Abou-Al-Shaar Hussam, Gozal Yair M, Taussky Philipp, Couldwell William T
Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.
Oper Neurosurg (Hagerstown). 2019 Dec 1;17(6):E242-E243. doi: 10.1093/ons/opz022.
Petrous internal carotid artery (ICA) aneurysms are rare, complicated lesions to treat. The management paradigms include observation, endovascular exclusion, or surgical trapping with or without revascularization. The case described in this video involved a 67-yr-old woman with a known history of chronic lymphocytic leukemia, who presented after a mechanical ground-level fall. Clinically, she had a nasal deformity and resolving epistaxis consistent with mild facial trauma. Computed tomography (CT) revealed a comminuted nasal bone fracture and an incidental 3-cm right petrous ICA aneurysm. Subsequent vascular imaging demonstrated a concurrent 1.5-cm right cervical ICA dissecting pseudoaneurysm. Flow diversion with a Pipeline stent (Medtronic, Dublin, Ireland) was unsuccessful because the aneurysm's size precluded microcatheter selection of the ICA distal to the lesion. When the patient did not tolerate balloon test occlusion of the ICA, we proceeded with surgical trapping of both aneurysms and high-flow extracranial-to-intracranial bypass. The patient underwent a right frontotemporal craniotomy and an external carotid artery-to-frontal M2 middle cerebral artery bypass with a radial artery graft. Following a clinoidectomy, an aneurysm clip was applied to the paraclinoid ICA, and the cervical ICA was ligated just distal to the bifurcation, effectively trapping both aneurysms. The patient tolerated the procedure well. Postoperatively, she experienced symptomatic hypotension requiring vasopressor therapy and a transient partial oculomotor palsy that resolved during her hospital course. She was discharged home without neurological sequelae. Postoperative CT angiography demonstrated complete exclusion of the ICA aneurysms and a patent radial bypass graft after surgery and at 6-month follow-up. The patient provided consent for publication.
岩骨段颈内动脉（ICA）动脉瘤是一种罕见且治疗复杂的病变。治疗模式包括观察、血管内栓塞或手术夹闭（可联合或不联合血管重建）。本视频中描述的病例是一位67岁的女性，有慢性淋巴细胞白血病病史，因地面机械性摔倒后就诊。临床上，她有鼻畸形和鼻出血逐渐缓解，符合轻度面部外伤表现。计算机断层扫描（CT）显示鼻骨粉碎性骨折以及偶然发现的一个3厘米大小的右侧岩骨段ICA动脉瘤。随后的血管成像显示同时存在一个1.5厘米大小的右侧颈段ICA夹层假性动脉瘤。使用Pipeline支架（美敦力公司，爱尔兰都柏林）进行血流导向治疗未成功，因为动脉瘤的大小使得无法选择病变远端的ICA微导管。当患者无法耐受ICA球囊试验闭塞时，我们对两个动脉瘤进行了手术夹闭并进行了高流量颅外 - 颅内搭桥。患者接受了右侧额颞开颅手术以及使用桡动脉移植进行的颈外动脉至额叶M2段大脑中动脉搭桥。在进行前床突切除术后，用动脉瘤夹夹闭海绵窦段ICA，并在颈段ICA分叉远端进行结扎，有效地夹闭了两个动脉瘤。患者对手术耐受良好。术后，她出现了需要血管加压药治疗的症状性低血压以及短暂的部分动眼神经麻痹，在住院期间症状缓解。她出院时没有神经后遗症。术后CT血管造影显示术后及6个月随访时ICA动脉瘤完全被夹闭，桡动脉搭桥移植血管通畅。患者同意发表本病例。
