Giant serpentine internal carotid artery aneurysm: endovascular parent artery occlusion. A pediatric case report

Abstract

We report on a case of a 14-year-old boy with a giant serpentine aneurysm of the left internal carotid artery cavernous segment with symptoms of acute mass-effect cranial nerve dysfunction. After a balloon occlusion test of the collateral circulation, the patient underwent parent artery occlusion with platinum Guglielmi detachable coils and fibered coils. An optimal angiographic result and successful clinical outcome were achieved with resolution of IIIrd, IVth and VIth cranial nerve ischemic symptoms. CT angiography and 3D-XRA rotational angiography reconstructions gave sufficient inclusion information on the giant serpentine aneurysm angioarchitechture.

Figure 1

A-C) Native CT scan-hyperdense spheric lesion in the left parasellar region with sphenoid bone defiguration, partially thrombosed, 3cm in diameter. D,E) CTA in sagittal and coronal projections with partially thrombosed left ICA cavernous segment aneurysm. F) Complete III, IV and incomplete VI cranial nerve palsy with severe retroorbital pain.

Figure 2

G,H) Left ICA DSA with fibromuscular dysplasia of the left cervical ICA and giant serpentine cavernous C4 segment aneurysm. Normal filling of the left ophthalmic and middle cerebral arteries. No filling of the A1 left ACA segment. I,J) 3D-XRA-rotational angiography - transparent reconstruction. K,L) AP of the left ICA and left lateral VA angiogram with PcomA collateral flow.

Figure 2

G,H) Left ICA DSA with fibromuscular dysplasia of the left cervical ICA and giant serpentine cavernous C4 segment aneurysm. Normal filling of the left ophthalmic and middle cerebral arteries. No filling of the A1 left ACA segment. I,J) 3D-XRA-rotational angiography - transparent reconstruction. K,L) AP of the left ICA and left lateral VA angiogram with PcomA collateral flow.

Figure 3

M,N) 30 minute left ICA occlusion test with good cross AcomA and PcomA collateral flow without neurological symptoms before PAO treatment. O,P) Left ICA - PAO by coil embolization. Q,R) Final angiogram after PAO embolization procedure with good left ophthalmic artery and left MCA territory filling.

Figure 3

M,N) 30 minute left ICA occlusion test with good cross AcomA and PcomA collateral flow without neurological symptoms before PAO treatment. O,P) Left ICA - PAO by coil embolization. Q,R) Final angiogram after PAO embolization procedure with good left ophthalmic artery and left MCA territory filling.

Figure 4

S) CTP-perfusion follow-up with symmetrical hemispheric perfusion in CBF, CBV and MTT color maps.

Figure 5

T) Six month follow-up with III^rd, IV^th and VI^th cranial nerve palsy improvement with slight diplopia and without retroocular pain. Left ocular physiotherapy training ongoing.

Figure 6

One Year MRI and CE-MRA follow-up. U,V) Thrombosed left ICA aneurysm after PAO procedure without ischemia. W,X) CE-MRA of the Willis circle with the left MCA territory filling through the left PcomA and hypoplastic left A1-ACA.