====== Paraclinoid Internal Carotid Artery Aneurysm Case Reports ======

[[Accidental anterior skull base defect]]s associated with [[surgery]] are difficult to treat. There are several [[method]]s for the [[repair]], yet [[postoperative rhinorrhea]] can occur despite the [[closure]]. A 56-year-old female patient was admitted for the treatment of a [[paraclinoid internal carotid artery aneurysm]]. The surgery included removal of the [[anterior clinoid process]], unroofing the [[optic canal]], decompressing the [[optic nerve]], and [[clipping]] the [[aneurysm]]. During the surgery, the [[planum sphenoidale]] was accidentally [[drill]]ed and the [[nasal cavity]] exposed. The [[dural defect]] was repaired using a U-[[flap]] [[technique]]. No postoperative [[cerebrospinal fluid rhinorrhea]] occurred in the [[patient]], and she was [[discharge]]d on [[postoperative]] day 3. On follow-up examination the patient did not have evidence of [[CSF leakage]]
((Ozdol C, Aghayev K. U-shaped Dural Flap: A Simple Method for Transcranial
Skull Base Defect Repair-Technical Report. J Neurol Surg A Cent Eur Neurosurg.
2019 May 10. doi: 10.1055/s-0039-1688558. [Epub ahead of print] PubMed PMID:
31075811.
)).
----
A 35-year-old woman presenting with clinical manifestations and tomographic findings compatible with SAH, due to rupture of a paraclinoid aneurysm in the left ICA. We had to treat the ruptured aneurysm and the concurrent dissection of both internal carotid arteries. The patient underwent high flow extracranial-intracranial (EC-IC) arterial graft bypass and subsequent trapping of the left ICA. Complete aneurysm exclusion from the cerebral circulation was achieved and the possible embolic events from the left side were prevented. The concomitant right internal CAD was treated conservatively with anticoagulants and antiplatelets.

Dealing only with the ruptured paraclinoid aneurysm, without taking care of the underlying cerebral ischemia due to concomitant extracranial ICA dissection could be an insufficient approach for treatment. In the presented case of a giant ruptured paraclinoid aneurysm and coexistence of severe bilateral ICA dissecting stenosis, trapping with matching the bypass flow, was the proper solution for managing simultaneously with the aneurysm and the cerebral ischemia from the left side. Anticoagulants and antiplatelets were safely applied to treat the right internal CAD
((Georgieva VB, Krastev ED, Byulbyuleva SK. Extracranial - intracranial high
flow bypass for giant ruptured paraclinoid aneurysm with concomitant bilateral
internal carotid artery stenotic dissection - a case report. World Neurosurg.
2018 Jun 21. pii: S1878-8750(18)31317-2. doi: 10.1016/j.wneu.2018.06.101. [Epub
ahead of print] PubMed PMID: 29936212.
)).
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A 56-year-old right-handed woman was successfully treated by [[coil]] [[embolization]] for a large unruptured [[paraclinoid aneurysm]] of the left [[internal carotid artery]]. Though she was discharged on day 3 after the intervention with uneventful clinical course, she was rehospitalised for continuous [[headache]] and right upper limb weakness 2 weeks after the treatment. Subsequent progression of cognitive dysfunction and right hemiparesis were observed. Repeated MRI revealed diffuse leucoencephalopathy within the ipsilateral brain hemisphere. Clinical course, serological examination, and radiological findings were consistent with localised hypocomplemental vasculitis caused by delayed hypersensitivity reaction. Immunosuppressive treatments using prednisolone successfully improved her symptoms. After a washout period for immunosuppressant, skin reaction test was performed and revealed polyglycolic-polylactic acid, coating material of the coil, positive for delayed allergic reaction. Given the increased frequency of endovascular treatment for unruptured aneurysms, even such a rare complication should be recognised and treated properly to avoid neurological sequelae
((Fukushima Y, Nakahara I. Delayed leucoencephalopathy after coil embolisation
of unruptured cerebral aneurysm. BMJ Case Rep. 2018 Jun 23;2018. pii:
bcr-2018-224569. doi: 10.1136/bcr-2018-224569. PubMed PMID: 29936444.
)).
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A 54-year-old woman who was admitted with a Hunt/Hess grade IV, Fisher grade III subarachnoid hemorrhage and multiple intracranial aneurysms. She was treated with coiling of the largest paraclinoid aneurysm and placement of a flow diverting pipeline embolization device that covered all internal carotid artery (ICA) aneurysms. A follow-up angiogram at 6 months showed remodeling of the ICA with complete obliteration of all treated aneurysms. A distant, untreated, right frontal M2 aneurysm regressed spontaneously, after the flow was diverted away from it with the stent. The literature is reviewed, and potential pathophysiological mechanisms leading to aneurysm regression are discussed
((Tsimpas A, Ashley WW, Germanwala AV. Spontaneous regression of intracranial
aneurysm following remote ruptured aneurysm treatment with pipeline stent
assisted coiling. J Neurointerv Surg. 2015 Aug 20. pii:
neurintsurg-2015-011931.rep. doi: 10.1136/neurintsurg-2015-011931.rep. [Epub
ahead of print] PubMed PMID: 26293473.
)).