Angioplasty and stenting are emerging alternative treatments to endarterectomy for carotid stenosis. The increasing number of procedures performed carries an increased diagnosis rate of associated asymptomatic intracranial aneurysms, resulting in a clinical and therapeutic dilemma, not fully solved in the literature. When an incidental lesion is found, the first question is whether it is necessary to treat it or not? If treatment is decided, the next question is which should be treated first, the intra or the extracranial lesion? We review our experience and the literature and discuss our preferred approach of single-procedure carotid stenting and aneurysm coiling, which we believe is feasible, safe and effective constituting an option when confronted with this difficult therapeutic dilemma.