Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases

Restricted access

✓ Interventional neurovascular techniques for treating patients with intracranial aneurysms are now being performed in selected cases. In certain anatomical locations that are difficult to reach surgically, such as the cavernous portion of the internal carotid artery (ICA), this technique may be especially useful. The procedure is performed from a transfemoral approach, using local anesthesia, thus permitting continuous neurological monitoring.

Between 1981 and 1989, 87 patients diagnosed as having an intracavernous aneurysm were treated with endovascular detachable balloon embolization techniques. The patients ranged in age from 11 to 84 years. The presenting symptom was mass effect in 69 cases (79.3%), rupture of a preexisting aneurysm resulting in a carotid-cavernous sinus fistula in eight cases (9.2%), trauma resulting in a cavernous pseudoaneurysm in seven cases (8.0%), and hemorrhage in three cases (3.4%). Therapeutic occlusion of the ICA across or just proximal to the aneurysm neck was performed in 68 patients (78.2%). Since 1984, with the development of a permanent solidifying agent (2-hydroxyethyl methacrylate) to fill the balloon, it is now feasible in some cases to guide the balloon directly into the aneurysm and preserve the parent artery; this was achieved in 19 cases (22%). Follow-up examination has demonstrated complete thrombosis with partial or total alleviation of symptoms in all patients with therapeutic occlusion of the parent vessel. Of the 19 patients with preservation of the parent artery, follow-up studies have demonstrated total exclusion in 12 cases (63%) and subtotal occlusion of greater than 85% in seven cases (37%), with clinical improvement in all cases. Complications from therapy included transient cerebral ischemia during or after therapy requiring volume expansion in seven cases, embolic symptoms requiring antiplatelet medication in two cases, and stroke in four cases; there were no deaths. Detachable balloon embolization therapy, particularly for large and giant symptomatic aneurysms of the cavernous ICA, can be an effective mode of treatment.

Article Information

Address reprint requests to: Randall T. Higashida, M.D., Department of Radiology, University of California Medical Center, 505 Parnassus Avenue, L-352, San Francisco, California 94143-0628.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Detachable silicone balloon used for the intracranial aneurysm embolization procedures described. The medium-sized balloon, shown uninflated, measures 1.5 × 3.9 mm. When fully inflated, it contains a maximum volume of 0.50 cc and expands to 7.5 × 13.5 mm.

  • View in gallery

    Case 1. Radiography in a patient treated for a giant cavernous aneurysm. Left: Computerized tomography scan demonstrating a 2.5-cm aneurysm (arrows). Center: Left internal carotid arteriogram, lateral view, confirming the giant, ectatic aneurysm involving the cavernous segment of the carotid artery. The inflow and outflow of the aneurysm are separate (arrows). Right: Follow-up magnetic resonance image obtained 6 months following carotid artery occlusion using detachable balloons placed at the neck of the aneurysm. There is complete thrombosis with a dramatic decrease in size of the aneurysm (arrows).

  • View in gallery

    Angiograms in Case 2. Left: Right internal carotid angiogram demonstrating the intracavernous aneurysm measuring 10 × 12 × 12 mm with a well-defined neck (arrows). Center: A single 1.5-mm detachable balloon (arrow) was directed into the aneurysm, filled with a polymerizing material, and detached. Right: Angiogram 2 days postembolization demonstrating complete and total obliteration of the aneurysm (arrow) with normal filling of the distal intracerebral vessels.

  • View in gallery

    Case 3. Left: Left internal carotid angiogram, frontal projection, demonstrating a large irregular aneurysm (arrows), measuring 14 × 14 × 18 mm, and involving the horizontal segment of the cavernous carotid artery. The aneurysm projects posterior and lateral and has a good neck. Right: Angiogram following placement of a large 1.8-mm silicone detachable balloon into the aneurysm demonstrating total obliteration of the aneurysm with normal filling of the distal intracranial vessels.

References

  • 1.

    Arkles BRedinger P: Silicones in biomedical applications in Szycher M (ed): Biocompatible Polymers Metals and Composites. Lancaster, Penn: Technomic1983 pp 749768Arkles B Redinger P: Silicones in biomedical applications in Szycher M (ed): Biocompatible Polymers Metals and Composites. Lancaster Penn: Technomic 1983 pp 749–768

    • Search Google Scholar
    • Export Citation
  • 2.

    Bakay LSweet WH: Cervical and intracranial intraarterial pressures with and without vascular occlusion. Surg Gynecol Obstet 95:67751952Bakay L Sweet WH: Cervical and intracranial intraarterial pressures with and without vascular occlusion. Surg Gynecol Obstet 95:67–75 1952

    • Search Google Scholar
    • Export Citation
  • 3.

    Berenstein ARansohoff JKupersmith Met al: Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries. Functional investigation and embolization. Surg Neurol 21:3121984Berenstein A Ransohoff J Kupersmith M et al: Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries. Functional investigation and embolization. Surg Neurol 21:3–12 1984

    • Search Google Scholar
    • Export Citation
  • 4.

    Brackett CE Jr: The complications of carotid artery ligation in the neck. J Neurosurg 10:911061953Brackett CE Jr: The complications of carotid artery ligation in the neck. J Neurosurg 10:91–106 1953

    • Search Google Scholar
    • Export Citation
  • 5.

    Debrun GFox ADrake Cet al: Giant unclippable aneurysms: treatment with detachable balloons. AJNR 2:1671731981Debrun G Fox A Drake C et al: Giant unclippable aneurysms: treatment with detachable balloons. AJNR 2:167–173 1981

    • Search Google Scholar
    • Export Citation
  • 6.

    Fox AJViñuela FPelz DMet al: Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms. J Neurosurg 66:40461987Fox AJ Viñuela F Pelz DM et al: Use of detachable balloons for proximal artery occlusion in the treatment of unclippable cerebral aneurysms. J Neurosurg 66:40–46 1987

    • Search Google Scholar
    • Export Citation
  • 7.

    Galbraith JGClark RM: Role of carotid ligation in the management of intracranial carotid aneurysms. Clin Neurosurg 21:1711811974Galbraith JG Clark RM: Role of carotid ligation in the management of intracranial carotid aneurysms. Clin Neurosurg 21:171–181 1974

    • Search Google Scholar
    • Export Citation
  • 8.

    Gelber BRSundt TM Jr: Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass. J Neurosurg 52:1101980Gelber BR Sundt TM Jr: Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass. J Neurosurg 52:1–10 1980

    • Search Google Scholar
    • Export Citation
  • 9.

    German WJBlack SPW: Cervical ligation for internal carotid aneurysms. An extended follow-up. J Neurosurg 23:5725771965German WJ Black SPW: Cervical ligation for internal carotid aneurysms. An extended follow-up. J Neurosurg 23:572–577 1965

    • Search Google Scholar
    • Export Citation
  • 10.

    Giannotta SLMcGillicuddy JEKindt GW: Gradual carotid artery occlusion in the treatment of inaccessible internal carotid artery aneurysms. Neurosurgery 5:4174211979Giannotta SL McGillicuddy JE Kindt GW: Gradual carotid artery occlusion in the treatment of inaccessible internal carotid artery aneurysms. Neurosurgery 5:417–421 1979

    • Search Google Scholar
    • Export Citation
  • 11.

    Goto KHalbach VVHardin CWet al: Permanent inflation of detachable balloons with a low-viscosity hydrophilic polymerizing system. Radiology 169:7877901988Goto K Halbach VV Hardin CW et al: Permanent inflation of detachable balloons with a low-viscosity hydrophilic polymerizing system. Radiology 169:787–790 1988

    • Search Google Scholar
    • Export Citation
  • 12.

    Gurdjian ESLindner DWThomas LM: Experiences with ligation of the common carotid artery for treatment of aneurysms of the internal carotid artery. J Neurosurg 23:3113181975Gurdjian ES Lindner DW Thomas LM: Experiences with ligation of the common carotid artery for treatment of aneurysms of the internal carotid artery. J Neurosurg 23:311–318 1975

    • Search Google Scholar
    • Export Citation
  • 13.

    Halbach VVHieshima GBHigashida RT: Treatment of intracranial aneurysms by balloon embolization. Semin Intervent Radiol 4:2612681987Halbach VV Hieshima GB Higashida RT: Treatment of intracranial aneurysms by balloon embolization. Semin Intervent Radiol 4:261–268 1987

    • Search Google Scholar
    • Export Citation
  • 14.

    Hardy WGThomas LMWebster JEet al: Carotid ligation for intracranial aneurysm. A follow-up study of 54 patients. J Neurosurg 15:2812891958Hardy WG Thomas LM Webster JE et al: Carotid ligation for intracranial aneurysm. A follow-up study of 54 patients. J Neurosurg 15:281–289 1958

    • Search Google Scholar
    • Export Citation
  • 15.

    Heyman ATindall GTFinney WHMet al: Measurement of retinal artery and intracarotid pressures following carotid artery occlusion with the Crutchfield clamp. J Neurosurg 17:2973051960Heyman A Tindall GT Finney WHM et al: Measurement of retinal artery and intracarotid pressures following carotid artery occlusion with the Crutchfield clamp. J Neurosurg 17:297–305 1960

    • Search Google Scholar
    • Export Citation
  • 16.

    Higashida RTHieshima GBHalbach VVet al: Intravascular detachable balloon embolization of intracranial aneurysms. Indications and techniques. Acta Radiol Suppl 369:5945961986Higashida RT Hieshima GB Halbach VV et al: Intravascular detachable balloon embolization of intracranial aneurysms. Indications and techniques. Acta Radiol Suppl 369:594–596 1986

    • Search Google Scholar
    • Export Citation
  • 17.

    Hopkins LNGrand W: Extracranial-intracranial arterial bypass in the treatment of aneurysms of the carotid and middle cerebral arteries. Neurosurgery 5:21311979Hopkins LN Grand W: Extracranial-intracranial arterial bypass in the treatment of aneurysms of the carotid and middle cerebral arteries. Neurosurgery 5:21–31 1979

    • Search Google Scholar
    • Export Citation
  • 18.

    Kak VKTaylor ARGordon DS: Proximal carotid ligation for internal carotid aneurysms. A long-term follow-up study. J Neurosurg 39:5035131973Kak VK Taylor AR Gordon DS: Proximal carotid ligation for internal carotid aneurysms. A long-term follow-up study. J Neurosurg 39:503–513 1973

    • Search Google Scholar
    • Export Citation
  • 19.

    Kindt GWYoumans JR: The effect of stricture length on critical arterial stenosis. Surg Gynecol Obstet 128:7297341969Kindt GW Youmans JR: The effect of stricture length on critical arterial stenosis. Surg Gynecol Obstet 128:729–734 1969

    • Search Google Scholar
    • Export Citation
  • 20.

    Kupersmith MJBerenstein AChoi ISet al: Percutaneous transvascular treatment of giant carotid aneurysms: neuro-ophthalmologic findings. Neurology 34:3283351984Kupersmith MJ Berenstein A Choi IS et al: Percutaneous transvascular treatment of giant carotid aneurysms: neuro-ophthalmologic findings. Neurology 34:328–335 1984

    • Search Google Scholar
    • Export Citation
  • 21.

    Landolt AMMillikan CH: Pathogenesis of cerebral infarction secondary to mechanical carotid artery occlusion. Stroke 1:52621970Landolt AM Millikan CH: Pathogenesis of cerebral infarction secondary to mechanical carotid artery occlusion. Stroke 1:52–62 1970

    • Search Google Scholar
    • Export Citation
  • 22.

    Lee JFTindall GT: Arterial erosion and hemorrhage during graded carotid ligation with the Crutchfield clamp. J Neurosurg 27:52551967Lee JF Tindall GT: Arterial erosion and hemorrhage during graded carotid ligation with the Crutchfield clamp. J Neurosurg 27:52–55 1967

    • Search Google Scholar
    • Export Citation
  • 23.

    Miller F: Elastomers in medicine. Elastomerics 117:15201985Miller F: Elastomers in medicine. Elastomerics 117:15–20 1985

  • 24.

    Miller JDJawad KJennett B: Safety of carotid ligation and its role in the management of intracranial aneurysms. J Neurol Neurosurg Psychiatry 40:64721977Miller JD Jawad K Jennett B: Safety of carotid ligation and its role in the management of intracranial aneurysms. J Neurol Neurosurg Psychiatry 40:64–72 1977

    • Search Google Scholar
    • Export Citation
  • 25.

    Mullan SRaimondi AJDobben Get al: Electrically induced thrombosis in intracranial aneurysms. J Neurosurg 22:5395471965Mullan S Raimondi AJ Dobben G et al: Electrically induced thrombosis in intracranial aneurysms. J Neurosurg 22:539–547 1965

    • Search Google Scholar
    • Export Citation
  • 26.

    Nishioka H: Report on the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Section VIII, Part 1: Results of the treatment of intracranial aneurysms by occlusion of the carotid artery in the neck. J Neurosurg 25:6606821966Nishioka H: Report on the Cooperative Study of Intracranial Aneurysms and Subarachnoid Hemorrhage. Section VIII Part 1: Results of the treatment of intracranial aneurysms by occlusion of the carotid artery in the neck. J Neurosurg 25:660–682 1966

    • Search Google Scholar
    • Export Citation
  • 27.

    Parkinson D: A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 23:4744831965Parkinson D: A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg 23:474–483 1965

    • Search Google Scholar
    • Export Citation
  • 28.

    Ranney MW: Silicones. Vol 1: Rubber Electrical Molding Resins and Functional Fluids. Park Ridge, NJ: Noyes Data Corp1977Ranney MW: Silicones. Vol 1: Rubber Electrical Molding Resins and Functional Fluids. Park Ridge NJ: Noyes Data Corp 1977

    • Search Google Scholar
    • Export Citation
  • 29.

    Romodanov APShcheglov VI: Intravascular occlusion of saccular aneurysms of the cerebral arteries by means of a detachable balloon catheter. Adv Tech Stand Neurosurg 9:25491982Romodanov AP Shcheglov VI: Intravascular occlusion of saccular aneurysms of the cerebral arteries by means of a detachable balloon catheter. Adv Tech Stand Neurosurg 9:25–49 1982

    • Search Google Scholar
    • Export Citation
  • 30.

    Roski RASpetzler RFNulsen FE: Late complications of carotid ligation in the treatment of intracranial aneurysms. J Neurosurg 54:5835871981Roski RA Spetzler RF Nulsen FE: Late complications of carotid ligation in the treatment of intracranial aneurysms. J Neurosurg 54:583–587 1981

    • Search Google Scholar
    • Export Citation
  • 31.

    Scott MSkwarok E: The treatment of cerebral aneurysms by ligation of the common carotid artery. Surg Gynecol Obstet 113:54611961Scott M Skwarok E: The treatment of cerebral aneurysms by ligation of the common carotid artery. Surg Gynecol Obstet 113:54–61 1961

    • Search Google Scholar
    • Export Citation
  • 32.

    Selverstone BWhite JC: A method for gradual occlusion of the internal carotid artery in the treatment of aneurysm. Proc N Engl Cardiovasc Soc 11:241952 (Abstract)Selverstone B White JC: A method for gradual occlusion of the internal carotid artery in the treatment of aneurysm. Proc N Engl Cardiovasc Soc 11:24 1952 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 33.

    Serbinenko FA: Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 41:1251451974Serbinenko FA: Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 41:125–145 1974

    • Search Google Scholar
    • Export Citation
  • 34.

    Somach FMShenkin HA: Angiographic end-results of carotid ligation in the treatment of carotid aneurysm. J Neurosurg 24:9669741966Somach FM Shenkin HA: Angiographic end-results of carotid ligation in the treatment of carotid aneurysm. J Neurosurg 24:966–974 1966

    • Search Google Scholar
    • Export Citation
  • 35.

    Spetzler RFSchuster HRoski RA: Elective extracranial-intracranial arterial bypass in the treatment of inoperable giant aneurysms of the internal carotid artery. J Neurosurg 53:22271980Spetzler RF Schuster H Roski RA: Elective extracranial-intracranial arterial bypass in the treatment of inoperable giant aneurysms of the internal carotid artery. J Neurosurg 53:22–27 1980

    • Search Google Scholar
    • Export Citation
  • 36.

    Sweet WHSarnoff SJBakay L: A clinical method for recording internal carotid pressure. Significance of changes during carotid occlusion. Surg Gynecol Obstet 90:3273341950Sweet WH Sarnoff SJ Bakay L: A clinical method for recording internal carotid pressure. Significance of changes during carotid occlusion. Surg Gynecol Obstet 90:327–334 1950

    • Search Google Scholar
    • Export Citation
  • 37.

    Taki WHanda HYamagata Set al: Radiopaque solidifying liquids for releasable balloon technique: a technical note. Surg Neurol 13:1401421980Taki W Handa H Yamagata S et al: Radiopaque solidifying liquids for releasable balloon technique: a technical note. Surg Neurol 13:140–142 1980

    • Search Google Scholar
    • Export Citation
  • 38.

    Tsuruda JSHalbach VVHigashida RTet al: MR evaluation of large intracranial aneurysms using cine low flip angle gradient-refocused imaging. AJR 151:1531621988Tsuruda JS Halbach VV Higashida RT et al: MR evaluation of large intracranial aneurysms using cine low flip angle gradient-refocused imaging. AJR 151:153–162 1988

    • Search Google Scholar
    • Export Citation
  • 39.

    Tytus JSReifel ESpencer MPet al: Common carotid ligation for intracranial aneurysms. Results in 26 cases. J Neurosurg 32:63731970Tytus JS Reifel E Spencer MP et al: Common carotid ligation for intracranial aneurysms. Results in 26 cases. J Neurosurg 32:63–73 1970

    • Search Google Scholar
    • Export Citation
  • 40.

    Yaşargil MGSmith RD: Management of aneurysms of anterior circulation by intracranial procedures in Youmans JR (ed): Neurological Surgery. Philadelphia: WB Saunders1982 Vol 3 pp 16631696Yaşargil MG Smith RD: Management of aneurysms of anterior circulation by intracranial procedures in Youmans JR (ed): Neurological Surgery. Philadelphia: WB Saunders 1982 Vol 3 pp 1663–1696

    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 103 103 8
Full Text Views 170 170 3
PDF Downloads 114 114 2
EPUB Downloads 0 0 0

PubMed

Google Scholar