Recommendations for the management of patients with unruptured intracranial aneurysms: A Statement for healthcare professionals from the Stroke Council of the American Heart Association

Magnetic resonance angiography of the circle of Willis in patients with symptomatic intracranial neuropathology: medicare LCD L25367(R4)

Patients with symptomatic intracranial neuropathology such as atherosclerotic occlusive disease or unruptured aneurysms face high risks for morbidity and mortality. Magnetic resonance angiography of the circle of Willis is an important tool used to detect and diagnose intracranial neuropathology; however, recent changes to the Medicare local coverage determinations for this procedure threaten to compromise the physician's ability to deliver this current standard of care. Physicians can assume an important role in advocating for this lifesaving procedure on behalf of this vulnerable patient population.

Interleukin-1 cluster gene polymorphisms and aneurysmal subarachnoid hemorrhage

BACKGROUND

Emerging data indicate that proinflammatory cytokines may be involved in the pathogenesis of intracranial aneurysms. Interleukin (IL)-1 is a proinflammatory cytokine that plays a pivotal role in both acute and chronic central nervous system injuries.

OBJECTIVE

To investigate whether select polymorphisms in the IL-1alpha, IL-1beta, and IL-1 receptor antagonist genes are associated with both susceptibility to and clinical characteristics of subarachnoid hemorrhage due to intracranial aneurysm rupture.

METHODS

Allelic and genotypic frequencies of the IL-1alpha (-889), IL-1beta (-511), and IL-1 receptor antagonist (VNTR) genes were determined in 215 patients and 155 healthy controls. Patient files were reviewed for the clinical characteristics at hospital admission and at 6-month follow-up.

RESULTS

No association between aneurysmal subarachnoid hemorrhage susceptibility and the examined cytokine gene polymorphisms was found. Haplotype analysis did not show any significant difference between cases and controls. However, aneurysmal subarachnoid hemorrhage patients carrying the T/T genotype of the IL-1beta gene showed a significant (P = .034) increase in the Hunt and Hess scores at hospital admission and a significant (P = .026) reduction in 6-month Glasgow Outcome Scale scores. The remaining polymorphisms showed no effect on the clinical features examined.

CONCLUSION

Our results do not support the hypothesis that genetic variation in select polymorphisms of the IL-1 cluster genes is associated with aneurysmal subarachnoid cerebral hemorrhage. However, the IL-1beta gene may modify disease severity and may be regarded as disease severity gene.

Microsurgical clipping in forty patients with unruptured anterior cerebral circulation aneurysms: an investigation into cognitive outcome

OBJECTIVE: It is a consensus that most unruptured intracranial aneurysms (UIA) can be treated with acceptably low morbidity. However, some studies recently reported postoperative cognitive impairment, suggesting that it could be attributable to surgical damage. Our goal is to evaluate cognitive function before and after microsurgical clipping in patients with UIA. METHOD: A consecutive series of 40 patients who underwent microsurgical clipping for UIA were studied. The cognitive assessment (Mini Mental State Examination, MMSE) was performed immediately before and at least one month after surgery. Paired Student's "t" test and analysis of variance (ANOVA) were used for statistical purposes. RESULTS: The mean MMSE score in the preoperative analysis was 28.12 (SD, 1.34). In the postoperative period the mean MMSE score was 28.40 (SD, 1.46). Paired Student's "t" test was applied to the scores and no significant difference was found (p=0.315). ANOVA did not find independent associations between MMSE scores and age, hypertension, smoking, dyslipidemia, education, aneurysm location, number, laterality or size. CONCLUSION: The present study suggests that microsurgical clipping for UIA does not result in major cognitive dysfunction as determined by the MMSE

Unruptured Intracranial Aneurysms with Oculomotor Nerve Palsy : Clinical Outcome between Surgical Clipping and Coil Embolization

OBJECTIVE

To evaluate the clinical outcome of coil embolization for unruptured intracranial aneurysm (UIA) with oculomotor nerve palsy (ONP) compared with surgical clipping.

METHODS

A total of 19 patients presented with ONP caused by UIAs between Jan 2004 and June 2008. Ten patients underwent coil embolization and nine patients surgical clipping. The following parameters were retrospectively analyzed to evaluate the differences in clinical outcome observed in both coil embolization and surgical clipping : 1) gender, 2) age, 3) location of the aneurysm, 4) duration of the symptom, and 5) degree of ONP.

RESULTS

Following treatment, complete symptomatic recovery or partial relief from ONP was observed in 15 patients. Seven of the ten patients were treated by coil embolization, compared to eight of the nine patients treated by surgical clipping (p = 0.582). Patient's gender, age, location of the aneurysm, size of the aneurysm, duration of symptom, and degree of the ONP did not statistically correlate with recovery of symptoms between the two groups. No significant differences were observed in mean improvement time in either group (55 days in coil embolization and 60 days in surgical clipping).

CONCLUSION

This study indicates that no significant differences were observed in the clinical outcome between coil embolization and surgical clipping techniques in the treatment of aneurysms causing ONP. Coil embolization seems to be more feasible and safe treatment modality for the relief and recovery of oculomotor nerve palsy.

Hemodynamic models of cerebral aneurysms for assessment of effect of vessel geometry on risk of rupture

Surgical decisions on treatment of cerebral aneurysms are based predominantly on aneurysm size. This study has assessed the influence of parent vessel geometry on intra-aneurysmal flow patterns and mass flow rate using computational fluid dynamics and finite element modeling of straight and curved vessels feeding saccular aneurysms of varying size and aspect ratio. Simulation results have shown that aneurysms of similar shape and size but with curved parent vessels can have more than 2 fold increase in flow rate, with markedly different flow velocity patterns and development of secondary flows. These are significant hemodynamic factors that can contribute to increased risk of aneurysm rupture, in addition to aneurysm size. The dependency of parent vessel geometry is a function of aneurysm aspect ratio and shows minimal dependency at an aspect ratio of 1.68. These findings could be used for improved quantification of risk of rupture of cerebral aneurysms detected from clinical imaging modalities and to aid surgical decision making.

Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis

OBJECTIVE

To quantify the prevalence of incidental findings on magnetic resonance imaging (MRI) of the brain.

DESIGN

Systematic review and meta-analysis of observational studies.

DATA SOURCES

Ovid Medline (1950 to May 2008), Embase (1980 to May 2008), and bibliographies of relevant articles. Review methods Two reviewers sought and assessed studies of people without neurological symptoms who underwent MRI of the brain with or without intravenous contrast for research purposes or for occupational, clinical, or commercial screening.

MAIN OUTCOME MEASURES

Overall disease specific and age specific prevalence of incidental brain findings, calculated by meta-analysis of pooled proportions using DerSimonian-Laird weights in a random effects model.

RESULTS

In 16 studies, 135 of 19 559 people had neoplastic incidental brain findings (prevalence 0.70%, 95% confidence interval 0.47% to 0.98%), and prevalence increased with age (chi(2) for linear trend, P=0.003). In 15 studies, 375 of 15 559 people had non-neoplastic incidental brain findings (prevalence 2.0%, 1.1% to 3.1%, excluding white matter hyperintensities, silent infarcts, and microbleeds). The number of asymptomatic people needed to scan to detect any incidental brain finding was 37. The prevalence of incidental brain findings was higher in studies using high resolution MRI sequences than in those using standard resolution sequences (4.3% v 1.7%, P<0.001). The prevalence of neoplastic incidental brain findings increased with age.

CONCLUSIONS

Incidental findings on brain MRI are common, prevalence increases with age, and detection is more likely using high resolution MRI sequences than standard resolution sequences. These findings deserve to be mentioned when obtaining informed consent for brain MRI in research and clinical practice but are not sufficient to justify screening healthy asymptomatic people.

A national internet-based survey of cerebral aneurysm preference-based quality of life

OBJECTIVE

Preference-based quality of life (QOL) instruments integrate all factors contributing to QOL and provide a comprehensive valuation of a health state. QOL values of the general public for cerebral aneurysm health states are not well understood.

METHODS

In an internet-based survey of a nationally representative sample of the United States population, we measured standard gamble QOL values for the subjects' own health and for low-, medium-, and high-risk cerebral aneurysm health state scenarios and determined the effect of depicting aneurysm-associated stroke and death risk as annual or cumulative.

RESULTS

The 1654 subjects matched the United States population demographics. The subjects' mean (standard deviation) QOL for their current health was 0.82 (0.19), and for a cerebral aneurysm it was 0.78 (0.19) (P < 0.001). Mean low-, medium-, and high-risk aneurysm QOL values were 0.01, 0.06, and 0.13 lower than for current health, respectively (P < 0.001). The average discrepancy between aneurysm QOL and current health narrowed with age: 18 to 25 years, 0.09; 24 to 44 years, 0.06; 45 to 64 years, 0.03; and 65+ years, 0.01 (trend P < 0.001). Subjects who received only annual risk data provided the highest mean aneurysm QOL values (0.81 [0.18]); those who received both annual and 20-year cumulative risk information gave intermediate values (0.79 [0.18]), and those who received only data on cumulative 20-year risk provided the lowest values (0.76 [0.20]) (P < 0.001).

CONCLUSION

Preference-based QOL values for cerebral aneurysms derived from the general public vary with the subjects' age, the risk of aneurysmal stroke and death, and the mathematical terminology used to convey the risk of stroke and death.

Screening in the dark: ethical considerations of providing screening tests to individuals when evidence is insufficient to support screening populations

During the past decade, screening tests using computed tomography (CT) have disseminated into practice and been marketed to patients despite neither conclusive evidence nor professional agreement about their efficacy and cost-effectiveness at the population level. This phenomenon raises questions about physicians' professional roles and responsibilities within the setting of medical innovation, as well as the appropriate scope of patient autonomy and access to unproven screening technology. This article explores how physicians ought to respond when new screening examinations that lack conclusive evidence of overall population benefit emerge in the marketplace and are requested by individual patients. To this end, the article considers the nature of evidence and how it influences decision-making for screening at both the public policy and individual patient levels. We distinguish medical and ethical differences between screening recommended for a population and screening considered on an individual patient basis. Finally, we discuss specific cases to explore how evidence, patient risk factors and preferences, and physician judgment ought to balance when making individual patient screening decisions.

Treatment of unruptured intracranial aneurysms: surgery, coiling, or nothing?

The decision of whether and how to treat an unruptured intracranial aneurysm (UIA) is complex. The goal in caring for patients with UIAs is to maximize their duration of high-quality life by optimally balancing the risks of aneurysm rupture--the "natural history" of the aneurysm--with those of treatment-related adverse outcomes. In this article, we review the literature concerning the natural history of UIAs and summarize the procedure-associated morbidity and mortality and efficacy of surgical clipping and endovascular coiling. Using this information, we make recommendations regarding the optimal management of patients with UIAs.

Susceptibility loci for intracranial aneurysm in European and Japanese populations

Stroke is the world's third leading cause of death. One cause of stroke, intracranial aneurysm, affects approximately 2% of the population and accounts for 500,000 hemorrhagic strokes annually in mid-life (median age 50), most often resulting in death or severe neurological impairment. The pathogenesis of intracranial aneurysm is unknown, and because catastrophic hemorrhage is commonly the first sign of disease, early identification is essential. We carried out a multistage genome-wide association study (GWAS) of Finnish, Dutch and Japanese cohorts including over 2,100 intracranial aneurysm cases and 8,000 controls. Genome-wide genotyping of the European cohorts and replication studies in the Japanese cohort identified common SNPs on chromosomes 2q, 8q and 9p that show significant association with intracranial aneurysm with odds ratios 1.24-1.36. The loci on 2q and 8q are new, whereas the 9p locus was previously found to be associated with arterial diseases, including intracranial aneurysm. Associated SNPs on 8q likely act via SOX17, which is required for formation and maintenance of endothelial cells, suggesting a role in development and repair of the vasculature; CDKN2A at 9p may have a similar role. These findings have implications for the pathophysiology, diagnosis and therapy of intracranial aneurysm.

Nontraumatic emergent neuroradiology: review and self-assessment module

Objectiv: The educational objectives for this case-based self-assessment module on imaging of nontraumatic emergent neuroradiology are to use case examples to teach the imaging features of CT and MRI of emergent neuroradiologic diagnoses and to improve the reader's understanding of the pathophysiology and clinical management of each clinical scenario. Imaging plays a critical role in assessing patients with acute neurologic symptoms. CT is quick and easy to perform in an emergency setting and is often the technique of choice for any neurologic emergency situations. Clinical correlation is crucial for accurate diagnosis and triaging patients for further evaluation. Persistent or progressive neurologic symptoms despite negative CT should prompt other imaging studies. Conclusio: At the end of this self-assessment module, readers will be able to generate a concise list of differential diagnoses for imaging findings that often are encountered in patients with nontraumatic neurologic emergency.

Screening for familial intracranial aneurysms: decision and cost-effectiveness analysis

RATIONALE AND OBJECTIVES

To evaluate the potential benefits, harms, and cost-effectiveness of screening for asymptomatic, unruptured intracranial aneurysms in family members of patients with aneurysmal subarachnoid hemorrhage (SAH).

MATERIALS AND METHODS

Using a Markov model, we performed a decision and cost-effectiveness analysis comparing magnetic resonance (MR) angiography screening for asymptomatic, unruptured intracranial aneurysms to no screening in family members of patients with aneurysmal SAH. Treatment of unruptured intracranial aneurysms was determined according to patient age and aneurysm size and location. Cohort age was taken as 40 years.

RESULTS

In family members with two or more affected first-degree relatives, screening compared with no screening had an incremental cost-effectiveness ratio (ICER) of $37,400 per quality-adjusted life-year (QALY). With screening, life expectancy increased from 39.44 years to 39.55 years. The ICER of screening was >$50,000 per QALY if age at screening was > or =50 years. In family members with one affected first-degree relative, screening compared with no screening had an ICER of $56,500 per QALY.

CONCLUSIONS

The results suggest that MR angiography screening for asymptomatic, unruptured intracranial aneurysms in family members with two or more affected first-degree relatives is cost-effective. The benefit and cost-effectiveness are dependent on age at screening.

GUIDELINES FOR THE SURGICAL TREATMENT OF UNRUPTURED INTRACRANIAL ANEURYSMS

THE MANAGEMENT OF unruptured cerebral aneurysms remains one of the most controversial topics in neurosurgery. To this end, we discuss the diagnosis and estimated prevalence of these lesions as well as review the literature regarding the rate of rupture for cerebral aneurysms and risks of operative intervention. Our interpretation of the literature concludes that aneurysms are present in approximately 1% of the adult population, varying between less than 1% in young adults to 4% in the elderly. The yearly risk of subarachnoid hemorrhage for an unruptured intracranial aneurysm is approximately 1% for lesions 7 to 10 mm in diameter. Based on these assumptions, we recommend that 1) with rare exceptions, all symptomatic unruptured aneurysms should be treated; 2) small, incidental aneurysms less than 5 mm in diameter should be managed conservatively in virtually all cases; 3) aneurysms larger than 5 mm in patients younger than 60 years of age should be seriously considered for treatment; 4) large, incidental aneurysms larger than 10 mm should be treated in nearly all patients younger than 70 years of age; and 5) microsurgical clipping rather than endovascular coiling should be the first treatment choice in low-risk cases. Critical to our guidelines is collaboration by a highly experienced cerebrovascular team of microneurosurgeons and endovascular neurosurgeons working at a tertiary medical center with a high case volume and using a decision-making paradigm designed to offer only low-risk treatments. In certain patients for whom both treatment and natural history carry high risks, such as those with giant aneurysms, nonoperative management is typically elected.

Postoperative quality of life of patients treated for asymptomatic unruptured intracranial aneurysms

Object

The aim of this study was to assess the quality of life (QOL) of patients who underwent surgery for asymptomatic unruptured intracranial aneurysms (UIAs).

Methods

The authors assessed QOL in 149 patients who had undergone microsurgical clipping of asymptomatic UIAs. They surveyed these patients using universal methods such as the 36-Item Short Form Health Survey (SF-36) for health-related QOL and the Hospital Anxiety and Depression Scale for anxiety and depression assessments.

Results

The patients' mean scores for each of the eight domains of SF-36 were comparable to those of a Japanese reference population. Analysis of data from the average-QOL and low-QOL subgroups showed that the low-QOL group contained a higher number of patients with preexisting heart diseases and restricted activities of daily living. Operative procedures and complications did not affect QOL.

Conclusions

Because 86% of the patients who underwent surgery manifested a QOL similar to the reference population, the authors suggest that elective surgery for asymptomatic UIAs is a reasonable treatment, especially in patients who are troubled by the risk of rupture. Postoperative decreases in QOL are not invariably attributable to the operation or its associated complications, but may be correlated with other chronic disorders. To select the appropriate treatment for asymptomatic UIAs, neurosurgeons and patients need information on the expected postoperative QOL.

Comparison of endovascular and surgical treatments for intracranial aneurysms: an evidence-based review

Intracranial aneurysms can be treated with endovascular or surgical techniques. We provide an objective comparison of these treatments, using data from single-centre studies, multicentre studies with and without independent outcome ascertainment, and randomised clinical trials. We compared the outcomes of patients who were candidates for endovascular treatment, surgical treatment, or both. In patients with ruptured intracranial aneurysms, rates of aneurysm obliteration were higher, and need for second treatment was lower, after surgery than after endovascular treatment. However, in observational studies and randomised trials, outcome at discharge, at 2-6 months, and at 1 year, and later survival, were all better after endovascular treatment than after surgery. The results suggest that the higher rates of incomplete obliteration and retreatment after endovascular treatment do not affect patients' clinical outcome. In observational studies of patients with unruptured intracranial aneurysms, discharge outcomes were better and hospital costs were lower after endovascular treatment than after surgery. These patients showed no difference between the two treatments in 1-year outcomes and later rebleeding, although few data were available for this comparison.

Aneurysmal subarachnoid haemorrhage and the anaesthetist

The anaesthetist may be involved at various stages in the management of subarachnoid haemorrhage (SAH). Thus, familiarity with epidemiological, pathophysiological, diagnostic, and therapeutic issues is as important as detailed knowledge of the optimal intraoperative anaesthetic management. As the prognosis of SAH remains poor, prompt diagnosis and appropriate treatment are essential, because early treatment may improve outcome. It is, therefore, important to rule out SAH as soon as possible in all patients complaining of sudden onset of severe headache lasting for longer than an hour with no alternative explanation. The three main predictors of mortality and dependence are impaired level of consciousness on admission, advanced age, and a large volume of blood on initial cranial computed tomography. The major complications of SAH include re-bleeding, cerebral vasospasm leading to immediate and delayed cerebral ischaemia, hydrocephalus, cardiopulmonary dysfunction, and electrolyte disturbances. Prophylaxis and therapy of cerebral vasospasm include maintenance of cerebral perfusion pressure (CPP) and normovolaemia, administration of nimodipine, triple-H therapy, balloon angioplasty, and intra-arterial papaverine. Occlusion of the aneurysm after SAH is usually attempted surgically ('clipping') or endovascularly by detachable coils ('coiling'). The need for an adequate CPP (for the prevention of cerebral ischaemia and cerebral vasospasm) must be balanced against the need for a low transmural pressure gradient of the aneurysm (for the prevention of rupture of the aneurysm). Effective measures to prevent or attenuate increases in intracranial pressure, brain swelling, and cerebral vasospasm throughout all phases of anaesthesia are prerequisite for optimal outcome.

Improvement of quality of life in patients surgically treated for asymptomatic unruptured intracranial aneurysms

OBJECTIVE

To compare the preoperative and postoperative health-related quality of life (QOL) and psychological state of patients with asymptomatic unruptured intracranial aneurysms (ICAs) who underwent elective surgery.

METHODS

Out of 67 patients who underwent neck clipping of ICAs, we assessed the QOL of 61 patients using Short Form-36 (SF-36); their psychological state was rated on the Hospital Anxiety and Depression Scale (HADS) before, 3 months, and 1 and 3 years after treatment.

RESULTS

The preoperative mean scores for each of the eight SF-36 domains except bodily pain were significantly lower in the study population than in the reference population. 14 (20.9%) patients experienced surgical complications defined as neurological deterioration and/or abnormal CT findings within 30 days of the operation. Despite some complications, the QOL of all operated patients returned to the mean level of the reference population 3 years after treatment. At 3 months after surgery, the scores for psychosocial activities and general health perception were transiently below the preoperative levels. According to the HADS, the patients experienced mild anxiety before the operation; it disappeared by the third postoperative month.

CONCLUSIONS

Preoperatively, patients with unruptured ICAs reported a significantly decreased QOL. It further declined transiently after elective surgery, but it returned to the mean level recorded for the reference population within 3 years. Our findings suggest that these patients derived significant QOL benefits from their surgery. Hence subjective QOL issues should be considered in deciding whether treatment-related risks and their natural history, such as their potential rupture, warrant surgery of asymptomatic unruptured ICAs.

[Issues involved with supply of medical and hygienic materials to home care patients]

Questionnaires were mailed to doctors and nurses who are involved in home care to survey their observations on medical and hygienic materials and its supply to home care patients. Some of the survey items, such as problems encountered frequently, areas where an improvement was needed most and concerns that are often raised in suppling of medical and hygienic materials for home care patients, were analyzed by the Berelson's content analysis method to observe problems in suppling adequate medical and hygienic materials. As a result, 5 categories and 17 subcategories were formed. The recognized future issues were: policies concerning support extended to medical organizations and disseminate information of the system, which medical and hygienic materials supplied to home care patients.

Current Options in Clipping Versus Coiling of Intracranial Aneurysms: to Clip, to Coil, to Wait and Watch

Treatment of intracranial aneurysms involves many factors: patient preference and demographics; aneurysm size, site, geometry, access, and intrinsics; practitioner experience and availability; facility; technology; and ancillaries. Volume counts, teamwork enhancement, and management should be individualized.

Reprint of: SYMPOSIUM ON CEREBROVASCULAR DISEASES. Pathogenesis, Natural History, and Treatment of Unruptured Intracranial Aneurysms

Unruptured intracranial aneurysms (UIAs) are a major public health issue. These lesions have become increasingly recognized in recent years with the advent of advanced cerebral imaging techniques. Epidemiological evidence from multiple sources suggests that most intracranial aneurysms do not rupture. Therefore, it is desirable to identify which UIAs are at greatest risk of rupture when considering which to repair. It is important to compare size-, site-, and group-specific natural history rates with size-, site-, and age-specific morbidity and mortality associated with UIA repair because increased natural history risk often is associated with increased risk of aneurysm repair. Patient age is crucial in decision making because of its major effect on operative morbidity and mortality; however, it does not substantially affect natural history. The effect of age is most notable in patients about 50 years of age and older for open surgery and about 70 years of age and older for endovascular procedures. In general, rupture risk is lowest for patients in asymptomatic group 1 (no history of subarachnoid hemorrhage) with UIAs less than 7 mm in diameter in the anterior circulation. Surgical morbidity and mortality are most favorable for asymptomatic patients younger than 50 years who have UIAs less than 24 mm in diameter in the anterior circulation and no history of ischemic cerebrovascular disease. Endovascular morbidity and mortality may be less age dependent, and this could favor endovascular procedures, particularly in patients aged 50 to 70 years. An important issue is determining immediate vs long-term risk regarding treatment effectiveness and durability. This issue emphasizes the importance of long-term follow-up in patients after surgical and endovascular procedures.

Endothelial nitric oxide gene T-786C polymorphism and subarachnoid hemorrhage in Korean population

We aimed to elucidate whether the eNOS T-786C mutant allele is implicated in subarachnoid hemorrhage (SAH) susceptibility or vasospasm after SAH, and whether the mutant allele is differentially expressed in those with small and large ruptured aneurysms in Korean population. 136 consecutive patients diagnosed with aneurismal SAH and 113 controls were recruited. Polymerase chain reaction and direct sequencing of both strands were performed to determine genotypes with respect to the eNOS T-786C mutation. No significant difference was found between cases and controls with respect to the distributions of the two eNOS T-786C single nucleotide polymorphism (SNP) genotypes. No significant differences in the distributions of the eNOS T-786C SNP genotypes were found with regard to the sizes of ruptured aneurysms or the occurrence of vasospasm after SAH. Multiple logistic regression analysis after controlling for age and sex showed the eNOS T-786C SNP T/C geno-type was independently associated with an unfavorable outcome (GOS grade 3-5) of SAH (Exp (beta)=4.27, 95% CI 1.131-16.108, p=0.032). In conclusion, the eNOS T-786C mutation was not found to be associated with either a susceptibility to SAH or vasospasm after SAH, or with aneurysm size in Korean population. The eNOS T-786C SNP T/C genotype could be used as a prognostic marker in individuals with SAH.

Unruptured Intracranial Aneurysms: Natural History and Clinical Management. Update on the International Study of Unruptured Intracranial Aneurysms

In guiding treatment decisions for all patients with unruptured intracranial aneurysms, it is important to compare size-, site-, and group-specific natural history data with size-, site- and age-specific treatment morbidity and mortality data. Because patient age has a major effect on operative morbidity and mortality, but relatively little effect on natural history, surgical treatment of an UIA patient over age 50 and any treatment of UIA patients over age 70 should be considered with particular vigilance. Optimally, patients should be evaluated and treated at high-volume centers in a setting that emphasizes neurovascular teamwork and unbiased presentation and delivery of different therapeutic option, including the option of observation, which is often appropriate for patients with UIAs.

Follow-up of Treated Aneurysms: the Challenge of Recurrences and Potential Solutions

Angiographic recurrences after endovascular treatment of aneurysms with platinum coils are frequent, but hemorrhages are unusual. Recurrences are more frequent in patients with large wide-necked aneurysms, when the initial occlusion is incomplete, and when patients are treated after subarachnoid hemorrhage. Although many occur early on, they can appear years after treatment. None of the recent devices has been proven effective in improving long-term results. A rigorous scientific approach, including randomized trials, is imperative to forward progress in this field.

Anévrysmes intracrâniens révélés par une ischémie cérébrale

PURPOSE

To report four cases of patient with an acute ischemic event as a presenting symptom of a berry aneurysm.

PATIENTS AND METHODS

One male and three female (aged range 38 to 65 years) patients were admitted for acute stroke. The neuroradiologic finding disclosed aneurysm thrombosis, inferior to twenty five millimetres in three cases. Lumbar puncture was done in one case and showed subarachnoid haemorrage.

DISCUSSION

We will discuss the hypothesis leading to the mechanism of aneurysm thrombosis. Two theories will be presented: "hemodynamic" and "parietal" modifications. We will propose a management protocol for these patients with atypical presentation of intracranial aneurysms given the potential risk of rupture.

CONCLUSION

The natural history of intracranial aneurysms is still not fully understood. Nevertheless, aneurym thrombosis may occur and lead to ischemic stroke.

Outcome of Surgical Clipping of Unruptured Aneurysms as it Compares with a 10-Year Nonclipping Survival Period

OBJECTIVE

Recent studies on the natural history of unruptured intracranial aneurysms dictate that we reevaluate the risks and benefits of surgical intervention as it compares with the natural course. We analyzed the outcome of surgical clipping of a patient cohort with unruptured aneurysms as it compares with a 10 year nonclipping survival period on the basis of two previously published studies (International Study on Unruptured Intracranial Aneurysms and a study by Juvela et al. [36] from Helsinki).

METHODS

Data on 148 unruptured aneurysms in 116 consecutive surgically treated patients were prospectively recorded and retrospectively analyzed. The overall majority were diagnosed with cerebral angiography. Data analyzed included aneurysmal properties and clinical outcomes including surgical related mortalities and morbidities. The observed outcomes were compared with the expected outcome of a 10 year nonclipping survival period if the patient cohort was included in recently reported studies on unruptured aneurysms. More than 1 year follow-up was available in 93.1% (108) of patients and follow-up cerebral angiography was performed in 80% (93) of patients.

RESULTS

Mean age was 53.57 years. There were 25 (16.8%) small aneurysms (less than 7 mm), 70 (47.2%) aneurysms 7 to 12 mm in size, 41 (27.70%) large (13-24 mm), and 12 (8.10%) giant (>25 mm) aneurysms. Posterior circulation aneurysm comprised 13.51%. One hundred forty-three (96.62%) aneurysms were successfully clipped, and 3.37% were either wrapped or later coiled. Surgical-related mortality was 0.82% (1 patient because of air embolism). Surgical related permanent morbidity was 3.44% (4 patients) and transient surgical-related mild morbidities was 7.7% (9 patients). Immediate postsurgical good outcome (Glasgow Outcome Score = 4-5) was 87.93% (102 patients) and 95.68% in 3 months (111 patients). At 1 year, the modified Rankin scale scores were 0 to I = 102, II = 3, III = 2, IV = 1, and V = 0. Residual aneurysms were seen in none of the postoperative angiograms (93 patients). Using the chi method, the comparison of the expected to the observed mortality and morbidity revealed a statistically significant difference in the mortality in favor of surgical clipping (P = 0.034 when compared with the International Study on Unruptured Intracranial Aneurysms and P = 0.05 when compared with the Juvela et al. [36] study). There was no statistically significant difference in the permanent morbidity.

CONCLUSION

Studies on natural history of unruptured intracranial aneurysms suggest 10 year cumulative bleeding-related mortality and severe morbidity of no less than 7.5%. In our study, surgical clipping resulted in an 0.8% rate of mortality and 3.4% permanent morbidity. This suggests that surgical clipping has the potential of a superior outcome to the natural history of patients who have an estimated life expectancy of no less than 10 years.

Modern cross-sectional imaging in the diagnosis and follow-up of intracranial aneurysms

Digital subtraction angiography (DSA) is still considered the gold standard for most applications in neurovascular imaging. However, with the ongoing development of cross-sectional imaging modalities DSA is increasingly being replaced by less invasive methods. This contribution describes the diagnostic value and the increasing potential of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) in the diagnosis and follow-up of intracranial aneurysms. The main role of CTA is in the diagnosis and therapy planning of ruptured aneurysms; in contrast, MRA plays an increasingly important role in the screening for asymptomatic aneurysms (especially in cases of familial subarachnoid hemorrhage) and in the follow-up after endovascular therapy with coils and/or intracranial stents. Technical issues concerning examination technique are covered here as well as an approach to advanced postprocessing of the image data. Furthermore, a brief outlook on the impact of new developments (MRA with parallel imaging and at 3.0 T) is given.

Extracranial Severe Carotid Stenosis and Incidental Intracranial Aneurysms

Among 474 patients having 547 carotid endarterectomies (CEAs) over an 80-month period, 11 (2.3%) with symptomatic (n = 8) and asymptomatic (n = 3) severe (>70%) carotid stenosis had 12 asymptomatic intracranial aneurysms (IAs). None had postoperative stroke or died, and none had surgical or endovascular IA treatment before or after CEA. In an average 5-year follow-up, no patients had subarachnoid hemorrhage. Having an IA does not seem to be an additional risk factor for CEA, nor does CEA seem to increase the chance of IA rupture.

Clipping or coiling of cerebral aneurysms

The management of a patient with a cerebral aneurysm is complex, and two accepted treatment modalities are now available. The superiority of either of the treatment options has not been defined, but data are now available with regard to the safety and efficacy of each modality and can be used to decide what is best for individual patients when combined with other important variables, such as the patient's expected longevity, specific aneurysm factors (eg, size, dome-to-neck ratio, location), and operator's experience. This complex decision entertaining all the variables should ensure that patients receive the most appropriate care. New developments in the endovascular management of cerebral aneurysms are likely to alter this algorithm.

Psychosocial Effects of Harboring an Untreated Unruptured Intracranial Aneurysm

OBJECTIVE:

The primary purpose of the study was to investigate the psychosocial effects of harboring a known but untreated unruptured intracranial aneurysm (UIA), information considered important to the decision of whether to treat or not treat an unruptured aneurysm.

METHODS:

Over a 24–month period, 70 Auckland Hospital patients with UIAs were identified. Of these, 30 completed treatment, 2 patients died before treatment, and 38 were either not treated or treatment was unable to be completed during the time frame of the study. Of this group of 38 untreated UIA patients, 23 were enrolled in the study and were assessed on a brief cognitive screen and a battery of psychosocial measures. Their performance was compared with a group of 26 treated UIA patients.

RESULTS:

Poorer functioning was reported by the untreated UIA group on most psychosocial measures when compared with the treated UIA group 6 months posttreatment, and 36% of untreated UIA patients presented with a pattern of significant psychosocial impairment when compared with the treated UIA group. Qualitative data from the current study suggested that a factor contributing to the poorer reported psychosocial functioning in the untreated group was past or current fear about their untreated UIA.

CONCLUSION:

A decrease in overall quality of life was found to be associated with harboring an identified but untreated UIA. Findings from the current study suggest that further investigation of psychosocial outcome in other groups of untreated UIA patients is warranted. Results also suggest that some untreated UIA patients might benefit from psychological intervention.