PMC9479563_01
Imaging findings before the embolization. (a and b) The right internal carotid artery (ICA) angiography before and after the percutaneous transluminal angioplasty and stent deployment of the petrous ICA stenosis (arrow). (c) Grocott (modified Gomori methenamine silver) stain of the fungus ball in the sphenoid sinus showing branching septate hyphae typical of Aspergillus species (original magnification x200, black bar = 100 um). (d) Endoscopic view in the sphenoid sinus during the hemostatic procedure. A pulsatile projection (arrowhead) between ON and CP was seen while no active bleeding was confirmed (ON: optic nerve and CP: carotid prominence). (e) Coronal section of the right three-dimensional rotational angiography. A tip of irregularly shaped aneurysm projected into the right sphenoid sinus (arrowhead), and the sinus was filled with blood. (f) Three-dimensional rotational angiography showing irregularly shaped stenosis and dilatation. Dotted rectangles in (e) and (f) indicate the same portion of the aneurysm.
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F1
He underwent a percutaneous transluminal angioplasty and stenting with Wingspan 4.5 mm*15 mm (Stryker, MI, U.S.A.) of a cavernous-petrous portion of the right ICA [Figures 1a and b]. Based on the pathological analysis of the fungal ball, the sinusitis was found to be due to an Aspergillus species [Figure 1c]. A retrospective review of the endoscopic hemostasis procedure revealed pulsatile projection on the roof of the sphenoid sinus [Figure 1d], and cerebral angiography showed an irregularly shaped de novo aneurysm at the medial side of the cavernous portion of the right ICA, the tip of which was projecting into the sphenoid sinus [Figures 1e and f].
Imaging findings during and after the embolization. (a) The right internal carotid artery (ICA) three-dimensional rotational angiography, lateral view. There were de novo aneurysmal projection (arrowhead) and stenosis (arrow), which were not seen 8 weeks before [Figure 1a and b]. (b) Three-dimensional rotational angiography after the deployment of the LVIS BLUE stent. The stent was deployed between the arrows and the proximal part was overlapped with the Wingspan stent (between the arrowheads). (c) The right ICA angiography after embolization showing no blood flow in the aneurysm and slight improvement of stenosis indicated in (a). (d) The right ICA angiography 6 months after embolization. There was no relapse of the aneurysm, while slight in-stent restenosis was seen in the Wingspan stent. (e) Magnetic resonance angiography 12 months after the embolization. There was no de novo intracranial aneurysm. Blood flow around the coils and stents cannot be seen because of the magnetic substance effect. (f) Endoscopic view in the sphenoid sinus 12 months after the embolization. Coils in the aneurysm were seen through the mucous membrane in the sphenoid sinus (arrowhead).
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F2
After that, we packed the aneurysm with a coil using the jailing technique [Figures 2a-c]. Moreover, three-dimensional rotational ICA angiography revealed no recurrence of the aneurysm after 6 months [Figure 2d]. Oral voriconazole was stopped after 12 months following the confirmation of no aneurysmal relapse in MR angiography [Figure 2e], no abnormal sphenoid sinus findings with endoscopy [Figure 2f], and a normal serum beta-d-Glucan level.