carotid endarterectomy in patients with incidental

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Tiirkish Neiirosiirgery 10: 48 - 53, 2000 Temiz: Carotid Endarterectomy Iii Patieiits Wit1i Iiicideiital Iiitracraiiial Aiieiirysms Patients Aneurysms In Intracranial Carotid Endarterectomy With Incidental Rastlantisal IntrakranIali AnevrIzmali Hastalarda Karotid EndarderektomI CÜNEYT TEMIz, KAGAN TUN, AGAHAN ÜNLÜ, ALI O.TASÇIOGLU Ankara University School of Medicine, Department of Neurosurgery, Ankara Received: 26.5.1999 ~ Accepted: 2.12.1999 Abstract: The surgical management of patients with symptomatic carotid stenosis in combination with one or more inciden ta i intracranial aneurysms is problematic. We discuss this issue with reference to two cases, and in light of the relevant literature. Our conclusion is that the best management plan is aneurysm elipping via craniotomy, followed by microvascular endarterectomy under barbiturate protection, all in the same surgical session. Özet: Semptomatik karotis stenozlu ve rastlantisalolarak tespit edilen bir veya daha fazla intrakranial anevrizmasi olan hastalarin cerrahi tedavisinin planlanmasi önemli bir problemdir.Bu konuyu makalemizde, 2 hastamizi sunarak ve ilgili literatür bilgileri isigi altinda tartistik. Sonuçlanmiza ve tecrübelerimize göre, ilk olarak kraniotomi ile intrakranial anevrizmanin kliplenmesi, ardindan barbitürat korumasi altinda mikrovasküler endarterektominin ayni seans ta uygulanmasi, en iyi cerrahi tedavi planidir. Key Words: Carotid endarterectomy, incidental aneurysm, surgical strategy Anahtar Kelimeler: Karotid endarterektomi, insidental anevrizma, cerrahi strateji INTRODUCTION The results of the Asymptomatic Carotid Atherosclerosis Study (ACAS) (1) showed that two trends have emerged for managing arteriosclerotic disease at the bifurcation of the carotid artery. One route taken by centers with less than 3% per- and postoperative mortality has been to expand the indications for carotid endarterectomy to include asymptomatic cases with 60% luminal stenosis. The other trend has been towards more widespread use of digital subtraction angiography (DSA) for evaIuating disease at the carotid bifurcation, but this technique has associated morbidity and mortality. These risks have led same vascular surgeons to operate on carotid stenosis cases after only a duplex ultrasound (US) sean of the bifurcabon, and without further evaIuating the intracranial vasculature. it has been estimated that incidental intracranial aneurysms are found in 2.8-5% of patients who undergo cerebral angiography while being evaluated for extracranial vascular disease (3,24,31,32). The patient with asyrnptomatic or symptomatic carotid stenosis who als o has an incidental intracranial aneurysm presents a different set of challenges than the individual with subarachnoid 48

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Page 1: Carotid Endarterectomy In Patients With Incidental

Tiirkish Neiirosiirgery 10: 48 - 53, 2000 Temiz: Carotid Endarterectomy Iii Patieiits Wit1i Iiicideiital Iiitracraiiial Aiieiirysms

Patients

Aneurysms

InIntracranial

Carotid EndarterectomyWith Incidental

Rastlantisal IntrakranIali AnevrIzmali Hastalarda KarotidEndarderektomI

CÜNEYT TEMIz, KAGAN TUN, AGAHAN ÜNLÜ, ALI O.TASÇIOGLU

Ankara University School of Medicine, Department of Neurosurgery, Ankara

Received: 26.5.1999 ~ Accepted: 2.12.1999

Abstract: The surgical management of patients withsymptomatic carotid stenosis in combination with one ormore inciden ta i intracranial aneurysms is problematic.We discuss this issue with reference to two cases, and inlight of the relevant literature. Our conclusion is that thebest management plan is aneurysm elipping viacraniotomy, followed by microvascular endarterectomyunder barbiturate protection, all in the same surgicalsession.

Özet: Semptomatik karotis stenozlu ve rastlantisalolaraktespit edilen bir veya daha fazla intrakranial anevrizmasiolan hastalarin cerrahi tedavisinin planlanmasi önemli birproblemdir.Bu konuyu makalemizde, 2 hastamizisunarak ve ilgili literatür bilgileri isigi altinda tartistik.Sonuçlanmiza ve tecrübelerimize göre, ilk olarakkraniotomi ile intrakranial anevrizmanin kliplenmesi,ardindan barbitürat korumasi altinda mikrovasküler

endarterektominin ayni seans ta uygulanmasi, en iyicerrahi tedavi planidir.

Key Words: Carotid endarterectomy, incidentalaneurysm, surgical strategy

Anahtar Kelimeler: Karotid endarterektomi, insidentalanevrizma, cerrahi strateji

INTRODUCTION

The results of the Asymptomatic CarotidAtherosclerosis Study (ACAS) (1) showed that twotrends have emerged for managing arterioscleroticdisease at the bifurcation of the carotid artery. Oneroute taken by centers with less than 3% per- andpostoperative mortality has been to expand theindications for carotid endarterectomy to includeasymptomatic cases with 60% luminal stenosis.The other trend has been towards more widespreaduse of digital subtraction angiography (DSA) forevaIuating disease at the carotid bifurcation, but thistechnique has associated morbidity and mortality.

These risks have led same vascular surgeons tooperate on carotid stenosis cases after only a duplexultrasound (US) sean of the bifurcabon, and withoutfurther evaIuating the intracranial vasculature.it has been estimated that incidental intracranialaneurysms are found in 2.8-5% of patients whoundergo cerebral angiography while beingevaluated for extracranial vascular disease(3,24,31,32).

The patient with asyrnptomatic or symptomaticcarotid stenosis who als o has an incidental

intracranial aneurysm presents a different set ofchallenges than the individual with subarachnoid

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hemorrhage, sinee the aiready serious problem ofearatid stenosis is eompounded by the life­threatening risk of aneurysm rupture. In this artiele,we examine this issue in two eases and diseuss therelevant literature.

CASE REPORTS

Cas e # 1:

A 60-year-old female patient reported havingexperieneed a transient right-sided episode ofhemiparesis 24 hours before admission. Her transientisehemie attaek resolved spontaneously within 8hours, but she also experieneed severe headaehe for10 hours. The results of the patient's physical andneurologieal examinations were within normallimits.Cranial eomputed tomography (CT) revealed anisehemie area in the right centrum semiovale.Duplex US sean of the earotid arteries showed70% luminal stenosis at the bifureation of the left

internal earotid artery, as well as alteredhemodynamies. DSA eonfirmed 70% stenosis of theleft internal earotid artery, and revealed an aneurysmat the bifureation of the right middle eerebral artery(MCA) (Figure lA-B).

Figure lA: Left cervica! segment OSA of Case # 1.

We elipped the right MCA aneurysm througha right-sided pterional eraniotomy, and thenperformed a left earotid endartereetomy during thesame session. Care was taken not to indueehypotension during the eraniotomy and elipping, andthe patient was not heparinized during theendarterectomy. The patient had an uneventfulreeovery. Follow-up OSA confirmed that the rightMCA aneurysm had been elipped sueeessfully, andshowed good eosmetie results of the left earatidartery endarterectomy (Figure 2A-B).

Cas e # 2:

A 58-year-old female patient was admitted aftershe reported having experieneed several episodes ofright-sided weakness over the previous 8 months.She said that all these episodes had resolvedspontaneously within 2-4 days, and she exhibited noneuralogieal defieits. The patient's physieal andneurologieal examinations were normal, apart frommild systolie hypertension. Cranial CT revealedmultiple periventrieular mieroinfarets bilaterally.Duplex sonography show ed 95% stenosis at thebifureation of the left internal earotid artery, withuleeration and altered hemodynamics at the site.DSA of the eervieal and intraeranial vaseulature

confirmed the ultrasonographie diagnosis and alsorevealed an aneurysmal dilatation in the left posterioreommunieating artery, a finding that was eonsistentin all angiographie positions (Figure 3A-B).

We performed a left pterional eraniotomy andexposed a fusiform dilatation of the left posterior

Figure 1B: Right intracrania! segment OSA of Case # 1.

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Turkis/i Neurosurgery 10: 48 - 53, 2000 Te/uiz: Caratid Eudarterectol1lY Iii Patieiits Witli liicideiita/ Iiitracmiiia/ Aiieurysms

Figure 2A: Post-operative !eft cervica! OSA of Case # 1.

communicating artery. Since elipping was notpossible due to the fusiform dilatation we wrappedthe aneurysm with fascia in usual fashion. After thecraniotomy, we did a left carotidmicroendarterectomy during the same session, underbarbiturate protection and without heparinization.The patienfs recovery was uneventful. FoIlow-upDSA showed good cosmetic results of theendarterectomy, and filling of the posteriorcommunicating aneurysm (Figure 4A-B).

DISCUSSION

Completion of the ACAS (1), which followedthe North American Symptomatic CarotidEndarterctomy Trial (NASCET) (28), expanded theindications for carotid endarterectomy surgery toinclude asymptomatic patients with 60% stenosis.The previous criterion for this type of treatment was70% or more carotid stenosis in a symptomaticpatient. Currently, vascular surgeons are doing moreof these operations than ever before, with patientclinical pictures ranging from more than 70%stenosisin symptomatic cas es to 60% stenosis in

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Figure 28: Post-operative right intracrania! segment OSAof Case # 1.

asymptomatic cases. This significant rise in numbershas led to the use of duplex US scan as the solediagnostic test for making decisions about how tomanage carotid stenosis. However, the use of thismethod alone has major limitations in that it teIlsnothing about how the condition of the carotidarteries is affecting the brain, the main organ ofinterest. Any vascular study that does not reveal theintracranial vasculature must be considered

incomplete. A duplex US scan of the cervical segmentof carotid arteries does not reveal intracranialaneurysms, arteriovenous malformations (AVMs) ordistal stenosis of the intracranial circulation. Lackingthis crucial information, a surgeon performing anendarterectomy at the bifurcation of a carotid arterycan find him- or herself in tragic circumstances if anunidentified intracranial aneurysm ruptures, or if thepatient's symptoms worsen due to havingoverlooked distal stenosis of the same artery.

DSA remains the gold standard of vascularstudies, and is required in all patients with carotidstenosis to fuIly evaluate intracranial and extracranialcirculation. The finding of incidental berryaneurysms in patients undergoing carotidendarterectomy raises the issues of which lesi onshould be treated first, and whether an incidentalaneurysm should be treated at all (23,27). The risk ofbleeding from an asymptomatic intracranialaneurysm during S-year follow-up has be en

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Tiirkish Neiirosiirgery 10: 48 - 53, 2000 Temiz: Cara/id Eiidar/eree/omy lIi Pa/ieii/s Wit1i Iiieideii/a/ bi/raeraiiiai Aiieiirysiiis

Figure 3A: Left cervical segment DSA of Case # 2.

Figure 4A: Post-operative left cervical DSA of Case # 2.

estimated at 10-17% (9,25). In view of the naturalhistory of this lesion, an increasing number ofneurosurgeons have recommended eledive elipping

Figure 3B: Left intracranial segment DSA of Case # 2.

Figure 4B: Post-operative left intracranial segment DSAof Case # 2.

of incidentally discovered intracranial aneurysms(12,26,30).More recent reports have suggested a moreaggressive approach to this type of aneurysm

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Tiirkis/i Neiirosiirgery 10: 48 - 53, 2000 Temiz: Carolid Elldarlereelomy LLLPalieiils Wii/i Iiieideiilal 1111memiiial Aiieiinjsnis

(15,16,17,18), with surgery indicated for patients lessthan 70 years of age who have a life expectancy ofmore than 5 years, and for coincidental aneurysmslarger than 4-5 mm (5,19,20,21,22). Data in theliterature suggest a 1-2% annual rate of bleeding(15,17), and a mortality rate of 50% per bleedingepisode (15,16) in aneurysmal subarachnoidhemorrhage. Since incidental aneurysms can betreated with 1% mortality and 4% overall morbidity(10,20,21), these can be efficiently managed togetherwith carotid stenosis in patients affected by bothproblems.

There is controversy over which lesion shouldbe treated first, the best sequence for carotid surgeryand craniotomy, and whether these proceduresshould be done in separate operations or together inone session. Our opinion is that an intracranialaneurysm should be treated first, followed by carotidendarterectomy performed under barbiturateprotection, and that both procedures should be doneduring one session. In contrast, several authors(2,7,11) have opted to deal with the stenosis issuefirst, regardless of the size or site of the aneurysm,and have reported no aneurysmal bleeding in theintraoperative or immediate postoperative period.However, one patient reported by Adams (2) and twoaneurysm patients in the NASCET (28) did bleedafter endarterectomy. Of these three, one patient inthe NASCET report and Adams' patient died due tohemorrhage.

Correction of severe stenosis generally causesa marked increase in blood flow distal to the lesion.

The classical work of Ferguson (11,12) showed thatpressure in the aneurysmal sac is equal to meansystemic pressure, and that both the turbulence andthe tension at the aneurysmal circumference risewhen the arterial blood pressure increases (theLaplace law). it follows that correction of severestenosis increases the chance of enlarging orrupturing an aneurysm. In other words, repairingcarotid stenosis before addressing an intracranialaneurysm may expose the aneurysm to increasedarterial pressure, and, theoretically, increase the riskof rupture (14). Conversely, partial carotid occlusionmay impart a protective effed upon an aneurysmdistal to the occlusion. Reduction in the size of

intracranial aneurysms has been documentedfollowing intentional parti al carotid occlusion (4,6).

Our experience is too limited to make definiteconclusions. Analysis performed by Dippel et aL.(8)suggested that a good technical job in a single case isnot a solid enough decision-making basis when

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considering the issues of quality of life, or the gambleof living with the knowledge that one has ananeurysm that could rupture at any time withdevastating results. We share the opinion express edby Pappada et aL.(29), that intracranial aneurysmsshould be treated first; however, in contrast to theirmethod, we perform microendarterctomy during thesame surgical session. We suggest that carotidstenosis patients with incidental aneurysms whomeet the required surgical criteria should have theiraneurysms addressed first. The carotid stenosisshould be treated second, during the same session,via microendarterectomy und er barbiturateprotection.

REFERENCES

1. ACAS Group: Endarterectomy for asymptomaticcarotid artery stenoses. Stroke 20:844-849, 1989.

2. Adams HP Jr: Carotid stenosis and coexistingipsilateral aneurysm. Arch NeuroI34:515-516, 1977.

3. Baker HL: Medical and surgical care of stroke.Circulation 32:559-562, 1955.

4. Bjorkesten G, Troupp H: Changes in the size of intra­cranial arterial aneurysms. J Neurosurg 19:583-588,1952.

5. Chang HS, Kirino T: Quantification of operative benefitfor unruptured cerebral aneurysms: a theoreticalapproach. J Neurosurg, 82:416-418, 1995.

6. Conqvist S: Temporary or incomplete occlusion of thecarotid artery in the neck for the treatment ofintracranial arterial aneurysms. Neurochirurgica 7:146­151, 1964.

7. Denton IC Jr, Gutmann L: Surgical treatment ofsymptomatic carotid stenosis and asymptomaticipsilateral intracranial aneurysm. Case report. JNeurosurg 38: 662-665, 1973.

8. Dippel DWJ, Vermeulen M., Braakman R, HabbemaJDF: Transient ischemic attacks, carotid stenosis, andan incidental intracranial aneurysm. A decisionanalysis. Neurosurgery 34: 449-458, 1994.

9. Drake CG, Givin J: The surgical treatment ofsubarachnoid hemorrhage with multiple aneurysins.In Morley TP ed, Current Controversies inNeurosurgery. Philadelphia: WB Saunders, 1976; 274­278.

10. Drake CG: Management of cerebral aneurysm. Stroke12:273-283 1981.

11. Ferguson GC: Turbulence in human intracranialsaccular aneurysms. J Neurosurg 33:485-497, 1970.

12. Ferguson GC: Direct measurement of mean andpulsatile blood pressure at operation in humanintracranial saccular aneurysms. J Neurosurg 35:550­563, 1972.

13. Garrido E: Modern treatment of intracranial

aneurysms. Pa Med 32-33, 1980.14. Gurdijan ES, Hardy WG, Lindrier DV: Symposium:

occlusive cerebrovascular disease. Diagnostic

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evaIuation and treatment (cited by Stern). Trans AmAcad Opthalmol Otolaryngol66: 149-165 1962.

15. Heiskanen O: Risk of surgery for unrupturedintracranial aneurysms. J Neurosurg 65:451-453,1986.

16. Heros RC, Kistler JP: Intracranial arterial aneurysms­an update. Stroke 14:628-631, 1993.

17. Jane JA, Kassel NF, Tomer JC, Winn HR: The naturalhistory of aneurysms and arteriovenousmalformations. J Neurosurg 62:321- 323, 1985.

18. Juvela S, Porras M, Heiskanen O: Natural history ofunruptured aneurysms: a long-term follow-up study.J Neurosurg 79:174-182, 1993.

19. Kassel NF, Tomer JC: Size of intracranial aneurysms.Neurosurgery 12:291-297, 1983.

20. Khanna RK,Malik GM, Oureshi N: Predicting outcomefollowing surgical treatment of umuptured intracranialaneurysms: a proposed grading system. J Neurosurg84: 49-54, 1996.

21. King JT, Berlin JA, Flamm ES:Mortality and morbidityfrom elective surgery for asymptomatic umupturedcerebral aneurysms. J Neurosurg 81:837-842, 1994.

22. King JT, Glick HA, Viason JJ, Flamm ES: Electivesurgery for asymptomatic umuptured intracranialaneurysms: a cost-effectiveness analysis. J Neurosurg83:403-412, 1995.

23. Ladowski JS, Webster MW, Jonas HO, Steed OL:Carotid endarterectomy in patients with asymptomaticintracranial aneurysms. Ann Surg 200:70-73, 1984.

24. McCormick WF, Schochet SS:Atlas of CerebrovascularOiseases. Philadelphia, WB Saunders 1916, pp 49.

25. Mount L, Brisman R:Treatment of multiple aneurysms- symptomatic and asymptomatic. Clin Neurosurg21:166-170,1974.

26. Moyes PO: Surgical treatment of multiple aneurysmsand of incidentally discovered unruptured aneurysms.J Neurosurg 35:291-295, 1971.

27. Nagashima M, Nemoto H, Hadeishi H: Umupturedaneurysms associated with ischemic cerebrovasculardiseases. Surgical indications. Acta Neurochir (Wien)124:71-78, 1993. .

28. NASCET Collaborators: Benefidal effect of carotid

endarterectomy in patients with high-grade carotidstenosis. N Engl J Med 325:445-453, 1991.

29. Pappada G, Fiori L, Marina R, Vaiani S, Gaini SM:Management of symptomatic carotid stenoses withcoincidental intracranial aneurysms. Acta Neurochir(Wien) 138:1386-1390, 1996.

30. Salazar JL: Surgical treatment of asymptomatic andincidental intracranial aneurysms. J Neurosurg 53: 20­21, 1980.

31. Schumaker RO, Avant WS, Choen GA: Coihcidentalmultiple intracranial aneurysms and symptomat.iccarotid stenosis. Stroke 7:504-506, 1976.

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