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

Objective: To evaluate the results of carotid endarterectomy (CEA) in patients with a concomitant asymptomatic intracranial aneurysm discovered at preoperative diagnostic imaging.Methods: From January 2000 to December 2020, 75 consecutive patients admitted for surgical treatment of asymptomatic more than 70% (North American Symptomatic Carotid Endarterectomy Trial) carotid artery stenosis presented at preoperative computed tomography angiography (CTA) with a concomitant, unruptured intracranial aneurysm (UIA). Aneurysm diameter was 5 mm or less in 25 patients (group A), from 6 to 9 mm in 38 patients (group B), and 10 or more 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. CEA was standard and performed through eversion of the internal carotid artery in 36 patients (48%) and through longitudinal arteriotomy with systematic patch closure in 39 patients (52%). The primary end points 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 end points were midterm survival and freedom from ischemic or hemorrhagic stroke and carotid restenosis.Results: One patient died during the 30 days after the clipping of a 11-mm diameter UIA of the basilar artery. No other death or complication was observed after CEA and treatment of the UIA, or during the time interval between the two procedures. During a median follow-up of 26 months (interquartile range, 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 that had not been treated initially owing to its small diameter. The 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.