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|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 5 | Page : 1250-1252
Visual Deterioration Due to Unruptured Saccular Internal Carotid Artery Aneurysm in an Operated Case of Craniopharyngioma
Mohamed A Jamaluddin, Ranjit D Rangnekar, George C Vilanilam, Gograj Garhwal, Mathew Abraham
Department of Neurosurgery, Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
|Date of Web Publication||27-Oct-2020|
Prof. Mathew Abraham
Department of Neurosurgery, Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jamaluddin MA, Rangnekar RD, Vilanilam GC, Garhwal G, Abraham M. Visual Deterioration Due to Unruptured Saccular Internal Carotid Artery Aneurysm in an Operated Case of Craniopharyngioma. Neurol India 2020;68:1250-2
|How to cite this URL:|
Jamaluddin MA, Rangnekar RD, Vilanilam GC, Garhwal G, Abraham M. Visual Deterioration Due to Unruptured Saccular Internal Carotid Artery Aneurysm in an Operated Case of Craniopharyngioma. Neurol India [serial online] 2020 [cited 2021 Jun 25];68:1250-2. Available from: https://www.neurologyindia.com/text.asp?2020/68/5/1250/299169
The First and Second authors have contributed equally to this
We report a case of 39-year-old male who initially presented at 22 years of age with headache and decreased secondary sexual characters. He had a marfanoid habitus, gynecomastia with absent secondary sexual characters. His visual examination was essentially normal. The patient underwent right pterional craniotomy and tumor decompression for a sellar-suprasellar lesion. The surgery was uneventful. Histopathology revealed predominantly cholesterol granulomas with cholesterol clefts and foreign body giant cells along with bony spicules, hyalinization, and mononuclear aggregates suggestive of craniopharyngioma. No adjuvant radiotherapy is given.
He was detected to have a right supra-clinoid carotid artery aneurysm with minimal residual lesion during a follow-up imaging four years after surgery. Patient was asymptomatic with normal visual fields and refused any intervention at that stage. The patient was lost to follow-up. 16 years after the initial surgery, patient presented with painless progressive loss of vision in the right eye. Corrected visual acuity was 6/5 in the right eye, 6/9 in the left eye with temporal field defect in right eye. Magnetic Resonance imaging showed a minimal residual supra-sellar lesion with interval increase in size of right supra-clinoid internal carotid artery aneurysm [Figure 1]. Digital subtraction angiogram done showed a wide-necked saccular dorsal wall aneurysm, directed anterosuperiorly and laterally, at communicating segment of right internal carotid artery measuring about 12 × 8.8 × 7.5 mm with a neck of 12 mm [Figure 2]. Right posterior communicating artery was incorporated in the inferomedial wall of the aneurysm.
|Figure 1: Coronal Sections of Preoperative Magnetic Resonance Imaging showing suprasellar lesion|
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|Figure 2: (a) Reconstructed CT Angiogram showing saccular aneurysm of right internal carotid artery (b) Digital Subtraction Angiogram showing dorsal wall aneurysm, arising at communicating segment of right internal carotid artery|
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In view of enlarging size, visual symptoms, and saccular nature of aneurysm, patient underwent re-exploratory craniotomy and clipping of the aneurysm [Figure 3]. Postoperatively patient was discharged with significant improvement in the vision and perimetry revealing resolution of the field defect.
|Figure 3: Intraoperative photograph (a) Saccular dorsal wall aneurysm arising from communicating segment of right internal carotid artery (b) Aneurysm secured with two titanium clips|
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| » Discussion|| |
The vascular complications following microsurgical and endoscopic approaches for craniopharyngioma range from direct injury, vasospasm to carotid artery aneurysms. Fusiform dilatations of internal carotid artery (FDCA) have been reported in children undergoing surgery for supra-sellar lesions, especially craniopharyngioma. Till date approximately 40 cases of iatrogenic intracranial aneurysms in childhood have been reported. Hoffman reported 2.4% incidence of fusiform dilations after surgery for craniopharyngioma with a median time of detection of 0.01–5.5 years. The incidence could range from as low as 0.2% to as high as 29% depending upon the approach taken., All except one were FDCA and all cases were less than 20 years of age.,,,,,,, Periera reported a case of an iatrogenic asymptomatic saccular aneurysm, detected on 5-year routine MR imaging, in a child who underwent craniopharyngioma decompression followed by radiotherapy. The pathogenesis of such aneurysms is yet unknown. It could be due to either involvement of adventitia by the tumor, injury to the sympathetic plexus around internal carotid artery by tumor, or the surgical dissection of carotid artery. Manipulation during surgery can occur while stripping of the tumor from the artery, retraction of the carotid for exposure or due to focal injury to the vessel wall. This is reiterated by the fact that these aneurysms occurred on the same side of the surgical approach.,, Irradiation has also been attributed in the pathogenesis while others have opposed it citing lack of temporal correlation.,,,
Unusual to the natural history of traumatic aneurysms, iatrogenic aneurysms are indolent and usually do not require further intervention.,, Most aneurysms, once detected within the second year following surgery, have a dormant course.,, None of patients presented with hemorrhage nor do they have any impact on the prognosis.,, However, any alarming clinico-radiological feature of these iatrogenic aneurysms, such as high risk of rupture or progressive symptoms, should necessitate some form of intervention. Even though few patients had symptoms such as non-specific headache attributable to mass effect, only two cases of the iatrogenic aneurysm presented with any neurological finding such as visual loss.,,,
Surgical repair of such aneurysms is difficult considering the absence of a true neck. Surgical options appropriate to such cases may be clipping, wrapping, or bypass., Cases where iatrogenic aneurysms underwent surgery were for progression in size, providing access to recurrent disease, visual impairment, and headache due to large size.,,, Many surgeons prefer endovascular management, especially, in small and asymptomatic cases without recurrence.,
The case presented herein is an adult and the eldest case ever reported to develop an iatrogenic carotid artery aneurysm opposed to the fact such aneurysms are found in children. This places the hypothesis, that such postoperative aneurysms are a result of the abnormal healing process in the vessel wall of children, in doubt.,,, Even though detected incidentally, the communicating segment aneurysm in this patient had grown significantly to cause mass effect, thus presenting with a monocular field defect secondary to compression. The dorsal wall location of the communicating segment aneurysm in the backdrop of residual tumor in the same location with subsequent visual deterioration can create confusing picture for the common physician. Considering the size of the aneurysm and high risk of rupture, the aneurysm was planned for clipping. The tumor was not tackled in view of the insignificant size of the lesion.
This case is the second case to be reported to have a de-novo saccular aneurysm arising following a craniopharyngioma surgery, rather than a FDCA., As opposed to the earlier reported saccular aneurysm, our patient had presented with gradual visual loss starting 16 years after the initial surgery but had early rapid complete postoperative recovery of vision confirming that the cause of visual loss was the gradually enlarging aneurysm, even without tumor decompression. Saccular aneurysm as compared to fusiform dilatation irrespective of the etiology possesses higher risk of rupture and needs to be tackled. The earlier saccular aneurysm reported by Pereira had spontaneous thrombosis and interval regression of the asymptomatic aneurysm, even though the patient was planned for coil embolization initially. This was in contrast to our patient had interval progression of the size of aneurysm and was symptomatic for the same. The saccular nature of the aneurysm might also be the reason for visual loss in these cases since only one FDCA has ever been reported to have any visual symptom.,
| » Conclusion|| |
Common neurosurgical causes of visual deterioration are sellar-suprasellar lesions, optic pathway tumors, supra-clinoid aneurysms, and raised intracranial pressure. Microsurgery for craniopharyngioma resection poses a risk of ICA adventitial injury. This can predispose to iatrogenic aneurysms that grow and mimic tumor recurrence. Reoperations are tough but nevertheless essential for cure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]