J Neurosurg 56:443-447, 1982

Treatment of bilateral mycotic intracavernous
carotid aneurysms
Case report
TSUNEYOSHI EGUCHI, M.D., TADAYOSHI NAKAGOMI, M.D., AND AKIRA TERAOKA, M.D.

Department of Neurosurgery, Tokyo Police Hospital, Tokyo, and Teraoka Memorial Hospital,
Fukuyama, Japan
I/ A case of bilateral mycotic intracavernous carotid aneurysms is reported. Because ofprogressive bilateral
ophthalmoplegia, the internal carotid artery (ICA) was ligated on both sides, combined with bilateral
extracranial-intracranial arterial bypass. A superficial temporal artery-middle cerebral artery anastomosis
was performed first on the right side followed by ligation of the right ICA at the neck. After an interval of
20 days, a bypass and ICA ligation was carried out on the left side. The patient developed mild hemiparesis
and dysphasia during and immediately after the second operation, but these neurological deficits disappeared after elevation of systemic blood pressure.
KEY WORDS
9 carotid aneurysm
mycotic aneurysm
9 cavernous sinus
9
internal carotid ligation
9 STA-MCA anastomosis
9 extracranial-intracranial bypass

B

ILATERALintracavernous carotid aneurysms are
rare 1~
and almost always inaccessible for
direct operation. 13 We have found only 27
cases of such aneurysms reported in the literature.
Five were treated surgically; two cases with partial
carotid ligation on one side, another two by internal
carotid artery (ICA) trapping on one side, and one
by ICA ligation on one side and wrapping on
the other side. 7,1~
In the present report, we describe a case of bilateral
mycotic intracavernous carotid aneurysms in which
bilateral ICA ligations combined with bilateral extracranial-intracranial (EC-IC) bypass procedures were
performed. The feasibility of this combined procedure
and precautions to be taken are examined.
Case Report

This 22-year-old man had been in excellent health
until a week before admission, when he experienced
a phlegmon at his nose and developed a toothache.
Four days later he developed a high fever of 39.8~
sore throat, and neck pain.
Examination. On admission to the Teraoka Memorial Hospital in Fukuyama on May 18, 1980, the

J. Neurosurg. / Volume 56 / March, 1982

patient's body temperature was 39.7 oC, pulse 96/min,
and blood pressure 140/60 mm Hg. Physical examination revealed signs of meningeal irritation, fight
exophthalmos with chemosis, axillary and inguinal
lymphadenopathy, and painful induration along the
right jugular vein. No bruit was audible over the eyes
or head. Heart sounds were normal. The neurological
examination of this conscious patient revealed anisocoria (greater on the left than the fight), diplopia, and
slight visual impairment in the right eye. No ptosis
was noted at this time. This clinical picture seemed to
come from meningitis and a possible thrombophlebitis
of the cavernous sinus and jugular vein.
Preoperative Course. On May 28, 1980, bilateral
total ophthalmoplegia developed; the patient could
not open or move his eyes, the pupils were maximally
dilated and did not react to light. Visual acuity was
still preserved. Hypesthesia and paresthesia were
noted in the distribution of the first division of both
trigeminal nerves.
A lumbar tap showed an initial pressure of 210 mm
H20 with turbid cerebrospinal fluid (CSF). Analysis
of CSF showed 847 cells/cu mm (almost all polynuclear cells), 76 mg/dl of protein, and 43 mg/dl of
sugar. Leukocytosis was noted, with up to 19,300
443

T. E g u c h i , T. N a k a g o m i a n d A. T e r a o k a
leukocytes/cu mm. No bacteria were cultured from
the blood nor from the CSF, since antibiotic therapy
had already been started before the patient was transferred to our clinic. He also had polyuria, with a urine
output of up to 8500 ml/day. The high fever persisted
until May 30, 1980.
Cerebral angiography (Fig. 1) revealed bilateral
intracavernous carotid aneurysms. The right ICA was
also moderately narrowed, probably because of angiitis of the carotid artery, which was believed to originate at the cavernous portion of the right ICA. 9
Ophthalmic venography showed that the cavernous
sinus was thrombosed. On computerized tomogtaphy
(CT) scan, partially thrombosed aneurysms were visualized in both parasellar regions. The patient's focal
neurological signs progressed during the course of his
hospitalization, so it was decided to treat these aneurysms surgically.
First Operation. On July 5, 1980, a right-sided
superficial temporal-middle cerebral artery (STAMCA) anastomosis was performed under general anesthesia, and the right ICA was completely ligated in
the neck at the same time. No cerebral ischemic
complications resulted. Only a mild reactive hypertension (about 150/80 mm Hg) developed and continued
for 2 weeks.
Postoperative right carotid angiography (Fig. 2)
showed a patent anastomosis and a good bypass circulation. Hypesthesia and paresthesia of the right
forehead diminished and the right palpebral fissure
opened to 2 mm in width. Right abducens nerve
weakness subsided. Right visual acuity had improved;
however, the pupils remained nonreactive to light.
Second Operation. On July 25, 1980, 20 days after
the first operation, the carotid bifurcation in the left
side of the neck was exposed under general anesthesia,
and an STA-MCA anastomosis was performed. The
patient was thereafter awakened and extubated. The
operation was continued under local anesthesia, in
full communication with the patient. The ICA was
temporarily clamped for 30 minutes under induced
hypotension to check whether any cerebral ischemic
signs occurred.
When the systolic blood pressure was below 100
mm Hg, tachycardia (160/min) appeared and a slight
right hemiparesis developed, but no speech disturbance was recognized. This hemiparesis disappeared
immediately after the systolic blood pressure was
raised above 120 mm Hg, and tachycardia was
controlled.
After confirming that the hemiparesis had resolved,
we ligated the ICA completely. The systolic blood
pressure was kept at 130 mm Hg.
Postoperative Course. Immediately after the operation, right hemiparesis and dysphasia developed again
without disturbance of consciousness, although blood
pressure was 130/90 mm Hg. Blood pressure was
raised to 160/100 mm Hg, and the ischemic signs

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FIG. 1. Preoperative angiograms, anteroposterior (left)
and lateral (righO views. Upper: Left cerebral angiography
revealing a giant intracavernous carotid aneurysm. Lower:
Right cerebral angiography showing an intracavernous carotid aneurysm (arrows) which was opacified even in the
films of the later phase. The fight internal carotid artery
was moderately narrowed.

immediately disappeared again. Four hours postoperatively, systolic blood pressure stabilized spontaneously at about 160 to 180 mm Hg systolic, and
hypertensive drugs were discounted. This moderate
reactive hypertension continued for about 2 weeks,
then subsided spontaneously.
Postoperative left carotid angiography (Fig. 3)
showed that the anastomosis was patent and there was
a good bypass circulation. Contrast-enhanced CT
scans (Fig. 4) revealed that the left intracavernous
carotid aneurysm was thrombosed postoperatively
and progressively decreased in size.
The bilateral ophthalmoplegia improved remarkably. Only slight residual anisocoria (with the left pupil
larger than the right), sluggish light reflex of the left
pupil, and moderate left abducens palsy remained at
the 1-month postoperative examination. No cerebral
ischemic complications were noted. The patient no
longer felt dizzy when standing or walking, as he had
shortly after the second operation.
J. Neurosurg. / Volume 56 / March, 1982

Bilateral intracavernous carotid aneurysms

FIG. 2. Postoperative right carotid angiograms, anteroposterior (left) and lateral (right) views. The
anastomosis was patent and almost all the branches of the middle cerebral artery were opacified through
the dilated superficial temporal arteries (arrows). The arrowhead shows the anastomotic site. The right
anterior cerebral artery was fed mainly via the ophthalmic artery.

FIG. 3. Postoperative left carotid angiography, anteroposterior (left) and lateral (right) views, showing
the remarkably dilated superficial temporal artery as a donor vessel (arrows). All the branches of the left
middle cerebral artery were opacified through the bypass. The left anterior cerebral artery was fed mainly
via the ophthalmic artery. Arrowhead indicates the anastomotic site.

J. Neurosurg. / Volume 56 / March, 1982

445

T. Eguchi, T. Nakagomi and A. Teraoka

FIG. 4. Preoperative (upper left) and follow-up axial enhanced computerized tomography scans at 10,
17, 25, 53, and 108 days. The left intracavernous carotid aneurysm (arrow) was thrombosed postoperatively
and decreased in size continuously. The right-sided aneurysm was not shown on these scans.

At his 4-month follow-up review, the patient was in
good condition and had returned to his previous job
as a woodworker. Blood pressure was 132/74 mm Hg,
and pulse was 72/min.

Intraarterial
Pressure

150

mrnHg

I CA opened
ICA clamped

100

50

0 Radial
artery

STA

MCA
proximal

MCA
distal

FIG. 5. Graph showing intraoperative intra-arterial
pressure measurements in a 61-year-old woman with a right
cavernous internal carotid artery (ICA) aneurysm. The
pressure gradient between the superficial temporal artery
(donor vessel) and the middle cerebral artery (recipient
vessel) rose from 4 to 64 mm Hg after ICA clamping.
446

Discussion

Bilateralintracavernous carotid aneurysms are rare,
and only 27 such cases have been reported in the
literature. 1~
The present case was treated with
bilateral ICA ligations combined with EC-IC anastomosis, with a successful result.
In the past, intracranial aneurysms which are inaccessible for direct operation due to their size or
location were treated by simple carotid ligation, sometimes using a Selverstone clamp. TM However, cerebral ischemia may develop after this operative procedure. 8,15,16,22According to the Cooperative Study in
1966, 59% of the patients with ICA ligation and 32%
of those with common carotid artery ligation developed cerebral ischemia. 12The combination of the ECIC bypass with the ICA ligation may reduce such fatal
complications. The effectiveness and safety of these
combined procedures for inaccessible carotid aneurysms were reported by Hopkins and Grand 6 in 1979,
and Gelber and Sundt 3 and Spetzler, et al., 2~ in 1980.
Gelber and Sundt used intraoperative cerebral blood
flow measurement to detect possible postoperative
ischemic complications. Spetzler, et aL, used a Selverstone clamp for staged ICA occlusion.
In our case, we performed the combined procedures
in one stage, with abrupt complete ICA ligation and
EC-IC bypass. In this manner, we obtained an increased pressure gradient between the STA (donor
vessel) and the MCA (recipient vessel), which is favorable for the patency of the bypass. 6 Figure 5 shows
the intra-arterial pressure measurements in another
case with an intracavernous carotid aneurysm. It is
clearly seen that the pressure gradient was remarkably
increased from 4 to 64 mm Hg after ICA occlusion.
To check the safety of the one-stage operation, we
awoke the patient from general anesthesia after the
bypass surgery, and observed his neurological condiJ. Neurosurg. / Volume 56 / March, 1982

Bilateral intracavernous carotid aneurysms
tions with a temporary I C A clamp under induced
hypotension. This method seems to be useful for
detecting postoperative cerebral ischemia.
The possibility o f late cerebral ischemia and aneurysmal formation after carotid ligation has been reported. 1,4,~,16,22 We are following this patient attentively to see if these complications will develop even
though he was treated by a combined E C - I C bypass
and I C A ligation procedure.

References
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Manuscript received February 19, 1981.
Accepted in final form September 29, 1981.
Address reprint requests to: Tsuneyoshi Eguchi, M.D.,
Department of Neurosurgery, Tokyo Police Hospital, 2-1041, Fujimi, Chiyoda-ku, Tokyo 102, Japan.

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