Long term visual and neurological prognosis in patients with treated and untreated cavernous sinus aneurysms

Natural History of Cavernous Carotid Artery Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

Cavernous carotid artery aneurysms (CCAAs) represent a common condition seen in clinical practice with significant practice variability. The aim of this systematic review and meta-analysis was to aggregate current evidence on the natural history of CCAAs.

METHODS

MEDLINE/PubMed, EMBASE, and Cochrane Library were queried from inception until December 2023. The primary outcome of this study was CCAA-related mortality. The secondary outcomes of this study were aneurysm growth, intracranial ischemic and hemorrhagic events, improved non-cerebrovascular symptoms, and new or worsened non-cerebrovascular symptoms during follow-up.

RESULTS

Ten studies met our inclusion criteria, involving 835 patients and 975 CCAAs. CCAA-related mortality had an incidence rate of 0.28 (95% CI 0.12-0.64) per 100 person-years (PYs) of follow-up. The incidence rate of CCAA growth was 2.91 (1.05-8.07) per 100 PYs of follow-up. The incidence rate of CCAA-related intracranial ischemic events was 0.4 (0.16-1.01) per 100 PYs of follow-up. The incidence rate of CCAA-related intracranial hemorrhagic events was 0.54 (0.33-0.87) per 100 PYs of follow-up. The incidence rate of improved non-cerebrovascular symptoms was 2.51 (1.18-5.33) per 100 PYs of follow-up. The incidence rate of new or worsened non-cerebrovascular symptoms was 3.41 (2.03-5.73) per 100 PYs of follow-up.

CONCLUSIONS

CCAAs are typically benign lesions with a low risk of rupture and life-threatening complications. CCAAs tend to follow an indolent course regarding non-cerebrovascular outcomes, and new or worsening symptoms are infrequent during the clinical course. However, spontaneous resolution of non-cerebrovascular symptoms and cranial nerve deficits at presentation is uncommon.

Benign Natural Progression of Small Cavernous Carotid Aneurysms Suggests Limited Clinical Utility of Serial Longitudinal Follow-up

BACKGROUND AND OBJECTIVES

Aneurysms in the cavernous segment of the internal carotid artery (ICA) often present in an indolent fashion with limited morbidity. However, their growth progression and possible rupture over time remains poorly defined, thereby limiting optimization of serial follow-up. Thus, we aim to describe the progression of cavernous ICA aneurysms over time, as well as the patient and aneurysm characteristics associated with possible growth and rupture status.

METHODS

We identified a consecutive cohort of 157 patients from 2007 to 2021 with cavernous ICA aneurysms. Patient demographic data, possible risk factors, presenting symptoms, radiographic features of aneurysms, size progression, rupture status, and concomitant noncavernous aneurysm rupture data were manually extracted.

RESULTS

One hundred and fifty-seven patients (mean age at diagnosis 57.2 ± 15.6 years; 85.4% females) with 174 cavernous carotid aneurysms (CCAs) were followed for an average of 7.1 ± 4.8 years. 76.4% of aneurysms were identified incidentally, with predominantly ocular palsies as the presenting symptoms in remaining primary cases. Most aneurysms were small, and of the 168 aneurysms that were followed, 98.2% did not demonstrate appreciable growth. Of the aneurysms that grew, it took an average of 6.0 years to grow 1.6 ± 0.2 mm. Demographic data, hypertension, and smoking status were not associated with aneurysm growth. Most radiographic features also were not associated with growth, except long-axis diameter, which had an odds ratio of 1.4 (CI: 1.2, 1.8) on multivariable analysis. Presenting clinical symptoms were not associated with growth. No CCAs ruptured during follow-up.

CONCLUSION

Cavernous ICA aneurysms in our series demonstrate no rupture and limited growth over years of clinical follow-up. No radiographic or patient risk factors were associated with growth except initial aneurysm size. Hence, small CCAs may not require close follow-up over time.

Transcirculation Approach for Matricidal Carotid Cavernous Aneurysm: Not a Good Choice - A Case Report of Unsuccessful Endovascular Treatment of Matricidal Carotid Cavernous Aneurysm

Matricidal carotid cavernous aneurysm (CCA) is a rare and dangerous condition. The treatment failure of the endovascular approach like flow diversion, coiling, or stent-coiling is relatively high with considerable morbidity and mortality. The transcirculation approach is an alternative treatment option, but in case of matricidal CCAs, the results are not well documented in the literature. The authors present a complicated case of an unsuccessful transcirculation approach for matricidal CCA finally treated with sacrifice of the parent artery and high-flow bypass.

Cefaléia e disfunção de nervos cranianos secundários a aneurisma de artéria carótida: relato de dois casos e revisão da literatura

O seio cavernoso é um plexo venoso localizado na base do crânio. Várias patologias, como processos inflamatórios, aneurismáticos ou metastáticos, podem afetar esse plexo. A síndrome do seio cavernoso ocorre quando os nervos estão envolvidos nessa região (nervos cranianos III, IV, VI e divisões do V). Essas relações anatômicas explicam que a diplopia e a dor são os sintomas iniciais mais comuns nesses pacientes. Os aneurismas carotídeos cavernosos (CCAs) representam 2% a 9% dos aneurismas. Relatamos dois pacientes que apresentaram síndrome do seio cavernoso decorrente de aneurismas da artéria carótida. O reconhecimento da etiologia desse quadro clínico diferenciado é fundamental para evitar complicações e direcionar a melhor conduta para cada paciente.

Clinical analysis of cavernous sinus anatomy, pathologies, diagnostics, surgical management and complications - comprehensive review

For decades, the cavernous sinus (CS) has been the subject of debates and scientific studies aimed at elucidating its anatomical variability, and at choosing the best method for accessing it so that optimal diagnoses and related surgical treatments can be decided. The present review considers a series of issues related to the CS. The anatomy of the CS and its features is explored first, and the most important structures, spaces and morphological variations are considered. This is followed by CS pathology and selected diagnostic methods that have proved useful in therapy, and then the management of these pathologies is discussed. Examples of therapeutic steps that have proved helpful in specific cases are taken from the literature. Finally, the various surgical accesses and complications that can be encountered during invasive interventions in the CS area are discussed. The aim of this study is to summarize up-to-date anatomical and clinical knowledge about the CS, citing the most informative scientific papers and aggregating their results. Morphological variations of the CS are common but have not been well described in the literature.

Giant intracavernous aneurysm presenting with isolated trigeminal neuralgia: a case report

Background

Trigeminal neuralgia (TN) commonly affects individuals aged more than 50 years and is mostly primary owing to trigeminal nerve neurovascular compression. We report a case of secondary TN attributed to a giant intracavernous aneurysm compressing the trigeminal nerve.

Case presentation

A 74-year-old female presented with classic TN symptoms, which were initially refractory to medical treatment. Imaging including MRI brain, MR angiography, and cerebral angiogram revealed a giant intracavernous aneurysm measuring 1.7 cm × 2.8 cm, inducing mass effect on the left Meckel's cave. Aneurysm embolization was challenging due to the difficult cannulation of the distal portion of the aneurysm. The patient opted for conservative management with mild improvement of symptoms.

Conclusions

Intracavernous aneurysm rarely present with isolated trigeminal neuralgia. This case report emphasizes that the assessment of the intracranial vasculature should be considered as part of the diagnostic imaging work-up for patients presenting with TN

Neurovascular disease, diagnosis, and therapy: Brain aneurysms

Unruptured intracranial aneurysms (UIAs) have a prevalence of 3% in the adult population worldwide. The majority of UIAs are incidental findings, but some UIAs cause cranial nerve palsies, brainstem compression, ischemic events, or epileptic seizures. The most frequent clinical presentation of intracranial aneurysms is, however, rupture and thereby subarachnoid hemorrhage (SAH). To avoid SAH with its fatal consequences, patients with UIAs require counseling by dedicated and interdisciplinary neurovascular specialists. For the purpose of assessment and decision-making for the management of patients with UIAs, numerous aspects have to be considered: radiological characteristics, clinical symptoms, estimated rupture risk of an individual aneurysm as well as patient- and aneurysm-related risks of preventive repair. Generally, two management options exist: observation with follow-up imaging or preventive repair. This chapter discusses current data on pathogenesis, clinical presentation, diagnostics, risk factors for rupture and preventive repair, and guidance tools for the management of patients with UIAs according to current evidence.

Surgical Sparing and Pairing Endovascular Interventions for Carotid-Cavernous Fistula: Case Series and Review of the Literature

BACKGROUND

Carotid-cavernous fistulas (CCFs) are abnormal communications between the arterial and venous circulation within the cavernous sinus, manifesting in myriad neurological and ophthalmological sequalae. In rare circumstances patients' unique vascular anatomies preclude standard endovascular treatment for this pathology, warranting combined surgical and endovascular approaches wherein the cavernous sinus is accessed via superior ophthalmic vein (SOV) exposure, cutdown, and cannulation.

CASE DESCRIPTION

We describe 3 cases of CCF treated at our quaternary neurovascular referral center between 2017 and 2019. The first is a 35-year-old man with symptomatic, traumatic, right-sided CCF, treated with endovascular therapy (transarterial detachable balloon placement). The other cases were treated with contrasting surgical and endovascular combined approaches because of unique vascular challenges. The second is a 71-year-old woman with spontaneous right-sided CCF whose carotid sinus was accessed and embolized through a transpalpebral cutdown of the SOV. The third case is a 70-year-old man with symptomatic, spontaneous bilateral CCF. After unsuccessful transarterial and transvenous endovascular approaches, transorbital (intracranial) SOV cutdown and cannulation were performed to embolize the shunting fistula.

CONCLUSIONS

Endovascular approaches are well described as the mainstay of treatment for CCF but are not possible for all patients. In circumstances where individual vascular anatomy is not amenable to transarterial or transvenous access or embolization, a combined surgical and endovascular approach may be appropriate. We describe 3 cases that illustrate the spectrum of interventions for CCF, as well as the technical aspects of treatment for 2 patients with complex, direct CCF, using an embolization approach reliant on SOV cutdown and cannulation.

Atypical Symptomatic Bilateral Spontaneous Cavernous Carotid Aneurysm with Systemic Vessel Wall Pathology in Young Female: A Rare Case Report

Bilateral cavernous carotid aneurysm (CCA) is a rare entity. Its association with connective tissue disorder makes the diagnosis and treatment of symptomatic patient an enigma. We present a case report of a 25-year-old female medical student presented to us with bilateral spontaneous atypically symptomatic CCA with incidentally diagnosed case of Ehlers–Danlos syndrome. Both surgical and endovascular options of treatment were weighed and were ultimately treated satisfactorily by high-flow bypass with carotid artery ligation with an insurance bypass.

Cavernous carotid artery aneurysms on a single institution: An epidemiological study with 201 patients

OBJECTIVES

Cavernous carotid aneurysms (CCA) represent 2-9% of all intracranial aneurysms. For long considered benign lesions, these entities are unique when it comes to clinical presentation and management. Usually asymptomatic, CCAs can grow and rupture causing different manifestations. The lack of a long-term assessment of both treated and untreated CCAs' natural history justifies why there is no consensus regarding what are the recommended therapeutic measures. While some advocate that an intervention is always necessary, others consider that patients deserve an individualized evaluation.

PATIENTS AND METHODS

We describe our single-institution experience in diagnosis, follow-up, and management of 201 CCAs. In addition, we evaluate the association of giant CCAs with aneurysms in other locations using a Chi-square test.

RESULTS

201 patients had 245 CCAs. 92% of the patients were women. The mean age at diagnosis was 61 years. Concomitant aneurysms were observed in 53.2% of the patients, and the middle cerebral artery was the most affected artery. 66 (30.6%) CCAs were considered "giant", and the follow-up period ranged from 1 to 23 years.The presence of a giant CCA seemed to hinder other aneurysms' formation - RR 0.47 (IC 95% 0.31-0.67), p < 0.0001.

CONCLUSIONS

CCAs should be individually assessed. A conservative approach ought to be adopted for asymptomatic and oligosymptomatic lesions. Finally, a multidisciplinary team must evaluate the other situations, in order to define whether the microsurgical or the endovascular treatment is better option. Presence of a giant lesion within the cavernous sinus is associated with less occurrence of other aneurysms.

Occipital lobe infarction: a rare presentation of bilateral giant cavernous carotid aneurysms: a case report

Background

Cavernous carotid aneurysm (CCA) represents 2–9% of all intracranial aneurysms and 15% of internal carotid artery (ICA) aneurysms; additionally, giant aneurysms are those aneurysms that are > 25 mm in size. Bilateral CCAs account for 11–29% of patients and are commonly associated with structural weaknesses in the ICA wall, secondary to systemic hypertension. CCAs are considered benign lesions, given the low risk for developing major neurologic morbidities (i.e., subarachnoid hemorrhage, cerebral infarction, or carotid cavernous fistula). Moreover, concurrent presentation with posterior circulation cerebral infarction is even rarer, given different circulation territory from CCA. Here, we report on a patient with bilateral giant CCAs who presented with both typical and atypical symptoms.

Case presentation

An 88-year-old hypertensive woman presented with acute vertical oblique binocular diplopia, followed by complete ptosis of the right eye. Ophthalmic examination showed dysfunction of the right third, fourth, and sixth cranial nerves. Further examination revealed hypesthesia of the areas supplied by the ophthalmic (V1) and maxillary (V2) branches of the right trigeminal nerve. Bilateral giant cavernous carotid aneurysms, with a concurrent subacute right occipital lobe infarction, were discovered on brain imaging and angiogram. Additionally, a prominent right posterior communicating artery (PCOM) was revealed. Seven months later, clinical improvement with stable radiographic findings was documented without any intervention.

Conclusions

Dysfunction of the third, fourth, and sixth cranial nerves, and the ophthalmic (V₁) and maxillary (V₂) branches of the trigeminal nerves, should necessitate brain imaging, with special attention given to the cavernous sinus. Despite unilateral symptomatic presentation, bilateral lesions cannot be excluded solely on the basis of clinical findings. CCA should be included in the differential diagnosis of cavernous sinus lesions. Although rare, ipsilateral posterior circulation cerebral infarction (i.e., occipital lobe infarction) can occur in CCA patients, presumably as a result of distal embolization through an ipsilateral, prominent PCOM. Spontaneous clinical improvement with stable radiographic support may occur.

High-flow bypass with radial artery graft followed by internal carotid artery ligation for large or giant aneurysms of cavernous or cervical portion: clinical results and cognitive performance

High-flow bypass followed by ligation of the internal carotid artery (ICA) is an effective treatment, but the impact of abrupt occlusion of the ICA is unpredictable, especially on postoperative cognitive function. The present study evaluated the clinical results as well as cognitive performances after high-flow bypass using radial artery graft (RAG) with supportive superficial temporal artery (STA)-middle cerebral artery (MCA) bypass, followed by ICA ligation. Ten consecutive patients underwent high-flow bypass surgery for large or giant ICA aneurysms of cavernous or cervical portion. Demographics, clinical information, magnetic resonance (MR) imaging, computed tomography, digital subtraction angiography (DSA), intraoperative somatosensory evoked potentials, neuropsychological examinations including the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R), and follow-up data were analyzed. The aneurysm was located on the cavernous segment in eight cases and cervical segment in two cases, and mean aneurysm size was 27.9 mm. Postoperative DSA demonstrated robust bypass flow from the external carotid artery to MCA via the RAG, and no anterograde flow into the aneurysm. No patient showed new symptoms after the operation. Follow-up clinical study and MR imaging were performed in nine patients and showed no additional ischemic lesion compared with preoperative imaging. Seven patients completed neuropsychological examinations before and after surgery. All postoperative scores except WMS-R composite memory score slightly improved. High-flow bypass followed by ICA ligation can achieve good clinical outcomes. Successful high-flow bypass using RAG with supportive STA-MCA bypass and ICA ligation does not adversely affect postoperative cognitive function.

Bilateral cavernous carotid aneurysms treated by two-stage extracranial-intracranial bypass followed by parent artery occlusion: case report and literature review

Bilateral cavernous carotid aneurysms (CCAs) are often not amenable to neurosurgical clipping or endovascular coiling. Here, we report the case of a 50-year-old female who presented with a 1-year history of gradual severe headache. Preoperative angiograms revealed bilateral CCAs. Among these findings, the right giant CCA had been trapped after the external carotid artery-saphenous vein-middle cerebral artery (ECA-SV-MCA) bypass 8 years prior. Additionally, the left CCA was again trapped after the internal maxillary artery-radial artery-middle cerebral artery (IMA-RA-MCA) bypass, followed by parent artery occlusion (PAO), because of the enlargement of a 0.4-cm aneurysm to a 1.3-cm aneurysm during the 5th to 8th years following surgery. Postoperative radiologic findings proved that the aneurysms disappeared with good graft patency of the bilateral anastomoses and excellent filling of the bilateral MCA territories. This is the first case of bilateral CCAs treated with two stages of bilateral high-flow extracranial-intracranial (EC-IC) bypass, including an IMA-RA-MCA bypass.

Incidence and Etiologies of Acquired Third Nerve Palsy Using a Population-Based Method

Importance

Among cranial nerve palsies, a third nerve palsy is important because a subset is caused by life-threatening aneurysms. However, there is significant disagreement regarding its incidence and the reported etiologies.

Objective

To determine the incidence and etiologies of acquired third nerve palsy using a population-based method.

Design, Setting, and Participants

All newly diagnosed cases of acquired third nerve palsy from January 1, 1978, through December 31, 2014, in Olmsted County, Minnesota, were identified using the Rochester Epidemiology Project, a record-linkage system of medical records for all patient-physician encounters among Olmsted County residents. All medical records were reviewed to confirm a diagnosis of acquired third nerve palsy and determine the etiologies, presenting signs, and symptoms. Incidence rates were adjusted to the age and sex distribution of the 2010 US white population.

Main Outcomes and Measures

Incidence and etiologies of acquired third nerve palsies. The secondary outcome was incidence of pupil involvement in acquired third nerve palsies.

Results

We identified 145 newly diagnosed cases of acquired third nerve palsy in Olmsted County, Minnesota, over the 37-year period. The age- and sex-adjusted annual incidence of acquired third nerve palsy was 4.0 per 100 000 (95% CI, 3.3-4.7 per 100 000). The annual incidence in patients older than 60 was greater than patients younger than 60 (12.5 vs 1.7 per 100 000; difference, 10.8 per 100 000; 95% CI, 4.7-16.9; P < .001). The most common causes of acquired third nerve palsy were presumed microvascular (42%), trauma (12%), compression from neoplasm (11%), postneurosurgery (10%), and compression from aneurysm (6%). Ten patients (17%) with microvascular third nerve palsies had pupil involvement, while pupil involvement was seen in 16 patients (64%) with compressive third nerve palsies.

Conclusions and Relevance

This population-based cohort demonstrates a higher incidence of presumed microvascular third nerve palsies and a lower incidence of aneurysmal compression than previously reported in non-population-based studies. While compressive lesions had a higher likelihood of pupil involvement, pupil involvement did not exclude microvascular third nerve palsy and lack of pupil involvement did not rule out compressive third nerve palsy.

Superior orbital fissure syndrome caused by an internal carotid artery aneurysm in the cavernous sinus

This article describes the case of superior orbital fissure syndrome caused by an internal carotid artery aneurysm in the cavernous sinus. Etiology, clinical presentations, and diagnostic methods are discussed. Possible regression of signs and symptoms after timely endovascular treatment of an internal carotid artery aneurysm in the cavernous sinus is reported.

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.

Neuroophthalmological outcomes associated with use of the Pipeline Embolization Device: analysis of the PUFS trial results

OBJECT

Neuroophthalmological morbidity is commonly associated with large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms. The authors sought to evaluate the neuroophthalmological outcomes after treatment of these aneurysms with the Pipeline Embolization Device (PED).

METHODS

The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial was an international, multicenter prospective trial evaluating the safety and efficacy of the PED. All patients underwent complete neuroophthalmological examinations both before the PED procedure and at a 6-month follow-up. All examinations were performed for the purpose of this study and according to study criteria.

RESULTS

In total, 108 patients were treated in the PUFS trial, 98 of whom had complete neuroophthalmological follow-up. Of the patients with complete follow-up, 39 (40%) presented with a neuroophthalmological baseline deficit that was presumed to be attributable to the aneurysm, and patients with these baseline deficits had significantly larger aneurysms. In 25 of these patients (64%), the baseline deficit showed at least some improvement 6 months after PED treatment, whereas in 1 patient (2.6%), the deficits only worsened. In 5 patients (5%), new deficits had developed at the 6-month follow-up, while in another 6 patients (6%), deficits that were not originally assumed to be related to the aneurysm had improved by that time. A history of diabetes was associated with failure of the baseline deficits to improve after the treatment. The aneurysm maximum diameter was significantly larger in patients with a new deficit or a worse baseline deficit at 6 months postprocedure.

CONCLUSIONS

Patients treated with the PED for large and giant ICA aneurysms had excellent neuroophthalmological outcomes 6 months after the procedure, with deficits improving in most of the patients, very few deficits worsening, and few new deficits developing.

Neuroimaging of headaches associated with vascular disorders

Headaches from vascular causes need to be differentiated from primary headaches because a misdiagnosis may lead to dire consequences for the patient. Neuroimaging is critical in identifying patients with vascular headaches and identifying the nature of the pathologic disorder causing these headaches. In addition, the imaging findings guide the physician regarding the optimal treatment modality for these lesions. This review summarizes the nuances of differentiating patients with secondary headaches related to vascular disease and discusses pertinent neuroimaging studies.

Parent artery occlusion in large, giant, or fusiform aneurysms of the carotid siphon: clinical and imaging results

BACKGROUND AND PURPOSE

Parent artery occlusion has long been considered the reference treatment for large/giant or fusiform aneurysms of the carotid siphon. However, meager recent data exist on this technique, which tends to be replaced by stent-assisted reconstructive techniques. In our department since 2004, we have assessed the safety, efficacy, and complication risk factors of parent artery occlusion by using coils for trapping these aneurysms.

MATERIALS AND METHODS

We determined retrospectively the complication rate, factors associated with the occurrence of an ischemic event, changes in symptoms of mass effect, evolution of the aneurysmal size, and the growth of an additional aneurysm after treatment.

RESULTS

Fifty-six consecutive patients were included, with a median age of 54 years (range, 25-85 years; 92% women), 48% with giant aneurysms and 75% with infraclinoid aneurysms. There was a permanent morbidity rate of 5% exclusively due to ischemia, a zero mortality rate, an aneurysmal retraction rate of 91%, and an improvement rate for pain of 98% and for cranial nerve palsy of 72%, with a median follow-up of >3 years. Para-/supraclinoid topography of the aneurysm (P = .043) and the presence of cardiovascular risk factors (P = .024) were associated with an excessive risk of an ischemic event, whereas the presence of a mural thrombus had a protective role (P = .033).

CONCLUSIONS

In this study, parent artery occlusion by using coils to treat large/giant or fusiform aneurysms of the carotid siphon was safe and effective, especially for giant infraclinoid aneurysms. According to recent meta-analyses, these results suggest that the validation of stent-assisted reconstructive treatments for these aneurysms requires controlled studies with parent occlusion artery.

Neuro-ophthalmic presentation and surgical results of unruptured intracranial aneurysms—prospective Helsinki experience of 142 patients

OBJECTIVE

To assess prospectively neuro-ophthalmic findings associated with unruptured intracranial aneurysms and treatment morbidity and to identify factors predicting these findings.

METHODS

Patients admitted to Helsinki University Central Hospital and treated surgically or endovascularly during 2011 underwent a neuro-ophthalmic examination, including formal visual field testing, before operation, at discharge, and 2-4 months and ≥6 months postoperatively. Univariate and multivariate analysis was used to identify factors predicting eye movement disorders.

RESULTS

Study participants included 142 patients with 184 treated aneurysms: 7 (5%) had a third, fourth, or sixth nerve palsy or skew deviation preoperatively, and 16 (11%) had a third, fourth, or sixth nerve palsy or skew deviation postoperatively; the frequency was 8 (6%) at the last follow-up evaluation. Other findings included compressive optic neuropathy (n = 4), ischemic optic neuropathy (n = 1), Weber syndrome (n = 3), Benedikt syndrome (n = 1), and Wallenberg syndrome (n = 1). Of the 140 survivors at 6 months, 7 (5%) presented with visual field defects resulting from the aneurysm or its treatment. In the best bivariate model, factors independently predicting postoperative eye movement disorders were aneurysm location in the posterior circulation with an odds ratio of 142.02 (95% confidence interval = 20.13-1002.22) and aneurysm size (odds ratio = 1.28 for each 1-mm increase in diameter, 95% confidence interval = 1.12-1.47).

CONCLUSIONS

Management of unruptured intracranial aneurysms is fairly safe from a neuro-ophthalmic perspective, with some treatment-related morbidity being transient and minor. Although rare, an irreversible deficit is possible and should be taken into account when considering preventive treatment.

Cavernous carotid aneurysms in the era of flow diversion: a need to revisit treatment paradigms

BACKGROUND AND PURPOSE

Recent techniques of endoluminal reconstruction with flow-diverting stents have not been incorporated into treatment algorithms for cavernous carotid aneurysms. This study examines the authors' institutional experience and a systematic review of the literature for outcomes and complications using the Pipeline Embolization Device in unruptured cavernous carotid aneurysms.

MATERIALS AND METHODS

A retrospective search for cavernous carotid aneurysms from a prospectively collected data base of aneurysms treated with the Pipeline Embolization Device at our institution was performed. Baseline demographic, clinical, and laboratory values; intrainterventional data; and data at all follow-up visits were collected. A systematic review of the literature for complication data was performed with inquiries sent when clarification of data was needed.

RESULTS

Forty-three cavernous carotid aneurysms were included in the study. Our mean radiographic follow-up was 2.05 years. On last follow-up, 88.4% of the aneurysms treated had complete or near-complete occlusion. Aneurysm complete or near-complete occlusion rates at 6 months, 12 months, and 36 months were 81.4%, 89.7%, and 100%, respectively. Of patients with neuro-ophthalmologic deficits on presentation, 84.2% had improvement in their visual symptoms. Overall, we had a 0% mortality rate and a 2.3% major neurologic complication rate. Our systematic review of the literature yielded 227 cavernous carotid aneurysms treated with the Pipeline Embolization Device with mortality and morbidity rates of 0.4% and 3.1%, respectively.

CONCLUSIONS

Endoluminal reconstruction with flow diversion for large unruptured cavernous carotid aneurysms can yield high efficacy with low complications. Further long-term data will be helpful in assessing the durability of the cure; however, we advocate a revisiting of current management paradigms for cavernous carotid aneurysms.

Cavernous carotid artery aneurysms: epidemiology, natural history, diagnostic and treatment. An experience of a single institution

BACKGROUND

Cavernous carotid aneurysms (CCA) account for 2-9% of all intracranial aneurysms. They have been considered benign lesions, most often asymptomatic, and to have a natural history with a low risk of life-threatening complications. These aneurysms are unique, their rupture can present in many different forms, they can suffer spontaneous thrombotic changes and the symptomatology related to the mass effect involves the neuro-ophthalmologic system. In this scenario the natural history and clinical presentation are largely different from other intracranial aneurysms. Some investigators advocate treatment of both symptomatic and asymptomatic CCAs, others recommend no treatment. The reason for this controversy relates to a lack of information on the long term natural history of these aneurysms, as well as on the long term results of treatment.

METHODS

In this article the authors discuss their single institution experience in diagnosis, natural history and management of 123 asymptomatic and oligosympotomatic aneurysms located in the cavernous portion of internal carotid artery.

CONCLUSIONS

According to our results asymptomatic or olygosymptomatic (pain) CCAs should be conservatively managed with serial images while the others presentations should be analyzed by a multidisciplinary team, involving the neuroendovascular and microsurgical services.

Evolution of management strategies for cavernous carotid aneurysms: a review

OBJECTIVE

Cavernous carotid aneurysms are considered benign lesions with indolent natural history. Apart from idiopathic aneurysms, traumatic, iatrogenic, and mycotic aneurysms are common in the cavernous segment of the carotid artery. With rapid advances in endovascular therapy, management of cavernous carotid aneurysms has evolved. Our aim was to review the management options available for cavernous carotid aneurysms.

METHODS

The English literature was searched for various studies describing the management of cavernous carotid aneurysms and the evolution of various treatments was studied.

RESULTS

Numerous treatment options are available such as conservative management, Hunterian ligation, surgical clipping, and endovascular therapy. The introduction of flow-diverting stents has revolutionized the management of these lesions. The evolution of various treatment strategies are described.

CONCLUSIONS

A thorough knowledge of all the options is paramount to individualize therapy. We discuss the indications of treatment, various management options for cavernous carotid aneurysms and their outcomes.

Collaborative retrospective multicentre series of giant intracavernous carotid aneurysms

Giant intracavernous carotid aneurysms (GICCA) occur with very unusual clinical symptoms often resulting from a compressive mechanism that may possibly resolve although seldom from a rupture or haemorrhage. In fact, due to their clinical presentation their treatment is different from that of the intracranial subarachnoid aneurysms. The aim of this study was to analyze the clinical symptoms, therapeutic decisions, and the clinical state at 6 months follow up in a retrospective consecutive multicentre series of 27 GICCA between 2004 and 2008. All the patients in the series were female, mean age 65 years (21 to 82 years). A pseudo tumoural cavernous sinus syndrome revealed the disease in 25 patients (92.6%), an atypical headache in one patient, and in another patient an intraoperative haemorrhage led to the diagnosis. In most of the cases the aneurysms were sacciform in shape (89%), with a size between 25 and 30 millimeters (66.6%) and contained a blood clot due to intrasacular thrombosis (57.5%). An occlusion test of the internal carotid artery was performed during the diagnostic angiography in 24 cases (88.8%) and good tolerance of occlusion was observed in 16 of them. An endovascular procedure was performed in 21 patients (77.7%): selective coiling of the aneurysm facilitated by stenting or by remodeling techniques in 2 cases, whereas internal carotid artery occlusion was performed on the 19 other cases. Among these latter patients, 2 of them (10.5%) presented with a poor tolerance during the pre-therapeutic carotid occlusion test, necessitating a surgical intra-extra cranial by-pass prior to the carotid endovascular occlusion. In 1 other case of these 19, the internal carotid endovascular occlusion was carried-out in emergency because the aneurysm was revealed by a major haemorrhage during the surgical transsphenoidal approach of a hypophyseal tumour. No treatment was decided in the remaining 6 cases of the series (22.2%). At 6 months follow-up, 18 of the 21 treated patients experienced a clinical recovery of their symptoms and 10 of them (50%) had a complete clinical recovery. Among the 6 untreated patients, 4 had a partial recovery but no complete recovery of oculomotor deficits was observed in this group of patients. No clinical worsening was observed in the entire series, neither among the treated patients nor among the untreated patients. In conclusion, this study underlines the need of a treatment for symptomatic GICCA in order to achieve a complete clinical recovery of the symptoms due to intracavernous compression, although only partial recovery may be expected from spontaneous evolution.

Clinical and angiographic outcome of endovascular and conservative treatment for giant cavernous carotid artery aneurysms

This study evaluated the outcome of endovascular and conservative treatment for giant cavernous carotid artery aneurysms (CCAAs). We retrospectively reviewed a series of 35 consecutive giant CCAAs treated with endovascular and conservative treatment. All patients were evaluated by balloon occlusion test (BOT) before treatment. Patients who could tolerate BOT were treated by parent artery occlusion (PAO), those who could not tolerate BOT were treated by stent/coil or conservative methods. Eight patients were treated conservatively, symptoms were worsened in four patients (50%), unchanged in three, and improved in one at 33.6±19.9 months (6~65 months) follow-up. In 27 aneurysms treated with endovascular methods, 17 aneurysms were treated by PAO, eight aneurysms were treated with stent-assisted coil embolization, and two aneurysms were embolized with coils. The initial post-procedure angiogram revealed complete occlusion, neck remnant, and incomplete occlusion in 81.5 %, 11.1 %, and 7.4 %, respectively. Procedure-related mortality and morbidity were 0 and 7.4 %, respectively. At 33.1±17.4 months (4~71 months) follow-up, a good clinical outcome (mRS 0-1) was observed in 25 (92.6%) patients, symptoms were resolved or improved in 20 (74.1%). Statistical analysis showed that risk factors for poor clinical outcome included age of 60 years and older (P=0.006), and conservative treatments (P=0.038). Risk factors for poor clinical outcome of giant CCAAs included conservative treatment and age older than 60 years. A symptomatic giant cavernous carotid aneurysm should be treated. The outcome of endovascular treatment of giant CCAAs is promising.

Stent-assisted coil embolization for cavernous carotid artery aneurysms

Internal carotid artery (ICA) occlusion with or without a bypass surgery is the traditional treatment for cavernous sinus (CS) aneurysms with cranial nerve (CN) dysfunction. Coil embolization without stents frequently requires retreatment because of the large size of CS aneurysms. We report the mid-term results of six unruptured CS aneurysms treated with stent-assisted coil embolization (SACE). The mean age of the patients was 72 years. The mean size of the aneurysms was 19.8 mm (range: 13–26 mm). Before treatment, four patients presented with CN dysfunction and two patients had no symptoms. SACE was performed under local or general anesthesia in three patients each. Mean packing density was 29.1% and tight packing was achieved. There were no neurological complications. CN dysfunction was cured in three patients (75%) and partly resolved in one patient (25%). Transient new CN dysfunction was observed in two patients (33%). Clinical and imaging follow-up ranged from 6 to 26 months (median: 16 months). Recanalization was observed in three patients (50%; neck remnant in two patients and dome filling in one patient), but no retreatment has yet been required. No recurrence of CN dysfunction has occurred yet. In summary, SACE increases packing density and may reduce requirement of retreatment with an acceptable cure rate of CN dysfunction. SACE may be a superior treatment for coiling without stents and be an alternative treatment of ICA occlusion for selected patients, such as older patients and those who require a high-flow bypass surgeryor cannot receive general anesthesia.

Improvement in Visual Symptomatology after Endovascular Treatment of Cavernous Carotid Aneurysms: A Multicenter Study

INTRODUCTION

Aneurysms arising from the cavernous internal carotid artery (CCAs) pose technical challenges for surgical management and such patients are frequently referred for endovascular treatment. These aneurysms often produce a variety of neurological deficits, primarily those related to oculoparesis. Our purpose was to determine the visual and neurological outcome of patients with treated CCAs.

METHODS

We reviewed the medical records and angiograms for patients who underwent endovascular treatment for CCAs at three academic medical centers. The following outcomes were analyzed: angiographic assessment, visual improvement and outcome at 3 months using Glasgow Outcome Scale (GOS).

RESULTS

Thirty-four patients (mean age 54.7 years) were treated for CCAs. The mean aneurysm size was 14.2 mm (range: 3-45 mm), and fourteen patients (41.2%) required stent assistance. Twenty-one aneurysms (61.8%) were completely occluded; nine aneurysms (26.6%) had near-complete occlusion; 4 aneurysms (11.8%) had partial occlusion. Seven patients (20.6%) required retreatment. Fifteen of the 34 patients (44.1%) presented with visual symptoms, while only eight patients had residual visual symptomatology at follow-up (44.1% vs. 23.5%; p=0.02). Patients that presented with visual symptoms (N=15) had a mean aneurysm size of 24.5 mm, while those without visual symptoms (N=19) had a size of 7.5 mm (p=0.001). Follow-up GOS was good (4-5) in 29 patients (90.6%). No thromboembolic complications were observed. One patient died (3.1%) of an unrelated cause.

CONCLUSIONS

Most patients in this multicenter series improved or remained stable after treatment. The results of this study indicate that endovascular treatment may improve the outcome of visual symptoms in patients with large cavernous aneurysms with low periprocedural morbidity.

COMPETING INTERESTS

MJA is a consultant for Stryker and Codman. AC receives a Cordis Endovascular Fellowship Training Grant and a Stryker Endovascular Neurosurgery Post-graduate Fellow Grant.

JUSTIFICATION OF AUTHORSHIP

Dr. Drazin: Conception and Design, Drafting the Article and Critically Revising the Article Dr. Choulakian: Analysis and Interpretation of Data and Drafting the Article Dr. Nuno: Analysis and Interpretation of Data Dr. Gandhi: Analysis and Interpretation of Data and Drafting the Article Dr. Edgell: Analysis and Interpretation of Data and Drafting the Article Dr. Alexander: Critically Revising the Article and Conception and Design.

Clinical presentation of cerebral aneurysms

Presentation of a cerebral aneurysm can be incidental, discovered at imaging obtained for unrelated causes, can occur in the occasion of imaging obtained for symptoms possibly or likely related to the presence of an unruptured aneurysm, or can occur with signs and symptoms at the time of aneurismal rupture. Most unruptured intracranial aneurysms are thought to be asymptomatic, or present with vague or non-specific symptoms like headache or dizziness. Isolated oculomotor nerve palsies, however, may typically indicate the presence of a posterior circulation aneurysm. Ruptured intracranial aneurysms are by far the most common cause of non-traumatic subarachnoid hemorrhage and represent a neurological emergency with potentially devastating consequences. Subarachnoid hemorrhage may be easily suspected in the presence of sudden and severe headache, vomiting, meningism signs, and/or altered mental status. However, failure to recognize milder and more ambiguous clinical pictures may result in a delayed or missed diagnosis. In this paper we will describe the clinical spectrum of unruptured and ruptured intracranial aneurysms by discussing both typical and uncommon clinical features emerging from the literature review. We will additionally provide the reader with descriptions of the underlying pathophysiologic mechanisms, and main diagnostic pitfalls.

Endovascular treatment of cavernous sinus aneurysms

BACKGROUND AND PURPOSE

Aneurysms of the cavernous segment of the internal carotid artery generally exhibit a benign clinical course, with mass effect on cranial nerves. Rupture generally leads to carotid cavernous fistula and, rarely, to subarachnoid hemorrhage. In this study we report results of treatment in 85 patients with 86 cavernous sinus aneurysms.

MATERIALS AND METHODS

In a 15-year period, 85 patients with 86 cavernous sinus aneurysms were treated. There were 77 women (91%) and 8 men, with a mean age of 55.5 years (range 26-78 years). Presentation was cranial neuropathy in 56, carotid cavernous fistula in 8, and subarachnoid hemorrhage in 1 patient. Twenty-one aneurysms were asymptomatic. Treatment was selective coiling in 31 aneurysms and carotid artery occlusion in 55 aneurysms, 5 after bypass surgery.

RESULTS

All 8 cavernous sinus fistulas were closed with coils. There were no complications of coiling and 1 patient had a permanent neurologic complication after carotid artery occlusion (morbidity 1.2%; 95% confidence interval, 0.01 to 6.9%). Clinical and MR imaging follow-up ranged from 3 months to 12 years. In 52 of 56 (93%) patients presenting with symptoms of mass effect, symptoms either were cured (n = 23) or improved (n = 29). All aneurysms were thrombosed after carotid artery occlusion and at latest MR imaging, 34 of 50 aneurysms (68%) were substantially decreased in size or completely obliterated.

CONCLUSIONS

In this series, for patients with cavernous sinus aneurysms, a treatment strategy including selective coiling and carotid artery occlusion was safe and effective. Most symptomatic patients (93%) were improved or cured, and most aneurysms (68%) shrank on follow-up.

Delayed caroticocavernous fistula after stent-assisted coil embolization of intracavernous carotid aneurysm: should we manage conservatively?

Constructive endovascular techniques remain the mainstay for the treatment of cavernous carotid aneurysms due to their efficacy. However, they do harbor risks of complications, such as thromboembolic events, arterial injuries, and vessel occlusions. A 58-year-old lady presented with delayed caroticocavernous fistula (CCF) 1 month after stent-assisted coil embolization of a cavernous carotid aneurysm (CCA). Following this, her caroticocavernous fistula resolved spontaneously with no further intervention. Our case demonstrates a unique presentation of a CCF as a delayed complication of stent-assisted coil embolization of CCA and the spontaneous resolution of the CCF. Symptomatic CCFs are commonly treated as an emergency in many institutions and the question arises as to whether we should adopt a conservative policy in the light of this case report.

Partially thrombosed intracranial aneurysms presenting with mass effect: long-term clinical and imaging follow-up after endovascular treatment

BACKGROUND AND PURPOSE

Partially thrombosed aneurysms as a distinct entity form a diverse collection of complex aneurysms characterized by organized intraluminal thrombus and solid mass. Endovascular treatment options are PVO or selective coil occlusion of the remaining lumen. We present long-term clinical and angiographic results of endovascular treatment of unruptured partially thrombosed aneurysms that presented with symptoms of mass effect.

MATERIALS AND METHODS

Between 1994 and 2008, 30 partially thrombosed aneurysms were treated by selective coiling and 26 by PVO. Of 56 aneurysms, 53 (95%) were large or giant. Neurologic recovery during a mean clinical follow-up of 42.7 months was established. Evolution of aneurysm size during a mean follow-up of 26.6 months in 46 patients was assessed with MR imaging.

RESULTS

Seventeen of 56 patients (30%) fully recovered, 22 patients (39%) partially recovered, 11 patients (20%) were unchanged, and 6 patients (11%) died. Complete recovery more often occurred after PVO than after coiling (12 of 26 versus 5 of 30, P = .02). Aneurysm size reduction occurred more often after PVO (17 of 18 versus 2 of 28, P < .001). Five aneurysms continued to grow after coiling, resulting in death in 3. During follow-up, 27 additional treatments were performed in 19 patients, all treated with coiling.

CONCLUSIONS

In partially thrombosed aneurysms presenting with mass effect, the results of PVO are much better than those of selective coiling. After coiling, additional treatments are often needed, and some aneurysms keep growing. When PVO is not tolerated or not possible, surgical options should be considered before proceeding with coiling.

Cavernous carotid aneurysms: to treat or not to treat?

Most cavernous carotid aneurysms (CCAs) are considered benign lesions, most often asymptomatic, and to have a natural history with a low risk of life-threatening complications. However, several conditions may exist in which treatment of these aneurysms should be considered. Several options are currently available regarding the management of CCAs with resultant good outcomes, namely expectant management, luminal preservation strategies with or without addressing the aneurysm directly, and Hunterian strategies with or without revascularization procedures. In this article, we discuss the sometimes difficult decision regarding whether to treat CCAs. We consider the natural history of several types of CCAs, the clinical presentation, the current modalities of CCA management and their outcomes to aid in the management of this heterogeneous group of cerebral aneurysms.

Trigeminal fistula treated by combined transvenous and transarterial embolisation

Trigeminal cavernous fistulae are rare, compared to other types of carotid-cavernous fistulae with only about 17 examples previously reported in English literature. The aetiology can be either post-traumatic or spontaneous, and in the latter group either due to a ruptured trigeminal aneurysm or postulated intrinsic weakness of the artery itself. The treatment goal is to close the fistula while preserving the parent artery and this can be done either by surgical or endovascular methods. We present a 35-year-old woman with a spontaneous trigeminal fistula treated by combined trans-venous and trans-arterial embolisation.

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

BACKGROUND AND PURPOSE

Internal carotid artery (ICA) aneurysms may present with cranial nerve dysfunction. Therapeutic ICA occlusion, when tolerated, is an effective treatment resulting in improvement or cure of symptoms in most patients. When ICA occlusion is not tolerated, selective endovascular aneurysm occlusion can be considered. We compare recovery of cranial nerve dysfunction in patients treated with selective coil occlusion and with therapeutic ICA occlusion.

MATERIALS AND METHODS

In 16 patients with 17 large or giant (11-45 mm) unruptured ICA aneurysms presenting with dysfunction of cranial nerves (CN) II, III, IV, or VI, selective coil occlusion was performed. From a cohort of 39 patients with ICA aneurysms treated with ICA occlusion and long-term follow-up, we selected 31 patients with aneurysms presenting with cranial nerve dysfunction. Clinical recovery at follow-up from oculomotor dysfunction and visual symptoms was compared for both treatment modalities.

RESULTS

Of 17 aneurysms treated with selective coiling, symptoms of cranial nerve dysfunction resolved in 3, improved in 10, and remained unchanged in 4. In 9 of 17 patients, additional coiling during follow-up was required. Of 31 aneurysms treated with carotid artery occlusion, cranial nerve dysfunction resolved in 19, improved in 9, and remained unchanged in 3. These differences were not significant. There were no complications of treatment.

CONCLUSION

Recovery of ICA aneurysm-induced cranial nerve dysfunction occurs in most patients, both after ICA occlusion and after selective coiling. In patients who cannot tolerate ICA occlusion, selective aneurysmal occlusion with coils is a valuable alternative.

Midterm clinical and magnetic resonance imaging follow-up of large and giant carotid artery aneurysms after therapeutic carotid artery occlusion

OBJECTIVE

The purpose of this study was to evaluate aneurysm size and clinical symptoms midterm after therapeutic carotid artery occlusion in 39 patients with large or giant carotid artery aneurysms.

METHODS

Between January 1996 and August 2004, 39 patients with large or giant carotid artery aneurysms were treated with therapeutic carotid artery occlusion and had clinical and magnetic resonance imaging follow-up of at least 3 months (mean, 35.9 mo; median, 29 mo; range, 3-107 mo; 117 patient-yr). Initial clinical presentation was mass effect caused by the aneurysm in 32 (82%) of the 39 patients. Three patients presented with subarachnoid hemorrhage and one presented with epistaxis; two aneurysms were an incidental finding and one was additional to another ruptured aneurysm.

RESULTS

There were no early or late complications of therapeutic carotid artery occlusion. All aneurysms seemed to have thrombosed completely after carotid artery occlusion as observed on early and late magnetic resonance imaging and magnetic resonance angiographic follow-up studies. At the time of the most recent magnetic resonance imaging follow-up study, 29 (74%) of the 39 aneurysms involuted totally, two aneurysms decreased to 25% of the original diameter, two aneurysms decreased to 50%, and five aneurysms decreased to 75%. Two aneurysms remained unchanged in size after 49 and 58 months, respectively. At the most recent clinical follow-up evaluation, symptoms of mass effect were cured in 19 (60%), improved in 10 (31%), and remained unchanged in three (9%) of the 32 patients.

CONCLUSION

Therapeutic carotid artery occlusion was a simple, safe, and effective treatment for large and giant carotid artery aneurysms. Almost all aneurysms involute completely or substantially decrease in size. Alleviation of symptoms of mass effect was achieved in most patients.

Primary treatment of an indirect carotid cavernous fistula by injection of N-butyl cyanoacrylate in the dural wall of the cavernous sinus

BACKGROUND

Carotid cavernous fistulae are abnormal communications between the carotid artery system and the cavernous sinus. Endovascular treatment is the treatment of choice, but because of their heterogeneous etiology and anatomy, an appropriate treatment plan must be tailored for each patient.

CASE DESCRIPTION

A 77-year-old diabetic woman presented with rapid onset of right eye pain, conjunctivitis, and chemosis. Angiography revealed an indirect CCF located in the posterior wall of the right cavernous sinus. N-Butyl cyanoacrylate was injected directly into the fistula site in the dural wall via a microcatheter, resulting in a cure.

CONCLUSION

We describe an unconventional treatment of an indirect CCF from an IPS approach. One type D(2) CCF was treated successfully using only N-butyl cyanoacrylate injected directly at the fistula site. This was achieved by microcatheterization of the fistula in the posterior wall of the right cavernous sinus.

Intracranial aneurysms

PURPOSE OF REVIEW

To review the neuroophthalmic manifestations of cavernous and posterior communicating artery aneurysms as well as the diagnosis and treatment options for patients with these kinds of aneurysms.

RECENT FINDINGS

The natural history of cavernous aneurysms has recently been systematically followed. Comparison of coiling and clipping for posterior communicating artery aneurysms has yielded new suggestions on how to best treat these patients.

SUMMARY

The review discusses how to follow these cases, diagnose and treat, and assess for complications after treatment decisions have been made.

Presentation, Natural History, and Management of Carotid Cavernous Aneurysms

OBJECTIVE:

We present the largest reported cohort of carotid cavernous aneurysms (CCA), comparing the neuro-ophthalmic presentation, complications, and outcome with and without endovascular treatment.

METHODS:

Retrospective review of 185 patients with 206 CCAs examined between 1980 and 2001 at a tertiary neuro-ophthalmology and neurovascular service. Patients' symptoms and findings at presentation were recorded and compared with those at outcome. The effect of treatment on outcome and on complication rate was analyzed using the χ2 test, multivariate analysis of covariance, model-selection log-linear analysis, and multinomial logistic regression.

RESULTS:

Long-term follow-up was available for 189 of 206 CCAs. Seventy-four CCAs underwent treatment (endovascular, 67 [91%]; surgical treatment, 6 [9%]), and 115 were followed for an average of 4 years, two of which required later treatment. Treatment reduced the incidence and severity of pain, even after adjusting for the severity of initial pain (F(1,192 = 9.59, P = 0.002). Treatment did not significantly affect the patient's final diplopia after adjusting for their initial diplopia (F(1, 182 = 2.01, P = 0.158). Statistical examination revealed that the treated group had a higher proportion of neurological and visual complications than people who were not treated (2(2). = 25.26, P = 0.0003).

CONCLUSION:

Endovascular treatment of carotid cavernous aneurysms leads to a significantly higher rate of pain resolution compared with untreated patients, even after adjusting for initial pain severity. Diplopia may not resolve after treatment. The results of this study underscore our approach indicating treatment only in cases of debilitating pain, visual loss from compression, or diplopia in primary gaze or in patients with risk factors for major complications such as pre-existing coagulopathy or sphenoid sinus erosion.