scholarly journals Warning Signs in the Era of Unruptured Intracranial Aneurysms: Report on 2 Cases of Fatal Aneurysmal Hemorrhage

2021 ◽  
pp. 77-80
Author(s):  
Katarzyna Wójtowicz ◽  
Przemysław Kunert ◽  
Łukasz Przepiórka ◽  
Andrzej Marchel
Keyword(s):  
Intracranial Aneurysms ◽  
Elective Surgery ◽  
Aneurysm Rupture ◽  
Warning Signs ◽  
Warning Sign ◽  
Short Term ◽  
Treatment Timing ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
History Of

<b><i>Introduction:</i></b> The timing of treatment remains unresolved for patients with unruptured intracranial aneurysms (UIAs) and headaches, particularly when the pain is short term, localized, and related to the aneurysm site. We lack evidence to support the notion that when a headache accompanies an aneurysm, it elevates the risk of rupture. <b><i>Results:</i></b> We describe 2 cases of fatal subarachnoid hemorrhage in patients with a history of headache and known aneurysms. Both of these patients had good indications for treatment: a young age and an aneurysm &#x3e;7 mm, and both were qualified for elective surgery. However, both patients died of fatal aneurysm ruptures before the planned surgery. <b><i>Conclusion:</i></b> These cases suggested that treatment should be started as soon as possible, when a UIA is diagnosed based on a short-term period of severe headaches or when a UIA is observed and then severe headaches appear. There is no straightforward guideline for treatment timing in these patients. However, in this era of UIAs, the significance of sentinel headaches should be reevaluated. Given the incidence of headaches in the general population and the very low risk of aneurysm rupture, there may be a tendency to neglect the role of headache as a possible warning sign.

Intrinsic, Transitional, and Extrinsic Morphological Factors Associated With Rupture of Intracranial Aneurysms

Neurosurgery ◽  
2015 ◽  
Vol 77 (3) ◽  
pp. 433-442 ◽  
Author(s):  
Allen L. Ho ◽  
Ning Lin ◽  
Kai U. Frerichs ◽  
Rose Du
Keyword(s):  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Aneurysm Rupture ◽  
Extrinsic Factors ◽  
Flow Angle ◽  
Computed Tomographic ◽  
Ruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
History Of

Abstract BACKGROUND: As diagnosis and treatment of unruptured intracranial aneurysms continues to increase, management principles remain largely based on size. This is despite mounting evidence that aneurysm location and other morphologic variables could play a role in predicting overall risk of rupture. Morphological parameters can be divided into 3 main groups, those that are intrinsic to the aneurysm, those that are extrinsic to the aneurysm, and those that involve both the aneurysm and surrounding vasculature (transitional). OBJECTIVE: We present an evaluation of intrinsic, transitional, and extrinsic factors and their association with ruptured aneurysms. METHODS: Using preoperative computed tomographic angiography, we generated 3-dimensional models of aneurysms and their surrounding vasculature with Slicer software. Using univariate and multivariate analyses, we examined the association of intrinsic, transitional, and extrinsic aspects of aneurysm morphology with rupture. RESULTS: Between 2005 and 2013, 227 cerebral aneurysms in 4 locations were evaluated/treated at a single institution, and computed tomographic angiographies of 218 patients (97 unruptured and 130 ruptured) were analyzed. Ruptured aneurysms analyzed were associated with clinical factors of absence of multiple aneurysms and history of no prior rupture, and morphologic factors of greater aspect ratio. On multivariate analysis, aneurysm rupture remained associated with history of no prior rupture, greater flow angle, greater daughter-daughter vessel angle, and smaller parent-daughter vessel angle. CONCLUSION: By studying the morphology of aneurysms and their surrounding vasculature, we identified several parameters associated with ruptured aneurysms that include intrinsic, transitional, and extrinsic factors of cerebral aneurysms and their surrounding vasculature.

Management of carotid artery stenosis in patients with coexistent unruptured intracranial aneurysms

2020 ◽  
Vol 132 (1) ◽  
pp. 94-97 ◽  
Author(s):  
Tiziano Tallarita ◽  
Thomas J. Sorenson ◽  
Lorenzo Rinaldo ◽  
Gustavo S. Oderich ◽  
Thomas C. Bower ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenosis ◽  
Intracranial Aneurysms ◽  
Early Period ◽  
Aneurysm Rupture ◽  
Artery Stenosis ◽  
Consecutive Series ◽  
Carotid Revascularization ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture

OBJECTIVEConcomitant unruptured intracranial aneurysms (UIAs) are present in patients with carotid artery stenosis not infrequently and result in unique management challenges. Thus, we investigated the risk of rupture of an aneurysm after revascularization of a carotid artery in a contemporary consecutive series of patients seen at our institution.METHODSData from patients who underwent a carotid revascularization in the presence of at least one concomitant UIA at our institution from 1991 to 2018 were retrospectively reviewed. Patients were evaluated for the incidence of aneurysm rupture within 30 days (early period) and after 30 days (late period) of carotid revascularization, as well as for the incidence of periprocedural complications from the treatment of carotid stenosis and/or UIA.RESULTSOur study included 53 patients with 63 concomitant UIAs. There was no rupture within 30 days of carotid revascularization. The overall risk of rupture was 0.87% per patient-year. Treatment (coiling or clipping) of a concomitant UIA, if pursued, could be performed successfully after carotid revascularization.CONCLUSIONSCarotid artery revascularization in the setting of a concomitant UIA can be performed safely without an increased 30-day or late-term risk of rupture. If indicated, treatment of the UIA can take place after the patient recovers from the carotid procedure.

Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture

2008 ◽  
Vol 108 (5) ◽  
pp. 1052-1060 ◽  
Author(s):  
Seppo Juvela ◽  
Matti Porras ◽  
Kristiina Poussa
Keyword(s):  
Risk Factors ◽  
Intracranial Aneurysms ◽  
Smoking Status ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Aneurysm Rupture ◽  
Unruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
History Of

Object The authors conducted a study to investigate the long-term natural history of unruptured intracranial aneurysms and the predictive risk factors determining subsequent rupture in a patient population in which surgical selection of cases was not performed. Methods One hundred forty-two patients with 181 unruptured aneurysms were followed from the 1950s until death or the occurrence of subarachnoid hemorrhage or until the years 1997 to 1998. The annual and cumulative incidence of aneurysm rupture as well as several potential risk factors predictive of rupture were studied using life-table analyses and Cox's proportional hazards regression models including time-dependent covariates. The median follow-up time was 19.7 years (range 0.8–38.9 years). During 2575 person-years of follow up, there were 33 first-time episodes of hemorrhage from previously unruptured aneurysms, for an average annual incidence of 1.3%. In 17 patients, hemorrhage led to death. The cumulative rate of bleeding was 10.5% at 10 years, 23% at 20 years, and 30.3% at 30 years after diagnosis. The diameter of the unruptured aneurysm (relative risk [RR] 1.11 per mm in diameter, 95% confidence interval [CI] 1–1.23, p = 0.05) and patient age at diagnosis inversely (RR 0.97 per year, 95% CI 0.93–1, p = 0.05) were significant independent predictors for a subsequent aneurysm rupture after adjustment for sex, hypertension, and aneurysm group. Active smoking status at the time of diagnosis was a significant risk factor for aneurysm rupture (RR 1.46, 95% CI 1.04–2.06, p = 0.033) after adjustment for size of the aneurysm, patient age, sex, presence of hypertension, and aneurysm group. Active smoking status as a time-dependent covariate was an even more significant risk factor for aneurysm rupture (adjusted RR 3.04, 95% CI 1.21–7.66, p = 0.02). Conclusions Cigarette smoking, size of the unruptured intracranial aneurysm, and age, inversely, are important factors determining risk for subsequent aneurysm rupture. The authors conclude that such unruptured aneurysms should be surgically treated regardless of their size and of a patient's smoking status, especially in young and middle-aged adults, if this is technically possible and if the patient's concurrent diseases are not contraindications. Cessation of smoking may also be a good alternative to surgery in older patients with small-sized aneurysms.

scholarly journals Prospective Randomized Open-label Trial to evaluate risk faCTor management in patients with Unruptured intracranial aneurysms: Study protocol

2018 ◽  
Vol 13 (9) ◽  
pp. 992-998 ◽  
Author(s):  
Mervyn DI Vergouwen ◽  
Gabriel JE Rinkel ◽  
Ale Algra ◽  
Jens Fiehler ◽  
Helmuth Steinmetz ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Home Blood Pressure ◽  
Open Label ◽  
Measuring Device ◽  
Risk Factor Management ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
Open Label Trial

Rationale Unruptured intracranial aneurysms are currently left untreated if the presumed complication risk of preventive endovascular or neurosurgical intervention is higher than the risk of rupture. Aneurysm wall inflammation and blood pressure are attractive modifiable risk factors of aneurysm rupture and growth. Aim To investigate in patients with an unruptured intracranial aneurysm who do not qualify for preventive endovascular or neurosurgical intervention whether a treatment strategy of acetylsalicylic acid 100 mg/day plus intensive blood pressure treatment (targeted systolic blood pressure < 120 mmHg, monitored with a home blood pressure measuring device) reduces the risk of aneurysm rupture or growth compared with care as usual (no acetylsalicylic acid, targeted office systolic blood pressure < 140 mmHg, no home blood pressure measuring device). Sample size We aim to randomize 776 patients 1:1 to the intervention arm or care as usual. Design Bi-national (Germany and the Netherlands) multicenter, prospective, randomized, open-label phase III trial with blinded outcome assessment. Outcomes The primary outcome is aneurysm rupture or growth (increase in any aneurysm diameter by ≥ 1 mm) on repeated MR or CT angiography within 36 ± 6 months after randomization. Discussion The Prospective Randomized Open-label Trial to Evaluate risk faCTor management in patients with Unruptured intracranial aneurysms (PROTECT-U) is the first randomized trial to investigate if a medical strategy reduces the risk of rupture or growth of intracranial aneurysms in patients not undergoing preventive endovascular or neurosurgical aneurysm treatment. Clinical trial Registration: NCT03063541.

scholarly journals Outcome of Patients with Multiple Intracranial Aneurysms after Subarachnoid Hemorrhage and Future Risk of Rupture of Unruptured Aneurysm

2021 ◽  
Vol 10 (8) ◽  
pp. 1712
Author(s):  
Seppo Juvela
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Severe Disability ◽  
Rank Test ◽  
Multiple Intracranial Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
Cumulative Rate

The purpose was to study the risk of rupture of unruptured intracranial aneurysms (UIAs) of patients with multiple intracranial aneurysms after subarachnoid hemorrhage (SAH), in a long-term follow-up study, from variables known at baseline. Future rupture risk was compared in relation to outcome after SAH. The series consists of 131 patients with 166 UIAs and 2854 person-years of follow-up between diagnosis of UIA and its rupture, death or the last follow-up contact. These were diagnosed before 1979, when UIAs were not treated in our country. Those patients with a moderate or severe disability after SAH, according to the Glasgow Outcome Scale, had lower rupture rates of UIA than those with a good recovery or minimal disability (4/37 or 11%, annual UIA rupture rate of 0.5% (95% confidence interval (CI) 0.1–1.3%) during 769 follow-up years vs. 27/94 or 29%, 1.3% (95% CI 0.9–1.9%) during 2085 years). Those with a moderate or severe disability differed from others by their older age. Those with a moderate or severe disability tended to have a decreased cumulative rate of aneurysm rupture (log rank test, p = 0.066) and lower relative risk of UIA rupture (hazard ratio 0.39, 95% CI 0.14–1.11, p = 0.077). Multivariable hazard ratios showed at least similar results, suggesting that confounding factors did not have a significant effect on the results. The results of this study without treatment selection of UIAs suggest that patients with a moderate or severe disability after SAH have a relatively low risk of rupture of UIAs. Their lower treatment indication may also be supported by their known higher treatment risks.

scholarly journals The natural history of unruptured intracranial aneurysms

2004 ◽  
Vol 17 (5) ◽  
pp. 1-5 ◽  
Author(s):  
J Mocco ◽  
Ricardo J. Komotar ◽  
Sean D. Lavine ◽  
Philip M. Meyers ◽  
E. Sander Connolly ◽  
...  
Keyword(s):  
Natural History ◽  
Intracranial Aneurysms ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
International Study ◽  
General Rule ◽  
Unruptured Intracranial Aneurysm ◽  
Risk Of Bleeding ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
History Of

Since the publication of preliminary results from the International Study of Unruptured Intracranial Aneurysms in 1998 there has been a great deal of debate concerning the natural history of these lesions and their attendant risk of aneurysmal subarachnoid hemorrhage. Therefore, the authors reviewed a selected number of crucial studies concerning this topic to determine the best evidence-based estimate of a rupture rate for these lesions. Based on this analysis, the yearly risk of bleeding for an unruptured intracranial aneurysm is estimated to be approximately 1% for aneurysms 7 to 10 mm in diameter. This risk of rupture increases with aneurysm size and it likewise diminishes as the size of the lesion decreases. This general rule serves as a reasonable interpretation of the results reported in the current body of literature.

scholarly journals Clinical relevance of short-term follow-up of unruptured intracranial aneurysms

2019 ◽  
Vol 47 (1) ◽  
pp. E7 ◽  
Author(s):  
Rob Molenberg ◽  
Marlien W. Aalbers ◽  
Jan D. M. Metzemaekers ◽  
Aryan Mazuri ◽  
Gert-Jan Luijckx ◽  
...  
Keyword(s):  
Clinical Relevance ◽  
Intracranial Aneurysms ◽  
Significant Risk ◽  
Patient Specific ◽  
Rupture Risk ◽  
Short Term ◽  
Unruptured Intracranial Aneurysms ◽  
Increased Risk ◽  
Risk Of Rupture

OBJECTIVEUnruptured intracranial aneurysms are common incidental findings on brain imaging. Short-term follow-up for conservatively treated aneurysms is routinely performed in most cerebrovascular centers, although its clinical relevance remains unclear. In this study, the authors assessed the extent of growth as well as the rupture risk during short-term follow-up of conservatively treated unruptured intracranial aneurysms. In addition, the influence of patient-specific and aneurysm-specific factors on growth and rupture risk was investigated.METHODSThe authors queried their prospective institutional neurovascular registry to identify patients with unruptured intracranial aneurysms and short-term follow-up imaging, defined as follow-up MRA and/or CTA within 3 months to 2 years after initial diagnosis. Medical records and questionnaires were used to acquire baseline information. The authors measured aneurysm size at baseline and at follow-up to detect growth. Rupture was defined as a CT scan–proven and/or CSF-proven subarachnoid hemorrhage (SAH).RESULTSA total of 206 consecutive patients with 267 conservatively managed unruptured aneurysms underwent short-term follow-up at the authors’ center. Seven aneurysms (2.6%) enlarged during a median follow-up duration of 1 year (range 0.3–2.0 years). One aneurysm (0.4%) ruptured 10 months after initial discovery. Statistically significant risk factors for growth or rupture were autosomal-dominant polycystic kidney disease (RR 8.3, 95% CI 2.0–34.7), aspect ratio > 1.6 or size ratio > 3 (RR 10.8, 95% CI 2.2–52.2), and initial size ≥ 7 mm (RR 10.7, 95% CI 2.7–42.8).CONCLUSIONSSignificant growth of unruptured intracranial aneurysms may occur in a small proportion of patients during short-term follow-up. As aneurysm growth is associated with an increased risk of rupture, the authors advocate that short-term follow-up is clinically relevant and has an important role in reducing the risk of a potential SAH.

scholarly journals Rapid Documented Growth of Aneurysm Bleb Led to Rupture of an Incidental Intracranial Anterior Communicating Artery Aneurysm

2017 ◽  
Vol 78 (05) ◽  
pp. 521-524 ◽  
Author(s):  
Jorn Fierstra ◽  
Giuseppe Esposito ◽  
Gerasimos Baltsavias ◽  
Oliver Bozinov ◽  
Luca Regli ◽  
...  
Keyword(s):  
High Risk ◽  
Artery Aneurysm ◽  
Aneurysm Rupture ◽  
Anterior Communicating Artery ◽  
Rupture Risk ◽  
Short Term ◽  
Anterior Communicating Artery Aneurysm ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture

Background A major challenge in the management of patients with unruptured intracranial aneurysms (UIAs) is to identify criteria indicating a higher risk of future UIA rupture. We report a rare patient with documented short-term bleb growth of an UIA followed by a fatal aneurysm rupture supporting the high risk of rupture of short-term shape changes in UIAs. Case Description A 72-year-old man with an incidental unruptured anterior communicating artery aneurysm of 9 mm showed a bleb growth on the aneurysm sac at 6-week follow-up computed tomography angiography (CTA). Aneurysm treatment was recommended by the interdisciplinary board (PHASES score: 9 points; rupture risk 4.3% in 5 years). The patient wanted to discuss the treatment plan with his family before making a final decision. Two days after the CTA showing bleb growth, he was admitted emergently with a severe subarachnoid hemorrhage (SAH) (World Federation of Neurologic Surgeons grade 5; Fisher 3). The aneurysm was occluded with coils. However, the patient died on day 14 after SAH due to delayed ischemic neurologic deficits and multiple organ failure. Conclusions This case illustrates the high rupture risk of an UIA presenting a documented growth of an aneurysm bleb over a short follow-up time. In retrospect, this patient might have benefited from emergent aneurysm occlusion. The interest of this report comes from the proof that aneurysmal bleb growth constitutes a high risk for short-term aneurysm rupture.

Results of watchful waiting of unruptured intracranial aneurysms in a Western patient population: a single-center cohort

2021 ◽  
pp. neurintsurg-2021-018151
Author(s):  
Mathilde Aubertin ◽  
Clément Jourdaine ◽  
Cédric Thépenier ◽  
Marc-Antoine Labeyrie ◽  
Vittorio Civelli ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Watchful Waiting ◽  
Single Center ◽  
Anterior Circulation ◽  
Patient Decision ◽  
Radiological Data ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
History Of

BackgroundThe natural history of unruptured intracranial aneurysms (UIAs) in Western populations is still debated, especially for those <7 mm. Reporting data of a large single-center cohort managed with watchful waiting is therefore interesting.MethodsFrom January 2011 to June 2019, 662 UIAs were followed up by yearly MR angiography. Morphologically stable UIAs were managed conservatively while unstable UIAs were offered treatment. The patients’ clinical and radiological data were analyzed retrospectively.ResultsUIAs were ≤4 mm in 60%, 4.1–7.0 mm in 33%, and >7 mm in 7%. They were located on the anterior circulation in 90% of cases. The mean follow-up duration was 51.32 months for a total of 2831 aneurysm-years. During follow-up, 37 UIAs (5.5%) were treated because of an increase in size, and 8 UIAs were treated because of patient decision. Three aneurysms ruptured during follow-up for an annual risk of rupture of 0.1% (95% CI 0% to 0.24%). No risk factors for rupture were identified. The three ruptured cases made an excellent recovery. During follow-up, annual mortality from unrelated causes was 0.8% (95% CI 0.51% to 1.18%).ConclusionsThis single-center cohort evaluated our watchful waiting policy applied in two-thirds of all incidental UIAs. Morphological change of UIAs during follow-up led to treatment in 5.5% of cases. With such a management paradigm, we found a low rupture rate in these selected UIAs and the mortality was unrelated to aneurysms.

scholarly journals Management of incidentally found unruptured intracranial aneurysms

2020 ◽  
Vol 63 (5) ◽  
pp. 267-274
Author(s):  
Won-Sang Cho ◽  
Sung Ho Lee ◽  
Hyun-Seung Kang ◽  
Jeong Eun Kim
Keyword(s):  
Health Insurance ◽  
Intracranial Aneurysms ◽  
Treatment Techniques ◽  
Foreign Countries ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture ◽  
History Of ◽  
Treatment Plans ◽  
Prospective Trials ◽  
Cerebrovascular Imaging

Incidentally found unruptured intracranial aneurysms are increasing because of the popularity of medical checkups with cerebrovascular imaging and the recent growing interest in health. Accordingly, surgical or endovascular treatments are also increasing in prevalence to improve aneurysm-related symptoms or prevent the rupture of aneurysms causing devastating conditions. However, treatment plans should be carefully determined based on the natural history of aneurysms, comorbidities of the patients, and institutional situations because of the relatively low risk of rupture, no uncommon treatment-related complications, and considerable economical and psychological burdens. Recently, domestic and international clinical guidelines for unruptured intracranial aneurysms were introduced, and the guidelines have been continuously revised according to advancements in imaging and treatment techniques. Here, this review paper introduces the clinical characteristics of unruptured intracranial aneurysms including the epidemiology, risk factors of development, growth and rupture, natural course, symptoms and signs, imaging tools for diagnosis and follow-up, and treatment methods. This paper also includes recent international prospective trials, analytic reports with big data from national health insurance and health insurance review and assessment services, and the guidelines of Korea and other foreign countries.

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