case_images: PMC10860580_01
case_images: MR axial T1-weighted post-contrast images (A and B) shows an enlarged left cavernous sinus with mild pachymeningeal enhancement along the left medial temporal lobe (black arrow) and mucosal thickening of bilateral ethmoid sinuses. There is extensive skull base osteomyelitis with destruction of the clivus and bilateral petrous temporal bone with abnormal post-contrast enhancement in both pterygopalatine fossae. (C) CT brain in bone window shows osteolytic destruction of the clivus, body of sphenoid, petrous part of bilateral temporal bones and bilateral pterygoid plates. (D) MR T2-weighted fat saturated image shows an additional flow void (block arrow) medial to the cavernous portion of the left ICA projecting into the sphenoid sinus and posteriorly into the eroded petrous bone. There is a mixed density laminated thrombus around it (elbow arrow). There is hyperintense signal in the body of the sphenoid suggesting fungal involvement (star). CT angiogram (maximum intensity projection) in oblique (E) and coronal plane (F) shows a large pseudoaneurysm (chevron arrow) arising from the cavernous portion of the left ICA projecting into the sphenoid sinus.
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case_images: PMC10860580_01_uaad006f1.jpg
case_images: uaad006-F1
case_images: MRI (Figures 1A and B) showed bilateral maxillary, ethmoid, and sphenoid sinusitis with enhancing soft tissue in the left cavernous sinus and pachymeningeal enhancement along the left anterior temporal lobe (black arrow in Figure 1A). An additional T2 flow void (block arrow in Figure 1D) was seen adjacent to the left cavernous ICA flow void, with a laminated mixed-intensity thrombus (elbow arrow in Figure 1D) adjacent to it, strongly suggestive of a left ICA pseudoaneurysm.
case_images: Digital subtraction angiogram in Towne's view (A) and lateral view (B) shows a large pseudoaneurysm arising from the petro-cavernous segment of the left ICA. The pseudoaneurysm is projecting medially into the sphenoid sinus with extension posteriorly into the body of the sphenoid and the clivus. There is narrowing of the distal petrous segment and proximal cavernous segment, adjacent to the rent (arrowhead). Endovascular treatment was performed using a flow diverter (Pipeline Embolization Device, Medtronic Pvt Ltd). Left ICA angiogram post-stent placement (C and D) shows good calibre of the stented segment with stasis within the pseudoaneurysm (curved arrow). Dyna CT angiogram axial section (E) post-stent placement shows reconstruction of the left cavernous ICA with contrast stasis (notched arrow). Plain radiograph (F) and Dyna CT angiogram reconstructed MIP image (G) shows flow diverter stent apposition. A thick MIP coronal section of the CT angiogram (H) done 8 weeks after the procedure shows thrombosis of the pseudoaneurysm and good flow through the stented segment of the cavernous ICA. Cerebral angiography (I) performed 8 months later revealed complete obliteration of the aneurysm with preservation of ICA and good distal flow.
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case_images: PMC10860580_02_uaad006f2.jpg
case_images: uaad006-F2
case_images: PMC10860580_02
case_images: Digital subtraction angiogram in Towne's view (A) and lateral view (B) shows a large pseudoaneurysm arising from the petro-cavernous segment of the left ICA. The pseudoaneurysm is projecting medially into the sphenoid sinus with extension posteriorly into the body of the sphenoid and the clivus. There is narrowing of the distal petrous segment and proximal cavernous segment, adjacent to the rent (arrowhead). Endovascular treatment was performed using a flow diverter (Pipeline Embolization Device, Medtronic Pvt Ltd). Left ICA angiogram post-stent placement (C and D) shows good calibre of the stented segment with stasis within the pseudoaneurysm (curved arrow). Dyna CT angiogram axial section (E) post-stent placement shows reconstruction of the left cavernous ICA with contrast stasis (notched arrow). Plain radiograph (F) and Dyna CT angiogram reconstructed MIP image (G) shows flow diverter stent apposition. A thick MIP coronal section of the CT angiogram (H) done 8 weeks after the procedure shows thrombosis of the pseudoaneurysm and good flow through the stented segment of the cavernous ICA. Cerebral angiography (I) performed 8 months later revealed complete obliteration of the aneurysm with preservation of ICA and good distal flow.
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case_images: PMC10860580_02_uaad006f2.jpg
case_images: uaad006-F2
case_images: A 51-year-old male with COVID 19 infection and intermittent epistaxis. MRI T2-weighted fat saturated image (A) shows T2 intermediate intensity abnormal soft tissue in the left orbital apex (black arrow) with mild ethmoid sinusitis. There is an abnormal flow void adjacent to the left ICA (block arrow), raising suspicion of pseudoaneurysm. MRI T2-weighted fat saturated image (B) shows mucosal thickening in bilateral maxillary sinuses with T2 hyperintense signal in bilateral pterygoid muscles and clivus. Post-contrast T1-weighted image (C) shows bulky left cavernous sinus with abnormal pachymeningeal enhancement along the left medial temporal lobe (curved arrow). There is abnormal post-contrast enhancement of the mandibular division of the right trigeminal nerve suggesting perineural extension (arrowhead). CT angiogram coronal section with MIP reconstruction (D) shows the left cavernous ICA pseudoaneurysm (thick bent arrow). Left ICA Towne's view (E) shows a pseudoaneurysm arising from the cavernous ICA with narrowing of the distal cavernous segment (elbow arrow). Anterior cerebral and middle cerebral artery branches are normal. Left ICA left anterior oblique view (F) shows 2 rents in the cavernous segment of ICA, one small rent in the proximal C3 segment (star) and another large rent in the distal C3 segment of cavernous ICA (circle).
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case_images: PMC10860580_02_uaad006f3.jpg
case_images: uaad006-F3
case_images: T2 flow void adjacent to the cavernous segment of the left ICA (block arrow in Figure 3A) with abnormal T2 intermediate signal intensity soft tissue in the left orbital apex (arrow in Figure 3A) and abnormal pachymeningeal enhancement along the left medial temporal lobe (curved arrow in Figure 3C). There was perineural extension along the right mandibular nerve (arrowhead in Figure 3C). DSA revealed narrowing (elbow arrow in Figure 3E) in the distal cavernous left ICA with 2 rents in the C3 segment(dot and star in Figure 3F).
case_images: Intraoperative cerebral angiography road map image of the left ICA angiogram (A) shows deployment of the overlapping Xcalibur stents covering both the rents in the ICA. Post-stent left ICA angiogram (B and C) shows good apposition of the stents with significant improvement in the calibre of the distal cavernous ICA and stasis (notched arrow) in both pseudoaneurysms. Plain Radiograph (D) shows the overlapping stents with good apposition along the C1 and C2 segment of cavernous ICA. Dyna CT angiogram (E) confirms the apposition of the stent. Left ICA angiogram (F) 2 days post-stent placement shows complete thrombosis of the pseudoaneurysm with good calibre of the stented segment.
case_images: uaad006f4.jpg
case_images: PMC10860580_02_uaad006f4.jpg
case_images: uaad006-F4
case_images: Aneurysm Occlusion device (3.25 x 30 mm) was deployed across the distal cavernous ICA (Figure 4A). Another overlapping stent (4.5 x 30 mm) was used to cover both the rents. Post-stent left ICA angiogram showed good apposition of the stents with significant improvement in the calibre (Figure 4B) of the distal cavernous ICA and stasis (notched arrow in Figure 4C) in both the pseudoaneurysms. The final angiogram and DynaCT MIP reconstruction showed stasis in the pseudoaneurysm with good distal flow (Figure 4E). Follow-up cerebral DSA was performed after 48 h and showed complete thrombosis of pseudoaneurysm with good patency of the stent (Figure 4F).