Giant infectious intracavernous carotid artery aneurysm presenting as intractable epistaxis

doi:10.1016/0090-3019(94)90010-8

Surgical Neurology

Volume 41, Issue 6, June 1994, Pages 472-476

https://doi.org/10.1016/0090-3019(94)90010-8 Get rights and content

Abstract

Infectious intracavernous carotid artery aneurysms usually present with ophthalmoplegia and/or signs of cavernous sinus thrombosis. We report an unusual case in which a patient with AIDS presented with intractable epistaxis secondary to rupture of a giant infectious intra-cavernous carotid artery aneurysm. Culture of the aneurysm grew mycobacterium avium intracellulare (MAI). The patient was treated successfully by excision of the aneurysm and reconstruction of the internal carotid artery with a saphenous vein interposition graft.

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Cited by (11)

Carotid Artery Aneurysm in HIV: A Review of Case Reports in Literature
2020, Annals of Vascular Surgery
Citation Excerpt :
As for extracranial aneurysms in HIV-positive patients, a different pathogenesis has been proposed, which may involve vasculitis of the vasa vasora, absent in the intracranial arteries.9 Where available, histologic findings were in line with previous reports, and with what has been previously described for aortic aneurysms7 showing the presence of vascular and perivascular acute inflammation, inflammatory cells (lymphocytes, plasma cells, eosinophils, multinucleated giant cells, histiocytosis), focal elastic lamina calcification, rarefaction or rupture; intimal thickening or medial fibrosis12,13,15; luminal thrombosis with neutrophil infiltration of thrombus and concentric intimal fibrosis was reported in an autoptic case of bilateral carotid artery aneurysms symptomatic for left ischemic lesion.9 These features overlapped active tuberculosis vascular findings in 3 cases,8 confirming that aneurysm features may be a result of the additional action of different etiological agents that must be suspected even in the presence of a negative blood culture.
HIV infection may affect the cardiovascular system through different physiopathological patterns. Rarely reported in HIV negative patients, aneurysms involving the carotid artery have been described for the first time in seropositive patients in 1989.
In our study, we have focused on aneurysm pathology affecting carotid arteries in HIV patients, analyzing clinical and surgical presentation, management, and outcome, through a review of cases published in the literature.
The MEDLINE (www.ncbi.nlm.nih.gov/pubmed) database was reviewed for “carotid artery aneurysm AND HIV OR AIDS OR immunodeficiency.”
Nineteen articles including a total of 46 cases were included in our report. The mean age of patients was 30.6 ± 14.2 years; 30 patients (65.2%) were male. Aneurysms were localized in the intracranial carotid (41.3%) or extracranial artery (58%). Presenting features included symptoms due to compression of neck structures; positivity for neurological symptoms occurred in 36.9%. Patients were managed surgically in 58.7% of cases; surgical morbidity and mortality were of 22.2% and 7.4% respectively, higher for endovascular procedures. The overall mortality in treated and untreated cases was 26.1%.
Aneurysms may occur in both the extracranial and intracranial carotid artery in patients with HIV at younger age than in non-HIV patients and are linked to a high morbidity and mortality. Seropositivity must be ruled out whenever this rare vascular condition may occur in the absence of a more likely aetiology and must also be suspected in HIV patients presenting with compressive symptoms of the neck, neurological impairment or stroke.
Carotid Artery Aneurysms: Serbian Multicentric Study
2007, Annals of Vascular Surgery
Citation Excerpt :
We had four such cases. Some of the ruptured ECAAs presented with unusual hemorrhage to the pharynx, ear, and nose.61-69 In 1808, Sir Astley Cooper70 successfully performed a ligature of the internal carotid artery aneurysm.
This multicentric Serbian study presents the treatment of 91 extracranial carotid artery aneurysms in 76 patients (13 had bilateral lesions). There were 61 (80.3%) male and 15 (19.7%) female patients, with an average age of 61.4 years. The aneurysms were caused by atherosclerosis in 73 cases (80.2%), trauma in six (6.6%), previous carotid surgery in six (6.6%), tuberculosis in one (1.1%), and fibromuscular dysplasia in five (5.5%). The majority (61 cases or 67%) of the aneurysms involved the internal carotid artery, 29 (31.9%) the common carotid artery bifurcation, and one (1.1%) the external carotid artery. Forty-five (49.4%) aneurysms were fusiform, while 46 (50.6%) were saccular. Twenty-nine (31.9%) cases were totally asymptomatic at the time of diagnosis. The remainder presented with compression in 14 (15.4%) cases, stroke in 11 (12.1%) cases, transient ischemic attack in 33 (36.3%) cases, and rupture in four (4.4%) cases. In cases where the aneurysm involved the internal carotid artery, four surgical procedures were performed: aneurysmectomy with end-to-end anastomosis in 30 (33.0%) cases, aneurysmectomy with vein graft interposition in 20 (22.0%) cases, aneurysmectomy with anastomosis between external and internal carotid artery in eight (8.8%) cases, and aneurysmectomy followed by arterial ligature in three cases. One case of external carotid artery aneurysm also was treated by aneurysmectomy and ligature. Aneurysm replacement with Dacron graft was performed in 29 (31.9%) cases where common carotid artery bifurcation was involved. Two (2.2%) patients died after the operation due to a stroke. They had ruptured internal carotid artery aneurysm treated by aneurysmectomy and ligature. Including these, a total of five (5.5%) postoperative strokes occurred. In two (2.2%) cases, transient cranial nerve injuries were found. Excluding the five patients who were lost to follow-up, 69 other surviving patients were followed from 2 months to 12 years (mean 5 years and 3 months). In this period, there were no new neurological events and all reconstructed arteries were patent. Three patients died more than 5 years after the operation, due to myocardial infarction. Aneurysms of the extracranial carotid arteries are rare vascular lesions that produce a high incidence of unfavorable neurological sequelae. Because of their varied etiology, location, and extension, different vascular procedures have to be used during repair of extracranial carotid artery aneurysms. In all of these procedures, an aneurysmectomy with arterial reconstruction is necessary.
Intra-cavernous aneurysm of the internal carotid artery complicating sphenoid sinusitis
2004, Revue Neurologique
Les anévrysmes mycotiques ou post-infectieux de la carotide interne intra-caverneuse sont une pathologie rare.
Nous rapportons l’observation d’un patient ayant présenté, trois semaines après une extraction dentaire, une ophtalmoplégie gauche d’installation progressive, ainsi que des céphalées à type d’hémicrânie gauche, dans un contexte fébrile. Les différents examens neuroradiologiques et microbiologiques ont permis de diagnostiquer une infection des sinus sphénoïdaux et ethmoïdaux avec une extension du processus infectieux au sinus caverneux gauche. Il existait également un anévrysme de la carotide interne gauche dans sa portion intra-caverneuse.
Le risque de rupture de ce type d’anévrysme est difficile à évaluer. Le traitement consiste toujours en une antibiothérapie adaptée et prolongée, avec parfois en addition un traitement neurochirurgicale ou endovasculaire de l’anévrysme. Pour ce patient, nous avons un suivi de quatre ans sans intervention, montrant la stabilité du diamètre de l’anévrysme.
Mycotic or post-infectious aneurysm of the intra-cavernous portion of the internal carotid artery is uncommon.
We report here the case of a patient who developed progressive left ophthalmoplegia, with left hemi-crania three weeks after a tooth extraction. The patient was febrile. Neuroradiological and microbiological analysis led to the diagnosis of sphenoidal and ethmoidal sinus infection with extension to the left cavernous sinus. An aneurysm of the intra-cavernous portion of the left internal carotid artery was also found.
The risk of rupture for this kind of aneurysm is difficult to assess. Treatment always consists in prolonged and adapted antibiotic therapy. For certain patients neurosurgical or endovascular repair is necessary. We followed our patient for four years without surgical intervention. The diameter of the aneurysm has remained stable.
Intrasphenoid mycotic aneurysm of the internal carotid artery
2003, Otolaryngology - Head and Neck Surgery
Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy
2014, Journal of NeuroInterventional Surgery
Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy
2013, BMJ Case Reports

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Giant infectious intracavernous carotid artery aneurysm presenting as intractable epistaxis

Abstract

Bilateral mycotic aneurysms of the intracavernous carotid artery

Neurosurgery

CT observations pertinent to septic cavernous sinus thrombosis

AJNR

Mycotic aneuryms

Ann Surg

Infectious intracranial aneurysms: comparison of groups with and without endocarditis

Neurosurgery

Treatment of bilateral mycotic intracavernous carotid aneuryms

J Neurosurg

Bacterial intracranial aneurysms

J Neurosurg

Intracavernous carotid artery aneurysms: surgical approach and complication avoidance

Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases

J Neurosurg

CT findings of mycotic aneurysm of the intracavernous part of the internal carotid artery: a case report and literature review

J Med Assoc Thai

Acute inflammations of arteries