Single-Stage Endovascular Management of Concurrent Intracranial Aneurysms and Arterial Stenoses: Clinical Outcomes, Procedural Strategies, and Predictive Factors

Abstract

Background: The coexistence of extracranial arterial stenoses and intracranial aneurysms presents a unique clinical dilemma. While staged interventions are traditionally preferred to reduce procedural risks, recent advances have enabled single-stage endovascular treatment. This study evaluates the clinical outcomes, procedural strategies, and predictive factors associated with such combined interventions.

Methods: This retrospective study included 47 patients treated with single-stage endovascular procedures for concurrent extracranial stenosis and intracranial aneurysm between 2016 and 2024. Clinical, angiographic, and procedural data were collected. Outcomes were assessed using the mmodified Rankin Scale (mRS), and statistical analyses were performed to identify associations between clinical variables and functional outcomes.

Results: Of the 47 patients, 85.1% achieved favorable outcomes (mRS 0-2) at ≥6-month follow-up. The most commonly treated arteries were the internal carotid artery (70.2%) and the middle cerebral artery (34%). Stent-assisted coiling or flow diversion was performed in 93.6% of aneurysm cases, while 91.5% underwent carotid or vertebral stenting. Lesion laterality (left-sided aneurysms, p = 0.019) and stenosis length (p = 0.0469) were significantly associated with outcomes. Smoking was linked to multiple stenoses (p = 0.0191). Two patients experienced major complications: one aneurysmal rebleed after stenting, and one intraoperative rupture.

Conclusions: Single-stage endovascular treatment for patients with concurrent extracranial stenosis and intracranial aneurysm is technically feasible and clinically effective in selected cases. Lesion configuration, anatomical considerations, and individualized planning are critical in optimizing outcomes.

Keywords: carotid artery stenosis; endovascular treatment; intracranial aneurysm; modified Rankin Scale; neurointervention; single-stage intervention; smoking; stroke prevention; subarachnoid hemorrhage; vertebral artery stenosis.

Figure 1

Simultaneous treatment of left MCA aneurysm and right vertebral artery stenosis. (A–C): balloon-assisted coiling with LEO stent (2.5 × 18 mm) of a left MCA bifurcation aneurysm. (D–F): stenting of right vertebral artery V1 segment using an Ultimaster 3.5 × 12 mm stent.

Figure 2

Endovascular management of dual intracranial aneurysms with cervical ICA stenosis. (A–C): angioplasty and CASPER stenting of the left cervical ICA after subocclusion and embolic protection. (D,E): coil embolization of left MCA and ICA aneurysms using half-T stenting technique with LEO stent (2.5 × 18 mm).

Figure 3

Proposed treatment algorithm for patients with coexisting extracranial stenosis and intracranial aneurysm. The initial step evaluates lesion ipsilaterality. If non-ipsilateral, the symptomatic pathology is prioritized. For ipsilateral lesions, the degree of stenosis is assessed. Stenoses exceeding 70% (as measured by NASCET criteria *) are treated first to ensure safe access and perfusion. If the stenosis is <70%, aneurysm rupture risk is evaluated using the PHASES score **. High-risk aneurysms are prioritized for embolization, while low-risk cases proceed with stenosis treatment. * North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. ** Population, hypertension, age, size of aneurysm, earlier SAH, site of aneurysm (PHASES) score.