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Kim YG, An H, Kim GE, Lee HW, Yang NR. Higher Risk of Mental Illness in Patients With Diagnosed and Untreated Unruptured Intracranial Aneurysm: Findings From a Nationwide Cohort Study. Stroke 2024; 55:2295-2304. [PMID: 39186554 DOI: 10.1161/strokeaha.123.045393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 06/26/2024] [Accepted: 07/09/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND We aimed to investigate the association between a diagnosis of untreated unruptured intracranial aneurysms (UIAs) and the development of mental illness. METHODS This retrospective, propensity-score-matched cohort study was based on the nationwide South Korean database. The UIA diagnosis group included participants newly diagnosed with UIA between 2011 and 2019. For a well-matched control group, patients diagnosed with an acute upper respiratory infection but without UIA during the same period were selected through 1:4 matching based on propensity scores, which were calculated using age, sex, economic status, and comorbidities. The study's outcome measure encompassed the incidence of mental illnesses over a 10-year period, using International Classification of Diseases-Tenth Revision codes for anxiety, stress, depressive, bipolar, and eating disorders, insomnia, and alcohol or drug misuse. RESULTS After propensity score matching, 85 438 participants with untreated UIAs (50.75% male; average age, 56.41 [±13.82] years; follow-up, 4.21 [±2.56] years) and 331 123 controls (49.44% males; average age, 56.69 [±12.92] years; follow-up, 7.48 [±2.12] years) were compared. Incidence rate of mental illness was higher in the UIA group (113.07 versus 90.41 per 1000 person-years; hazard ratio, 1.104 [95% CI, 1.089-1.119]). The risk of mental illness varied slightly by sex (males: hazard ratio, 1.131 [95% CI, 1.108-1.155]; females: hazard ratio, 1.082 [95% CI, 1.063-1.103]). Hazard ratios showed a U-shaped relationship with age, peaking in younger age groups, decreasing in middle-aged groups, and slightly increasing in older age groups, especially in patients with severe mental illness receiving psychotherapy. CONCLUSIONS Our findings indicate a higher risk of mental illness in patients with UIA diagnosis in specific demographic groups, suggesting a possible psychological burden associated with UIAs. Clinicians treating cerebral aneurysms should be aware that the psychological burden caused by the diagnosis of UIA itself could contribute to mental illness and strive to provide comprehensive care for these patients.
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Affiliation(s)
- Young Goo Kim
- Department of Neurosurgery, Ewha Womans University Mokdong Hospital (Y.G.K., N.R.Y.)
| | - Hyungmi An
- Institute of Convergence Medicine, Ewha Womans University College of Medicine (H.A.)
| | - Ga Eun Kim
- Department of Psychiatry, Ewha Womans University Mokdong Hospital (G.E.K.)
| | - Hyang Woon Lee
- Department of Neurology, Ewha Womans University Mokdong Hospital (H.W.L.), Ewha Womans University College of Medicine, Seoul, Republic of Korea
- Department of Medical Science, Ewha Womans University School of Medicine, Seoul, Republic of Korea (H.W.L.)
- Computational Medicine, System Health Science and Engineering Program, Ewha Womans University, Seoul, Republic of Korea (H.W.L.)
| | - Na Rae Yang
- Department of Neurosurgery, Ewha Womans University Mokdong Hospital (Y.G.K., N.R.Y.)
- Department of Neurosurgery (N.R.Y.), Ewha Womans University College of Medicine, Seoul, Republic of Korea
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2
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Bizjak Ž, Špiclin Ž. Aneurysm growth evaluation and detection: a computer-assisted follow-up MRA analysis. Sci Rep 2024; 14:19609. [PMID: 39179696 PMCID: PMC11343880 DOI: 10.1038/s41598-024-70453-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 08/16/2024] [Indexed: 08/26/2024] Open
Abstract
Growing intracranial aneurysms pose a high risk of rupture, making the detection and quantification of the growth crucial for timely treatment strategy adoption. In this paper we propose a computer-assisted approach based on the extraction of IA shapes from associated baseline and follow-up angiographic scans and non-rigid morphing of the two shapes. From the obtained shape deformations we computed four novel features, including differential volume (dV), surface area (dSA), aneurysm-size normalized median deformation path length (dMPL), and integral of cumulative deformation distances (dICDD). An experienced neuroradiologist manually extracted the IA shape models from the baseline and follow-up MRAs and, by utilizing size change and visual assessments, classified each aneurysm into stable with morphology changes, stable or growing. We investigated the classification performance and found that three of the novel and one cross-sectional feature exhibited significantly different mean values (p-value < 0.05 ; Tukey's HSD test) between the stable and growing IA groups, while the mean dICDD was significantly different between all the three groups. The cross-sectional features has sensitivity to growing IAs in range 0.05-0.86, while novel features had generally higher sensitivity in range 0.81-0.90, making them promising candidates as surrogate follow-up imaging-based biomarkers for IA growth detection. These findings may offer valuable information for clinical management of patients with IAs based on follow-up imaging.
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Affiliation(s)
- Žiga Bizjak
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia.
| | - Žiga Špiclin
- Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia
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3
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van der Kamp LT, Edjlali M, Naggara O, Matsushige T, Bulters DO, Digpal R, Zhu C, Saloner D, Hu P, Zhai X, Mossa-Basha M, Tian B, Sakamoto S, Fu Q, Ruigrok YM, Zhao H, Chen H, Rinkel GJE, van der Schaaf IC, Vergouwen MDI. Gadolinium-enhanced intracranial aneurysm wall imaging and risk of aneurysm growth and rupture: a multicentre longitudinal cohort study. Eur Radiol 2024; 34:4610-4618. [PMID: 38108888 PMCID: PMC11213723 DOI: 10.1007/s00330-023-10388-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES In patients with an unruptured intracranial aneurysm, gadolinium enhancement of the aneurysm wall is associated with growth and rupture. However, most previous studies did not have a longitudinal design and did not adjust for aneurysm size, which is the main predictor of aneurysm instability and the most important determinant of wall enhancement. We investigated whether aneurysm wall enhancement predicts aneurysm growth and rupture during follow-up and whether the predictive value was independent of aneurysm size. MATERIALS AND METHODS In this multicentre longitudinal cohort study, individual patient data were obtained from twelve international cohorts. Inclusion criteria were as follows: 18 years or older with ≥ 1 untreated unruptured intracranial aneurysm < 15 mm; gadolinium-enhanced aneurysm wall imaging and MRA at baseline; and MRA or rupture during follow-up. Patients were included between November 2012 and November 2019. We calculated crude hazard ratios with 95%CI of aneurysm wall enhancement for growth (≥ 1 mm increase) or rupture and adjusted for aneurysm size. RESULTS In 455 patients (mean age (SD), 60 (13) years; 323 (71%) women) with 559 aneurysms, growth or rupture occurred in 13/194 (6.7%) aneurysms with wall enhancement and in 9/365 (2.5%) aneurysms without enhancement (crude hazard ratio 3.1 [95%CI: 1.3-7.4], adjusted hazard ratio 1.4 [95%CI: 0.5-3.7]) with a median follow-up duration of 1.2 years. CONCLUSIONS Gadolinium enhancement of the aneurysm wall predicts aneurysm growth or rupture during short-term follow-up, but not independent of aneurysm size. CLINICAL RELEVANCE STATEMENT Gadolinium-enhanced aneurysm wall imaging is not recommended for short-term prediction of growth and rupture, since it appears to have no additional value to conventional predictors. KEY POINTS • Although aneurysm wall enhancement is associated with aneurysm instability in cross-sectional studies, it remains unknown whether it predicts risk of aneurysm growth or rupture in longitudinal studies. • Gadolinium enhancement of the aneurysm wall predicts aneurysm growth or rupture during short-term follow-up, but not when adjusting for aneurysm size. • While gadolinium-enhanced aneurysm wall imaging is not recommended for short-term prediction of growth and rupture, it may hold potential for aneurysms smaller than 7 mm.
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Affiliation(s)
- Laura T van der Kamp
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, University Medical Center Utrecht, room number G3-201, Postbox 85500, 3508, Utrecht, GA, The Netherlands.
| | - Myriam Edjlali
- Department of Radiology, APHP, Hôpitaux Raymond-Poincaré and Ambroise Paré, DMU Smart Imaging, Laboratoire d'imagerie Biomédicale Multimodale (BioMaps), GH Université Paris-Saclay, Université Paris-Saclay, CEA, CNRS, Inserm, Service Hospitalier Frédéric Joliot, Orsay, France
| | - Olivier Naggara
- Department of Neuroradiology, Université de Paris, IMABRAIN-INSERM-UMR1266, DHU-Neurovasc, GHU Paris, Centre Hospitalier Sainte-Anne, Paris, France
| | - Toshinori Matsushige
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Diederik O Bulters
- Department of Neurosurgery, University Hospital Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ronneil Digpal
- Department of Neurosurgery, University Hospital Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chengcheng Zhu
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
| | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Peng Hu
- Department of Neurosurgery, Capital Medical University Xuanwu Hospital, Capital Medical University, Bejing, China
| | - Xiaodong Zhai
- Department of Neurosurgery, Capital Medical University Xuanwu Hospital, Capital Medical University, Bejing, China
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, USA
- Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Bing Tian
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Shigeyuki Sakamoto
- Department of Neurosurgery and Interventional Neuroradiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Qichang Fu
- Department of Magnetic Resonance, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ynte M Ruigrok
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, University Medical Center Utrecht, room number G3-201, Postbox 85500, 3508, Utrecht, GA, The Netherlands
| | - Huilin Zhao
- Department of Radiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huijun Chen
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Bejing, China
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, University Medical Center Utrecht, room number G3-201, Postbox 85500, 3508, Utrecht, GA, The Netherlands
| | - Irene C van der Schaaf
- Department of Radiology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht University, University Medical Center Utrecht, room number G3-201, Postbox 85500, 3508, Utrecht, GA, The Netherlands
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Marsool Marsool MD, Bharadwaj HR, Ali SH, Aderinto N, Shah MH, Shing N, Dalal P, Huang H, Wellington J, Chaudri T, Awuah WA, Pacheco-Barrios N, Macha-Quillama L, Fernandez-Guzman D, Hussien Mohamed Ahmed KA. Exploring the Landscape of Intracranial Aneurysms in South America: A Comprehensive Narrative Review Intracranial Aneurysms in South America. World Neurosurg 2024; 185:3-25. [PMID: 38286319 DOI: 10.1016/j.wneu.2024.01.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Abstract
Exploring the landscape of intracranial aneurysms in South America unravels a complex interplay of epidemiological factors, clinical manifestations, and therapeutic challenges. The study methodically conducts a comprehensive literature review spanning the years 2003 to 2023, focusing on English-language articles obtained from diverse databases to elucidate the multifaceted nature of intracranial aneurysms in the region. Results and discussions categorize outcomes into positive domains, emphasizing successful treatments, favorable recoveries, and high survival rates, while also shedding light on negative aspects such as residual aneurysms and complications. The research illuminates significant gaps in pathological typing of intracranial aneurysms and exposes challenges in healthcare accessibility, notably the disparities in neurosurgical resources. Management challenges, including constrained infrastructure access, a neurosurgeon shortage, and gender disparities, are underscored. Transitioning to future prospects, the study advocates for strategic interventions, proposing expanded neurosurgical training, multidisciplinary approaches, improved funding, enhanced access to care, and fostering international collaborations. The study concludes by emphasizing the pivotal role of collaborative efforts, intensified training programs, and global partnerships in propelling intracranial aneurysm management forward in South America, ultimately contributing to enhanced patient outcomes across the region.
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Affiliation(s)
| | | | - Syed Hasham Ali
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Nicholas Aderinto
- Internal Medicine Department, LAUTECH Teaching Hospital, Oyo, Nigeria
| | | | - Nathanael Shing
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Priyal Dalal
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Helen Huang
- University of Medicine and Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jack Wellington
- Department of Neurosurgery, Bradford Teaching Hospital NHS Foundation Trust, Bradford, United Kingdom
| | | | | | | | - Luis Macha-Quillama
- Alberto Hurtado Medical School, Cayetano Heredia Peruvian University, Lima, Peru
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5
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Bagg MK, Hicks AJ, Hellewell SC, Ponsford JL, Lannin NA, O'Brien TJ, Cameron PA, Cooper DJ, Rushworth N, Gabbe BJ, Fitzgerald M. The Australian Traumatic Brain Injury Initiative: Statement of Working Principles and Rapid Review of Methods to Define Data Dictionaries for Neurological Conditions. Neurotrauma Rep 2024; 5:424-447. [PMID: 38660461 PMCID: PMC11040195 DOI: 10.1089/neur.2023.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to develop a health informatics approach to collect data predictive of outcomes for persons with moderate-severe TBI across Australia. Central to this approach is a data dictionary; however, no systematic reviews of methods to define and develop data dictionaries exist to-date. This rapid systematic review aimed to identify and characterize methods for designing data dictionaries to collect outcomes or variables in persons with neurological conditions. Database searches were conducted from inception through October 2021. Records were screened in two stages against set criteria to identify methods to define data dictionaries for neurological conditions (International Classification of Diseases, 11th Revision: 08, 22, and 23). Standardized data were extracted. Processes were checked at each stage by independent review of a random 25% of records. Consensus was reached through discussion where necessary. Thirty-nine initiatives were identified across 29 neurological conditions. No single established or recommended method for defining a data dictionary was identified. Nine initiatives conducted systematic reviews to collate information before implementing a consensus process. Thirty-seven initiatives consulted with end-users. Methods of consultation were "roundtable" discussion (n = 30); with facilitation (n = 16); that was iterative (n = 27); and frequently conducted in-person (n = 27). Researcher stakeholders were involved in all initiatives and clinicians in 25. Importantly, only six initiatives involved persons with lived experience of TBI and four involved carers. Methods for defining data dictionaries were variable and reporting is sparse. Our findings are instructive for AUS-TBI and can be used to further development of methods for defining data dictionaries.
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Affiliation(s)
- Matthew K. Bagg
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Health Sciences, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Amelia J. Hicks
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Sarah C. Hellewell
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Jennie L. Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Natasha A. Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Terence J. O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter A. Cameron
- National Trauma Research Institute, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - D. Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Belinda J. Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
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6
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Liu J, Zhang Y, Levitt MR, Mossa-Basha M, Wang C, Turhon M, Zhang Y, Zhang Y, Wang K, Zhu C, Yang X. Risk of unruptured aneurysms in subarachnoid hemorrhage patients with multiple intracranial aneurysms: a multicenter, longitudinal, comparative study from China. J Neurointerv Surg 2024:jnis-2023-021113. [PMID: 38171610 PMCID: PMC11219528 DOI: 10.1136/jnis-2023-021113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND In aneurysmal subarachnoid hemorrhage patients with multiple intracranial aneurysms (aSAH-MIA patients), the risk of secondary unruptured intracranial aneurysms is inconsistent. This study aimed to explore the risk of unruptured aneurysms in Chinese aSAH-MIA patients. METHODS The medical records and angiographic images of aSAH-MIA patients from eight cerebrovascular centers in China were retrospectively reviewed and analyzed. Patients with a single unruptured intracranial aneurysm (UIA) and no prior aSAH were used as controls. Propensity score matching (PSM) was employed to balance the differences in age, gender, aneurysm size, aneurysm site, and follow-up duration between the two groups. RESULTS The study included 267 unruptured aneurysms from 204 aSAH-MIA patients and 769 single UIA. After PSM, 201 aneurysms were enrolled in the aSAH-MIA group and 201 aneurysms in the control group. The mean follow-up was 2.2 years. Thirty-four aneurysm instability events (28 growth and 6 rupture, 16.9%) occurred during follow-up in the aSAH-MIA group and 16 instability events (13 growth and 3 rupture, 8%) occurred in the control group. Risk factors for aneurysmal instability were aneurysm irregularity (OR 2.53; 95% CI 1.18 to 4.31), higher size ratio (OR 1.23; 95% CI 1.37 to 4.39), and middle cerebral artery location (OR 1.86; 95% CI 1.03 to 3.17). The risk of aneurysmal instability was substantially elevated in the aSAH-MIA group (HR 2.07; 95% CI 1.12 to 3.02). CONCLUSIONS Unruptured aneurysms in Chinese aSAH-MIA patients exhibited higher risks of growth and rupture than in patients with a single UIA. Middle cerebral artery location, higher size ratio and irregular shape were associated with higher risk of growth or rupture.
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Affiliation(s)
- Jian Liu
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yiping Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Chao Wang
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mirzat Turhon
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kun Wang
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengcheng Zhu
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Xinjian Yang
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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7
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Yamaguchi S, Osaki M, Kitamura T, Hokazono M, Wakisaka K, Maruyama T, Yasuda C, Sayama T, Arakawa S, Yoshimoto K. Narrowing of the Parent Artery Angle Is Associated With Intracranial Aneurysm Growth. Cureus 2024; 16:e51677. [PMID: 38318545 PMCID: PMC10839434 DOI: 10.7759/cureus.51677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVE Although risk factors for intracranial aneurysm growth have been reported, studies investigating the influence of the parent artery angle are limited. In this study, we examined the relationship between intracranial aneurysm growth and parent artery angle narrowing by analyzing long-term follow-up magnetic resonance angiography data. METHODS We retrospectively reviewed data of patients with untreated aneurysms and those treated by simple coil embolization, who were followed up by magnetic resonance angiography for over 24 months at the Steel Memorial Yawata Hospital between August 2007 and March 2023. We investigated the relationship of aneurysm growth with parent artery angle narrowing, age, sex, follow-up duration, previous subarachnoid hemorrhage, hypertension, smoking, aneurysm location, aneurysm type, maximum size, and neck size. RESULTS A total of 180 aneurysms of 162 patients (women, n=113; untreated, n=136) were included. The median age at aneurysm diagnosis was 71 (63.8-76) years and the median follow-up duration was 69 (45-120) months. Among the 180 aneurysms, 41 (untreated, n=30; treated by simple coil embolization, n=11) showed growth during the follow-up period, with a risk of 4.4%/patient-year. In the univariable analysis, the parent artery angles on the initial and last follow-up images and angle change were significantly associated with aneurysm growth. However, in the multivariable analysis, the association remained significant only for angle change (odds ratio, 2.21; 95% confidence interval, 1.42-3.45). The cutoff value of parent artery angle change for intracranial aneurysm growth was -3.4°. CONCLUSION Parent artery angle narrowing was significantly associated with intracranial aneurysm growth. This parameter may be useful for the monitoring of patients with unruptured intracranial aneurysms and may contribute to discerning the mechanism of intracranial aneurysm growth.
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Affiliation(s)
- Shinya Yamaguchi
- Department of Neurosurgery, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Masato Osaki
- Department of Cerebrovascular Disease, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Taisuke Kitamura
- Department of Cerebrovascular Disease, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Mariya Hokazono
- Department of Neurosurgery, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Kayo Wakisaka
- Department of Cerebrovascular Disease, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Takako Maruyama
- Department of Cerebrovascular Disease, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Chiharu Yasuda
- Department of Cerebrovascular Disease, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Tesuro Sayama
- Department of Neurosurgery, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Shuji Arakawa
- Department of Cerebrovascular Disease, Steel Memorial Yawata Hospital, Kitakyushu, JPN
| | - Koji Yoshimoto
- Department of Neurosurgery, Kyushu University, Fukuoka, JPN
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8
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Raghuram A, Sanchez S, Wendt L, Cochran S, Ishii D, Osorno C, Bathla G, Koscik TR, Torner J, Hasan D, Samaniego EA. 3D aneurysm wall enhancement is associated with symptomatic presentation. J Neurointerv Surg 2023; 15:747-752. [PMID: 35853699 PMCID: PMC10173164 DOI: 10.1136/jnis-2022-019125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Aneurysm wall enhancement (AWE) is a potential surrogate biomarker for aneurysm instability. Previous studies have assessed AWE using 2D multiplanar methods, most of which were conducted qualitatively. OBJECTIVE To use a new quantitative tool to analyze a large cohort of saccular aneurysms with 3D-AWE maps METHODS: Saccular aneurysms were imaged prospectively with 3T high resolution MRI. 3D-AWE maps of symptomatic (defined as ruptured or presentation with sentinel headache/cranial nerve neuropathy) and asymptomatic aneurysms were created by extending orthogonal probes from the aneurysm lumen into the wall. Three metrics were used to characterize enhancement: 3D circumferential AWE (3D-CAWE), aneurysm-specific contrast uptake (SAWE), and focal AWE (FAWE). Aneurysms with a circumferential AWE higher than the corpus callosum (3D-CAWE ≥1) were classified as 3D-CAWE+. Symptomatic presentation was analyzed with univariate and multivariate logistic models. Aneurysm size, size ratio, aspect ratio, irregular morphology, and PHASES and ELAPSS scores were compared with the new AWE metrics. Bleb and microhemorrhage analyses were also performed. RESULTS Ninety-three aneurysms were analyzed. 3D-CAWE, SAWE, and FAWE were associated with symptomatic status (OR=1.34, 1.25, and 1.08, respectively). A multivariate model including aneurysm size, 3D-CAWE+, age, female gender, and FAWE detected symptomatic status with 80% specificity and 90% sensitivity (area under the curve=0.914, =0.967). FAWE was also associated with irregular morphology and high-risk location (p=0.043 and p=0.001, respectively). In general, blebs enhanced 56% more than the aneurysm body. Areas of microhemorrhage co-localized with areas of increased SAWE (p=0.047). CONCLUSIONS 3D-AWE mapping provides a new set of metrics that could potentially improve the identification of symptomatic aneurysms.
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Affiliation(s)
- Ashrita Raghuram
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sebastian Sanchez
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Linder Wendt
- Institute for Clinical and Translational Science, The University of Iowa, Iowa City, Iowa, USA
| | - Steven Cochran
- Department of Psychiatry, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Daizo Ishii
- Department of Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Carlos Osorno
- Department of Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Girish Bathla
- Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Timothy R Koscik
- Department of Psychiatry, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - James Torner
- Institute for Clinical and Translational Science, The University of Iowa, Iowa City, Iowa, USA
- Department of Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David Hasan
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Department of Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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9
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Hall S, Birks J, Anderson I, Bacon A, Brennan PM, Bennett D, Chavredakis E, Critchley G, Dow G, Downer J, Galea J, Grover P, Gurusinghe N, Helmy A, Kounin G, Mukerji N, Patel H, Patel J, Ross N, St George J, Teo M, Tolias CM, Tzerakis N, Uff C, van Beijum J, Veighey K, White E, Whitfield P, Bulters DO. Risk of Aneurysm Rupture (ROAR) study: protocol for a long-term, longitudinal, UK multicentre study of unruptured intracranial aneurysms. BMJ Open 2023; 13:e070504. [PMID: 36927598 PMCID: PMC10030903 DOI: 10.1136/bmjopen-2022-070504] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Unruptured intracranial aneurysms (UIA) are common in the adult population, but only a relatively small proportion will rupture. It is therefore essential to have accurate estimates of rupture risk to target treatment towards those who stand to benefit and avoid exposing patients to the risks of unnecessary treatment. The best available UIA natural history data are the PHASES study. However, this has never been validated and given the known heterogeneity in the populations, methods and biases of the constituent studies, there is a need to do so. There are also many potential predictors not considered in PHASES that require evaluation, and the estimated rupture risk is largely based on short-term follow-up (mostly 1 year). The aims of this study are to: (1) test the accuracy of PHASES in a UK population, (2) evaluate additional predictors of rupture and (3) assess long-term UIA rupture rates. METHODS AND ANALYSIS The Risk of Aneurysm Rupture study is a longitudinal multicentre study that will identify patients with known UIA seen in neurosurgery units. Patients will have baseline demographics and aneurysm characteristics collected by their neurosurgery unit and then a single aggregated national cohort will be linked to databases of hospital admissions and deaths to identify all patients who may have subsequently suffered a subarachnoid haemorrhage. All matched admissions and deaths will be checked against medical records to confirm the diagnosis of aneurysmal subarachnoid haemorrhage. The target sample size is 20 000 patients. The primary outcome will be aneurysm rupture resulting in hospital admission or death. Cox regression models will be built to test each of the study's aims. ETHICS AND DISSEMINATION Ethical approval has been given by South Central Hampshire A Research Ethics Committee (21SC0064) and Confidentiality Advisory Group support (21CAG0033) provided under Section 251 of the NHS Act 2006. The results will be disseminated in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN17658526.
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Affiliation(s)
- Samuel Hall
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jacqueline Birks
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Ian Anderson
- Department of Neurosurgery, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew Bacon
- Department of Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Paul M Brennan
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | | | | | - Giles Critchley
- Department of Neurosurgery, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Graham Dow
- Department of Neurosurgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jonathan Downer
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - James Galea
- Neurosurgical Department, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Patrick Grover
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nihal Gurusinghe
- Department of Neurosurgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Adel Helmy
- Department of neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gueorgui Kounin
- Department of Neurosurgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Nitin Mukerji
- Department of Neurosurgery, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Hiren Patel
- Department of Neurosurgery, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Jash Patel
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas Ross
- Department of Neurosurgery, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Jerome St George
- Department of Neurosurgery, Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Mario Teo
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | | | - Nikolaos Tzerakis
- Department of Neurosurgery, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Christopher Uff
- Department of Neurosurgery, Barts Health NHS Trust, London, UK
| | - Janneke van Beijum
- Neurosurgical Department, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Kristin Veighey
- Department of Renal Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Edward White
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Whitfield
- South West Neurosurgery Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Diederik Oliver Bulters
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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10
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Liu J, Xing H, Chen Y, Lin B, Zhou J, Wan J, Pan Y, Yang Y, Zhao B. Rupture Risk Assessment for Anterior Communicating Artery Aneurysms Using Decision Tree Modeling. Front Cardiovasc Med 2022; 9:900647. [PMID: 35647040 PMCID: PMC9135965 DOI: 10.3389/fcvm.2022.900647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Although anterior communicating artery (ACoA) aneurysms have a higher risk of rupture than aneurysms in other locations, whether to treat unruptured ACoA aneurysms incidentally found is a dilemma because of treatment-related complications. Machine learning models have been widely used in the prediction of clinical medicine. In this study, we aimed to develop an easy-to-use decision tree model to assess the rupture risk of ACoA aneurysms. Methods This is a retrospective analysis of rupture risk for patients with ACoA aneurysms from two medical centers. Morphologic parameters of these aneurysms were measured and evaluated. Univariate analysis and multivariate logistic regression analysis were performed to investigate the risk factors of aneurysm rupture. A decision tree model was developed to assess the rupture risk of ACoA aneurysms based on significant risk factors. Results In this study, 285 patients were included, among which 67 had unruptured aneurysms and 218 had ruptured aneurysms. Aneurysm irregularity and vessel angle were independent predictors of rupture of ACoA aneurysms. There were five features, including size ratio, aneurysm irregularity, flow angle, vessel angle, and aneurysm size, selected for decision tree modeling. The model provided a visual representation of a decision tree and achieved a good prediction performance with an area under the receiver operating characteristic curve of 0.864 in the training dataset and 0.787 in the test dataset. Conclusion The decision tree model is a simple tool to assess the rupture risk of ACoA aneurysms and may be considered for treatment decision-making of unruptured intracranial aneurysms.
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Affiliation(s)
- Jinjin Liu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haixia Xing
- Department of Pathology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yongchun Chen
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Boli Lin
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jiafeng Zhou
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jieqing Wan
- Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yaohua Pan
- Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Department of Nuclear Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Yunjun Yang,
| | - Bing Zhao
- Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Bing Zhao,
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11
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Morel S, Bijlenga P, Kwak BR. Intracranial aneurysm wall (in)stability-current state of knowledge and clinical perspectives. Neurosurg Rev 2022; 45:1233-1253. [PMID: 34743248 PMCID: PMC8976821 DOI: 10.1007/s10143-021-01672-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/15/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022]
Abstract
Intracranial aneurysm (IA), a local outpouching of cerebral arteries, is present in 3 to 5% of the population. Once formed, an IA can remain stable, grow, or rupture. Determining the evolution of IAs is almost impossible. Rupture of an IA leads to subarachnoid hemorrhage and affects mostly young people with heavy consequences in terms of death, disabilities, and socioeconomic burden. Even if the large majority of IAs will never rupture, it is critical to determine which IA might be at risk of rupture. IA (in)stability is dependent on the composition of its wall and on its ability to repair. The biology of the IA wall is complex and not completely understood. Nowadays, the risk of rupture of an IA is estimated in clinics by using scores based on the characteristics of the IA itself and on the anamnesis of the patient. Classification and prediction using these scores are not satisfying and decisions whether a patient should be observed or treated need to be better informed by more reliable biomarkers. In the present review, the effects of known risk factors for rupture, as well as the effects of biomechanical forces on the IA wall composition, will be summarized. Moreover, recent advances in high-resolution vessel wall magnetic resonance imaging, which are promising tools to discriminate between stable and unstable IAs, will be described. Common data elements recently defined to improve IA disease knowledge and disease management will be presented. Finally, recent findings in genetics will be introduced and future directions in the field of IA will be exposed.
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Affiliation(s)
- Sandrine Morel
- Department of Pathology and Immunology, Faculty of Medicine, Centre Medical Universitaire, University of Geneva, Rue Michel-Servet 1, 1211, Geneva, Switzerland.
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
| | - Philippe Bijlenga
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Brenda R Kwak
- Department of Pathology and Immunology, Faculty of Medicine, Centre Medical Universitaire, University of Geneva, Rue Michel-Servet 1, 1211, Geneva, Switzerland
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12
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Timmins K, Kuijf H, Vergouwen M, Ruigrok Y, Velthuis B, van der Schaaf I. Relationship between 3D Morphologic Change and 2D and 3D Growth of Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 2022; 43:416-421. [PMID: 35144935 PMCID: PMC8910794 DOI: 10.3174/ajnr.a7418] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/02/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Untreated unruptured intracranial aneurysms are usually followed radiologically to detect aneurysm growth, which is associated with increased rupture risk. The ideal aneurysm size cutoff for defining growth remains unclear and also whether change in morphology should be part of the definition. We investigated the relationship between change in aneurysm size and 3D quantified morphologic changes during follow-up. MATERIALS AND METHODS We performed 3D morphology measurements of unruptured intracranial aneurysms on baseline and follow-up TOF-MRAs. Morphology measurements included surface area, compactness, elongation, flatness, sphericity, shape index, and curvedness. We investigated the relation between morphologic change between baseline and follow-up scans and unruptured intracranial aneurysm growth, with 2D and 3D growth defined as a continuous variable (correlation statistics) and a categoric variable (t test statistics). Categoric growth was defined as ≥1-mm increase in 2D length or width. We assessed unruptured intracranial aneurysms that changed in morphology and the proportion of growing and nongrowing unruptured intracranial aneurysms with statistically significant morphologic change. RESULTS We included 113 patients with 127 unruptured intracranial aneurysms. Continuous growth of unruptured intracranial aneurysms was related to an increase in surface area and flatness and a decrease in the shape index and curvedness. In 15 growing unruptured intracranial aneurysms (12%), curvedness changed significantly compared with nongrowing unruptured intracranial aneurysms. Of the 112 nongrowing unruptured intracranial aneurysms, 10 (9%) changed significantly in morphology (flatness, shape index, and curvedness). CONCLUSIONS Growing unruptured intracranial aneurysms show morphologic change. However, nearly 10% of nongrowing unruptured intracranial aneurysms change in morphology, suggesting that they could be unstable. Future studies should investigate the best growth definition including morphologic change and size to predict aneurysm rupture.
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Affiliation(s)
- K.M. Timmins
- From the Image Sciences Institute (K.M.T., H.J.K.)
| | - H.J. Kuijf
- From the Image Sciences Institute (K.M.T., H.J.K.)
| | - M.D.I. Vergouwen
- Department of Neurology and Neurosurgery (M.D.I.V., Y.M.R.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Y.M. Ruigrok
- Department of Neurology and Neurosurgery (M.D.I.V., Y.M.R.), University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - B.K. Velthuis
- Department of Radiology (B.K.V., I.C.v.d.S.), University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - I.C. van der Schaaf
- Department of Radiology (B.K.V., I.C.v.d.S.), University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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13
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van der Kamp LT, Rinkel GJE, Verbaan D, van den Berg R, Vandertop WP, Murayama Y, Ishibashi T, Lindgren A, Koivisto T, Teo M, St George J, Agid R, Radovanovic I, Moroi J, Igase K, van den Wijngaard IR, Rahi M, Rinne J, Kuhmonen J, Boogaarts HD, Wong GKC, Abrigo JM, Morita A, Shiokawa Y, Hackenberg KAM, Etminan N, van der Schaaf IC, Zuithoff NPA, Vergouwen MDI. Risk of Rupture After Intracranial Aneurysm Growth. JAMA Neurol 2021; 78:1228-1235. [PMID: 34459846 DOI: 10.1001/jamaneurol.2021.2915] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Unruptured intracranial aneurysms not undergoing preventive endovascular or neurosurgical treatment are often monitored radiologically to detect aneurysm growth, which is associated with an increase in risk of rupture. However, the absolute risk of aneurysm rupture after detection of growth remains unclear. Objective To determine the absolute risk of rupture of an aneurysm after detection of growth during follow-up and to develop a prediction model for rupture. Design, Setting, and Participants Individual patient data were obtained from 15 international cohorts. Patients 18 years and older who had follow-up imaging for at least 1 untreated unruptured intracranial aneurysm with growth detected at follow-up imaging and with 1 day or longer of follow-up after growth were included. Fusiform or arteriovenous malformation-related aneurysms were excluded. Of the 5166 eligible patients who had follow-up imaging for intracranial aneurysms, 4827 were excluded because no aneurysm growth was detected, and 27 were excluded because they had less than 1 day follow-up after detection of growth. Exposures All included aneurysms had growth, defined as 1 mm or greater increase in 1 direction at follow-up imaging. Main Outcomes and Measures The primary outcome was aneurysm rupture. The absolute risk of rupture was measured with the Kaplan-Meier estimate at 3 time points (6 months, 1 year, and 2 years) after initial growth. Cox proportional hazards regression was used to identify predictors of rupture after growth detection. Results A total of 312 patients were included (223 [71%] were women; mean [SD] age, 61 [12] years) with 329 aneurysms with growth. During 864 aneurysm-years of follow-up, 25 (7.6%) of these aneurysms ruptured. The absolute risk of rupture after growth was 2.9% (95% CI, 0.9-4.9) at 6 months, 4.3% (95% CI, 1.9-6.7) at 1 year, and 6.0% (95% CI, 2.9-9.1) at 2 years. In multivariable analyses, predictors of rupture were size (7 mm or larger hazard ratio, 3.1; 95% CI, 1.4-7.2), shape (irregular hazard ratio, 2.9; 95% CI, 1.3-6.5), and site (middle cerebral artery hazard ratio, 3.6; 95% CI, 0.8-16.3; anterior cerebral artery, posterior communicating artery, or posterior circulation hazard ratio, 2.8; 95% CI, 0.6-13.0). In the triple-S (size, site, shape) prediction model, the 1-year risk of rupture ranged from 2.1% to 10.6%. Conclusion and Relevance Within 1 year after growth detection, rupture occurred in approximately 1 of 25 aneurysms. The triple-S risk prediction model can be used to estimate absolute risk of rupture for the initial period after detection of growth.
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Affiliation(s)
- Laura T van der Kamp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Yuichi Murayama
- Department of Neurosurgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Antti Lindgren
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland.,Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Timo Koivisto
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.,Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Mario Teo
- Department of Neurosurgery, Institute of Neurological Science, Glasgow, United Kingdom
| | - Jerome St George
- Department of Neurosurgery, Institute of Neurological Science, Glasgow, United Kingdom
| | - Ronit Agid
- Division of Neuroradiology, Joint Department of Medical Imaging and Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ivan Radovanovic
- Division of Neuroradiology, Joint Department of Medical Imaging and Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Junta Moroi
- Department of Surgical Neurology, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Keiji Igase
- Department of Advanced Neurosurgery, Ehime University Graduate School of Medicine, Toon City, Ehime, Japan
| | | | - Melissa Rahi
- Clinical Neurosciences, University of Turku, Turku, Finland.,Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
| | - Jaakko Rinne
- Clinical Neurosciences, University of Turku, Turku, Finland.,Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
| | - Johanna Kuhmonen
- Clinical Neurosciences, University of Turku, Turku, Finland.,Department of Neurosurgery, Neurocenter, Turku University Hospital, Turku, Finland
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - George K C Wong
- Department of Surgery, Prince of Wales Hospital, Hong Kong, China
| | - Jill M Abrigo
- Department of Imaging and Interventional Radiology, Basement, Yue Kong Pao Centre for Cancer and the Lady Pao Children's Cancer Centre, Prince of Wales Hospital, Hong Kong, China
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | | | - Katharina A M Hackenberg
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Irene C van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nicolaas P A Zuithoff
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, University Medical Center Utrecht Brain Center, Utrecht University, University Medical Center Utrecht, Utrecht, the Netherlands
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14
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Timmins KM, Kuijf HJ, Vergouwen MDI, Otten MJ, Ruigrok YM, Velthuis BK, van der Schaaf IC. Reliability and Agreement of 2D and 3D Measurements on MRAs for Growth Assessment of Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol 2021; 42:1598-1603. [PMID: 34210663 DOI: 10.3174/ajnr.a7186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/29/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Reliable and reproducible measurement of unruptured intracranial aneurysm growth is important for unruptured intracranial aneurysm rupture risk assessment. This study aimed to compare the reliability and reproducibility of 2D and 3D growth measurements of unruptured intracranial aneurysms. MATERIALS AND METHODS 2D height, width, and neck and 3D volume measurements of unruptured intracranial aneurysms on baseline and follow-up TOF-MRAs were performed by two observers. The reliability of individual 2D and 3D measurements and of change (growth) between paired scans was assessed (intraclass correlation coefficient) and stratified for aneurysm location. The smallest detectable change on 2D and 3D was determined. Proportions of growing aneurysms were compared, and Bland-Altman plots were created. RESULTS Seventy-two patients with 84 unruptured intracranial aneurysms were included. The interobserver reliability was good-to-excellent for individual measurements (intraclass correlation coefficient > 0.70), poor for 2D change (intraclass correlation coefficient < 0.5), and good for 3D change (intraclass correlation coefficient = 0.76). For both 2D and 3D, the reliability was location-dependent and worse for irregularly shaped aneurysms. The smallest detectable changes for 2D height, width, and neck and 3D volume measurements were 1.5 , 2.0, and 1.9 mm and 0.06 mL, respectively. The proportion of growing unruptured intracranial aneurysms decreased from 10% to 2%, depending on the definition of growth (1 mm or the smallest detectable changes for 2D and 3D). CONCLUSIONS The interobserver reliability of the size measurements of individual 2D and 3D unruptured intracranial aneurysms was good-to-excellent but lower for 2D and 3D growth measurements. For growth assessment, 3D measurements are more reliable than 2D measurements. The smallest detectable change for 2D measurements was larger than 1 mm, the current clinical definition of unruptured intracranial aneurysm growth.
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Affiliation(s)
- K M Timmins
- From the Image Sciences Institute (K.M.T., H.J.K.)
| | - H J Kuijf
- From the Image Sciences Institute (K.M.T., H.J.K.)
| | | | - M J Otten
- , UMC Utrecht Brain Center, and Department of Radiology (M.J.O., B.K.V., I.C.v.d.S), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Y M Ruigrok
- Department of Neurology and Neurosurgery (M.D.I.V., Y.M.R.)
| | - B K Velthuis
- , UMC Utrecht Brain Center, and Department of Radiology (M.J.O., B.K.V., I.C.v.d.S), University Medical Center Utrecht, Utrecht, the Netherlands
| | - I C van der Schaaf
- , UMC Utrecht Brain Center, and Department of Radiology (M.J.O., B.K.V., I.C.v.d.S), University Medical Center Utrecht, Utrecht, the Netherlands
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15
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Juvela S. PHASES score and treatment scoring with cigarette smoking in the long-term prediction of rupturing of unruptured intracranial aneurysms. J Neurosurg 2021; 136:156-162. [PMID: 34243151 DOI: 10.3171/2020.11.jns203480] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment indications in unruptured intracranial aneurysms (UIAs) are challenging because of the lack of prospective natural history studies without treatment selection and the decreasing incidence of aneurysm rupture. The purpose of this study was to test whether the population, hypertension, age, size of aneurysm, earlier aneurysm rupture, site of aneurysm (PHASES) score obtained from an individual-based meta-analysis could predict the long-term rupture risk of UIAs. METHODS The series included 142 patients of working age with UIAs diagnosed before 1979, when these were not treated but were followed up until the first rupture, death, or the last contact. PHASES scores were recorded for all patients by using the baseline variables and compared with the new treatment score obtained from a recent cohort, consisting of age, smoking status, and aneurysm size and location. RESULTS Of the 142 patients, 34 had an aneurysm rupture during a total follow-up of 3064 person-years. The median time between diagnosis and an aneurysm rupture was 10.6 years. The PHASES score at baseline was higher in those with an aneurysm rupture than in the others (5.3 ± 2.3 vs 4.2 ± 2.2, p = 0.012), and the difference relative to the new treatment score was 5.3 ± 2.4 versus 3.0 ± 2.2 (p < 0.001). The receiver operating characteristic curve of the PHASES score for predicting rupture showed a fair area under the curve (0.674, 95% CI 0.558-0.790) where the optimal cutoff point was obtained at ≥ 6 versus < 6 points for sensitivity (0.500) and specificity (0.811). The area under the curve of the new score was 0.755 (95% CI 0.657-0.853), with the optimal cutoff point at ≥ 5 versus < 5 points for sensitivity (0.607) and specificity (0.789). CONCLUSIONS The PHASES and the new scores predicted the long-term aneurysm rupture risk moderately well, with the latter, which also included smoking, being slightly better and easier in clinical practice. The findings suggest that treatment decisions about UIAs in patients of working age can be done with an improved cost-effectiveness.
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16
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Abstract
Unruptured intracranial aneurysms (UIAs) are common and are being detected with increasing frequency given the improved quality and higher frequency of cross-sectional imaging. The long-term natural history of UIAs remains poorly understood. To date, there is relative lack of clear guidelines for selection of patients with UIAs for treatment. Surveillance imaging for untreated UIAs is frequently performed, but frequency, duration, and modality of surveillance imaging need clearer guidelines. The authors review the current evidence on prevalence, natural history, role of treatment, and surveillance and screening imaging and highlight the areas for further research.
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17
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Juvela S. Outcome of Patients with Multiple Intracranial Aneurysms after Subarachnoid Hemorrhage and Future Risk of Rupture of Unruptured Aneurysm. J Clin Med 2021; 10:1712. [PMID: 33921120 PMCID: PMC8071506 DOI: 10.3390/jcm10081712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/02/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Seppo Juvela
- Department of Clinical Neurosciences, University of Helsinki, FI-00029 Helsinki, Finland
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Neurovascular disease, diagnosis, and therapy: Brain aneurysms. HANDBOOK OF CLINICAL NEUROLOGY 2020; 176:121-134. [PMID: 33272392 DOI: 10.1016/b978-0-444-64034-5.00001-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Unruptured intracranial aneurysms (UIAs) have a prevalence of 3% in the adult population worldwide. The majority of UIAs are incidental findings, but some UIAs cause cranial nerve palsies, brainstem compression, ischemic events, or epileptic seizures. The most frequent clinical presentation of intracranial aneurysms is, however, rupture and thereby subarachnoid hemorrhage (SAH). To avoid SAH with its fatal consequences, patients with UIAs require counseling by dedicated and interdisciplinary neurovascular specialists. For the purpose of assessment and decision-making for the management of patients with UIAs, numerous aspects have to be considered: radiological characteristics, clinical symptoms, estimated rupture risk of an individual aneurysm as well as patient- and aneurysm-related risks of preventive repair. Generally, two management options exist: observation with follow-up imaging or preventive repair. This chapter discusses current data on pathogenesis, clinical presentation, diagnostics, risk factors for rupture and preventive repair, and guidance tools for the management of patients with UIAs according to current evidence.
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Scoring of Growth of Unruptured Intracranial Aneurysms. J Clin Med 2020; 9:jcm9103339. [PMID: 33080974 PMCID: PMC7603243 DOI: 10.3390/jcm9103339] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/07/2020] [Accepted: 10/16/2020] [Indexed: 11/24/2022] Open
Abstract
The purpose was to obtain a reliable scoring for growth of unruptured intracranial aneurysms (UIAs) in a long-term follow-up study from variables known at baseline and to compare it with the ELAPSS (Earlier subarachnoid hemorrhage, Location of the aneurysm, Age > 60 years, Population, Size of the aneurysm, and Shape of the aneurysm) score obtained from an individual-based meta-analysis. The series consists of 87 patients with 111 UIAs and 1669 person-years of follow-up between aneurysm size measurements (median follow-up time per patient 21.7, range 1.2 to 51.0 years). These were initially diagnosed between 1956 and 1978, when UIAs were not treated in our country. ELAPSS scores at baseline did not differ between those with and those without aneurysm growth. The area under the curve (AUC) for the receiver operating curve (ROC) of the ELAPSS score for predicting long-term growth was fail (0.474, 95% CI 0.345–0.603), and the optimal cut-off point was obtained at ≥7 vs. <7 points for sensitivity (0.829) and specificity (0.217). In the present series UIA growth was best predicted by female sex (4 points), smoking at baseline (3 points), and age <40 years (2 points). The AUC for the ROC of the new scoring was fair (0.662, 95% CI 0.546–0.779), which was significantly better than that of ELAPSS score (p < 0.05). The optimal cut-off point was obtained at ≥4 vs. <4 points for sensitivity (0.971) and specificity (0.304). A new simple scoring consisting of only female sex, cigarette smoking and age <40 years predicted growth of an intracranial aneurysm in long-term follow-up, significantly better than the ELAPSS score.
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Cognitive behavioral therapy reduces illness perceptions and anxiety symptoms in patients with unruptured intracranial aneurysm. J Clin Neurosci 2020; 80:56-62. [PMID: 33099367 DOI: 10.1016/j.jocn.2020.07.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 11/23/2022]
Abstract
The main purpose of this study was to assess the relation between cognitive behavioral therapy and possible changes in illness perceptions and anxiety in patients diagnosed with unruptured intracranial aneurysm. An observational study of an intervention with 67 patients with an unruptured intracranial aneurysm from two medical centers in a Colombian city (n = 35 on the intervention group) was carried out. To assess changes, measurements were taken at baseline and at one-year follow-up with the Beck Anxiety Inventory and the Illness Perception Questionnaire, brief version, taking into account the importance of perceptions in the process of adjusting to illness and acquiring healthy life habits. Hypotheses were tested by a structural model. The results obtained from this study showed that illness perceptions were related to anxiety levels at both time points; however, the relations were stronger before cognitive behavioral therapy (βt0 = 0.61, p < 0.01; βt1 = 0.37, p < 0.01). Cognitive behavioral therapy was found to be a moderator of changes in both illness perceptions and anxiety at the time of follow-up (β = -0.31, p < 0.01; β = -0.26, p < 0.01). The structural model suggests that cognitive behavioral therapy is associated with less anxiety (β = -0.17, p < 0.05) and better illness perceptions (β = -0.35, p < 0.01) in patients diagnosed with unruptured intracranial aneurysms.
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Personality and anxiety are related to health-related quality of life in unruptured intracranial aneurysm patients selected for non-intervention: A cross sectional study. PLoS One 2020; 15:e0229795. [PMID: 32163437 PMCID: PMC7067413 DOI: 10.1371/journal.pone.0229795] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/14/2020] [Indexed: 01/19/2023] Open
Abstract
Background Personality traits and mental health problems have been previously reported in unruptured intracranial aneurysm (UIA) patients; however, few studies have clarified the relations between these variables and health-related quality of life (HRQoL). This study was designed to characterize the personality traits, HRQoL and mental health of patients with UIA and to evaluate whether personality has an influence on HRQoL and whether this is mediated by the patients' emotional symptoms. Methods Sixty-three patients with UIAs (mean age 62.6 years, 83.9% women) answered questionnaires for depression, anxiety, HRQoL and personality traits between June 2016 and May 2019. Results Eight percent of the sample had depression, and 27.4% had anxiety. Participants showed high levels of responsibility, kindness and neuroticism and low levels of extraversion and openness. HRQoL scores were normal compared with the Colombian population. Structural equation analysis showed that patients' HRQoL was negatively affected by anxiety levels and that the latter are associated with the patient's personality, where neuroticism is directly associated with symptomatology and inversely associated with extraversion. Conclusions The results of this study showed the importance of personality and emotional symptoms in the HRQoL of UIA patients. These results are important for developing strategies for psychological counseling in patients with UIAs.
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Suarez JI, Macdonald RL. The End of the Tower of Babel in Subarachnoid Hemorrhage: Common Data Elements at Last. Neurocrit Care 2020; 30:1-3. [PMID: 31152313 DOI: 10.1007/s12028-019-00751-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jose I Suarez
- Division of Neurosciences Critical Care, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Sheikh Zayed Building, 3014C, Baltimore, MD, 21287, USA.
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Common Data Elements for Unruptured Intracranial Aneurysms and Subarachnoid Hemorrhage Clinical Research: A National Institute for Neurological Disorders and Stroke and National Library of Medicine Project. Neurocrit Care 2020; 30:4-19. [PMID: 31087257 DOI: 10.1007/s12028-019-00723-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The goal for this project was to develop a comprehensive set of common data elements (CDEs), data definitions, case report forms and guidelines for use in unruptured intracranial aneurysm (UIA) and subarachnoid hemorrhage (SAH) clinical research, as part of a new joint effort between the National Institute of Neurological Disorders and Stroke (NINDS) and the National Library of Medicine of the US National Institutes of Health. These UIA and SAH CDEs will join several other neurological disease-specific CDEs that have already been developed and are available for use by research investigators. METHODS A Working Group (WG) divided into eight sub-groups and a Steering Committee comprised of international UIA and SAH experts reviewed existing NINDS CDEs and instruments, created new elements when needed and provided recommendations for UIA and SAH clinical research. The recommendations were compiled, internally reviewed by the entire UIA and SAH WG and posted online for 6 weeks for external public comments. The UIA and SAH WG and the NINDS CDE team reviewed the final version before posting the SAH Version 1.0 CDE recommendations. RESULTS The NINDS UIA and SAH CDEs and supporting documents are publicly available on the NINDS CDE ( https://www.commondataelements.ninds.nih.gov/#page=Default ) and NIH Repository ( https://cde.nlm.nih.gov/home ) websites. The recommendations are organized into domains including Participant Characteristics and Outcomes and Endpoints. CONCLUSION Dissemination and widespread use of CDEs can facilitate UIA and SAH clinical research and clinical trial design, data sharing, and analyses of observational retrospective and prospective data. It is vital to maintain an international and multidisciplinary collaboration to ensure that these CDEs are implemented and updated when new information becomes available.
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