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Spontaneous internal carotid artery dissection with pseudoaneurysm formation
Trung D. Bui, MD, Roy M. Fujitani, MD, Stephen M. Kubaska, III, MD
University of California Irvine College of Medicine; UCI Medical Center, Division of Vascular and Endovascular Surgery, Orange, CA
 

A 39 year old male presenting with an acute left hemispheric ischemic stroke was found to have a spontaneous left internal carotid artery (ICA) dissection and pseudoaneurysm on duplex ultrasonography (DUS) and computed tomography angiogram (CTA) (Figures 1 and 2).

Figure 1. Duplex US demonstrated a pseudoaneurysm with arterial inflow and outflow

Figure 2. CTA confirmed an ICA pseudoaneurysm which measured 15x10mm

He was initially managed nonoperatively with warfarin anticoagulation. Serial imaging demonstrated a persistent dissection and enlarging pseudoaneurysm after five months of treatment. Endovascular repair was not attempted due to severe vessel tortuosity on cervical angiography (Figure 3).

Figure 3. Catheter angiogram revealed severe vessel tortuosity and an enlarging pseudoaneurysm measuring 20x15mm. Note the intimal flap indicating dissection

The patient subsequently underwent pseudoaneurysm resection with primary end-to-end anastomosis. Duplex ultrasound surveillance at 1 month demonstrated restored vessel integrity and patency (Figure 4). The patient has since reported no new neurological deficit.

Figure 4. Follow up Duplex US demonstrated a patent ICA and appropriate flow. 

References

1. Jewells, V; Castillo, M. MR angiography of the extracranial circulation. Magn Reson Imaging Clin N Am. 2003 Nov;11(4):585-97.2. Kubaska SM, Greenberg RK, Clair D, Barber G, Srivastava SD, Green RM, Waldman DL, Ouriel K. Internal Carotid Pseudoaneurysms: treatment with the Wallgraft endoprosthesis. J Endovasc Ther. 2003 Apr,10 (2):182-9. 3. Stapf, C; Elkind, MS; Mohr, JP. Carotid Artery Dissection. Ann Rev Med. 2000;51:329-47.

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