Tandem cervical carotid stenting for stenosis with flow diversion embolisation for the treatment of intracranial aneurysms

Abstract

BackgroundAn estimated 2%–3% of the population harbour an intracranial aneurysm. Concomitant atherosclerotic cervical carotid disease is not uncommon. The management of these two entities remains a challenge within the field.Case presentationWe report a single case of concomitant carotid stenosis and two ipsilateral unruptured intracranial aneurysms treated with a single-staged cervical carotid stenting and cerebral aneurysm embolisation with the Pipeline embolisation device.DiscussionNo consensus currently exists to guide endovascular treatment of intracranial aneurysms associated with asymptomatic ipsilateral stenosis. Here, we present a case of asymptomatic moderate carotid stenosis with two ipsilateral intracranial aneurysms and suggest carotid artery stenting takes procedural priority over aneurysm embolisation in single-stage treatment. The rationale for the sequence of neurointerventions is based on the tracking a robust distal access system beyond a stenotic proximal carotid lesion and stabilisation of the ulcerated plaque to avoid thromboembolic complications associated with plaque irritation during aneurysm embolisation. Additional cases and longer follow-up will be needed to further assess the efficacy of this technique.

Endovascular treatment of patient with multiple extracranial large vessel stenosis and coexistent unruptured wide-neck intracranial aneurysm using a WEB device and Szabo-technique

“…In the cases of microsurgical treatment it can due to the decreased intracranial hemodynamic reserve and a temporary reduction in perfusion pressure during anesthesia [18 , [20] , [21] , [22] ]. Risk of cerebral ischemia increases in the cases of endovascular treatment of an aneurysm through untreated carotid stenosis due to need for traverse of stenotic lesion and mechanical interaction between the access catheters and stenotic plaque [17 , 18 , 24] .…”

“…Moreover, endovascular aneurysm treatment in patients with carotid stenosis has its own risks [17 , 18] . The mechanical interaction between the access catheters and stenotic carotid plaque may increase the risk of thromboembolic complications [24] .…”

Safety of Endovascular Treatment for Concomitant Unruptured Intracranial Aneurysms and Cerebral Vascular Stenosis

“…As the safety of endovascular modalities for UIA treatment and carotid stenosis continues to improve, the notion of single-staged treatment has increasing appeal. Cases reports have demonstrated the feasibility of simultaneous single-staged treatment of concomitant carotid stenosis and ipsilateral UIAs [7,17,20,21]. Some authors hold different views.…”

“…Many patients with concomitant carotid stenosis and ipsilateral UIA underwent endovascular treatment have been reported. The overall complication rate is not high and clinical outcome turn out to be good [2][3][4][5][6][7]. However, rare authors have reported endovascular treatment results of concomitant UIAs and cerebral vascular stenosis despite location and degree of stenosis, as well as location and morphology characteristics of UIAs.…”

Intervals of endovascular treatment for coincidental non-adjacent unruptured aneurysms in patients with symptomatic intracranial atherosclerotic stenosis

“…A few studies have reported patients with concomitant extracranial carotid stenosis and UIA, and also patients with adjacent atherosclerotic stenosis and UIA. The overall complication rate is not high and clinical outcomes turn out to be good (5)(6)(7)(8)(9)(10)(11)(12). To the best of our knowledge, few authors have reported the safety of endovascular treatment for non-adjacent concomitant intracranial symptomatic atherosclerotic stenosis and UIA.…”