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SUMMARY A patient experiencing transient cerebral ischemic attacks (TIAs) was studied angiographically and found to have a symptomatic stenosis of the appropriate internal carotid artery (ICA) and three asymptomatic intracranial aneurysms. A therapeutic approach to this type of problem is discussed in this article.IN PATIENTS undergoing cerebral angiographical examination for evaluation of occlusive cerebrovascular disease, about 5% will show an unexpected aneurysm.1 ' 2 The number with multiple aneurysms is difficult to ascertain from the literature, but must be considerably less. The following case illustrates the rare association of three asymptomatic intracranial aneurysms and a symptomatic carotid stenosis demonstrated on angiographical evaluation. Case ReportA 67-year-old white woman gave a history of a fiveminute episode of left arm numbness occurring three months prior to admission. On the day of admission, April 3, 1974, she noted the onset of complete numbness and slight weakness of her left arm and leg lasting about 45 minutes. By the time she was hospitalized, the symptoms had nearly resolved.She had a history of hypertension for at least 20 years, which had been under fair control with multiple medications. She also had chronic bronchitis, headaches, and occasional depression and was being treated for hypothyroidism. There was no history of diabetes mellitus, angina or prior neurological deficits. Family history was negative for any neurological disorders.Examination on admission revealed an alert apprehensive woman with a blood pressure of 160/92 mm Hg, regular pulse of 96 per minute. Funduscopic examination showed mild arteriolar narrowing. No hemorrhages, exudates or bright plaques were seen. Ophthalmodynamometry showed a 25% difference in systolic pressures, with the left greater than the right. Her neck was supple and bruits were heard over both carotids, most prominent at the midcervical region, right greater than the left. Cardiac examination suggested left ventricular enlargement but no murmurs or gallops were heard. The rest of the general examination was normal. Neurological examination was normal except for some extinction of the left arm with two-point simultaneous stimulation testing and slight downward drift of her left arm when extended. No pathological reflexes were elicited.Complete blood count, urinalysis, blood chemistries, partial thromboplastin time, and prothrombin time were all normal. Cholesterol was 200 mg/dl, and triglyceride was 235 mg/dl. Arterial gases showed a pH of 7.44, Po 2 of 81 mm Hg, and Pco 2 of 32 mm Hg. Chest and skull x-rays were normal. EKG was suggestive of an old anteroseptal myocardial infarct. A radioisotope brain scan and flow study with 99m technetium was normal. During the 12 hours after admission, the patient had two more episodes of left arm and leg numbness with minimal weakness lasting 20 minutes. A lumbar puncture showed an opening pressure of 175 mm H 2 O, clear fluid with two mononuclear cells and no RBCs; glucose and protein were normal. She wa...

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