structure. False aneurysms from spontaneous dissections are believed to occur only in those dissections that begin distally; they are not found in dissections that begin proximally. Treatment was individualized and dependent upon: 1) the size and location of the aneurysm; 2) symptomatology; and 3) hemodynamic considerations based upon intraoperative cerebral blood flow (CBF) measurements determined from the clearance of xenon-133 injected into the ipsilateral ICA. Methods of treatment included: resection of the aneurysm with placement of an interposition saphenous vein graft in seven patients; resection of the aneurysm with end-to-end anastomosis of the ICA in five; ICA ligation in three; clipping of the aneurysm in one; and extracranial-to-intracranial bypass in four. One patient sustained a postoperative cerebral ischemic complication from embolization which resulted in a mild permanent impairment in right hand dexterity. There were no other cerebral ischemic complications in the group, largely attributable, it is thought, to the use of intraoperative CBF measurements and continuous electroencephalograms. Four patients had transient dysphagia from traction damage to the pharyngeal and superior laryngeal nerves, and one patient with preoperative difficulty in swallowing required a gastrostomy. Long-term results have been excellent. Use of the operating microscope facilitated the suturing of the distal anastomosis in cases in which the ICA was reconstructed by an interposition vein graft or end-to-end anastomosis.

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Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905.

© AANS, except where prohibited by US copyright law.

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    Skin incision follows the leading border of the sternocleidomastoid muscle to a point behind the ear. It swings anteriorly around the lower margin of the earlobe, then rises in front of the tragus to end above the level of the zygoma. Note the position of the parotid gland and the location of the facial nerve.

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    The lower pole of the parotid gland has been mobilized and retracted anteriorly and superiorly after the superficial, deep, and temporoparotid fascia have been incised. The dissection is carried along the anterior border of the cartilage of the external ear canal and the anterior surface of the mastoid process. The posterior belly of the digastric muscle is exposed. The deep cervical veins will now be divided by bipolar coagulation and the internal carotid artery exposed distal to its origin from the common carotid artery. The carotid body and carotid sinus should be injected with xylocaine to avoid troublesome fluctuations in blood pressure.

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    The descendens hypoglossi nerve has been divided, and the occipital artery and muscular branch of that vessel to the sternocleidomastoid vessel are doubly ligated and divided. This frees the hypoglossal nerve from tethering effects by these structures and allows the surgeon to mobilize the structure superiorly out of danger. The internal carotid artery aneurysm is identified distal to the hypoglossal nerve and is noted to extend as far superiorly as the styloid process. The digastric muscle has been transected and reflected, revealing the aneurysm. The stylohyoid muscle is detached from the styloid muscle and reflected with the digastric muscle. The stylomandibular ligament has been incised and the mandible retracted anteriorly. The styloid process has been resected.

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    The proximal and distal internal carotid arteries are temporarily occluded with soft low-pressure intracranial vascular clips. The proximal and distal ends of the internal carotid artery are prepared in fish-mouth fashion as is the saphenous vein which is sewn into place distally with the aid of the operating microscope using interrupted 7-0 or 8-0 monofilament nylon sutures and microvascular instruments. The proximal end of the anastomosis is contructed with 6-0 interrupted Prolene sutures. Although proximal and distal self-retaining retractors are illustrated in this diagram, less traumatic retraction is provided by the use of spring or elastic activated fishhook restraints.

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    Left: When sufficient working space is available without resection of the aneurysm, it is advisable to leave the aneurysm in situ in order to protect motor branches from the vagus nerve leading to the pharynx. Unfortunately, in large aneurysms extending quite far distally, it is often not possible to perform the distal anastomosis until the aneurysm has been excised because of the space constraints. In this case, control of the distal internal carotid artery was possible distal to the superior margin of the aneurysm and accordingly the aneurysm was opened, a thrombectomy performed, and the wall of the aneurysm left in place. Right: Interposition vein graft has been placed between the distal and proximal internal carotid arteries in the bed of the collapsed aneurysm. Note the relative position of the hypoglossal nerve as it crosses the interposition vein graft.

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    Case 5. Left: Angiogram after the initial ischemic insult revealing the presence of a small aneurysm of the extracranial right internal carotid artery opposite the C-2 vertebral body. The decision was made at this time to manage the patient conservatively. Center: Nine months later the patient sustained a transient hemiplegia. An angiogram at this time revealed enlargement of the cervical aneurysm (double arrow) along with a trunk occlusion (single arrow) of the middle cerebral artery just distal to the origin of the striatic vessels. Right: Angiogram performed approximately 2 weeks later shows normal flow at this time through the middle cerebral group but with persistence of the aneurysm in the extracranial internal carotid artery.

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    Case 5. Postoperative angiogram, oblique projection, identifies proximal and distal points of the anastomosis (arrows). There is a slight tortuosity in the vein graft.

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    Case 3. Left: Preoperative angiogram demonstrating a large aneurysm of the extracranial internal carotid artery extending as high as the superior margin of the C-1 vertebra. Right: Angiogram following resection of the aneurysms illustrating a good flow through the interposition vein graft (arrows) with no areas of angulation or stenoses.

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    Resected specimen from Case 3, illustrating the fusiform gross external appearance of these lesions. With serial sectioning, the apparent lumen and the false lumen can usually be identified. These lesions probably develop initially as a false aneurysm from rupture of all three layers of the vessel wall. Ischemic symptoms are usually related to embolization from soft clot adjacent to the persisting lumen of the vessel.

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    Case 7. Left: Preoperative angiogram showing an aneurysm (large arrow) of the internal carotid artery at the C-1 vertebral level projecting posteriorly and somewhat laterally. Note the presence of a trigeminal artery (small arrow). Right: Postoperative angiogram showing occlusion of the aneurysm with good flow through the internal carotid artery at the site of repair.

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    Left: Spontaneous dissections that begin in proximal internal carotid artery do not develop false aneurysms. Right: False aneurysm from a spontaneous dissection beginning in the distal internal carotid artery. Dil = dilatation.

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    Angiograms in Case 4 showing fibromuscular disease with dissection and distal aneurysm. The distinctive “stacked coin” feature of fibromuscular disease is obscured following the development of a dissection.

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    Postoperative angiograms in Case 4 revealing good flow through temporal artery and bypass graft which is now a major source of blood supply to the middle cerebral artery group. The preoperative stenosis and aneurysm of the internal carotid artery, the pathogenesis of which was fibromuscular dysplasia, persist.

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    Case 12. Left: Preoperative angiogram showing an extracranial internal carotid artery aneurysm associated with elongation and tortuosity of the internal carotid artery. These changes were the result of fibromuscular disease. Center: The aneurysm, along with a segment of internal carotid artery, is resected (A and B) and the vessel is repaired using an end-to-end anastomosis (C). Right: Postoperative angiogram showing good flow through the site of the primary end-to-end anastomosis. The typical appearance of fibromuscular dysplasia is now better appreciated than on the preoperative study.

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    Case 13. Left: Superimposed right and left angiograms showing a patent temporal artery to middle cerebral artery anastomosis (small arrow) with resolution of the previous dissection present in the left internal carotid artery. The dissection of the right internal carotid artery has resolved but the aneurysm (large arrow) persists at the distal limit of the previous dissection. Center and Right: Postoperative anteroposterior (center) and lateral (right) angiograms, revealing good flow through the interposition vein graft with no areas of major narrowing or stenoses. The proximal and distal points of the anastomosis are identified by arrows.

References

  • 1.

    Alexander E JrWigser SMDavis CH: Bilateral extracranial aneurysm of the internal carotid artery. Case report. J Neurosurg 25:4374421966Alexander E Jr Wigser SM Davis CH: Bilateral extracranial aneurysm of the internal carotid artery. Case report. J Neurosurg 25:437–442 1966

  • 2.

    Astrup JSiesjö BKSymon L: Thresholds in cerebral ischemia — the ischemic penumbra. Stroke 12:7237251981Astrup J Siesjö BK Symon L: Thresholds in cerebral ischemia — the ischemic penumbra. Stroke 12:723–725 1981

  • 3.

    Astrup JSymon LBranston NMet al: Cortical evoked potential and extracellular K+ and H+ at critical levels of brain ischemia. Stroke 8:51571977Astrup J Symon L Branston NM et al: Cortical evoked potential and extracellular K+ and H+ at critical levels of brain ischemia. Stroke 8:51–57 1977

  • 4.

    Barnes WTJacoby GE: Aneurysm of the common carotid artery due to cystic medial necrosis treated by excision and graft. Ann Surg 155:82851962Barnes WT Jacoby GE: Aneurysm of the common carotid artery due to cystic medial necrosis treated by excision and graft. Ann Surg 155:82–85 1962

  • 5.

    Beall AC JrCrawford ESCooley DAet al: Extracranial aneurysms of the carotid artery. Report of seven cases. Postgrad Med 32:931021962Beall AC Jr Crawford ES Cooley DA et al: Extracranial aneurysms of the carotid artery. Report of seven cases. Postgrad Med 32:93–102 1962

  • 6.

    Boysen G: Cerebral hemodynamics in carotid surgery. Acta Neurol Scand (Suppl 52):1841973Boysen G: Cerebral hemodynamics in carotid surgery. Acta Neurol Scand (Suppl 52):1–84 1973

  • 7.

    Busuttil RWDavidson RKFoley KTet al: Selective management of extracranial carotid arterial aneurysms. Am J Surg 140:85911980Busuttil RW Davidson RK Foley KT et al: Selective management of extracranial carotid arterial aneurysms. Am J Surg 140:85–91 1980

  • 8.

    Buxton JT JrStevenson TBStallworth JM: Arteriosclerotic aneurysm of the extracranial internal carotid artery treated by excision and primary re-anastomosis under controlled hypertension. Ann Surg 159:2222261964Buxton JT Jr Stevenson TB Stallworth JM: Arteriosclerotic aneurysm of the extracranial internal carotid artery treated by excision and primary re-anastomosis under controlled hypertension. Ann Surg 159:222–226 1964

  • 9.

    Crowell RMOlsson YKlatzo Iet al: Temporary occlusion of the middle cerebral artery in the monkey: clinical and pathological observations. Stroke 1:4394481970Crowell RM Olsson Y Klatzo I et al: Temporary occlusion of the middle cerebral artery in the monkey: clinical and pathological observations. Stroke 1:439–448 1970

  • 10.

    Deysine MAdiga RWilder JR: Traumatic false aneurysm of the cervical internal carotid artery. Surgery 66:100410071969Deysine M Adiga R Wilder JR: Traumatic false aneurysm of the cervical internal carotid artery. Surgery 66:1004–1007 1969

  • 11.

    Ehrenfeld WKHays RJ: False aneurysm after carotid endarterectomy. Arch Surg 104:2282911972Ehrenfeld WK Hays RJ: False aneurysm after carotid endarterectomy. Arch Surg 104:228–291 1972

  • 12.

    Fisher CMOjemann RGRoberson GH: Spontaneous disection of cervico-cerebral arteries. Can J Sci Neurol 5:9191978Fisher CM Ojemann RG Roberson GH: Spontaneous disection of cervico-cerebral arteries. Can J Sci Neurol 5:9–19 1978

  • 13.

    Fox SL: Aneurysm of internal carotid artery found during tonsillectomy. Eye Ear Nose Throat Monthly 26:83841947Fox SL: Aneurysm of internal carotid artery found during tonsillectomy. Eye Ear Nose Throat Monthly 26:83–84 1947

  • 14.

    Friedman WADay ALQuisling RGet al: Cervical carotid dissecting aneurysms. Neurosurgery 7:2072141980Friedman WA Day AL Quisling RG et al: Cervical carotid dissecting aneurysms. Neurosurgery 7:207–214 1980

  • 15.

    Goldstone J: Aneurysms of the extracranial carotid artery in Rutherford RB (ed): Vascular Surgery. Philadelphia: WB Saunders1977 pp 11311139Goldstone J: Aneurysms of the extracranial carotid artery in Rutherford RB (ed): Vascular Surgery. Philadelphia: WB Saunders 1977 pp 1131–1139

  • 16.

    Halasz NAKennady JC: Excision of arteriosclerotic anurysm of the cervical internal carotid artery. J Neurosurg 21:3523571964Halasz NA Kennady JC: Excision of arteriosclerotic aneurysm of the cervical internal carotid artery. J Neurosurg 21:352–357 1964

  • 17.

    Hammon JW JrSilver DYoung WG Jr: Congenital aneurysm of the extracranial carotid arteries. Ann Surg 176:7777811972Hammon JW Jr Silver D Young WG Jr: Congenital aneurysm of the extracranial carotid arteries. Ann Surg 176:777–781 1972

  • 18.

    Hanson EJ JrAnderson RESundt TM Jr: Comparison of 85krypton and 133xenon cerebral blood flow measurements before, during, and following focal, incomplete ischemia in the squirrel monkey. Circ Res 36:18261975Hanson EJ Jr Anderson RE Sundt TM Jr: Comparison of 85krypton and 133xenon cerebral blood flow measurements before during and following focal incomplete ischemia in the squirrel monkey. Circ Res 36:18–26 1975

  • 19.

    Harrison DFN: Two cases of bleeding from the ear from carotid aneurysm. Guys Hosp Rep 103:2072121954Harrison DFN: Two cases of bleeding from the ear from carotid aneurysm. Guys Hosp Rep 103:207–212 1954

  • 20.

    Hejhal LHejhal JFirt Pet al: Aneurysms following endarterectomy associated with patch graft angioplasty. J Cardiovasc Surg 15:6206241974Hejhal L Hejhal J Firt P et al: Aneurysms following endarterectomy associated with patch graft angioplasty. J Cardiovasc Surg 15:620–624 1974

  • 21.

    Houser OWMokri BSundt TM Jret al: Spontaneous cervical cephalic arterial dissection and its residuum: angiographic spectrum. AJNR 5:27341984Houser OW Mokri B Sundt TM Jr et al: Spontaneous cervical cephalic arterial dissection and its residuum: angiographic spectrum. AJNR 5:27–34 1984

  • 22.

    Jones THMorawetz RBCrowell RMet al: Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg 54:7737821981Jones TH Morawetz RB Crowell RM et al: Thresholds of focal cerebral ischemia in awake monkeys. J Neurosurg 54:773–782 1981

  • 23.

    Kaupp HAHaid SPJurayj MNet al: Aneurysms of the extracranial carotid artery. Surgery 72:9469521972Kaupp HA Haid SP Jurayj MN et al: Aneurysms of the extracranial carotid artery. Surgery 72:946–952 1972

  • 24.

    Kim USFriedman EWWerther LJet al: Carotid artery aneurysm associated with nonbacterial suppurative arteritis. Arch Surg 106:8658671973Kim US Friedman EW Werther LJ et al: Carotid artery aneurysm associated with nonbacterial suppurative arteritis. Arch Surg 106:865–867 1973

  • 25.

    McCollum CHWheeler WGNoon GPet al: Aneurysms of the extracranial carotid artery. Twenty-one years' experience. Am J Surg 137:1962001979McCollum CH Wheeler WG Noon GP et al: Aneurysms of the extracranial carotid artery. Twenty-one years' experience. Am J Surg 137:196–200 1979

  • 26.

    Michenfelder JDTheye RA: The effects of anesthesia and hypothermia on canine cerebral ATP and lactate during anoxia produced by decapitation. Anesthesiology 33:4304391970Michenfelder JD Theye RA: The effects of anesthesia and hypothermia on canine cerebral ATP and lactate during anoxia produced by decapitation. Anesthesiology 33:430–439 1970

  • 27.

    Mokri BPiepgras DGSundt TM Jret al: Extracranial internal carotid artery aneurysms. Mayo Clin Proc 57:3103211982Mokri B Piepgras DG Sundt TM Jr et al: Extracranial internal carotid artery aneurysms. Mayo Clin Proc 57:310–321 1982

  • 28.

    Raphael HABernatz PESpittell JA Jr: Cervical carotid aneurysms: treatment by excision and restoration of arterial continuity. Am J Surg 105:7717781963Raphael HA Bernatz PE Spittell JA Jr: Cervical carotid aneurysms: treatment by excision and restoration of arterial continuity. Am J Surg 105:771–778 1963

  • 29.

    Rhodes ELStanley JCHoffman GLet al: Aneurysms of extracranial carotid arteries. Arch Surg 111:3393431976Rhodes EL Stanley JC Hoffman GL et al: Aneurysms of extracranial carotid arteries. Arch Surg 111:339–343 1976

  • 30.

    Rittenhouse EARadke HMSumner DS: Carotid artery aneurysm. Review of the literature and report of a case with rupture into the oropharynx. Arch Surg 105:7867891972Rittenhouse EA Radke HM Sumner DS: Carotid artery aneurysm. Review of the literature and report of a case with rupture into the oropharynx. Arch Surg 105:786–789 1972

  • 31.

    Shipley AMWinslow NWalker WW: Aneurysm in the cervical portion of the internal carotid artery. An analytical study of the cases recorded in the literature between August 1, 1925 and July 31, 1936. Report of two new cases. Ann Surg 105:6736991937Shipley AM Winslow N Walker WW: Aneurysm in the cervical portion of the internal carotid artery. An analytical study of the cases recorded in the literature between August 1 1925 and July 31 1936. Report of two new cases. Ann Surg 105:673–699 1937

  • 32.

    Sundt TM JrMichenfelder JD: Focal transient cerebral ischemia in the squirrel monkey. Effect on brain adenosine triphosphate and lactate levels with electrocorticographic and pathologic correlation. Circ Res 30:7037121972Sundt TM Jr Michenfelder JD: Focal transient cerebral ischemia in the squirrel monkey. Effect on brain adenosine triphosphate and lactate levels with electrocorticographic and pathologic correlation. Circ Res 30:703–712 1972

  • 33.

    Sundt TM JrSharbrough FWAnderson REet al: Cerebral blood flow measurements and electroencephalograms during carotid endarterectomy. J Neurosurg 41:3103201974Sundt TM Jr Sharbrough FW Anderson RE et al: Cerebral blood flow measurements and electroencephalograms during carotid endarterectomy. J Neurosurg 41:310–320 1974

  • 34.

    Sundt TM JrSharbrough FWPiepgras DGet al: Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy, with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 56:5335431981Sundt TM Jr Sharbrough FW Piepgras DG et al: Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy with results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 56:533–543 1981

  • 35.

    Thompson JEAustin DJ: Surgical management of cervical carotid aneurysms. Arch Surg 74:80881957Thompson JE Austin DJ: Surgical management of cervical carotid aneurysms. Arch Surg 74:80–88 1957

  • 36.

    Waltz AGSundt TM Jr: The microvasculature and microcirculation of the cerebral cortex after arterial occlusion. Brain 90:6816961967Waltz AG Sundt TM Jr: The microvasculature and microcirculation of the cerebral cortex after arterial occlusion. Brain 90:681–696 1967

  • 37.

    Webb R JrBarker WF: Aneurysms of the extracranial internal carotid artery. Arch Surg 99:5015051969Webb R Jr Barker WF: Aneurysms of the extracranial internal carotid artery. Arch Surg 99:501–505 1969

  • 38.

    Winslow N: Extracranial aneurysm of the internal carotid artery. History and analysis of the cases registered up to Aug. 1, 1925. Arch Surg 13:6897291926Winslow N: Extracranial aneurysm of the internal carotid artery. History and analysis of the cases registered up to Aug. 1 1925. Arch Surg 13:689–729 1926

  • 39.

    Wychulis ARBeahrs OHBernatz PE: Aneurysm of internal carotid artery treated by excision and anastomosis to external carotid artery. Arch Surg 88:8038061964Wychulis AR Beahrs OH Bernatz PE: Aneurysm of internal carotid artery treated by excision and anastomosis to external carotid artery. Arch Surg 88:803–806 1964

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