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Endovascular Treatment of Carotid Stenosis Associated with Incidental Intracranial Aneurysm
Endovascular Treatment of Carotid Stenosis Associated with Incidental Intracranial Aneurysm Gaudencio Espinosa,1,2 Lukasz Dzieciuchowicz,1 and Lukasz Grochowicz,1 Pamplona, Spain, and Rio de Janeiro, Brazil
The coexistence of internal carotid artery (ICA) stenosis and intracranial aneurysm, although uncommon, can be a therapeutic dilemma. We present a case of a 73-year-old woman with a history of arterial hypertension and diabetes who had a severe symptomatic ICA stenosis (>90%) and an incidental ipsilateral cerebral aneurysm. The carotid stenosis was treated with angioplasty and stenting using a distal cerebral protection system. The patient was anticoagulated and maintained on antiplatelet therapy according to a standard protocol. Microcoil embolization of the aneurysm was performed 5 months after an intracranial stent was implanted. No growth has been observed in the aneurysm of the arterial lumen since the carotid intervention. There were no complications after the procedures during the postoperative period. This case shows that the incidental presence of an ipsilateral intracranial aneurysm does not appear to be a contraindication for the endovascular treatment of a carotid artery stenosis.
Internal carotid artery (ICA) stenosis is one of the most common causes of cerebral stroke. It has been shown that when the stenosis is >70%, invasive treatment, whether by surgery or by angioplasty with a stent implantation, decreases the long-term risk of a cerebral event.1-4 Cerebral aneurysm is another significant cause of stroke but with a different pathophysiological mechanism. The incidence of cerebral aneurysm in patients with ICA stenosis is estimated to be 2.3-4.9%.5-9 The coexistence of the two diseases, although uncommon, may present a therapeutic dilemma. It is essential to keep the patient anticoagulated and under antiplatelet medications during the carotid artery stenosis intervention. Variations in 1 Angiology and Vascular Surgery, University Clinic, Faculty of Medicine, University of Navarre, Pamplona, Spain. 2 Department of Surgery, Rio de Janeiro Federal University, Rio de Janeiro, Brazil.
Correspondence to: L. Dzieciuchowicz, Angiologıa y Cirugıa Vascular, Clınica Universitaria de Navarra, Avda. Pio XII 36, 31008 Pamplona, Espana, E mail: [email protected] Ann Vasc Surg 2009; 23: 688.e1 688.e5 DOI: 10.1016/j.avsg.2008.10.012 Ó Annals of Vascular Surgery Inc. Published online: June 19, 2009
blood pressure are also a common occurrence during these procedures. In theory, these factors may increase the risk of rupture of the aneurysm and subsequent cerebral hemorrhage. On the other hand, intervention of the aneurysm requires advancing wires and microcatheters through the ICA. In the presence of a severe carotid stenosis, these maneuvers may trigger serious embolic complications in the ipsilateral cerebral parenchyma. There are some reports on the surgical treatment of carotid stenosis in patients with a coexisting cerebral aneurysm. However, despite the widespread use of endovascular procedures, there is scarce information on the use of these techniques to manage this situation in clinical practice.5-7,10,11 We present a case of endovascular treatment in a patient with both lesions.
CASE REPORT A 73-year-old female patient, with a past history of smoking, type 2 diabetes mellitus, use of oral hypoglycemic agents, and high blood pressure, presented several transient ischemic attacks (TIAs) in a form of brief loss of consciousness with recovery without 688.e1
688.e2 Case reports
neurological sequelae. Duplex scanning and further angiography showed a critical preocclusive stenosis (>90%) of the left ICA with an ulcerated plaque. The presence of an incidental aneurysm in the ophthalmic segment of the ICA was identified during cerebral angiography. The intracranial aneurysm had a saccular morphology, a diameter of 14 x 8 mm, and a 4 mm wide neck (Fig. 1). A brain computed tomographic (CT) scan was obtained afterward, ruling out intracranial bleeding or associated ischemic lesions. Antiplatelet therapy was started, and the patient was discharged waiting for elective treatment. Given the preference of the patient and the experience of the authors in the endovascular treatment of carotid lesions, angioplasty and stenting of the ICA stenosis was offered as the best therapeutic strategy. A standard vascular access was gained through a femoral approach under local anesthetic. The patient was given 5,000 IU sodium heparin intra-arterially during the procedure. An Angioguard (Cordis, Warren, NJ) cerebral protection system was advanced distally through the ICA stenosis. Then, the lesion was dilated with a 4 40 mm Gazelle balloon catheter (Boston Scientific, Watertown, MA). A 7 40 mm stent (Smart, Cordis) was deployed in the ICA (Fig. 2), with postdilation being performed with a 6 40 mm Gazelle balloon catheter (Boston Scientific). Postprocedure angiography showed recovery of the vascular lumen to its normal size with no residual stenosis (Fig. 3). The action of the heparin was reversed with protamine sulfate. There were no incidents during the postoperative period, and the patient was discharged home 3 days after the operation. The patient was advised that the intracranial aneurysm should be embolized within 4 weeks. However, the patient decided to have the operation 5 months later. The procedure was performed under general anesthesia. Selective catheterization of the left ICA was performed through a right femoral artery approach. This showed that the aneurysm was intact and that the size of its lumen had not increased compared with previous images (Fig. 4). Due to the large neck of the aneurysm (4 mm), it was decided to implant a Neuroform (Boston Scientific) 4.5 mm intracranial stent, covering the entrance of the aneurysm. We then performed microcatheterization of the aneurysm sac through the stent mesh using an Excel 14 microcatheter (Boston Scientific) (Fig. 5). Thirteen GDC (Boston Scientific) microcoils were impacted. In the postprocedure angiogram, the microcoils were seen to be
Annals of Vascular Surgery
Fig. 1. Selective angiography of the left carotid artery, which shows a critical stenosis of the ICA and a saccular aneurysm in its intracranial ophthalmic segment.
well compacted, with a good flow in the ICA (Fig. 6). The patient was discharged home on the third day after the procedure. Both interventions were performed by the same vascular surgeon, with wide experience in endovascular, including intracranial, procedures.
DISCUSSION This case shows that angioplasty and stenting of a symptomatic ICA stenosis can be performed safely and effectively in a patient with an asymptomatic ipsilateral cerebral aneurysm. We found only two similar cases described in the literature that were successfully treated without cerebral hemorrhagic complications.12 In the present case no intraoperative complications were noted and no increase of the aneurysm lumen size was observed 5 months after carotid angioplasty. There is much more information published on carotid endarterectomy in patients with a cerebral aneurysm. The greatest experience comes from the North American Symptomatic Carotid Endarterectomy Trial (NASCET), which included 90 cases of carotid endarterectomy in patients with a cerebral aneurysm. There was only one case of subarachnoid hemorrhage on the sixth day after surgery.7 In addition, other case reports and short series include 71
Vol. 23, No. 5, September 2009
Fig. 2. The stent implant is performed after positioning the distal protection system.
patients, with only one case of rupture of a cerebral aneurysm 7 months after carotid endarterectomy.5,6,10,11 At present, there is no definitive evidence to support the preferential use of carotid stenting in patients with ICA stenosis. In the present case, the reasons for the preferential indication of ICA stenting instead of performing a carotid endarterectomy were the wide experience of the authors with the former technique and patient´s preference. Moreover, a recently published meta-analysis did not detect any differences between the two methods regarding the development of major postoperative complications, such as death or disabling stroke.13 Subarachnoid hemorrhage has a mortality rate of around 40%.14-16 In the event of a cerebral aneurysm rupture while performing carotid stenting, the endovascular technique appears to have an advantage over carotid endarterectomy, allowing rapid detection and immediate treatment without the need to gain an additional access. Of course, under this situation, specific training and experience in the endovascular treatment of cerebral aneurysms are mandatory. The patient of the present report was treated according to a standard protocol that includes the preoperative use of antiplatelet therapy and systemic anticoagulants on starting the procedure. It has been shown that previous treatment with aspirin worsens the prognosis in patients with
Case reports 688.e3
Fig. 3. Angiography after the procedure, showing good patency of the ICA with no residual stenosis.
Fig. 4. Angiography of the ICA performed 5 months later shows the aneurysm with no change in size.
intracerebral parenchymatous hematoma. The role of aspirin is not clear in the evolution of subarachnoid hemorrhage.17 Toussaint et al.18 found that previous treatment with aspirin, despite increasing the rate of recurrent hemorrhage, also decreased the risk of cerebral vasospasm, which continues to be the most common cause of disability and death after the rupture of intracranial aneurysms.
688.e4 Case reports
Fig. 5. Microcatheter inside the aneurysm (large radi opaque outlines), after protecting the neck by means of an intracranial stent (small radiopaque outlines).
Annals of Vascular Surgery
stenting. Castro et al.12 reported the absence of hemorrhage in two cases of carotid angioplasty and stenting in patients with a coexistent cerebral aneurysm when antiplatelet therapy and anticoagulation with nonfractionated heparin was used. However, a previously published study suggests that, in the event of a rupture of the cerebral aneurysm, patients anticoagulated with warfarin had double the risk of death or disabilty.19 For this reason, we think that the patients should receive an antiplatelet agent before the procedure and should be anticoagulated in order to minimize the risk of hemorrhagic complications, reversing the action of heparin with protamine sulfate as soon as the procedure is completed. It has been shown that an increase in blood pressure not only increases the risk of cerebral aneurysm rupture but also worsens the prognosis of the patient with subarachnoid hemorrhage.20-24 In theory, the initial treatment of carotid artery stenosis could increase the risk of rupture of an ipsilateral aneurysm. There is no consensus on which lesion should be treated first. Navaneethan et al.25 achieved simultaneous and successful treatment of carotid stenosis and cerebral aneurysm. However, we believe that if there are no specific indications, it is safer to perform the carotid angioplasty first. Performing the two procedures at the same time is lengthy and significantly increases the amount of contrast medium used. Moreover, cerebral embolization is usually performed under general anesthesia. This is a clear disadvantage for carrying out carotid angioplasty simultaneously as having an unconscious patient may delay the diagnosis of thromboembolic complications and, thus, their treatment. In conclusion, we believe that the incidental presence of an ipsilateral intracranial aneurysm does not appear to be a contraindication for the endovascular treatment of carotid artery stenosis.
REFERENCES Fig. 6. Good compaction of the microcoils can be observed in the angiogram after embolization of the aneurysm.
However, its use did not significantly change the prognosis of the patient with subarachnoid hemorrhage. For this reason, the authors concluded that the presence of a cerebral aneurysm is not a contraindication for the use of aspirin. Systemic anticoagulation with nonfractionated heparin is advisable to prevent ICA thrombosis or embolization during carotid angioplasty and
1. Coward LJ, Featherstone RL, Brown MM. Safety and effi cacy of endovascular treatment of carotid artery stenosis compared with carotid endarterectomy: a Cochrane system atic review of the randomized evidence. Stroke 2005;36: 905 911. 2. European Carotid Surgery Trialists’ Collaborative Group. Randomised trial of endarterectomy for recently symptom atic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351:1379 1387. 3. Halliday A, Mansfield A, Marro J, et al. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Preven tion of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological
Vol. 23, No. 5, September 2009
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
symptoms: randomised controlled trial. Lancet 2004;363: 1491-1502. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-453. Ballotta E, Da Giau G, Manara R, Baracchini C. Extracranial severe carotid stenosis and incidental intracranial aneurysms. Ann Vasc Surg 2006;20:5-8. Kann BR, Matsumoto T, Kerstein MD. Safety of carotid endarterectomy associated with small intracranial aneurysms. South Med J 1997;90:1213-1216. Kappelle LJ, Eliasziw M, Fox AJ, Barnett HJ. Small, unruptured intracranial aneurysms and management of symptomatic carotid artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Group. Neurology 2000;55: 307-309. Long SM, Kern JA, Fiser SM, et al. Carotid arteriography impacts carotid stenosis management. Vasc Surg 2001;35: 251-256. Pappad a G, Fiori L, Marina R, Vaiani S, Gaini SM. Management of symptomatic carotid stenoses with coincidental intracranial aneurysms. Acta Neurochir. (Wien) 1996;138: 1386-1390. Ladowski JS, Webster MW, Yonas HO, Steed DL. Carotid endarterectomy in patients with asymptomatic intracranial aneurysm. Ann Surg 1984;200:70-73. Orecchia PM, Clagett GP, Youkey JR, et al. Management of patients with symptomatic extracranial carotid artery disease and incidental intracranial berry aneurysm. J Vasc Surg 1985;2:158-164. Castro E, Villoria F, Fortea F, et al. Simultaneous cerebral aneurysms and carotid disease. Should the symptomatic lesion always be the first to be treated? A case report. Intervent Neuroradiol 2003;9:213-218. Gurm HS, Nallamothu BK, Yadav J. Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis. Eur Heart J 2008;29:113-119. Anderson CS, Jamrozik KD, Burvill PW, et al. Determining the incidence of different subtypes of stroke: results from
Case reports 688.e5
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
the Perth Community Stroke Study, 1989-1990. Med J Aust 1993;158:85-89. Broderick JP, Brott TG, Duldner JE, Tomsick T, Leach A. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke 1994;25: 1342-1347. Longstreth WT, Jr, Nelson LM, Koepsell TD, van Belle G. Clinical course of spontaneous subarachnoid hemorrhage: a population-based study in King County, Washington. Neurology 1993;43:712-718. Saloheimo P, Juvela S, Hillbom M. Use of aspirin, epistaxis, and untreated hypertension as risk factors for primary intracerebral hemorrhage in middle-aged and elderly people. Stroke 2001;32:399-404. Toussaint LG, 3rd, Friedman JA, Wijdicks EF, et al. Influence of aspirin on outcome following aneurysmal subarachnoid hemorrhage. Neurosurgery 2004;101:921-925. Rinkel GJ, Prins NE, Algra A. Outcome of aneurysmal subarachnoid hemorrhage in patients on anticoagulant treatment. Stroke 1997;28:6-9. Inagawa T. Risk factors for aneurysmal subarachnoid hemorrhage in patients in Izumo City. Japan J Neurosurg 2005;102:60-67. Isaksen J, Egge A, Waterloo K, Romner B, Ingebrigtsen T. Risk factors for aneurysmal subarachnoid haemorrhage: the Tromsø Study. J Neurol Neurosurg Psychiatry 2002;73: 185-187. Ohkuma H, Tabata H, Suzuki S, Islam MS. Risk factors for aneurysmal subarachnoid hemorrhage in Aomori, Japan. Stroke 2003;34:96-100. Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke 2007;38:2315-2321. Teunissen LL, Rinkel GJ, Algra A, van Gijn J. Risk factors for subarachnoid hemorrhage: a systematic review. Stroke 1996;27:544-549. Navaneethan SD, Kannan VS, Osowo A, Shrivastava R, Singh S. Concomitant intracranial aneurysm and carotid artery stenosis: a therapeutic dilemma. South Med J 2006;99:757-758.
The coexistence of internal carotid artery (ICA) stenosis and intracranial aneurysm, although uncommon, can be a therapeutic dilemma. We present a case of a 73-year-old woman with a history of arterial hypertension and diabetes who had a severe symptomatic ICA stenosis (>90%) and an incidental ipsilateral cerebral aneurysm. The carotid stenosis was treated with angioplasty and stenting using a distal cerebral protection system. The patient was anticoagulated and maintained on antiplatelet therapy according to a standard protocol. Microcoil embolization of the aneurysm was performed 5 months after an intracranial stent was implanted. No growth has been observed in the aneurysm of the arterial lumen since the carotid intervention. There were no complications after the procedures during the postoperative period. This case shows that the incidental presence of an ipsilateral intracranial aneurysm does not appear to be a contraindication for the endovascular treatment of a carotid artery stenosis.
Internal carotid artery (ICA) stenosis is one of the most common causes of cerebral stroke. It has been shown that when the stenosis is >70%, invasive treatment, whether by surgery or by angioplasty with a stent implantation, decreases the long-term risk of a cerebral event.1-4 Cerebral aneurysm is another significant cause of stroke but with a different pathophysiological mechanism. The incidence of cerebral aneurysm in patients with ICA stenosis is estimated to be 2.3-4.9%.5-9 The coexistence of the two diseases, although uncommon, may present a therapeutic dilemma. It is essential to keep the patient anticoagulated and under antiplatelet medications during the carotid artery stenosis intervention. Variations in 1 Angiology and Vascular Surgery, University Clinic, Faculty of Medicine, University of Navarre, Pamplona, Spain. 2 Department of Surgery, Rio de Janeiro Federal University, Rio de Janeiro, Brazil.
Correspondence to: L. Dzieciuchowicz, Angiologıa y Cirugıa Vascular, Clınica Universitaria de Navarra, Avda. Pio XII 36, 31008 Pamplona, Espana, E mail: [email protected] Ann Vasc Surg 2009; 23: 688.e1 688.e5 DOI: 10.1016/j.avsg.2008.10.012 Ó Annals of Vascular Surgery Inc. Published online: June 19, 2009
blood pressure are also a common occurrence during these procedures. In theory, these factors may increase the risk of rupture of the aneurysm and subsequent cerebral hemorrhage. On the other hand, intervention of the aneurysm requires advancing wires and microcatheters through the ICA. In the presence of a severe carotid stenosis, these maneuvers may trigger serious embolic complications in the ipsilateral cerebral parenchyma. There are some reports on the surgical treatment of carotid stenosis in patients with a coexisting cerebral aneurysm. However, despite the widespread use of endovascular procedures, there is scarce information on the use of these techniques to manage this situation in clinical practice.5-7,10,11 We present a case of endovascular treatment in a patient with both lesions.
CASE REPORT A 73-year-old female patient, with a past history of smoking, type 2 diabetes mellitus, use of oral hypoglycemic agents, and high blood pressure, presented several transient ischemic attacks (TIAs) in a form of brief loss of consciousness with recovery without 688.e1
688.e2 Case reports
neurological sequelae. Duplex scanning and further angiography showed a critical preocclusive stenosis (>90%) of the left ICA with an ulcerated plaque. The presence of an incidental aneurysm in the ophthalmic segment of the ICA was identified during cerebral angiography. The intracranial aneurysm had a saccular morphology, a diameter of 14 x 8 mm, and a 4 mm wide neck (Fig. 1). A brain computed tomographic (CT) scan was obtained afterward, ruling out intracranial bleeding or associated ischemic lesions. Antiplatelet therapy was started, and the patient was discharged waiting for elective treatment. Given the preference of the patient and the experience of the authors in the endovascular treatment of carotid lesions, angioplasty and stenting of the ICA stenosis was offered as the best therapeutic strategy. A standard vascular access was gained through a femoral approach under local anesthetic. The patient was given 5,000 IU sodium heparin intra-arterially during the procedure. An Angioguard (Cordis, Warren, NJ) cerebral protection system was advanced distally through the ICA stenosis. Then, the lesion was dilated with a 4 40 mm Gazelle balloon catheter (Boston Scientific, Watertown, MA). A 7 40 mm stent (Smart, Cordis) was deployed in the ICA (Fig. 2), with postdilation being performed with a 6 40 mm Gazelle balloon catheter (Boston Scientific). Postprocedure angiography showed recovery of the vascular lumen to its normal size with no residual stenosis (Fig. 3). The action of the heparin was reversed with protamine sulfate. There were no incidents during the postoperative period, and the patient was discharged home 3 days after the operation. The patient was advised that the intracranial aneurysm should be embolized within 4 weeks. However, the patient decided to have the operation 5 months later. The procedure was performed under general anesthesia. Selective catheterization of the left ICA was performed through a right femoral artery approach. This showed that the aneurysm was intact and that the size of its lumen had not increased compared with previous images (Fig. 4). Due to the large neck of the aneurysm (4 mm), it was decided to implant a Neuroform (Boston Scientific) 4.5 mm intracranial stent, covering the entrance of the aneurysm. We then performed microcatheterization of the aneurysm sac through the stent mesh using an Excel 14 microcatheter (Boston Scientific) (Fig. 5). Thirteen GDC (Boston Scientific) microcoils were impacted. In the postprocedure angiogram, the microcoils were seen to be
Annals of Vascular Surgery
Fig. 1. Selective angiography of the left carotid artery, which shows a critical stenosis of the ICA and a saccular aneurysm in its intracranial ophthalmic segment.
well compacted, with a good flow in the ICA (Fig. 6). The patient was discharged home on the third day after the procedure. Both interventions were performed by the same vascular surgeon, with wide experience in endovascular, including intracranial, procedures.
DISCUSSION This case shows that angioplasty and stenting of a symptomatic ICA stenosis can be performed safely and effectively in a patient with an asymptomatic ipsilateral cerebral aneurysm. We found only two similar cases described in the literature that were successfully treated without cerebral hemorrhagic complications.12 In the present case no intraoperative complications were noted and no increase of the aneurysm lumen size was observed 5 months after carotid angioplasty. There is much more information published on carotid endarterectomy in patients with a cerebral aneurysm. The greatest experience comes from the North American Symptomatic Carotid Endarterectomy Trial (NASCET), which included 90 cases of carotid endarterectomy in patients with a cerebral aneurysm. There was only one case of subarachnoid hemorrhage on the sixth day after surgery.7 In addition, other case reports and short series include 71
Vol. 23, No. 5, September 2009
Fig. 2. The stent implant is performed after positioning the distal protection system.
patients, with only one case of rupture of a cerebral aneurysm 7 months after carotid endarterectomy.5,6,10,11 At present, there is no definitive evidence to support the preferential use of carotid stenting in patients with ICA stenosis. In the present case, the reasons for the preferential indication of ICA stenting instead of performing a carotid endarterectomy were the wide experience of the authors with the former technique and patient´s preference. Moreover, a recently published meta-analysis did not detect any differences between the two methods regarding the development of major postoperative complications, such as death or disabling stroke.13 Subarachnoid hemorrhage has a mortality rate of around 40%.14-16 In the event of a cerebral aneurysm rupture while performing carotid stenting, the endovascular technique appears to have an advantage over carotid endarterectomy, allowing rapid detection and immediate treatment without the need to gain an additional access. Of course, under this situation, specific training and experience in the endovascular treatment of cerebral aneurysms are mandatory. The patient of the present report was treated according to a standard protocol that includes the preoperative use of antiplatelet therapy and systemic anticoagulants on starting the procedure. It has been shown that previous treatment with aspirin worsens the prognosis in patients with
Case reports 688.e3
Fig. 3. Angiography after the procedure, showing good patency of the ICA with no residual stenosis.
Fig. 4. Angiography of the ICA performed 5 months later shows the aneurysm with no change in size.
intracerebral parenchymatous hematoma. The role of aspirin is not clear in the evolution of subarachnoid hemorrhage.17 Toussaint et al.18 found that previous treatment with aspirin, despite increasing the rate of recurrent hemorrhage, also decreased the risk of cerebral vasospasm, which continues to be the most common cause of disability and death after the rupture of intracranial aneurysms.
688.e4 Case reports
Fig. 5. Microcatheter inside the aneurysm (large radi opaque outlines), after protecting the neck by means of an intracranial stent (small radiopaque outlines).
Annals of Vascular Surgery
stenting. Castro et al.12 reported the absence of hemorrhage in two cases of carotid angioplasty and stenting in patients with a coexistent cerebral aneurysm when antiplatelet therapy and anticoagulation with nonfractionated heparin was used. However, a previously published study suggests that, in the event of a rupture of the cerebral aneurysm, patients anticoagulated with warfarin had double the risk of death or disabilty.19 For this reason, we think that the patients should receive an antiplatelet agent before the procedure and should be anticoagulated in order to minimize the risk of hemorrhagic complications, reversing the action of heparin with protamine sulfate as soon as the procedure is completed. It has been shown that an increase in blood pressure not only increases the risk of cerebral aneurysm rupture but also worsens the prognosis of the patient with subarachnoid hemorrhage.20-24 In theory, the initial treatment of carotid artery stenosis could increase the risk of rupture of an ipsilateral aneurysm. There is no consensus on which lesion should be treated first. Navaneethan et al.25 achieved simultaneous and successful treatment of carotid stenosis and cerebral aneurysm. However, we believe that if there are no specific indications, it is safer to perform the carotid angioplasty first. Performing the two procedures at the same time is lengthy and significantly increases the amount of contrast medium used. Moreover, cerebral embolization is usually performed under general anesthesia. This is a clear disadvantage for carrying out carotid angioplasty simultaneously as having an unconscious patient may delay the diagnosis of thromboembolic complications and, thus, their treatment. In conclusion, we believe that the incidental presence of an ipsilateral intracranial aneurysm does not appear to be a contraindication for the endovascular treatment of carotid artery stenosis.
REFERENCES Fig. 6. Good compaction of the microcoils can be observed in the angiogram after embolization of the aneurysm.
However, its use did not significantly change the prognosis of the patient with subarachnoid hemorrhage. For this reason, the authors concluded that the presence of a cerebral aneurysm is not a contraindication for the use of aspirin. Systemic anticoagulation with nonfractionated heparin is advisable to prevent ICA thrombosis or embolization during carotid angioplasty and
1. Coward LJ, Featherstone RL, Brown MM. Safety and effi cacy of endovascular treatment of carotid artery stenosis compared with carotid endarterectomy: a Cochrane system atic review of the randomized evidence. Stroke 2005;36: 905 911. 2. European Carotid Surgery Trialists’ Collaborative Group. Randomised trial of endarterectomy for recently symptom atic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351:1379 1387. 3. Halliday A, Mansfield A, Marro J, et al. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Preven tion of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological
Vol. 23, No. 5, September 2009
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
symptoms: randomised controlled trial. Lancet 2004;363: 1491-1502. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-453. Ballotta E, Da Giau G, Manara R, Baracchini C. Extracranial severe carotid stenosis and incidental intracranial aneurysms. Ann Vasc Surg 2006;20:5-8. Kann BR, Matsumoto T, Kerstein MD. Safety of carotid endarterectomy associated with small intracranial aneurysms. South Med J 1997;90:1213-1216. Kappelle LJ, Eliasziw M, Fox AJ, Barnett HJ. Small, unruptured intracranial aneurysms and management of symptomatic carotid artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Group. Neurology 2000;55: 307-309. Long SM, Kern JA, Fiser SM, et al. Carotid arteriography impacts carotid stenosis management. Vasc Surg 2001;35: 251-256. Pappad a G, Fiori L, Marina R, Vaiani S, Gaini SM. Management of symptomatic carotid stenoses with coincidental intracranial aneurysms. Acta Neurochir. (Wien) 1996;138: 1386-1390. Ladowski JS, Webster MW, Yonas HO, Steed DL. Carotid endarterectomy in patients with asymptomatic intracranial aneurysm. Ann Surg 1984;200:70-73. Orecchia PM, Clagett GP, Youkey JR, et al. Management of patients with symptomatic extracranial carotid artery disease and incidental intracranial berry aneurysm. J Vasc Surg 1985;2:158-164. Castro E, Villoria F, Fortea F, et al. Simultaneous cerebral aneurysms and carotid disease. Should the symptomatic lesion always be the first to be treated? A case report. Intervent Neuroradiol 2003;9:213-218. Gurm HS, Nallamothu BK, Yadav J. Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis. Eur Heart J 2008;29:113-119. Anderson CS, Jamrozik KD, Burvill PW, et al. Determining the incidence of different subtypes of stroke: results from
Case reports 688.e5
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
the Perth Community Stroke Study, 1989-1990. Med J Aust 1993;158:85-89. Broderick JP, Brott TG, Duldner JE, Tomsick T, Leach A. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke 1994;25: 1342-1347. Longstreth WT, Jr, Nelson LM, Koepsell TD, van Belle G. Clinical course of spontaneous subarachnoid hemorrhage: a population-based study in King County, Washington. Neurology 1993;43:712-718. Saloheimo P, Juvela S, Hillbom M. Use of aspirin, epistaxis, and untreated hypertension as risk factors for primary intracerebral hemorrhage in middle-aged and elderly people. Stroke 2001;32:399-404. Toussaint LG, 3rd, Friedman JA, Wijdicks EF, et al. Influence of aspirin on outcome following aneurysmal subarachnoid hemorrhage. Neurosurgery 2004;101:921-925. Rinkel GJ, Prins NE, Algra A. Outcome of aneurysmal subarachnoid hemorrhage in patients on anticoagulant treatment. Stroke 1997;28:6-9. Inagawa T. Risk factors for aneurysmal subarachnoid hemorrhage in patients in Izumo City. Japan J Neurosurg 2005;102:60-67. Isaksen J, Egge A, Waterloo K, Romner B, Ingebrigtsen T. Risk factors for aneurysmal subarachnoid haemorrhage: the Tromsø Study. J Neurol Neurosurg Psychiatry 2002;73: 185-187. Ohkuma H, Tabata H, Suzuki S, Islam MS. Risk factors for aneurysmal subarachnoid hemorrhage in Aomori, Japan. Stroke 2003;34:96-100. Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke 2007;38:2315-2321. Teunissen LL, Rinkel GJ, Algra A, van Gijn J. Risk factors for subarachnoid hemorrhage: a systematic review. Stroke 1996;27:544-549. Navaneethan SD, Kannan VS, Osowo A, Shrivastava R, Singh S. Concomitant intracranial aneurysm and carotid artery stenosis: a therapeutic dilemma. South Med J 2006;99:757-758.