ELSEVIER CONCURRENT ANEURYSM RUPTURE AND THROMBOSIS OF HIGH GRADE INTERNAL CAROTID ARTERY STENOSIS: REPORT OF Two CASES Randall W. Porter, M.D.,* Michael T. Lawton, M.D.,* Mark G. Hamilton, M.D.C.M., F.R.C.S.(C),“( and Robert F. Spetzler, M.D., F.A.C.S.* *Barrow Neurological Institute, Division of Neurological Surgery, St. Joseph3 Hospital and Medical Center, Phoenix, Arizona; and TAlberta Children’s Hospital, Division of Neurosurgery, Calgary, Alberta, Canada Porter RW, Lawton MT, Hamilton MG, Spetzler RF. Concurrent aneurysm rupture and thrombosis of high grade internal carotid artery stenosis: report of two cases. Surg Neural 1997;47:532-40. BACKGROUND The simultaneous presentation of aneurysmal subarach- noid hemorrhage and thrombosis of a high-grade internal carotid artery stenosis is rare, and their management raises several treatment dilemmas. METHODS Two such patients with ruptured aneurysms are pre- sented: one with high-grade internal carotid artery steno- sis that progressed to occlusion and one with acute in- ternal carotid artery occlusion. RESULTS Both patients were treated with craniotomy for clip- ping of the ruptured aneurysm followed by carotid thromboendarterectomy. CONCLUSlONS We advocate urgent surgical treatment of both lesions, dealing with the most symptomatic lesion first. These two cases demonstrate the importance of reestablishing blood flow in patients with an acutely thrombosed ca- rotid artery. 0 1997 by Elsevier Science Inc. KEY WORDS Aneurysm, hemodynamic stress, internal carotid artery ste- nosis,subarachnoid hemorrhage, thromboendarterectomy, thrombosis. A neurysmal subarachnoid hemorrhage (SAH) is a common neurosurgical entity and the man- agement of these patients is well-established [8,15, 32,401. Symptomatic high-grade internal carotid ar- tery (KA) stenosis is also a common neurosurgical Address reprint requests to: Robert F. Spetzler, M.D., % Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road; Phoenix, AZ 850134496. Received April 28, 1995; accepted June 8, 1996. 0090-3019/97/$17.00 PI1 s0090-3019(96)00392-8 entity and the guidelines for management have been suggested by the North American Sympto- matic Carotid Endarterectomy Trial (NASCET) 1281. However, simultaneous occurrence of these two symptomatic clinical entities is uncommon and raises treatment dilemmas. Several authors have described patients in whom either the carotid ste- nosis or aneurysm was symptomatic and the other lesion was asymptomatic, but there are few reports of patients in whom both lesions are symptomatic [3,30]. We present two patients with a ruptured cerebral aneurysm and thrombosis of a stenotic internal carotid artery. These patients represent the first report of aneurysm clipping and thrombo- endarterectomy for concurrent symptomatic le- sions. Treatment strategies and the role of reopen- ing an acutely thrombosed internal carotid artery are discussed. CASE REPORTS CASE 1 This 65year-old female suddenly developed a se- vere headache, nausea, and vomiting. During the next 24 hours she deteriorated from an alert to a comatose state. She was intubated at the referring hospital and transferred to this institution. The pa- tient had a history of hypertension, peripheral vas- cular disease, and smoking. Her Glasgow Coma Scale (GCS) score [21] was 8 (eyes = 2, motor = 5, verbal = 1; intubated). Cranial nerve function was intact and she localized painful stimuli with both upper extremities. The patient’s Hunt-Hess grade was 4 [ 191. 0 1997 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010