Management of symptomatic carotid stenoses with coincidental intracranial aneurysms

Abstract

There are at present strong indications for surgery in patients suffering from symptomatic extracranial carotid stenoses of > 70%. Surgery of coincidental aneurysms is a still debated problem, but there is general agreement that it is indicated in selected cases according to the patient's life-expectancy and size and site of the aneurysm. The coexistence of these two lesions raises a decision-making problem. We reviewed 389 endarterectomies and found 12 intracranial berry aneurysms in 10 (2.6%) patients. All the 10 patients were harbouring a symptomatic carotid stenosis of > 70%. Since the correction of a stenosis increases blood flow to an aneurysm, our approach was to first operate on the intracranial lesion and then the stenosis in 7 patients harbouring aneurysms > 5 mm. Two patients affected by small aneurysms < 5 mm of an A2 azygos and left internal carotid artery underwent left endarterectomy only. The last patient was submitted first to percutaneous angioplasty of a left stenosis, then to open surgery of a contralateral middle cerebral aneurysm and finally to intravascular occlusion of a small aneurysm of the left internal carotid bifurcation by menas of a coil; this policy was adopted in order to restore normal haemodynamic conditions before the intracranial procedure. There was no mortality or permanent morbidity following surgery for aneurysm or endarterectomy. Transient morbidity occurred in 2 cases after clipping of aneurysms of the anterior communicating and middle cerebral arteries. Our results suggest that surgery of coincidental aneurysms may give good results even when there is a severe symptomatic stenosis in the neck. Moreover, the presence of a small intracranial aneurysm does not seem to be an additional risk factor for endarterectomy. When the lesions are on different sides, it may be better to treat the stenosis first if it decreases the ipsilateral cerebral blood flow.

Incidental Intracranial Aneurysms in Patients With Internal Carotid Artery Stenosis

“…Sex-specific prevalences could be retrieved from our study and 2 studies from the literature review. 2,5 In these three studies, women had a higher risk of aneurysms than men (relative risk 1.6; 95% CI 1.1 to 2.3).…”

“…Mean ages ranged form 62 to 72 years old. The populations were North American 2,6 or European (Italy, 3,5 Great Britain 2,4 ). A total of 147 aneurysms was found in 136 patients.…”

“…The disadvantage for DSA when used to assess internal carotid artery (ICA) stenosis is that the vertebrobasilar system often is not visualized properly. [2][3][4][5][6] Accordingly, aneurysms at the posterior circulation may go undetected. CT angiography (CTA) is routinely used in patients with subarachnoid hemorrhage, but can also be used in aneurysm screening, follow-up, and anatomic characterization, 7,8 and includes the most important parts of the vertebrobasilar circulation.…”

Single-Stage Extracranial Carotid Artery Stenting and Intracranial Aneurysm Coiling: Technical Feasibility and Clinical Outcome

“…During an average five-year follow-up, only one patient had SAH six days after CE. Although some reports suggest no increased risk of rupture in asymptomatic aneurysms after carotid revascularization 2,4 , several studies have concluded that the treatment of either condition may provoke events related to the other lesion, which include subarachnoid hemorrhage after revascularization of carotid artery stenosis and perioperative stroke related to carotid artery stenosis after aneurysmal treatment 1,5 . The sequence of treatment and the number of sessions are the critical issues that should be addressed.…”

Coil embolization of intracranial aneurysms with ipsilateral carotid stenosis; technical considerations

“…endarterectomy (6,14) performing both the procedures in the same sitting (17) and performing carotid angioplasty/ endarterectomy without repairing the intracranial aneurysm (7,9,13) However there are no reports of coiling of aneurysm in patient with significant stenosis without treating the parent vessel carotid origin stenosis. We hereby report three cases of cerebral aneurysm with ipsilateral cervical carotid stenosis in whom successful embolization of aneurysm was done safely without carotid revascularization before or at the time of the embolization.…”