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Jha R, Zhao M, Ghannam JY, Blitz S, Chalif JI, Altshuler M, Du R. Benign Natural Progression of Small Cavernous Carotid Aneurysms Suggests Limited Clinical Utility of Serial Longitudinal Follow-up. Neurosurgery 2024:00006123-990000000-01218. [PMID: 38899866 DOI: 10.1227/neu.0000000000003033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/15/2024] [Indexed: 06/21/2024] Open
Abstract
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.
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Affiliation(s)
- Rohan Jha
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Maryann Zhao
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jack Y Ghannam
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah Blitz
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joshua I Chalif
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marcelle Altshuler
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rose Du
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Nguyen VN, Heiferman DM, Dornbos D, Johnson KD, Dawkins DW, Moore KA, Khan NR, Hoit DA, Arthur AS. Sequential Flow Diversion After Nitinol Stent Placement for a Large, Matricidal Cavernous Internal Carotid Artery Aneurysm: Technical Video. Interv Neuroradiol 2024; 30:424-425. [PMID: 36113015 PMCID: PMC11310729 DOI: 10.1177/15910199221127455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/02/2022] [Indexed: 02/18/2024] Open
Abstract
The Surpass Evolve flow diverter is a novel 64-wire braided intravascular stent approved to treat unruptured large or giant saccular wide-neck or fusiform intracranial aneurysms of the intracranial internal carotid artery.1-3 Flow diverting stents have been used for the treatment of previously stented aneurysms, including residual aneurysms following prior flow diversion.5-8 This patient initially presented with a large symptomatic matricidal cavernous ICA aneurysm4 that was treated with stand-alone Neuroform Atlas stenting at an outside hospital. Here we present a video demonstrating the placement of sequential Surpass Evolve flow diverter stents within a Neuroform Atlas nitinol stent.
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Affiliation(s)
- Vincent N Nguyen
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | | | - David Dornbos
- Department of Neurosurgery, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Demi W Dawkins
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
| | - Kenneth A Moore
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Nickalus R Khan
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Daniel A Hoit
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, TN, USA
- Department of Neurological Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
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3
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Salih M, Young M, Shutran M, Taussky P, Ogilvy CS. Spontaneous Thrombosis of a Giant Cavernous Internal Carotid Artery Aneurysm and Parent Vessel Occlusion in a Patient With Bilateral Cavernous Internal Carotid Artery Aneurysms. Cureus 2023; 15:e35231. [PMID: 36968945 PMCID: PMC10033139 DOI: 10.7759/cureus.35231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 02/22/2023] Open
Abstract
Spontaneous thrombosis of giant aneurysms is a well-reported phenomenon. However, reports of complete occlusion of the aneurysm and parent vessel are scarce. Here, we describe the case of a patient with spontaneous thrombosis of a giant cavernous internal carotid artery (ICA) aneurysm and occlusion of the ICA. A 59-year-old female initially presented with frequent headaches and was otherwise completely neurologically intact. Magnetic resonance angiography (MRA) demonstrated a giant, partially thrombosed right cavernous ICA aneurysm. She was also found to have a contralateral left-sided intracavernous aneurysm. Cerebral angiogram revealed a giant, partially thrombosed right cavernous segment ICA aneurysm measuring 27.1 x 32.4 mm with slow, turbulent flow within the lesion. The patient was started on aspirin 325 mg and a dexamethasone taper with plans for follow-up flow diversion for treatment of the right cavernous ICA aneurysm. The patient presented three months later with worsening headaches, and on examination was found to have anisocoria (right > left) with a nonreactive right pupil as well as cranial nerve III/IV palsies, and facial edema. There was no evidence of intracranial hemorrhage or ischemia seen on head computed tomography (HCT). The diagnostic cerebral angiogram demonstrated complete occlusion of the right ICA at the carotid bifurcation with no filling of the giant right cavernous ICA aneurysm and a stable left cavernous ICA aneurysm. Although the exact mechanism of simultaneous thrombosis of the aneurysm and its parent artery remains unclear, it is likely due to stagnant flow. The presence of cranial nerve palsies was most likely secondary to acute edema of the lesion after thrombus formation. There was no evidence of ischemic symptoms due to collateral flow across a patent anterior communicating artery.
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4
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Svoboda N, Malik J, Charvat F, Netuka D. Transcirculation Approach for Matricidal Carotid Cavernous Aneurysm: Not a Good Choice - A Case Report of Unsuccessful Endovascular Treatment of Matricidal Carotid Cavernous Aneurysm. Case Rep Neurol 2023; 15:215-221. [PMID: 37901130 PMCID: PMC10601690 DOI: 10.1159/000533832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 07/29/2023] [Indexed: 10/31/2023] Open
Abstract
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.
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Affiliation(s)
- Norbert Svoboda
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Military University Hospital and Charles University, Prague, Czech Republic
| | - Jozef Malik
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Military University Hospital and Charles University, Prague, Czech Republic
| | - Frantisek Charvat
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Military University Hospital and Charles University, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Military University Hospital and Charles University, Prague, Czech Republic
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5
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Srinivasan VM, Hartke JN, Catapano JS, Winkler EA, Jadhav AP, Albuquerque FC, Ducruet AF. Challenging access during flow diversion treatment of a giant cavernous ICA aneurysm. NEUROSURGICAL FOCUS: VIDEO 2022; 7:V3. [PMID: 36425262 PMCID: PMC9664495 DOI: 10.3171/2022.7.focvid2258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/18/2022] [Indexed: 12/07/2022]
Abstract
A man in his 60s presented with severe ophthalmoparesis and loss of visual acuity in his right eye. He was found to have a giant aneurysm of the cavernous internal carotid artery (ICA). Treatment with a flow diverter was recommended. The aneurysm caused matricidal outflow restriction of the ICA. Microwire and microcatheter access through the aneurysm was challenging, requiring multiple wires, stentriever reduction, and more. Eventually, a construct of 3 Pipeline embolization devices was created across the aneurysm. Troubleshooting access across giant aneurysms is an important part of treatment. Informed consent was obtained for the procedure and for publication. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2258.
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Yamagami K, Hatano T, Ando M, Chihara H, Ogura T, Suzuki K, Kondo D, Kamata T, Higashi E, Sakai S, Sakamoto H, Nagata I. Symptomatic Cavernous Internal Carotid Artery Aneurysm Complicated by Simultaneous Rapid Growth of the Intra-aneurysmal and Parent Artery Thromboses. NMC Case Rep J 2022; 8:177-182. [PMID: 35079460 PMCID: PMC8769381 DOI: 10.2176/nmccrj.cr.2020-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/03/2020] [Indexed: 11/20/2022] Open
Abstract
Cavernous internal carotid artery (ICA) aneurysm complicated by simultaneous and spontaneous formation of thromboses in the aneurysm and the parent artery is a rare clinical condition. Although the majority of patients have good outcomes, some patients experience severe ischemic stroke. Here, we report a case of symptomatic large cavernous ICA aneurysm complicated by rapid growth of an intra-aneurysmal thrombosis with simultaneous parent artery thrombosis. A 68-year-old female presented with sudden-onset diplopia, right ptosis, right conjunctival hyperemia, and paresthesia of the right face. Magnetic resonance imaging (MRI) and digital subtract angiography (DSA) revealed the presence of a large partially thrombosed aneurysm in the cavernous portion of the right ICA. We planned endovascular embolization using a flow-diverting (FD) stent. Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel was started 2 weeks prior to treatment. Although the neurological state was stable, DSA conducted on the day of the endovascular treatment showed rapid growth of an intra-aneurysmal thrombosis and de novo thrombosis in the parent artery. Direct aspiration was performed via a distal support catheter with proximal blood flow arrest using a balloon-guide catheter, and the FD stent was successfully deployed. The patient’s symptoms improved postoperatively and DSA obtained 12 months after the procedure confirmed complete occlusion of the aneurysm. Although the exact mechanism of simultaneous thrombosis formation of the aneurysm and its parent artery remains unclear, it is important to recognize that rapid growth of the thrombosis increases the risk of ischemic stroke.
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Affiliation(s)
- Keitaro Yamagami
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Taketo Hatano
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Mitsushige Ando
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Hideo Chihara
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Takenori Ogura
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Keita Suzuki
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Daisuke Kondo
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Takahiko Kamata
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Eiji Higashi
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Shota Sakai
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Hiroki Sakamoto
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Izumi Nagata
- Stroke Center, Department of Neurosurgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
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7
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Dodier P, Wang WT, Hosmann A, Hirschmann D, Marik W, Frischer JM, Gruber A, Rössler K, Bavinzski G. Combined standard bypass and parent artery occlusion for management of giant and complex internal carotid artery aneurysms. J Neurointerv Surg 2021; 14:593-598. [PMID: 34353887 DOI: 10.1136/neurintsurg-2021-017673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/25/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Complex aneurysms do not have a standard protocol for treatment. In this study, we investigate the safety and efficacy of microsurgical revascularization combined with parent artery occlusion (PAO) in giant and complex internal carotid artery (ICA) aneurysms. METHODS Between 1998 and 2017, 41 patients with 47 giant and complex ICA aneurysms were treated by an a priori planned combined treatment strategy. Clinical and radiological outcomes were stratified according to mRS and Raymond classification. Bypass patency was assessed. Median follow-up time was 3.9 years. RESULTS After successful STA-MCA bypass, staged endovascular (n=37) or surgical (n=1) PAO was executed in 38 patients following a negative balloon occlusion test. Intolerance to PAO led to stent/coil treatments in two patients. Perioperative bypass patency was confirmed in 100% of completed STA-MCA bypass procedures. Long-term overall bypass patency rate was 99%. Raymond 1 occlusion and good outcome were achieved in 95% and 97% (mRS 0-2) of cases, respectively. No procedure-related mortality was encountered. Eighty-four percent of patients with preoperative cranial nerve compression syndromes improved during follow-up. CONCLUSIONS The combined approach of STA-MCA bypass surgery followed by parent artery occlusion achieves high aneurysm occlusion and low morbidity rates in the management of giant and complex ICA aneurysms. This combined indirect approach represents a viable alternative to flow diversion in patients with cranial nerve compression syndromes or matricidal aneurysms, and may serve as a backup strategy in cases of peri-interventional complications or lack of suitable endovascular access.
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Affiliation(s)
- Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Dorian Hirschmann
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Wolfgang Marik
- Department of Radiology, Medical University of Vienna, Wien, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler Universitätsklinikum GmbH, Linz, Oberösterreich, Austria
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Wien, Austria
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