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Clinical Brief

Pseudoaneurysm of Internal Carotid Artery

N.V. Beena, M.S. Kishore, Ajit Mahale and Vinaya Poornima

Department of Radodiagnosis, Kasturba Medical College, Mangalore-1, Karnataka, India.

[Received : June 15, 2006; accepted : August 29, 2006]

ABSTRACT
Pseudoaneurysms of the extracranial Internal Carotid Artery (ICA) are rare. Here it is reported a case of posttraumatic
extracranial ICA pseudoaneurysm in a three-year-old boy. The pseudoaneurysm arising from the extracranial ICA was initially
diagnosed by DSA. Later on confirmed by Doppler and MRA. The imaging features are described with a brief review of
literature. [Indian J Pediatr 2007; 74 (3) : 307-309] E-mail : kishoremsrd@yahoo.co.in

Key words : Traumatic; Extracranial ICA; Pseudoaneurysm

The word aneurysm comes from the Latin word ICA showed communication of the artery with the
aneurysma, which means dilatation. Aneurysm is an aneurysm (Fig 6). The pseudoaneurysm projects, well
abnormal local dilatation in the wall of a blood vessel, beyond the expected confines of the arterial wall.
usually an artery, due to a defect, disease, or injury.
Aneurysms can be true or false. A false aneurysm
(pseudo)cavity is lined by blood clot. The 3 major types of
true intracranial aneurysms are saccular, fusiform, and
dissecting. When aneurysms occur in the pediatric age
group they are more often posttraumatic or mycotic than
degenerative, and they have a slight male predilection.
Aneurysms in children are also larger than those found in
adults, averaging 17 mm in diameter.

CASE REPORT

A 3 year-old male child presented with a history of

swelling under right mandibular angle and pain. There
Fig 1. Doppler image shows a large pseudoaneurysm from the
was history of parotitis for which needling was done.
extra cranial right ICA, at the carotid bifurcation with
Postprocedure was followed by the swelling. Traumatic swirling motion of the blood within the pseudoaneurysm
pseudoaneurysm was suspected clinically.
Color Doppler showed a large pseudoaneurysm from
the extra cranial right ICA, at the carotid bifurcation with
swirling motion of the blood within the pseudoaneurysm
(Fig 1). CT scan study (Fig 2) and MRI study (Figs 3,4)
confirmed the above findings of the Doppler.
DSA was performed to know the exact origin of the
aneurysm. DSA (AP, oblique lateral) reveals a large
pseudoaneurysm arising from the Rt ICA just above the
level of CCA bifurcation (Fig 5). Selective injection of the

Correspondence and Reprint requests : Dr. M.S. Kishore, Specialist

Resident, Department of Radiodiagnosis, Kasturba Medical college
Hospital, Attavara, Mangalore-01. Fax no: 0091-824-24283791
Phone : 9880365534 / 04651 - 261333 Fig 2A

Indian Journal of Pediatrics, Volume 74—March, 2007 307

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N.V. Beena et al

DISCUSSION occasionally result from blunt trauma to the neck. This

can cause severe stretching of the ICA at the point where
Traumatic injuries of the carotid arteries are most it crosses over the lateral masses of C1 and C2. Blunt or
commonly caused by penetrating wounds. They penetrating trauma can produce arterial occlusions,

Fig 2B
Fig. 4. MRI scan confirms large pseudoaneurysm from the extra
Fig 2. CT scan shows large pseudoaneurysm from the extra cranial cranial right ICA. ICA seen as flow void within the
right ICA. aneurysm

Fig 3A Fig. 5. Conventional angiography performed to look for all the

feeders reveals a large pseudoaneurysm arising from the Rt
ICA just above the level of CCA bifurcation

Fig 3B
Fig. 3. MRI scan confirms large pseudoaneurysm from the extra Fig. 6. Selective injection of the ICA showed communication of the
cranial right ICA. ICA seen as flow void within the artery with the aneurysm and no evidence of contrast feeding
aneurysm to other vessels.

308 Indian Journal of Pediatrics, Volume 74—March, 2007

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Pseudoaneurysm of Internal Carotid Artery
traumatic aneurysms, carotid sheath hematomas, or
intramural dissecting hematomas. These complications
result from injuries of the intima, media,or entire arterial
wall.
Traumatic aneurysms of the internal carotid artery are
generally “false aneurysms” (pseudoaneurysms) with at
least part of the aneurysm wall composed only of the
adventitial layer, or even just by the hematoma.
Pseudoaneurysms typically become symptomatic from 2­
8 weeks after trauma, although they may become
symptomatic at any point in time. Presentation may even
be delayed for as long as long as 30 years after injury. The
most common presenting complaint is a pulsatile or
nonpulsatile neck mass. Less commonly, patients may
experience embolic episodes (TIAs, amaurosis fugax). The
emboli may arise from mural thrombi within the
pseudoaneurysm or from associated intimal tears. Neck
pain (carotidynia) is also quite frequent. Carotidynia can
be caused by enlargement of the pseudoaneurysm,
rupture of the aneurysm into the carotid sheath, or from
an associated intramural dissection.
Arterial spasm may be the only radiographic finding
in patients with minimal arterial injury. An arteriogram is
necessary to make this diagnosis. More severe arterial
injuries, such as pseudoaneurysms or dissecting
hematomas, can often be detected on thin-section T1- and
T2-weighted MR scans. The MR appearance of these
lesions will vary, depending on their size, age, extent of
thrombosis, and presence or absence of associated arterial
occlusions. A pseudoaneurysm generally appears, on
sectional MR images, as a small mass lesion that is closely
contiguous with the parent artery but which projects
outside its normal confines. The lumen of the
pseudoaneurysm may be patent or thrombosed. Clotted
aneurysms often contain concentric, laminated rings of
thrombus in various stages of evolution. Patency of the
aneurysm is often discernible on MR scans by an absence
of signal (flow-void) in the aneurysm sac due to rapid/
turbulent flow. Dissecting hematomas and, occasionally,
large pseudoaneurysms can compromise the normal
arterial lumen and impair cerebral blood flow. If the
artery is completely occluded or flow markedly slowed,
the normal “flow-void” within the internal carotid artery
lumen may disappear on standard spin-echo images. A
narrowed but patent vessel can be differentiated from an
occluded one through the use of flow-sensitive MR pulse
sequences (e.g., GRASS, FLASH). Carotid Doppler
evaluation can also reliably establish the presence or
absence of complete occlusion of the proximal segment of
the internal carotid artery. The distal cervical segment,
however, is not usually accessible to this technique.
Arteriography, of course, is still essential for definitive
diagnosis and precise delineation of pseudoaneurysms,
dissecting hematomas, and traumatic arteriovenous
fistulae.
Indian Journal of Pediatrics, Volume 74—March, 2007
Extracranial ICA aneurysms can also be caused by a
wide variety of conditions, including atherosclerosis,
fibromuscular dysplasia, infection, autoimmune
connective tissue disease, heritable connective tissue
disorders, or arterial dissection. In most series the most
common cause of intracranial ICA aneurysms has been
spontaneous or traumatic arterial dissection. In a review
of 22 cases of extracranial ICA aneurysms 50% were
caused by spontaneous dissections and the remaining
were caused by traumatic dissection of the ICA.
In many large series of extracranial ICA dissection, the
age of presentation varied widely between 16-68 years.
The authors patient was only 3-year-old at the time of
diagnosis. Misra BK et al, have reported a distal
extracranial aneurysm in a 5 year old boy.
Pseudoaneurysms must be treated because of the
complications inherent to it. The usual treatment to such
injuries is surgery, with dissection and ligation of the
afferent artery and, if possible, resection of the
aneurysmal sac. Such maneuver may increase the risk of
injury to surrounding structures involved in the
pseudoaneurysm. A bibliographical review at Medline
made four years ago found four reports of such case.
Three of them, in which patients presented with a swollen
area that could be mistaken for an abscess, were treated
through surgery and had a successful outcome.
Although surgical repair has long been the standard
treatment for pseudoaneurysms, recent reports describe
the use of stent-grafts for selected cases. This therapeutic
option has been hampered by the limited number and
types of available stent-grafts, the large diameter and
stiffness of introducing systems, and regulatory issues
surrounding these devices. Endovascular surgery using
stents will become the prime modality for treatment of
traumatic pseudoaneurysm in the future.
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injury: devastating consequences of undetected
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carotid artery aneurysms: Case report and literature review.
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3. Mokri et al. Traumatic and spontaneous extracranial internal
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