Endovascular treatment of carotid cavernous aneurysms: complications, outcomes and comparison of interventional strategies

The best treatment modality for cavernous carotid aneurysms (CCA) remains unclear. We treated 82 CCA in 79 patients with endovascular coiling (n=14), stent assistance (n=53), and carotid vessel deconstruction (CVD) (n=15). Favorable outcomes were defined as a Glasgow Outcome Scale of 4 to 5 without worsening signs or symptoms. Mean CCA size was 13.3±9.2 mm, and CCA treated with CVD were larger (p=0.010). Fourteen patients had incidental CCA, 40 (50.6%) had cranial nerve palsies (CNP), and 25 (31.7%) had pain leading to diagnosis. Immediate occlusion (>95%) occurred in 91.5% of aneurysms. Ischemic or hemorrhagic complications developed following eight treatments (9.8%) and three were permanent (3.7%). There were no deaths, and favorable discharge outcome occurred following 87.8% of procedures. Although there was no difference in immediate occlusion or complications amongst treatment cohorts, fewer permanent complications (0% versus 10.3%, p=0.041) and favorable discharge outcomes (p=0.039) were associated with stent assisted treatment. Follow-up was available following 75 procedures (mean 21.4±17.4 months). Recanalization occurred in 36% of patients and retreatment in 25%. Patients presenting with CNP improved over time (p<0.001); 54% of patients presenting with CNP remained unchanged while 46% improved; there was no difference in improvement rates stratified by treatment. Favorable follow-up outcome occurred after 96% of treatments and those receiving stents were more likely to have favorable outcome in multivariate analysis (p=0.039). Endovascular therapy is a safe and effective therapy for CCA. When possible, stent assisted therapy may be the best option with fewer complications and low recanalization rates.