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

Abstract

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.

Fig 1.

A 65-year-old woman who presented with progressive left-sided ophthalmoparesis due to third and fourth cranial nerve palsy. Digital subtraction angiography in frontal (A) and lateral (B) views demonstrates a large (19-mm-diameter) aneurysm arising from the cavernous segment of the left internal carotid artery. The patient was treated by endoluminal reconstruction of the LICA with 3 overlapping PEDs (frontal, C, and lateral, D). One-year follow-up digital subtraction angiography in frontal (E) and lateral (F) views and 5-year follow-up digital subtraction angiography in frontal (G) and lateral (H) views confirm stable angiographic cure. Regression of symptoms was correlated with the resolution of aneurysm mass effect as illustrated by comparison of the pretreatment gadolinium-enhanced axial T1-weighted MR image (I, white arrow) with the 5-year follow-up axial T2-weighted MR image (J).

Fig 2.

Radiographic outcomes at 6, 12, and 36 months.