Cavernous Internal Carotid Artery Aneurysm Treatment

• A 7-year retrospective single-center study on treatment strategy and clinical outcome of giant intracranial aneurysm
• A Case of thrombosed intracavernous carotid giant aneurysm with ipsilateral carotid thrombosis: Imaging, and management challenges
• A 15-year follow-up of permanent intraoperative internal carotid artery occlusion for hemostasis in a giant cavernous sinus hemangioma: a case report
• Adjunctive Coiling in Flow Diverter Treatment Does Not Prevent Delayed Rupture: A Nationwide Survey
• Spontaneous carotid-cavernous sinus fistula with fibromuscular dysplasia: illustrative case
• Unexpected internal carotid artery injury during endoscopic transsphenoidal surgery
• Trigeminal nerve palsy associated with intracranial aneurysms: Scoping review
• Challenges in the treatment of giant cavernous carotid aneurysm associated with hemophilia A: illustrative case

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 ligation with or without revascularization procedures ¹⁾.

Treatment of a cavernous internal carotid artery (ICA) aneurysm depends on various factors, including the aneurysm's size, shape, symptoms, and risk of rupture or growth.

Indication: Small aneurysms with no symptoms or minimal risk of rupture. Actions: Regular monitoring with imaging (e.g., CT angiography or MR angiography). Blood pressure management and smoking cessation. Control of risk factors like hyperlipidemia or diabetes.

Preferred for most cases due to its minimally invasive nature. Techniques: Flow Diversion: Placement of flow-diverting stents like the Pipeline Embolization Device. These devices redirect blood flow away from the aneurysm, promoting thrombosis within the sac and reducing rupture risk. Coiling: Placement of detachable coils to occlude the aneurysm. Parent Vessel Occlusion: Involves closing off the ICA proximal to the aneurysm (requires adequate collateral circulation to ensure brain perfusion, usually confirmed via balloon occlusion test).

Rarely performed due to the complexity and risks associated with the cavernous segment of the ICA. Options: Direct Clipping: Generally avoided due to the deep location and proximity to critical neurovascular structures. Bypass Surgery: High-flow or low-flow bypass to maintain perfusion if ICA sacrifice is necessary.

Direct aneurysm clipping is technically difficult and results in a significant postoperative neurological deficit. Therefore, several techniques of indirect surgical treatment were developed with different surgical outcomes, such as proximal internal carotid artery occlusion (ICA) or trapping with or without bypass (Superficial temporal artery to middle cerebral artery bypass or high-flow bypass). High-flow bypass with proximal ICA occlusion seems to be the most appropriate surgical treatment for CCA because of the high rate of symptom improvement, aneurysm thrombosis, and minimal postoperative complications. However, in cases of CCA presented with direct carotid cavernous fistula, the appropriate surgical treatment is high-flow bypass with aneurysm trapping, which the fistula can be obliterated immediately after surgery ²⁾.

For Mass Effect Symptoms: If the aneurysm compresses cranial nerves causing pain or dysfunction: Endovascular techniques are typically first-line. Decompression may alleviate symptoms. For Ruptured Aneurysms: Rupture in this location is rare due to the low-pressure venous system, but prompt treatment with endovascular methods is indicated.

Ongoing research into newer devices (e.g., advanced flow diverters, intrasaccular devices) and pharmacological agents to optimize outcomes. Factors Influencing Treatment Choice Size and Growth: Larger or growing aneurysms are more likely to be treated. Symptoms: Presence of cranial nerve palsies or other mass effects increases the need for intervention. Patient Factors: Age, comorbidities, and life expectancy. Anatomy: Adequacy of collateral circulation and feasibility of endovascular access. Complications of Treatment Endovascular: Vessel occlusion or ischemia. Stent migration or thrombosis (requires antiplatelet therapy). Surgical: Cranial nerve injury. Hemorrhage or infection. For cavernous ICA aneurysms, endovascular therapy, particularly flow diversion, is the gold standard for most symptomatic or high-risk aneurysms.