Massive Epistaxis Revealing a Post-Traumatic Aneurysm of the Internal Carotid Artery: A Clinical Case and Review of the Literature

Internal carotid artery (ICA) aneurysms are an unusual but serious cause of epistaxis. This epistaxis is massive and sometimes uncontrollable threatening the vital prognosis of patients. We report the case of a 16-year-old adolescent received in emergency with severe bilateral epistaxis, asthenia and grade-3 left exophthalmos. In his history, the subject had been the victim of an assault six months before consultation. He had received blows on the cephalic extremity with light but repeated epistaxis. The treatment consisted to blood products transfusion and local compression by sterile gazes. An ICA aneurysm in sphenoid sinus has been confirmed in a craniofacial CT scan coupled to vascular opacification. Although the ICA has a variable course in contact with the sphenoid sinus, massive epistaxis would be the consequence of a pronounced dehiscence of the ICA in the sphenoid sinus, particularly in a traumatic context. In front of this type of epistaxis in our context, general practitioners must be able to suspect a ruptured ICA aneurysm in the presence of exophthalmos and a notion of old or recent cranio-encephalic injury. Additionally, due to the high morbidity and mortality of this condition, a monitoring algorithm is necessary for patients with head trauma to facilitate early detection.

Metformin effect on internal carotid artery blood flow assessed by area under the curve of carotid artery Doppler in women with polycystic ovarian syndrome

BACKGROUND Insulin resistance(IR)was reported in most polycystic ovarian syndrome(PCOS)cases.Metformin,a biguanide drug,successfully reduced IR.Homeostatic Model Assessment for IR(HOMA-IR)and Doppler parameters assessed metformin's effectiveness.AIM To verify whether the area under the curve of the internal carotid artery(AUC-ICA)Doppler wave can be a useful marker for assessing IR among PCOS cases who presented with menstrual irregularity and were treated with metformin over 6 mo.METHODS An observational,cross-sectional study recruited 54 eligible PCOS women;the anthropometrics were as follows:age,body mass index(BMI),menstrual cycle days,biochemical serum cholesterol,low and high-density lipoprotein,sex hormone-binding globulin,fasting blood glucose,and HOMA-IR,hormonal testosterone,luteinizing hormone over follicle-stimulating hormone ratio,and ultrasonic pulsatility index(PI)and resistance index(RI),carotid artery intima-media thickness(CIMT)and(AUC-ICA)parameters were initially recorded and repeated 3 mo and 6 mo later with metformin tab 500 mg;three times/day for 6 mo.In addition,AUC-ICA was assessed by taking repeated systolic and diastolic wave height measurements.RESULTS Metformin caused a progressive reduction in BMI,menstrual cycle days,biochemical hormonal,and Doppler parameters(CIMT,PI,RI,and AUC-ICA).AUC-ICA correlated strongly to all PCOS parameters.AUC-ICA correlated inversely with treatment time(r=-0.98,P<0.001)and positively with HOMA-IR(r=0.98,P<0.0001).Via the best subset regression model,the AUC-ICA had the highest predictive value for HOMA-IR.CONCLUSION AUC-ICA preceded PI,RI,and CIMT with a strong,meaningful correlation to all PCOS parameters,making it a reliable marker for the assessment of IR,especially during metformin therapy.Further studies are recommended to promote the application in practice.

Efficacy of Willis covered stent of intracranial pseudoaneurysms in the internal carotid artery: A systematic review and meta-analysis

Objective:To evaluate the efficacy of a novel coated stent in the treatment of intracranial pseudoaneurysm.Methods:MEDLINE,EMBASE,and PubMed databases were searched for literature published between 1990 and April 2022 according to PRISMA guidelines.All studies with≥10 patients reporting successful implantation of Willis covered stent,therapeutic effect,complications,and postoperative follow-up were included.The combined incidence and corresponding 95%confidence intervals were assessed using a generalized linear mixed method and random effects model.Results:Five studies(116 patients with pseudoaneurysms)were included.The experimental groups in the selected studies showed a combined technical success rate of 81.03%(OR=18.31,95%CI=9.39-35.69,I^(2)=79%,P<0.001).Clinical follow-up showed that the complete cure rate was as high as 94.4%after the follow-up(OR=106.81,95%CI=39.08-291.88,I^(2)=0%,P=0.71).Conclusions:Willis covered stent is feasible,safe,and effective in the treatment of intracranial pseudoaneurysm.

Endovascular Therapy of Internal Carotid Artery Tandem Occlusions and Literature Review

Acute large vessel occlusion is a common cause of acute ischemic stroke (AIS), with high rates of disability and lethality. The incidence of tandem occlusion of the internal carotid artery accounts for about 20% of patients with large vessel occlusion of the anterior circulation in acute ischemic stroke. The low rate of recanalization by intravenous thrombolysis in AIS due to internal carotid artery tandem occlusion, the poor establishment of collateral circulation within a short time, and the complex pathogenesis often suggest a poor prognosis for patients. Mechanical thrombectomy (MT) is beneficial for the opening of intracranial large vessel occlusion with internal carotid artery tandem occlusion, there are many problems regarding the emergency management of carotid artery occlusion or stenosis after mechanical thrombectomy, and there are currently no standardized treatment recommendations;The sequential approach to the management of carotid tandem occlusion, the timing of carotid stenting, and the use of antiplatelet agents remain controversial. The current state of research on carotid tandem occlusion is analyzed in the literature to promote clinical understanding of endovascular treatment for patients with acute ischemic stroke due to carotid tandem occlusion.

Carotid-cavernous fistula following mechanical thrombectomy of the tortuous internal carotid artery:A case report

BACKGROUND A carotid-cavernous fistula(CCF)is an abnormal connection between the internal carotid artery(ICA)and the cavernous sinus.Although direct CCFs typically result from trauma or as an iatrogenic complication of neuroendovascular procedures,they can occur as surgery-related complications after mechanical thrombectomy(MT).With the widespread use of MT in patients with acute ischemic stroke complicated with large vessel occlusion,it is important to document CCF following MT and how to avoid them.In this study,we present a case of a patient who developed a CCF following MT and describe in detail the characteristics of ICA tortuosity in this case.CASE SUMMARY A 60-year-old woman experienced weakness in the left upper and lower limbs as well as difficulty speaking for 4 h.The neurological examination revealed left central facial paralysis and left hemiplegia,with a National Institutes of Health Stroke Scale score of 9.Head magnetic resonance imaging revealed an acute cerebral infarction in the right basal ganglia and radial crown.Magnetic resonance angiography demonstrated an occlusion of the right ICA and middle cerebral artery.Digital subtraction angiography demonstrated distal occlusion of the cervical segment of the right ICA.We performed suction combined with stent thrombectomy.Then,postoperative angiography was performed,which showed a right CCF.One month later,CCF embolization was performed,and the patient’s clinical symptoms have significantly improved 5 mo after the operation.CONCLUSION Although a CCF is a rare complication after MT,it should be considered.Understanding the tortuosity of the internal carotid-cavernous sinus may help predict the complexity of MT and avoid this complication.

Fatal Cataclysmic Otorrhagia and Epistaxis Due to a Ruptured Aneurysm of the Petrous Internal Carotid Artery: A Case Report

Background: Aneurysms of the internal carotid artery within the petrous temporal bone are extremely rare;their true incidence is unknown. The exact cause is unclear: they may be congenital or result from trauma, infection, or radiation. Aim: We report a case of massive otorrhagia and epistaxis from a ruptured aneurysm of the petrous internal carotid artery. Case Presentation: A 34-year-old man presented to our department for the first time with repeated left otorrhagia ongoing for 5 years, left sided pulsatile tinnitus and left conductive hearing loss. In his history, we noted a right hemi-corporeal deficit of sudden onset one month ago and the head-CT showed a left frontoparietal subarachnoid hemorrhage without any visualised vascular malformation. Otomicroscopy showed a pulsatile mass visible at the posterior part of the hypotympanum. There was a right-sided hemiparesis estimated at 2/5 with no disorder of the sensitivity. After hemodynamic stabilization, the patient was discharged from the hospital and treatment was scheduled in interventional radiology and neurosurgery unit. Unfortunately the patient presented at home with a cataclysmic hemorrhage by massive otorrhagia and epistaxis and arrived dead at the emergency unit. Conclusion: The treatment of a petrous carotid aneurysm must be carried out quickly considering the risk of rupture leading to a cataclysmic hemorrhage that can be rapidly life threatening.

Imageology of internal carotid artery siphon in nonarteritic anterior ischaemic optic neuropathy

AIM:To evaluate whether narrowing of internal carotid artery siphon(ICAS)may increase the risk of developing non-arteritic anterior ischaemic optic neuropathy(NAION).METHODS:Totally 30 consecutive patients who had unilateral NAION and 30 gender-matched control subjects were recruited in the present study.The diameter of ICAS of all the participants were measured using head-and-neck computed tomographic angiography(CTA).Color doppler flow imaging(CDI)was used to measure the haemodynamics parameters of ICAS and short posterior ciliary arteries(SPCAs)in all subjects.Comparison of parameters between the NAION patients and controls as well as between the two sides within the patients were performed.The correlation between the diameter of ICAS and NAION was analyzed.RESULTS:A comparison of parameters between the affected side of the NAION patients and the controls,including the diameter of ICAS,the resistance index(RI)of ICAS,the blood flow velocities of SPCAs and RI of SPCAs,showed significantly difference(P<0.01),while there was no significant difference in terms of the mean blood flow velocity(Vm)of ICAS;Similar results were found while comparing all the measurements of the affected and unaffected side of patients(P for RI of SPCAs<0.05).No marked difference was detected in nearly all parameters except for RI of ICAS and SPCAs between the unaffected side of the NAION patients and the controls(P<0.05).The diameter of ICAS were significantly positive correlated with both peak systolic velocity(PSV)of SPCAs and end diastolic velocity(EDV)of SPCAs in patients with NAION(r=0.514,P<0.01 and r=0.418,P<0.05,respectively).CONCLUSION:Narrowing of ICAS may increase the risk of developing NAION.

Imaging characteristics and treatment strategies for carotid artery occlusion caused by skull base fracture:Three case reports

BACKGROUND Traumatic internal carotid artery(ICA)occlusion is a rare complication of skull base fractures,characterized by high mortality and disability rates,and poor prognosis.Therefore,timely discovery and correct management are crucial for saving the lives of such patients and improving their prognosis.This article retrospectively analyzed the imaging and clinical data of three patients,to explore the imaging characteristics and treatment strategies for carotid artery occlusion,combined with severe skull base fractures.CASE SUMMARY This case included three patients,all male,aged 21,63,and 16 years.They underwent plain film skull computed tomography(CT)examination at the onset of their illnesses,which revealed fractures at the bases of their skulls.Ultimately,these cases were definitively diagnosed through CT angiography(CTA)examinations.The first patient did not receive surgical treatment,only anticoagulation therapy,and recovered smoothly with no residual limb dysfunction(Case 1).The other two patients both developed intracranial hypertension and underwent decompressive craniectomy.One of these patients had high intracranial pressure and significant brain swelling postoperatively,leading the family to choose to take him home(Case 2).The other patient also underwent decompressive craniectomy and recovered well postoperatively with only mild limb motor dysfunction(Case 3).We retrieved literature from PubMed on skull base fractures causing ICA occlusion to determine the imaging characteristics and treatment strategies for this type of disease.CONCLUSION For patients with cranial trauma combined with skull base fractures,it is essential to complete a CTA examination as soon as possible,to screen for blunt cerebrovascular injury.

Idiopathic steno-occlusive disease with bilateral internal carotid artery occlusion:A Case Report

BACKGROUND Moyamoya disease(MMD)is a rare cause of acute stroke and transient ischemic attacks in children.We described clinical,diagnostic features and follow-ups of a young child with acute stroke.CASE SUMMARY We report a 4-year-old girl with left hemiparesis after an acute ischemic stroke.Her history was also significant for repeated left or right focal motor seizures,generalized tonic-clonic convulsions and transient ischemic attacks.Her magnetic resonance imaging and computed tomography(CT)of the brain and magnetic resonance angiography,CT angiography and venography on the cerebral vessels revealed evidence of bilateral fronto-parietal ischemic infarctions,occlusion of the right and left internal carotid arteries started at its bifurcation and non-visualization of right and left anterior and middle cerebral arteries.There was evidence of progression in angiography manifested as development of collaterals from the basal perforating vessels,increase in the extent of large intracranial arterial stenosis/occlusion and extensive collateral circulation with predominance from the posterior circulation.Physical and neurological evaluation and comprehensive laboratory investigations excluded an obvious comorbid disease or risk factor for the child’s condition.The diagnosis of MMD was highly suggested as a cause of the child’s steno-occlusive condition.She was treated symptomatically with levetiracetam,an antiepileptic medication.Aspirin was prescribed for secondary prevention.Her clinical manifestations were improved during the three years of follow-up.Revascularization surgery was postponed.CONCLUSION Up to our knowledge,this is the first report for MMD in a child in our country.The clinical improvement and the stabilization of the child’s condition over the 3 years of follow-up could be attributed to the rapid and extensive recruitment of collaterals and absence of risk factors or comorbidities.Revascularization surgery is highly recommended.

Initial clinical experience with Xpert-Pro peripheral self-expanding stent system for internal carotid artery dissection:Two case reports

Background:The standard treatment for internal carotid artery(ICA)dissection is obscure.Current therapeutic strategies include the use of antiplatelet drugs,anticoagulant drugs,intravenous thrombolysis,and endovascular treatment.Endovascular treatment is important in acute internal carotid artery dissection.This study reports two acute internal carotid artery dissection cases that were treated successfully using the Xpert-Pro peripheral selfexpanding stent system.Case summary:The first case was of a 38-year-old male patient with transient speechlessness and paralysis of the right limb in July 2021.Cervical computed tomographic angiography(CTA)showed ICA occlusion on the left side.Digital subtraction angiography(DSA)showed severe stenosis of the C1 segment of the left internal carotid artery with intermural hematoma.The patient subsequently underwent Xpert-Pro peripheral self-expanding stent implantation,and his condition stabilized.The second case was of a 56-year-old male patient with speechlessness and paralysis of the right limb.Cervical CTA showed a dissected left ICA,and DSA showed an occluded left ICA and middle cerebral artery.The patient subsequently underwent stent implantation,and his condition stabilized.

Ocular manifestations of internal carotid artery dissection

Internal carotid artery dissection(ICAD) results from disruption of the intima of the arterial wall, and can lead to intrusion of blood into the arterial wall and form an intramural hematoma. The hematoma can compress the true lumen of the vessel, causing functional stenosis or occlusion. The classic triad signs of ICAD include pain in the ipsilateral neck, head and orbital regions; a(partial) Horner syndrome; and cerebral or retinal ischemia. However, not all ICAD patients present with this classic signs. In some cases, ocular manifestations are the initial(and sometimes the only) findings. We summarize the ocular manifestations associated with ICAD in 3 categories: visual symptoms, oculosympathetic palsy, and ocular motor nerve palsy.

Hybrid surgery for symptomatic chronic complete occlusion of the internal carotid artery: A case report

Currently,there are antiplatelet drugs,extracranial-intracranial(EC-IC)vascular bypass,carotid endarterectomy(CEA),endovascular intervention(EI),and other revascularization procedures for symptomatic chronic internal carotid artery occlusion(CICAO).In consulting the literature,we found that existing techniques for single treatments cannot achieve satisfactory results when there is a long segment occlusion with plaque attached to the intracranial segment and a short stump at the initial segment.We reported the case of a 50-year-old male patient with blurred vision,headache,and weakness in the right upper limb.After the exclusion of other neurological diseases,he was diagnosed with symptomatic CICAO;the occlusion segment was long and the stump was too short.We performed a novel hybrid surgery for the patient—a carotid endarterectomy combined with internal carotid artery stenting.After 6 months of follow-up,computed tomography angiography(CTA)confirmed that the left internal carotid artery was unobstructed,and the symptoms were relieved.A brief review of the literature is presented in addition to this report.

Bilateral cerebral infarction in diabetic ketoacidosis and bilateral internal carotid artery occlusion:A case report and review of literature

BACKGROUND Diabetic ketoacidosis(DKA)is a serious complication of type 1 diabetes mellitus(T1DM).Very rarely does DKA lead to cerebral edema,and it is even rarer for it to result in cerebral infarction.Bilateral internal carotid artery occlusion(BICAO)is also rare and can cause fatal stroke.Moreover,case reports about acute cerebral infarction throughout both internal carotid arteries with simultaneous BICAO are very scarce.In this study,we present a patient with BICAO,T1DM,hypertension,and hyperlipidemia,who had a catastrophic bilateral cerebral infarction after a DKA episode.We briefly introduce BICAO and the mechanisms by which DKA results in cerebral infarction.CASE SUMMARY A 41-year-old woman presented with ischemic stroke that took place 3 mo prior over the left corona radiata,bilateral frontal lobe,and parietal lobe with right hemiplegia and Broca’s aphasia.She had a history of hypertension for 5 years,hyperlipidemia for 4 years,hyperthyroidism for 3 years,and T1DM for 31 years.The first brain magnetic resonance imaging not only revealed the aforementioned ischemic lesions but also bilateral internal carotid artery occlusion.She was admitted to our ward for rehabilitation due to prior stroke sequalae.DKA took place on hospital day 2.On hospital day 6,she had a new massive infarction over the bilateral anterior cerebral artery and middle cerebral artery territory.After weeks of aggressive treatment,she remained in a coma and on mechanical ventilation due to respiratory failure.After discussion with her family,compassionate extubation was performed on hospital day 29 and she died.CONCLUSION DKA can lead to cerebral infarction due to several mechanisms.In people with existing BICAO and several stroke risk factors such as hypertension, T1DM,hyperlipidemia, DKA has the potential to cause more serious ischemic strokes.

Endoleak management and postoperative surveillance following endovascular repair of internal carotid artery vascular diseases using Willis covered stent

Background:To report the clinical results and experiences of endoleak management and postoperative surveillance following endovascular repair of internal carotid artery vascular diseases(ICAVDs)using Willis covered stents.METHODS:Seventy-three patients with ICAVD who received Willis covered stent implantation between November 2013 and September 2018 were retrospectively reviewed.The clinical data of endoleak management and postoperative surveillance were analyzed.RESULTS:Seventy-three cases with ICAVD,including 57 aneurysms,11 carotid-cavernous sinus fistulas(CCF),and 5 surgical injuries,were all successfully installed with covered stents.Total isolation of ICAVDs was achieved in 59 patients(80.8%),and endoleaks were observed in 14 patients(19.2%).Of the 14 patients with endoleaks,12 had type I endoleaks and 2 had type II;13 had aneurysms and one had CCF.10 patients with type I endoleaks received balloon dilatation,and 7 of them underwent a second stent-graft implantation after then.One patient with type II endoleak received embolization of the branch artery,and another one received follow-up observation.Endoleaks resolved in 6 patients and were minimal in 5 patients after balloon dilatation or the second stent implantation.During the follow-up period,minor endoleaks spontaneously resolved in 4 patients and minimal endoleaks were still demonstrated in 4 patients without enlargement of residual lumen and rupture.CONCLUSIONS:Endoleaks are the major complication after endovascular repair of ICAVDs and represent one of the limitations of this procedure.Improving the understanding and management of endoleaks can be beneficial in the clinical setting,including the popularization and application of this technique.

Percutaneous cervical carotid artery access with stenting of the left internal carotid artery in an elderly patient

To describe the successful endovascular treatment in a nonagenarian with symptomatic internal carotid artery stenosis using direct carotid artery access. An independent 98 year-old man was admitted to our hospital for symptoms of progressive weakness with disorientation and dysphasia. Carotid Duplex ultrasonography was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery by velocities of 608/240 cm/sec. The patient refused surgical endarterectomy and thus he was referred for carotid artery stenting. Using the femoral artery approach and multiple catheter techniques, access to the common carotid artery could not be accomplished safely. The procedure was aborted and he was therefore brought back to the catheterization laboratory the following day for direct carotid access. Carotid artery stenting was accomplished by using of a 6F sheath percutaneously in the left common carotid, cerebral protection device (CPD) and a Nitinol stent. The patient was discharged the following day without complications. At 14 months follow-up the patient is functional and independent without recurrence of symptoms. Carotid artery stenting via direct access can be accomplished in patients when the femoral artery approach is anatomically prohibitive. In this case of advanced age and the patient’s refusal for surgery, direct carotid access was his only option.

Treatment of extracranial internal carotid artery dissecting aneurysm with SUPERA stent implantation:Two case reports

BACKGROUND There is no standard endovascular treatment for extracranial internal carotid artery dissecting aneurysms.In the past,stent-graft isolation and stent-assisted coil embolization were commonly used for wide-necked and fusiform aneurysms.Here,we present two cases of extracranial internal carotid artery dissecting aneurysms treated successfully using the SUPERA stent.CASE SUMMARY Case 1 was a 57-year-old male patient with sudden right limb weakness and vague speech and diagnosed with cerebral infarction in February 2019.Cervical computed tomographic angiography(CTA)revealed left internal carotid artery dissection with stenosis.CTA at 2 mo showed an eccentric wide-necked dissecting aneurysm(5 mm×5 mm×12 mm,10-mm neck)that was enlarged at 4 mo(7 mm×6 mm×12 mm,11-mm neck).The patient underwent SUPERA stent implantation.His condition was stable in July 2020.Case 2 was a 57-year-old man who suddenly felt dizzy and developed unsteady walking in November 2019.Cervical CTA suggested right internal carotid artery dissecting aneurysm(11 mm×9 mm×31 mm)complicated with severe lumen stenosis(95%).The patient underwent SUPERA stent implantation.The patient had no residual symptoms and was stable in December 2020.CONCLUSION SUPERA stent implantation might achieve good results in treating wide-necked or long fusiform internal carotid artery dissecting aneurysms.

Emergency treatment and anesthesia management of internal carotid artery injury during neurosurgery:Four case reports

BACKGROUND During skull base surgery,intraoperative internal carotid artery(ICA) injury is a catastrophic complication that can lead to fatal blood loss or secondary cerebral ischemia.Appropriate management of ICA injury plays a crucial role in the prognosis of patients.Neurosurgeons have reported multiple techniques and management strategies;however,the literature on managing this complication from the anesthesiologist’s perspective is limited,especially in the aspect of circulation management and airway management when patients need transit for further endovascular treatment.CASE SUMMARY We describe 4 cases of ICA injury during neurosurgery;there were 3 cases of pathologically proven pituitary adenoma and 1 case of cavernous sinus endothelial meningioma.After the onset of ICA injury,all four patients were immediately transferred for endovascular therapy under general anesthesia with vital signs monitored and mechanical ventilation.Three patients were transferred to the hybrid operating room,and one patient was transferred to the catheter operating room.Three patients underwent covered stent implantation,and one patient underwent embolization.All four patients experienced hypovolemic shock and received blood products infusion and vasoactive drugs to maintain stable circulation.After the neurosurgery,one patient was extubated and returned to the ward,and the other three were delayed tracheal extubation and returned to the intensive care unit.One patient died from serious neurological complications after 62 d in the hospital,but the other three showed good clinical outcomes.CONCLUSION ICA injury imposes a high risk of massive hemorrhage and subsequent infarction.Immediate treatment is critical and requires interdisciplinary collaboration among neurosurgeons,anesthesiologists,and interventional neuroradiologists.Effective hemostatic methods,stable hemodynamics sufficient to ensure perfusion of vital organs,airway safety during transit,rapid localization and implementation of appropriate measures to occlude the damaged vessel are strong guarantees of patient safety.

Acute onset of massive epistaxis due to post-traumatic cavernous internal carotid artery pseudoaneurysm: A case report

Rationale:Cavernous internal carotid artery(ICA)pseudoaneurysm caused by non-penetrating head trauma is a rare cause of massive epistaxis.The sudden onset of epistaxis due to such a fatal aneurysm protruding into the sphenoid sinus is extremely rare in clinical practice.The management is often challenging because of anatomical inaccessibility of the bleeding point.Patient's concern:A 42-year-old man with a history of head trauma showing an ICA aneurysm eroding the sphenoid sinus followed by massive epistaxis.Diagnosis:A computerized tomography(CT)scan showed a fracture in the sphenoid sinus.CT angiogram revealed cavernous ICA pseudoaneurysm.Interventions:Endovascular coil embolization.Outcomes:The patient recovered well and was discharged without any neurological deficits Lessons:Cavernous ICA pseudoaneurysm may lead to a life-threatening situation.If a patient has a history of head trauma,post-traumatic cavernous ICA pseudoaneurysm should be considered a differential diagnosis of massive epistaxis.

Extracranial Internal Carotid Artery (ICA) Aneurysm Repair and End to End Anastamosis of the Artery

We present a case of extracranial internal carotid artery (ICA) aneurysm, which presented as an inflammatory submandibular swelling in the upper part of the right side of the neck. The lack of frank pulsatility and signs of inflammation though was a bit confusing, the Doppler and CT angiogram clinched the diagnosis. We were able to surgically resect and reform the ICA using the native vessel itself, which is an unusual technique, which we thought was worth presenting.

Rupture of a True Aneurysm of the Posterior Meningeal Artery at Its Anomalous Origin from the Internal Carotid Artery: Case Report

The posterior meningeal artery (PMA) usually originates from the third segment of the vertebral artery. Many variations in its origin and course have been observed;however, as far as we know, the association of true aneurysm of the PMA and its anomalous origin from the internal carotid artery has not been reported previously. We reported the case of a 59-year-old woman who suddenly presented a loss of consciousness without head trauma, computed tomography (CT) revelated intracerebellous hematoma associated with a subarachnoid hemorrhage of the posterior cerebral fossa. Cerebral angiography demonstrated a true aneurysm of the PMA which originated from the internal carotid artery.