External carotid artery-to-petrous internal carotid artery radial artery graft bypass for a giant high cervical aneurysm

External carotid artery-to-petrous internal carotid artery radial artery graft bypass for a giant high cervical aneurysm | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article External carotid artery-to-petrous internal carotid artery radial artery graft bypass for a giant high cervical aneurysm Kaiming Gao, Wenqiang Guo, Xiaoguang Tong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3878275/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 Objective To investigate optimal treatment strategies for giant high-cervical internal carotid artery aneurysms. Methods A retrospective analysis was conducted, examining clinical data, surgical approaches, and postoperative outcomes in a case involving a patient with a giant high-cervical internal carotid artery aneurysm. Additionally, pertinent literature was reviewed to contextualize the findings. Results A 52-year-old male patient presented with a one-year history of intermittent coughing, exacerbated by a two-month history of headaches. Digital Subtraction Angiography (DSA) revealed the presence of a giant high-cervical internal carotid artery aneurysm on the right side. The patient underwent an external carotid artery-radial artery-internal carotid artery petrosal segment bypass and aneurysm isolation surgery. Postoperative angiography demonstrated the disappearance of the aneurysm and patency of the bypass. Notably, there were no occurrences of new cerebral ischemia or infarction, no manifestation of new neurological dysfunction, and a marked improvement in the patient's original symptoms. Conclusion The treatment of giant high-cervical internal carotid artery aneurysms necessitates cerebral vascular bypass surgery, with the external carotid artery-radial artery-internal carotid artery petrosal bone segment bypass proving to be an efficacious and preferable therapeutic modality for such lesions. High cervical portion Giant Aneurysm Petrous segment Bypass Figures Figure 1 Introduction Extracranial internal carotid artery aneurysms (EICAs) are an infrequent occurrence, constituting less than 1% of all aneurysms [1, 2] . Despite their low rupture rate, the associated risk of substantial disability and mortality necessitates proactive surgical intervention. Particularly challenging are EICAs situated at the skull base [3-7] . Although endovascular interventions and the application of flow-diverting stents have become commonplace, cerebrovascular bypass surgery remains a crucial therapeutic avenue for addressing these aneurysms [8] . In this report, we present a case involving a giant high cervical EICA situated at the skull base. The aneurysm was effectively managed through the implementation of cervical external carotid artery-radial artery-internal carotid artery bypass and subsequent isolation of the aneurysm. Case Presentation: A 52-year-old male presented with a one-year history of intermittent coughing and a two-month history of progressively worsening headaches. Physical examination revealed the presence of a pulsatile mass in the right cervical region. A computed tomography (CT) scan illustrated a mixed-density round mass in the right parapharyngeal space, and endoscopy identified a pulsatile mass within the pharyngeal mucosa. Subsequent computed tomography angiography (CTA) confirmed the diagnosis of a right high cervical extracranial internal carotid artery aneurysm (EICA), measuring approximately 2.4 × 2.5 × 3.2 cm. High-resolution magnetic resonance imaging (MRI) delineated a sizable aneurysm at the C1 segment of the right internal carotid artery with associated thrombus formation. MR perfusion revealed slightly delayed mean transit time (MTT) and time to peak (TTP) in the right lateral ventricular zone and centrum semiovale. Preoperative angiography and balloon occlusion test indicated an opening anterior communicating artery and yielded negative results for the balloon occlusion test, with no resultant neurological deficits during the procedure. Due to the location of the aneurysm at the skull base, characterized by a substantial volume and indistinct boundaries, conventional endovascular treatment was deemed unsuitable. A decision was made to perform cervical external carotid artery-radial artery-internal carotid artery bypass coupled with aneurysm isolation. The patient, positioned supine with the head turned oppositely, underwent exposure of cervical vessels. Utilizing a frontal-temporal-zygomatic approach, the petrous segment of the right internal carotid artery (approximately 1 cm in length) was exposed. Simultaneously, hand surgeons harvested the radial artery. The cervical external carotid artery was initially anastomosed end-to-end to the radial artery, with the bypass vessel subsequently routed subcutaneously to the petrous segment of the internal carotid artery. Subsequently, the radial artery was anastomosed end-to-side to the petrous segment of the internal carotid artery. Permanent aneurysm clips were deployed at the origin of the internal carotid artery and the proximal end of the anastomosis between the radial artery and petrous segment of the internal carotid artery, effectively isolating the cervical internal carotid artery. The surgical procedure progressed without complications, and postoperative angiography confirmed the absence of residual aneurysm filling or obstruction of the bypass graft. Follow-up MRI perfusion exhibited marked improvement in perfusion within previously hypoperfused areas. The patient experienced a favorable postoperative recovery with significant amelioration of initial symptoms and the absence of new neurological deficits. He was discharged in a stable condition, and as of the current submission, remains asymptomatic with complete resolution of preoperative symptoms for a duration of six months postoperatively. Discussion EICAA, while uncommon, poses considerable risks necessitating a proactive therapeutic approach Extracranial internal carotid artery aneurysms (EICAs) are infrequently encountered pathological entities, constituting less than 1% of all aneurysms and approximately 0.4% of peripheral aneurysms [ 1 , 2 ] . The etiology of EICAs remains subject to debate, with proposed associations including atherosclerosis, trauma, surgical history, infection, radiation exposure, and connective tissue diseases, such as Marfan syndrome [ 2 , 9 ] . While EICAs seldom rupture, they commonly manifest as pulsatile masses or present with focal symptoms related to adjacent structures [ 2 ] . Notably, infarction or transient ischemic attacks (TIAs) may ensue due to thromboembolism from intra-aneurysmal thrombus or a floating thrombus within a narrow neck remnant [ 2 ] . The case under consideration presented with dysphagia attributed to cranial nerves IX-XII involvement from aneurysm mass effect and TIA symptoms stemming from acute thromboembolism formation within the aneurysm. Surgical excision with in-situ anastomosis stands as the gold standard, yet is not applicable to massive aneurysms located in the high cervical segment near the skull base. The absence of unified treatment guidelines for EICAs underscores their rarity. Nonetheless, surgical intervention is generally regarded as the preferred option, encompassing approaches such as simple carotid ligation, aneurysm repair, aneurysm resection with anastomosis/vascular reconstruction, and endovascular treatment [ 10 , 11 ] . Historical perspectives reveal the evolution of treatment methodologies. The initial utilization of carotid ligation by Professor Cooper in 1805 [ 12 ] , though associated with substantial risks and high stroke incidence, persisted until the mid-20th century [ 12 ] . With advancements in surgical and endovascular techniques, carotid occlusion has yielded to aneurysm resection and blood flow reconstruction [ 2 ] , with carotid ligation reserved for exceptional cases [ 13 ] . Open surgical repair remains the contemporary gold standard for EICAs [ 11 ] , encompassing aneurysm resection with end-to-end anastomosis, aneurysm repair, and patch angioplasty. Pioneering procedures by Professors Dimtza and Beall in the 1950s and 1960s laid the foundation for addressing extracranial internal carotid aneurysms [ 14 , 15 ] . However, challenges arise in treating high cervical segment aneurysms near the skull base [ 16 ] , necessitating lateral skull base techniques [ 17 , 18 ] . In 1978, Professor Fisch introduced the infratemporal fossa approach, maximizing exposure but at the expense of potential complications, including hearing loss and neurologic damage [ 10 , 17 , 19 – 21 ] . Despite these drawbacks, open surgical repair remains the prevailing standard for EICAs [ 11 ] . Endovascular Intervention: Selective Yet Risk-Laden Advancements in endovascular techniques have expanded treatment options for EICAs, particularly those in high cervical segments. Endovascular methods, including covered stents, stent-assisted embolization, and flow-diverting devices [ 22 – 24 ] , offer alternatives to open surgery, particularly in cases where conventional exposure is challenging [ 10 ] . However, the limitations of endovascular treatment are evident, with reported risks of stroke, aneurysm rupture, and vascular injury [ 25 ] . Factors such as unclear aneurysm neck display and large size pose challenges [ 23 ] , underscoring the need for selective application of endovascular intervention. Cerebrovascular Bypass: Advantages and Considerations Cerebrovascular bypass emerges as a favorable option for EICAs, particularly in cases where open surgery or endovascular intervention presents challenges. High cervical segment aneurysms carry inherent risks, including unpredictable embolism, distal control difficulty, peripheral structure injury, and cranial nerve damage [ 11 ] . To address these concerns, high-flow bypass techniques, such as carotid-radial/ saphenous vein-middle cerebral artery bypass, offer a promising avenue for restoring normal blood flow and isolating the aneurysm [ 26 – 28 ] . However, when dealing with high cervical aneurysms, particularly those situated below the petrous segment of the internal carotid artery, the recipient vessel for bypass surgery is often found at challenging depths, either at ICA-C7 or MCA-M2. This poses difficulties in access, and the bypass method employed cannot entirely isolate the affected internal carotid artery, leaving a residual risk of thrombus embolism. Temporary occlusion of the internal carotid artery or middle cerebral artery during surgery may significantly impact patients sensitive to ischemia [ 27 ] . The primary objective, therefore, is to maximize the restoration of antegrade blood flow without the necessity of opening the skull. In 1980, Fisch et al. introduced a pioneering method for reaching the high cervical and petrous segments of the internal carotid artery through a "subtotal petrosectomy" combined with cervical exposure. This method revolutionized the exposure of the petrous segment of the internal carotid artery [ 17 , 18 ] . Subsequently, many surgeons have endeavored to repair and bypass the cervical and petrous segments of the internal carotid artery using this approach, achieving favorable therapeutic outcomes [ 29 , 30 ] . Despite not requiring skull opening, the primary risk associated with exposing the petrous segment involves potential hearing loss and damage to cranial nerve function [ 10 ] . It has been reported that there is a 20–23% incidence of temporary cranial nerve palsy after surgery [ 31 ] , with almost all patients experiencing temporary facial paralysis. Other drawbacks include impaired ear function and chorda tympani nerve damage [ 10 ] . These complications are linked to petrous bone removal, facial nerve displacement, and condyle process exposure, with no substantial advantage apparent in utilizing this approach. In contrast to the aforementioned procedure, Miyazaki et al. exposed the petrous segment of the internal carotid artery through resection of the middle skull base, enabling bridge surgery based on this exposure [ 32 , 33 ] . Fitzpatrick et al. subsequently standardized and improved this bridge method [ 34 ] . Building upon the detailed anatomical insights provided by Glassock [ 29 ] and Sekhar [ 30 ] , Fitzpatrick devised a modified bypass technique requiring minimal resection of the temporal bone at the middle skull base, eliminating the need for extensive petrous bone removal or facial nerve displacement. This approach allows for the horizontal exposure of approximately 1cm of the petrous segment of the internal carotid artery, sufficient for subsequent bypass surgery. In our approach, we utilized this exposure method to horizontally expose the petrous segment of the internal carotid artery as the recipient vessel, with the ipsilateral external carotid artery serving as the donor vessel. The radial artery was connected to them through a subcutaneous tunnel and subsequently anastomosed. By completely isolating the affected segment of the internal carotid artery, this process involved only one temporary occlusion of the internal carotid artery, further diminishing the potential risk of ischemia. The feasibility of such bypasses is contingent upon meticulous surgical planning and consideration of individual patient characteristics. Conclusion In conclusion, the management of giant high cervical internal carotid aneurysms necessitates a nuanced approach, with cerebrovascular bypass proving to be a crucial therapeutic modality. The external carotid artery-radial artery-petrous segment internal carotid artery bypass, combined with aneurysm isolation, presents a viable solution for treating high cervical or skull base aneurysms. This extradural operation minimizes the impact on cranial circulation, offering reliable treatment effects. Further research is warranted to refine and promote the application of this approach, ensuring optimal outcomes for patients with these challenging pathologies. Declarations Ethical Approval This study was approved by the Ethics Committee of Tianjin Huanhu Hospital. Competing interests The authors declare no competing interests. Authors' contributions Xiaoguang Tong conception and design, critical revision, approval of the manuscript, agreement to be accountable. Kaiming Gao and Wenqiang Guo analysis and interpretation, data collection, writing the manuscript, approval of the manuscript, agreement to be accountable. Funding There was no funding in this study. Availability of data and materials Not applicable. Conflict of Interest and Source of Funding The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. There was no funding in this study. 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Also discoverable on Platform About Our Team In Review Editorial Policies 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-3878275","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":268555388,"identity":"7ee75caa-fe81-4470-ac0e-d3fc21ab3805","order_by":0,"name":"Kaiming Gao","email":"","orcid":"","institution":"Tianjin Huanhu Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kaiming","middleName":"","lastName":"Gao","suffix":""},{"id":268555389,"identity":"74e8e455-af35-4d1e-a651-a062121469a2","order_by":1,"name":"Wenqiang Guo","email":"","orcid":"","institution":"Qilu Hospital of Shandong University (Qingdao)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wenqiang","middleName":"","lastName":"Guo","suffix":""},{"id":268555390,"identity":"00bfb754-6658-405f-8f2c-6bc8ffe9733a","order_by":2,"name":"Xiaoguang Tong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYNACAyjN2HAggZ+Z+fADfIp5MLRItrOlGeDWANMCAyAtBud5FCTwabFn7z38mqfATk4+IvnZw6877uQZH+YB2lpjE43TFp5zaZYzDJKNDW+kmRvLnnlWbHaY98ADhmNpuQ24tEjkmBl8MGBO3DgjwUxasu1w4rbDfAkGjA2H8WtJMKgHakn/BtayuZnHQIKAFuMHHwwOJ84H6pX8CNSygZmQljNnzBhnGBw3NuB5UybNCNQy4zAwkBPw+IW9vcf4M8+fajn59vRtkj+BWvr7Dx9+8KHGBqcWIGADx4LBAQYGZngsJeBWDgLMH0CkPNBQxh/4VY6CUTAKRsEIBQBxGV7IwVAh1gAAAABJRU5ErkJggg==","orcid":"","institution":"Tianjin Huanhu Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Xiaoguang","middleName":"","lastName":"Tong","suffix":""}],"badges":[],"createdAt":"2024-01-19 09:30:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3878275/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3878275/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50188091,"identity":"381f137f-6db8-4e9e-a4db-184ad08e0725","added_by":"auto","created_at":"2024-01-25 21:19:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2313702,"visible":true,"origin":"","legend":"\u003cp\u003eA: Preoperative CT examination; B: 3D-CTA examination; C: Preoperative Preoperative high resolution MRI; D: Preoperative DSA examination; E: Preoperative MRP; F: Intraoperative image; G~H: Postoperative DSA and 3D-DSA examination; I: Postoperative 3D-CTA examination; J: Postoperative MRP.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3878275/v1/7f8720c042a6b15ea44ce524.jpg"},{"id":50271870,"identity":"49207578-ccc9-4a07-8bba-7c1a302693b4","added_by":"auto","created_at":"2024-01-28 18:11:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":445358,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3878275/v1/6957e40f-c6e4-4da5-b501-3be74d6f6e85.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"External carotid artery-to-petrous internal carotid artery radial artery graft bypass for a giant high cervical aneurysm","fulltext":[{"header":"Introduction","content":"\u003cp\u003eExtracranial internal carotid artery aneurysms (EICAs) are an infrequent occurrence, constituting less than 1% of all aneurysms\u003csup\u003e[1, 2]\u003c/sup\u003e. Despite their low rupture rate, the associated risk of substantial disability and mortality necessitates proactive surgical intervention. Particularly challenging are EICAs situated at the skull base\u003csup\u003e[3-7]\u003c/sup\u003e. Although endovascular interventions and the application of flow-diverting stents have become commonplace, cerebrovascular bypass surgery remains a crucial therapeutic avenue for addressing these aneurysms\u0026nbsp;\u003csup\u003e[8]\u003c/sup\u003e. In this report, we present a case involving a giant high cervical EICA situated at the skull base. The aneurysm was effectively managed through the implementation of cervical external carotid artery-radial artery-internal carotid artery bypass and subsequent isolation of the aneurysm.\u003c/p\u003e\n\u003cp\u003eCase Presentation: A 52-year-old male presented with a one-year history of intermittent coughing and a two-month history of progressively worsening headaches. Physical examination revealed the presence of a pulsatile mass in the right cervical region. A computed tomography (CT) scan illustrated a mixed-density round mass in the right parapharyngeal space, and endoscopy identified a pulsatile mass within the pharyngeal mucosa. Subsequent computed tomography angiography (CTA) confirmed the diagnosis of a right high cervical extracranial internal carotid artery aneurysm (EICA), measuring approximately 2.4 \u0026times; 2.5 \u0026times; 3.2 cm. High-resolution magnetic resonance imaging (MRI) delineated a sizable aneurysm at the C1 segment of the right internal carotid artery with associated thrombus formation. MR perfusion revealed slightly delayed mean transit time (MTT) and time to peak (TTP) in the right lateral ventricular zone and centrum semiovale. Preoperative angiography and balloon occlusion test indicated an opening anterior communicating artery and yielded negative results for the balloon occlusion test, with no resultant neurological deficits during the procedure. Due to the location of the aneurysm at the skull base, characterized by a substantial volume and indistinct boundaries, conventional endovascular treatment was deemed unsuitable. A decision was made to perform cervical external carotid artery-radial artery-internal carotid artery bypass coupled with aneurysm isolation. The patient, positioned supine with the head turned oppositely, underwent exposure of cervical vessels. Utilizing a frontal-temporal-zygomatic approach, the petrous segment of the right internal carotid artery (approximately 1 cm in length) was exposed. Simultaneously, hand surgeons harvested the radial artery. The cervical external carotid artery was initially anastomosed end-to-end to the radial artery, with the bypass vessel subsequently routed subcutaneously to the petrous segment of the internal carotid artery. Subsequently, the radial artery was anastomosed end-to-side to the petrous segment of the internal carotid artery. Permanent aneurysm clips were deployed at the origin of the internal carotid artery and the proximal end of the anastomosis between the radial artery and petrous segment of the internal carotid artery, effectively isolating the cervical internal carotid artery. The surgical procedure progressed without complications, and postoperative angiography confirmed the absence of residual aneurysm filling or obstruction of the bypass graft. Follow-up MRI perfusion exhibited marked improvement in perfusion within previously hypoperfused areas. The patient experienced a favorable postoperative recovery with significant amelioration of initial symptoms and the absence of new neurological deficits. He was discharged in a stable condition, and as of the current submission, remains asymptomatic with complete resolution of preoperative symptoms for a duration of six months postoperatively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eEICAA, while uncommon, poses considerable risks necessitating a proactive therapeutic approach\u003c/h2\u003e \u003cp\u003eExtracranial internal carotid artery aneurysms (EICAs) are infrequently encountered pathological entities, constituting less than 1% of all aneurysms and approximately 0.4% of peripheral aneurysms\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The etiology of EICAs remains subject to debate, with proposed associations including atherosclerosis, trauma, surgical history, infection, radiation exposure, and connective tissue diseases, such as Marfan syndrome\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. While EICAs seldom rupture, they commonly manifest as pulsatile masses or present with focal symptoms related to adjacent structures\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Notably, infarction or transient ischemic attacks (TIAs) may ensue due to thromboembolism from intra-aneurysmal thrombus or a floating thrombus within a narrow neck remnant\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The case under consideration presented with dysphagia attributed to cranial nerves IX-XII involvement from aneurysm mass effect and TIA symptoms stemming from acute thromboembolism formation within the aneurysm.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSurgical excision with in-situ anastomosis stands as the gold standard, yet is not applicable to massive aneurysms located in the high cervical segment near the skull base.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe absence of unified treatment guidelines for EICAs underscores their rarity. Nonetheless, surgical intervention is generally regarded as the preferred option, encompassing approaches such as simple carotid ligation, aneurysm repair, aneurysm resection with anastomosis/vascular reconstruction, and endovascular treatment\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Historical perspectives reveal the evolution of treatment methodologies. The initial utilization of carotid ligation by Professor Cooper in 1805\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, though associated with substantial risks and high stroke incidence, persisted until the mid-20th century\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. With advancements in surgical and endovascular techniques, carotid occlusion has yielded to aneurysm resection and blood flow reconstruction\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, with carotid ligation reserved for exceptional cases \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOpen surgical repair remains the contemporary gold standard for EICAs\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, encompassing aneurysm resection with end-to-end anastomosis, aneurysm repair, and patch angioplasty. Pioneering procedures by Professors Dimtza and Beall in the 1950s and 1960s laid the foundation for addressing extracranial internal carotid aneurysms\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. However, challenges arise in treating high cervical segment aneurysms near the skull base\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, necessitating lateral skull base techniques\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. In 1978, Professor Fisch introduced the infratemporal fossa approach, maximizing exposure but at the expense of potential complications, including hearing loss and neurologic damage\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Despite these drawbacks, open surgical repair remains the prevailing standard for EICAs \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEndovascular Intervention: Selective Yet Risk-Laden\u003c/h3\u003e\n\u003cp\u003eAdvancements in endovascular techniques have expanded treatment options for EICAs, particularly those in high cervical segments. Endovascular methods, including covered stents, stent-assisted embolization, and flow-diverting devices\u003csup\u003e[\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e, offer alternatives to open surgery, particularly in cases where conventional exposure is challenging \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. However, the limitations of endovascular treatment are evident, with reported risks of stroke, aneurysm rupture, and vascular injury \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Factors such as unclear aneurysm neck display and large size pose challenges\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e, underscoring the need for selective application of endovascular intervention.\u003c/p\u003e\n\u003ch3\u003eCerebrovascular Bypass: Advantages and Considerations\u003c/h3\u003e\n\u003cp\u003eCerebrovascular bypass emerges as a favorable option for EICAs, particularly in cases where open surgery or endovascular intervention presents challenges. High cervical segment aneurysms carry inherent risks, including unpredictable embolism, distal control difficulty, peripheral structure injury, and cranial nerve damage \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. To address these concerns, high-flow bypass techniques, such as carotid-radial/ saphenous vein-middle cerebral artery bypass, offer a promising avenue for restoring normal blood flow and isolating the aneurysm\u003csup\u003e[\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, when dealing with high cervical aneurysms, particularly those situated below the petrous segment of the internal carotid artery, the recipient vessel for bypass surgery is often found at challenging depths, either at ICA-C7 or MCA-M2. This poses difficulties in access, and the bypass method employed cannot entirely isolate the affected internal carotid artery, leaving a residual risk of thrombus embolism. Temporary occlusion of the internal carotid artery or middle cerebral artery during surgery may significantly impact patients sensitive to ischemia\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. The primary objective, therefore, is to maximize the restoration of antegrade blood flow without the necessity of opening the skull.\u003c/p\u003e \u003cp\u003eIn 1980, Fisch et al. introduced a pioneering method for reaching the high cervical and petrous segments of the internal carotid artery through a \"subtotal petrosectomy\" combined with cervical exposure. This method revolutionized the exposure of the petrous segment of the internal carotid artery\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Subsequently, many surgeons have endeavored to repair and bypass the cervical and petrous segments of the internal carotid artery using this approach, achieving favorable therapeutic outcomes\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Despite not requiring skull opening, the primary risk associated with exposing the petrous segment involves potential hearing loss and damage to cranial nerve function\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. It has been reported that there is a 20\u0026ndash;23% incidence of temporary cranial nerve palsy after surgery \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e, with almost all patients experiencing temporary facial paralysis. Other drawbacks include impaired ear function and chorda tympani nerve damage\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. These complications are linked to petrous bone removal, facial nerve displacement, and condyle process exposure, with no substantial advantage apparent in utilizing this approach.\u003c/p\u003e \u003cp\u003eIn contrast to the aforementioned procedure, Miyazaki et al. exposed the petrous segment of the internal carotid artery through resection of the middle skull base, enabling bridge surgery based on this exposure \u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. Fitzpatrick et al. subsequently standardized and improved this bridge method\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. Building upon the detailed anatomical insights provided by Glassock\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e and Sekhar\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e, Fitzpatrick devised a modified bypass technique requiring minimal resection of the temporal bone at the middle skull base, eliminating the need for extensive petrous bone removal or facial nerve displacement. This approach allows for the horizontal exposure of approximately 1cm of the petrous segment of the internal carotid artery, sufficient for subsequent bypass surgery. In our approach, we utilized this exposure method to horizontally expose the petrous segment of the internal carotid artery as the recipient vessel, with the ipsilateral external carotid artery serving as the donor vessel. The radial artery was connected to them through a subcutaneous tunnel and subsequently anastomosed. By completely isolating the affected segment of the internal carotid artery, this process involved only one temporary occlusion of the internal carotid artery, further diminishing the potential risk of ischemia. The feasibility of such bypasses is contingent upon meticulous surgical planning and consideration of individual patient characteristics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the management of giant high cervical internal carotid aneurysms necessitates a nuanced approach, with cerebrovascular bypass proving to be a crucial therapeutic modality. The external carotid artery-radial artery-petrous segment internal carotid artery bypass, combined with aneurysm isolation, presents a viable solution for treating high cervical or skull base aneurysms. This extradural operation minimizes the impact on cranial circulation, offering reliable treatment effects. Further research is warranted to refine and promote the application of this approach, ensuring optimal outcomes for patients with these challenging pathologies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003eThis study was approved by the Ethics Committee of Tianjin Huanhu Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003eXiaoguang Tong conception and design, critical revision, approval of the manuscript, agreement to be accountable. Kaiming Gao and Wenqiang Guo analysis and interpretation, data collection, writing the manuscript, approval of the manuscript, agreement to be accountable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e There was no funding in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest and Source of Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. There was no funding in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFankhauser GT, Stone WM, Fowl RJ, O'Donnell ME, Bower TC, Meyer FB, et al. Surgical and medical management of extracranial carotid artery aneurysms[J]. 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Operative exposure and management of the petrous and upper cervical internal carotid artery[J]. Neurosurgery, 1986,19(6):967\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi FD, Gao ZQ, Ren HL, Liu CW, Song XJ, Li YF, et al. Pre-reconstruction of cervical-to-petrous internal carotid artery: An improved technique for treatment of vascular lesions involving internal carotid artery at the lateral skull base[J]. Head Neck, 2016,38 Suppl 1:E1562-7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyazaki S, Fukushima T, Fujimaki T. Resection of high-cervical paraganglioma with cervical-to-petrous internal carotid artery saphenous vein bypass. Report of two cases[J]. J Neurosurg, 1990,73(1):141\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpetzler RF, Fukushima T, Martin N, Zabramski JM. Petrous carotid-to-intradural carotid saphenous vein graft for intracavernous giant aneurysm, tumor, and occlusive cerebrovascular disease[J]. J Neurosurg, 1990,73(4):496\u0026ndash;501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitzpatrick BC, Spetzler RF, Ballard JL, Zimmerman RS. Cervical-to-petrous internal carotid artery bypass procedure. Technical note[J]. J Neurosurg, 1993,79(1):138\u0026ndash;41.\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":"High cervical portion, Giant Aneurysm, Petrous segment, Bypass","lastPublishedDoi":"10.21203/rs.3.rs-3878275/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3878275/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective To investigate optimal treatment strategies for giant high-cervical internal carotid artery aneurysms.\u003c/p\u003e\n\u003cp\u003eMethods A retrospective analysis was conducted, examining clinical data, surgical approaches, and postoperative outcomes in a case involving a patient with a giant high-cervical internal carotid artery aneurysm. Additionally, pertinent literature was reviewed to contextualize the findings.\u003c/p\u003e\n\u003cp\u003eResults A 52-year-old male patient presented with a one-year history of intermittent coughing, exacerbated by a two-month history of headaches. Digital Subtraction Angiography (DSA) revealed the presence of a giant high-cervical internal carotid artery aneurysm on the right side. The patient underwent an external carotid artery-radial artery-internal carotid artery petrosal segment bypass and aneurysm isolation surgery. Postoperative angiography demonstrated the disappearance of the aneurysm and patency of the bypass. Notably, there were no occurrences of new cerebral ischemia or infarction, no manifestation of new neurological dysfunction, and a marked improvement in the patient's original symptoms.\u003c/p\u003e\n\u003cp\u003eConclusion The treatment of giant high-cervical internal carotid artery aneurysms necessitates cerebral vascular bypass surgery, with the external carotid artery-radial artery-internal carotid artery petrosal bone segment bypass proving to be an efficacious and preferable therapeutic modality for such lesions.\u003c/p\u003e","manuscriptTitle":"External carotid artery-to-petrous internal carotid artery radial artery graft bypass for a giant high cervical aneurysm","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-25 21:19:04","doi":"10.21203/rs.3.rs-3878275/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":"fb849f7b-2012-4ccf-9287-bf304c9a92f6","owner":[],"postedDate":"January 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-12T11:25:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-25 21:19:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3878275","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3878275","identity":"rs-3878275","version":["v1"]},"buildId":"cTy_lsJlmDsVRNrSptgXS","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}