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Multimodality Treatment of Complex Unruptured Cavernous and Paraclinoid Aneurysms

Kim, Louis J. MD*,‡; Tariq, Farzana MD*; Levitt, Michael MD*; Barber, Jason MS*; Ghodke, Basavaraj MD; Hallam, Danial K. MD; Sekhar, Laligam N. MD*,‡

doi: 10.1227/NEU.0000000000000192
Research-Human-Clinical Studies

BACKGROUND: Unruptured aneurysms of the cavernous and paraclinoid internal carotid artery can be approached via microsurgical and endovascular approaches. Trends in treatment reflect a steady shift toward endovascular techniques.

OBJECTIVE: To analyze our results with multimodal treatment.

METHODS: We reviewed patients with unruptured cavernous and paraclinoid internal carotid artery aneurysms proximal to the posterior communicating artery treated at a single center from 2007 to 2012. Treatment included 4 groups: (1) stent-assisted coiling, (2) pipeline endovascular device (PED) flow diverter, (3) clipping, and (4) trapping/bypass. Follow-up was 2 to 60 months.

RESULTS: The 109 aneurysms in 102 patients were studied with the following treatment groupings: 41 were done with stent-assisted coiling, 24 with Pipeline endovascular device, 24 by microsurgical clipping, and 20 by trap/bypass. Group: (1) two percent had delayed significant intraparenchymal hemorrhage; (2) thirteen percent had central nerve palsies, 8% had small asymptomatic infarcts, and 4% had small, asymptomatic remote-site hemorrhages; (3) twenty-nine percent of patients suffered from transient central nerve palsies, 4% experienced major stroke, and 8% had small intracerebral hemorrhages; (4) thirty-five percent had transient central nerve palsies, 10% had strokes, and 10% had intracerebral hemorrhages. In terms of follow-up obliteration, 83% had complete/nearly complete obliteration at last follow-up, 17% had residual aneurysms, and 10% required retreatment. Ninety-six percent of group 1 (35/38), 100% of group 2 (23/23), 100% of group 3 (21/21), and 95% of group 4 had modified Rankin Scale scores of 0 to 1.

CONCLUSION: Treatment of these aneurysms can be carried out with acceptable rates of morbidity. Careful patient selection is crucial for optimal outcome. Endovascular treatment volumes likely will continue to predominate over microsurgical techniques as changing skill sets evolve in neurosurgery, but individualized application of all available treatment options will continue.

ABBREVIATIONS: ICA, internal carotid artery

MCA, middle cerebral artery

mRS, modified Rankin Scale

PED, Pipeline Embolization Device

*Department of Neurological Surgery; and

Department of Radiology, University of Washington, Seattle, Washington

Correspondence: Louis J. Kim, MD, University of Washington, 325 9th Avenue, Box 359924, Seattle, WA 98104. E-mail:

Received May 10, 2013

Accepted September 24, 2013

Copyright © by the Congress of Neurological Surgeons