Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 96-98

Single-stage ruptured internal carotid artery aneurysm clipping with contralateral carotid endarterectomy: Tips and tricks


Department of Neurosurgery, Sakra World Hospital, Bengaluru, Karnataka, India

Date of Submission11-Oct-2020
Date of Acceptance15-Oct-2020
Date of Web Publication30-Aug-2021

Correspondence Address:
Abinash Dutta
Department of Neurosurgery, Sakra World Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_139_20

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  Abstract 


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 2021 Nov 30];8, Suppl S1:96-8. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/96/324932




  Introduction Top


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%).[1],[2] This combination is a therapeutic challenge. Uneventful carotid endarterectomy (CEA) as well as rupture of the aneurysm after CEA has been reported.[3],[4] In 1970, Portnoy and Avellanosa[5] 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 Top


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 Top


Hemodynamic forces play a major role in the management of cerebrovascular pathology and influence decision-making.[6] 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%[1],[7] 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.[4],[6],[8],[9] Several reports of SAH after CEA also reaffirm this thinking.[4],[8]

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.[1],[2],[3],[7] 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.[2],[6],[8] 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.[5],[6] 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.[5] 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.[10] 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kappelle LJ, Eliasziw M, Fox AJ, Barnett HJ. Small, unruptured intracranial aneurysms and management of symptomatic carotid artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Group. Neurology 2000;55:307-9.  Back to cited text no. 1
    
2.
Pappadà G, Fiori L, Marina R, Citerio G, Vaiani S, Gaini SM. Incidence of asymptomatic berry aneurysms among patients undergoing carotid endarterectomy. J Neurosurg Sci 1997;41:257-62.  Back to cited text no. 2
    
3.
Ladowski JS, Webster MW, Yonas HO, Steed DL. Carotid endarterectomy in patients with asymptomatic intracranial aneurysm. Ann Surg 1984;200:70-3.  Back to cited text no. 3
    
4.
Riphagen JH, Bernsen H. Carotid Endarterectomy and T.I.A.s. Lancet 1974;303:51-2.  Back to cited text no. 4
    
5.
Portnoy HD, Avellanosa A. Carotid aneurysm and contralateral carotid stenosis with successful surgical treatment of both lesions; case report. J Neurosurg 1970;32:476-82.  Back to cited text no. 5
    
6.
van Laar PJ, van der Grond J, Moll FL, Mali WP, Hendrikse J. Hemodynamic effect of carotid stenting and carotid endarterectomy. J Vasc Surg 2006;44:73-8.  Back to cited text no. 6
    
7.
Héman LM, Jongen LM, van der Worp HB, Rinkel GJ, Hendrikse J. Incidental intracranial aneurysms in patients with internal carotid artery stenosis: A CT angiography study and a metaanalysis. Stroke 2009;40:1341-6.  Back to cited text no. 7
    
8.
Bodenant M, Leys D, Lucas C. Isolated subarachnoidal hemorrhage following carotid endarterectomy. Case Rep Neurol 2010;2:80-4.  Back to cited text no. 8
    
9.
McDonald RJ, Cloft HJ, Kallmes DF. Intracranial hemorrhage is much more common after carotid stenting than after endarterectomy: Evidence from the National Inpatient Sample. Stroke 2011;42:2782-7.  Back to cited text no. 9
    
10.
Badruddin A, Teleb MS, Abraham MG, Taqi MA, Zaidat OO. Safety and feasibility of simultaneous ipsilateral proximal carotid artery stenting and cerebral aneurysm coiling. Front Neurol 2010;1:120.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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