Letter to the Editor
Transient ischaemic attack secondary to extracranial carotid artery aneurysm
Accidente isquémico transitorio secundario a aneurisma carotídeo extracraneal
E. Bravo Ruiz
, M.J. Suarez Tornín, A. Salazar Agorria, R. Vega Manrique
Corresponding author
Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, Vizcaya, Spain
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Bravo Ruiz, M.J. Suarez Tornín, A. Salazar Agorria, R. Vega Manrique" "autores" => array:4 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Bravo Ruiz" "email" => array:1 [ 0 => "esther.bravoruiz@osakidetza.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.J." "apellidos" => "Suarez Tornín" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Salazar Agorria" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Vega Manrique" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, Vizcaya, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Accidente isquémico transitorio secundario a aneurisma carotídeo extracraneal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 682 "Ancho" => 1800 "Tamanyo" => 171804 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT-angiography of SAT: patent saccular aneurysm in the distal portion of both ICs (19<span class="elsevierStyleHsp" style=""></span>mm on the RIC and 16<span class="elsevierStyleHsp" style=""></span>mm on the LIC).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Extracranial carotid artery aneurysms present a low incidence (1.3%), making it more difficult to study their aetiology, natural course, and response to treatment.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 32-year-old woman, a former smoker taking oral contraceptives. The patient presented a 15-minute self-limited episode of dysarthria and loss of strength in the right arm, followed by spontaneous full recovery. Results from the neurological examination were normal and no alterations were found in the blood test, electrocardiogram, chest radiography, or head CT. Clinical signs were compatible with transient ischaemic attack (TIA) in the left hemisphere. We requested tumour markers, serology tests, immunology tests, and a hypercoagulation study, which only revealed a homozygous <span class="elsevierStyleItalic">MTHFR</span> C667T mutation. We performed a transthoracic echocardiogram that showed no alterations. An echo Doppler study of the supra-aortic trunks (SAT) and a CT-angiography of SAT, circle of Willis (CW) and thoracoabdominal aorta revealed a patent saccular aneurysm in the distal cervical portion of both internal carotid arteries (IC), with a maximum diameter of 19<span class="elsevierStyleHsp" style=""></span>mm on the RIC and 16<span class="elsevierStyleHsp" style=""></span>mm on the LIC (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). After evaluating the case and ruling out surgical intervention because carotid artery aneurysms were inaccessible, we decided to perform endoluminal repair. Firstly, the symptomatic aneurysm on the LIC was repaired by placing 3 intraaneurysmal Matrix<span class="elsevierStyleSup">®</span> coils and a Silk<span class="elsevierStyleSup">®</span> stent (4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mm). Total thrombosis of the aneurysm, adequate permeability of the distal portion of the LIC and intracranial circulation were achieved (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Secondly, the asymptomatic aneurysm on the RIC was repaired by placing 3 intraaneurysmal GDC<span class="elsevierStyleSup">®</span> coils and a Silk<span class="elsevierStyleSup">®</span> stent (4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mm). Total thrombosis of the aneurysm, adequate permeability of the distal portion of DIC and intracranial circulation were achieved (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The patient was asymptomatic upon discharge and treated with dual anti-platelet therapy for 2 months, followed by single anti-platelet therapy to be continued for indefinitely. After 2 years of follow-up, she remains asymptomatic and the results of the endoluminal repair appear to be good.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Extracranial carotid artery aneurysms are usually located in the carotid bifurcation, followed by the IC and the external carotid artery as the next most frequent locations.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4</span></a> As in our case and according to some series, they may be bilateral, and/or associated with aneurysms in other locations.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> They may be fusiform or saccular in shape<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and their aetiologies vary.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a> Their main cause in the past was infection, but it is currently atherosclerosis (55%), followed by fibromuscular dysplasia of the arteries, trauma, dissection, and surgical procedures. Other less frequent causes are cystic medial necrosis, Marfan syndrome, Takayasu arteritis and idiopathic medial aortopathy.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Up to 60% of extracranial carotid artery aneurysms are symptomatic and their clinical manifestations vary according to their location, size, and aetiology. Patients may present symptoms compatible with TIA or stroke (40-45%)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> as in our case, retro-orbital compression, pulsating headache, dysphagia, relapsing facial pain, deafness, hoarseness, tinnitus, Horner syndrome, and Raeder paratrigeminal syndrome. Physical examination usually reveals a pulsating mass on the neck or pharynx, often painful, and associated in some cases with deficits and/or focal neurological signs.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Differential diagnosis should examine carotid artery kinking or elongation, carotid body tumour, adenopathies, peritonsillar abscess, branchial cleft cyst, and cystic hygroma.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Echo Doppler and especially CT-angiography or MRI-angiography of SAT and CW are necessary to determine the diagnosis, but today's gold standard for assessing anatomical details and choosing the optimal treatment is arteriography of SAT and CW.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Treatment indications depend on the aneurysm's clinical manifestations, size, location, and aetiology, as well as the patient's surgical risk.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3,5,6</span></a> The aim of treatment is to prevent severe neurological complications and associated secondary mortality.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5</span></a> Extracranial carotid artery aneurysms show a mortality rate of 71% due to thrombosis, embolism, or rupture. In patients undergoing surgical or endoluminal repair, this rate decreases to 30%.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Today's treatment alternatives are surgical procedures involving aneurysm exclusion and arterial suture, or bypass graft (prosthetic or autologous). Techniques are associated with neurological morbidity (peripheral and central) ranging between 6% and 20%, depending on the series, and a mortality rate of about 2%.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a> Another alternative is endoluminal treatment with aneurysm embolisation and placement of endoprosthesis; this is useful when the aneurysms are surgically inaccessible, as in our case, or in patients with a high surgical risk. This last alternative is on the rise, but no randomised studies that analyse long-term results are available at present.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> To conclude, we highlight that while this entity is infrequent, it should be considered among the possible causes of TIA or stroke.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bravo Ruiz E, Suarez Tornín MJ, Salazar Agorria A, Vega Manrique R. Accidente isquémico transitorio secundario a aneurisma carotídeo extracraneal. Neurología. 2014;29:505-507.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 682 "Ancho" => 1800 "Tamanyo" => 171804 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT-angiography of SAT: patent saccular aneurysm in the distal portion of both ICs (19<span class="elsevierStyleHsp" style=""></span>mm on the RIC and 16<span class="elsevierStyleHsp" style=""></span>mm on the LIC).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 682 "Ancho" => 1300 "Tamanyo" => 137496 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Embolisation of aneurysm on the RIC and LIC.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Rutherford" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:6 [ "edicion" => "6.s ed." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 17 | 6 | 23 |
| 2024 September | 17 | 7 | 24 |
| 2024 August | 19 | 9 | 28 |
| 2024 July | 13 | 3 | 16 |
| 2024 June | 16 | 1 | 17 |
| 2024 May | 10 | 4 | 14 |
| 2024 April | 10 | 5 | 15 |
| 2024 March | 22 | 2 | 24 |
| 2024 February | 11 | 6 | 17 |
| 2024 January | 19 | 5 | 24 |
| 2023 December | 17 | 14 | 31 |
| 2023 November | 27 | 10 | 37 |
| 2023 October | 43 | 15 | 58 |
| 2023 September | 13 | 2 | 15 |
| 2023 August | 13 | 12 | 25 |
| 2023 July | 20 | 8 | 28 |
| 2023 June | 29 | 1 | 30 |
| 2023 May | 42 | 5 | 47 |
| 2023 April | 34 | 1 | 35 |
| 2023 March | 14 | 2 | 16 |
| 2023 February | 18 | 7 | 25 |
| 2023 January | 16 | 13 | 29 |
| 2022 December | 27 | 6 | 33 |
| 2022 November | 13 | 12 | 25 |
| 2022 October | 16 | 10 | 26 |
| 2022 September | 21 | 8 | 29 |
| 2022 August | 31 | 9 | 40 |
| 2022 July | 12 | 6 | 18 |
| 2022 June | 15 | 6 | 21 |
| 2022 May | 13 | 6 | 19 |
| 2022 April | 16 | 9 | 25 |
| 2022 March | 18 | 7 | 25 |
| 2022 February | 7 | 5 | 12 |
| 2022 January | 13 | 7 | 20 |
| 2021 December | 25 | 12 | 37 |
| 2021 November | 23 | 5 | 28 |
| 2021 October | 25 | 8 | 33 |
| 2021 September | 13 | 11 | 24 |
| 2021 August | 11 | 6 | 17 |
| 2021 July | 7 | 5 | 12 |
| 2021 June | 16 | 10 | 26 |
| 2021 May | 15 | 7 | 22 |
| 2021 April | 24 | 10 | 34 |
| 2021 March | 22 | 5 | 27 |
| 2021 February | 11 | 10 | 21 |
| 2021 January | 15 | 8 | 23 |
| 2020 December | 13 | 8 | 21 |
| 2020 November | 18 | 2 | 20 |
| 2020 October | 11 | 6 | 17 |
| 2020 September | 14 | 5 | 19 |
| 2020 August | 13 | 3 | 16 |
| 2020 July | 12 | 7 | 19 |
| 2020 June | 12 | 8 | 20 |
| 2020 May | 14 | 13 | 27 |
| 2020 April | 11 | 4 | 15 |
| 2020 March | 17 | 4 | 21 |
| 2020 February | 18 | 10 | 28 |
| 2020 January | 25 | 9 | 34 |
| 2019 December | 9 | 6 | 15 |
| 2019 November | 11 | 12 | 23 |
| 2019 October | 11 | 4 | 15 |
| 2019 September | 24 | 4 | 28 |
| 2019 August | 7 | 4 | 11 |
| 2019 July | 21 | 9 | 30 |
| 2019 June | 24 | 15 | 39 |
| 2019 May | 81 | 30 | 111 |
| 2019 April | 30 | 16 | 46 |
| 2019 March | 14 | 8 | 22 |
| 2019 February | 16 | 6 | 22 |
| 2019 January | 10 | 5 | 15 |
| 2018 December | 10 | 3 | 13 |
| 2018 November | 18 | 4 | 22 |
| 2018 October | 15 | 12 | 27 |
| 2018 September | 11 | 3 | 14 |
| 2018 August | 6 | 1 | 7 |
| 2018 July | 5 | 0 | 5 |
| 2018 June | 2 | 1 | 3 |
| 2018 May | 5 | 4 | 9 |
| 2018 April | 3 | 1 | 4 |
| 2018 March | 4 | 3 | 7 |
| 2018 February | 0 | 5 | 5 |
| 2018 January | 7 | 4 | 11 |
| 2017 December | 3 | 5 | 8 |
| 2017 November | 9 | 1 | 10 |
| 2017 October | 9 | 4 | 13 |
| 2017 September | 14 | 5 | 19 |
| 2017 August | 13 | 4 | 17 |
| 2017 July | 5 | 1 | 6 |
| 2017 June | 15 | 27 | 42 |
| 2017 May | 17 | 7 | 24 |
| 2017 April | 5 | 5 | 10 |
| 2017 March | 11 | 19 | 30 |
| 2017 February | 8 | 3 | 11 |
| 2017 January | 7 | 3 | 10 |
| 2016 December | 18 | 7 | 25 |
| 2016 November | 18 | 2 | 20 |
| 2016 October | 55 | 7 | 62 |
| 2016 September | 92 | 10 | 102 |
| 2016 August | 37 | 7 | 44 |
| 2016 July | 22 | 2 | 24 |
| 2016 June | 18 | 16 | 34 |
| 2016 May | 22 | 6 | 28 |
| 2016 April | 25 | 7 | 32 |
| 2016 March | 39 | 17 | 56 |
| 2016 February | 23 | 10 | 33 |
| 2016 January | 17 | 3 | 20 |
| 2015 December | 12 | 7 | 19 |
| 2015 November | 25 | 2 | 27 |
| 2015 October | 26 | 7 | 33 |
| 2015 September | 24 | 5 | 29 |
| 2015 August | 15 | 4 | 19 |
| 2015 July | 9 | 4 | 13 |
| 2015 June | 6 | 1 | 7 |
| 2015 May | 28 | 6 | 34 |
| 2015 April | 24 | 8 | 32 |
| 2015 March | 31 | 5 | 36 |
| 2015 February | 30 | 9 | 39 |
| 2015 January | 38 | 12 | 50 |
| 2014 December | 43 | 19 | 62 |
| 2014 November | 40 | 14 | 54 |
| 2014 October | 91 | 37 | 128 |
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