Download PDF
CC BY-NC-ND 4.0 · J Neurol Surg Rep 2024; 85(03): e128-e131
DOI: 10.1055/a-2377-8490
Case Report

Surgical Management of Ipsilateral Internal Carotid Artery Stenosis and Unruptured Intracranial Aneurysm: Case Review and Treatment Considerations

Diwas Gautam
1   Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, United States
,
Matthew C. Findlay
1   Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, United States
,
Kyril L. Cole
2   Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health, Salt Lake City, Utah, United States
,
William T. Couldwell 
2   Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health, Salt Lake City, Utah, United States
,
Robert C. Rennert
2   Department of Neurosurgery, Clinical Neurosciences Center, University of Utah Health, Salt Lake City, Utah, United States
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Introduction The coexistence of carotid artery stenosis and a concomitant downstream ipsilateral unruptured intracranial aneurysm requires unique treatment considerations to balance the risk of thromboembolic complications from carotid artery stenosis and the risk of subarachnoid hemorrhage from intracranial aneurysm rupture. These considerations include the selection of optimal treatment modalities, the order and timing of interventions, and potential management of antiplatelet agents with endovascular approaches. We present strategies to optimize treatment in such a case.

Case Report We discuss the case of a 69-year-old woman with 90% stenosis of the right internal carotid artery and an ipsilateral, wide-necked, 4.8-mm, irregular-appearing right A1–2 junction aneurysm with an associated daughter sac. Open, endovascular, and mixed treatment strategies were considered. The patient selected and underwent a staged, open treatment approach with a carotid endarterectomy followed by a right craniotomy for microsurgical clipping of the aneurysm 5 days later. Both procedures were performed on daily full-dose aspirin without complications. On follow-up, the right carotid artery was widely patent, the aneurysm was secured, and the patient remained at her neurologic baseline.

Discussion The presented strategy for ipsilateral carotid artery stenosis and an unruptured intracranial aneurysm initially optimized cerebral perfusion to mitigate ischemic risks while permitting timely aneurysm intervention without a need for dual antiplatelet therapy or to traverse an earlier procedure site.

Keywords

carotid artery stenosis - intracranial aneurysm - staged treatment - carotid endarterectomy - microsurgical clipping

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent.




Publication History

Received: 07 June 2024

Accepted: 27 July 2024

Accepted Manuscript online:
01 August 2024

Article published online:
20 August 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Kappelle LJ, Eliasziw M, Fox AJ, Barnett HJ. North American Symptomatic Carotid Endarterectomy Trial Group. Small, unruptured intracranial aneurysms and management of symptomatic carotid artery stenosis. Neurology 2000; 55 (02) 307-309
    CrossrefPubMedGoogle Scholar
  • 2 Korotkikh AV, Nekrasov DA, Khilchuk AA, Scherbak SG, Sarana AM. Simultaneous internal carotid artery stenosis and ipsilateral anterior communicating artery saccular aneurysm treatment: a case report. Radiol Case Rep 2020; 15 (07) 1083-1086
    CrossrefPubMedGoogle Scholar
  • 3 Shakur SF, Amin-Hanjani S, Bednarski C. et al. Intracranial blood flow changes after extracranial carotid artery stenting. Neurosurgery 2015; 76 (03) 330-336
    CrossrefPubMedGoogle Scholar
  • 4 Shakur SF, Hrbac T, Alaraj A. et al. Effects of extracranial carotid stenosis on intracranial blood flow. Stroke 2014; 45 (11) 3427-3429
    CrossrefPubMedGoogle Scholar
  • 5 Ballotta E, Da Giau G, Manara R, Baracchini C. Extracranial severe carotid stenosis and incidental intracranial aneurysms. Ann Vasc Surg 2006; 20 (01) 5-8
    CrossrefPubMedGoogle Scholar
  • 6 Wiebers DO, Whisnant JP, Huston III J. et al; International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003; 362 (9378): 103-110
    CrossrefPubMedGoogle Scholar
  • 7 Stienen MN, Germans M, Burkhardt JK. et al; Swiss SOS Study Group. Predictors of in-hospital death after aneurysmal subarachnoid hemorrhage: analysis of a nationwide database (Swiss SOS [Swiss Study on aneurysmal subarachnoid hemorrhage]). Stroke 2018; 49 (02) 333-340
    CrossrefPubMedGoogle Scholar
  • 8 Vlak MH, Algra A, Brandenburg R, Rinkel GJ. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol 2011; 10 (07) 626-636
    CrossrefPubMedGoogle Scholar
  • 9 Wermer MJ, van der Schaaf IC, Algra A, Rinkel GJ. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: an updated meta-analysis. Stroke 2007; 38 (04) 1404-1410
    CrossrefPubMedGoogle Scholar
  • 10 Bijlenga P, Ebeling C, Jaegersberg M. et al; @neurIST Investigators. Risk of rupture of small anterior communicating artery aneurysms is similar to posterior circulation aneurysms. Stroke 2013; 44 (11) 3018-3026
    CrossrefPubMedGoogle Scholar
  • 11 Petty GW, Brown Jr RD, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Ischemic stroke subtypes: a population-based study of incidence and risk factors. Stroke 1999; 30 (12) 2513-2516
    CrossrefPubMedGoogle Scholar
  • 12 Barnett HJ, Taylor DW, Eliasziw M. et al; North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998; 339 (20) 1415-1425
    CrossrefPubMedGoogle Scholar
  • 13 Bonati LH, Kakkos S, Berkefeld J. et al. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6 (02) I-XLVII
    CrossrefPubMedGoogle Scholar
  • 14 Wajima D, Nakagawa I, Wada T, Nakase H. A trial for an evaluation of perianeurysmal arterial pressure change during carotid artery stenting in patients with concomitant severe extracranial carotid artery stenosis and ipsilateral intracranial aneurysm. Turk Neurosurg 2019; 29 (05) 785-788
    PubMedGoogle Scholar
  • 15 Tallarita T, Sorenson TJ, Rinaldo L. et al. Management of carotid artery stenosis in patients with coexistent unruptured intracranial aneurysms. J Neurosurg 2019; 132 (01) 94-97
    CrossrefPubMedGoogle Scholar
  • 16 Siddiqui A, Vora N, Edgell RC, Callison RC, Kitchener J, Alshekhlee A. Rupture of a cerebral aneurysm following carotid endarterectomy. J Neurointerv Surg 2012; 4 (05) e27
    CrossrefPubMedGoogle Scholar
  • 17 Riphagen JH, Bernsen HJ. Rupture of an intracerebral aneurysm after carotid endarterectomy: a case report. Acta Neurol Belg 2009; 109 (04) 314-316
    PubMedGoogle Scholar
  • 18 Khan UA, Thapar A, Shalhoub J, Davies AH. Risk of intracerebral aneurysm rupture during carotid revascularization. J Vasc Surg 2012; 56 (06) 1739-1747
    CrossrefPubMedGoogle Scholar
  • 19 Park JC, Kwon BJ, Kang HS. et al. Single-stage extracranial carotid artery stenting and intracranial aneurysm coiling: technical feasibility and clinical outcome. Interv Neuroradiol 2013; 19 (02) 228-234
    CrossrefPubMedGoogle Scholar
  • 20 Iwata T, Mori T, Tajiri H. Successful staged endovascular treatment of a symptomatic cervical carotid bifurcation stenosis coupled with a coincidental unruptured cerebral aneurysm in the carotid distal segment. AJNR Am J Neuroradiol 2008; 29 (10) 1948-1950
    CrossrefPubMedGoogle Scholar
  • 21 Kaçar E, Nas ÖF, Erdoğan C, Hakyemez B. Single-stage endovascular treatment in patients with severe extracranial large vessel stenosis and concomitant ipsilateral unruptured intracranial aneurysm. Diagn Interv Radiol 2015; 21 (06) 476-482
    CrossrefPubMedGoogle Scholar
  • 22 Ni H, Zhong Z, Zhu J. et al. Single-stage endovascular treatment of severe cranial artery stenosis coexisted with ipsilateral distal tandem intracranial aneurysm. Front Neurol 2022; 13: 865540
    CrossrefPubMedGoogle Scholar
  • 23 Illuminati G, Missori P, Hostalrich A, Chaufour X, Nardi P, Ricco JB. Retrospective multicenter study on the management of asymptomatic carotid artery stenosis with coexistent unruptured intracerebral aneurysm. J Vasc Surg 2022; 76 (05) 1298-1304
    CrossrefPubMedGoogle Scholar
  • 24 Higashiguchi S, Sadato A, Nakahara I. et al. Reduction of thromboembolic complications during the endovascular treatment of unruptured aneurysms by employing a tailored dual antiplatelet regimen using aspirin and prasugrel. J Neurointerv Surg 2021; 13 (11) 1044-1048
    CrossrefPubMedGoogle Scholar
  • 25 Palmerini T, Bruno AG, Redfors B. et al. Risk-benefit of 1-year DAPT after DES implantation in patients stratified by bleeding and ischemic risk. J Am Coll Cardiol 2021; 78 (20) 1968-1986
    CrossrefPubMedGoogle Scholar