Factors influencing management of unruptured intracranial aneurysms: an analysis of 424 consecutive patients

OBJECTIVEThe choice between treating and observing unruptured intracranial aneurysms is often difficult, with little guidance on which variables should influence decision making on a patient-by-patient basis. Here, the authors compared demographic variables, aneurysm-related variables, and comorbidities in patients who received microsurgical or endovascular treatment and those who were conservatively managed to determine which factors push the surgeon toward recommending treatment.METHODSA retrospective chart review was conducted of all patients diagnosed with an unruptured intracranial aneurysm at their institution between January 1, 2013, and January 1, 2016. These patients were dichotomized based on whether their aneurysm was treated. Demographic, geographic, socioeconomic, comorbidity, and aneurysm-related information was analyzed to assess which factors were associated with the decision to treat.RESULTSA total of 424 patients were identified, 163 who were treated surgically or endovascularly and 261 who were managed conservatively. In a multivariable model, an age < 65 years (OR 2.913, 95% CI 1.298–6.541, p = 0.010), a lower Charlson Comorbidity Index (OR 1.536, 95% CI 1.274–1.855, p < 0.001), a larger aneurysm size (OR 1.176, 95% CI 1.100–1.257, p < 0.001), multiple aneurysms (OR 2.093, 95% CI 1.121–3.907, p = 0.020), a white race (OR 2.288, 95% CI 1.245–4.204, p = 0.008), and living further from the medical center (OR 2.125, 95% CI 1.281–3.522, p = 0.003) were all associated with the decision to treat rather than observe.CONCLUSIONSWhereas several factors were expected to be considered in the decision to treat unruptured intracranial aneurysms, including age, Charlson Comorbidity Index, aneurysm size, and multiple aneurysms, other factors such as race and proximity to the medical center were unanticipated. Further studies are needed to identify such biases in patient treatment and improve treatment delineation based on patient-specific aneurysm rupture risk.

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2D and 3D Morphologic Metrics Associated Intracranial Aneurysm Rupture

ASME 2010 Summer Bioengineering Conference, Parts A and B ◽

10.1115/sbc2010-19633 ◽

2010 ◽

Author(s):

Ding Ma ◽

Sabareesh K. Natarajan ◽

Jianping Xiang ◽

Adnan Siddiqui ◽

Elad I. Levy ◽

...

Keyword(s):

Image Segmentation ◽

Intracranial Aneurysms ◽

Vessel Diameter ◽

Aneurysm Rupture ◽

Size Ratio ◽

Patient Specific ◽

3D Image ◽

Parent Vessel ◽

3D Image Segmentation ◽

Aneurysm Size

Intracranial aneurysms (IAs) rupture results in severe morbidity and mortality. Therefore indentifying IA rupture risk is highly critical. Although it has been recognized that IA rupture is the result of a complex vascular degeneration process involving multiple mechanobiological factors, such information for each patient is not readily available in clinical setting. Alternatively, morphology and hemodynamic metrics can be derived from routine patient-specific imaging. In previous studies, a number of morphological metrics derived from analysis of reconstructed vascular 3D geometry have shown significance in discriminating ruptured from unruptued IAs, including in particular aneurysm size ratio, defined as IA size divided by the parent vessel diameter. However, these measures rely on 3D image segmentation and measurement, which makes them less practical in current angiographic rooms often equipped with only biplane angiogram capability and even when 3D rotational angiography is available, on-site 3D image segmentation and analyses are still not practical. Our foregoing study examined three parameters measured on 2D angiographs: aneurysm Size Ratio (SR), Aspect Ratio (AR) and Size. We found that SR had the strongest correlation with IA rupture. The current study further evaluates these geometric metrics, measured both from 3D and 2D images, with a larger cohort of saccular intracranial aneurysms.

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Abstract WP87: Endovascular Treatment of Very Small Ruptured Intracranial Aneurysms: Complications, Occlusion Rates and Prediction of Outcome

Stroke ◽

10.1161/str.44.suppl_1.awp87 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Robert M Starke ◽

Nohra Chalouhi ◽

Muhammad S Ali ◽

David L Penn ◽

Stavropoula I Tjoumakaris ◽

...

Keyword(s):

Multivariate Analysis ◽

Endovascular Treatment ◽

Endovascular Therapy ◽

Intracranial Aneurysms ◽

Aneurysm Rupture ◽

Post Treatment ◽

Favorable Outcome ◽

Predictors Of Outcome ◽

Aneurysm Size ◽

Ruptured Intracranial Aneurysms

Purpose: In this study we assess predictors of outcome following endovascular treatment of small ruptured intracranial aneurysms (SRA). Methods: Between 2004 and 2011, 91 patients with SRA (≤ 3 mm) were treated at our institution. Multivariate analysis was carried out to assess predictors of endovascular related complications, aneurysm obliteration (>95%), recanalization, and favorable outcome (Glasgow Outcome Scale 3-5). Results: Endovascular treatment was aborted in 9 of 91 patients (9.9%). Procedure-related complications occurred in 8 of 82 patients (9.8%) of which 5 were transient and 3 were permanent. Three patients (3.7%) undergoing endovascular therapy experienced an intra-procedural aneurysm rupture. Three of 9 patients (33.3%) treated with stent or balloon assisted coiling experienced peri-procedural complications compared to 5 of 73 patients (6.8%) receiving only coils or Onyx (p=0.039). There were no procedural deaths or rehemorrhages. Rates of recanalization and retreatment were 18.2% and 12.7%, respectively. No factors predicted initial occlusion or recanalization. In multivariate analysis pre-treatment factors predictive of favorable outcome included younger age (OR=0.94; 95% CI 0.91-0.99, p=0.017), larger aneurysm size (OR=3.4; 95% CI 1.02-11.11, p=0.045), Hunt and Hess grade (OR=0.38; 95% CI 0.19-0.75, p=0.005), and location (OR=5.12; 95% CI 1.29-20.25, p=0.02). When assessing treatment and post-treatment variables, vasospasm was the only additional covariate predictive of poor outcome (OR=5.90; 95% CI 1.34=25.93, p=0.019). Conclusions: The majority of SRA can be treated with endovascular therapy and limited complications. Overall predictors of outcome for patients undergoing endovascular treatment of SRA include age, aneurysm size, Hunt and Hess grade, location, and post-treatment vasospasm.

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Increased rupture risk in small intracranial aneurysms associated with methamphetamine use

Interventional Neuroradiology ◽

10.1177/1591019920959534 ◽

2020 ◽

pp. 159101992095953

Author(s):

Dylan Noblett ◽

Lotfi Hacein-Bey ◽

Ben Waldau ◽

Jordan Ziegler ◽

Brian Dahlin ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Significant Risk ◽

Retrospective Chart Review ◽

Anterior Circulation ◽

Unruptured Aneurysms ◽

Methamphetamine Use ◽

Aneurysm Size ◽

Unruptured Intracranial Aneurysms ◽

History Of

Background Aneurysmal subarachnoid hemorrhage (SAH) is the most common cause of nontraumatic SAH. Current guidelines generally recommend observation for unruptured intracranial aneurysms smaller than 7 mm, for those are considered at low risk for spontaneous rupture according to available scoring systems. Objective We observed a tendency for SAH in small intracranial aneurysms in patients who are methamphetamine users. A retrospective, single center study to characterize the size and location of ruptured and unruptured intracranial aneurysms in methamphetamine users was performed. Materials and methods Clinical characteristics and patient data were collected via retrospective chart review of patients with intracranial aneurysms and a history of methamphetamine use with a specific focus on aneurysm size and location. Results A total of 62 patients were identified with at least one intracranial aneurysm and a history of methamphetamine use, yielding 73 intracranial aneurysms (n = 73). The mean largest diameter of unruptured aneurysms (n = 44) was 5.1 mm (median 4.5, SD 2.5 mm), smaller than for ruptured aneurysms (n = 29) with a mean diameter of 6.3 mm (median 5.5, SD 2.5 mm). Aneurysms measuring less than 7 mm presented with SAH in 36.5%. With regard to location, 28% (n = 42) of anterior circulation aneurysms less than 7 mm presented with rupture, in contrast to 70% (n = 10) of posterior circulation aneurysms which were found to be ruptured. Conclusions Methamphetamine use may be considered a significant risk factor for aneurysmal SAH at a smaller aneurysm size than for other patients. These patients may benefit from a lower threshold for intervention and/or aggressive imaging and clinical follow-up.

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

Journal of Neurosurgery ◽

10.3171/2018.9.jns182155 ◽

2020 ◽

Vol 132 (1) ◽

pp. 94-97 ◽

Cited By ~ 2

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.

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Flow-induced, inflammation-mediated arterial wall remodeling in the formation and progression of intracranial aneurysms

Neurosurgical FOCUS ◽

10.3171/2019.5.focus19234 ◽

2019 ◽

Vol 47 (1) ◽

pp. E21 ◽

Cited By ~ 25

Author(s):

Juhana Frösen ◽

Juan Cebral ◽

Anne M. Robertson ◽

Tomohiro Aoki

Keyword(s):

Drug Therapy ◽

Intracranial Aneurysms ◽

Arterial Wall ◽

Macrophage Infiltration ◽

Patient Specific ◽

Diagnostic Tools ◽

Flow Conditions ◽

Internal Elastic Lamina ◽

Specific Flow ◽

Unruptured Intracranial Aneurysms

OBJECTIVEUnruptured intracranial aneurysms (UIAs) are relatively common lesions that may cause devastating intracranial hemorrhage, thus producing considerable suffering and anxiety in those affected by the disease or an increased likelihood of developing it. Advances in the knowledge of the pathobiology behind intracranial aneurysm (IA) formation, progression, and rupture have led to preclinical testing of drug therapies that would prevent IA formation or progression. In parallel, novel biologically based diagnostic tools to estimate rupture risk are approaching clinical use. Arterial wall remodeling, triggered by flow and intramural stresses and mediated by inflammation, is relevant to both.METHODSThis review discusses the basis of flow-driven vessel remodeling and translates that knowledge to the observations made on the mechanisms of IA initiation and progression on studies using animal models of induced IA formation, study of human IA tissue samples, and study of patient-derived computational fluid dynamics models.RESULTSBlood flow conditions leading to high wall shear stress (WSS) activate proinflammatory signaling in endothelial cells that recruits macrophages to the site exposed to high WSS, especially through macrophage chemoattractant protein 1 (MCP1). This macrophage infiltration leads to protease expression, which disrupts the internal elastic lamina and collagen matrix, leading to focal outward bulging of the wall and IA initiation. For the IA to grow, collagen remodeling and smooth muscle cell (SMC) proliferation are essential, because the fact that collagen does not distend much prevents the passive dilation of a focal weakness to a sizable IA. Chronic macrophage infiltration of the IA wall promotes this SMC-mediated growth and is a potential target for drug therapy. Once the IA wall grows, it is subjected to changes in wall tension and flow conditions as a result of the change in geometry and has to remodel accordingly to avoid rupture. Flow affects this remodeling process.CONCLUSIONSFlow triggers an inflammatory reaction that predisposes the arterial wall to IA initiation and growth and affects the associated remodeling of the UIA wall. This chronic inflammation is a putative target for drug therapy that would stabilize UIAs or prevent UIA formation. Moreover, once this coupling between IA wall remodeling and flow is understood, data from patient-specific flow models can be gathered as part of the diagnostic workup and utilized to improve risk assessment for UIA initiation, progression, and eventual rupture.

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Estimating the annual rate of de novo multiple aneurysms: three statistical approaches

Neurosurgical FOCUS ◽

10.3171/foc.2004.17.5.8 ◽

2004 ◽

Vol 17 (5) ◽

pp. 1-8 ◽

Cited By ~ 3

Author(s):

James Ju Yong Cheong ◽

Narcyz Ghinea ◽

James M. van Gelder

Keyword(s):

Intracranial Aneurysms ◽

De Novo ◽

Annual Rate ◽

Rate Of Development ◽

Multiple Intracranial Aneurysms ◽

Multiple Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

Study Heterogeneity ◽

Age Stratification

Object Individuals with unruptured intracranial aneurysms experience a higher rate of rupture if their history includes another aneurysm that has previously bled. The authors used systematic review and metaregression to estimate the annual rate of development of second de novo aneurysms after subarachnoid hemorrhage. Methods This investigation included studies in which more than 300 patients with intracranial aneurysms were described, and in which the age of the patients and the proportion with multiple aneurysms were documented. Studies describing delayed follow-up angiography that was performed after treatment of aneurysms were also reviewed. Twenty studies were included in a between-study analysis. The univariate odds ratio (OR) for multiple intracranial aneurysms per year of age was 1.085 (95% confidence interval [CI] 1.015–1.165); this value was calculated using a hierarchical model for between-study heterogeneity. Five studies were included that provided age stratification. The estimated OR for multiple intracranial aneurysms per year was 1.011 (95% CI 1.005–1.018). Four follow-up studies were available. Conclusions According to the three different approaches (study-level, patient-level, and follow-up analyses), the estimated annual rates of development of de novo aneurysms were 1.62% (95% CI 0.28–3.59%), 0.28% (95% CI 0.12–0.49%), and 0.92% (95% CI 0.64–1.25%), respectively. The estimated annual rate of development of second de novo aneurysms ranged from 0.28 to 1.62%.

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

Journal of Neurosurgery ◽

10.3171/jns/2008/108/5/1052 ◽

2008 ◽

Vol 108 (5) ◽

pp. 1052-1060 ◽

Cited By ~ 105

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.

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Role of apoptosis in intracranial aneurysm rupture

Journal of Neurosurgery ◽

10.3171/jns.2004.101.6.1018 ◽

2004 ◽

Vol 101 (6) ◽

pp. 1018-1025 ◽

Cited By ~ 51

Author(s):

Luigi Pentimalli ◽

Andrea Modesti ◽

Andrea Vignati ◽

Enrico Marchese ◽

Alessio Albanese ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Superficial Temporal Artery ◽

Aneurysm Rupture ◽

Terminal Deoxynucleotidyl Transferase ◽

Content Type ◽

Unruptured Aneurysms ◽

Ruptured Aneurysms ◽

Aneurysm Wall ◽

Unruptured Intracranial Aneurysms ◽

Fine Print

Object. Mechanisms involved in the rupture of intracranial aneurysms remain unclear, and the literature on apoptosis in these lesions is extremely limited. The hypothesis that apoptosis may reduce aneurysm wall resistance, thus contributing to its rupture, warrants investigation. The authors in this study focused on the comparative evaluation of apoptosis in ruptured and unruptured intracranial aneurysms. Peripheral arteries in patients harboring the aneurysms and in a group of controls were also analyzed. Methods. Between September 1999 and February 2002, specimens from 27 intracranial aneurysms were studied. In 13 of these patients apoptosis was also evaluated in specimens of the middle meningeal artery (MMA) and the superficial temporal artery (STA). The terminal deoxynucleotidyl transferase—mediated deoxyuridine triphosphate nick-end labeling technique was used to study apoptosis via optical microscopy; electron microscopy evaluation was performed as well. Apoptotic cell levels were related to patient age and sex, aneurysm volume and shape, and surgical timing. Significant differences in apoptosis were observed when comparing ruptured and unruptured aneurysms. High levels of apoptosis were found in 88% of ruptured aneurysms and in only 10% of unruptured lesions (p < 0.001). Elevated apoptosis levels were also detected in all MMA and STA specimens obtained in patients harboring ruptured aneurysms, whereas absent or very low apoptosis levels were observed in MMA and STA specimens from patients with unruptured aneurysms. A significant correlation between aneurysm shape and apoptosis was found. Conclusions. In this series, aneurysm rupture appeared to be more related to elevated apoptosis levels than to the volume of the aneurysm sac. Data in this study could open the field to investigations clarifying the causes of aneurysm enlargement and rupture.

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