|Year : 2021 | Volume
| Issue : 5 | Page : 96-98
Single-stage ruptured internal carotid artery aneurysm clipping with contralateral carotid endarterectomy: Tips and tricks
Swaroop Gopal, Abinash Dutta, Rudrappa Satish
Department of Neurosurgery, Sakra World Hospital, Bengaluru, Karnataka, India
|Date of Submission||11-Oct-2020|
|Date of Acceptance||15-Oct-2020|
|Date of Web Publication||30-Aug-2021|
Department of Neurosurgery, Sakra World Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Concomitant ruptured intracranial aneurysm and severe contralateral internal carotid artery (ICA) stenosis pose a surgical dilemma. There are no guidelines. Most reports suggest an ipsilateral association. The outcome depends on planning and strategy. This 49-year-old male with ruptured C6 segment ICA aneurysm had 90% calcific carotid stenosis contralaterally. He underwent simultaneous surgery for both. The surgical steps involved and the reason behind the sequence of steps are unique to this situation and led to a good outcome. The strategy and the technicalities involved are discussed in this report.
Keywords: Aneurysm clipping, carotid endarterectomy, carotid stenosis, cerebral aneurysms
|How to cite this article:|
Gopal S, Dutta A, Satish R. Single-stage ruptured internal carotid artery aneurysm clipping with contralateral carotid endarterectomy: Tips and tricks. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:96-8
|How to cite this URL:|
Gopal S, Dutta A, Satish R. Single-stage ruptured internal carotid artery aneurysm clipping with contralateral carotid endarterectomy: Tips and tricks. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jan 26];8, Suppl S1:96-8. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/96/324932
| Introduction|| |
Hemodynamic forces play an important role in the development, symptoms, and management of cerebrovascular lesions. This factor along with the presence of atherosclerosis, hypertension, smoking, age, and poor lifestyle adds to the development of strokes both ischemic and hemorrhagic. The presence of intracranial aneurysm and stenosis of the cervical internal carotid artery (ICA) is infrequently reported (3%–5%)., This combination is a therapeutic challenge. Uneventful carotid endarterectomy (CEA) as well as rupture of the aneurysm after CEA has been reported., In 1970, Portnoy and Avellanosa successfully managed a lady with a right ICA aneurysm and left ICA origin severe stenosis with symptoms for both and she underwent a left CEA first, followed by clipping of the ICA aneurysm 5 days later. A broad review of literature reveals no definite treatment recommendation with varied treatment methodology.
| Case Report|| |
A 49-year-old male, hypertensive and smoker, presented with severe left temporal headache and vomiting. He was alert with meningeal signs. Brain computed tomography (CT) (plain) revealed extensive subarachnoid hemorrhage (SAH) in all basal cisterns. CT angiography (64 slice) revealed severe cervical right ICA calcific stenosis [Figure 1] and the presence of a saccular aneurysm about 9 mm × 6 mm in size with a 4-mm neck at the intracranial origin of left ICA (C6 segment) [Figure 2].
|Figure 1: Computed tomography angiography showing severe calcific stenosis of the right cervical internal carotid artery|
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|Figure 2: Computed tomography angiography showing a saccular aneurysm about 9 mm × 6 mm in size with a 4 mm neck at the intracranial origin of the left internal carotid artery (C6 segment)|
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Surgery was performed under general anesthesia with the head fixed on a Sugita head frame for a left pterional craniotomy. Simultaneously, a transverse bilateral cervical skin incision was planned. Initially, he underwent a left pterional craniotomy and dural opening. Sylvian fissure was opened and fully exposed, but the ICA aneurysm was not dissected. Subsequently, exposure of both the carotids, right then left was performed, and loops were placed. Heparin was administered before right ICA clamping (3500 units) and a microscopic CEA was done (clamp time 15 min). No shunt or patch was used. During this period, signs of aneurysm rupture were observed for. After carotid hemostasis, the left-sided ICA aneurysm was dissected further and successfully clipped with an 8-mm straight standard Yasargil clip without any temporary clipping. There were no intraoperative adverse events. The patient was reversed, extubated, and retained in the neurosurgical intensive care unit overnight. He was uneventfully discharged on day 5 with aspirin and anticonvulsants. The patient was seen on follow-up 3 and 6 months later. He remained asymptomatic and was continued on 150 mg of aspirin only.
| Discussion|| |
Hemodynamic forces play a major role in the management of cerebrovascular pathology and influence decision-making. In a dual pathology situation like carotid stenosis and intracranial aneurysm, a decision-making guideline is not available.
The prevalence of intracranial aneurysm co-existing with carotid stenosis is about 1%–4%, and the incidence of aneurysms is slightly higher in these patients compared to the general population. Cerebral hyperperfusion syndrome can occur after carotid artery stenting (CAS) and very rarely after CEA.,,, Several reports of SAH after CEA also reaffirm this thinking.,
If the dual pathology co-exists on the same side, which is more common, the management paradigm seems relatively simple and manages the symptomatic lesion first and the other one later.,,, However, when a ruptured aneurysm and severe carotid stenosis are present simultaneously on contralateral sides, the situation is different since each has an ability to influence the management of the other.,, In our patient, the ruptured left ICA aneurysm was the priority and had to be managed first. During the aneurysm clipping, in the event of intraoperative aneurysm rupture needing proximal control, it would have a devastating effect on the cerebral circulation due to severe contralateral carotid stenosis and dominant right A1 and poor PCoM arteries. The same situation could arise with coiling the left ICA aneurysm, wherein case of spasm of the cervical ICA or inflation of a balloon proximally, it would have the same effect hemodynamically. Postoperative vasospasm could also have a severe impact on the patient outcome in this scenario.
Based on all these possibilities, we approached this conundrum uniquely. Bilateral electroencephalogram monitoring with cerebral protection using propofol was followed throughout the procedure.
The left pterional craniotomy with dural opening and Sylvian fissure dissection followed by exposure of bilateral carotids in the neck was done to avoid precipitous intracranial pressure rise and have proximal control in the event of aneurysm rupture during CEA. Such a scenario was possible during clamping of the right ICA during the CEA because of increased blood flow in the left ICA and a surge in blood pressure., The right CEA was then performed to obviate any effects of the severe carotid stenosis on cerebral blood flow in case of proximal control during aneurysm clipping. We also adapted the “No shunt – No patch” technique for the CEA to keep clamp times short with a smaller dose of heparin. After the microscopic CEA and hemostasis, the left ICA aneurysm was uneventfully dissected and clipped.
In literature, there is only one report of a similar situation. In this 1970 report, Portnoy and Avellanosa, have operated on a patient with a right ICA aneurysm and severe left carotid stenosis wherein they performed a left CEA followed by clipping of the aneurysm. Badruddin et al. reported several cases of simultaneous carotid intervention along with coiling of co-existing intracranial aneurysms. Although this approach has been reported safe and feasible, CAS requires dual antiplatelet administration, which could potentially increase risk of aneurysm rebleed, inadequate aneurysm occlusion, and increased risk of intracerebral bleed if ventricular drainage procedures are needed for hydrocephalus management.
Given the sparse literature and no definitive guideline, it is imperative that a symptomatic life-threatening cerebrovascular lesion is always managed first. When a second lesion compounds the scenario and likely to influence the outcome of the primary pathology, the management paradigm must be tailored uniquely, as we have done here to account for all possible variations during the clinical course to achieve a good outcome.
| Conclusion|| |
Co-existing multiple cerebrovascular lesions can rarely present both ipsilaterally and contralaterally. An evaluation must encompass both the cerebral circulation and the neck vessels from the aortic arch onwards. Each patient is unique with various other added risk factors, and the whole scenario must be viewed in toto to plan the operative strategy. The advent of intraoperative neuromonitoring lately has added further safety to these complex situations.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]