Case Presentation: A 78-year-old female presented with headaches of ten days duration associated jaw soreness while chewing. She was afebrile and erythrocyte sedimentation rate (ESR) was elevated at 74 mm/hr. After performing a magnetic resonance angiogram, a conventional cerebral angiogram confirmed the presence of a wide-necked right posterior communicating artery aneurysm approximately 5 mm in size and a right cervical carotid aneurysm measuring 12 mm in its greatest dimension.Temporal arteritis was suspected. She was started on 55 mg daily of prednisone prior to temporal artery biopsy one day later. Biopsy of the temporal artery revealed prominent lymphoplasmacytic inflammation with numerous histiocytes involving the internal and external elastic lamina. Elastic stain demonstrated patchy destruction of the internal elastic lamina. These biopsy findings were consistent with the diagnosis of giant cell arteritis. One day following steroid initiation, the patient reported improvement in her headaches. She was discharged home on prednisone 55 mg oral daily with close follow up.
Discussion: Our patient is unusual due to her posterior communicating artery aneurysm and her extracranial carotid aneurysm. It is rare for TA to effect intradural arteries, and when it does, patients may present with ischemic stroke due to narrowing and occlusion of the arteries, often the intradural portions of the vertebral arteries (Zwicker J, Parra, Siemonson, Sheehan). We are aware of only seven reports of patients with intradural aneurysms with GCA in the literature (Thal, Love, Takahashi, Kozuka, Waggenvoort, Corliss, Shuangshoti). Death due to ruptured intradural giant posterior circulation aneurysms has been described in two young children with GCA with giant cells in the wall of the aneurysms (Love, Corliss). Waggenvoort describes a boy who died of a ruptured renal artery aneurysm which contained giant cells. Also discovered was an aneurysm of the intracranial internal carotid and brachial and subclavian arteries. Two previously healthy teenage women died of ruptured posterior circulation aneurysms (Thal, Shuangshoti). Giant cells were seen in the aneurysm wall.Takahashi describes a female with a ruptured fusiform PICA aneurysm whose wall was infiltrated with giant cells.Kozuka describes A 52 year old man with rupture of a distal MCA aneurysm/ Giant cells were found in the wall of the excised aneurysm. It is possible that our patient’s aneurysm was an incidental finding and not result of giant cell arteritis. However, she did not have traditional risk factors for the formation of aneurysms of the circle of Willis such as smoking or hypertension. Since she was found to have an inflammatory disease, likely the aneurysm and inflammatory disease are related. Our patient also had an aneurysm of the cervical internal carotid artery which is unusual. Only one case of a patient with temporal arteritis and fusiform aneurysms of common carotid, innominate and subclavian arteries has been reported (Eton). A case of a patient with a saccular subclavian artery aneurysm and temporal arteritis was also reported (Klein). No other cases of dissecting aneurysms of the cervical internal carotid have been reported in association with GCA or TA.
Conclusions: We describe a unique presentation of TA and a posterior communicating artery aneurysm and an aneurysm of the cervical internal carotid. This is likely the first case of a cervical internal carotid aneurysm associated with TA to be reported in the literature.
