Ahead of Print: Carotid Artery Dissection-Related Intracranial Aneurysm Development

06/10/2011

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BACKGROUND AND IMPORTANCE: We analyzed the physiopathology of the association between cervical artery dissections (CADs), intracranial aneurysms (IAs) and aneurysmal – subarachnoid hemorrhage (SAH).

CLINICAL PRESENTATION: A 43 year-old-woman presented with diffuse SAH (Fisher 3; Hunt-Hess 1). Computed Tomography-Angiography (CT-A) revealed a cervical internal carotid artery (ICA) dissection and two IAs: right paraclinoid and right posterior communicating artery (PComA). The patient underwent surgical clipping of the two aneurysms. CAD was managed conservatively. Post-operative course was initially uneventful. After 24 hours, digital subtraction angiography (DSA) documented the exclusion of the aneurysms and an improvement of the CAD. After 3 days, the patient’s neurological condition suddenly worsened; CT-scan documented a subarachnoid rebleeding (Hunt-Hess 4) and DSA revealed the recurrence of CAD and a new right ICA aneurysm. The patient underwent clipping of the new aneurysm and decompressive craniectomy because of severe brain swelling. Post-operative neurological conditions remained poor. DSA showed the exclusion of the aneurysms and improvement of CAD. Three days later, CT-scan performed after a sudden raise in intracranial pressure (ICP) documented a wide intracerebral hematoma. CT-A did not show new vascular malformations. Surgical removal of the hematoma was performed, but poor neurological conditions persisted.

CONCLUSION: CAD-related hemodynamic changes may play a role in the development of IAs. The presence of IAs must be screened carefully in case of CAD since dynamic behavior of CAD definitively increases the risk of IAs formation, enlargement and rupture.

Full article access for Neurosurgery subscribers at Neurosurgery-Online.com.