Extracranial-Intracranial High-Flow Bypass for Giant Ruptured Paraclinoid Aneurysm with Concomitant Bilateral Internal Carotid Artery Stenotic Dissection.

BACKGROUND: Giant ruptured paraclinoid aneurysm with concomitant bilateral internal carotid artery dissection (CAD) can be a difficult condition to treat with current surgical and endovascular techniques. Paraclinoid internal carotid artery (ICA) aneurysms remain a major challenge for vascular neurosurgeons. There are still controversies in the management of carotid artery (CA) dissections. Surgical and endovascular treatment is recommended in cases with multivessel dissections or those complicated by subarachnoid hemorrhage (SAH).

CASE DESCRIPTION: We report a case of a 35-year-old woman presenting clinical manifestations and tomographic findings compatible with SAH caused by rupture of a paraclinoid aneurysm in the left ICA. We had to treat the ruptured aneurysm and the concurrent dissection of both ICAs. The patient underwent high-flow extracranial-intracranial arterial graft bypass and subsequent trapping of the left ICA. Complete aneurysm exclusion from the cerebral circulation was achieved, and the possible embolic events from the left side were prevented. The concomitant right internal CAD was treated conservatively with anticoagulants and antiplatelets.

CONCLUSIONS: Dealing only with the ruptured paraclinoid aneurysm, without taking care of the underlying cerebral ischemia owing to concomitant extracranial ICA dissection, could be an insufficient approach for treatment. In the presented case of a giant ruptured paraclinoid aneurysm and coexistence of severe bilateral ICA dissecting stenosis, trapping with matching the bypass flow was the proper solution for managing simultaneously with the aneurysm and the cerebral ischemia from the left side. Anticoagulants and antiplatelets were applied safely to treat the right internal CAD.