Answer for BIR CoW 08 July 2018
Giant left ICA aneurysm
Findings
• 2.5 x 2.9 cm giant saccular aneurysm noted arising from left internal carotid artery cavernous segment with neck size 4 mm and fundus facing posterosuperiorly.
Discussion
• Giant intracranial aneurysms are those that ex-ceed 25 mm in greatest dimension o Giant aneurysms typically manifest during the fifth to seventh decades of life and have a female predominance. Advanced age, hypertension, tobacco use, arte¬riovenous malformations, connective tissue dis¬orders (including Ehlers-Danlos syndrome type IV, Marfan syndrome, and autosomal dominant polycystic renal disease), and vasculitis are factors associated with aneurysm formation and rupture. • Most common is saccular type when compared to fusiform • Saccular aneurysms are berry-like outpouch¬ings that tend to occur at arterial bifurcations and favor the anterior circulation. These are thought to arise from hemodynamic stress and repeated endothelial damage accrued from tur-bulent blood flow o Acute aneu¬rysm rupture generally manifests as abrupt onset of clinical signs and symptoms such as “the worst headache of my life” with or without meningis¬mus, loss of consciousness, nausea and vomiting, and focal neurologic deficits. • Cavernous segment aneurysm rupture causes carotico-cavernous fistula • Unruptured giant aneurysms may have a more insidious onset, usually related to mass effect, and may mimic a slowly growing tumor. • Symptoms are dependent on aneurysm location : visual disturbance, headache, cranial nerve palsies, seizures or Transient ischemic attacks Risk of rupture may increase proportionately with aneurysm size. • Over 50% of giant aneurysms will rupture. Mortality rates in patients with untreated gi¬ant aneurysms : 68% and 80% at 2 and 5 years, respectively • Optimal therapy requires careful consideration of aneurysm size, aneurysm shape (saccular vs fusiform), neck dimensions, relation to adjacent neural structures and branch artery origins, and the presence of collateral cir¬culation or intraluminal thrombus • Endovascular therapy (including embolization with or without stent or balloon assistance) may be used alone or in combination with surgical techniques • Flow diverter is an endovascular prosthesis used to divert blood and determine progressive thrombus of sac. Surgical techniques include direct clipping, par¬ent vessel occlusion, aneurysm trapping, aneu¬rysmectomy, and aneurysmorrhaph Rupture of giant intracranial aneurysms is a catastrophic event, and most patients who survive have severe, permanent neurologic dysfunction
Reference
Rashi I. Mehta, MD et al; Best Cases from the AFIP Giant Intracranial Aneurysm. RSNA 2010; 30:1133–1138
Findings
• 2.5 x 2.9 cm giant saccular aneurysm noted arising from left internal carotid artery cavernous segment with neck size 4 mm and fundus facing posterosuperiorly.
Discussion
• Giant intracranial aneurysms are those that ex-ceed 25 mm in greatest dimension o Giant aneurysms typically manifest during the fifth to seventh decades of life and have a female predominance. Advanced age, hypertension, tobacco use, arte¬riovenous malformations, connective tissue dis¬orders (including Ehlers-Danlos syndrome type IV, Marfan syndrome, and autosomal dominant polycystic renal disease), and vasculitis are factors associated with aneurysm formation and rupture. • Most common is saccular type when compared to fusiform • Saccular aneurysms are berry-like outpouch¬ings that tend to occur at arterial bifurcations and favor the anterior circulation. These are thought to arise from hemodynamic stress and repeated endothelial damage accrued from tur-bulent blood flow o Acute aneu¬rysm rupture generally manifests as abrupt onset of clinical signs and symptoms such as “the worst headache of my life” with or without meningis¬mus, loss of consciousness, nausea and vomiting, and focal neurologic deficits. • Cavernous segment aneurysm rupture causes carotico-cavernous fistula • Unruptured giant aneurysms may have a more insidious onset, usually related to mass effect, and may mimic a slowly growing tumor. • Symptoms are dependent on aneurysm location : visual disturbance, headache, cranial nerve palsies, seizures or Transient ischemic attacks Risk of rupture may increase proportionately with aneurysm size. • Over 50% of giant aneurysms will rupture. Mortality rates in patients with untreated gi¬ant aneurysms : 68% and 80% at 2 and 5 years, respectively • Optimal therapy requires careful consideration of aneurysm size, aneurysm shape (saccular vs fusiform), neck dimensions, relation to adjacent neural structures and branch artery origins, and the presence of collateral cir¬culation or intraluminal thrombus • Endovascular therapy (including embolization with or without stent or balloon assistance) may be used alone or in combination with surgical techniques • Flow diverter is an endovascular prosthesis used to divert blood and determine progressive thrombus of sac. Surgical techniques include direct clipping, par¬ent vessel occlusion, aneurysm trapping, aneu¬rysmectomy, and aneurysmorrhaph Rupture of giant intracranial aneurysms is a catastrophic event, and most patients who survive have severe, permanent neurologic dysfunction
Reference
Rashi I. Mehta, MD et al; Best Cases from the AFIP Giant Intracranial Aneurysm. RSNA 2010; 30:1133–1138
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!