Endovascular Treatment of 147 Cases of Cavernous Carotid Aneurysms: A Single-Center Experience

Acute Venous Outflow Obstruction After Coil Embolization of Giant Cavernous Carotid Aneurysm: 2-Dimensional Operative Video

BACKGROUND AND IMPORTANCE

Endovascular treatment of giant carotid cavernous aneurysms (GCCAs) may be associated with complications including rapid intrasaccular thrombosis, embolic ischemic stroke, and caroticocavernous fistula.

CLINICAL PRESENTATION

A female in her 6th decade presented with a chronic, right partial abducens nerve palsy. Magnetic resononance angiography demonstrated a 25-mm right GCCA causing mass effect on the right cavernous sinus. Coil embolization of the aneurysm and parent vessel was performed after passing a balloon test occlusion. Final angiography demonstrated complete embolization of the aneurysm, however, absent ipsilateral cavernous sinus drainage, which was present previously. Intraprocedurally, the patient had ipsilateral proptosis and chemosis. Once extubated, urgent ophthalmology review documented preserved and symmetrical visual acuity with both pupils reactive to light. Intraocular pressure was 19-mm and 11-mm Hg in the right and left eye, respectively. The right eye had -2 abduction with otherwise intact extraocular movements. Acute management included a total of 16-mg IV dexamethasone on day 1, followed by a course of oral steroids and prophylactic low molecular weight heparin. Postprocedure computed tomography of the head demonstrated periorbital soft tissue edema and dilatation of the right superior ophthalmic vein, which peaked at 6 hours postprocedure. The patients' ocular findings and visual disturbances subsided within 36 hours postprocedure. The chronic partial abducens nerve palsy remained.

CONCLUSION

Acute proptosis, chemosis, and visual disturbances may occur from mass effect on the cavernous sinus with venous outflow obstruction after GCCA embolization. This is thought to be secondary to increased mass effect from intrasaccular thrombosis and the large coil mass.

Surgical Trapping of a Cavernous Carotid Aneurysm Causing Carotid Cavernous Fistula After Flow Diverter Placement: Technical Note and Literature Review

BACKGROUND

Flow diverter (FD) treatment is a promising therapeutic strategy for intracranial aneurysms such as cavernous carotid aneurysms (CCAs). Direct cavernous carotid fistula (CCF) caused by delayed rupture of FD-treated CCAs has been reported, and endovascular therapy has been used in the literature. Surgical treatment is warranted for patients who have failed or are ineligible for endovascular treatment. However, no studies have evaluated surgical treatment to date. Here, this paper presents the first case of direct CCF due to delayed rupture of an FD-treated CCA managed with surgical internal carotid artery (ICA) trapping with bypass revascularization, in which the intracranial ICA with FD placement was successfully occluded with aneurysm clips.

METHODS

A 63-year-old man with a diagnosis of large symptomatic left CCA underwent FD treatment. The FD was deployed from the supraclinoid segment of the ICA distal to the ophthalmic artery to the petrous segment of the ICA. Since angiography 7 months after the FD placement showed progressive direct CCF, left superficial temporal artery-middle cerebral artery bypass followed by ICA trapping was performed.

RESULTS

The intracranial ICA proximal to the ophthalmic artery where the FD was placed was successfully occluded using two aneurysm clips. The postoperative course was uneventful. Follow-up angiography 8 months after the surgery confirmed complete obliteration of the direct CCF and CCA.

CONCLUSIONS

The intracranial artery in which the FD was deployed was successfully occluded with two aneurysm clips. ICA trapping can be a feasible and useful therapeutic option to treat direct CCF caused by FD-treated CCAs.

Bypass Surgery to Treat Giant Cavernous Carotid Artery Aneurysms

BACKGROUND

With the development of bypass technique, more and more complex aneurysms can be treated with bypass surgery. The goal of this study is to evaluate the efficacy and safety of bypass in patients with giant cavernous carotid aneurysms (GCCAs). To further discuss the treatment of asymptomatic GCCAs.

METHODS

The authors retrospectively reviewed our experience of the internal carotid artery (ICA) ligation/constriction combined with high/low-flow bypass surgery in the treatment of GCCAs.

RESULTS

Among the entire cohort, 4 patients underwent ICA ligation combined with high-flow bypass, 7 patients underwent ICA ligation/constriction combined with low-flow bypass. The postoperative symptom improvement: of 9 patients with preoperative ophthalmoplegia, the symptom resolved in 2 patients, improved in 7 patients, of 7 patients with preoperative pain, the symptom resolved in 2 patients, improved in 4 patients and was unchanged in 1 patient. The results of following-up were measured using the modified Rankin scale (mRS). During the follow-up, there were 9 patients with mRS score 0 to 1, 1 patient with mRS score 2, and 1 patient with mRS score 3. The long-term graft patency rate was 100%. All patients had no recurrence of intracranial aneurysm.

CONCLUSIONS

Bypass surgery is a safe and effective method to treat GCCAs. Because of the risk of GCCAs and the improvement of bypass surgery technology, active surgical strategies should be adopted for asymptomatic or mild symptomatic GCCAs.

Cavernous carotid artery large aneurysm treated with a new flow diverter – Xcalibur aneurysm occlusion device (AOD)

We report a case of an unruptured, symptomatic, large right cavernous internal carotid artery aneurysm successfully treated with a new balloon-expandable flow diverter – Xcalibur Aneurysm Occlusion Device (AOD). Follow up imaging performed at six months demonstrated complete exclusion of the aneurysm and regression in dimensions, resulting in resolution of mass effect and clinical improvement.

Endovascular Treatment for Cavernous Carotid Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Coiling and flow diversion are established endovascular techniques for treatment of cavernous carotid aneurysms (CCAs). We performed a systematic review of published series on endovascular treatment of CCAs in order to assess the efficacy and safety between coiling and flow diversion.

METHODS

We conducted a computerized search of PubMed, MEDLINE, and Web of Science electronic databases for reports on endovascular treatment of CCAs from 1990 to 2019. Comparisons were made in complete occlusion rate, improvement of symptoms rate and intraoperative complication rate between coiling and flow diversion.

RESULTS

Fourteen studies with 736 patients were included in this systematic review. Five hundred ninety-4 patients underwent coiling, 142 patients underwent flow diversion. The complete occlusion rate in the coiling group was significantly lower than that in the flow division group (odds ratio .37, 95%CI .16-.83, P < .00001), a forest plot did not reveal any significant differences in the improvement of symptoms rate or intraoperative complication rate following coiling and flow diversion. Complete occlusion rate was significantly lower in the coiling group (53%, 95%CI .40-.67) compared with the flow diversion group (74%, 95%CI .55-.94). Improvement of symptoms was significantly lower in the coiling group (54%, 95%CI .46-.63) compared with the flow diversion group (92%, 95%CI .85-.99). Coiling group had lower intraoperative complication rate (9%, 95%CI .06-.12) compared with flow division group (36%, 95%CI .25-.47).

CONCLUSIONS

Compared with coiling, the use of flow diversion for the treatment of CCAs may increase complete occlusion rate, and improvement of symptoms rate, but it also raised intraoperative complication rate. Due to the lack of high quality control research, further randomized controlled trials are needed to verify our conclusions.

Unruptured giant intracavernous aneurysms untolerate internal carotid artery occlusion test: Untreated and treated with flow-diversion

BACKGROUND AND OBJECTIVE

Giant intracavernous aneurysms (GICAs) are located in extradural space; their clinical manifestation and treatment are different from other intradural aneurysms. This study reports clinical outcomes of GICAs untolerate internal carotid artery occlusion tests.

METHODS

Between January 2012 and September 2017, 14 consecutive cases of GICAs untolerated internal carotid artery occlusion test were retrospectively reviewed. A total of nine patients were not treated and five patients were treated using a Pipeline Embolization Device.

RESULTS

Of the 14 patients, 12 had compression symptoms and 2 were incidental. In nine untreated patients, during 34 months' (range, 7-64 months) follow-up, four worsened to headaches or ablepsia (more than 34 months). One patient, who presented with ophthalmoplegia and diplopia, showed spontaneous resolution of symptoms at 32-month follow-up. Symptoms in four patients remained unchanged during less than 36-month follow-up period. In five (100%, 95% confidence interval 57% to 100%) treated patients, symptoms recovered completely during 11 months' follow-up after transient worsening of mass compression.

CONCLUSIONS

GICAs frequently result in intractable cranial neuropathy requiring treatment. The Pipeline Embolization Device is an effective option for these complex aneurysms in selective cases.

Predictors of the Resolution of Cavernous Sinus Syndrome Caused by Large/Giant Cavernous Carotid Aneurysms After Parent Artery Occlusion with High-Flow Bypass

OBJECTIVE

To evaluate the clinical results and factors related to the resolution of preoperative cranial neuropathy after internal carotid artery ligation with high-flow bypass in patients with symptomatic large or giant cavernous carotid aneurysms.

METHODS

This study included 18 consecutive patients (15 women) with cranial neuropathy. All patients underwent therapeutic internal carotid artery ligation with high-flow bypass using a radial artery graft. Patient demographics, duration of symptoms, clinical outcomes, complications, and radiographic findings were retrospectively analyzed. The mean follow-up period was 31.0 months (range: 3-74 months).

RESULTS

Patients' mean age was 66.6 years, and the mean aneurysm size was 23.7 mm. Six patients (33%) had partially thrombosed aneurysms. Preoperatively, 16 (89%) and 8 (44%) patients presented with ophthalmoplegia and facial pain, respectively. Bypass patency was confirmed in 15 patients (83%), and obliteration of the aneurysm was confirmed in all patients at the final follow-up. Preoperative ophthalmoplegia resolved in 10 patients (63%), and trigeminal pain resolved in all patients. Postoperative resolution of patients' ophthalmoplegia was significantly associated with age (P = 0.044), symptom duration before treatment (P = 0.042), and the degree of ophthalmoplegia (P = 0.046). The degree of postoperative residual ophthalmoplegia was positively correlated with the duration of ophthalmoplegia from onset to surgery (r = 0.619; P = 0.011). Preoperative trigeminal pain resolved regardless of the preoperative duration of this symptom in all patients.

CONCLUSIONS

Early treatment is recommended when treating large or giant cavernous carotid aneurysms with cranial neuropathy. Complete resolution is possible in younger patients with partial neuropathy.

Orbital Compartment Syndrome Secondary to Direct Carotid Cavernous Fistula After Carotid Cavernous Aneurysm Rupture: Case Report and Review of Literature

BACKGROUND

Carotid cavernous aneurysm (CCA) rupture is rare. However, it can result in various complications such as carotid cavernous fistula (CCF), epistaxis, spontaneous thrombosis, and subarachnoid hemorrhage.

CASE DESCRIPTION

We report a 65-year-old woman with a history of uncontrolled diabetes who was referred with complaints of acute headache, diplopia, proptosis, and chemosis. Ophthalmic examination revealed elevated intraocular pressure in the right eye, optic disk edema, and retinal venous congestion. Canthotomy was performed based on a diagnosis of orbital compartment syndrome (OCS). Further imaging revealed a dilated superior ophthalmic vein and cavernous sinus, as well as swelling of the extraocular muscles in the right eye. Digital subtraction angiography revealed the fistulous connection between the cavernous part of the internal carotid and cavernous sinus (direct CCF) due to the large ruptured CCA, resulting in retrograde flow through the superior and inferior ophthalmic veins. Successful endovascular coiling of the aneurysm resulted in complete occlusion of the fistula. Postintervention ophthalmic examination demonstrated progressive improvement of ophthalmic signs and symptoms; however, the patient's right eye remained sightless.

CONCLUSIONS

In patients with clinical manifestation of OCS with no history of any predisposing risk factors, diagnosis of ruptured cavernous sinus aneurysm and resulting direct CCF should be considered. In such cases, emergent imaging along with early endovascular intervention can resolve OCS and prevent permanent ocular injury and vision loss.