Management of Saccular Aneurysm of the Carotid Artery
For saccular aneurysms of the carotid artery, treatment depends critically on whether the aneurysm is intracranial (ruptured or unruptured) versus extracranial, with intracranial ruptured aneurysms requiring emergency endovascular coiling or surgical clipping within 24 hours, while extracranial aneurysms are typically managed with open surgical repair.
Intracranial Carotid Saccular Aneurysms (Ruptured)
Immediate Securing of the Aneurysm
Treat the ruptured aneurysm as soon as feasible, ideally within 24 hours of symptom onset, to prevent rebleeding which carries 50-80% mortality if untreated 1.
For anterior circulation carotid aneurysms in good-grade patients (Hunt-Hess grades I-III), primary endovascular coiling is recommended over surgical clipping to improve 1-year functional outcome 2, 1.
The decision between coiling and clipping should be made by a multidisciplinary team including both experienced cerebrovascular surgeons and endovascular specialists, evaluating patient age, aneurysm geometry, location, and clinical grade 2.
Complete obliteration of the aneurysm is the goal whenever technically feasible, as incomplete treatment significantly increases rebleeding risk 2.
Special Considerations for Treatment Selection
For patients over 70 years of age, endovascular coiling may receive increased consideration due to better outcomes in this population 2.
For patients under 40 years of age, surgical clipping might be preferred to improve long-term durability of treatment 2.
For wide-neck saccular aneurysms not amenable to primary coiling or clipping, stent-assisted coiling is reasonable to reduce rebleeding risk 2.
Avoid using stents or flow diverters for ruptured saccular aneurysms amenable to primary coiling or clipping, as these devices increase complication rates due to required dual antiplatelet therapy 2.
Medical Management
Administer nimodipine 60 mg orally every 4 hours for 21 consecutive days, starting within 96 hours of subarachnoid hemorrhage onset, to reduce delayed cerebral ischemia 1, 3.
Control blood pressure with titratable agents, avoiding aggressive reduction before aneurysm securing to maintain cerebral perfusion pressure while balancing rebleeding risk 1, 3.
Management of Acute Complications
Acute symptomatic hydrocephalus requires immediate cerebrospinal fluid diversion via external ventricular drain or lumbar drainage 1, 3.
For large intraparenchymal hematomas (>50 mL) with depressed consciousness, emergency clot evacuation should be performed to reduce mortality 2.
Intracranial Carotid Saccular Aneurysms (Unruptured)
Unruptured aneurysms require careful risk-benefit analysis comparing rupture risk (0.05-3.2% annually for aneurysms <10mm, up to 5.5% for large aneurysms) against treatment-related morbidity and mortality 2.
Treatment decisions should involve the same multidisciplinary evaluation as ruptured aneurysms, with endovascular coiling generally preferred when technically feasible 2.
Extracranial Carotid Saccular Aneurysms
Indications for Treatment
Symptomatic extracranial carotid aneurysms (causing neurological symptoms from embolization, local compression, or dysphagia) require treatment 4, 5, 6, 7.
Asymptomatic but growing lesions should be treated due to risk of embolization and rupture 5, 7.
Surgical Approach
Open surgical repair is the preferred treatment for extracranial internal carotid artery saccular aneurysms, particularly for large aneurysms with tortuous anatomy 4, 5, 6.
Aneurysmectomy with end-to-end anastomosis is the primary surgical technique when the carotid axis is elongated and adequate length exists for tension-free reconstruction 5, 6.
Presternocleidomastoid cervicotomy extended distally provides adequate exposure, with nasotracheal intubation facilitating access to high cervical lesions 6.
Alternative techniques include aneurysm neck ligation from within the sac followed by aneurysmectomy, or interposition grafting when direct anastomosis is not feasible 6.
Endovascular Approach
Endovascular treatment with stenting and coiling may be considered for aneurysms in anatomically difficult locations (retromandibular, high cervical) where open surgical access would require complex procedures 7, 8.
A hybrid approach combining surgical exposure with endovascular treatment can be used for complex cases with redundant loops or kinks preventing purely endovascular access 8.
Endovascular approaches are particularly advantageous in patients with prior neck radiation or significant comorbidities 7.
Post-Treatment Surveillance
Immediate postoperative cerebrovascular imaging is mandatory to identify aneurysm remnants or incomplete obliteration requiring retreatment 2, 1.
Delayed follow-up vascular imaging should be performed (timing and modality individualized) to detect recurrence, regrowth, or de novo aneurysm formation 2, 1.
Incompletely treated aneurysms require long-term angiographic surveillance due to increased rehemorrhage risk 2.