Petrous Internal Carotid Artery Aneurysm: Giant Fusiform Aneurysm, Flow Diversion, Several Treatment Sessions, Metamizole Intake Five Years After the Initial Treatment, Thrombotic Internal Carotid Artery Occlusion, Thrombectomy
A giant fusiform aneurysm of the petrous segment of the right internal carotid (ICA) artery was diagnosed in a 52-year-old woman, who presented with headache. Balloon test occlusion of the right ICA was clinically tolerated, yet the venous phase of the right anterior circulation after injection of the left ICA opacified with delay. The continuity of the right ICA was reconstructed with three Pipeline flow diverters (Medtronic) in September 2012. From there on, the patient was under dual platelet function inhibition by a medication with 1× 100 mg acetylsalicylic acid (Aspirin, Bayer Vital) and 2× 90 mg ticagrelor (Brilique, AstraZeneca) daily. Subsequent examinations showed that the aneurysm was not completely isolated from the blood circulation. A balloon expandable drug-eluting stent and an additional 12 flow diverters (10× p64 (phenox), 2× PEDs) were implanted into the petrous segment of the right ICA in the subsequent treatment sessions. In October 2015, a de novo stenosis of the proximal right ICA was treated by stent angioplasty. The patient had been asymptomatic for the last 5 years, when she then presented with an episode of headache, visual disturbance of her right eye, and fatigue on September 10, 2017. MRI showed an occlusion of the right ICA at the level of the implanted stents and flow diverters. CT perfusion (CTP) revealed an exhausted reserve capacity of the right anterior circulation. The Multiplate test (Roche) confirmed that the ASA effect was insufficient. The patient had taken the prescribed medication as usual, however, on September 5, 2017, she had a tooth extraction; on the following 5 days she had consumed a cumulative dosage of 10 g of metamizole. The onset of her neurological symptoms was on September 9, 2017. The recanalization of the right ICA was achieved by combining aspiration and mechanical thrombectomy on September 13, 2017. MRI showed minor ischemic lesions of the dependent right hemisphere. Follow-up DSA 1 week later confirmed the patency of the right ICA and on CTP the concerning reserve capacity was restituted. The flow diverter treatment of fusiform aneurysms and the interaction between metamizole and ASA are the main topics of this report.
KeywordsPetrous internal carotid artery Fusiform aneurysm Giant aneurysm Flow diversion Endoleak Reserve capacity Thrombectomy ASA interaction
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