Presentation, natural history, and management of carotid cavernous aneurysms.

OBJECTIVE: We present the largest reported cohort of carotid cavernous aneurysms (CCA), comparing the neuro-ophthalmic presentation, complications, and outcome with and without endovascular treatment. METHODS: Retrospective review of 185 patients with 206 CCAs examined between 1980 and 2001 at a tertiary neuro-ophthalmology and neurovascular service. Patients' symptoms and findings at presentation were recorded and compared with those at outcome. The effect of treatment on outcome and on complication rate was analyzed using the chi test, multivariate analysis of covariance, model-selection log-linear analysis, and multinomial logistic regression. RESULTS: Long-term follow-up was available for 189 of 206 CCAs. Seventy-four CCAs underwent treatment (endovascular, 67 [91%]; surgical treatment, 6 [9%]), and 115 were followed for an average of 4 years, two of which required later treatment. Treatment reduced the incidence and severity of pain, even after adjusting for the severity of initial pain (F(1,192 = 9.59, P = 0.002). Treatment did not significantly affect the patient's final diplopia after adjusting for their initial diplopia (F(1, 182 = 2.01, P = 0.158). Statistical examination revealed that the treated group had a higher proportion of neurological and visual complications than people who were not treated (2(2). = 25.26, P = 0.0003). CONCLUSION: Endovascular treatment of carotid cavernous aneurysms leads to a significantly higher rate of pain resolution compared with untreated patients, even after adjusting for initial pain severity. Diplopia may not resolve after treatment. The results of this study underscore our approach indicating treatment only in cases of debilitating pain, visual loss from compression, or diplopia in primary gaze or in patients with risk factors for major complications such as pre-existing coagulopathy or sphenoid sinus erosion.

Cavernous carotid aneurysms rarely cause subarachnoid hemorrhage or major neurologic morbidity.

GOAL: To determine whether aneurysms of the cavernous internal carotid artery (CCA) cause major neurologic morbidity or death. METHODS: Retrospective analysis of all patients with a spontaneous CCA evaluated by a referral multidisciplinary neurovascular service from 1981 to 2000. All patients had complete clinical neuro-ophthalmologic and neurologic examinations and magnetic resonance imaging (MRI) or computed tomography (CT) with angiographic diagnostic confirmation. Follow-up evaluations were performed by our service in the majority of patients, and the remaining patients' subsequent examinations were obtained from the referring physicians. RESULTS: One hundred seventy-four patients (mean age 60.7 years, median age 63 years, 161 women, 13 men) had 193 CCA. All 19 patients with bilateral CCAs were female. Twenty-eight patients had 1 or more subarachnoid aneurysms. The presentation included 156 aneurysms with pain or cranial neuropathy or both, 13 with a carotid cavernous fistula (CCF), and 24 asymptomatic CCAs. Two patients, both with a coagulopathy, had a cerebral infarct ipsilateral to the CCA, 1 at presentation and the other 2 years after partial third nerve palsy. One patient had a subarachnoid hemorrhage (SAH) 2.3 years after presentation, and no patient had arterial epistaxis or a CCA-related death. Excluding the 15 patients (16 aneurysms) who had no follow-up or died from SAH due to a subarachnoid aneurysm, 177 aneurysms were followed up for a mean duration of 3.10 years (SD = 3.6). One hundred six never-treated aneurysms were followed for 4.5 years (SD = 3.80, range 0.1-17), and 71 ultimately treated aneurysms were followed for 1.56 years (SD = 2.69, range 0.1-15). The overall rate for SAH was 0.19% and for a CCA-associated cerebral infarct was 0.37% per patient year. There were no correlations with cerebral infarct, SAH, or CCF and diabetes mellitus, hypertension, gender, age, cranial neuropathy, or size of the aneurysm, except for the largest diameter of the aneurysm and CCF (r = 0.17, P = .018). However, all of the patients with cerebral infarct or SAH and 12 of the 13 CCF had an aneurysm diameter > or = 1 cm. CONCLUSIONS: CCA is a disorder with strong female gender bias that uncommonly causes major neurologic complications. These data suggest that CCA should not be included in analyses that determine the risk of severe neurologic morbidity, hemorrhage, or death due to intracranial aneurysms.