Therapeutic Strategy for Unruptured Cerebral Aneurysms. Strategy for Unruptured Intracranial Aneurysms and Rupture Rate of Previously Unruptured Aneurysms in Japan.

BackgroundExperience with the endovascular treatment of unruptured small intracranial aneurysms by flow diverter devices is still limited.ObjectiveTo assess the safety and efficacy of the SILK flow diverter (SFD) in the treatment of small unruptured cerebral aneurysms (<10 mm).MethodsWe performed a retrospective review of a prospectively maintained database of patients treated with a SFD between July 2008 and December 2013 at 4 institutions in Spain to identify all patients with small unruptured aneurysms (<10 mm). Data for patient demographics, aneurysm characteristics, and technical procedures were analyzed. Angiographic and clinical findings were recorded during the procedure and at 6- and 12-month follow-ups.ResultsA total of 109 small aneurysms were treated with a SFD in 104 patients (78 women; 26 men; mean, median, and range of age: 55.2, 57.1, and 19–80 years, respectively). A total of 60 patients were asymptomatic (57.7%). All except 7 aneurysms (6.4%) arose from the anterior circulation. The mean size of the aneurysms was 4.7±1.9 mm. At 6 months, the neuromorbidity and neuromortality rates were 2.9% and 0.9%, respectively. Imaging at the 12-month follow-up showed complete occlusion, neck remnants, and residual aneurysm in 88.5% (69/78), 7.7% (6/78), and 3.3% (3/78) of cases, respectively. No delayed hemorrhage occurred.ConclusionsThe findings suggest that the indications for SFD can be safely extended to small intracranial aneurysms.

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The incidence and treatment of asymptomatic, unruptured cerebral aneurysms

Journal of Neurosurgery ◽

10.3171/jns.1994.80.2.0217 ◽

1994 ◽

Vol 80 (2) ◽

pp. 217-223 ◽

Cited By ~ 170

Author(s):

Toshio Nakagawa ◽

Kazuo Hashi

Keyword(s):

Early Detection ◽

Internal Carotid ◽

Cerebral Aneurysms ◽

Maximum Diameter ◽

Anterior Communicating Artery ◽

Content Type ◽

Unruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

History Of ◽

Unruptured Cerebral Aneurysms

✓ The importance of early detection by various radiological techniques of asymptomatic, unruptured aneurysms as a means of preventing subarachnoid hemorrhage (SAH) is discussed in this report. Four hundred volunteers underwent clinical and radiological evaluations between March, 1988, and September, 1992. Studies included a neurological examination as well as digital subtraction cerebral angiography via a femoral arterial catheter, computerized tomography, T1- and T2-weighted magnetic resonance (MR) imaging of the whole brain, and MR angiography. The evaluation revealed 27 asymptomatic, unruptured intracranial aneurysms in 26 volunteers, for an incidence of 6.5%. The subjects ranged in age from 39 to 71 years, with an average of 55 years. The aneurysms were located on the internal carotid artery in 13 cases (48%), the anterior communicating artery in six (22%), the middle cerebral artery in six (22%), and the basilar artery in two (7%). Aneurysms ranged in size from 5 mm or less in 16 cases, 6 to 10 mm in nine, and 11 to 15 mm in one; one aneurysm was more than 15 mm, with a maximum diameter of 2 cm. Volunteers with a family history of SAH within the second degree of consanguinity showed a higher incidence of aneurysms (17.9%). Aneurysm clipping was performed on 20 of the 26 cases with no significant morbidity or mortality. These findings support the contention that aggressive early detection of unruptured aneurysms may improve the outcome in patients harboring cerebral aneurysms by preventing the devastating effects of SAH.

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Treatment of Asymptomatic Unruptured Intracranial Aneurysms

Interventional Neuroradiology ◽

10.1177/15910199010070s109 ◽

2001 ◽

Vol 7 (1_suppl) ◽

pp. 61-64

Author(s):

S. Hirai ◽

J. Ono ◽

M. Odaki ◽

T. Serizawa ◽

M. Sato ◽

...

Keyword(s):

Decision Analysis ◽

Conservative Management ◽

Intracranial Aneurysms ◽

Clinical Decision ◽

Systemic Complications ◽

Unruptured Aneurysms ◽

Rupture Rate ◽

Preventive Surgery ◽

Unruptured Intracranial Aneurysms ◽

Risk Of Rupture

The indication of preventive surgery for patients who harbor asymptomatic unruptured intracranial aneurysms remains controversial. To evaluate the benefit of this treatment, we investigated the management outcome in 128 patients with 157 unruptured aneurysms. Surgery was planned in patients 70 years old or younger without serious systemic complications. A total of 77 patients underwent surgery including four endovascular interventions, and conservative management was chosen in 51 patients. There was no mortality and 6.5% morbidity as postoperative results, and no complication was found after endovascular treatment. Among the patients in conservative management, four patients suffered from subsequent rupture during the total follow-up period of 148 person-years. The annual rupture rate was estimated at 2.7%. According to the clinical decision analysis based on our data, preventive surgery is beneficial for a Japanese 70 years old or younger. However, the expected utility decreases if the rupture rate is set at 0.5% or 0.05%, posing a doubt about the benefit of the surgery. Decision analysis provides an aid for logical and objective choice in the management of unruptured aneurysms. The actual risk of rupture has a major impact on decision making in therapeutic strategy.

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Natural history and general management of unruptured intracranial aneurysms

Neurosurgical FOCUS ◽

10.3171/foc.2004.17.5.1 ◽

2004 ◽

Vol 17 (5) ◽

pp. 1-6 ◽

Cited By ~ 6

Author(s):

Peng Roc Chen ◽

Kai Frerichs ◽

Robert Spetzler

Keyword(s):

Natural History ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Aneurysms ◽

Population Based ◽

Unruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Risk Of Rupture ◽

History Of ◽

Unruptured Cerebral Aneurysms ◽

Noninvasive Neuroimaging

After an aneurysmal subarachnoid hemorrhage, nearly half of the patients die and the half who survive suffer from irreversible cerebral damage. With increasing use of noninvasive neuroimaging techniques (for example, magnetic resonance and computerized tomography angiography), more unruptured cerebral aneurysms are found. To understand the prevalence of unruptured aneurysms in the general population, along with the risks of aneurysm formation, data on growth and rupture rates are crucial. The risk of rupture in aneurysms smaller than 10 mm is still not quite clear without a population-based prospective study. Nevertheless, a 0.5 to 2% annual risk may be a reasonable estimate. Growing aneurysms and those larger than 10 mm carry a higher rate of rupture. The management of an unruptured intracranial aneurysm should be based on a thorough understanding of the natural history of these lesions and careful evaluation of the morbidity and mortality levels associated with each treatment option.

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Treatment Results of Endosaccular Coil Embolization of Asymptomatic Unruptured Intracranial Aneurysms(Horizons of Treatment for Unruptured Cerebral Aneurysms)

Japanese Journal of Neurosurgery ◽

10.7887/jcns.20.499 ◽

2011 ◽

Vol 20 (7) ◽

pp. 499-505

Author(s):

Hidenori Oishi ◽

Hajime Arai

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Cerebral Aneurysms ◽

Special Issue ◽

Treatment Results ◽

Unruptured Intracranial Aneurysms ◽

Unruptured Cerebral Aneurysms

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Simulation of the natural history of cerebral aneurysms based on data from the International Study of Unruptured Intracranial Aneurysms

Journal of Neurosurgery ◽

10.3171/jns.2006.104.2.188 ◽

2006 ◽

Vol 104 (2) ◽

pp. 188-194 ◽

Cited By ~ 34

Author(s):

Han Soo Chang

Keyword(s):

Natural History ◽

Intracranial Aneurysms ◽

Cerebral Aneurysms ◽

International Study ◽

Medical Decision ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Median Diameter ◽

History Of

Object Despite recent publications of large-scale study data, controversy over the management of unruptured cerebral aneurysms continues. The low rupture rates in the International Study of Unruptured Intracranial Aneurysms (ISUIA) apparently contradicted surgeons’ experiences with ruptured aneurysms. In the present study, based on data from the ISUIA, a mathematical model describing the natural history of cerebral aneurysms was developed. With this model, the author aimed to examine the validity of data from the ISUIA and to provide a better treatment guideline for unruptured aneurysms. Methods The author made a computer simulation of the natural history of cerebral aneurysms that was used to calculate such figures as the prevalence of unruptured aneurysms, incidence of subarachnoid hemorrhage (SAH), and age and size distribution of both unruptured and ruptured aneurysms. The lifetime lesion rupture probability for individual patients with various ages and aneurysm sizes was also computed, thereby providing a useful index to help patients in the medical decision-making process. The computer model produced a sample of unruptured aneurysms in the general population with a prevalence of 4.2% and a median diameter of 5.8 mm. These unruptured aneurysms—affected by the rupture rate reported in the ISUIA—had a yearly SAH incidence of 19.6 per 100,000 persons. The median diameter of these aneurysms was 9.4 mm. Conclusions Findings in the present study validated the results of the ISUIA by showing that the seemingly low rupture rates could explain the statistical data for ruptured aneurysms. With the featured model, the author calculated the lifetime probability of lesion rupture—a useful measure for deciding on the optimal treatment for unruptured aneurysms.

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Risk Profile of Intracranial Aneurysms

Stroke ◽

10.1161/strokeaha.111.625871 ◽

2011 ◽

Vol 42 (12) ◽

pp. 3376-3381 ◽

Cited By ~ 36

Author(s):

Koji Sato ◽

Yuhei Yoshimoto

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

Healing Process ◽

Age Distribution ◽

Unruptured Aneurysms ◽

Portal Site ◽

Rupture Rate ◽

Unruptured Intracranial Aneurysms ◽

Short Period ◽

History Of

Background and Purpose— Management of asymptomatic unruptured intracranial aneurysms remains controversial, and recent prospective follow-up studies showed that the rupture rate of small aneurysms is very low. These results are inconsistent with the finding that the majority of ruptured aneurysms in patients with subarachnoid hemorrhage are small. Methods— A Markov model was constructed to simulate the natural history of intracranial aneurysms. All epidemiological and statistical data obtained from the Portal Site of Official Statistics of Japan (e-Stat) were adjusted to the standardized age distribution. From the selected data of aneurysm formation, the prevalence of unruptured aneurysms was estimated as 1.45% and the incidence of subarachnoid hemorrhage calculated to be 19.7/100 000/year in the whole standardized population. Results— The function for rupture rate constant with time was first analyzed. Selected values for annual rupture rates of 0.3%, 0.5%, 0.7%, and 1.0% showed inconsistencies in the relationship between the prevalence of unruptured aneurysm and the incidence of subarachnoid hemorrhage. Next, the function for a short period of high risk followed by a long period of low risk was considered. Annual rupture rates of 0.5%, 0.7%, and 1.0% indicated epidemiological compatibility with additional early rupture rates of 20%, 15%, and 10%, respectively. Conclusions— This study suggests that some aneurysms bleed shortly after formation and thus are rarely detected as unruptured aneurysms. Most aneurysms without early rupture remain stable for the remainder of life through some healing process, and prophylactic treatment for incidentally identified small unruptured aneurysms has no rationale.

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Evaluation of the Accero Stent for Stent-Assisted Coiling of Unruptured Wide-Necked Intracranial Aneurysm Treatment with Short-Term Follow-Up

Journal of Clinical Medicine ◽

10.3390/jcm9092808 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2808

Author(s):

Wojciech Poncyljusz ◽

Kinga Kubiak ◽

Leszek Sagan ◽

Bartosz Limanówka ◽

Katarzyna Kołaczyk

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

Clinical Results ◽

Class I ◽

Unruptured Aneurysms ◽

Patient Demographics ◽

Stent Deformation ◽

Unruptured Intracranial Aneurysms ◽

Occlusion Rate

Background: Stent-assisted coiling is an effective method of treating intracranial aneurysms. The aim of the study was to assess the safety and efficacy of the new Accero stent for the treatment of intracranial aneurysms. Materials and Methods: It was a retrospective, single-center study. Eighteen unruptured intracranial aneurysms were treated using the stent-assisted coiling method with the Accero stent. Patient demographics, aneurysm characteristics, procedural parameters, grade of occlusion, complications, and clinical results were analyzed. Follow-up magnetic resonance (MR) was performed 6 months after intervention. Results: Seventeen patients with 18 incidental unruptured aneurysms were electively treated with coiling and the Accero stent. The aneurysms were located on internal carotid artery (ICA), middle cerebral artery (MCA) and basilar artery (BA). All stents were deployed successfully. Immediate complete occlusion rate Raymond-Roy occlusion classification (RROC) class I was achieved in 13 cases and class II in 4 cases. Complications occurred in 2/17 treatments and included guidewire stent perforation with subarachnoid hemorrhage (SAH) and stent deformation. Vascular spasm in the subarachnoid hemorrhage (SAH) patient subsided before discharge. Ninety days after intervention, the modified Rankin Scale (mRS) value was 0. RROC class I was observed in 88.23% of cases in follow-up. Conclusion: The Accero stent provides excellent support for coil mass. It constitutes an efficacious device with good initial occlusion rate for treating wide-necked unruptured intracranial aneurysms.

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Peri-Procedural Morbidity and Mortality Associated with Stent-Assisted Coiling for Intracranial Aneurysms

Interventional Neuroradiology ◽

10.1177/159101991301900106 ◽

2013 ◽

Vol 19 (1) ◽

pp. 43-48 ◽

Cited By ~ 10

Author(s):

K. Wang ◽

Y. Sun ◽

A-M. Li

Keyword(s):

Intracranial Aneurysms ◽

Cerebral Aneurysms ◽

Mortality Rates ◽

Stent Migration ◽

Aneurysm Rupture ◽

Morbidity And Mortality ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Attractive Option ◽

Technological Improvements

Despite experience and technological improvements, stent-assisted coiling for intracranial aneurysms still has inherent risks. We evaluated peri-procedural morbidity and mortality associated with stent-assisted coiling for intracranial aneurysms. Patients with cerebral aneurysms that were broad-based (>4 mm) or had unfavorable dome/neck ratios (<1.5) were enrolled in this study between February and November 2011 at our center. Aneurysms were treated with the self-expanding neurovascular stents with adjunctive coil embolization. Seventy-two consecutive patients (27 men and 45 women; 22–78 years of age; mean age, 52.8 years) underwent 13 procedures for 13 ruptured aneurysms and 64 procedures for 73 unruptured aneurysms. Nine [11.7%, 95% CI(4.5%–18.9%)] procedure-related complications occurred: one and eight with initial embolization of ruptured and unruptured aneurysms, respectively. Complications included six acute in-stent thromboses, one spontaneous stent migration, one post-procedural aneurysm rupture, and one perforator occlusion. Three complications had no neurologic consequences. Two caused transient neurologic morbidity, two persistent neurologic morbidity, and two death. Procedure-related neurologic morbidity and mortality rates, respectively, were as follows: overall, 5.2% (95%CI, 0.2%–10.2%) and 2.6% (95%CI, 0%–6.2%); ruptured aneurysms, 7.7% (95%CI, 0%–36%) and 0% (95%CI, 0%–25%); unruptured aneurysms, 4.7% (95%CI, 0%–9.9%) and 3.1% (95%CI, 0%–7.3%). Combined procedure-related morbidity and mortality rates for ruptured and unruptured aneurysms were 7.7% (95%CI, 1.7%–13.7%) and 7.8% (95%CI, 1.8%–13.8%), respectively. Stent-assisted coiling is an attractive option for intracranial aneurysms. However, stent-assisted coiling for unruptured aneurysms is controversial for its comparable risk to natural history.

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Abstract 1122‐000145: Impact of Age on Outcomes Following Endovascular vs Clipping of Ruptured and Unruptured Cerebral Aneurysms

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000145 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Hamidreza Saber ◽

Naoki Kaneko ◽

David Kimball ◽

Jose Morales ◽

Satoshi Tateshima ◽

...

Keyword(s):

Hospital Mortality ◽

Endovascular Therapy ◽

Age Groups ◽

Cerebral Aneurysms ◽

Unruptured Aneurysm ◽

Favorable Outcome ◽

Hospital Length Of Stay ◽

Surgical Clipping ◽

Unruptured Aneurysms ◽

Unruptured Cerebral Aneurysms

Introduction : Age is an important determinant of outcome in patients with unruptured or ruptured cerebral aneurysms. Advancements in endovascular therapies have significantly impacted patient selection and treatment of patients with cerebral aneurysm. Recent release of the National claims data for 2017–2018 provides the opportunity to explore novel population‐level outcomes following clipping vs endovascular treatment of ruptured and unruptured cerebral aneurysms in different age groups. Methods : Analysis of US National Inpatient Sample of hospitalizations with aneurysmal subarachnoid hemorrhage (aSAH) or unruptured aneurysms treated with clipping or endovascular therapy from January 1, 2017 to December 31, 2018. Pre‐defined age strata included: younger than 50 years; 50–64 years; 65–79 years; and 80 years or older. Primary outcomes included in‐hospital mortality and favorable outcome defined as discharge to home. Results : Overall, 34,955 hospitalizations with unruptured aneurysm treatment, (26,695 endovascular and 8,260 surgical clipping), and 17,525 hospitalizations with aSAH were identified in the study period. In unruptured aneurysm group, endovascular therapy was associated with significantly higher favorable outcome across all age groups, and lower mortality in those 65 years or older (all P<0.001) when compared to clipping. Median hospital length‐of‐stay was 1 day (IQR 1–4) in endovascular vs 4 days (IQR 3–8) in clipping group (P<0.001). In aSAH group, endovascular therapy was associated with higher favorable outcome in 50–80 years age groups when compared to clipping, with no significant differences for in‐hospital mortality outcome (Table). Significantly more favorable outcomes were achieved with coiling vs clipping in those aged 65 or above with unruptured aneurysms. Conclusions : In 2017–2018 in US, unruptured aneurysm patients treated with endovascular therapy had significantly lower morbidity and mortality compared to those treated with surgical clipping, and differences were more pronounced with age. Similar but less strong association was observed in patients with aSAH.

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