Sequential successful surgical management of extracranial internal carotid stenosis and ipsilateral intracranial aneurysm. Case reports.

The coexistence of extracranial internal carotid stenosis and ipsilateral intracranial aneurysm is a rare event whose management is controversial. Theoretically, the correction of a significant stenosis of the extracranial internal carotid may lead to an increase in the downstream pressure in the intracranial carotid, and may consequently increase the risk of rupture of the ipsilateral aneurysm. Moreover, dramatic increase of blood pressure is not uncommon after carotid endarterectomy, and may promote aneurysmal rupture. Intracranial surgical correction of a hypoperfused aneurysm down to extracranial carotid stenosis should carry an increased risk of inadequate cerebral flow during procedure, and unspecific postoperative stimulation of platelets aggregation and coagulation may complete obstruction of a subtotal carotid stenosis. We report the cases of two patients successfully treated by a two-stage surgical procedure. In a first step, the intracerebral aneurysms were controlled and electively excluded by clipping. In a second step, carotid endarteriectomies were performed some days later without any neurological complications. Postoperative recoveries were uneventful and six months after these surgical procedures, clinical examination of both patients did not reveal any worsening of the preoperative neurological status.