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

Abstract

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.

Fig 1.

A 48-year-old woman presenting in 1994 with visual field deficit from a right giant carotid ophthalmic aneurysm and acute left ophthalmoplegia from a left-sided carotid cavernous sinus aneurysm. A, Right ophthalmic aneurysm completely occluded with coils (see coil mesh in C and D). B, Left cavernous sinus aneurysm with intraluminal thrombus. Note additional small middle cerebral artery aneurysm. C, Angiogram 7 days after B shows enlargement of the aneurysm by resolution of intraluminal thrombus. D, Loose coil packing after embolization. Follow-up angiograms 6 to 72 months later showed progressive aneurysmal thrombosis with complete occlusion. E and F, MR imaging after 3 weeks (E) and 18 months (F). At 18 months, the aneurysm is almost completely obliterated. Visual field deficit remained unchanged, and ophthalmoplegia improved to isolated abducens palsy.

Fig 2.

A 52-year-old man presenting with acute ipsilateral ophthalmoplegia and contralateral CN III palsy with intact vision. A and B, Contrast-enhanced MR imaging (A) and angiography (B) shows giant left carotid hypophyseal aneurysm with intraluminal thrombus. Angiographic test occlusion was not tolerated. C, Angiogram 2 days after B shows enlargement of the aneurysmal lumen due to resolution of thrombus. D, Complete occlusion after stent-assisted coiling. One year later, right ophthalmoplegia was resolved. Residual upper gaze diplopia and 1- to 2-mm residual ptosis on the left side.

Fig 3.

A 38-year-old woman presenting with progressive visual field deficit. A, Giant carotid hypophyseal aneurysm compressing the chiasm treated with balloon-assisted coiling. Angiographic test occlusion was not tolerated. B, MR imaging at 3 intervals after coiling. At 12 months, the aneurysm has increased in size from 24 to 31 mm. Size is stable during an interval of 12 to 24 months. C, Perimetric results before coiling and different intervals thereafter. Incomplete hemianopsia before coiling. At 12 months, increased aneurysmal size caused progressive hemianopsia that gradually decreased at 17 and 29 months. Final result was classified as unchanged.