Korean Journal of Cerebrovascular Surgery 2011;13(1):24-27.
Published online March 1, 2011.
Five Aneurysms Arising from the Ipsilateral Internal Carotid Artery : Case Report.
Jang, Hong Jeon , Cho, Kyu Yong , Lim, Jun Seob , Lee, Rae Seop , Ok, Young Chel , Lim, Byung Chan
Department of Neurosurgery, Kwangju Christian Hospital, Kwangju, Korea. nsmh1@hanmail.net
Abstract
Although the incidence of intracranial multiple aneurysms are not low, the occurrence of multiple aneurysms more than three developing on the ipsilateral carotid artery is quite rare. We present a patient with five aneurysms on the left internal carotid artery. Four aneurysms arising from the left internal carotid artery underwent microsurgical clipping and wrapping, and remnant superior hypophyseal artery aneurysm was treated by using coil embolization. Incidence and risk factors for management of multiple aneurysms were investigated with the literature review.
Key Words: Multiple aneurysms, Ipsilateral internal carotid artery, Clipping, Coiling

Introduction

Multiple intracranial aneurysms occur in approximately 15% to 20% of patients presenting with subarachnoid hemorrhage. Multiple aneurysms occur more frequently in women, and bilaterally symmetrical aneurysms (mirror aneurysms) are common.1)2)3) Ninety five percent of them showed two lesions and 5% had three or more (3.5% had three aneurysms and only 1.4% had four or more).15) It is clear that the presented case is uncommon. We report a case of multiple aneurysms at the ipsilateral intracranial internal carotid artery (ICA) which were treated by surgical clipping and endovascular coiling.

 

Case report

 

A 53-year-old menopausal state female presented with sudden headache, vomiting, and posterior neck discomfort. In the patient's past history, she had smoked regularly one pack/day during 20 years. But she had no history of hypertension, alcohol consumption (in excess of 5 units/day), diabetes mellitus, and cerebrovascular or cardiovascular disease. There were no abnormal findings in vital signs and routine laboratory examinations. The computerized tomography (CT) revealed subarachnoid hemorrhage in the basal cistern and both Sylvian cisterns. A three dimensional CT angiography was performed and showed three aneurysms definitely in the left ICA (Fig. 2) : one large aneurysm at ICA bifurcation, another from the anterior choroidal artery (AchoA) and a third from the posterior communicating artery (PcomA) (Fig. 1).

Operation. The patient underwent surgery using the standard pterional approach. With the aid of the microscope, the left Sylvian fissure was widely divided. Cautious dissection was performed because we did not know which aneurysm ruptured. We confirmed that infundibulum shape AchoA aneurysm was ruptured site. The ruptured AchoA aneurysm was occluded first using Yasagil straight clip and the other large dome shape aneurysm of the ICA bifurcation and bi-lobular type PcomA aneurysms were seen and treated easily with the aid of Yasagil curved clips. Thus, allowing good patency of the left ICA. And hidden blood blister like-aneurysm was discovered at the dorsal wall of ICA at the proximal PcomA that was not detected by preoperative CT angiography. The ICA dorsal wall aneurysm was treated successfully with coagulation and wrapping without the ICA narrowing. However, one month later, she complained of gait disturbance, slurred speech and urinary incontinence. Brain CT showed a progressive ventricular dilatation with widening of cortical sulci. The patient was treated by ventriculo-peritoneal shunt and fully recovered one day after the operation.

Postoperative Course. The patient's postoperative course was uneventful and cerebral angiography was performed at two months after operation. Left carotid angiogram with submentovertex view revealed additional aneurysm arising from the superior hypophyseal artery that could not be verified by previous routine CT angiography. The patient was taken to the endovascular suite for coil embolization treatment. Neuroleptic anesthesia was initiated, and the right femoral artery was accessed percutaneously to place an 8-F introducer sheath under full heparinization. Embolization was performed using Guglielmi detachable coils (GDCs) and was considered complete performance when a dense packing of the aneurysm with coils was achieved without compromising the lumen of the parent artery. The patient made an uneventful recovery and was discharged with no neurological sequalae. Six-month follow-up angiograms showed persistent complete obliteration of the aneurysm with excellent flow through the left ICA.

 

Discussion

Multiple intracranial aneurysms occur in approximately up to one third (15~45%) of patients presenting with subarachnoid hemorrhage.1)2)4)12) The majority of multiple aneurysms simultaneously arise at different sites of the cerebral arteries, but more than two aneurysms at the ipsilateral ICAbranching site have been rarely reported. In the cooperative study of Sahs and Perret, the chance of multiple aneurysms occurring on the same side was 21%, on opposite side 47% and other combinations 32%. The overall chance of aneurysms being situated on opposite side was 2:1.15) Kojima and Waga reviewed 356 cases of cerebral aneurysms. Of 59 patients with multiple aneurysms, 10 had more than one aneurysm on the same artery, providing an incidence of 2.8%. The finding of multiple aneurysms on the same artery frequently occurs with the ICA and the middle cerebral artery (MCA).1)4)6)

Makio, et al.6) researched age-and sex-specific incidence of 361 patients of ruptured multiple aneurysm in Nagasaki Prefecture. The incidences of single and multiple aneurysms in men showed a relative plateau between 50 and 79 years of age, but the incidences continued to increase with age in women between 50 and 69 years of age. Sex-specific hormonal factors, especially decreased estrogen levels, are presumably related to the preponderance of women with ruptured aneurysm. Female-specific factors contribute to the increased incidence of both single and multiple aneurysms in patients ≥50 years of age.11)6)

Habib, et al.2) have examined associations between risk factors and the presence of multiple aneurysms. Of the 392 patients, 284 harbored a single aneurysm and 108 harbored multiple aneurysms. In this study, hypertension, cigarette smoking, a familial history of cerebrovascualr disease, and the postmenopausal state in female patients seem to increase the risk of multiple aneurysm formation.2)6)7)12) Using systematic review and metaregression of twenty- three studies between 1970 and 2004, James, et al. described risk factors for multiple intracranial aneurysms. The prevalence of multiple aneurysms may increase with age more quickly in women, smokers, or in those with hypertension, compared with individuals without these risk factors.3)4)6)

In our case, the superior hypophyseal artery aneurysm was missed on CT angiography preoperatively. This is a limitation of CT angiography. Three dimensional CT angiography (3DCTA) has been an important tool for noninvasive evaluation of vasculature, and there have been numerous reports on its accuracy and utility for detecting intracranial aneurysms. But 3DCTA may be less useful than conventional digital subtraction angiography (DSA) for evaluation of cerebrovascular structure near the base of the skull because of difficulties in separating vessels from bony structure.11)13) Although the neurosurgeon would have been happy to proceed to surgery on the basis of CTA alone in all cases, the author judged that DSA might have provided helpful additional information.

 

Conclusion

 

We report a case of five aneurysms arising from the short part of ipsilateral ICA from ophthalmic segment to the ICA bifurcation. Old age, female, and smoking seem to be the major risk factors for multiple aneurysm formation. For unmistakable evaluation of multiple aneurysms, performing of 4-vessel angiography would be efficacious, especially in cases of aneurysms near the skull base.

 

REFERENCES

 

1) Back BS, Choi SJ, Ji C, Ahn JG. Multiple aneurysms on the same bifurcation site of the middle cerebral artery. J Korean Neurosurg Soc 41:258-60, 2007

2) Ellamushi HE, Grieve JP, Jäger HR, Kitchen ND. Risk factors for the formation of multiple intracranial aneurysms. J Neurosurg 94:728-32, 2001

3) James Ju Young Cheong, Narcyz Ghinea, James M. Van Gelder. Estimating the annual rate of de novo multiple aneurysms: three statistical approaches. Neurosurg Focus 17(5):E8, 2004

4) Jin SC, Kwon DH, Song Y, Kim HJ, Ahn JS, Kwun BD. Multimodal treatment for complex intracranial aneurysms: clinical research. J Korean Neurosurg Soc 44:314-9, 2008

5) Joon K. Song, Yasunari Niimi, Jonathan L. Brisman, Patricia M. Fernandez, Alejandro Berenstein. Multiple cerebral Aneurysms in a neonate: occlusion and rupture. J Neurosurg (Pediatrics) 102:81-5, 2005

6) Kaminogo M, Yonekura M, Shibata S. Incidence and outcome of multiple intracranial aneurysms in a defined population. Stroke 34:16-21, 2003

7) Kim SK, Kim CJ. One stage operation of triple aneurysms. J Korean Neurosurg Soc 21:834-8, 1992

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9)Mount LA, Brisman R. Treatment of multiple intracranial aneurysms. J Neurosurg 35:728-31, 1971

10)Nehls DG, Flom RA, Carter LP, Spetzler RF. Multiple intracranial aneurysms: determining the site of rupture. J Neurosurg 63:342-8,1985

11)Nishihara M, Tamaki N. Usefulness of volume-rendered three- dimensional computed tomographic angiography for surgical planning in treating unruptured paraclinoid internal carotid artery aneurysms. Kobe J Med Sci 47:221-30, 2001

12)Østergaard JR, Høg E. Incidence of multiple intracranial aneurysms. J Neurosurg 63:49-55, 1985

13)Sakamoto S, Kiura Y, Shibukawa M, Ohba S, Arita K, Kurisu K. Subtracted 3DCT angiography for evaluation of internal carotid artery aneurysms: comparison with conventional digital subtraction angiography. AJNR Am J Neuroradial 27:1332-7, 2006

14)Solander S, Ulhoa A, Viñuela F, Duckwiler GR, Gobin YP, Marti NA, et al. Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils. J Neurosurg 90:857-64, 1999

15)Zacks DJ. Multiple intracranial aneurysms. Am J Roentgenol 130:180-2, 1978



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