Rapid revascularization after therapeutic parent artery occlusion for a large intracavernous carotid artery aneurysm -Case report

A 21-year-old woman presented with an unruptured large intracavernous aneurysm, which was spontaneously revascularized via unusual collateral pathways a short time after extracranial-intracranial by-pass and surgical ligation of the proximal internal carotid artery. The patient had been treated for a large basilar trunk aneurysm with intraaneurysmal embolization using Guglielmi detachable coils, and an intracavernous carotid artery aneurysm treated conservatively. Two years later, the patient presented with right abducens nerve palsy, and was referred to our hospital. She had small nevi in the right forehead and eyelid. Cerebral angiography revealed enlargement of the intracavernous aneurysm. Superficial temporal artery-middle cerebral artery bypass followed by surgical carotid artery ligation were performed, and good patency of bypass and disappearance of the aneurysm were confirmed by intraoperative angiography. However, follow-up magnetic resonance angiography and cerebral angiography on the 20th postoperative day revealed revascularization of the internal carotid artery and the intracavernous carotid artery aneurysm via unusual collateral pathways. Subsequently, the recurrent aneurysm and the recanalized internal carotid artery were occluded by endovascular procedures. Histological examination of the nevus showed lack of properly organized vascular structures, and the diagnosis was angiodysplasia. The early development of unusual collateral pathway, and aneurysm formation at a young age might be related to the angiodysplasia. Revascularization is possible within a short time even in cases of intracavernous carotid artery aneurysm successfully treated with surgical ligation of the parent artery.