Endovascular treatment of cavernous sinus aneurysms

Abstract

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.

Fig 1.

62-year-old woman with incidentally discovered bilateral cavernous sinus aneurysms. A, MR imaging for headaches in 2006 shows bilateral cavernous sinus aneurysms. Treatment was not recommended. B, MR imaging 3 years later demonstrates growth of both aneurysms. The patient was asymptomatic. C, In 2010, the left aneurysm ruptured causing a carotid cavernous fistula with proptosis and ophthalmoplegia. Left carotid angiogram in frontal view shows early filling of both cavernous sinus and many skull base and neck veins. There was no filling of intracranial vessels. Arrows indicate internal carotid artery. D, The aneurysm was coiled; the carotid artery was also occluded with coils and sealed with a balloon. Clinical symptoms were cured within 2 weeks. E and F, Frontal views of right internal carotid artery (E) and left vertebral artery (F) after left internal carotid artery occlusion demonstrate collateral flow to the left hemisphere via the circle of Willis.

Fig 2.

54-year-old woman with ophthalmoplegia by mass effect of a giant right cavernous sinus aneurysm, treated with carotid artery occlusion. A, MR imaging demonstrates the giant cavernous sinus aneurysm (arrows). B, On follow-up MR imaging 18 months later, the aneurysm is completely obliterated; ophthalmoplegia was improved to isolated abducens palsy. There was no diplopia in primary gaze.