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Vol. 18. Issue 5.
Pages 414-419 (January 2007)
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Vol. 18. Issue 5.
Pages 414-419 (January 2007)
Hemorragia subaracnoidea como forma de presentación de aneurisma disecante carotídeo
Subarachnoid hemorrhage caused by a disecting carotid artery aneurysm
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A. Lagares
, J.A. Fernández-Alén, L. Jiménez-Roldán, R.D. Lobato
Servicios de Neurocirugía. Hospital 12 de Octubre. Madrid
J. Porto*, J. Campollo**, A. Ramos**
* Servicios de Cirugía Vascular. Hospital 12 de Octubre. Madrid
** Servicios de Neurorradiología. Hospital 12 de Octubre. Madrid
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Resumen

Las disecciones carotídeas se presentan con muy poca frecuencia en forma de hemorragia subaracnoidea. Sin embargo, la implicación de la disección arterial en la patogenia de algunos aneurismas de la pared dorsal o anterior de la carótida, tronco carotídeo y aneurismas “blister-like”, ha hecho que cobre interés la descripción de los aneurismas disecantes, ya que con frecuencia son lesiones de difícil tratamiento y requieren de técnicas quirúrgicas no habituales.

Presentamos el caso de una enferma que debutó con una hemorragia subaracnoidea en mal grado clínico secundaria a un aneurisma disecante de la carótida interna derecha, caracterizado por la presencia en el estudio angiográfico de una estenosis carotídea asociada a una dilatación postestenótica y al hallazgo de una lesión sacular que creció en el estudio de control. Se realizó un test de oclusión carotídea que mostró una asimetría en la aparición del drenaje venoso que determinó la conveniencia de practicar un by-pass extraintracraneal de alto flujo con injerto de safena para su tratamiento mediante sacrificio de la carótida interna. Ocho meses tras la cirugía la enferma no presenta focalidad neurológica alguna y los estudios de imagen muestran una resolución de la lesión carotídea con permeabilidad del bypass.

Se discuten las dificultades en el diagnóstico de estos aneurismas, sus características clínicas y radiológicas y los problemas en su tratamiento que casi siempre requieren de sacrificio arterial con o sin revascularización cerebral previa.

Palabras clave:
Hemorragia subaracnoidea
Aneurisma cerebral
Aneurisma disecante
Disección arterial
Arteria carótida interna
Revascularización cerebral
Summary

Dissecting aneurysms of the carotid artery as a cause of subarachnoid hemorrhage are rare. However, the association of arterial dissection with the etiology of some aneurysms of the dorsal or anterior wall of the carotid artery, carotid trunk or “blister-like” aneurysms has increased the interest in the description of dissecting aneurysms, as they are difficult to treat and require non-habitual surgical techniques. We present the case of a patient that presented with a poor grade subarachnoid hemorrhage secondary to a right carotid artery dissecting aneurysm characterised in angiography by a carotid artery stenosis accompanied by a post-stenotic dilatation and the finding of a saccular aneurysm that increased in size in the follow-up study. A carotid occlusion test showed an asymmetry in the opacification of the venous phase indicating the need for a revascularization procedure prior to arterial sacrifice. A high flow EC-IC bypass was performed using a saphenous vein graft prior to right carotid artery occlusion without morbidity. Eight months after the procedure the patient is free of neurological deficit. Control image studies demonstrate the resolution of the carotid lesion and the bypass permeability.

We discuss the difficulties in the diagnosis of these aneurysms, their clinical and imaging characteristics and the problems related to their treatment as they often require arterial sacrifice with or without prior cerebral revascularization.

Key words:
Subarachnoid hemorrhage
Cerebral aneurysm
Dissecting aneurysm
Arterial dissection
Internal carotid artery
Cerebral revascularization

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