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

doi:10.1016/j.jocn.2013.03.003

Journal of Clinical Neuroscience

Volume 21, Issue 1, January 2014, Pages 40-46

https://doi.org/10.1016/j.jocn.2013.03.003 Get rights and content

Abstract

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.

Introduction

Aneurysms arising from the cavernous segment of the internal carotid artery represent approximately 2–12% of intracranial aneurysms.1, 2, 3 Due to increasing use of non-invasive imaging, a larger percentage of cavernous carotid aneurysms (CCA) are found incidentally. These lesions may also cause signs or symptoms secondary to mass effect on adjacent structures or rupture resulting in carotid cavernous fistulas or subarachnoid hemorrhage (SAH). Due to the complexity and risk of microsurgical treatment,⁴ endovascular intervention has become the preferred therapy when necessary. Although results following treatment of aneurysms originating from the Circle of Willis have been extensively reviewed in the literature, rates of complications and outcomes following treatment of symptomatic CCA remain less clear.1, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 Additionally, improvements in technology have increased the number of treatment options for CCA. We review our experience with the endovascular treatment of CCA, assess results following intervention with endovascular coiling, stent assistance, or carotid deconstruction, and determine predictors of outcome.

Section snippets

Patient cohort

The study protocol was approved by the Thomas Jefferson University Institutional Review Board. We searched our prospectively maintained database for all patients with CCA undergoing endovascular treatment between 2005 and 2011. A total of 79 patients with 82 CCA were identified. Medical charts, angiographic studies, MRI, and CT scans were carefully reviewed. Patients’ age, sex, Hunt and Hess grades, and aneurysm locations were recorded. Treatment was dictated by the attending neurosurgeon.

Patient characteristics

Of 79 patients with CCA, the mean age was 60.2 ± 10.7 years and 73 were women (92.4%). Mean aneurysm size was 13.3 ± 9.2 mm and 12 (15.2%) were found to be enlarging on serial imaging. CCA were treated with endovascular coiling (14; 17.7%), carotid vessel deconstruction (CVD) following balloon occlusion test (15; 18.3%), and stent assistance (53; 64.6%). A representative patient treated with stent assisted coiling is presented in Fig. 1, CVD in Fig. 2, and coiling in Fig. 3. Of those receiving

Discussion

CCA are unique in that they have a low risk of rupture except in giant aneurysms.¹⁹ Treatment is often necessary due to progressive aneurysm enlargement or symptoms from mass effect. Due to the complexity and potential morbidity of microsurgical treatment, endovascular therapy has become the preferred treatment for CCA. Additionally, advances in interventional materials and techniques have expanded treatment options for CCA. We have found endovascular therapy to be a safe and durable option for

Conclusions

Endovascular therapy is a safe and effective therapy for CCA. In patients whereby prolonged dual antiplatelet therapy is not an option both primary coiling and CVD are acceptable alternatives. Treatment with CVD following balloon occlusion testing is safe and may be the most durable treatment option. When possible, stent assisted therapy may be the best option with fewer complications and low recanalization rates.

Conflicts of interest/disclosures

Aaron S. Dumont: Consultant for ev3, Stryker, Pascal Jabbour: Consultant for ev3, Codman, Mizuho, Stavropoula Tjoumakaris: Consultant for Stryker, L. Fernando Gonzalez: Consultant for ev3, Robert 93Rosenwasser: Consultant for Boston Scientific.

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Cited by (13)

Coiling ruptured aneurysms arising from the posterior genu of the cavernous internal carotid artery: A report of two cases
2024, International Journal of Surgery Case Reports
Exceptionally, aneurysms from the posterior genu of the cavernous internal carotid artery (ICA) can rupture, resulting in subarachnoid hemorrhage (SAH). We reported such a case and provided another case with an unruptured aneurysm as a control to confirm the rarity of the ruptured aneurysm from the posterior genu of the cavernous ICA.
Case 1: This was a 46-year-old female with SAH. Computed tomography angiography (CTA) and digital subtraction angiography (DSA) confirmed that an aneurysm from the posterior genu of the right cavernous ICA had expanded into the intradural space and ruptured; the aneurysm was coiled completely. Postoperatively, she died from cerebral ischemia due to vasospasm. Case 2: This was a 59-year-old female with SAH. CTA and DSA revealed six aneurysms, including two mirror-like aneurysms from the bilateral anterior communicating artery (AcomA), two tandem aneurysms from the posterior genu of the left cavernous ICA, and two aneurysms from the bilateral anterior cavernous ICAs. After coiling the two tandem aneurysms from the posterior genu of the left cavernous ICA, the bilateral AcomA aneurysms were clipped, and rupture of the right AcomA aneurysm was confirmed. Follow-up CTA showed complete clipping of the bilateral AcomA aneurysms. Her Glasgow Outcome Scale score was 5. Endovascular treatment for residual aneurysms is planned for the future.
As shown in these two cases, the aneurysm from the posterior genu of the cavernous ICA can rupture, resulting in SAH; however, the rupture of other aneurysms must be excluded.
Once a ruptured aneurysm from the posterior genu of the cavernous ICA was confirmed, EVT was considered an alternative treatment.
Endovascular Treatment for Cavernous Carotid Aneurysms: A Systematic Review and Meta-Analysis
2020, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
A total of 265 articles were searched through the 3 online databases, and108 duplicates were excluded. After exclusion of 157 records through assessment of titles, abstracts and full texts, 14 articles8-21 fulfilling the inclusion criteria were included. The search selection process is showed in Figure 1.
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.
A Contemporary Review of Endovascular Treatment of Wide-Neck Large and Giant Aneurysms
2019, World Neurosurgery
Citation Excerpt :
To be included in this group, there have to be at least 2 consecutive control angiograms, by definition, at least 6 months apart, and expanding for a period of not <1 year exceptionally; 1 control angiogram could be sufficient for definition of class 5 only in selected cases of contrast filling the branch coming off the sac, with an appearance of a different vessel course than the original (e.g., tortuous or dilated), given that it is in continuation with the parent artery with no sac filling.7 In the studies reviewed where retreatment rates were reported, recurrence with coiling techniques was high, frequently >20%.13,16,17,20-24 This rate of recurrence is noteworthy and often an identified disadvantage of endovascular coiling.25
Despite widespread use of flow diverters, wide-necked large and giant aneurysms are still treated with other techniques as well. A contemporary review of results from different endovascular treatments is timely.
A literature review of the English language literature since 2011 was conducted using PubMed and Science Direct. Keywords and Medical Subheadings included large and giant aneurysms, ruptured aneurysms, aneurysms located in posterior circulation, and aneurysm occlusion status. Case reports were excluded. A combined model was built including both flow diverter and coil treatments in addition to separate models. Efficacy and safety were pooled using random effects analysis and regression.
The review comprised 29 studies. For coiling techniques, complete occlusion was 40.2%–82.8%, and adjusted regression resulted in 53% (95% confidence interval [CI] 22%–81%). Flow diverter complete occlusion rate was 40.5%–87.8%, and adjusted regression resulted in 87% (95% CI 76%–93%). Overall occlusion rate for both techniques combined was 62%–75%, and adjusted regression resulted in 81% (95% CI 68%–89%). Overall stroke and death regression rate was 5% (95% CI 3%–10%); flow diverters showed slightly higher rates than coiling (6% vs. 3%).
All current treatments of large and giant wide-necked aneurysms have comparable safety and efficacy with a trend of superiority of efficacy toward flow diverters. Results of future treatment options and devices can be compared with current technology to evaluate feasibility.
Comparison of Flow Diversion and Coiling for the Treatment of Unruptured Intracranial Aneurysms
2019, World Neurosurgery
To systematically assess the efficacy and safety between flow diversion and coiling for patients with unruptured intracranial aneurysms.
Potential academic articles were identified from Cochrane Library, Medline, PubMed, EMBASE, ScienceDirect, and other databases. The time range we retrieved from was the inception of electronic databases to February 2019. Gray studies were identified from the references of included literature reports. STATA version 11.0 was used to analyze the pooled data.
A total of 11 articles (10 retrospective studies and 1 prospective study) were involved in our study. The overall participants of the coiling group were 611, whereas 576 were in the flow diversion group. Our meta-analysis showed that flow diversion was preferable for unruptured intracranial aneurysms as its lower value of total cost per case (weighted mean difference, 5705.906; 95% confidence interval [CI], [4938.536, 6473236]; P < 0.001), fluoroscopy time per case (weighted mean difference, 25.786; 95% CI, 17.169–34.377; P < 0.001), and retreatment rates (odds ratio [OR], 7.127; 95% CI, [3.525, 14.410]; P < 0.001), at the same time, a higher rate of immediate completed occlusion (OR, 0.390; 95% CI, [0.224, 0.680]; P = 0.001) and follow-up completed occlusion (OR, 0.173; 95% CI, [0.080, 0.375]; P < 0.001) was demonstrated in the flow diversion group. There was no difference on intraoperative complication rates (P = 0.070), procedure-related mortality (P = 0.609) and rupture rates (P = 0.408), modified Rankin Scale (mRS) 0–2 at discharge (P = 0.077), and mRS 0–2 at follow-up (P = 0.484).
The use of flow diversion for the treatment of unruptured intracranial aneurysms may reduce total cost per case, fluoroscopy time per case, retreatment rates, and increases immediate completed occlusion and follow-up completed occlusion rates without affecting the results of mRS and intraoperative complication.
Endovascular Treatment of 147 Cases of Cavernous Carotid Aneurysms: A Single-Center Experience
2016, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Studies have demonstrated that endovascular coil embolization and PAO are effective for the treatment of CCAs; PAO is associated with an increased rate of complete occlusion, and endovascular coil embolization is associated with lower rates of complications.18 Starke et al9 compared endovascular coil embolization and stent-assisted coil occlusion and suggested that primary coiling represents an acceptable alternative for patients who are unable to tolerate dual antiplatelet therapy. However, stent-assisted coil occlusion had a lower rate of complication compared with endovascular coil embolization.
Cavernous carotid aneurysms (CCAs) are characterized by pain and neuro-ophthalmologic deficits. The optimal treatment remains unclear, especially for asymptomatic CCAs. This study investigated the efficacy of endovascular treatment for CCAs in our center.
Data obtained from patients who underwent endovascular treatment for CCAs from July 2011 to July 2014 were reviewed. A retrospective analysis was conducted regarding the general condition, clinical presentation, aneurysm characteristics, therapeutic strategy, and prognosis of CCA patients.
One hundred forty-seven patients who exhibited 155 CCAs were included, which comprised 46 asymptomatic and 101 symptomatic CCA cases. Forty-eight cases presented with headache, 5 cases presented with subarachnoid hemorrhage, 20 cases presented with diplopia, 38 cases presented with cranial nerve palsy, and 27 cases presented with ischemic stroke. The mean aneurysm sizes were 15.3 ± 12.2 and 8.1 ± 7.1 mm in the symptomatic and asymptomatic groups, respectively. Different treatments were administered: coil occlusion (n = 15), stent/balloon-assisted coil occlusion (n = 123), and parent artery occlusion (PAO) (n = 17). The PAO-treated group exhibited the highest aneurysm occlusion rate. Follow-up data were available for 131 cases, which included 86 symptomatic and 45 asymptomatic cases. There were no deaths. Among the symptomatic patients, 40.7% improved, 58.1% remained stable, and 1.2% worsened; 12 patients exhibited regrowth and 6 patients had repeated endovascular treatment. The asymptomatic patients remained stable, including 5 patients who exhibited regrowth and 2 patients who had repeated endovascular treatment.
Endovascular treatment is safe and effective for CCAs and should be considered in patients with minimal complications, as well as in asymptomatic patients with stable symptoms.
Treatment of symptomatic bilateral cavernous carotid aneurysms: Long-term results of 6 cases
2015, Journal of Stroke and Cerebrovascular Diseases
Bilateral cavernous carotid aneurysms (CCAs) are very rare. A treatment strategy for symptomatic bilateral CCAs has not been established because of their complex pathogenesis. Here we report our treatment strategy and long-term results for 6 cases of symptomatic bilateral CCAs.
From January 2007 to December 2013, we treated 6 patients (2 men and 4 women; mean age at first treatment, 56.0 years) with symptomatic bilateral CCAs.
All patients began to experience unilateral symptoms. Five of the 6 underwent high-flow bypass (HFB) with parent artery occlusion (PAO), and 1 received PAO only. Mean follow-up period after the first treatment was 61.3 months. All symptoms improved after the treatment. Five contralateral CCAs became enlarged during the follow-up period. Of these, 4 became symptomatic. One patient received superficial temporal–middle cerebral artery bypass with PAO, 2 received HFB with PAO, and 1 refused treatment. Final modified Rankin Scale scores were 0 in 4 patients, 1 in 1 patient, and 2 in 1 patient. There was no mortality in this series.
HFB with PAO is feasible as the first treatment for symptomatic bilateral CCAs. This treatment strategy steadies and simplifies future treatment of contralateral CCAs should they become symptomatic.

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Clinical StudyEndovascular treatment of carotid cavernous aneurysms: Complications, outcomes and comparison of interventional strategies

Abstract

Introduction

Section snippets

Patient cohort

Patient characteristics

Discussion

Conclusions

Conflicts of interest/disclosures

J Clin Neurosci

Surg Neurol

Lancet

Lancet

J Stroke Cerebrovasc Dis

Presentation and treatment of carotid cavernous aneurysms

Arq Neuropsiquiatr

Presentation, natural history, and management of carotid cavernous aneurysms

Neurosurgery

Unruptured large and giant carotid artery aneurysms presenting with cranial nerve palsy: comparison of clinical recovery after selective aneurysm coiling and therapeutic carotid artery occlusion

AJNR Am J Neuroradiol

Endovascular treatment of aneurysms in the cavernous sinus: a systematic review on balloon occlusion of the parent vessel and embolization with coils

Stroke

Cavernous internal carotid artery aneurysms treated with electrolytically detachable coils

J Neuroophthalmol

Symptomatic cavernous sinus aneurysms: management and outcome after carotid occlusion and selective cerebral revascularization

AJNR Am J Neuroradiol

Excimer laser-assisted bypass in aneurysm treatment: short-term outcomes

J Neurosurg

Clinical Study
Endovascular treatment of carotid cavernous aneurysms: Complications, outcomes and comparison of interventional strategies