Large cavernous carotid artery aneurysm with spontaneous thrombosis: is there more to a change in morphology than there seems to be? Illustrative case

BACKGROUND The pathogenesis and endovascular treatment strategy for spontaneously thrombosed unruptured cerebral aneurysms have not yet been comprehensively described. OBSERVATIONS The authors reported on a 78-year-old woman who had large bilateral unruptured cavernous carotid artery aneurysms that induced chronic disseminated intravascular coagulation and acquired factor XIII deficiency. The right aneurysm was symptomatic and partially thrombosed. Hemorrhagic diathesis and abnormal values of laboratory data improved after administration of recombinant human thrombomodulin followed by endovascular treatment in which three pipeline embolization devices were deployed for the right aneurysm. LESSONS To the best of the authors’ knowledge, this was the first report of an unruptured cerebral aneurysm leading to coagulation disorders with clinical manifestation that was treated successfully by endovascular intervention after intensive perioperative management.

Endovascular treatment of cavernous carotid artery aneurysms: A 10-year, single-center experience

Background Cavernous carotid artery aneurysms can be treated by several endovascular techniques including flow diversion (FD) and parent vessel occlusion (PVO). We reviewed our institution’s consecutive series of endovascularly treated cavernous carotid artery aneurysms to compare these two modalities and their associated clinical and radiographic outcomes. Methods All patients harboring a cavernous carotid artery aneurysm treated by FD or PVO from January 2008 to December 2018 were enrolled. Data were collected retrospectively and analyzed on patient presentation, aneurysm dimensions, treatments and related complications, rate of aneurysm occlusion, sac regression, and outcomes. Results Fourteen patients were treated with FD and 12 underwent PVO subsequent to passing a balloon test occlusion. There was no significant difference between treatment modalities in aneurysmal occlusion (97.0 ± 8.4% (FD) vs. 100% (PVO), p = 0.23), degree of sac regression (62.5 ± 16.7% (FD) vs. 56.8 ± 24.3% (PVO), p = 0.49), or near-complete to complete symptom improvement (66.7% (FD) vs. 81.8% (PVO), p = 0.62). Major complications included subarachnoid hemorrhage from aneurysmal rupture in 1 (7.1%) patient post-FD and 2 (16.7%) ischemic strokes following PVO. Conclusions Endovascular treatment of cavernous carotid artery aneurysms by FD or PVO are both effective and safe. There is insufficient evidence to recommend one technique over the other and decision making should be individualized to the patient, their aneurysm morphology, and operator experience.

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

Traumatic pseudoaneurysm of the cavernous carotid: a lethal complication of craniofacial trauma

Pseudoaneurysm of the cavernous carotid artery is a rare, yet life-threatening complication of craniofacial trauma. It may well present itself with delayed massive epistaxis up to several months after the initial insult. Early recognition and prompt treatment are the key in management and a high index of clinical suspicion is always required. In this article, we report a patient with a penetrating head injury who developed delayed epistaxis along with unilateral abducent and partial oculomotor palsy. Urgent diagnostic carotid angiography was undertaken, followed by endovascular coiling that resulted in no recurrence for a year of follow-up.

Evaluating the Tubridge™ flow diverter for large cavernous carotid artery aneurysms

Background The Tubridge™ flow diverter (TFD) was recently developed in China; however, its safety and efficacy in treating large cavernous carotid artery aneurysms (LCCAs) are unclear. Our objective was to evaluate the safety and efficacy of the TFD in patients receiving TFDs to treat LCCAs (10–25 mm). Methods Between June 2013 and May 2014, seven patients with LCCAs were enrolled in our study, and all seven patients underwent TFD implantation combined with coils. Results Angiographic follow-up images were available for all seven patients at a median of 57.5 ± 16.7 (range, 6–69) months. Seven patients obtained favorable angiographic results defined as O’Kelly–Marotta Scale C and D. Clinical follow-up data were available for all seven patients at a median of 73.32 ± 3.6 (range, 66–78) months. No patients developed new neurological deficits. Six patients achieved a modified Rankin scale score of 0, and diplopia improved in the remaining patient. Conclusions The results were excellent for the aneurysms treated with TFDs in our patients with LCCAs. TFDs are feasible for the treatment of LCCAs, but a multicenter, controlled clinical trial is needed to evaluate the long-term safety and efficacy of the TFD to treat LCCAs.

Evaluating the TubridgeTM flow diverter for large cavernous carotid artery aneurysms

Background: The TubridgeTM flow diverter (TFD) was recently developed in China; however, its safety and efficacy in treating large cavernous carotid artery aneurysms (LCCAs) are unclear.Our objective was to evaluate the safety and efficacy of the TFD in patients receiving TFDs to treat LCCAs (10–25 mm). Methods: Between June 2013 and May 2014, seven patients with LCCAs were enrolled in our study, and all seven patients underwent TFD implantation combined with coils.Results: Angiographic follow-up images were available for all seven patients at a median of 57.5 ± 16.7 (range, 6–69) months. Seven patients obtained favorable angiographic results defined as O’Kelly–Marotta Scale C and D. Clinical follow-up data were available for all seven patients at a median of 73.32 ± 3.6 (range, 66–78) months. No patients developed new neurological deficits. Six patients achieved a modified Rankin scale score of 0, and diplopia improved in the remaining patient.Conclusions: Results were excellent for the aneurysms treated with TFDs in our patients with LCCAs. TFDs are feasible for the treatment of LCCAs, but a multicenter, controlled clinical trial is needed to evaluate the long term safety and efficacy of the TFD to treat LCCAs.

Navigating a Carotico-Clinoid Foramen and an Interclinoidal Bridge in the Endonasal Endoscopic Approach: An Anatomical and Technical Note

Objective The carotico-clinoid foramen and interclinoid bridge are two anatomical variants of the sellar region. If these anatomical variants go unrecognized and are not managed safely by the surgeon during expanded endoscopic endonasal surgery for a posterior clinoidectomy, a carotid artery injury may occur. We summarize a method to safely navigate in the presence of the carotico-clinoid foramen and interclinoid bridge in an endoscopic endonasal approach. Design The study involves cadaveric dissection and management of the anatomical variants. Setting The study took place in a cadaveric dissection laboratory. Participants The object of study is one cadaveric head. Main Outcome Measures After discovering the two variants in both cavernous sinuses of a cadaveric head, we established a stepwise coping strategy to avoid carotid artery injury while performing an endoscopic endonasal bilateral interdural pituitary transposition, and we report the final view after endoscopic management. Results Debulking of the middle clinoid process can decrease the obstacle effect, and the pituitary transposition can be performed medial to the ossified carotico-clinoid ligament. Disconnection of the interclinoid bridge is the prerequisite to an effective posterior clinoidectomy, and distinguishing the transition between the sellar diaphragm and the interclinoid bridge is essential. Conclusion In the presence of both the carotico-clinoid foramen and the interclinoid bridge, a bilateral interdural pituitary transposition can still be performed, although preoperative strategic preparation, full inspection, and stepwise disconnections are of paramount importance in such a scenario to avoid cavernous carotid artery injury.

Image-guided endonasal endoscopic excision of Meckel’s cave trigeminal schwannoma from cavernous and petrous carotid artery

Trigeminal schwannoma is the second most common schwannoma after vestibular schwannoma. Symptoms vary depending on the anatomical structures affected by the tumor, including facial pain, paresthesia, dizziness and ataxia. The primary goals are controlling the symptoms and the maintenance of cranial nerves’ integrity perioperatively. We report a 39-year-old lady who was complaining of mild right-sided headache, vision and hearing loss, right facial weakness and dysphagia. CT and MRI showed a large dumbbell-shaped tumor originating from the trigeminal fossa abutting the petrous and cavernous carotid artery and extending to the infratemporal fossa. An image-guided endonasal endoscopic removal was successfully done. Image-guided endonasal endoscopic removal of a trigeminal schwannoma abutting the petrous and cavernous carotid artery and extending to the infratemporal fossa is a safe, effective approach, as it offers excellent visualization, accurate localization and safe dissection of the tumor from the critical anatomical neurovascular structures surrounding it.