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Fusiform Dilatation of the Internal Carotid Artery After Craniopharyngioma Resection
Images in Child Neurology
Fusiform Dilatation of the Internal Carotid Artery After Craniopharyngioma Resection Italo Linfante, MD*, Celeste Tucci, MD†, and Vincenzo Andreone, MD†
Clinical History Five years after the successful resection of a craniopharyngioma, a 20-year-old woman presented to the emergency room with severe headache, nausea, and vomiting. Computed tomography of the head and a lumbar puncture were not suggestive of subarachnoid hemorrhage. Magnetic resonance imaging of the head with gadolinium did not reveal tumor recurrence. However, magnetic resonance angiography revealed a fusiform dilatation of the right internal carotid artery. Cerebral angiography confirmed the lesion (Fig 1), and excluded the presence of other aneurysms or vascular malformations. The patient’s headache was diagnosed as a migraine and she was successfully treated with medication. At 6-month followup, magnetic resonance angiography and catheter angiography revealed no changes in the fusiform dilatation of the right internal carotid artery. At 1-year follow-up, the patient was asymptomatic. Magnetic resonance angiography was also unchanged. Discussion Fusiform dilatation of the right internal carotid artery is a rare vascular complication after surgery for craniophar-
From the *Section of Neuroimaging and Intervention, Department of Radiology and Department of Neurology, University of Massachusetts, Worcester, Massachusetts, and †Department of Neurology, Cardarelli Hospital, Naples, Italy.
© 2008 by Elsevier Inc. All rights reserved. doi:10.1016/j.pediatrneurol.2008.04.001 ● 0887-8994/08/$—see front matter
Figure 1. Digital subtraction angiography: anteroposterior and lateral views of a right internal carotid artery injection. The arrow indicates a fusiform dilatation of the supraclinoid portion of the right internal carotid artery. The lesion seems to extend from the origin of the posterior communicating artery to the bifurcation of the right internal carotid artery, and into the middle cerebral and anterior cerebral artery.
yngioma [1-5]. To date, only 18 patients have been reported in the literature [1-5]. An additional 4 patients with a fusiform dilatation of the internal carotid artery were described after resection of other types of suprasellar tumors (3 astrocytomas, and 1 hamartoma) [3,5]. The mean age of patients at time of the surgery was 10 years
Communications should be addressed to: Dr. Linfante; Section of Neuroimaging and Intervention, Department of Radiology; University of Massachusetts; Memorial University Campus; 55 Lake Avenue North; Worcester, MA 01655. E-mail: [email protected] Received February 29, 2008; accepted April 16, 2008.
Linfante et al: ICA Aneurysm After Craniopharyngioma 139
(range, 3-24 years). Fusiform dilatation of the internal carotid artery occurs predominantly in children. In 20 of 22 patients, the fusiform dilatation of the internal carotid artery was diagnosed within 18 months after surgery (range, 4-17 months). In only 2 patients fusiform dilatation of the internal carotid artery was first noted several years after surgery (at 8 and 11 years) [5]. In all patients, the fusiform dilatation of the internal carotid artery was ipsilateral to the surgical approach, except for one patient, who exhibited bilateral fusiform dilatation of the internal carotid artery [5]. The fusiform dilatation of the internal carotid artery was asymptomatic in the majority of patients. In one patient, the progressive aneurysmal dilatation caused visual impairment secondary to opticnerve compression [6], and 2 patients reported severe headaches [4,5]. With regard to the pathogenesis of the lesion, subclinical injury of the internal carotid artery adventitia during surgical manipulation [1,5] and injury of the sympathetic plexus around the internal carotid artery have been hypothesized [3,4]. With regard to outcomes, fusiform aneurysms are generally associated with high morbidity and mortality. However, most cases of fusiform dilatation after craniopharyngioma resection were reported as benign [1,3,5]. Delayed enlargement in sequential studies was evident in 4 patients. However, 2 of these patients were previously treated with radiotherapy [2,3]. Conservative versus aggressive treatment of a fusiform dilatation of the internal carotid artery after craniopharyngioma resection is an object of debate. Microsurgery with fenestrated microclips was reported
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as a treatment for fusiform aneurysms and for fusiform dilatations of the internal carotid artery occurring after craniopharyngioma resection [1,2,4-6]. Endovascular treatment with stent remodeling for fusiform aneurysms has also been reported [7]. However, because of its rarity, the best treatment for this condition remains unknown. In addition, treatment may not be needed in accordance with the benign nature of the lesion. In conclusion, more data are required for a better understanding of the pathophysiology and long-term prognosis of fusiform dilatations of the internal carotid artery after craniopharyngioma resection. References [1] Sutton L, Gusnard D, Bruce DA, Fried A, Packer RJ, Zimmerman RA. Fusiform dilatations of the carotid artery following radical surgery of childhood craniopharyngioma. J Neurosurg 1991;74:695-700. [2] Liu SS, Zabramski JM, Spetzler R. Fusiform aneurysm after surgery for craniopharyngioma. J Neurosurg 1991;75:670-1. [3] Bendszus M, Sorensen N, Hofmann E, Röll E, Solymosi L. Fusiform dilatations of the internal carotid artery following surgery for pediatric suprasellar tumors. Pediatr Neurosurg 1998;29:304-8. [4] Tirakotai W, Sure U, Benes L, et al. Successful management of a symptomatic fusiform dilatation of the internal carotid artery following surgery of childhood craniopharyngioma. Childs Nerv Syst 2002;18:717-21. [5] Sutton L. Vascular complications of surgery for craniopharyngioma and hypothalamic gliomas. Pediatr Neurosurg 1994;21:124-8. [6] Lakhanpal SK, Glasier CM, James CA, Angtuaco EJ. MR and CT diagnosis of carotid pseudoaneurysm in children following surgical resection of craniopharyngioma. Pediatr Radiol 1995;25:249-51. [7] Wakhloo AK, Mandell J, Gounis MJ, et al. Stent-assisted reconstructive endovascular repair of cranial fusiform atherosclerotic and dissecting aneurysms—Long-term clinical and angiographic follow-up. Stroke 2008; in press.
Fusiform Dilatation of the Internal Carotid Artery After Craniopharyngioma Resection Italo Linfante, MD*, Celeste Tucci, MD†, and Vincenzo Andreone, MD†
Clinical History Five years after the successful resection of a craniopharyngioma, a 20-year-old woman presented to the emergency room with severe headache, nausea, and vomiting. Computed tomography of the head and a lumbar puncture were not suggestive of subarachnoid hemorrhage. Magnetic resonance imaging of the head with gadolinium did not reveal tumor recurrence. However, magnetic resonance angiography revealed a fusiform dilatation of the right internal carotid artery. Cerebral angiography confirmed the lesion (Fig 1), and excluded the presence of other aneurysms or vascular malformations. The patient’s headache was diagnosed as a migraine and she was successfully treated with medication. At 6-month followup, magnetic resonance angiography and catheter angiography revealed no changes in the fusiform dilatation of the right internal carotid artery. At 1-year follow-up, the patient was asymptomatic. Magnetic resonance angiography was also unchanged. Discussion Fusiform dilatation of the right internal carotid artery is a rare vascular complication after surgery for craniophar-
From the *Section of Neuroimaging and Intervention, Department of Radiology and Department of Neurology, University of Massachusetts, Worcester, Massachusetts, and †Department of Neurology, Cardarelli Hospital, Naples, Italy.
© 2008 by Elsevier Inc. All rights reserved. doi:10.1016/j.pediatrneurol.2008.04.001 ● 0887-8994/08/$—see front matter
Figure 1. Digital subtraction angiography: anteroposterior and lateral views of a right internal carotid artery injection. The arrow indicates a fusiform dilatation of the supraclinoid portion of the right internal carotid artery. The lesion seems to extend from the origin of the posterior communicating artery to the bifurcation of the right internal carotid artery, and into the middle cerebral and anterior cerebral artery.
yngioma [1-5]. To date, only 18 patients have been reported in the literature [1-5]. An additional 4 patients with a fusiform dilatation of the internal carotid artery were described after resection of other types of suprasellar tumors (3 astrocytomas, and 1 hamartoma) [3,5]. The mean age of patients at time of the surgery was 10 years
Communications should be addressed to: Dr. Linfante; Section of Neuroimaging and Intervention, Department of Radiology; University of Massachusetts; Memorial University Campus; 55 Lake Avenue North; Worcester, MA 01655. E-mail: [email protected] Received February 29, 2008; accepted April 16, 2008.
Linfante et al: ICA Aneurysm After Craniopharyngioma 139
(range, 3-24 years). Fusiform dilatation of the internal carotid artery occurs predominantly in children. In 20 of 22 patients, the fusiform dilatation of the internal carotid artery was diagnosed within 18 months after surgery (range, 4-17 months). In only 2 patients fusiform dilatation of the internal carotid artery was first noted several years after surgery (at 8 and 11 years) [5]. In all patients, the fusiform dilatation of the internal carotid artery was ipsilateral to the surgical approach, except for one patient, who exhibited bilateral fusiform dilatation of the internal carotid artery [5]. The fusiform dilatation of the internal carotid artery was asymptomatic in the majority of patients. In one patient, the progressive aneurysmal dilatation caused visual impairment secondary to opticnerve compression [6], and 2 patients reported severe headaches [4,5]. With regard to the pathogenesis of the lesion, subclinical injury of the internal carotid artery adventitia during surgical manipulation [1,5] and injury of the sympathetic plexus around the internal carotid artery have been hypothesized [3,4]. With regard to outcomes, fusiform aneurysms are generally associated with high morbidity and mortality. However, most cases of fusiform dilatation after craniopharyngioma resection were reported as benign [1,3,5]. Delayed enlargement in sequential studies was evident in 4 patients. However, 2 of these patients were previously treated with radiotherapy [2,3]. Conservative versus aggressive treatment of a fusiform dilatation of the internal carotid artery after craniopharyngioma resection is an object of debate. Microsurgery with fenestrated microclips was reported
140
PEDIATRIC NEUROLOGY
Vol. 39 No. 2
as a treatment for fusiform aneurysms and for fusiform dilatations of the internal carotid artery occurring after craniopharyngioma resection [1,2,4-6]. Endovascular treatment with stent remodeling for fusiform aneurysms has also been reported [7]. However, because of its rarity, the best treatment for this condition remains unknown. In addition, treatment may not be needed in accordance with the benign nature of the lesion. In conclusion, more data are required for a better understanding of the pathophysiology and long-term prognosis of fusiform dilatations of the internal carotid artery after craniopharyngioma resection. References [1] Sutton L, Gusnard D, Bruce DA, Fried A, Packer RJ, Zimmerman RA. Fusiform dilatations of the carotid artery following radical surgery of childhood craniopharyngioma. J Neurosurg 1991;74:695-700. [2] Liu SS, Zabramski JM, Spetzler R. Fusiform aneurysm after surgery for craniopharyngioma. J Neurosurg 1991;75:670-1. [3] Bendszus M, Sorensen N, Hofmann E, Röll E, Solymosi L. Fusiform dilatations of the internal carotid artery following surgery for pediatric suprasellar tumors. Pediatr Neurosurg 1998;29:304-8. [4] Tirakotai W, Sure U, Benes L, et al. Successful management of a symptomatic fusiform dilatation of the internal carotid artery following surgery of childhood craniopharyngioma. Childs Nerv Syst 2002;18:717-21. [5] Sutton L. Vascular complications of surgery for craniopharyngioma and hypothalamic gliomas. Pediatr Neurosurg 1994;21:124-8. [6] Lakhanpal SK, Glasier CM, James CA, Angtuaco EJ. MR and CT diagnosis of carotid pseudoaneurysm in children following surgical resection of craniopharyngioma. Pediatr Radiol 1995;25:249-51. [7] Wakhloo AK, Mandell J, Gounis MJ, et al. Stent-assisted reconstructive endovascular repair of cranial fusiform atherosclerotic and dissecting aneurysms—Long-term clinical and angiographic follow-up. Stroke 2008; in press.