Coil embolization of intracranial aneurysms with ipsilateral carotid stenosis: technical considerations

Simultaneous occurrence of carotid atherosclerotic disease and ipsilateral cerebral aneurysm is known because of common risk factors. When interventional neuroradiologists encounter such cases, issue of 'in which order to treat these lesions ' is raised. If carotid artery disease is treated first, then acute increase in perfusion pressure and high dose antiplatelets might increase the risk of aneurysm rupture. If aneurysm coiling is performed first, the stroke risk may increase due to manipulations through plaque and compromise of cerebral flow secondary to catheter placement through stenotic vessel. Even though aneurysm coiling first is a rational approach, there are technical problems like crossing the carotid lesion safely and making sure that placement of catheter through the stenosed vessel will not compromise the cerebral blood flow. This technical report describes our protocol in performing safe and successful coil embolization in three cases with moderate carotid stenosis and ipsilateral intracranial aneurysm. Our emphasis is mainly on technical considerations with the aim of avoiding cerebral embolism during crossing of carotid plaque and to avoid compromise of cerebral blood flow using 'syngo iflow'. These technical considerations may have important implications in treatment of intracranial aneurysm in patients with moderate ipsilateral cervical carotid stenosis.