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Retrospective multicenter study on the management of asymptomatic carotid artery stenosis with coexistent unruptured intracerebral aneurysm

AIM OF THE STUDY

To evaluate the results of carotid endarterectomy (CEA) in patients with a concomitant asymptomatic intracranial aneurysm discovered at preoperative diagnostic imaging.

MATERIAL AND METHODS

From January 2000 to December 2020, 75 consecutive patients admitted for surgical treatment of asymptomatic >70% (NASCET) carotid artery stenosis presented at preoperative computed tomography angiography (CTA) with a concomitant, unruptured intracranial aneurysm (UIA). Aneurysm diameter was ≤ 5 mm in 25 patients (Group A), from 6 to 9 mm in 38 patients (Group B) and ≥ 10 mm in 12 patients (Group C). Sixty UIAs (80%) were treated before performing CEA, 10 in Group A (40%), 38 (100%) in Group B and 12 (100%) in Group C. Twenty-five UIAs (42%) were subjected to surgical clipping and 35 (58%) to coiling. The mean time intervals were 48 days (range, 20-55 days) between clipping and CEA, and 8 days (range, 4 -13 days) between coiling and CEA. Carotid endarterectomy (CEA) was standard and performed through eversion of the internal carotid artery (ICA) in 36 patients (48%) and through longitudinal arteriotomy with systematic patch closure in 39 patients (52%). Primary endpoints of the study were mortality and morbidity related to each of the two treatments including any complication occurring during the time interval between the two procedures or within 30 days after the last procedure. Secondary endpoints were mid-term survival and freedom from ischemic or hemorrhagic stroke and carotid restenosis.

RESULTS

One patient died during the 30 days following clipping of a 11 mm diameter UIA of the basilar artery. No other death or complication was observed following CEA and treatment of the UIA, or during the time interval between the two procedures. During median follow-up of 26 months (IQR, 18-30 months), no late stroke and no carotid restenosis were observed. At 22, 27, 29 and 31 months after CEA, four patients in group A underwent surgical clipping of an enlarging intracranial aneurysm, which had not been treated initially due to its small diameter. Cumulative survival rate at 30 months by Kaplan-Meier plots was 83±5%.

CONCLUSIONS

Concomitant asymptomatic carotid artery stenosis and UIA is a rare entity. Our study suggests that in this setting, prior treatment of the UIA followed by CEA is safe.