Letters to the Editor / Clinical Neurology and Neurosurgery 120 (2014) 142–146

Management of coexistent intracranial aneurysms and extracranial carotid atherosclerotic disease Keywords: Intracranial aneurysm Subarachnoid hemorrhage Atherosclerosis Carotid stenosis Stroke

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

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.

Reference [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,

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∗ 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 6 February 2014 http://dx.doi.org/10.1016/j.clineuro.2013.12.027

Replying to the letter entitled ‘Management of coexistent intracranial aneurysms and extracranial carotid atherosclerotic disease’ Keywords: Intracranial aneurysms Extracranial carotid atherosclerotic disease Endovascular treatment Surgery

We would like to thank Dr. Ding for his interest in our paper [1]. The management of intracranial aneurysms in patients with coexistent extracranial carotid atherosclerotic disease (ECAD) is sometimes challenging and imposes a high complication rate. Before the procedure, we should be able to answer the following questions: (1) Is the age, daily-life performance and underlying medical condition of the patients suitable to receive any therapeutic options? (2) Is each procedure for both disease conditions more beneficial than medical management or a natural course? (3) Is the procedural risk tolerable? (4) Did the patient and their family understand and give informed consent to have the procedures conducted? As Dr. Ding mentioned, several clinical and anatomical factors should be taken into account to determine which approach is the best for patients between surgery and endovascular treatments. Our strategy for both intracranial aneurysms and ECAD is as follows: If possible, both lesions should be treated in single session by single treatment modality [2]. In cases both lesions are treated by different treatment modalities, more severe or more risky lesions should be treated first. If only one lesion requires intervention, the best modality should be chosen based on the lesions’ characteristics. If possible, we prefer endovascular management to open surgery because of the less invasive procedure and lower procedural and general anesthesia times, (sometimes no general anesthesia) despite of similar procedural and postprocedural outcomes. This is because of the fact that most patients with both diseases are elderly and have serious comorbidities. We also agree with Dr. Ding’s comments about future translational research efforts for the understanding of pathobiological commonalities.

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Letters to the Editor / Clinical Neurology and Neurosurgery 120 (2014) 142–146

Reference [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] 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. Interv Neuroradiol 2013;19(2):228–34.

Young Dae Cho Department of Radiology, Seoul National University Hospital, Seoul, South Korea Keun-Hwa Jung ∗ Department of Neurology, Seoul National University Hospital, Seoul, South Korea ∗ Corresponding

author at: Department of Neurology, Seoul National University Hospital, 101, Daehangno, Jongno-gu, Seoul 110-744, South Korea. Tel.: +82 2 2072 2278; fax: +82 2 3672 4949. E-mail address: [email protected] (K.-H. Jung)

abstract if the full text is unavailable or if they have insufficient time to read the article thoroughly. Correct interpretation of statistical results is imperative and should be emphasized, especially for studies in which the conclusions are exclusively drawn from statistics. In summary, we congratulate the authors for their excellent article and express our gratitude to them for sharing their extensive experience on the issue with the scientific community. Disclosure None. Reference [1] Chotai S, Qi S, Xu S. Prediction of outcomes for brainstem cavernous malformation. Clin Neurol Neurosurg 2013;115:2117–23. [2] du Prel JB, Hommel G, Rohrig B, Blettner M. Confidence interval or p-value?: part 4 of a series on evaluation of scientific publications. Dtsch Arztebl Int 2009;106:335–9.

Da Li Jun-Ting Zhang ∗ Beijing Tiantan Hospital, Capital Medical University, Beijing, China

2 January 2014

∗ Corresponding

author. Tel.: +86 10 67098431; fax: +86 10 67051377. E-mail address: [email protected] (J.-T. Zhang)

Available online 1 March 2014 http://dx.doi.org/10.1016/j.clineuro.2014.01.029

Brainstem cavernous malformations

28 September 2013

Dear Editor, We read with great interest and comment the study by Chotai et al. [1], which concluded that early surgical timing (p = 0.05, odds ratio [OR] = 0.087, 95% confidence interval [CI] = 0.07–1.03) was an independent predictor of favorable 1-year outcomes and that preoperative modified Rankin Scale (mRS) scores (p = 0.039, OR = 0.07, 95% CI = 0.79–10.23) and lesion size (

Replying to the letter entitled 'management of coexistent intracranial aneurysms and extracranial carotid atherosclerotic disease'.

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