Cervical Internal Carotid Artery Aneurysm: Spontaneous Dissection of the Cervical Internal Carotid Artery Resulting in Elongation and Pseudoaneurysm Formation Causing Hypoglossal Nerve Palsy; Endovascular Vessel Reconstruction with Stenting, Followed by Telescoping Flow Diversion, Achieving Straightening of the Artery, Aneurysm Occlusion, Hypoglossal Nerve Recovery, and Normalization of the Tongue

Abstract

A 48-year-old male patient, with a history of intermittent atrial fibrillation, endogenous depression, and Meulengracht syndrome, presented 2 days after the acute onset of a paralysis of the right-hand side of his tongue, causing dysarthria and difficulty swallowing. When he stuck out his tongue, it deviated to the right. Otherwise, his neurological condition was within normal limits, and the diagnosis of an acute hypoglossal nerve palsy was made. Magnetic resonance imaging and angiography (MRI, MRA), followed by diagnostic digital subtraction angiography (DSA), showed a 360° loop and a dissecting aneurysm in his right cervical internal carotid artery (ICA) just proximal to the petrous segment. The maximum neck and fundus diameters were 6 mm and 11 mm, respectively. Endovascular treatment was carried out, starting with balloon straightening of the ICA followed by deploying a self-expanding Carotid Wallstent (Boston Scientific) into the affected ICA segment. Follow-up examinations after 2 months showed a straightened ICA with persistent perfusion of the false ICA lumen and the dissecting aneurysm. A p64 flow diverter (phenox) was implanted inside the Carotid Wallstent. DSA 3 months later confirmed the occlusion of the pseudoaneurysm and the false lumen. The hypoglossal nerve palsy disappeared within 2 months after the first treatment in which the ICA had been straightened. Hypoglossal nerve palsy due to ICA dissection with pseudoaneurysm formation, including management of this condition, is the main topic of this chapter.