MANAGEMENT OF SYMPTOMATIC CAROTID STENOSES WITH COINCIDENTAL INTRACRANIAL ANEURYSMS

There are at present strong indications for surgery in patients suffer ing from symptomatic extracranial carotid stenoses of >70%. Surgery of coincidental aneurysms is a still debated problem, but there is gener al agreement that it is indicated in selected cases according to the p atient's life-expectancyh and size and site of the aneurysm. The coexi stence of these two lesions raises a decision-making problem. We revie wed 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 i ntracranial lesion and then the stenosis in 7 patients harbouring aneu rysms >5 mm. Two patients affected by small aneurysms <5 mm of an A2 a zygos and left internal carotid artery underwent left endarterectomy o nly. The last patient was submitted first to percutaneous angioplasty of a left stenosis, then to open surgery of a contralateral middle cer ebral aneurysm and finally to intravascular occlusion of a small aneur ysm 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 ante rior communicating and middle cerebral arteries. Our results suggest t hat surgery of coincidental aneurysms may give good results even when there is a severe symptomatic stenosis in the neck. Moreover, the pres ence of a small intracranial aneurysm does not seem to be an additiona l risk factor for endarterectomy. When the lesions are on different si des, it may be better to treat the stenosis first if it decreases the ipsilateral cerebral blood flow.