G Model CLINEU-3618; No. of Pages 1
ARTICLE IN PRESS Clinical Neurology and Neurosurgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Letter to the Editor Management of coexistent intracranial aneurysms and extracranial carotid atherosclerotic disease Keywords: Intracranial aneurysm Subarachnoid hemorrhage Atherosclerosis Carotid stenosis Stroke
Dear Sir, I have read, with great interest, a recently published article in Clinical Neurology and Neurosurgery by Cho et al. titled ‘Characteristics of intracranial aneurysms associated with extracranial carotid disease in South Korea’ [1]. The authors report angiographic evaluation of 606 patients with extracranial carotid atherosclerotic disease (ECAD), defined as at least 50% stenosis of the cervical internal carotid artery, of which 86 patients (14.2%) were diagnosed with 120 coexisting unruptured intracranial aneurysms (UIA). The patients were segregated based on unilateral (68 patients with 97 aneurysms) or bilateral (18 patients with 23 aneurysms) presence of ECAD. Carotid revascularization, including endarterectomy, stenting, and bypass, was undertaken in 46 patients (53.5%). A total of 31 aneurysms were treated with coil embolization or microsurgical clipping (25.8%) and another 28 were lost to follow-up (23.3%) thus yielding 61 patients with untreated UIAs who were followed with serial angiography for a mean period of 29 months. There were no cases of aneurysm rupture and only one case of aneurysm growth (1.6%). Upon closer inspection, the benign course of the aneurysms reported in this study is not surprising based on the current understanding of UIA natural history [2,3]. The mean aneurysm size was very small (3 mm) and only a minority were located in the posterior circulation or posterior communicating artery (N = 31, 25.8%). Furthermore, it is likely that aneurysms deemed high risk for rupture based on angiographic characteristics, such as size, location, and presence of a daughter sac, were treated preferentially with coiling or clipping. It would be interesting to know, based on the authors’ experience, their recommendations regarding factors affecting choice of surgical versus endovascular approaches, treatment staging, and order of intervention in patients
requiring treatment of both an intracranial aneurysm and ECAD. Despite concerns of increased hemodynamic stress to the aneurysmal sac following carotid revascularization, it does not appear that carotid revascularization in the setting of an UIA is associated with increased risk of aneurysm rupture although the current literature is relatively sparse [4,5]. Finally, while it is tempting to postulate underlying pathobiological commonalities between intracranial aneurysms and ECAD, the association between the two cerebrovascular entities remains poorly understood. Future translational research efforts are necessary to better delineate the molecular mechanisms which lead to intracranial aneurysm formation, progression, and eventual subarachnoid hemorrhage as well as those associated with atherosclerotic plaque development, destabilization and eventual ischemic stroke. References [1] Cho YD, Jung KH, Roh JK, Kang HS, Han MH, Lim JW. Characteristics of intracranial aneurysms associated with extracranial carotid artery disease in South Korea. Clin Neurol Neurosurg 2013;115(9):1677–81. [2] Wiebers DO, Whisnant JP, Huston 3rd J, Meissner I, Brown Jr RD, Piepgras DG, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362(9378): 103–10. [3] Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med 2012;366(26):2474–82. [4] Khan UA, Thapar A, Shalhoub J, Davies AH. Risk of intracerebral aneurysm rupture during carotid revascularization. J Vasc Surg 2012;56(6):1739–47. [5] Park JC, Kwon BJ, Kang HS, Kim JE, Kim KM, Cho YD, et al. Single-stage extracranial carotid artery stenting and intracranial aneurysm coiling: technical feasibility and clinical outcome. Intervent Neuroradiol 2013;19(2):228–34.
Dale Ding ∗ University of Virginia, Department of Neurosurgery, Charlottesville 22908, USA ∗ Correspondence
to: University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville 22908, USA. Tel.: +1 434 924 2203; fax: +1 434 982 5753. E-mail address: [email protected] 11 September 2013 Available online xxx
0303-8467/$ – see front matter © 2014 Published by Elsevier B.V. http://dx.doi.org/10.1016/j.clineuro.2013.12.027
Please cite this article in press as: Ding D. Management of coexistent intracranial aneurysms and extracranial carotid atherosclerotic disease. Clin Neurol Neurosurg (2014), http://dx.doi.org/10.1016/j.clineuro.2013.12.027
ARTICLE IN PRESS Clinical Neurology and Neurosurgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Letter to the Editor Management of coexistent intracranial aneurysms and extracranial carotid atherosclerotic disease Keywords: Intracranial aneurysm Subarachnoid hemorrhage Atherosclerosis Carotid stenosis Stroke
Dear Sir, I have read, with great interest, a recently published article in Clinical Neurology and Neurosurgery by Cho et al. titled ‘Characteristics of intracranial aneurysms associated with extracranial carotid disease in South Korea’ [1]. The authors report angiographic evaluation of 606 patients with extracranial carotid atherosclerotic disease (ECAD), defined as at least 50% stenosis of the cervical internal carotid artery, of which 86 patients (14.2%) were diagnosed with 120 coexisting unruptured intracranial aneurysms (UIA). The patients were segregated based on unilateral (68 patients with 97 aneurysms) or bilateral (18 patients with 23 aneurysms) presence of ECAD. Carotid revascularization, including endarterectomy, stenting, and bypass, was undertaken in 46 patients (53.5%). A total of 31 aneurysms were treated with coil embolization or microsurgical clipping (25.8%) and another 28 were lost to follow-up (23.3%) thus yielding 61 patients with untreated UIAs who were followed with serial angiography for a mean period of 29 months. There were no cases of aneurysm rupture and only one case of aneurysm growth (1.6%). Upon closer inspection, the benign course of the aneurysms reported in this study is not surprising based on the current understanding of UIA natural history [2,3]. The mean aneurysm size was very small (3 mm) and only a minority were located in the posterior circulation or posterior communicating artery (N = 31, 25.8%). Furthermore, it is likely that aneurysms deemed high risk for rupture based on angiographic characteristics, such as size, location, and presence of a daughter sac, were treated preferentially with coiling or clipping. It would be interesting to know, based on the authors’ experience, their recommendations regarding factors affecting choice of surgical versus endovascular approaches, treatment staging, and order of intervention in patients
requiring treatment of both an intracranial aneurysm and ECAD. Despite concerns of increased hemodynamic stress to the aneurysmal sac following carotid revascularization, it does not appear that carotid revascularization in the setting of an UIA is associated with increased risk of aneurysm rupture although the current literature is relatively sparse [4,5]. Finally, while it is tempting to postulate underlying pathobiological commonalities between intracranial aneurysms and ECAD, the association between the two cerebrovascular entities remains poorly understood. Future translational research efforts are necessary to better delineate the molecular mechanisms which lead to intracranial aneurysm formation, progression, and eventual subarachnoid hemorrhage as well as those associated with atherosclerotic plaque development, destabilization and eventual ischemic stroke. References [1] Cho YD, Jung KH, Roh JK, Kang HS, Han MH, Lim JW. Characteristics of intracranial aneurysms associated with extracranial carotid artery disease in South Korea. Clin Neurol Neurosurg 2013;115(9):1677–81. [2] Wiebers DO, Whisnant JP, Huston 3rd J, Meissner I, Brown Jr RD, Piepgras DG, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362(9378): 103–10. [3] Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med 2012;366(26):2474–82. [4] Khan UA, Thapar A, Shalhoub J, Davies AH. Risk of intracerebral aneurysm rupture during carotid revascularization. J Vasc Surg 2012;56(6):1739–47. [5] Park JC, Kwon BJ, Kang HS, Kim JE, Kim KM, Cho YD, et al. Single-stage extracranial carotid artery stenting and intracranial aneurysm coiling: technical feasibility and clinical outcome. Intervent Neuroradiol 2013;19(2):228–34.
Dale Ding ∗ University of Virginia, Department of Neurosurgery, Charlottesville 22908, USA ∗ Correspondence
to: University of Virginia, Department of Neurosurgery, P.O. Box 800212, Charlottesville 22908, USA. Tel.: +1 434 924 2203; fax: +1 434 982 5753. E-mail address: [email protected] 11 September 2013 Available online xxx
0303-8467/$ – see front matter © 2014 Published by Elsevier B.V. http://dx.doi.org/10.1016/j.clineuro.2013.12.027
Please cite this article in press as: Ding D. Management of coexistent intracranial aneurysms and extracranial carotid atherosclerotic disease. Clin Neurol Neurosurg (2014), http://dx.doi.org/10.1016/j.clineuro.2013.12.027
