Neurological Research A Journal of Progress in Neurosurgery, Neurology and Neurosciences ISSN: 0161-6412 (Print) 1743-1328 (Online) Journal homepage: http://www.tandfonline.com/loi/yner20 A false traumatic giant aneurysm of the supraclinoid carotid artery. A case report and review of the literature Mustafa K. Baskaya, Nurullah Yüceer & Nihat Egemen To cite this article: Mustafa K. Baskaya, Nurullah Yüceer & Nihat Egemen (1996) A false traumatic giant aneurysm of the supraclinoid carotid artery. A case report and review of the literature, Neurological Research, 18:2, 135-139, DOI: 10.1080/01616412.1996.11740391 To link to this article: http://dx.doi.org/10.1080/01616412.1996.11740391 Published online: 21 Jul 2016. Submit your article to this journal View related articles Citing articles: 6 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yner20 Download by: [Australian Catholic University] Date: 23 August 2017, At: 03:36 A false traumatic giant aneurysm of the supraclinoid carotid artery. A case report and review of the literature Mustafa K. Ba~kaya:, Nurullah Yi.iceer* and Nihat Egemen* Downloaded by [Australian Catholic University] at 03:36 23 August 2017 Division of Neurosurgery, Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky, USA and *Department of Neurosurgery, Ankara University, School of Medicine, Jbni Sina Hospital, Ankara, Turkey A patient presented_ with left hemiparesis and facial palsy developed 20 days after a traffic accident. A computerized tomography (CT) scan revealed right suprasellar mass lesion. A repeated CT scan revealed a growing mass. Carotid angiogram demonstrated a giant aneurysm of the supracliiwid internal carotid artery (ICA) with no distal filling. Formation of the aneurysm was thought to be due to an overstretching or torsion of the artery or tearing of the /CA by nearby prominent bony structure since no basal skull fracture was detected in the plain skull film or CT scans. The aneurysm was treated by intracranial trapping of the /CA. We present this patient's findings and review previously reported cases in the literature. [Neural Res 1996; 18: 135-139] Keywords: Head trauma; internal carotid artery; traumatic aneurysm; trapping INTRODUCTION Less than 1% of all intracranial aneurysms are caused by trauma; these aneurysms are rarely a complication of traumatic head injuri - 3 . Traumatic cerebral aneurysms that occur after penetrating or nonpenetrating head injuries of iatrogenic vascular injuries4 - 8 are usually located on branches of the distal cerebral arteries such as the anterior or middle. Traumatic aneurysms of the intracranial internal carotid artery (ICA), which are infrequent, are often encountered in the petrous or cavernous segments. Only 34 cases of traumatic aneur)'sms of the supraclinoid ICA have been reported2·5·6·9-27. These traumatic aneurysms are not only rare, but they can easily be missed on initial examination and their management is challenging. Early diagnosis and appropriate surgical treatment improve the outcome. We report a case of traumatic aneurysm of the supracl inoid ICA and a reviewof the previously reported occurrences of aneurysm in this rare location. CASE REPORT A 27-year-old man who was involved in a traffic accident had been admitted to another hospital. His init[al physical examination revealed an open tibia fracture · and bruising of his face and scalp. His neurological examination at admission was normal. No fraCture showed on the plain x-ray of his skull. The patient under-Went surgery for the tibia fracture. During the operation, he developed signs of mild malignant hyperthermia but his recovery from anesthesia was Correspondence and reprint requests to: Mustafa K. Ba:;kaya, MD, Department of Neurosurgery, University of Kentucky Medical Center, 800 Rose Street, Lexington, Kentucky 40536- 0084 USA. Accepted for publication O ctober 1995. © 1996 Forefront Publ ishing Group 0161 - 6412/96/ 0201 35-05 smooth . Results of routine post-operative tests, including serum electrolite, urine, and blood gases, were within normal limits. Twenty days after admission, however, he experienced sudden onset of left hemiparesis and facial paresis and these became worse. Computerized tomography (CT) scan of the patient's head revealed a hyperderise mass lesion in the right parasellar and suprasellar regions and a slight subarachnoid hemorrhage on the right sylvian cistern (Fig11re 1). : He was transferred to the Department of Neurosurgery, Ankara University, lbni Sina Hospital. Three days later, the patient underwent a repeat CT scan that showed the mass to be expanding dramatically. A four-vessel angiogram showed that the mass was a giant aneurysm of the right supracl inoid ICA with no distal filling (Figure 2a). When the right carotid artery was compressed low in the neck, good cross-filling of the right hemisphere was observed (Figure 2b). B.ecause his neurological condition was becoming gradually worse, the patient underwent CTexamination again just before emergency operation to repair the aneurysm. This CT scan also showed a huge hyperderise parasellar mass (Figure 3). An operation · was performed via a right frontotell]poral craniotomy. t\t the same time the right carotid artery in the neck was exposed. The sylvian fissure was ope[1ed. A giant anewrysm wit~ very thin, fragile wallh md a broad-based neck were seen : The aneurysm wall was dissected free from the surrounding cortex. The base of the aneurysm extended at least 8 to 9mm. The aneurysm ruptured and was trapped by occluding the ICA just proximal to the ophthalmic artery and distal to the neck. The wall of the aneurysm was formed by thickened arachnoid and surrounding cortex. The patient's post-operative course was uneventful. A postoperative carotid angiogram revealed the trapped ICA. Neurological Research, 1996, Volume 18, April 135 False giant aneurysm of the supraclinoid ICA: Mustafa K. Ba?kya et al. Six months after operation, a follow-up examination showed well-improved, very mild hemiparesis that does not restrict the patient's daily activities. False aneurysms develop as a result of complete interruption of the arterial wall with formation of a perivascular hematoma that subsequently develops a fibrous wall by organization; its hemodynamic Downloaded by [Australian Catholic University] at 03:36 23 August 2017 DISCUSSION Traumatic intracranial aneurrsms comprise less than 1% of intracranial aneurysms 1- . Laun's study of 73 traumatic aneurysms showed that 27% were located on the meningeal, 40% on the middle cerebral, and 13% on the anterior cerebral arteries 28 • The next most frequent site is the petrous or cavernous segment of the ICA1 . Reviewing the literature, we found only 34 cases of traumatic aneurysms of the supraclinoid ICA. Parkinson and West18 have suggested the following diagnostic criteria to distinguish traumatic from congenital aneurysms: 1. history of trauma; 2. site of aneurysm; 3. age of patient; 4. histological findings. Our review of the literature revealed that most previously reported cases occurred in male patients (69%) and in patients less than 30 years old (49%). Traumatic aneurysms are classified into three main groups according to their pathogenesis: dissecting, true, and false aneurysms. A dissecting aneurysm is formed when disrupted intima and internal elastica allow blood to dissect these two layers from the muscularis. True aneurysms develop as a result of incomplete rupture of the arterial wall that leaves the adventitia intact10, 25 . Figure 1: Computed tomography (CT} scans, performed at another hospital on twenty-first day after injury showed a right hype rdense parasellar mass lesion and light suba rachnoid hemorrhage on the right sylvian c iste rn 136 Neurological Research, 1996, Volume 18, April Figure 2 a: A right carotid angiogram showing a giant aneurysm of the supraclinoid internal carotid artery with no distal filling. b: A left carotid angiogram showing good cross filling of the right hemisphe re whe n the right carotid artery was compressed in the neck False giant aneurysm of the supraclinoid ICA: Mustafa K. Ba~kya et al. Downloaded by [Australian Catholic University] at 03:36 23 August 2017 Table 1: Summary of previously reported cases of \raumatic aneurysm of the supraclinoid internal carotid artery Author (year) · Age/Sex Alexander (1963) Salmon (1968) . Dechaume (1969) Benoit (1973) Dharker (1975) Funahashi (1977) Parkinson (1980) 56/M Iatrogenic 24/M Type of injury Basal skull fracture Treatment Presentation/ interval Type of aneurysm Unknown Unknown Closed head trauma Asymptomatic 4.5 months EDH 7 days Unknown Unknown 15/M Closed head trauma Asymptomatic Unknown Wrapping Improved 4S/M Closed head trauma + SAH 11 days Unknown Trapping Unknown 17/M Closed head trauma + Unknown 1S/M Closed head trauma 11/M Closed head trauma 27/F Closed head trauma 43/M Iatrogenic 4S/M Closed head trauma Hemiparesis 5 years SAH 9 days decerbrate 1 day SAH 1 day ICH 9 days Asymptomatic 14/M Closed head trauma 17/M Closed head trauma 16/M Closed head trauma 22/M Closed head trauma 45/M Closed head trauma + 24/5/M Closed head trauma + 42/M Closed head trauma + Unknown Stab wound Unknown Loss of vision 5 days 6th nerve palsy 5 days Loss of vision 2S days SAH, IVH 17 days SAH 1 day SAH 15 days ICH 4 days ·Unknown Unknown Stab wound Unknown Unknown Unknown 42/M Closed head trauma Unknown 23/M Closed head trauma 20/M Closed head trauma False Haddad (1991) 26/M Missile wound SAH, IVH 1 day Hemiparesis 5 years Hemiparesis, 3rd nerve palsy 16 days Unknown Weinstein (1991) Saito (1992) 28/M Unknown Loss of vision False 35/F Iatrogenic Unknown 35/F Iatrogenic ICH, IVH 2 months ICH 2 weeks Li (1994) 25/M Closed head traum Confusion, leg weakness False Present case 27/M Closed head trauma Hemiparesis, facial paresis False Yon as (1980) Reddy (1981) Pozzati (1982) Shigemori (1982) Enomoto (1984) Jakobsson (1984) Kieck (1984) Salcman (1985) Steinmetz (1988) Bousquet (1989) + Unknown Unknown Unknown Outcome Death Neck ligation Improved False Death False Death False Trapping Death True Carotid ligation Trapping Unchanged False Unknown Improved Improved False Carotid ligation Carotid ligation Carotid ligation Trapping False Trapping Improved Unknown Unknown False Unknown Unknown Unknown Unknown Improved Unchanged Death Death Surgical treatment Surgical treatment Carotid ligation Carotid ligation Excision, repair Improved No surgical treatment Neck ligation IC ballon occlusion IC ballon occlusioh Carotid ligation Unknown Trapping Improved Improved Unknown Improved Improved Improved Improved Improved Improved In the series of du Trevou (1992), 7 patients had traumatic aneurysms of the supraclinoid ICA due to penetrating stab wounds. Exact data about these patients were not described by the authors. . EDH, epidural hematoma; F, female; IC, internal carotid; ICH, intracerebral hematoma; IVH, intraventricular hemorrhage; M, male; SAH, subarachnoid hemorrhage · · · Neurological Research, 7996, Volume 18, April 137 Downloaded by [Australian Catholic University] at 03:36 23 August 2017 False giant aneurysm of the supraclinoid /CA: Mustafa K. Ba~kya et al. excavation or repeated hemorrhage causes the increase 10 25 . . ' . 0 f t he previously reported cases of 1n s1ze ~raumatic supraclinoid ICA aneurysms, only 12 (includrng our case) were diagnosed either operatively or histologically (11 false aneurysms and 1 true aneurysm) (Table 1). In our patient, the diagnosis was false traumatic aneurysm because the wall of the aneurysm was formed by thickened arachnoid and because we did not see any normal vascular structures, such as adventitia, after the aneurysm was trapped. Traumatic aneurysms occur a~er penetrating injur~ or closed head trauma, the latter be1ng more common 4 - . A traumatic aneurysm of supraclinoid ICA following closed head trauma may be due to one of these ~~chanisms : a basal skull fracture may cause direct Injury to the ICA, overstretching or torsion of the carotid artery during the impact of head injury may cause injury, and the ICA may be torn by nearby prominent bony structures such as the anterior or posterior clinoid processes 2 ' 6 ' 1 0 ' 22 ' 25 . Twenty of the previously reported cases including our case were caused by closed head trauma, only 6 of them as a result of basal sku II fractures. The remaining causes of injury included penetrating stab :-vounds _(9 patients), iatrogenic trauma during the rn~ra_cran1al or transsphenoidal surgery (4 patients), m1ssrle wound (1 patient) (Table 1). In our patient, the aneurysm was located on the ICA just distal to the ophthalmic artery. Formation of traumatic aneurysm at this location may be caused by several factors. In the absence of a basal skull fracture, the injury to the ICA ~a~ be caused by blunt contusion produced by a severe 1n:'p1~gement of the artery on the overlying anterior clrno1d process or by overstretching or sudden torsion of the vessel during brain movements within the calvaria. . Traumatic aneurysm is Jho.u:ghtJo ;rupture ;at~·a .:gi\!en . rnterval after the head injury, most often at 2 to 3 . . Weeks 1,5,10,11,21 . In our rev1ew we foun d o fth e 11terature, after years 5 that the interval ranged from a few hours to the cases 12 In weeks. 2 at peak a with injury, head patien_ts presented with intracranial hemorrhages, ~ost of wh1ch (n = 7) were subarachnoi_d hemorrhages. In 6 cases, the patients presented with progressive neurological deficits· and in 3 cases presented with visual loss. In 10 cases the patients' presenting problems are unknown (Table 1). The radiological diagnosis of traumatic aneurysms is made by angiography. Angiograph ically, traumatic aneurysms differ from congenital aneurysms in their site (away fr~m arterial division), their often irregular outline, and the1r slow hemodynamics (delayed filling and empty_ing of aneurysmal sac). The neck of the aneurysm sometimes cannot be detected easily. Most of the reported traumatic aneurysms of the supraclinoid ICA, including the present case, were treated by trapping or carotid ligation in the neck (13 cases) but in a recent case reported by Bousquet eta/. 11 , aneurysm excision and microsurgical repair of the vessel were performed, and the patient improved post-opera. et a/.2o suggested that ballon occlusion of . Iy. sa1to t1ve the carotid artery is effective and relatively easy for treatment of this lesion. Yonas and Dujovn/ 5 stated that 138 Neurological Research, 7996, Volume 18, April Figure 3: CT scans on twenty-sixth day after injury showed hydrocephalus and a mass lesion that had reached huge size early, direct surgical treatment of these traumatic aneurysms should be avoided until after a maturation process, which was described by Thompson et a/. 29 as thickening, thrombosis, _or calcification of the aneurysm wall. However, traumatic aneurysm of the supraclinoid ICA seems to have a high rebleeding rate and therefore the:pat-ient~may- cl ie·.d ur in.gthi swa iting perind ." F'arldtiSo~· and West who pointed out the importance of early diagnosis and surgical treatment, reported that the mortality rate is 50% in untreated cases 18. Although two successful surgical treatment types have been reported [excision of the aneurysm followed by microsurgical repair of the ICA 11 and ligation of the ~ne~r~smal neck14] direct surgery on these aneurysms IS d1ff1cult because of their fragile, broad-based, and obsc~re nec~s.