Figure 1
MIP Curved and 3D- imaging
Stenosis and aneurysm of internal carotid artery: a double endovascular procedure
SectionInterventional radiology
Case TypeClinical Cases
AuthorsPampana E, Loreni G, Nezzo M, Salvatori E, Gandini R, Simonetti G.
Connected authors
72 years, female
Clinical History
A 72-year-old female patient, under drug treatment for hypertension and TIA history, presented at our emergency center for syncopal attack with vertigo.
Vital signs were checked (Pa 180/80 mmHg, PaO2 95%, normal ECG), and she underwent head-neck CT-angiography.
Vital signs were checked (Pa 180/80 mmHg, PaO2 95%, normal ECG), and she underwent head-neck CT-angiography.
Imaging Findings
Angio-CT revealed the presence of severe stenosis with simultaneous extracranial large aneurysm of the right internal carotid artery (ICA) [Fig. 1].Two days after a failed surgical approach we decided to treat both diseases with endovascular technique. After written informed consent, a right trans-femoral approach was obtained and 8 Fr 10 cm long introducer sheath was placed. To catheterise the right common carotid artery 8 Fr 90 degree guide-catheter (Boston Scientific) and standard guidewire (Terumo) were used. The angiography confirmed the presence of stenosis and aneurism [Fig. 2]. We positioned an embolic protection device (EPD) (Emboshield, Abbott Vascular) in the distal portion of internal carotid artery and then, considering the Angio-TC plaque characterisation, a self-expandable closed-cells stent device was used (Wallstent, Boston Scientific) [Fig. 3-4]. After the retrieval of the EPD and an angiographic check, we embolised the aneurysm with Orbit Galaxy coils (Codman Neurovascular) [Fig. 5].
There was no peri-procedural complication.
There was no peri-procedural complication.
Discussion
Carotid stenosis is a narrowing of the carotid arteries and may be either symptomatic or asymptomatic. Symptomatic carotid stenosis often presents with transient ischaemic attacks (TIA), stroke or amaurosis fugax.
Aneurysms of the extracranial internal carotid artery are rare, accounting for only 0.1%-2% of carotid interventions [1]. Extracranial carotid artery aneurysms have been defined as a localised increase in calibre of >50% compared with the reference values. These reference values are 0.55–0.06cm in men and 0.49–0.07cm in women at the level of ICA, and 0.99 – 0.10 cm in men and 0.92 – 0.10 cm in women at the level of the carotid bulb [2].
Causes of aneurysm of the ICA are multiple and include atherosclerosis, dysplasia, trauma [3].
Although aneurysms of the extracranial ICA do not usually produce neurological symptoms, they may result in potentially serious problems, such as cerebrovascular events, consequence of thromboembolic phenomena or impairment of flow in the proximal carotid artery [4].
Isolated cranial neuropathies can also occur as the result of direct nerve compression [5].
Although in most cases for the extracranial internal carotid aneurysm a surgical treatment is preferred [6], in our patient the aneurysm of the right internal carotid artery was too close to the skull base, risky for a surgical approach, indeed failed two days before.
The simultaneous presence of ipsilateral carotid stenosis and aneurysm is very rare in literature and presents difficulties for both surgical and endovascular treatments.
Our intent was to obtain the complete stenosis resolution first and subsequently embolise the aneurysm: a carotid artery patency would allow us to work more easily and with less risk.
In fact emboli are usually created during the filter’s passages and stent deployment, especially in sub-occlusive plaque or those with complex anatomy, due to the friction between the devices and plaque.
Stent sizes were chosen on the basis of pre-procedural CT evaluation.
Pre-procedural assessment of carotid stenosis revealed a fibro-lipid plaque with a small ulcerate component; it was decided to place a closed-cells stent (Wallstent, Boston Scientific) in order to reduce the risk of a possible distal thrombo-embolisation.
The subsequent aneurysm embolisation was performed exclusively with coils, without stent-assisted, because the curve situated after the aneurysm did not allow a safe stent release.
It was widely demonstrated that CAS procedure is safe and reliable, with complications and mortality rates similar to TEA [7]. In our opinion, endovascular neuro-interventional procedures presents many advantages and limited risks, especially if performed by medical staff with proven experience.
Aneurysms of the extracranial internal carotid artery are rare, accounting for only 0.1%-2% of carotid interventions [1]. Extracranial carotid artery aneurysms have been defined as a localised increase in calibre of >50% compared with the reference values. These reference values are 0.55–0.06cm in men and 0.49–0.07cm in women at the level of ICA, and 0.99 – 0.10 cm in men and 0.92 – 0.10 cm in women at the level of the carotid bulb [2].
Causes of aneurysm of the ICA are multiple and include atherosclerosis, dysplasia, trauma [3].
Although aneurysms of the extracranial ICA do not usually produce neurological symptoms, they may result in potentially serious problems, such as cerebrovascular events, consequence of thromboembolic phenomena or impairment of flow in the proximal carotid artery [4].
Isolated cranial neuropathies can also occur as the result of direct nerve compression [5].
Although in most cases for the extracranial internal carotid aneurysm a surgical treatment is preferred [6], in our patient the aneurysm of the right internal carotid artery was too close to the skull base, risky for a surgical approach, indeed failed two days before.
The simultaneous presence of ipsilateral carotid stenosis and aneurysm is very rare in literature and presents difficulties for both surgical and endovascular treatments.
Our intent was to obtain the complete stenosis resolution first and subsequently embolise the aneurysm: a carotid artery patency would allow us to work more easily and with less risk.
In fact emboli are usually created during the filter’s passages and stent deployment, especially in sub-occlusive plaque or those with complex anatomy, due to the friction between the devices and plaque.
Stent sizes were chosen on the basis of pre-procedural CT evaluation.
Pre-procedural assessment of carotid stenosis revealed a fibro-lipid plaque with a small ulcerate component; it was decided to place a closed-cells stent (Wallstent, Boston Scientific) in order to reduce the risk of a possible distal thrombo-embolisation.
The subsequent aneurysm embolisation was performed exclusively with coils, without stent-assisted, because the curve situated after the aneurysm did not allow a safe stent release.
It was widely demonstrated that CAS procedure is safe and reliable, with complications and mortality rates similar to TEA [7]. In our opinion, endovascular neuro-interventional procedures presents many advantages and limited risks, especially if performed by medical staff with proven experience.
Differential Diagnosis List
Stenosis and aneurysm of internal carotid artery.
Giant cell arteritis
Congenital aneurysm
Final Diagnosis
Stenosis and aneurysm of internal carotid artery.
References
[1] Mahmoud M. Taha et al (2010) Interventional neuroradiology techniques for the treatment of aneurysms of the supra-aortic extracranial arteries. Neurol Med Chir 50,275-280 (PMID: 20448417)
[2] Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC (1991) Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 13(3):452-8 (PMID: 1999868)
[3] Rosset E, Albertini JN, Magnan PE, Ede B, Thomassin JM, Branchereau A. (2000) Surgical treatment of extracranial internal carotid artery aneurysms. J Vasc Surg Apr;31(4):713-23 (PMID: 10753279)
[4] Lim YM, Lee SA, Kim DK, Kim GE (2002) Aneurysm of the extracranial internal carotid artery presenting as the syndrome of glossopharyngeal pain and syncope. J Neurol Neurosurg Psychiatry Jul;73(1):87-8 (PMID: 12082060)
[5] Lane RJ, Weisman RA, Savino PJ, Schatz NJ (1980) Aneurysm of the internal carotid artery at the base of the skull: an unusual cause of cranial neuropathies. Otolaryngol Head Neck Surg May-Jun;88(3):230-2 (PMID: 7402662)
[6] Kaouel K, Mechergui S, Ben Mrad I, Ben Mrad M, Ghédira F, Mizouni H, Ben Omrane S, Elleuch N, Denguir R, Kalfat T, Menif E, Khayati A (2012) Surgical management of extracranial carotid artery aneurysm. J Mal Vasc May 22 (PMID: 22626454)
[7] Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Mes (2010) Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med Jul 1;363(1):11-23. Epub 2010 May 26 (PMID: 20505173)
Case information
| URL: | https://www.eurorad.org/case/10262 |
| DOI: | 10.1594/EURORAD/CASE.10262 |
| ISSN: | 1563-4086 |
Figure 2
Angiography imaging
The angiography confirmed the consensual presence of stenosis and aneurysm
Figure 3
The release of embolic protection device
The imaging show the release fo EPD
Figure 4
The angiography control after stent placement
The imaging show the correct stent placement
Figure 5
Control after aneurysm embolisation
Control after procedure confirmed the complete aneurysm exclusion
MIP Curved and 3D- imaging
MIP-curved imaging show a consensual aneurysm and stenosis of internal carotid artery
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy
3D reconstruction
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy
Angiography imaging
The angiography confirmed the consensual presence of stenosis and aneurysm
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy; viale Oxford 81 00133 Rome, Italy
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy; viale Oxford 81 00133 Rome, Italy
The release of embolic protection device
The imaging show the release fo EPD
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy; viale Oxford 81 00133 Rome, Italy
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy; viale Oxford 81 00133 Rome, Italy
The angiography control after stent placement
The imaging show the correct stent placement
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy; viale Oxford 81 00133 Rome, Italy
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy; viale Oxford 81 00133 Rome, Italy
Control after aneurysm embolisation
Control after procedure confirmed the complete aneurysm exclusion
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy; viale Oxford 81 00133 Rome, Italy
University Hospital, Diagnostic Immaging. Molecular Imaging, Interventional Radiology and Radiation Therapy; viale Oxford 81 00133 Rome, Italy