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Vol. 11. Issue 6.
Pages 435-439 (January 2000)
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Vol. 11. Issue 6.
Pages 435-439 (January 2000)
Aneurisma en ampolla (blister-like) de la carótida asociado a aneurismas múltiples y malformación arteriovenosa cerebral tratado con oclusión carotidea y bypass de alto flujo
Blister-like aneurysm of the internal carotid artery associated with multiple sacular aneurysms and an arteriovenous malformation treated by high flow extra-intracranial bypass and carotid oclusion.
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R.D. Lobato, J. Porto, P.A. Gómez, J. Campollo, R. Alday, P. González, G. Rodríguez Boto, A. de la Lama
Servicios de Neurocirugía, Cirugia Vascular y Neurorradiología. Hospital “12 de Octubre”. Madrid
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Resumen

Se presenta el caso de una paciente de 45 años con aneurismas múltiples de la carótida derecha, uno de los cuales era del tipo “blister-like” o en ampolla y una malformación arteriovenosa (MAV) temporal contralateral. La presentación fue con hemorragia subaracnoidea por rotura aneurismatica. En la intervención inicial se clipó un aneurisma de carótida-comunicante posterior y se coaguló otro pequeño (baby-aneurysm) del origen de la coroidea, recubriéndose, por considerarlo no clipable, el aneurisma en ampolla situado en la cara anterior de la carótida entre la coroidea y la bifurcación. A los diecisiete días de la cirugía, la paciente resangró, siendo evacuado un hematoma temporal cuyo origen no pudo ser determinado con claridad. La angiografía de control demostró un crecimiento del aneurisma en ampolla.

Se decidió practicar oclusión de la carótida derecha a nivel cervical, previo “bypass” de alto flujo. Para disminuir el robo de flujo hacia el lado izquierdo, secundario a la presencia de la MAV, se procedió antes a embolizar esta última lesión, ocluyendo aproximadamente un 65% del “nidus”. Posteriormente, se practicó bypass de alto flujo con injerto de safena desde carótida externa a un segmento M2 de cerebral media ligándose la carótida interna a nivel cervical. Finalmente, se trató con radiocirugía la MAV temporal.

Se comentan las peculiaridades de los aneurismas en ampolla de la cara anterior de la carótida, que carecen de verdadero cuello y tienen una frágil pared. Estos aneurismas son difíciles de objetivar en el estudio angiográfico y conllevan un alto riesgo de rotura intraoperatoria. Su manejo más adecuado consiste casi siempre en oclusión carotidea con o sin revascularización cerebral previa.

Palabras Clave:
Aneurisma
Hemorragia subaracnoidea
Malformación arteriovenosa
“Bypass”
Radiocirugia
Summary

The case of a 45 year-old woman with multiple intracranial aneurysms, one of hich was of “blister-like” type and an arteriovenous malformation (AVM) of the contralateral temporal lobe is presented. Clinical presentation was with subarachnoid hemorrhage. At the initial operation a carotid-posterior communicating artery aneurysm was clipped and a baby aneurysm of the anterior choridal artery was coagulated; the blister-like aneurysm located between the origin of the anterior choroidal artery and the carotid bifurcation was wrapped with muscle because it was deemed not suitable for clipping. Seventeen days after the operation, the patient suddendly became comatose and a control CT scan showed a big temporal hematoma which was evacuated. Postoperative control carotid angiography showed enlargement of the blister-like aneurysm.

Occlusion of the internal carotid artery was planned after the contralateral AVM was embolized in order to decrease blood flow steal from the right cerebral hemisphere. Following occlusion of approximately 65% of the AVM nidus a reversal of flow from the left to the right hemisphere was observed. Ahigh flow bypass with saphenous graft between the external carotid artery and a M2 segment was performed and the internal carotid artery was ligated at cervical level. Thereafter the patient underwent radiosurgery of the AVM.

The therapeutic problems posed by-blister-like aneurysms which are usually located at the anterior walI of the supraclinoidal carotid artery, have a thin wall and no neck and are rarely detected by angiography are commented. The most appropriate management usualIy consists in carotid occlusion with or without previous cerebral revascularization.

Key Words:
Aneurysm
Subarachnoid hemorrhage
Arteriovenous malformation
Bypass
Radiosurgery

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