From the Guidelines
Internal carotid artery (ICA) aneurysms are a serious medical condition that requires prompt attention to prevent rupture and subsequent morbidity and mortality, with endovascular coiling being a preferred treatment option due to its association with fewer adverse outcomes and lower mortality rates compared to surgical clipping, as evident from studies such as 1.
Implications of ICA Aneurysms
The implications of ICA aneurysms are significant, with a risk of rupture leading to subarachnoid hemorrhage, which can result in high mortality and morbidity rates. The management of ICA aneurysms depends on the size, location, and risk of rupture, with treatment options including observation, surgical clipping, endovascular coiling, and flow diversion devices.
Treatment Options
- Observation with regular imaging (typically MRA or CTA every 6-12 months) may be recommended for small aneurysms (less than 7mm) without symptoms.
- For larger aneurysms, those causing symptoms, or those with high rupture risk, intervention is typically advised, with endovascular coiling being a preferred option due to its association with fewer adverse outcomes and lower mortality rates compared to surgical clipping, as seen in studies such as 1.
- Surgical clipping, where a neurosurgeon places a metal clip across the neck of the aneurysm to prevent blood flow into it, may be considered in certain cases.
- Flow diversion devices like the Pipeline Embolization Device may be used to redirect blood flow away from the aneurysm in some cases.
Recommendations
- Patients with unruptured aneurysms should control blood pressure (target <140/90 mmHg), avoid smoking, limit alcohol consumption, and maintain regular follow-up with a neurosurgeon or neurointerventionalist, as recommended by guidelines such as 1.
- Endovascular therapy is reasonable in selected patients for the initial management of ICA aneurysms, as stated in 1.
- Neurosurgical intervention for ICA aneurysms is reasonable in patients with rupture of ICA aneurysm with a mass effect to evacuate a hematoma, reduce intracranial pressure, and control bleeding, as recommended by 1.
From the Research
Implications of Internal Carotid Artery (ICA) Aneurysms
- ICA aneurysms can be challenging to treat due to their location and size, with a high recanalization and rebleeding rate 2
- The treatment of ICA aneurysms can lead to complications such as occlusion of the ICA, as seen in two cases of giant ICA aneurysms treated with Onyx embolization 2
- ICA aneurysms can cause oculomotor nerve palsy (ONP), which can be treated with microsurgical clipping or endovascular coiling, with similar recovery outcomes 3
- The use of flow-diverting stents, such as the Pipeline Flex Embolization Device, can be an effective treatment option for ruptured ICA blister aneurysms, allowing for vessel preservation and complete aneurysm obliteration 4
- In some cases, flow diversion covering the M1 origin may be necessary as a last resort, but this approach should be reserved for select rare cases and requires strict attention to blood pressure augmentation during the periprocedural period to minimize potential ischemic compromise 5
Treatment Options
- Endovascular embolization with Onyx is a useful treatment for ICA large or giant aneurysms, which are unsuitable for coiling or surgical treatment 2
- Microsurgical clipping and endovascular coiling are two major options for treating ONP caused by ICA aneurysm, with similar recovery outcomes 3
- Flow-diverting stent-assisted coiling is a reconstructive, vessel-preserving, endovascular treatment option for ruptured ICA blister aneurysms 4
Complications and Outcomes
- ICA aneurysms can lead to severe neurologic deficits, recurrence, and the need for retreatment, emphasizing the importance of multidisciplinary discussion and careful patient selection 6
- The use of flow-diverting stents can result in complete aneurysm obliteration, but may also lead to complications such as occlusion of the MCA or reliance on ACA and external carotid artery collaterals 5