Carotid Artery Aneurysm
Boris Zurita –Cueva MD, Marcela Solano MD and
Jaime Velásquez MD.
Departamento de Neurocirugía Hospital Naval
Key Words · Carotid artery ·
Double aneurysm · clipping
This 72 year-old woman
presented with a sudden onset of severe headache and then loss of consciousness.
Computed tomography scanning revealed a subarachnoid haemorrhage (SHA) that appeared
pronounced in the right carotid cistern. Angiography demonstrated right double
carotid –posterior communicating aneurysms (fig.1). Surgery was preformed on Day
10 post –SHA. The proximal carotid aneurysm was directed to the temporal lobe
and appeared reddish and fragile with hemosiderin around it . We thought It was
the one that bled. The second aneurysm was of ventral type and was situated
before the origin of the anterior choroidal artery. Figure 2 shows an
intraoperative view of the lesion with clip application in the proximal
aneurysm. The postoperative course was uneventful and the patient remains
The occurrence of multiple
aneurysms has been well described in the literature; these lesions represent
approximately 20% of all intracranial aneurysms. However, the finding of more
than one aneurysm of the same artery is rare (1,2,5,6,7,8,9).
Kojima and Waga reviewed 356
cases of cerebral aneurysms. Of the 59 patients with multiple aneurysms, there
were 10 with more than one aneurysms on the same artery. Thus the incidence was
2.8%. The aneurysms arose from the internal carotid artery in seven patients ,
from the middle cerebral artery in two, and from anterior communicating artery
in only one. This entity is so uncommon, only three articles were found in the
We think that in our case the
lesion is a complex aneurysm, with the whole carotid artery involved at the
posterior communicating segment. That is, a fusiform carotid artery with two
saccular dilatations, the proximal one was directed outward and the distal
Special care deserves the
surgical technique in these lesions, we recommend a large fronto-lateral
approach beginning with arachnoidal dissection from the medial to lateral
side of the perichiasmatic cisterns, leaving the temporal lobe untouched .Only
proximal Sylvian dissection is needed. First the proximal saccular dilatation
that was fragile and that seemed that had bled was clipped . The fusiform
dilatation with the distal saccular part was wrapped with gauze.
Another possibility could be a
fenestrated clip, but we thought this technique was too dangerous because of
sudden rupture of the ventrolateral part of the aneurysm or occlusion of the
nearby anterior choroidal artery.
Double carotid artery aneurysms
are rare, hypertension seems to have an important role in the development of
this entity. In this case it was a complex aneurysm with a fusiform and two
saccular parts (4).
Angiography frequently does not
show the real shape of the aneurysm and only direct observation at surgery can
proves it. It is important that surgeon keeps in mind all the probabilities of
manouvres available when he or she suspects it preoperatively. We think that
direct clipping of the saccular part of the aneurysm plus wrapping of the
fusiform dilatation was a safe surgical solution (3).
Behari S, Krishna H,
Kumar MV,SawlaniV,Phadhke RV,Jain VK..Association between an aplastic
basilar artery accompanied by a primitive carotid-vertebrobasilar
anastomosis, and multiple aneurysms on the dominant posterior communicating
artery J Neurosurg 2004;100: 946-9.
Bendorf G, Naeni RM,
and Lehman. Triple carotid aneurysms in a patient with migrane attacks. Journal
of Neurol,neurosurg psyq 2004;75: 993.
Cossu M,Pau A, Turtas
V, ViolC , VialemG. Subsequent bleeding from rupture intracranial
aneurysms treated by wrapping or coating; A review of long term results in
47 cases. Neurosurg . 1993; 32: 344-347.
Inci S, Spetzler RF:
Intracranial aneurysms and arterial hypertension : a review and hypotesis.
Surg Neurol 2000; 53:530-542.
Inci S, Ozges T:
Multiple aneurysms of the anterior communicating artery: radiological and
surgical difficulties. J Neurosurg 2005;102:
Jefferson A: The
significance for diagnosis and for surgical technique of multiple aneurysms
of the same internal carotid artery. Acta
Neurochir 1978 ;41: 23-37.
Kojima T,Waga S. : More
than one aneurysm on the same artery. Surg Neurol
Mercado M, De Jesus O.
Bilobulated Aneurysms at the origin of
posterior communicating artery. P R Health Sci J.
2003; 22 (4) : 405-408.
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Kokunai T, Kobayashi M. Seven intracranial aneurysms of the internal
carotid artery. Diagnosis by magnification angioautotomography.
Neuroradiology 1978; 15:189-192.
Angiography shows a double carotid aneurysm at the posterior communicating
Intraoperative view showing clipping of the proximal sacular part of the
aneurysm (<) , the fusiform (*) and distal secular part (<)
of the aneurysm. ICA :
internal carotid artery. A1: anterior cerebral artery, M1 : middle
cerebral artery, achor: Anterior choroidal artery , II : right
optic nerve , III : Third cranial nerve.
BORIS ZURITA CUEVA - Neurocirujano
Clínica Alcívar. Chimborazo 3310 y Cañar. Torre Médica No. 3. Piso 7 Oficina
2446097 2333275 Metro:
2563500 Celular: 099950037