PMC3513845_01
MRI at initial diagnosis (a) Axial T2-weighted fluid-attenuated inversion recovery (FLAIR) MRI showing features of tuberous sclerosis, including white matter radial migration lines and cortical tubers. MRI at presentation of cranial nerve deficits (b) Axial T2-weighted FLAIR MRI showing an 18-mm left cavernous sinus internal carotid artery aneurysm
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F1
MRI now showed the interval development of a left cavernous sinus lesion suspicious for an aneurysm [Figure 1].
MRA showing the same 18-mm left cavernous sinus internal carotid artery (ICA) aneurysm with extension to the petrous and distal cervical ICA
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F2
Magnetic Resonance Angiogram (MRA) of the brain revealed an 18-mm-diameter left cavernous internal carotid artery (ICA) aneurysm that further extended into the petrous and distal cervical ICA [Figure 2].
Digital subtraction angiography further characterizing the left internal carotid artery aneurysm (a) Digital subtraction angiography just prior to intervention (b)
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F3
Under general anesthesia and using intraoperative neuromonitoring (somatosensory and motor-evoked potentials), the BTO was performed using a 3 x 7 mm HyperForm Occlusion Balloon System (ev3 Neurovascular, Irvine, CA, USA) positioned and inflated in the proximal ICA with 10 min of normotension followed by 10 min of hypotension (systolic blood pressures reduced to 70% of baseline) without changes in neuromonitoring signals [Figure 3].
Digital subtraction angiography following coil embolization and complete occlusion of the left cavernous, petrous, and distal cervical internal carotid artery. The contrast seen demonstrates reflux in the external carotid artery branches
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F4
Serial angiography through the left ICA confirmed complete occlusion and isolation of the aneurysm (Aneurysm Embolization Grade "A" and Raymond-Roy Occlusion "1") from anterograde flow [Figure 4].