Supraclinoid internal carotid artery blister-like aneurysms: hypothesized pathogenesis and microsurgical clipping outcomes

Abstract Background Blister-like aneurysms (BLAs) on the supraclinoid segment of the internal carotid artery (ICA) are an enigma of cerebrovascular disease. Neither has a definite pathogenesis been so far identified, nor have uniform treatment guidelines been established for them. Our aim was to develop a hypothesis regarding the evolution of BLAs according to their macroscopic morphologies and to evaluate the efficacy of microsurgical clipping. Methods The clinical data and morphological features of 15 consecutive patients with 16 BLAs on the supraclinoid ICA were retrospectively reviewed. The treatment strategies were analyzed, and functional outcomes were evaluated using the modified Rankin scale (mRS). Favorable outcomes were defined as a mRS score of 0–2. Results Morphologically, aneurysm growth with expansion of the aneurysm neck before the surgical procedure occurred in two ruptured and one unruptured aneurysm. Daughter bleb formation was observed in two ruptured and five unruptured aneurysms. A varied degree of parent artery sclerosis was observed in nine patients. Thirteen patients were treated with direct surgical clipping, one patient was treated with clipping and wrapping, and the remaining patient was treated with an encircling clipping graft. Favorable and unfavorable outcomes were observed in 13 and two cases, respectively. Follow-up angiograms revealed 4 cases of stenosis with respective degree of mild, 30%, 50%, and 80% without any neurological dysfunction. Conclusions We suggest a hypothesis that BLAs on the supraclinoid ICA may share different evolving mechanisms between ruptured and unruptured lesions. A majority of them can be reliably and safely obliterated by direct clipping technique, except for the aneurysms accompanied with severely atherosclerotic parent walls.

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Flow diversion of large internal carotid artery aneurysms with the surpass device: impressions and technical nuance from the initial North American experience

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011769 ◽

2015 ◽

Vol 8 (3) ◽

pp. 279-286 ◽

Cited By ~ 29

Author(s):

Geoffrey P Colby ◽

Li-Mei Lin ◽

Justin M Caplan ◽

Bowen Jiang ◽

Barbara Michniewicz ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Flow Diverter ◽

Flow Diversion ◽

Initial Experience ◽

Unruptured Aneurysms ◽

Aneurysm Neck ◽

Aneurysm Embolization ◽

Grade Ii

BackgroundFlow diversion is an important tool for treatment of cerebral aneurysms, particularly large and giant aneurysms. The Surpass flow diverter is a new system under evaluation in the USA.ObjectiveTo report our initial experience of 20 cases with the Surpass flow diverter to demonstrate its basic properties, the required triaxial delivery platform, and the methodologies used to deploy it during treatment of large internal carotid artery (ICA) aneurysmsMethodsTwenty patients with ICA aneurysms ≥10 mm with ≥4 mm neck treated as part of the Surpass IntraCranial Aneurysm Embolization System Pivotal Trial (the SCENT trial; Stryker) were included. Details of patient demographics, aneurysm characteristics, and technical procedures were collected.ResultsTwenty patients (mean age 63.3±1.3 years; range 51–72) with 20 unruptured aneurysms (mean size 13.4±0.9 mm; range 10–21 mm) were treated. For proximal access, 60% of cases had aortic arch ≥grade II, 55% had significant cervical ICA tortuosity, and 60% had cavernous ICA ≥grade II. The Surpass device was implanted in 19/20 (95%) cases. Of 19 cases, a single device was used in 18 cases (95%) and 2 devices in only 1 case (5%). Balloon angioplasty was performed in 8/19 cases (42%). Complete aneurysm neck coverage and adequate vessel wall apposition was obtained in all 19 cases.ConclusionsSurpass is a next-generation flow diverter with unique device-specific and delivery-specific features compared with clinically available endoluminal flow diverters. Our initial experience demonstrates a favorable technical profile in treatment of large and giant ICA aneurysms.Trial registration numberNCT01716117.

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Endovascular treatment of unruptured aneurysms of cavernous and ophthalmic segment of internal carotid artery with flow diverter device Pipeline

Radiology and Oncology ◽

10.1515/raon-2016-0049 ◽

2016 ◽

Vol 50 (4) ◽

pp. 378-384 ◽

Cited By ~ 4

Author(s):

Marko Jevsek ◽

Charbel Mounayer ◽

Tomaz Seruga

Keyword(s):

Blood Flow ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Treatment Success ◽

Giant Aneurysm ◽

Flow Diverter ◽

Unruptured Aneurysms ◽

Aneurysm Neck ◽

Flow Diverter Device

Abstract Background Intra-arterial treatment of aneurysms by redirecting blood flow is a newer method. The redirection is based on a significantly more densely braided wire stent. The stent wall keeps the blood in the lumen of the stent and slows down the turbulent flow in the aneurysms. Stagnation of blood in the aneurysm sac leads to the formation of thrombus and subsequent exclusion of the aneurysm from the circulation. The aim of the study was to evaluate flow diverter device Pipeline for broad neck and giant aneurysm treatment. Methods Fifteen patients with discovered aneurysm of the internal carotid artery were treated between November 2010 and February 2014. The majority of aneurysms of the internal carotid artery were located intradural at the ophthalmic part of the artery. The patients were treated using a flow diverter device Pipeline, which was placed over the aneurysm neck. Treatment success was assessed clinically and angiographically using O’Kelly Marotta scale. Results Control angiography immediately after the release of the stent showed stagnation of the blood flow in the aneurysm sac. In none of the patients procedural and periprocedural complications were observed. 6 months after the procedure, control CT or MR angiography showed in almost all cases exclusion of the aneurysm from the circulation and normal blood flow in the treated artery. Neurological status six months after the procedure was normal in all patients. Conclusions Treatment of aneurysms with flow diverter Pipeline device is a safe and significantly less time consuming method in comparison with standard techniques. This new method is a promising approach in treatment of broad neck aneurysms.

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Visual complications after coil embolization of internal carotid artery aneurysms at the ophthalmic segment

Interventional Neuroradiology ◽

10.1177/1591019921996886 ◽

2021 ◽

pp. 159101992199688

Author(s):

Shotaro Michishita ◽

Toshihiro Ishibashi ◽

Ichiro Yuki ◽

Mitsuyoshi Urashima ◽

Kostadin Karagiozov ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Coil Embolization ◽

Internal Carotid ◽

Visual Outcome ◽

Unruptured Aneurysms ◽

Aneurysm Neck ◽

Significant Difference ◽

Aneurysmal Neck ◽

The Relationship

Background Coil embolization of aneurysms of the ophthalmic segment of the internal carotid artery (ICA-OphA ANs) has potential risks of visual complications. We analyzed this risk and focused on the relationship of the ophthalmic artery (OphA) origin with the aneurysm neck. Methods From January 2003 to April 2018, 179 unruptured ICA-OphA ANs were treated with endovascular surgery in our institution. Two ruptured and four aneurysms with missing data were excluded. Finally, 173 unruptured aneurysms were included in this study. The aneurysms were classified into three groups according to the location of the OphA origin: Separate, Shared, and Dome type. We retrospectively assessed visual complications based on the relationship between types of aneurysm and postoperative angiographic findings for the OphA. Results Visual deficits remained permanent in eleven cases (6.4%). In the Dome type, visual complications were significantly more frequent compared to the Separate type. Change in the OphA flow was significantly associated with a higher complication rate of 2.9%, but patients with changed OphA flow had a significant rate of 7.5% ( p = 0.020). We found no significant difference in the incidence of visual complications concerning the use of perioperative antithrombotic therapy. Conclusions The location of OphA origin regarding the aneurysmal neck and postoperative OphA flow were significantly correlated with the visual outcome after coil embolization for ICA-OphA ANs. Post-procedural flow in the OphA was an important factor affecting the rate of ischemic retinal complications. Retinal embolic events occurred with preserved flow in the OphA, albeit at a lower rate.

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The Paraclinoid Carotid Artery: Anatomical Aspects of a Microneurosurgical Approach

Neurosurgery ◽

10.1227/00006123-198805000-00015 ◽

1988 ◽

Vol 22 (5) ◽

pp. 896-901 ◽

Cited By ~ 49

Author(s):

Engelbert Knosp ◽

Gerd Müller ◽

Axel Perneczky

Keyword(s):

Carotid Artery ◽

Connective Tissue ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Cranial Nerves ◽

Parent Artery ◽

Connective Tissue Layer ◽

Aneurysm Neck ◽

C3 Segment

Abstract The paraclinoid area is investigated anatomically for possible microneurosurgical approaches to the C3 segment of the internal carotid artery and to structures in the vicinity of the anterior siphon knee. Removal of the anterior clinoid process reveals a tight connective tissue ring that fixes the internal carotid artery to the surrounding osseous structures at the point of its transdural passage. Transection of this fibrous ring opens a microsurgical pathway to the carotid C3 segment. The artery is surrounded by a loose connective tissue layer that allows blunt preparation along the C3 segment, without compromising the cranial nerves and without damaging venous compartments of the cavernous sinus. This approach provides neurosurgical access to paraclinoidal aneurysms, to partly intracavernous aneurysms, and to carotid-ophthalmic aneurysms, allowing control of the proximal aneurysm neck and of the parent artery itself. In cases of tumors involving the medial sphenoid ridge, the apex of the orbit, or the cavernous sinus, the pericarotid connective tissue can serve as a guide layer for access along the internal carotid artery.

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Free-Floating Thrombus in the Distal Internal Carotid Artery Causing a Stroke

International Journal of Angiology ◽

10.1055/s-0040-1720973 ◽

2020 ◽

Author(s):

Spyros Papadoulas ◽

Konstantinos Moulakakis ◽

Natasa Kouri ◽

Petros Zampakis ◽

Stavros K. Kakkos

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Medical Management ◽

Internal Carotid ◽

Treatment Strategies ◽

Rare Condition ◽

Residual Stenosis ◽

Floating Thrombus ◽

Distal Internal Carotid Artery ◽

Carotid Bulb

AbstractWe present a patient suffering from a stroke with a free-floating thrombus extending up to the distal internal carotid artery. The thrombus was totally resolved after a 2-week anticoagulation regimen without leaving behind any severe residual stenosis in the carotid bulb. The optimal treatment of this rare condition remains uncertain. We report some important treatment strategies that have been used in the literature, emphasizing the anticoagulation as the mainstay of therapy. Immediate surgical and interventional manipulations carry the risk of thrombus dislodgement and embolization and should be considered if there are recurrent symptoms despite medical management.

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Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent

Neurosurgery ◽

10.1227/neu.0000000000001412 ◽

2016 ◽

Vol 79 (5) ◽

pp. E634-E638 ◽

Cited By ~ 25

Author(s):

Marcus D. Mazur ◽

Philipp Taussky ◽

Joel D. MacDonald ◽

Min S. Park

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Successful Treatment ◽

Internal Carotid ◽

Case Reports ◽

Treatment Strategies ◽

Artery Aneurysm ◽

Flow Diversion ◽

Multiple Treatment ◽

Internal Carotid Artery Aneurysm

Abstract BACKGROUND AND IMPORTANCE: As the use of flow-diverting stents (FDSs) for intracranial aneurysms expands, a small number of case reports have described the successful treatment of blister aneurysms of the internal carotid artery with flow diversion. Blister aneurysms are uncommon and fragile lesions that historically have high rates of morbidity and mortality despite multiple treatment strategies. We report a case of rebleeding after treatment of a ruptured blister aneurysm with deployment of a single FDS. CLINICAL PRESENTATION: A 29-year-old man presented with subarachnoid hemorrhage and a ruptured dorsal variant internal carotid artery aneurysm. Despite a technically successful treatment with a single FDS, a second catastrophic hemorrhage occurred during the course of his hospitalization. CONCLUSION: This case highlights the risk of hemorrhage during the period after deployment of a single FDS. Ruptured aneurysms, especially of the blister type, are at risk for rehemorrhage while the occlusion remains incomplete after flow diversion.

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Temporary Aneurysm Orifice Balloon Occlusion as an Alternative to Retrograde Suction Decompression for Giant Paraclinoid Internal Carotid Artery Aneurysms: Technical Note

Operative Neurosurgery ◽

10.1227/01.neu.0000157102.01803.8c ◽

2005 ◽

Vol 56 (suppl_4) ◽

pp. ONS-E442-ONS-E442 ◽

Cited By ~ 7

Author(s):

Hans-Jakob Steiger ◽

Farias Lins ◽

Thomas Mayer ◽

Robert Schmid-Elsaesser ◽

Walter Stummer ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Local Circulation ◽

Occlusion Balloon ◽

Aneurysm Neck ◽

Symptomatic Vasospasm ◽

First Case ◽

Clip Occlusion ◽

Cervical Internal Carotid Artery

Abstract OBJECTIVE: Giant paraclinoid carotid artery aneurysms frequently require the temporary interruption of local circulation to facilitate safe clip occlusion. Owing to the brisk retrograde blood flow through the ophthalmic artery and cavernous branches, the simple trapping of the aneurysm by cervical internal carotid artery clamping and intracranial distal clipping may not adequately soften the lesion. Retrograde suction decompression aspiration of this collateral supply by a catheter introduced into the cervical internal carotid artery is a popular method to achieve aneurysm deflation. With a large collateral supply, the method is not effective enough. The advent of relatively long and maneuverable soft balloons allows temporary occlusion of the aneurysm orifice. METHODS: We applied this method in two instances of giant carotid ophthalmic aneurysms. In both instances, a 15- to 20-mm-long and 4-mm-wide occlusion balloon was inserted in the internal carotid artery at the level of the aneurysm before craniotomy. After craniotomy and dissection of the aneurysm neck, the balloon was inflated under intraoperative angiographic control. RESULTS: The aneurysm became soft enough in both cases without tapping and aspiration to allow safe clip occlusion. In the first case, the postoperative course was uneventful and visual acuity improved. A known additional infraclinoid part of the aneurysm was eliminated endovascularly 5 months later using balloon-protected injection of vinyl alcohol copolymer (Onyx; Micro Therapeutics, Inc., Irvine, CA). In the second case, a postoperative symptomatic vasospasm developed 15 hours after surgery. Hypertensive therapy resulted in the disappearance of symptoms and an otherwise uneventful course with improvement of vision. CONCLUSION: This preliminary experience suggests that this new method is a feasible alternative to retrograde suction decompression.

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Retrograde Suction Decompression for Clipping of a Giant Ophthalmic Internal Carotid Artery Aneurysm: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab349 ◽

2021 ◽

Author(s):

Visish M Srinivasan ◽

Michael Zhang ◽

Lea Scherschinski ◽

Alexander C Whiting ◽

Mohamed A Labib ◽

...

Keyword(s):

Visual Acuity ◽

Carotid Artery ◽

Internal Carotid ◽

Artery Aneurysm ◽

Carotid Bifurcation ◽

Aneurysm Neck ◽

Microsurgical Clipping ◽

Complex Anatomy ◽

Internal Carotid Artery Aneurysm ◽

Paraclinoid Aneurysms

Abstract Microsurgical clipping of large paraclinoid aneurysms is challenging because of the complex anatomy of the dural rings, lack of easy proximal control, and wide aneurysm necks. Proximal retrograde suction decompression, or the Dallas technique, can reduce aneurysm turgor and, with aspiration of the trapped cervical and supraclinoid internal carotid arteries (ICAs), can collapse the aneurysm to aid microsurgical clipping.1-5 A woman in her late 30s presented with decreased right-eye visual acuity. Informed written consent was obtained for microsurgical management and publication. Upon cervical exposure of the carotid bifurcation, we performed a standard pterional craniotomy, trans-sylvian exposure, and intradural anterior clinoidectomy. After burst suppression and cross-clamping of the carotid, we inserted an angiocatheter at the common carotid artery (CCA). Distal temporary clips were placed on the posterior communicating artery and C7 ICA. With the cervical ICA unclamped, retrograde suction was continuously applied to deflate the aneurysm. We applied 2 pairs of fenestrated-booster clips to the aneurysm dome and a fifth clip to the aneurysm neck. After restoration of flow, indocyanine green angiography and Doppler assessments were performed. The proximal clip was converted into a curved clip to optimize ICA flow. Postoperative angiography confirmed complete occlusion of the aneurysm. The patient was discharged on postoperative day 3, with stable visual acuity.6 This video demonstrates that retrograde suction decompression via the cervical CCA can be safely performed to facilitate clipping of complex paraclinoid ICA aneurysms. Comprehensive planning of temporary aneurysm trapping for suction decompression and permanent clip construct for aneurysm occlusion are needed for effective aneurysm repair.

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Pipeline embolization device treatment of internal carotid artery terminus aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014312 ◽

2018 ◽

Vol 11 (5) ◽

pp. 485-488 ◽

Cited By ~ 5

Author(s):

Amit Pujari ◽

Brian Matthew Howard ◽

Thomas P Madaelil ◽

Susana Libhaber Skukalek ◽

Anil K Roy ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Treatment Strategies ◽

Maximum Diameter ◽

Class Iii ◽

Pipeline Embolization Device ◽

Proximal Internal Carotid Artery ◽

The Mean

BackgroundThe pipeline embolization device (PED) is approved for the treatment of large aneurysms of the proximal internal carotid artery (ICA). Its off-label application in treating aneurysms located specifically at the ICA terminus (ICA-T) has not been studied.MethodsWe conducted a retrospective chart review of patients from 2011 to 7 treated with PEDs. Out of 365 patients, 10 patients with ICA-T aneurysms were included. Patient demographics, procedural information, follow-up imaging, and clinical assessments were recorded.ResultsMean age was 46.9 years (± 8.8), and 6 (60%) patients were women. The mean maximum diameter of the aneurysms treated was 14.7 mm (± 10.7) and the mean neck diameter was 9.3 mm (± 6.6). Reasons for presentation included six incidental findings, one acute subarachnoid hemorrhage (SAH), and three patients with prior SAH. Kamran–Byrne Occlusion Scale scores for the treated aneurysms were as follows: three class IV (complete obliteration), four class III (<50% filling in both height and width for fusiform aneurysms or residual neck for saccular aneurysms), one class II fusiform aneurysm, 1 class 0 saccular aneurysm (residual aneurysm body), and one not classified due to pipeline thrombosis. Two clinically asymptomatic complications were noted: one patient who had a small distal cortical SAH post PED and one patient whose stent was found to be thrombosed on follow-up angiogram. All patients were seen in follow-up, and no patients were found to have worsening of their pre-procedure modified Rankin Scale score.ConclusionThe PED has potential for treating ICA-T aneurysms not amenable to conventional treatment strategies. Further studies are warranted to confirm the long term outcomes.

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