Cavernous Sinus Aneurysm


Article Author:
Abdul Waheed
Joshua Seinfeld


Article Editor:
Shahnawaz Karim


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
3/18/2019 9:52:53 PM

Introduction

Aneurysms of the internal carotid arteries involving the portion of the vessel contained within the cavernous sinus pose different risks and often are managed differently from other intracranial aneurysms. Unlike other cerebral aneurysms, these lesions usually are contained by the dura of the cavernous sinus outside the subarachnoid space. [1][2][3]Therefore the risk of subarachnoid hemorrhage from these lesions is exceptionally low.

Cavernous sinus aneurysms are most common in the elderly population and often present with an indolent ophthalmoplegia. The morbidity of these aneurysms is limited, and many patients do not require treatment. However, in selected patients, endovascular occlusion is an option. It is important to note that cavernous sinus aneurysms are not malignant lesions, and the majority are asymptomatic. Hence good clinical judgment is required in the management of these lesions.

Etiology

The exact cause of cavernous sinus aneurysms is not known, but experts believe that it may be a combination of degenerative changes in the tissues. [4][5] These aneurysms are not associated with atherosclerosis, smoking, or hypertension.

Epidemiology

Cerebral aneurysms are more common in women than men, and this holds true for aneurysms in the cavernous sinus, a common site for aneurysm formation. Aneurysms, as demonstrated by van Rooij et al. 2006, represent a small percentage of treated cerebral aneurysms (2.7% in their study) given the differences in indication for treatment and subarachnoid hemorrhage risk from aneurysms in other locations.

Pathophysiology

If ruptured, cavernous aneurysms most commonly cause direct carotid-cavernous fistulas, though they may also cause massive epistaxis if there is erosion into the sphenoid sinus or subarachnoid hemorrhage if there is an extension through the dural ring into the subarachnoid space. However, the most common symptoms from these aneurysms are as a result of a mass effect on the adjacent cranial nerves. Many cavernous carotid aneurysms present without symptoms as incidental findings or with only mild symptoms and require no treatment.

History and Physical

Stiebel-Kalish et al. 2005 reported the most common symptoms at presentation as diplopia (65%), pain (59%), asymptomatic incidental finding (12%), and optic neuropathy with decreased vision (8%). Abnormal neurologic and ophthalmologic examination findings included cranial neuropathies of cranial nerves (CN) III, IV, VI, Horner syndrome, compressive optic neuropathy, CN V dysesthesia, and abnormal corneal reflex. Also, van Rooij et al. 2006 found that, out of 41 symptomatic cavernous aneurysms, 68% presented with visual symptoms or ophthalmoplegia, 24% with a cavernous carotid fistula, 5% with subarachnoid hemorrhage, and 2% with epistaxis.

Evaluation

Evaluation of cavernous aneurysms, as well as other intracranial aneurysms, usually can be evaluated with noninvasive CT or MR angiography. [6][7][8]Conventional digital subtraction angiography, however, remains the gold standard for aneurysm detection and anatomic characterization.

Treatment / Management

Small  asymptomatic cavernous sinus aneurysms less than 12 mm do not need emergent treatment. Most small aneurysms have a benign history and a very low risk of rupture. Lesions that are observed should be followed with serial CT scan or MRI imaging. A few small series do indicate that thromboembolic events and acute thrombosis may occur in about 2% of asymptomatic patients with cavernous sinus aneurysms.[9][10][11] However, if the lesion is unstable, appears to be growing, or the patient is symptomatic, these patients need to be treated.

Proposed indications for treatment of cavernous aneurysms include disabling pain, diplopia/decline in vision, a cavernous carotid fistula as a result of aneurysm rupture, erosion of an aneurysm through the bone into the sphenoid sinus that can result in life-threatening epistaxis, and extension into the subarachnoid space. Strategies for treatment have evolved in recent decades and employ deconstructive or reconstructive strategies. Deconstructive techniques include open surgical or endovascular parent vessel occlusion. This is most safely accomplished following an angiogram with balloon test occlusion study of the affected internal carotid artery demonstrating adequate collateral circulation to compensate for the occluded vessel. If a cavernous carotid fistula is present this study should be performed with the occlusion balloon distal to the aneurysm/fistula to prevent dumping of the collateral circulation through the fistula during the test occlusion which can result in a falsely positive test. Even if the test occlusion demonstrates inadequate collaterals to support permanent occlusion of the vessel parent vessel, sacrifice is still possible if combined with a surgical bypass.

When a cavernous sinus aneurysm ruptures, this constitutes a surgical emergency and requires a experienced neurosurgeon. The type of surgery depends on the location of rupture, the patient comorbidity and age, and availability of endovascular therapy. The majority of ruptured lesions are managed with endovascular techniques.

In the past, reconstructive methods for the treatment of cavernous aneurysms were limited to surgical clip ligation. This often resulted in significant morbidity secondary to the often large size and atherosclerotic nature of these aneurysms as well as the necessary cavernous sinus dissection which put the adjacent cranial nerves and parent vessel at risk. With advances in endovascular technology, aneurysm embolization with vessel preservation is often possible using a combination of detachable aneurysm coils and stents. Flow-diverting stents represent the newest technological advance in the endovascular management of these lesions. The decreased porosity of these devices results in the disruption of blood flow within an aneurysm and, in most cases, gradual aneurysm thrombosis. The long-term follow-up of the PUFS trial (Pipeline Embolization Device for Uncoilable or Failed Aneurysms) showed a 95% 5-year aneurysm occlusion rate with a 5.6% risk of major stroke neurologic death morbidity, all of which occurred within the first six months of treatment for large internal carotid artery aneurysms treated with flow-diverting devices.

Prognosis

Generally, the prognosis is positive.

  • Most small cavernous sinus aneurysms are small and asymptomatic. The risk of rupture is very low.
  • Symptomatic or large lesions can be managed with endovascular balloon occlusion with excellent outcomes.
  • The morbidity of these aneurysms is low.
  • When surgery is done to repair a cavernous sinus aneurysm, the risk of neurological and ophthalmological deficits is always a concern, and hence, good judgment is required before undertaking an open procedure.

Pearls and Other Issues

  • On the available data, it appears that cavernous sinus aneurysms are benign lesions and are not likely to rupture.
  • The risk of thrombotic events is about 2% in asymptomatic patients.
  • The majority of patients who are asymptomatic can be observed and followed up with imaging studies.
  • The current treatment of choice for cavernous sinus aneurysms is endovascular therapy.

 

Enhancing Healthcare Team Outcomes

The diagnosis and management of cavernous sinus aneurysms is best done with an interprofessional team that includes a neurologist, neurosurgeon, invasive radiologist, ophthalmologist, neurosurgical nurses, and rehab specialists. The treatment of cavernous sinus aneurysms depends on their size and symptoms. Today, the preferential treatment is endovascular therapy which is associated with significantly less morbidity than surgery. However, ruptured aneurysms can be life-threatening and need immediate treatment. Even after successful surgery, many patients are left with residual neurological and visual deficits.[12][13] (Level V)

 

 

 


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Cavernous Sinus Aneurysm - Questions

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Which is true about aneurysms in a parasellar/cavernous sinus distribution?



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Which of the following is not generally considered an indication for treatment of cavernous internal carotid artery aneurysm?



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Which cranial nerve(s) (CN) travels within the body of the cavernous sinus rather than the wall making it most susceptible to compression and injury by an enlarging aneurysm in this region?



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Endovascular treatment of a large cavernous aneurysm is planned using a flow diverting device. The patient had been started on clopidogrel as well as aspirin prior to the procedure. P2Y12 reactivity units are tested prior to the procedure. Which of the following values would potentially place the patient at increased risk of thromboembolic complications.



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Cavernous Sinus Aneurysm - References

References

Dacus MR,Nickele C,Welch BG,Ban VS,Ringer AJ,Kim LJ,Levitt MR,Lanzino G,Kan P,Arthur AS, Matricidal cavernous aneurysms: a multicenter case series. Journal of neurointerventional surgery. 2019 Feb 27;     [PubMed]
Andrade-Barazarte H,Patel K,Turel MK,Doglietto F,Agur A,Gentili F,Tymianski R,Mendes Pereira V,Tymianski M,Radovanovic I, The endoscopic transpterional port approach: anatomy, technique, and initial clinical experience. Journal of neurosurgery. 2019 Feb 22;     [PubMed]
Vercelli G,Sorenson TJ,Aljobeh AZ,Vine R,Lanzino G, Cavernous sinus aneurysms: risk of growth over time and risk factors. Journal of neurosurgery. 2019 Jan 11;     [PubMed]
Lam JJH,Shah MTBM,Chung SL,Ho CL, Persistent primitive trigeminal artery associated with a cavernous carotid aneurysm. Case report and literature review. Journal of radiology case reports. 2018 Nov;     [PubMed]
Li W,Sun Q,Duan X,Yi F,Zhou Y,Hu Y,Yao L,Xu H,Zhou L, [Etiologies and risk factors for young people with intracerebral hemorrhage]. Zhong nan da xue xue bao. Yi xue ban = Journal of Central South University. Medical sciences. 2018 Nov 28;     [PubMed]
Buño BO 2nd,Cruz FM, Neuro-ophthalmological presentation of giant intracavernous carotid artery aneurysm in a child. BMJ case reports. 2018 Nov 28;     [PubMed]
Liu HC,Wang W,Li Y,Dong H,Sun BW,Xu Y,Zhao JW,Zhang JL,Zhang TM,Kang J, [The diagnosis and treatment of traumatic optic nerve neuropathy combined with carotid artery injury]. Zhonghua yi xue za zhi. 2018 Oct 23;     [PubMed]
Goyal P,Mangla R,Gupta S,Malhotra A,Almast J,Sapire J,Kolar B, Pediatric Congenital Cerebrovascular Anomalies. Journal of neuroimaging : official journal of the American Society of Neuroimaging. 2018 Oct 31;     [PubMed]
Raza HK,Chen H,Chansysouphanthong T,Cui G, The aetiologies of the unilateral oculomotor nerve palsy: a review of the literature. Somatosensory     [PubMed]
Lipschitz N,Kohlberg GD,Zuccarello M,Samy RN, Comprehensive review of the extended middle cranial fossa approach. Current opinion in otolaryngology     [PubMed]
Margolin E,Lam CTY, Approach to a Patient with Diplopia in the Emergency Department. The Journal of emergency medicine. 2018 Jun;     [PubMed]
Wang SS,Zhao QS,Hong JF,Zhao L,Zhang XJ,Wang RM, Microsurgical and Endovascular Treatments for Ruptured Paraclinoid Aneurysms. Journal of neurological surgery. Part A, Central European neurosurgery. 2018 Jan;     [PubMed]
Turfe ZA,Brinjikji W,Murad MH,Lanzino G,Cloft HJ,Kallmes DF, Endovascular coiling versus parent artery occlusion for treatment of cavernous carotid aneurysms: a meta-analysis. Journal of neurointerventional surgery. 2015 Apr;     [PubMed]

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