Technical failure of giant supraclinoid aneurysm after internal carotid artery occlusion. A report of three cases

Abstract

We describe three cases of technical failure in patients with giant supraclinoid aneurysm treated with internal carotid artery (ICA) occlusion. Case 1 was a 65-year-old woman who presented with a two-month history of headache accompanied by blurred vision of the left eye. Case 2 was a 43-year-old woman who presented with a six-month history of headache accompanied by blurred vision of the right eye. Case 3 was a 21-year-old man admitted due to headache and blurred vision of the left eye, accompanied by left oculomotor nerve palsy for three months. Cerebral angiography revealed giant supraclinoid aneurysms in these patients. All of them were treated with ICA occlusion. One case had recurrent headache symptoms after the first procedure and was retreated. Two cases suffered from post-procedural intracranial hemorrhagic complications. Before ICA occlusion for giant supraclinoid aneurysm, balloon occlusion test was used to evaluate the collateral anastomosis between the external carotid artery (ECA) and the ICA, and still plays an important role in preventing treatment failure.

Keywords: aneurysm; balloon occlusion test; collateral anastomosis; internal carotid artery; parent artery occlusion.

Figure 1

DSA presentations of Case 1. A) Lateral DSA view of the left ICA demonstrating the giant supraclinoid aneurysm and the primitive trigeminal artery (white arrow). B) Frontal DSA view of the right ICA (top) and lateral DSA view of the right vertebral artery (bottom) performed during BOT of the left ICA demonstrating collateral support of the left hemispheric circulation through the circle of Willis. C) The left ICA was occluded by 3 detachable balloons. The first balloon (white arrow) was placed into the aneurysm cavity unintentionally. D) Postoperative DSA image of the left ECA demonstrates the aneurysm opacified via the internal maxillary artery-ophthalmic artery anastomosis. E) DSA re-examination of the left ECA 10 months later revealing that the ophthalmic artery fed the aneurysm (left) and then the distal ICA (right). F) Lateral microcatheter angiography during coiling the aneurysm showing the microcatheter route from the vertebrobasilar artery, via the left posterior communicating artery, to the aneurysm cavity. G) Lateral mask showing the coil mass packed into the aneurysm cavity and the origin of the left ophthalmic artery. H) Postoperative angiography of the left ECA, showing the aneurysm was not opacifying.

Figure 2

DSA and CT images of Case 2. A) Lateral DSA view of the left ICA demonstrating a small aneurysm at the supraclinoid segment. B) Frontal (left) and lateral (right) DSA views of the right ICA demonstrating a giant aneurysm at the supraclinoid segment. C) Postoperative lateral DSA view of the left ICA showing that the small aneurysm was embolized with detachable coils. D) DSA re-examination of the left ICA 2 months later showing no recanalization of the small aneurysm. E) Lateral mask showing that the right ICA was occluded with 3 detachable balloons after the BOT. The arrow indicates the coil mass in the contralateral aneurysm. F) The mid (left) and late (right) phases of the lateral DSA of the right ECA revealing that the aneurysm was perfused by reversal of flow through the ophthalmic artery anastomosing with the collaterals of the internal maxillary artery. G) Emergent CT scan on the third postoperative day, showing intracranial hemorrhage resulting from rupture of the right supraclinoid aneurysm. H) Lateral view of DSA re-examination of the right ECA, showing absence of aneurysm opacification, possibly due to thrombosis within the cavity of the right supraclinoid aneurysm after rupture.

Figure 3

DSA and CT images of Case 3. A) Oblique DSA view of the left ICA demonstrating a giant aneurysm at the cavernous segment and a smaller aneurysm at the supraclinoid segment. B) Frontal DSA view of the right ICA (left) and lateral DSA view of the left vertebral artery (right) during BOT of the left ICA, showing adequate collateral support of the left hemisphere circulation through the circle of Willis. C) Lateral DSA view of the left ECA during BOT of the left ICA, showing a faint anastomosis between the foramen rotundum artery (white arrow) and the ICA cavernous inferolateral trunk (black arrow). The intracavernous aneurysm opacified marginally via this anastomosis. D) The roadmap of the left ICA (left) showing that the supraclinoid aneurysm was coiled; subsequent oblique DSA view of the left ICA (right) demonstrating that the ophthalmic segment of the left ICA was occluded by the coils. E) Occlusion of the proximal ICA by two detachable balloons, as seen on roadmap of the left ICA. F) Postoperative lateral DSA of the common carotid artery showing trapping of the giant intracavernous aneurysm. G) CT scan on the postoperative 14th hour indicating intracranial bleeding. H) Faint opacification of the intracavernous aneurysm via the collaterals of the internal maxillary artery on lateral DSA view of the left ECA. I) Superselective microcatheter angiography of the left artery of the foramen rotundum on lateral projection revealed re-directed circulation from the artery of the foramen rotundum to the cavernous ICA, then to the ophthalmic artery whose origin was not completely occluded by coils. This circulation passed through the intracavernous aneurysm and caused its rupture. J) Lateral mask showing the Onyx 18 cast (arrow) within the artery of the foramen rotundum and the ICA cavernous inferolateral trunk. K) Aneurysm was no longer opacifying on postoperative lateral DSA view of the left ECA. L) Lateral DSA view of the left ECA 4 months later showing no recanalization of the aneurysm.

Figure 4

Schematic illustration of the blood flow pattern within the aneurysm cavity in case 1. 1, ICA; 2, ophthalmic artery; 3, aneurysm cavity; solid arrow, the flow direction before PAO; empty arrow, the flow direction after PAO.

Figure 5

Schematic illustration of the blood flow pattern within the aneurysm cavity in case 2. 1, ICA; 2, ophthalmic artery; 3, aneurysm cavity; solid arrow, the flow direction before PAO; empty arrow, the flow direction after PAO.

Figure 6

Schematic illustration of the blood flow pattern within the aneurysm cavity in case 3. 1, ICA; 2, ophthalmic artery; 3, aneurysm cavity; solid arrow, the flow direction before PAO; empty arrow, the flow direction after PAO.