Endovascular management of a ruptured cavernous carotid artery aneurysm associated with a carotid cavernous fistula with an intracranial self-expanding microstent and hydrogel-coated coil embolization: case report and review of the literature

Background: Ruptured CCAs are traditionally treated with endovascular management. Advances in microstent and coil technology have allowed improved intracranial navigation, increased coil packing density, and coil volume expansion to facilitate complete coil embolization of aneurysms/fistulae. We report a case of a ruptured CCA with an associated CCF treated with an intracranial, self-expanding microstent in combination with coil embolization using hydrogel-coated platinum coils. Case Description: A 50-year-old woman presented with a 7-day history of severe headache and 2 days of progressive left-sided ptosis, ophthalmoplegia, and facial dysesthesias. A cerebral angiogram demonstrated a left ruptured wide-necked CCA with an associated CCF. An intracranial, self-expanding microstent (Neuroform³, Boston Scientific, Natick, MA) was placed across the aneurysmal neck. The aneurysm was subsequently embolized with hydrogel-coated platinum coils (HydroCoil). A 3-month follow-up angiogram showed complete resolution of arteriovenous shunting with near-complete occlusion of the CCA. The patient's ocular pain and facial dysesthesias resolved completely, with near-complete resolution of ophthalmoplegia. Conclusions: This case demonstrates near-complete occlusion of a ruptured CCA and obliteration of an associated CCF using endovascular combinational therapy of an intracranial, self-expanding microstent with hydrogel-coated platinum coils. Use of this newer-generation stent-coil combination may allow more complete and durable lesion occlusion because of increased coil packing density and coil volume expansion without the need for parent artery sacrifice or balloon-remodeling techniques, thus avoiding the potential complications of such therapies.