Aneurysm of extracranial carotid artery is a rare vascular
lesion. Extracranial carotid artery aneurysms account
for 0.1 to 2% of all carotid surgeries.[
4] Moreover, the
most common causes of intracranial aneurysms are
atherosclerosis, fibromuscular dysplasia, and trauma.
Radak et al.[
5] showed aneurysms due to atherosclerosis
(80.2%), trauma (6.6%), carotid surgery (6.6%), and
fibromuscular dysplasia (5.5%). Additionally, Zhou
et al.[
6] showed carotid artery aneurysms due to
atherosclerosis (50%), pseudoaneurysms (30%), and
trauma (12%). Although extracranial carotid artery
aneurysms are rare, they may cause potentially fatal
complications including embolization, rupture, and
local compression. Therefore, early diagnosis and
treatment are of utmost importance for these patients.
Sometimes, diagnosis can be challenging in patients
without neurological symptoms, in particular. Radak
et al.[
5] showed that 31.9% of cases are asymptomatic
at the time of diagnosis. Although the most common
symptom is a pulsatile mass in the neck, it is not
detected in calcified saccular aneurysms. However,
Szopinski et al.[
7] showed no pulsatile mass in six of
15 patients. Although rare, aneurysms can be dangerous
and they should be considered in the differential
diagnosis in patients with non-specific symptoms,
such as dysphagia, speech disorders, headache, neck
pain, anisocoria, even in the absence of findings of a pulsatile mass in the neck.[
8] We did not detect any
pulsatile mass in the neck at the physical examination
in our case. El Sabrout and Cooley[
9] showed a pulsatile
mass in the neck in 59%, neurological symptoms
in 43%, and signs of local compression in 10% in
their study. In addition, most internal carotid artery
aneurysms are hospitalized with embolic stroke.[
10]
Symptoms such as Horner's syndrome and dysphagia
caused by cranial nerve lesions require careful research
about underlying possible vascular pathologies. The
first step in the diagnosis is Doppler ultrasound,
which is a simple and noninvasive imaging modality;
however, it may be inadequate to detect aneurysms
which are small or close to the skull base distal internal
carotid artery lesions. Contrast computed tomography,
magnetic resonance imaging, and angiography are
other methods used in the diagnosis of such aneurysms.
Also, arteriography is the gold standard for aneurysms
due to occurrence of thrombus location and collateral
circulation.[
11]
Furthermore, isolated and short-segment
aneurysms at the level of the carotid bulb and a
80-90% stenosis due to a 20x6 mm plaque formation
in the internal carotid artery was detected in our case
angiographically. However, aneurysmal dilatation
caused an atheroma plaque or ulcer. During surgery,
muscular defect in the medial layer and the ballooning
of the vessel wall brought us to the definitive
diagnosis.
Moreover, open surgery is the preferred and accepted
treatment method for extracranial internal carotid
artery aneurysm.[6] The primary indication for surgery
is the prevention of permanent neurological damage
from thromboembolic events.[7] During surgery of
large aneurysms, stroke due to distal embolization of
atherosclerotic debris and damage due to cranial nerve
traction are the potential risks.[12] In addition, aneurysm
size, location, and etiology are the decisive factors in
choosing the surgical procedure for a surgeon. Surgical
treatment approaches include clipping, resection, and
end-to-end anastomosis, resection and graft placement,
extracranial to intracranial bypass, patch plasty and
carotid artery ligation. Following aneurysmectomy
and endarterectomy, we repaired internal carotid artery
with saphenous vein patch plasty in our case. In some
cases, endovascular treatment can be recommended
as an alternative to surgery. However, intracranial
carotid artery aneurysms and extracranial internal
carotid artery stenoses in different localizations were
published in the literature.[13,14]
In conclusion, the most characteristic feature of
our case was the concurrence of an internal carotid
artery stenosis with a saccular aneurysm. Review of
the literature revealed a few reports of concurrence
of an arterial aneurysm and an internal carotid artery
stenosis.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.