Neurochirurgia 18 (1975), 190-193 © Georg Thieme Verlag Stuttgart
Giant Aneurysm of the Internal Carotid Artery Simulating Posterior Fossa Tumour in a 13 Year old Girl Thomas A. Duff, M.D., H. H. Gossmann, M.B., B.S., F.R.C.S.E.
Summary A young patient, who presented with the signs and symptoms of a posterior fossa neoplasm, was found on bilateral carotid angiography to have a posteriorly directed giant aneurysm arising from the right internal carotid artery. Key words: aneurysm - cerebral aneurysm intracranial mass - pseudobulbar palsy
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(Money 1969), is far less c o m m o n in this age g r o u p , b u t nevertheless, has been well-documented (Devadiga 1969, Jane 1 9 6 1 , Vapolohti 1969). T h e following case, t h a t of a 13 year old girl, is of particular interest, however, because her progressive neurological deficit, which suggested an e x p a n d i n g lesion of the u p p e r brain stem, w a s found t o be due t o a posteriorly directed, giant a n e u r y s m arising from t h e internal carotid artery.
Zusammenfassung Bei einem jungen Patienten, der die Zeichen und Symptome eines Tumors der hinteren Schädelgrube hatte, wurde bei der bilateralen Carotisangiographie ein nach posterior gerichtetes gigantisches Aneurysma der rechten Carotis interna nachgewiesen.
Résumé Anévrisme géant de l'artère carotide interne simulant une tumeur de la fosse ostérieure chez une fillette de 13 ans. Chez une jeune malade présentant une Symptomatologie de tumeur de la fosse postérieure on trouve à l'artériographie carotidienne bilatérale un anévrisme géant à développement postérieur partant de l'artère carotide droite.
Introduction According to m o s t large series (Dandy 1969, du Boulay 1965, Lartinen 1964, McDonald 1939) a p p r o x i m a t e l y 3 % of clinically a p p a r e n t intracranial aneurysms occur in patients u n d e r 17 years of age. T h e occurrence of so-called giant aneurysms, w h i c h m a y simulate n e o p l a s m s in their m o d e of presentation
Case Report This 13 year old female, who had a two year history of intermittent but mild occipital headaches, began to complain of more severe headaches four months prior to admission. Over the interim period she experienced, in addition, episodes of vomiting, lethargy, unsteadiness of gait, and difficulty with articulation and swallowing. Her weight decreased from 108 lbs to 91 lbs. Examination. On physical examination the vital signs were all within normal limits. The patient appeared listless and, although able to follow commands, became easily fatigued. The pupillary reflex was normal and there was no pap i l l e d e m a or visual field defect. Eye movements were saccadic in character, but there was no extraocular paralysis. The corneal reflex was intact bilaterally. There was mild bilateral facial weakness and horizontal as well as vertical nystagmus. Speech was dysarthric and the patient had difficulty in swallowing and in protruding the tongue. The jaw jerk was increased. In addition to generalised weakness of the extremities, the deep tendon reflexes were hyperactive throughout, with extensor plantar responses and bilateral ankle clonus. Skull films revealed no abnormalities. A brain scan showed markedly increased uptake of the nucleotide in the midbrain region (Fig. 1). The presumptive diagnosis at this point was a neoplastic process involving the ventral mesencephalon and
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Department of Medical and Surgical Neurology, Plymouth General Hospital, Plymouth, England
Giant Aneurysm of the Internal Carotid Artery Simulating Posterior Fossa Tumour
191
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.v*
Fig. 1: " T e brain scan in left lateral and anteroposterior views showing increased uptake of the nucleotide in the upper brain stem region.
producing a pseudobulbar palsy and spastic tetraparesis. In order to determine the presence of any supratentorial component of the lesion, and to make initial assessment of ventricular size, bilateral carotid angiography was performed. This, unexpectedly, revealed a giant aneurysm, 6 cms. in length, arising from a point very near the bifurcation of the right internal carotid artery (Fig. 2). The fundus projected over the petrous ridge into the midbrain and upper pontine region. Operation. Using a left fronto-temporal craniotomy, the neck of the aneurysm was approached by the subfrontal route. It was found in the expected place, 5 mms proximal to the internal carotid termination arising from its postero-
lateral aspect. The neck was satisfactorily ligated. Aspiration of the sac produced bleeding and therefore an additional clip was placed across the neck. The neck was then divided and the sac emptied of its liquid and clotted blood contents. An attempt to deliver the wall of the sac produced a decrease in the blood pressure and in the pulse rate. Under these circumstances the sac was merely left to drain into the subarachnoid space. Postoperative Course. Postoperatively the patient was found to have a complete third nerve palsy on the right side, but her previous neurological deficits rapidly cleared. She was able to return to school for the beginning of the autumn term three months later.
Thomas A. Duff, H. H. Gossmann
Fig. 2: Right carotid angiogram showing posteriorly directed giant aneurysm arising from the internal carotid artery.
Discussion This case illustrates two pertinent points. First, that even in young persons large aneurysms may be responsible for producing signs and symptoms of an expanding neoplastic process. Secondly, depending upon its size and shape, an intracranial aneurysm may cause compression of neural structures relatively distant from its origin. Whereas compression of midbrain or posterior fossa structures has been found with aneurysms arising within the vertebro-basilar artery complex (Bull 1969, Fox 1968, Obrador 1967), aneurysms arising from the anterior circulation will nearly always exert their effects on structures such as the hypothalmus, pituitary
gland, or adjacent cranial nerves (Bull 1969, Gallaghan 1956, Morley 1969, Polis 1973, White 1961). In a review of the literature, we have found only one case which perhaps did not follow this general rule and that was a patient only very sketchily described in the series reported by Morley and Barr (Morley 1969). The present case, therefore, demonstrates a most unusual situation wherein the size and shape of the aneurysm led to compression of neural structures relatively distant from its origin. Although rare, this type of lesion re-emphasizes the need, even in the young, for thorough investigation of the intracranial circulation in order to determine as accurately as possible the true nature of intracranial mass lesions.
References Hull, James: Massive aneurysms at the base of the brain. Brain 92 (1969) 535-570 Dandy, W. E.: Intracranial Arterial Aneurysms. Comstock Publishing Co., Inc. Ithaca, N. Y. (1945) Devadiga, K. V., K. V. Mathai, J. Chandy: Spontaneous cure of intracavernous aneurysm of the internal carotid
artery in a 14 month old child: case report. J. Neurosurg. 30 (1969) 165-168 du Boulay, G. H.: Some observations on the natural history of intracranial aneurysms. The Brit. J. Radiol. 38 (1965) 721-757 Fox, ]. L.; Tentorial section for decompression of the brain
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192
193
Lartinen, L.: Artenella aneurysm med. subarachnoid alboduing hos barn. Nordisk M e d i a n 71 (1964) 329-333 McDonald, C. A., M. Koeb: Intracranial aneurysms. Archives of Neurol. Psychiat. 42 (1939) 298-328 Morley, T. P., H. W. K. Barr: Giant intracranial aneurysms,
Diagnosis, Course and M a n a g e m e n t . Clinical Neurosurgery 16 (1969) 73-94 Obrador, S., G. Dierssen, ], R. Dermandez: Giant aneurysm of the posterior cerebral artery: case report. J. Neurosurg. 26 (1967) 413-416 Polis, Z., J. Brzezinski, M. Cbodak-Gajeuriecz: Giant intracranial aneurysm: case report. J. Neurosurg. 39 (1973) 408-411 Vapolobti, P. M. et al.: Intracranial aneurysm in a three month old infant: case report. J. Neurosurg. 30 (1969) 169-171 White, J. C, H. T. Ballantine, Jr.: Intra-sellar aneurysms simulating hypophyseal t u m o u r s . J. N e u r o s u r g . 18 (1961) 34-50
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stem and a large basilar aneurysm: case report. J. Neurosurg. 28 (1963) 74-79 Gallaghan, P. G. et al.: Large intracranial aneurysm producing panhypopituitarism and frontal lobe syndrome. Neurology 6 (1956) 829-837 Jane, J. A.: A large aneurysm of the posterior inferior cerebellar artery in a one year old child: case report. J. Neurosurg. 18 (1961) 245-247
Giant Aneurysm of the Internal Carotid Artery Simulating Posterior Fossa Tumour in a 13 Year old Girl Thomas A. Duff, M.D., H. H. Gossmann, M.B., B.S., F.R.C.S.E.
Summary A young patient, who presented with the signs and symptoms of a posterior fossa neoplasm, was found on bilateral carotid angiography to have a posteriorly directed giant aneurysm arising from the right internal carotid artery. Key words: aneurysm - cerebral aneurysm intracranial mass - pseudobulbar palsy
-
(Money 1969), is far less c o m m o n in this age g r o u p , b u t nevertheless, has been well-documented (Devadiga 1969, Jane 1 9 6 1 , Vapolohti 1969). T h e following case, t h a t of a 13 year old girl, is of particular interest, however, because her progressive neurological deficit, which suggested an e x p a n d i n g lesion of the u p p e r brain stem, w a s found t o be due t o a posteriorly directed, giant a n e u r y s m arising from t h e internal carotid artery.
Zusammenfassung Bei einem jungen Patienten, der die Zeichen und Symptome eines Tumors der hinteren Schädelgrube hatte, wurde bei der bilateralen Carotisangiographie ein nach posterior gerichtetes gigantisches Aneurysma der rechten Carotis interna nachgewiesen.
Résumé Anévrisme géant de l'artère carotide interne simulant une tumeur de la fosse ostérieure chez une fillette de 13 ans. Chez une jeune malade présentant une Symptomatologie de tumeur de la fosse postérieure on trouve à l'artériographie carotidienne bilatérale un anévrisme géant à développement postérieur partant de l'artère carotide droite.
Introduction According to m o s t large series (Dandy 1969, du Boulay 1965, Lartinen 1964, McDonald 1939) a p p r o x i m a t e l y 3 % of clinically a p p a r e n t intracranial aneurysms occur in patients u n d e r 17 years of age. T h e occurrence of so-called giant aneurysms, w h i c h m a y simulate n e o p l a s m s in their m o d e of presentation
Case Report This 13 year old female, who had a two year history of intermittent but mild occipital headaches, began to complain of more severe headaches four months prior to admission. Over the interim period she experienced, in addition, episodes of vomiting, lethargy, unsteadiness of gait, and difficulty with articulation and swallowing. Her weight decreased from 108 lbs to 91 lbs. Examination. On physical examination the vital signs were all within normal limits. The patient appeared listless and, although able to follow commands, became easily fatigued. The pupillary reflex was normal and there was no pap i l l e d e m a or visual field defect. Eye movements were saccadic in character, but there was no extraocular paralysis. The corneal reflex was intact bilaterally. There was mild bilateral facial weakness and horizontal as well as vertical nystagmus. Speech was dysarthric and the patient had difficulty in swallowing and in protruding the tongue. The jaw jerk was increased. In addition to generalised weakness of the extremities, the deep tendon reflexes were hyperactive throughout, with extensor plantar responses and bilateral ankle clonus. Skull films revealed no abnormalities. A brain scan showed markedly increased uptake of the nucleotide in the midbrain region (Fig. 1). The presumptive diagnosis at this point was a neoplastic process involving the ventral mesencephalon and
Downloaded by: University of British Columbia. Copyrighted material.
Department of Medical and Surgical Neurology, Plymouth General Hospital, Plymouth, England
Giant Aneurysm of the Internal Carotid Artery Simulating Posterior Fossa Tumour
191
Downloaded by: University of British Columbia. Copyrighted material.
.v*
Fig. 1: " T e brain scan in left lateral and anteroposterior views showing increased uptake of the nucleotide in the upper brain stem region.
producing a pseudobulbar palsy and spastic tetraparesis. In order to determine the presence of any supratentorial component of the lesion, and to make initial assessment of ventricular size, bilateral carotid angiography was performed. This, unexpectedly, revealed a giant aneurysm, 6 cms. in length, arising from a point very near the bifurcation of the right internal carotid artery (Fig. 2). The fundus projected over the petrous ridge into the midbrain and upper pontine region. Operation. Using a left fronto-temporal craniotomy, the neck of the aneurysm was approached by the subfrontal route. It was found in the expected place, 5 mms proximal to the internal carotid termination arising from its postero-
lateral aspect. The neck was satisfactorily ligated. Aspiration of the sac produced bleeding and therefore an additional clip was placed across the neck. The neck was then divided and the sac emptied of its liquid and clotted blood contents. An attempt to deliver the wall of the sac produced a decrease in the blood pressure and in the pulse rate. Under these circumstances the sac was merely left to drain into the subarachnoid space. Postoperative Course. Postoperatively the patient was found to have a complete third nerve palsy on the right side, but her previous neurological deficits rapidly cleared. She was able to return to school for the beginning of the autumn term three months later.
Thomas A. Duff, H. H. Gossmann
Fig. 2: Right carotid angiogram showing posteriorly directed giant aneurysm arising from the internal carotid artery.
Discussion This case illustrates two pertinent points. First, that even in young persons large aneurysms may be responsible for producing signs and symptoms of an expanding neoplastic process. Secondly, depending upon its size and shape, an intracranial aneurysm may cause compression of neural structures relatively distant from its origin. Whereas compression of midbrain or posterior fossa structures has been found with aneurysms arising within the vertebro-basilar artery complex (Bull 1969, Fox 1968, Obrador 1967), aneurysms arising from the anterior circulation will nearly always exert their effects on structures such as the hypothalmus, pituitary
gland, or adjacent cranial nerves (Bull 1969, Gallaghan 1956, Morley 1969, Polis 1973, White 1961). In a review of the literature, we have found only one case which perhaps did not follow this general rule and that was a patient only very sketchily described in the series reported by Morley and Barr (Morley 1969). The present case, therefore, demonstrates a most unusual situation wherein the size and shape of the aneurysm led to compression of neural structures relatively distant from its origin. Although rare, this type of lesion re-emphasizes the need, even in the young, for thorough investigation of the intracranial circulation in order to determine as accurately as possible the true nature of intracranial mass lesions.
References Hull, James: Massive aneurysms at the base of the brain. Brain 92 (1969) 535-570 Dandy, W. E.: Intracranial Arterial Aneurysms. Comstock Publishing Co., Inc. Ithaca, N. Y. (1945) Devadiga, K. V., K. V. Mathai, J. Chandy: Spontaneous cure of intracavernous aneurysm of the internal carotid
artery in a 14 month old child: case report. J. Neurosurg. 30 (1969) 165-168 du Boulay, G. H.: Some observations on the natural history of intracranial aneurysms. The Brit. J. Radiol. 38 (1965) 721-757 Fox, ]. L.; Tentorial section for decompression of the brain
Downloaded by: University of British Columbia. Copyrighted material.
192
193
Lartinen, L.: Artenella aneurysm med. subarachnoid alboduing hos barn. Nordisk M e d i a n 71 (1964) 329-333 McDonald, C. A., M. Koeb: Intracranial aneurysms. Archives of Neurol. Psychiat. 42 (1939) 298-328 Morley, T. P., H. W. K. Barr: Giant intracranial aneurysms,
Diagnosis, Course and M a n a g e m e n t . Clinical Neurosurgery 16 (1969) 73-94 Obrador, S., G. Dierssen, ], R. Dermandez: Giant aneurysm of the posterior cerebral artery: case report. J. Neurosurg. 26 (1967) 413-416 Polis, Z., J. Brzezinski, M. Cbodak-Gajeuriecz: Giant intracranial aneurysm: case report. J. Neurosurg. 39 (1973) 408-411 Vapolobti, P. M. et al.: Intracranial aneurysm in a three month old infant: case report. J. Neurosurg. 30 (1969) 169-171 White, J. C, H. T. Ballantine, Jr.: Intra-sellar aneurysms simulating hypophyseal t u m o u r s . J. N e u r o s u r g . 18 (1961) 34-50
Downloaded by: University of British Columbia. Copyrighted material.
stem and a large basilar aneurysm: case report. J. Neurosurg. 28 (1963) 74-79 Gallaghan, P. G. et al.: Large intracranial aneurysm producing panhypopituitarism and frontal lobe syndrome. Neurology 6 (1956) 829-837 Jane, J. A.: A large aneurysm of the posterior inferior cerebellar artery in a one year old child: case report. J. Neurosurg. 18 (1961) 245-247
