Figura 1. 3D reconstruction of the internal carotid artery.

Figura 2. Right internal carotid artery arteriography. The arrow points to the aneurysmal dilation.

Figura 3. Placement of the first coil prior to stent deployment. The arrow points to the coil.

Figura 4. 5 × 30 mm Wallstent implantation in the aneurysm and coil cast deployment. Final angiogra...

Introduction

Extracranial internal carotid artery aneurysms account for less than 2% of all arterial aneurysms and are more frequent in men than in women (ratio 2:1)1. Most are located near the carotid bifurcation; however, only 10.5% occur in the cervical region (segment C1)2. While they are usually asymptomatic, they may present as cervical pain, neurological deficit due to embolism, or, less frequently, spontaneous rupture3.

The most common causes include trauma, atherosclerosis, infection (such as syphilis), and iatrogenic procedures3. However, spontaneous aneurysms are unusual and pose diagnostic and therapeutic challenges.

The evolution of endovascular techniques has expanded treatment options, especially in patients at high surgical risk1. In this case, treatment with coils and a closed-cell stent achieved complete resolution of the aneurysm.

Clinical case

The patient was 40-year-old male rural worker, without cardiovascular risk factors or history of trauma. He consulted for persistent holocranial headaches, 10/10 intensity, over 4 months, unresponsive to analgesics. During the aforementioned period, he visited the emergency room multiple times, but computed tomography scans showed no relevant findings.

Given the persistent symptoms, a cerebral MR angiography was requested, revealing a saccular aneurysm with a narrow neck in the right internal carotid artery, cervical portion (segment C1), affecting the lateral wall. The neck measured 2.1 mm and the sac, 9.5 × 6.1 mm, with distal segments of normal caliber and flow. There were no abnormalities in the left internal carotid artery (Figure 1).

Digital angiography confirmed aneurysm location and morphology (Figure 2). Given the complexity of the case and the anatomical location of the aneurysm, the Department of Neurosurgery ruled out open surgery and referred the patient to the Department of Hemodynamics for endovascular treatment.

Embolization technique

Local anesthesia was administered under cardiac monitoring. A right femoral arterial access was used, applying the Seldinger technique, to place a 6-Fr introducer with side flush that was later exchanged for a carotid sheath (Destination®, 7 Fr). Through the sheath, a Vitek® catheter was advanced to perform baseline angiography. It confirmed the presence of an aneurysm in the right internal carotid artery, cervical portion, immediately before the intrapetrosal segment. A 1.7-Fr double-marker microcatheter was advanced into the aneurysm, and a first coil was positioned without deployment (Figure 3). In parallel, a 0.014 guidewire was used to advance a closed-cell self-expanding stent (WallstentTM, 5 × 30 mm) (Figure 4), which was deployed using a jailing technique over the 1.7-Fr microcatheter. Finally, the aneurysm was completely filled with three detachable Axium® 3D coils (7 × 15 mm, 9 × 30 mm, 6 × 10 mm), and both the microcatheter and stent delivery catheter were removed. Angiographic control confirmed aneurysmal occlusion with complete stent apposition to the vessel wall and no residual lesions.

The patient progressed favorably without complications and was discharged on dual antiplatelet therapy. On follow-up visits at 1, 6, and 12 months, he reported no headaches, and a 12-month follow-up CT angiography confirmed stent patency and complete aneurysm occlusion.

Discussion

Aneurysms in the cervical part of the internal carotid artery are unusual and pose a clinical challenge due to their low prevalence and nonspecific manifestations. Noninvasive imaging studies for their diagnosis, including MR angiography and CT angiography, are class I indications according to international guideline recommendations4. However, in our daily practice, digital angiography often remains the reference standard when defining obstruction percentages, evaluating flow, and ensuring precise imaging accuracy.

Endovascular therapy is especially relevant in complex aneurysms or in patients who are not suitable for open surgery5. The use of stents and coils, as in this case, provided effective aneurysm exclusion while reducing the risks associated with conventional surgery.

The satisfactory outcomes in this case reinforce the usefulness of the endovascular approach in the different treatments of carotid disease.

Conclusion

Endovascular treatment with coils and closed-cell stents is an effective and minimally invasive alternative for aneurysms in the cervical segment of the internal carotid artery. Proper patient and device selection is key to optimizing outcomes.

1. Cárdenas Figueroa E, Abdo Sarras G, Durán Carrillo F. Stent micromallado para el tratamiento del aneurisma cervical sintomático de la arteria carótida interna. Angiología vol.74 no.1 Madrid ene./feb. 2022. Epub 14-Mar-2022.

2. Hayami H, Fukutome K, Aketa S, Fukumori J, Mitsui T, Shiraishi Y, et al. Covered stent deployment for a recurrent cervical internal carotid artery aneurysm referencing angioscopy: illustrative case. J Neurosurg Case Lessons. 2024 Sep 16;8(12): CASE24383. Doi:10.3171/CASE24383. PMID: 39284234; PMCID: PMC11418031.

3. Bartolomé Sánchez A, Inaraja Pérez G , Vélez Lomana A, Tejero Juste C, Buisán Bardaji JM. Aneurisma sintomático de arteria carótida interna. Angiología vol.72 no.5 Madrid sep./oct. 2020 Epub 30-Nov-2020.

4. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. European Heart Journal, Volume 45, Issue 36, 21 September 2024. Pages 3538-3700.

5. Talledo O, Mena MA, Durand W, Plaza F, De la Peña O, Torres L. Aneurismas de carótida extracraneal: técnicas quirúrgicas y endovasculares. A propósito de 4 casos. Rev Med Hered vol.28 no.4 Lima oct./dic. 2017.

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