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

Coiling ruptured aneurysms arising from the posterior genu of the cavernous internal carotid artery: A report of two cases

INTRODUCTION AND IMPORTANCE

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 PRESENTATION

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.

CLINICAL DISCUSSION

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.

CONCLUSION

Once a ruptured aneurysm from the posterior genu of the cavernous ICA was confirmed, EVT was considered an alternative treatment.

Endovascular treatment of cavernous carotid artery aneurysms: A 10-year, single-center experience

BACKGROUND

Cavernous carotid artery aneurysms can be treated by several endovascular techniques including flow diversion (FD) and parent vessel occlusion (PVO). We reviewed our institution's consecutive series of endovascularly treated cavernous carotid artery aneurysms to compare these two modalities and their associated clinical and radiographic outcomes.

METHODS

All patients harboring a cavernous carotid artery aneurysm treated by FD or PVO from January 2008 to December 2018 were enrolled. Data were collected retrospectively and analyzed on patient presentation, aneurysm dimensions, treatments and related complications, rate of aneurysm occlusion, sac regression, and outcomes.

RESULTS

Fourteen patients were treated with FD and 12 underwent PVO subsequent to passing a balloon test occlusion. There was no significant difference between treatment modalities in aneurysmal occlusion (97.0 ± 8.4% (FD) vs. 100% (PVO), p = 0.23), degree of sac regression (62.5 ± 16.7% (FD) vs. 56.8 ± 24.3% (PVO), p = 0.49), or near-complete to complete symptom improvement (66.7% (FD) vs. 81.8% (PVO), p = 0.62). Major complications included subarachnoid hemorrhage from aneurysmal rupture in 1 (7.1%) patient post-FD and 2 (16.7%) ischemic strokes following PVO.

CONCLUSIONS

Endovascular treatment of cavernous carotid artery aneurysms by FD or PVO are both effective and safe. There is insufficient evidence to recommend one technique over the other and decision making should be individualized to the patient, their aneurysm morphology, and operator experience.

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.

Comparison of Flow Diversion and Coiling for the Treatment of Unruptured Intracranial Aneurysms

BACKGROUND

To systematically assess the efficacy and safety between flow diversion and coiling for patients with unruptured intracranial aneurysms.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Intraoperative Computed Tomography (CT) for Treating Giant Carotid Intracavernous Aneurysms

Background

Giant carotid intracavernous aneurysm refers to those lesions larger than 2.5 cm and derived from a cavernous segment, accounting for about 30% of all intracranial tumors. Dynamic CT perfusion imaging (PCT) is a common method recently employed to evaluate cerebral perfusion. This study investigated the efficacy and clinical application of intraoperative CT in the surgery for giant symptomatic carotid intracavernous aneurysm.

Material/Methods

A retrospective analysis was performed on 23 cases with giant symptomatic carotid intracavernous aneurysm. BTO testing was performed before surgery. Differential treatments were performed based on the condition of aneurysm, and some patients received intraoperative PCT. Postoperative anti-coagulation was given with DSA or CTA follow-up examinations at 3–6 months, 1 year, and 2 years after surgery.

Results

A total of 17 patients received aneurysm isolation coupled with high-flow bypass surgery. Among those, 9 developed early-onset neurological function after surgery, with gradual recover within 6 months. One coma patient died 25 months after discharge. One patient had aneurysm isolation with clapping of anterior communicating artery, and the other 5 cases received artery clapping only. In those patients, 4 had improvement at early phase, while 1 patient had numbness of the oculomotor nerve. Six patients received surgery in the CT room, including 5 cases with single proximal ligation of the internal carotid artery plus 1 aneurysm isolation combined with high-flow bypass surgery.

Conclusions

Intraoperative PCT can provide objective evidence and effective evaluation of cerebral perfusion.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

A case of bilateral giant internal carotid artery aneurysms at the cavernous portion managed by 2-stage extracranial-intracranial bypass with parent artery occlusion: consideration for bypass selection and timing of surgeries

Bilateral giant internal carotid artery (ICA) aneurysms at the cavernous portion with bilateral cranial nerve symptoms are extremely rare. Extracranial-intracranial (EC-IC) bypass with parent artery occlusion (PAO) is one of the preferred procedures for giant ICA aneurysm at the cavernous portion with cranial nerve palsy; however, optimal bypass selection and the timing of surgery are controversial, particularly in bilateral cases. A 28-year-old woman developed left third nerve palsy with giant ICA aneurysms at the bilateral cavernous portion. Because only the left aneurysm was symptomatic, she initially underwent left EC-IC bypass using a saphenous vein graft with PAO without complications, which relieved her symptoms. However, she developed right third/fifth nerve palsy 10 months later, at which time magnetic resonance (MR) imaging and MR angiography revealed an enlarged right ICA aneurysm and shrunken left ICA aneurysm. Balloon test occlusion of the right ICA identified sufficient ischemic tolerance; therefore, she underwent right superficial temporal artery-middle cerebral artery bypass with PAO. Both bypasses were confirmed by MR angiography to be patent after surgery. Cranial nerve palsy gradually improved postoperatively, and single-photon emission computed tomography confirmed static cerebral hemodynamics. In conclusion, high-flow EC-IC bypass with PAO is recommended in the first stage of surgery on a unilaterally symptomatic side to minimize postoperative hemodynamic stress to the contralateral aneurysm. Once the contralateral side becomes symptomatic, second stage EC-IC bypass with PAO, either low-flow or high-flow bypass, is recommended based on the results of balloon test occlusion.