Symptomatic Cavernous Internal Carotid Artery Aneurysm Complicated by Simultaneous Rapid Growth of the Intra-aneurysmal and Parent Artery Thromboses

Abstract

Cavernous internal carotid artery (ICA) aneurysm complicated by simultaneous and spontaneous formation of thromboses in the aneurysm and the parent artery is a rare clinical condition. Although the majority of patients have good outcomes, some patients experience severe ischemic stroke. Here, we report a case of symptomatic large cavernous ICA aneurysm complicated by rapid growth of an intra-aneurysmal thrombosis with simultaneous parent artery thrombosis. A 68-year-old female presented with sudden-onset diplopia, right ptosis, right conjunctival hyperemia, and paresthesia of the right face. Magnetic resonance imaging (MRI) and digital subtract angiography (DSA) revealed the presence of a large partially thrombosed aneurysm in the cavernous portion of the right ICA. We planned endovascular embolization using a flow-diverting (FD) stent. Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel was started 2 weeks prior to treatment. Although the neurological state was stable, DSA conducted on the day of the endovascular treatment showed rapid growth of an intra-aneurysmal thrombosis and de novo thrombosis in the parent artery. Direct aspiration was performed via a distal support catheter with proximal blood flow arrest using a balloon-guide catheter, and the FD stent was successfully deployed. The patient's symptoms improved postoperatively and DSA obtained 12 months after the procedure confirmed complete occlusion of the aneurysm. Although the exact mechanism of simultaneous thrombosis formation of the aneurysm and its parent artery remains unclear, it is important to recognize that rapid growth of the thrombosis increases the risk of ischemic stroke.

Spontaneous thrombosis and calcification of giant cavernous carotid artery aneurysm: A rare case and management insights

“…[ 6 , 8 , 11 ] The simultaneous occurrence of both giant aneurysm obliteration and vessel occlusion is exceedingly rare and reported only in a handful of cases. [ 1 - 15 ] As per current literature, only 20 such occurrences have been reported to date, with our case being the 21 st , distinguished by its unique features.…”

“…[ 1 - 3 , 9 - 13 ] In all these studies, a slow, insidious course without neurological deficit suggests the absence of a thromboembolic phenomenon, which may have a better course and prognosis compared to patients with a thromboembolic phenomenon, suggesting hemodynamically unstable aneurysms with an unpredictable course. [ 3 , 6 , 9 , 13 , 15 ]…”

Spontaneous thrombosis of a giant cavernous-carotid aneurysm with simultaneous ipsilateral complete parent artery occlusion: a rare phenomenon and review of the literature

“…Even though the chances are extremely narrow, it is possible and has been reported in a case of a thrombosed PCA aneurysm with parent vessel occlusion followed by recanalization of the aneurysmal neck and PCA several years later [ 10 ]. To date, of all the reported cases of thrombosed CCA aneurysms with ICA occlusion, no recanalization has been reported [ 11 - 22 ]. Therefore, it appears that the simultaneous parent vessel thrombosis, especially of the ICA, may act as a safeguard for recanalization and rupture prevention of a thrombosed aneurysm.…”

“…Of the 20 cases, 14 patients, including ours, were successfully managed using a conservative strategy, 4 with surgical intervention, and 1 with endovascular treatment ( Table 1 ). Endovascular interventions for the aneurysm and/or parent vessel can also be offered and are associated with satisfactory results and less morbidity than surgical methods [ 11 ]. We initially opted for endovascular treatment.…”

Spontaneous Thrombosis of a Giant Cavernous Internal Carotid Artery Aneurysm and Parent Vessel Occlusion in a Patient With Bilateral Cavernous Internal Carotid Artery Aneurysms

“…The patient initially presented with headache, double vision and trigeminal numbness that resolved after six months [ 13 ]. Yamagami et al treated a partially thrombosed cavernous ICA aneurysm with embolization through flow diversion [ 14 ]. In another case study, Ono et al performed coil embolization of the primitive trigeminal artery and ligation of the ICA at the cervical portion followed by high‑flow bypass from the cervical external carotid artery to the middle cerebral artery in a patient with a large, partially thrombosed cavernous carotid aneurysm that caused repeated embolic stroke in spite of antiplatelet therapy [ 15 ].…”