Flow-diverting stents for the obliteration of symptomatic, infectious cavernous carotid artery aneurysms

Andrew Joshua Kobets, Aleka Scoco, Jonathan Nakhla, Allan L. Brook, Merritt D. Kinon, Nrupen Baxi, David J. Altschul

Research output: Contribution to journalReview article

2 Citations (Scopus)

Abstract

Background: Intracavernous aneurysms constitute up to 9% of all intracranial aneurysms and 6% are infectious (IIA). First line therapy is a protracted antibiotic course, yetwith failure, surgery and endovascular parent vessel sacrifice have been utilized. Reconstructive endovascular therapies have emerged for aneurysm control and may demonstrate a safer therapeutic alternative. Objective: To present an IIA treated with a flow-diverting Pipeline stent (ev3 Neurovascular, Irvine, California). Methods: A 41-yr-old female presented with visual loss, ophthalmoplegia, and cavernous sinus thrombosis with an associated phlegmon. Transsphenoidal evacuation was performed without complication or bleeding and she continued on medical therapy. Two weeks postoperatively, she developed a worsening right third cranial nerve palsy and MRA demonstrated a 1-cm right IIA, not evident on postoperative MRI. Three days of dual antiplatelet therapy preceded successful pipeline embolization. Angiography demonstrated aneurysm obliteration at 3 mo and her right ophthalmoplegia resolved. Results: A literature review identified 6 reported cases of IIAs treated with stent embolization. Only 1 documented a flow-diverting Silk stent used in a child. All lesions were obliterated at follow-up without neurological sequelae. No complication arose with implantation in the setting of infection, and as few as 3 d of dual antiplatelet therapy was sufficient for preprocedural prophylaxis, although in Vivo antiplatelet activitymay be more significant. Conclusion: We report the first case of an IIA treated with a flow-diverting pipeline stent. These devices preserve native vasculature and neurological function compared to surgical and endovascular vessel sacrifice strategies. They appear to be safe management options for the treatment of IIAs.

Original languageEnglish (US)
Pages (from-to)681-685
Number of pages5
JournalOperative Neurosurgery
Volume14
Issue number6
DOIs
StatePublished - Jan 1 2018

Fingerprint

Carotid Arteries
Stents
Aneurysm
Ophthalmoplegia
Therapeutics
Cavernous Sinus Thrombosis
Oculomotor Nerve Diseases
Oculomotor Nerve
Cranial Nerve Diseases
Cellulitis
Silk
Intracranial Aneurysm
Angiography
Hemorrhage
Anti-Bacterial Agents
Equipment and Supplies
Infection

Keywords

  • Cavernous carotid
  • Flow-diversion
  • Infectious aneurysm
  • Intracavernous carotid
  • Mycotic aneurysm
  • Pipeline
  • Stent

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Flow-diverting stents for the obliteration of symptomatic, infectious cavernous carotid artery aneurysms. / Kobets, Andrew Joshua; Scoco, Aleka; Nakhla, Jonathan; Brook, Allan L.; Kinon, Merritt D.; Baxi, Nrupen; Altschul, David J.

In: Operative Neurosurgery, Vol. 14, No. 6, 01.01.2018, p. 681-685.

Research output: Contribution to journalReview article

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title = "Flow-diverting stents for the obliteration of symptomatic, infectious cavernous carotid artery aneurysms",
abstract = "Background: Intracavernous aneurysms constitute up to 9{\%} of all intracranial aneurysms and 6{\%} are infectious (IIA). First line therapy is a protracted antibiotic course, yetwith failure, surgery and endovascular parent vessel sacrifice have been utilized. Reconstructive endovascular therapies have emerged for aneurysm control and may demonstrate a safer therapeutic alternative. Objective: To present an IIA treated with a flow-diverting Pipeline stent (ev3 Neurovascular, Irvine, California). Methods: A 41-yr-old female presented with visual loss, ophthalmoplegia, and cavernous sinus thrombosis with an associated phlegmon. Transsphenoidal evacuation was performed without complication or bleeding and she continued on medical therapy. Two weeks postoperatively, she developed a worsening right third cranial nerve palsy and MRA demonstrated a 1-cm right IIA, not evident on postoperative MRI. Three days of dual antiplatelet therapy preceded successful pipeline embolization. Angiography demonstrated aneurysm obliteration at 3 mo and her right ophthalmoplegia resolved. Results: A literature review identified 6 reported cases of IIAs treated with stent embolization. Only 1 documented a flow-diverting Silk stent used in a child. All lesions were obliterated at follow-up without neurological sequelae. No complication arose with implantation in the setting of infection, and as few as 3 d of dual antiplatelet therapy was sufficient for preprocedural prophylaxis, although in Vivo antiplatelet activitymay be more significant. Conclusion: We report the first case of an IIA treated with a flow-diverting pipeline stent. These devices preserve native vasculature and neurological function compared to surgical and endovascular vessel sacrifice strategies. They appear to be safe management options for the treatment of IIAs.",
keywords = "Cavernous carotid, Flow-diversion, Infectious aneurysm, Intracavernous carotid, Mycotic aneurysm, Pipeline, Stent",
author = "Kobets, {Andrew Joshua} and Aleka Scoco and Jonathan Nakhla and Brook, {Allan L.} and Kinon, {Merritt D.} and Nrupen Baxi and Altschul, {David J.}",
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T1 - Flow-diverting stents for the obliteration of symptomatic, infectious cavernous carotid artery aneurysms

AU - Kobets, Andrew Joshua

AU - Scoco, Aleka

AU - Nakhla, Jonathan

AU - Brook, Allan L.

AU - Kinon, Merritt D.

AU - Baxi, Nrupen

AU - Altschul, David J.

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: Intracavernous aneurysms constitute up to 9% of all intracranial aneurysms and 6% are infectious (IIA). First line therapy is a protracted antibiotic course, yetwith failure, surgery and endovascular parent vessel sacrifice have been utilized. Reconstructive endovascular therapies have emerged for aneurysm control and may demonstrate a safer therapeutic alternative. Objective: To present an IIA treated with a flow-diverting Pipeline stent (ev3 Neurovascular, Irvine, California). Methods: A 41-yr-old female presented with visual loss, ophthalmoplegia, and cavernous sinus thrombosis with an associated phlegmon. Transsphenoidal evacuation was performed without complication or bleeding and she continued on medical therapy. Two weeks postoperatively, she developed a worsening right third cranial nerve palsy and MRA demonstrated a 1-cm right IIA, not evident on postoperative MRI. Three days of dual antiplatelet therapy preceded successful pipeline embolization. Angiography demonstrated aneurysm obliteration at 3 mo and her right ophthalmoplegia resolved. Results: A literature review identified 6 reported cases of IIAs treated with stent embolization. Only 1 documented a flow-diverting Silk stent used in a child. All lesions were obliterated at follow-up without neurological sequelae. No complication arose with implantation in the setting of infection, and as few as 3 d of dual antiplatelet therapy was sufficient for preprocedural prophylaxis, although in Vivo antiplatelet activitymay be more significant. Conclusion: We report the first case of an IIA treated with a flow-diverting pipeline stent. These devices preserve native vasculature and neurological function compared to surgical and endovascular vessel sacrifice strategies. They appear to be safe management options for the treatment of IIAs.

AB - Background: Intracavernous aneurysms constitute up to 9% of all intracranial aneurysms and 6% are infectious (IIA). First line therapy is a protracted antibiotic course, yetwith failure, surgery and endovascular parent vessel sacrifice have been utilized. Reconstructive endovascular therapies have emerged for aneurysm control and may demonstrate a safer therapeutic alternative. Objective: To present an IIA treated with a flow-diverting Pipeline stent (ev3 Neurovascular, Irvine, California). Methods: A 41-yr-old female presented with visual loss, ophthalmoplegia, and cavernous sinus thrombosis with an associated phlegmon. Transsphenoidal evacuation was performed without complication or bleeding and she continued on medical therapy. Two weeks postoperatively, she developed a worsening right third cranial nerve palsy and MRA demonstrated a 1-cm right IIA, not evident on postoperative MRI. Three days of dual antiplatelet therapy preceded successful pipeline embolization. Angiography demonstrated aneurysm obliteration at 3 mo and her right ophthalmoplegia resolved. Results: A literature review identified 6 reported cases of IIAs treated with stent embolization. Only 1 documented a flow-diverting Silk stent used in a child. All lesions were obliterated at follow-up without neurological sequelae. No complication arose with implantation in the setting of infection, and as few as 3 d of dual antiplatelet therapy was sufficient for preprocedural prophylaxis, although in Vivo antiplatelet activitymay be more significant. Conclusion: We report the first case of an IIA treated with a flow-diverting pipeline stent. These devices preserve native vasculature and neurological function compared to surgical and endovascular vessel sacrifice strategies. They appear to be safe management options for the treatment of IIAs.

KW - Cavernous carotid

KW - Flow-diversion

KW - Infectious aneurysm

KW - Intracavernous carotid

KW - Mycotic aneurysm

KW - Pipeline

KW - Stent

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U2 - 10.1093/ons/opx166

DO - 10.1093/ons/opx166

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