Successful endovascular embolization of a cervical internal carotid artery fenestration associated with an aneurysm: a rare case report

Successful endovascular embolization of a cervical internal carotid artery fenestration associated with an aneurysm: a rare case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Successful endovascular embolization of a cervical internal carotid artery fenestration associated with an aneurysm: a rare case report Liangbin Li, Weiqiang Liao, Zhicong Jian, Miaofeng Deng, Weitian Qian, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6722784/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Fenestration of the cervical segment of the internal carotid artery is a rare cerebrovascular variation, and its origin is not fully understood. There are few reports of aneurysm with fenestration of the cervical segment of the internal carotid artery. We report a case of fenestration of the cervical segment of the left internal carotid artery with a cystic aneurysm, which was treated by vascular embolization, and the follow-up results to 3 months after treatment. Case presentation: A 62-year-old male patient was admitted because of dizziness. Magnetic resonance imaging (MRI) revealed a fenestration of the cervical segment of the left internal carotid artery with a cystic aneurysm. The diagnosis was confirmed by digital subtraction angiography (DSA), and aneurysm embolization was performed. At 3 months after treatment the patient indicated that the dizziness had subsided, and he had no complaints. DSA showed that the aneurysm had not recurred. Conclusions: This case demonstrates the feasibility of interventional embolization for the treatment of fenestration of the carotid artery neck segment combined with an aneurysm. Fenestration cervical segment internal carotid artery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Aneurysmal fenestration of cerebral arteries refers to a situation where the vessel originates from one point, branches into two branches during its course, and then recombines into one vessel to form a hollow fenestrated structure 1 . Fenestration of cerebral vessels is commonly observed in the basilar artery, vertebral artery, and anterior cerebral artery 2 – 3 . In clinical practice, fenestration of the internal carotid artery is rarely observed. The fenestration structure is typically accompanied by aneurysms, primarily fusiform aneurysms. This may be related to the reduced collagen content of the fenestrated vessel, defects in smooth muscle and vessel intima, and changes in hemodynamics at both ends of the fenestration 4 . There are no treatment guidelines for fenestration of the internal carotid artery combined with an aneurysm. However, there are a few reports of fenestration deformities of the carotid body of the internal carotid artery combined with aneurysms, which provide treatment experience. However, aneurysms combined with fenestration deformities of the cervical segment of the internal carotid artery have rarely been reported, and there is a lack of treatment reference experience. Therefore, herein we report the treatment and follow-up results of a patient with a cystic aneurysm and fenestration of the left cervical segment of the internal carotid artery. Case presentation A 62-year-old Asian male came to the hospital due to experiencing dizziness and vomiting for 1 day. The dizziness was intermittent, causing a feeling of vertigo, and each episode lasted approximately 5 minutes. The symptoms worsened with changes in body position. When the dizziness was severe, vomiting occurred. There were no accompanying symptoms such as headache or double vision. Apart from a positive Romberg sign, no other positive neurological symptoms were found during the physical examination. The patient was a farmer with no history of hypertension, hyperlipidemia, or diabetes. He had no history of alcohol use or smoking, and no family history of genetic diseases. To determine if the dizziness was related to posterior circulation ischemia, cerebral and cervical magnetic resonance angiography (MRA) was performed, and the results showed a non-ruptured aneurysm in the cervical segment of the left internal carotid artery (Fig. 1A, C 1 − 3 ). Subsequent 3D-arterial spin labeling (3D-ASL) MRI showed no abnormal changes in bilateral brain tissue perfusion (Fig. 2B). Interventional embolization was planned to treat the aneurysm. Five days before the surgery the patient was begun on aspirin 100 mg and clopidogrel 75 mg daily as antiplatelet therapy. The surgery was performed under general anesthesia, and prior to embolization digital subtraction angiography (DSA) showed a fenestrated malformation in the cervical segment of the left internal carotid artery (Fig. 3D), with a localized dilated area identified as a 12 × 9 mm cystic aneurysm (Fig. 3A, C). The diameter of the distal vessel of the left internal carotid artery was 5 mm, and the diameter of the proximal vessel was 6 mm (Fig. 3B). First, a WALLSTENT stent (7 mm × 40 mm) was partially released. Then, two Target 360ULTRA stents (5 mm × 10 cm, 4 mm × 8 cm) were used to embolize the aneurysms in the fenestrated malformation area. The WALLSTENT was then completely released (Fig. 3E, F). Finally, a complete embolization was performed on the entire aneurysm, and the feeding artery remained unobstructed after embolization. The surgery lasted for 1.3 hours, and there were no complications such as aneurysm rupture or cerebral vasospasm. Postoperatively, the patient was continued on antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg daily) for 3 months. At follow-up 3 months after surgery the patient indicated that the dizziness had resolved and had no other complaints. The patient stated that since the surgery he had not experienced subcutaneous ecchymosis, black stool, hematuria, or other bleeding symptoms. Repeat DSA showed that the aneurysm was completely embolized without recurrence, and the supplying artery was unobstructed(Fig. 4A, B). After the DSA, the antiplatelet drugs were changed(clopidogrel 75 mg daily). Discussion and conclusion The detection rate of cerebral artery fenestration malformations by DSA is only 0.3–0.9%, and the cause of their formation remains unknown 2 . According to embryological theory, the formation of cerebral artery fenestration is due to failure of the fusion of two equivalent vessels. In this kind, the diameters of the two forming vessels were equal 5 . Some scholars have proposed that the extracranial anastomosis between perforating arteries, where the embryonic reticular structure of the perforating arteries remains partial, may also lead to fenestration malformations 6 . Due to reasons such as reduced collagen in the fenestrated vessels, smooth muscle and intimal defects, and changes in hemodynamics at both ends of the fenestration, fenestration malformations are frequently combined with aneurysms and are a cause of ischemic cerebral strokes 1 , 7 . Fenestration malformations of cerebral arteries are more common in the posterior circulation. As early as 1907, some scholars described fenestration malformations of the basilar artery, and it was not until 1980 that the first case of fenestration malformation of the intracranial segment of the internal carotid artery was reported 8 . Fenestration malformations of the internal carotid artery combined with aneurysms are primarily seen in the petrous segment of the internal carotid artery 9 – 10 . The occurrence of fenestration malformations of the cervical segment of the internal carotid artery combined with aneurysms is extremely rare. Our patient was admitted to the hospital due to dizziness, which is a non-specific symptom of an intracranial aneurysm. After being examined by an otolaryngologist, he was diagnosed with "peripheral vestibular vertigo", and treatment with oral betahistine mesylate tablets the dizziness symptom was alleviated. However, in the initial stage of diagnosis in order to rule out ischemia in the posterior circulation 3D-ASL MRI and MRA were performed. The results showed no cerebral infarction or abnormal changes in brain tissue perfusion. However, cerebral vascular magnetic resonance angiography(MRA) revealed a "double lumen sign" change in the left internal carotid artery segment(Fig. 1B 1 − 3 ), which could be misdiagnosed as an aneurysmal dissection 11 . To differentiate between an internal carotid artery fenestration malformation and arterial dissection, DSA, which is the “gold standard” for diagnosis was performed. The fenestration malformation variation and aneurysm of the cervical segment of the internal carotid artery were clearly visualized on DSA imaging (Fig. 3A). The treatment of a cerebral vascular fenestration malformation combined with an aneurysm can be achieved through surgery or interventional embolization. However, there have been few reported cases of the treatment of a fenestration malformation combined with an aneurysm in the cervical segment of the internal carotid artery; thus, there is a lack of treatment experience. Our treatment was based on the following information. 1) The surgical procedures for the treatment of a cerebral vascular fenestration malformation combined with an aneurysm include internal carotid artery aneurysm resection and end-to-end anastomosis of the internal carotid artery, internal carotid artery aneurysm resection and carotid patch formation, and vascular bypass transplantation combined with aneurysm resection. Considering that the aneurysm in this case was located in the extracranial segment of the internal carotid artery and close to the base of the skull (MRI indicated with was at the level of the first cervical vertebra), the surgical approaches were limited because the exposure of the aneurysm would be difficult. In addition, complications such as neurological function impairment are not infrequent with open surgery. 2) In a prior report, Qi et al. reported treating 23 patients with fenestration malformations combined with aneurysms in the petrous region. The treatment consisted of overlapping WALLSTENT implantation to treat large or giant aneurysms in the extracranial segment of the internal carotid artery, and interventional embolization. Based on the above points, we chose interventional embolization as the treatment method. Due to the unique structure of the fenestration malformation of the cervical segment of the internal carotid artery, some difficulties were encountered during interventional embolization. 1) The vessel carrying aneurysms is locally dilated and expanded, and it is difficult to select the normal lumen with a micro guidewire. It is necessary to present the local normal lumen path based on the vascular reconstruction image for selection, and then use a micro catheter for angiography verification. 2) The aneurysm was located in the cervical segment of the internal carotid artery, and the distal part of the vessel with the aneurysm was curved. This made it difficult to deliver the carotid stent. During the operation, the micro catheter was used to guide the intermediate catheter across the distal end of the aneurysm, and then the stent was delivered using the intermediate catheter. 3) The vessel carrying aneurysms is locally dilated and expanded and it is difficult to select the aneurysm cavity with a micro catheter. It is necessary to present the expanded aneurysm based on the vascular reconstruction image and perform selection and embolization under the path. Notably, DSA 3 months after treatment showed that one of the blood vessels that was part of the fenestration malformation that was not stented was almost invisible (Fig. 4A, B). A possible reason is that after the vascular endothelial cells grew along the stent, the changes in hemodynamics led to a reduction in blood flow to the other branch vessels, gradually causing the vessels to close. Due to the limited follow-up results of previous reports of carotid artery malformations combined with aneurysms, this conjecture requires more similar cases to verify. Conducting hemodynamic and pathological studies on this phenomenon may be the direction of future research. Compared with the report by Tanqi et al. on the use of interventional therapy for large or giant aneurysms in the extracranial segment of the carotid artery, the treatment process and the subsequent follow-up results of this case indicate that interventional embolization for aneurysms combined with carotid artery fenestration malformations is feasible. It also provides reference experience for the treatment of carotid artery fenestration malformations combined with aneurysms. However, attention must be given to the possible risks during treatment and follow-up. The case reported by Christian et al. of a carotid artery neck segment fenestration combined with transient cerebral ischemic attacks pointed out that even without abnormal blood perfusion, a carotid artery neck segment fenestration may be associated with a higher risk of stroke 4 . In this situation, whether the change in vascular morphology after treatment would lead to abnormal blood perfusion has not been studied. Considering that our patient had no symptoms of cerebral infarction, we did not conduct a blood perfusion examination during follow-up. For patients with a fenestration malformation of the carotid artery neck segment combined with an aneurysm, interventional embolization is a feasible treatment method. However, the safety and efficacy of this approach need to be confirmed through more similar cases. At the same time, the risk of cerebral infarction during follow-up should be considered. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of the Affiliated Sanshui Hospital, Zhujiang Hospital, Southern Medical University, and informed consent was obtained from the patient. Consent to publish This manuscript has obtained the informed consent of the patient and his/her daughter for publication and the written informed consent forms have been obtained from the patient and their family members. Data availability No datasets were generated or analysed during the current study. Conflicts of interest The authors declare that there are no conflicts of interest relevant to this work. Competing interests The authors declare no competing interests. Funding The project was supported by Foshan the 14th Five-Year Plan Key Discipline Foundation. Author contributions Writing-Original Draft:Liangbin Li Conceptualization:Weiqiang Liao Formal analysis:Zhicong Jian Data Curation:Miaofeng Deng,Weitian Qian Investigation:Jianpei Mai Writing-Review&Editing:Jiwei Song Acknowledgements The authors thank the patient and his family for contributing to this study and the members of the Neurosurgery Department at Sanshui Hospital for their exceptional managing this case. References Nasel C, Poetsch A, Brunner C, et al. Transitory ischemic attack associated with a rare fenestration of the cervical segment of the internal carotid artery: a case report[J]. J Med Case Rep. 2022;16(1):95. 10.1186/s13256-022-03341-7 . Patel MA, Caplan JM, Yang W, et al. Arterial fenestrations and their association with cerebral aneurysms.[J]. J Clin Neurosci. 2014;21(12):2184–8. 10.1016/j.jocn.2014.07.005 . Czyżewski W, Hoffman Z, Szymoniuk M et al. The Incidence, Localization and Clinical Relevance of Arterial Fenestrations and Their Association to Brain Aneurysms: A Case-Control Study Based on the STROBE Guidelines.[J].Brain Sci. 2022 -09-28;12(10).DOI:10.3390/brainsci12101310 Zheng M, Liu X, Song Y, et al. Rare fenestration of an occluded internal carotid artery treated with stenting[J].Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery. North Am Chapter. 2020;72(1):319–20. 10.1016/j.jvs.2020.03.034 . Koenigsberg RA, Zito JL, Patel M, et al. Fenestration of the internal carotid artery: a rare mass of the hypotympanum associated with persistence of the stapedial artery.[J]. Ajnr Am J Neuroradiol. 1995;16(4 Suppl):908–10. 10.1016/S1076-6332(05)80200-4 . Gailloud P, Carpenter J, Heck DV, et al. Pseudofenestration of the cervical internal carotid artery: a pathologic process that simulates an anatomic variant.[J]. Am J Neuroradiol. 2004;25(3):421–4. 10.1055/s-2003-814851 . Abdo M, Guinto G, Contreras R, et al. Management of distal anterior cerebral artery aneurysms:PartⅡ:surgical technique. [J] Contemp Neurosurg. 2011;33:1–5. Killien FC, Wyler AR, Cromwell LD. Duplication of the internal carotid artery. Neuroradiology. 1980;19(2):101–2. Miyake S, Falzon A, Kee TP et al. Treatment of an intracranial aneurysm in the setting of fenestration of cranial division of the internal carotid artery: Technical considerations and a literature review.[J].INTERV NEURORADIOL.DOI:2024-06-17.10.1177/15910199241262845. Zhou Z, Yu J. Endovascular treatment of a supraclinoid internal carotid artery fenestration aneurysm: A case report and literature review.[J].Heliyon. 2023-06-01;9(6):e17605. 10.1016/j.heliyon.2023.e17605 Mrginean L, Filep RC, Constantin C et al. Fenestration of the cervical internal carotid artery misdiagnosed as dissection[J].Romanian journal of morphology and embryology = Revue roumaine de morphologie et embryologie, 2020, 61(1). 10.47162/RJME.61.1.30 Additional Declarations No competing interests reported. Supplementary Files Abbreviations.doc Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6722784","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":489850570,"identity":"9b9b604d-5df4-4912-b5c7-4be1b3b1dead","order_by":0,"name":"Liangbin Li","email":"","orcid":"","institution":"Department of Neurosurgery, Sanshui Hospital, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Liangbin","middleName":"","lastName":"Li","suffix":""},{"id":489850571,"identity":"41107d6d-17ff-4716-8c22-8e8937bc1061","order_by":1,"name":"Weiqiang Liao","email":"","orcid":"","institution":"Department of Neurosurgery, Sanshui Hospital, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Weiqiang","middleName":"","lastName":"Liao","suffix":""},{"id":489850572,"identity":"baea314e-d8d8-450d-ac76-09694321b5e2","order_by":2,"name":"Zhicong Jian","email":"","orcid":"","institution":"Department of Neurosurgery, Sanshui Hospital, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhicong","middleName":"","lastName":"Jian","suffix":""},{"id":489850573,"identity":"8f999ba0-6a56-41f7-9f40-b06a8ec2ac70","order_by":3,"name":"Miaofeng Deng","email":"","orcid":"","institution":"Department of Neurosurgery, Sanshui Hospital, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Miaofeng","middleName":"","lastName":"Deng","suffix":""},{"id":489850577,"identity":"97f96dc8-da03-4242-ae28-8a9108b20d49","order_by":4,"name":"Weitian Qian","email":"","orcid":"","institution":"Department of Neurosurgery, Sanshui Hospital, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Weitian","middleName":"","lastName":"Qian","suffix":""},{"id":489850578,"identity":"65d3d287-974a-447d-91e9-39979b7b0e97","order_by":5,"name":"Jianpei Mai","email":"","orcid":"","institution":"Department of Neurosurgery, Sanshui Hospital, Zhujiang Hospital, Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jianpei","middleName":"","lastName":"Mai","suffix":""},{"id":489850579,"identity":"31108ce9-a9fa-4827-bb0b-4df07f4e0487","order_by":6,"name":"Jiwei Song","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYFCCA4wPPvywqednb2x8+IFILcyGM3vSEiR7DjcbSxBpDZs0D9vhBIMb6W0CPMSol288Y2zAw8OcJznzYRuDBIOdnG4DAS0GB84YPpCwYCvml05se1DAkGxsdoCQFoazmw2A1jDOnJ3YbiDBcCBxGyEt8g1nt0kksEkwbrh5sE2ChxgtDAeAWg6wGSRuuMFIpBaDA+c/Gzb2JBhL9iQCA9mACL/IzziW+PjPj/9y/OzHHz78UGEnR1ALgwSKCgNCykGAv4EYVaNgFIyCUTCiAQDQ0Ul4Yed9yQAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Neurosurgery, Sanshui Hospital, Zhujiang Hospital, Southern Medical University","correspondingAuthor":true,"prefix":"","firstName":"Jiwei","middleName":"","lastName":"Song","suffix":""}],"badges":[],"createdAt":"2025-05-22 08:23:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6722784/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6722784/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87709876,"identity":"d1a01671-1e80-49e7-9146-ed88a0ebc24b","added_by":"auto","created_at":"2025-07-28 08:29:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":251585,"visible":true,"origin":"","legend":"\u003cp\u003eHigh-resolution enhanced MRI shows local dilation of the left internal carotid artery at its neck segment (white arrows in A, C\u003csub\u003e1-3\u003c/sub\u003e). Multiple cross-sectional images demonstrate the \"double lumen sign\" alteration (white arrows in B\u003csub\u003e1-3\u003c/sub\u003e).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6722784/v1/7cef7a5d1aa04a2fa19857fc.png"},{"id":87709880,"identity":"749a646e-9519-44a8-8d7a-c01233910e74","added_by":"auto","created_at":"2025-07-28 08:29:02","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":420811,"visible":true,"origin":"","legend":"\u003cp\u003eDWI sequence results showed no cerebral infarction changes (A). 3D-ASL sequence indicated no obvious abnormal perfusion changes in bilateral brain tissues (B).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6722784/v1/6b90d609c0aba567631edf3f.png"},{"id":87710491,"identity":"4d7efbd1-c94a-4dc3-a84e-fe4e94e03305","added_by":"auto","created_at":"2025-07-28 08:37:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":914971,"visible":true,"origin":"","legend":"\u003cp\u003eThe 3D-DSA imaging shows that the cervical segment of the left internal carotid artery shows a fenestrated-like change, presenting a fenestration deformity. There is a local dilation at one of the branches (white arrows in A, C, and D). The Wallstent stent implantation combined with dense coils achieved a tight embolization of the aneurysm, and the blood flow was unobstructed in the two branches of the fenestration deformity (white arrows in E and F).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6722784/v1/e14812e053ae7b6aa735490c.png"},{"id":87710489,"identity":"4c230245-f00b-41ea-89fb-98877f215a44","added_by":"auto","created_at":"2025-07-28 08:37:02","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":290309,"visible":true,"origin":"","legend":"\u003cp\u003e3D-DSA imaging results from the 3-month postoperative follow-up showed complete embolization of the aneurysm and no recurrence (white arrow in A). The non-aneurysmal branches of the fenestrated artery were almost not visualized (white arrow in B).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6722784/v1/f51d7ce8b3a1b084d115239c.png"},{"id":87709878,"identity":"ad50aed5-b669-488e-94fc-94cd0bfad893","added_by":"auto","created_at":"2025-07-28 08:29:02","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":14910,"visible":true,"origin":"","legend":"\u003cp\u003eTreatment and medication process\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6722784/v1/ced937099d506e2168b5cb00.png"},{"id":101401785,"identity":"6b694ca1-27dd-4698-9eec-9f4a52f12ec5","added_by":"auto","created_at":"2026-01-29 10:03:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2776705,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6722784/v1/1f79857e-1e1a-4253-91f0-16f4a63c4f5c.pdf"},{"id":87709873,"identity":"c33d1e02-4002-424f-bd5d-631f7429aa7a","added_by":"auto","created_at":"2025-07-28 08:29:02","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":11264,"visible":true,"origin":"","legend":"","description":"","filename":"Abbreviations.doc","url":"https://assets-eu.researchsquare.com/files/rs-6722784/v1/a7676ced8dbff81af622d5e9.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Successful endovascular embolization of a cervical internal carotid artery fenestration associated with an aneurysm: a rare case report","fulltext":[{"header":"Background","content":"\u003cp\u003eAneurysmal fenestration of cerebral arteries refers to a situation where the vessel originates from one point, branches into two branches during its course, and then recombines into one vessel to form a hollow fenestrated structure\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. Fenestration of cerebral vessels is commonly observed in the basilar artery, vertebral artery, and anterior cerebral artery\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. In clinical practice, fenestration of the internal carotid artery is rarely observed. The fenestration structure is typically accompanied by aneurysms, primarily fusiform aneurysms. This may be related to the reduced collagen content of the fenestrated vessel, defects in smooth muscle and vessel intima, and changes in hemodynamics at both ends of the fenestration\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. There are no treatment guidelines for fenestration of the internal carotid artery combined with an aneurysm. However, there are a few reports of fenestration deformities of the carotid body of the internal carotid artery combined with aneurysms, which provide treatment experience. However, aneurysms combined with fenestration deformities of the cervical segment of the internal carotid artery have rarely been reported, and there is a lack of treatment reference experience. Therefore, herein we report the treatment and follow-up results of a patient with a cystic aneurysm and fenestration of the left cervical segment of the internal carotid artery.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 62-year-old Asian male came to the hospital due to experiencing dizziness and vomiting for 1 day. The dizziness was intermittent, causing a feeling of vertigo, and each episode lasted approximately 5 minutes. The symptoms worsened with changes in body position. When the dizziness was severe, vomiting occurred. There were no accompanying symptoms such as headache or double vision. Apart from a positive Romberg sign, no other positive neurological symptoms were found during the physical examination. The patient was a farmer with no history of hypertension, hyperlipidemia, or diabetes. He had no history of alcohol use or smoking, and no family history of genetic diseases.\u003c/p\u003e\u003cp\u003eTo determine if the dizziness was related to posterior circulation ischemia, cerebral and cervical magnetic resonance angiography (MRA) was performed, and the results showed a non-ruptured aneurysm in the cervical segment of the left internal carotid artery (Fig.\u0026nbsp;1A, C\u003csub\u003e1 − 3\u003c/sub\u003e). Subsequent 3D-arterial spin labeling (3D-ASL) MRI showed no abnormal changes in bilateral brain tissue perfusion (Fig.\u0026nbsp;2B). Interventional embolization was planned to treat the aneurysm.\u003c/p\u003e\u003cp\u003eFive days before the surgery the patient was begun on aspirin 100 mg and clopidogrel 75 mg daily as antiplatelet therapy. The surgery was performed under general anesthesia, and prior to embolization digital subtraction angiography (DSA) showed a fenestrated malformation in the cervical segment of the left internal carotid artery (Fig.\u0026nbsp;3D), with a localized dilated area identified as a 12 × 9 mm cystic aneurysm (Fig.\u0026nbsp;3A, C). The diameter of the distal vessel of the left internal carotid artery was 5 mm, and the diameter of the proximal vessel was 6 mm (Fig.\u0026nbsp;3B).\u003c/p\u003e\u003cp\u003eFirst, a WALLSTENT stent (7 mm × 40 mm) was partially released. Then, two Target 360ULTRA stents (5 mm × 10 cm, 4 mm × 8 cm) were used to embolize the aneurysms in the fenestrated malformation area. The WALLSTENT was then completely released (Fig.\u0026nbsp;3E, F). Finally, a complete embolization was performed on the entire aneurysm, and the feeding artery remained unobstructed after embolization. The surgery lasted for 1.3 hours, and there were no complications such as aneurysm rupture or cerebral vasospasm. Postoperatively, the patient was continued on antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg daily) for 3 months.\u003c/p\u003e\u003cp\u003eAt follow-up 3 months after surgery the patient indicated that the dizziness had resolved and had no other complaints. The patient stated that since the surgery he had not experienced subcutaneous ecchymosis, black stool, hematuria, or other bleeding symptoms. Repeat DSA showed that the aneurysm was completely embolized without recurrence, and the supplying artery was unobstructed(Fig.\u0026nbsp;4A, B). After the DSA, the antiplatelet drugs were changed(clopidogrel 75 mg daily).\u003c/p\u003e"},{"header":"Discussion and conclusion","content":"\u003cp\u003eThe detection rate of cerebral artery fenestration malformations by DSA is only 0.3–0.9%, and the cause of their formation remains unknown\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. According to embryological theory, the formation of cerebral artery fenestration is due to failure of the fusion of two equivalent vessels. In this kind, the diameters of the two forming vessels were equal\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. Some scholars have proposed that the extracranial anastomosis between perforating arteries, where the embryonic reticular structure of the perforating arteries remains partial, may also lead to fenestration malformations\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. Due to reasons such as reduced collagen in the fenestrated vessels, smooth muscle and intimal defects, and changes in hemodynamics at both ends of the fenestration, fenestration malformations are frequently combined with aneurysms and are a cause of ischemic cerebral strokes\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. Fenestration malformations of cerebral arteries are more common in the posterior circulation. As early as 1907, some scholars described fenestration malformations of the basilar artery, and it was not until 1980 that the first case of fenestration malformation of the intracranial segment of the internal carotid artery was reported\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. Fenestration malformations of the internal carotid artery combined with aneurysms are primarily seen in the petrous segment of the internal carotid artery\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. The occurrence of fenestration malformations of the cervical segment of the internal carotid artery combined with aneurysms is extremely rare.\u003c/p\u003e\u003cp\u003eOur patient was admitted to the hospital due to dizziness, which is a non-specific symptom of an intracranial aneurysm. After being examined by an otolaryngologist, he was diagnosed with \"peripheral vestibular vertigo\", and treatment with oral betahistine mesylate tablets the dizziness symptom was alleviated. However, in the initial stage of diagnosis in order to rule out ischemia in the posterior circulation 3D-ASL MRI and MRA were performed. The results showed no cerebral infarction or abnormal changes in brain tissue perfusion. However, cerebral vascular magnetic resonance angiography(MRA) revealed a \"double lumen sign\" change in the left internal carotid artery segment(Fig.\u0026nbsp;1B\u003csub\u003e1 − 3\u003c/sub\u003e), which could be misdiagnosed as an aneurysmal dissection\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. To differentiate between an internal carotid artery fenestration malformation and arterial dissection, DSA, which is the “gold standard” for diagnosis was performed. The fenestration malformation variation and aneurysm of the cervical segment of the internal carotid artery were clearly visualized on DSA imaging (Fig.\u0026nbsp;3A).\u003c/p\u003e\u003cp\u003eThe treatment of a cerebral vascular fenestration malformation combined with an aneurysm can be achieved through surgery or interventional embolization. However, there have been few reported cases of the treatment of a fenestration malformation combined with an aneurysm in the cervical segment of the internal carotid artery; thus, there is a lack of treatment experience. Our treatment was based on the following information. 1) The surgical procedures for the treatment of a cerebral vascular fenestration malformation combined with an aneurysm include internal carotid artery aneurysm resection and end-to-end anastomosis of the internal carotid artery, internal carotid artery aneurysm resection and carotid patch formation, and vascular bypass transplantation combined with aneurysm resection. Considering that the aneurysm in this case was located in the extracranial segment of the internal carotid artery and close to the base of the skull (MRI indicated with was at the level of the first cervical vertebra), the surgical approaches were limited because the exposure of the aneurysm would be difficult. In addition, complications such as neurological function impairment are not infrequent with open surgery. 2) In a prior report, Qi et al. reported treating 23 patients with fenestration malformations combined with aneurysms in the petrous region. The treatment consisted of overlapping WALLSTENT implantation to treat large or giant aneurysms in the extracranial segment of the internal carotid artery, and interventional embolization. Based on the above points, we chose interventional embolization as the treatment method.\u003c/p\u003e\u003cp\u003eDue to the unique structure of the fenestration malformation of the cervical segment of the internal carotid artery, some difficulties were encountered during interventional embolization. 1) The vessel carrying aneurysms is locally dilated and expanded, and it is difficult to select the normal lumen with a micro guidewire. It is necessary to present the local normal lumen path based on the vascular reconstruction image for selection, and then use a micro catheter for angiography verification. 2) The aneurysm was located in the cervical segment of the internal carotid artery, and the distal part of the vessel with the aneurysm was curved. This made it difficult to deliver the carotid stent. During the operation, the micro catheter was used to guide the intermediate catheter across the distal end of the aneurysm, and then the stent was delivered using the intermediate catheter. 3) The vessel carrying aneurysms is locally dilated and expanded and it is difficult to select the aneurysm cavity with a micro catheter. It is necessary to present the expanded aneurysm based on the vascular reconstruction image and perform selection and embolization under the path.\u003c/p\u003e\u003cp\u003eNotably, DSA 3 months after treatment showed that one of the blood vessels that was part of the fenestration malformation that was not stented was almost invisible (Fig.\u0026nbsp;4A, B). A possible reason is that after the vascular endothelial cells grew along the stent, the changes in hemodynamics led to a reduction in blood flow to the other branch vessels, gradually causing the vessels to close. Due to the limited follow-up results of previous reports of carotid artery malformations combined with aneurysms, this conjecture requires more similar cases to verify. Conducting hemodynamic and pathological studies on this phenomenon may be the direction of future research. Compared with the report by Tanqi et al. on the use of interventional therapy for large or giant aneurysms in the extracranial segment of the carotid artery, the treatment process and the subsequent follow-up results of this case indicate that interventional embolization for aneurysms combined with carotid artery fenestration malformations is feasible. It also provides reference experience for the treatment of carotid artery fenestration malformations combined with aneurysms. However, attention must be given to the possible risks during treatment and follow-up. The case reported by Christian et al. of a carotid artery neck segment fenestration combined with transient cerebral ischemic attacks pointed out that even without abnormal blood perfusion, a carotid artery neck segment fenestration may be associated with a higher risk of stroke\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e. In this situation, whether the change in vascular morphology after treatment would lead to abnormal blood perfusion has not been studied. Considering that our patient had no symptoms of cerebral infarction, we did not conduct a blood perfusion examination during follow-up.\u003c/p\u003e\u003cp\u003eFor patients with a fenestration malformation of the carotid artery neck segment combined with an aneurysm, interventional embolization is a feasible treatment method. However, the safety and efficacy of this approach need to be confirmed through more similar cases. At the same time, the risk of cerebral infarction during follow-up should be considered.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of the Affiliated Sanshui Hospital, Zhujiang Hospital, Southern Medical University, and informed consent was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript has obtained the informed consent of the patient and his/her\u0026nbsp;\u003c/p\u003e\n\u003cp\u003edaughter for publication and the written informed consent forms have been\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eobtained from the patient and their family members.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest relevant to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was supported by Foshan the 14th Five-Year Plan Key Discipline\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFoundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWriting-Original Draft:Liangbin Li\u003c/p\u003e\n\u003cp\u003eConceptualization:Weiqiang Liao\u003c/p\u003e\n\u003cp\u003eFormal analysis:Zhicong Jian\u003c/p\u003e\n\u003cp\u003eData Curation:Miaofeng Deng,Weitian Qian\u003c/p\u003e\n\u003cp\u003eInvestigation:Jianpei Mai\u003c/p\u003e\n\u003cp\u003eWriting-Review\u0026amp;Editing:Jiwei Song\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the patient and his family for contributing to this study and the members of the Neurosurgery Department at Sanshui Hospital for their exceptional managing this case.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNasel C, Poetsch A, Brunner C, et al. 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Fenestration of the cervical internal carotid artery misdiagnosed as dissection[J].Romanian journal of morphology and embryology\u0026thinsp;=\u0026thinsp;Revue roumaine de morphologie et embryologie, 2020, 61(1).\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.47162/RJME.61.1.30\u003c/span\u003e\u003cspan address=\"10.47162/RJME.61.1.30\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Fenestration, cervical segment, internal carotid artery","lastPublishedDoi":"10.21203/rs.3.rs-6722784/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6722784/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eFenestration of the cervical segment of the internal carotid artery is a rare cerebrovascular variation, and its origin is not fully understood. There are few reports of aneurysm with fenestration of the cervical segment of the internal carotid artery. We report a case of fenestration of the cervical segment of the left internal carotid artery with a cystic aneurysm, which was treated by vascular embolization, and the follow-up results to 3 months after treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eA 62-year-old male patient was admitted because of dizziness. Magnetic resonance imaging (MRI) revealed a fenestration of the cervical segment of the left internal carotid artery with a cystic aneurysm. The diagnosis was confirmed by digital subtraction angiography (DSA), and aneurysm embolization was performed. At 3 months after treatment the patient indicated that the dizziness had subsided, and he had no complaints. DSA showed that the aneurysm had not recurred.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis case demonstrates the feasibility of interventional embolization for the treatment of fenestration of the carotid artery neck segment combined with an aneurysm.\u003c/p\u003e","manuscriptTitle":"Successful endovascular embolization of a cervical internal carotid artery fenestration associated with an aneurysm: a rare case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-28 08:28:57","doi":"10.21203/rs.3.rs-6722784/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81d8a714-3953-4347-8ad2-c0ddcce755c7","owner":[],"postedDate":"July 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-29T09:59:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-28 08:28:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6722784","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6722784","identity":"rs-6722784","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}