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Carotid Artery Aneurysm

A carotid artery aneurysm (CAA) is a section of the carotid artery that is swollen towards the outside, due to a weakness in the wall. These aneurysms can be found in all three branches, the common, internal and external carotid artery, and can occur both extracranially and intracranially.


Presentation

The carotid artery is divided into three segments: the common carotid artery and the internal and external carotid artery. The latter two, the internal and external are the two branches into which the common carotid artery is divided, at the level of the 4th cervical vertebra (carotid bifurcation). Anyone of these segments can be affected with an aneurysm; the internal carotid artery is the one most prone to aneurysms. Based on their location, CAAs are divided into intracranial and extracranial and lead to different symptoms. Very small aneurysms or larger aneurysms that do not exert pressure or influence adjacent structures in any way may remain asymptomatic in both cases.

Intracranial

It has been reported that, on average, 2,5% of the population is affected by an intracranial carotid artery aneurysm, most of which lead to no significant clinical manifestations [1]. The symptoms greatly depend on the specific location of the aneurysm and indicate a neurological, cerebral pathology. Intracranial CAAs may manifest with diplopia, persistent headaches, and cranial nerve palsy, such as a palsy of the abducens nerve (VI cranial nerve) [2]. An aneurysmal rupture is a medical emergency and patients present with complaints related to a hemorrhagic stroke or subarachnoid hemorrhage; death may even ensue [3]. A hemorrhagic stroke will manifest with focal deficits, such as a facial droop, visual impairment or aphasia, alongside a decreased level of consciousness, nausea, and vomiting. Subarachnoid hemorrhage usually causes photophobia, intense headache, meningismus signs or fainting. Aneurysms that have a diameter of over 2,5 cm have a 50% chance of rupturing [4].

Extracranial

Extracranial CAAs are a rare medical occurrence. Affected cases are expected to exhibit symptoms related to a transient ischemic attack (TIA), as transient strokes are caused by aneurysmal emboli [5] [6]. A transient ischemic attack is a stroke whose symptoms last for a brief period of time and may involve a variety of deficits, including loss of orientation and confusion, lightheadedness, ataxia, numbness of one body side, memory disturbances and other symptoms [7]. Although a TIA stops producing signs after minutes or a few hours, patients have an augmented risk of stroking severely in the near future. Extracranial aneurysms located in the common carotid artery may also present as a mass in the neck area.

Fever
  • An 11-year-old female child presented with acute onset fever, headache, chemosis followed by diplopia, right-sided ptosis with ophthalmoplegia. Magnetic resonance imaging revealed bilateral cavernous sinus thrombosis.[ncbi.nlm.nih.gov]
  • Fever, a severe headache on one side of the head, and jaw pain when chewing can be symptoms. Carotid hypersensitivity syndrome: In a few people, applying pressure to the carotid sinus can cause fainting from a sudden drop in blood pressure.[webmd.com]
Multiple Congenital Anomalies
  • Hardikar syndrome is a multiple congenital anomaly syndrome first characterized in 1992 by Hardikar et al. to describe two individuals with cholestasis, cleft lip/palate, retinal pigmentation, intestinal abnormalities, and genitourinary anomalies.[ncbi.nlm.nih.gov]
Vascular Disease
  • Spontaneous fistulae usually result from a ruptured carotid aneurysm, in collagen vascular disease, atherosclerotic disease, hypertension, or at childbirth 3. 2. Flow: high or low flow 3.[sonoworld.com]
  • diseases I73.0 Raynaud's syndrome Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.[icd10data.com]
Carotid Bruit
  • Examination may reveal neurological deficits, Horner's syndrome (half of cases), hemiparesis, carotid bruit.[patient.info]
Skin Lesion
  • Abstract Behcet disease (BD) is a chronic systemic inflammatory disorder characterized by recurrent oral and genital ulcerations, üveitis, and skin lesions. Vascular system involvement is common in BD.[ncbi.nlm.nih.gov]
Chemosis
  • An 11-year-old female child presented with acute onset fever, headache, chemosis followed by diplopia, right-sided ptosis with ophthalmoplegia. Magnetic resonance imaging revealed bilateral cavernous sinus thrombosis.[ncbi.nlm.nih.gov]
Retinal Pigmentation
  • Hardikar syndrome is a multiple congenital anomaly syndrome first characterized in 1992 by Hardikar et al. to describe two individuals with cholestasis, cleft lip/palate, retinal pigmentation, intestinal abnormalities, and genitourinary anomalies.[ncbi.nlm.nih.gov]
Neck Pain
  • Pelliccia et al. headache and neck pain. Neurological examination was normal. CT scan of the head and the neck showed frontal and skull base fractures involving the right sphenoid sinus and walls of the right carotid canal (Fig. 1).[docksci.com]
  • These patients may have complaints such as dysphagia, headache and neck pain, feeling of retroorbital pressure, otalgia and cerbrovascular symptoms.[ispub.com]
Tinnitus
  • Headaches can occur without any reason due to fatigue Bad sleep Dizziness Tinnitus Pulsation of blood vessels passing through the head and ears, which you have not noticed before Diagnosis It is impossible to diagnose carotid artery aneurysm without special[bookinghealth.com]
  • Episodes of transient blindness, syncope, swelling neck and pulsating tinnitus may also occur. Examination may reveal neurological deficits, Horner's syndrome (half of cases), hemiparesis, carotid bruit.[patient.info]
Headache
  • Intracranial CAAs may manifest with diplopia, persistent headaches, and cranial nerve palsy, such as a palsy of the abducens nerve (VI cranial nerve).[symptoma.com]
  • An 11-year-old female child presented with acute onset fever, headache, chemosis followed by diplopia, right-sided ptosis with ophthalmoplegia. Magnetic resonance imaging revealed bilateral cavernous sinus thrombosis.[ncbi.nlm.nih.gov]
  • Abstract A 65-year-old man presented with a hyperplastic anomalous anterior choroidal artery (AChA) associated with a ruptured internal carotid artery aneurysm at the origin of a perforating artery manifesting as sudden onset of headache and vomiting.[ncbi.nlm.nih.gov]
  • Symptoms Frequent and severe headaches.[bookinghealth.com]
  • Figure 1: Subarachnoid haemorrhage predominantly on the right side after the first episode of headache and vomiting.[ommegaonline.org]

Workup

Carotid artery aneurysms may be asymptomatic or symptomatic. Asymptomatic ones may be incidentally diagnosed during evaluation carried out for another cause, by means of a brain or cervical computerized tomography scan (CT) or magnetic resonance imaging scan (MRI) [1]. Other imaging modalities that may be employed to diagnose symptomatic carotid artery aneurysms include a CT or MRI scan as well as diffusion-weighted imaging (DWI), magnetic resonance angiography (MRA) and T2-weighted imaging (T2WI). The final precise diagnosis is rendered possible by means of an arteriography, which allows for the comprehensive assessment of the cerebral and cervical vessels [8].

Treatment

  • Patients with primary or secondary ECAA can be enrolled in CAR independent of the type of treatment (conservative or invasive). CAR participation does not interfere with the local physician's treatment policy.[ncbi.nlm.nih.gov]
  • Treatment consisted of either conservative treatment in 11% of the cases or invasive treatment in 89% of the cases. Invasive treatment comprised surgery in 94%, endovascular approach in 5%, and a hybrid approach in 1% of the patients.[ncbi.nlm.nih.gov]
  • Mean intervals between the onset and treatment were significantly longer in microsurgical group (18.2 days) than in endovascular group (3.5 days).[ncbi.nlm.nih.gov]
  • METHODS: From January 1991 through December 2013, 181 patients with 190 paraclinoid carotid artery aneurysms received treatment at Shinshu University Hospital and its affiliated hospitals.[ncbi.nlm.nih.gov]
  • We present a case of ruptured internal carotid artery (ICA) aneurysm that became a complex aneurysm after failure of multi-endovascular and surgery treatment.[ncbi.nlm.nih.gov]

Prognosis

  • Treatment and prognosis Management options can range from traditional surgical repair to endovascular repair (stent placement - combined stent placement and coil embolization 7 ).[radiopaedia.org]
  • In saccular and fusiform aneurysms with local extension and in an anatomically accessible neck, resection of the aneurysm and replacement by vein or prosthetic graft is the preferred technique and that with a better prognosis.[elsevier.es]
  • CONCLUSION In the setting of carotid artery aneurysms with a poor natural history prognosis consisting of stroke and death and difficult surgical treatment, endovascular stent grafting will likely emerge as the treatment of choice similar to this case[evtoday.com]
  • Clinical course and prognosis of temporal lobe epilepsy survey of 666 patients. Brain. 1971. 94: 173-90 4. Kuba R, Krupa P, Okacova L, Rektor I.[surgicalneurologyint.com]
  • Older patients and those with poorer Hunt and Hess grades on admission have a poor prognosis.[en.wikipedia.org]

Etiology

  • The underlying etiology is variable, with atherosclerosis being the most common entity in older subjects. Several treatments have been developed over the last 20 years, but the preferred method remains unknown.[ncbi.nlm.nih.gov]
  • Author information 1 Department of Neurology, Virgen de la Salud Hospital, Toledo, Spain. pjimenez1010j@yahoo.es Abstract Takayasu's arteritis (TA) is a chronic inflammatory disease of unknown etiology affecting large vessels, most markedly the aorta[ncbi.nlm.nih.gov]
  • Herein, we discuss this additional clinical information, speculate briefly on possible molecular etiologies, and discuss potential cardiac surveillance recommendations.[ncbi.nlm.nih.gov]
  • RESULTS: Analyses will relate outcome to etiology, imaging characteristics, ECAA growth patterns, and (if applicable) revascularization technique applied.[ncbi.nlm.nih.gov]
  • The underlying etiology was trauma in five (35.7%), prior carotid endarterectomy in five (35.7%), and degenerative atherosclerosis in four (28.6%).[ncbi.nlm.nih.gov]

Epidemiology

  • Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM (2010) Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol 8: 92–102. pmid:21079638 View Article PubMed/NCBI Google Scholar 17.[journals.plos.org]
  • "Epidemiology and genetics of intracranial aneurysms". European Journal of Radiology. 82 (10): 1598–605. doi : 10.1016/j.ejrad.2012.12.026. PMID 23399038.[en.wikipedia.org]
  • Etiology and Epidemiology Most common etiological factor for AEICA is atherosclerosis with an incidence of 34 to 70% in different series.[ispub.com]
Sex distribution
Age distribution

Pathophysiology

  • Comprehension of the pathophysiological mechanism associated with the rupture of ICCA and early diagnosis of the related symptoms are essential in order to plan a correct treatment that includes the management of the aneurysm rupture and of possible complications[ncbi.nlm.nih.gov]
  • Fondazione Cà Granda Ospedale Maggiore Policlinico, Milan, Italy. 6 Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy. Abstract Extracranial carotid artery aneurysms (ECAA) are a rare cause of embolic stroke.[ncbi.nlm.nih.gov]
  • In contrast, the pathophysiological mechanisms and natural course of ECAA are largely unknown. Understanding the pathophysiological background may add to prediction of risk for adverse outcome and need for surgical exclusion.[journals.plos.org]
  • A review of pathophysiology, radiological imaging, clinical manifestations and management is presented and discussed. Introduction Mirror aneurysms are paired aneurysms found within similar distributions on bilateral intracranial arteries.[ommegaonline.org]
  • We examined the pathophysiology underlying the development of olfactory hallucinations. We found craniotomy clipping and focal resection to be useful from the standpoint of seizure control.[surgicalneurologyint.com]

Prevention

  • Coil embolization of the aneurysm and parent artery occlusion for the posttraumatic direct CCF was a good option to manage the abducens nerve palsy and to prevent postoperative hyperperfusion.[ncbi.nlm.nih.gov]
  • This case of internal carotid artery aneurysm with a perforating artery arising from the aneurysm dome shows that sacrifice of the perforator may be necessary to prevent rebleeding.[ncbi.nlm.nih.gov]
  • Prevention See the separate Primary Prevention of Cardiovascular Disease and Cardiovascular Risk Assessment articles.[patient.info]
  • If this occurs, or in order to prevent this from occurring, treatment may be warranted. Other symptoms can occur secondary to pressure of the aneurysm on surrounding structures such as veins and nerves.[my.clevelandclinic.org]
  • Surgical repair was safe and effective with no significant morbidity or mortality and good midterm stroke prevention. Copyright 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.[ncbi.nlm.nih.gov]

References

Article

  1. Vernooij MW, Ikram MA, Tanghe HL, et al. Incidental findings on brain mri in the general population. N Engl J. Med. 2007;357:1821–1828.
  2. Lin LM, Colby GP, Jiang B, Pero G, Boccardi E, Coon AL. Transvenous approach for the treatment of direct carotid cavernous fistula following Pipeline embolization of cavernous carotid aneurysm: a report of two cases and review of the literature. BMJ Case Rep. 2014; 2014: bcr2014011235.
  3. Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711–1737.
  4. Wiebers DO, Whisnant JP, Huston J, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003;362:103–110.
  5. Choudhary AS, Evans RJ, Naik DK, Tripathi RK, Wickremesekera JK. Surgical management of extracranial carotid artery aneurysms. ANZ J Surg. 2009;79:281–7.
  6. El-Sabrout R, Cooley DA. Extracranial carotid artery aneurysms: Texas Heart Institute experience. J Vasc Surg. 2000;31:702–12.
  7. Sehatzadeh S. Is Transient Ischemic Attack a Medical Emergency? An Evidence-Based Analysis. Ont Health Technol Assess Ser. 2015; 15(3): 1–45
  8. Roger W. Countee and Thurairasah Vijayanathan. Extra-Arachnoid and Extracranial Aneurysms of the Carotid Artery: Diagnosis and Management. J Natl Med Assoc. 1982 Sep; 74(9): 857–870.

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Last updated: 2019-06-28 10:26