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