Sensitivity of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) in the Elderly: Retrospective Analysis of Ruptured Aneurysms

Sensitivity of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) to detect aneurysms at high-risk of rupture: Retrospective analysis in a cohort of 346 patients with a proven subarachnoid hemorrhage

INTRODUCTION

The aim of this study was to assess the capability of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) to discriminate unruptured intracranial aneurysms (UIAs) at high risk for subarachnoid hemorrhage (aSAH).

MATERIAL AND METHOD

During the period from January 2012 to December 2022, we included all consecutive adult patients admitted to our institution for an aSAH caused by the rupture of a saccular IA. The patient-related, aneurysm-related and treatment-related risk factors considered by UIATS were retrieved from medical records. After UIATS calculation for all ruptured IAs in the cohort, patients were categorized as "true positives (TP)" if UIATS would have (appropriately) oriented the management toward treatment, whereas patients for whom the UIATS would have (inappropriately) recommended observation were categorized as "false negatives (FN)". Patients for whom UIATS was inconclusive were categorized as "undetermined (UND)". Sensitivity of the UIATS (Se UIATS) was calculated by using the following formula: TP/(TP + FN).

RESULTS

A total of 346 patients (253 women, 73%; mean age = 56 ± 1.45 years) were incorporated into the final analysis. There were 140 T P (40%), 79 F N (23%) and 127 UND (37%), leading to a Se UIATS of 63.9% (CI 58.3-69.5). Cumulatively, the UIATS failed to provide an appropriate recommendation in 60% of the entire cohort.

CONCLUSION

By retrospectively applying the UIATS in a cohort of ruptured IAs, our study emphasizes how vulnerable the UIATS can be. Even if the UIATS suggests conservative management, clinicians should inform patients that there is still a small risk of rupture.

Gender Differences in Procedural Clinical Complications and Outcomes of Intracranial Aneurysms: Analysis of the Stroke Thrombectomy and Aneurysm Registry

BACKGROUND AND OBJECTIVES

Some studies have shown that female patients had a poorer prognosis after endovascular treatment for ruptured intracranial aneurysm than male patients. However, data have been sparse regarding differences in the periprocedural and perioperative complication rate with ruptured and unruptured intracranial aneurysms.

METHODS

This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry, a database of 9 institutions in the United States, Europe, and Asia. The study presented intracranial aneurysms after microsurgical and/or endovascular treatment from January 1, 2013, to December 31, 2022. The primary outcome was incidence of periprocedural cerebral infarction. Secondary outcomes were periprocedural intracranial hemorrhage, periprocedural mortality, perioperative vasospasm, and functional outcome at 90 days after procedure.

RESULTS

Among 3342 patients with aneurysm, 2447 were female and 857 were male, and the mean age of female and male patients was 59.6 and 57.1 years, respectively. Current smoker, family history of aneurysm, and ruptured aneurysm were observed in 23.5% vs 35.7 %, 10.8 % vs 5.7%, and 28.2% vs 40.5% of female and male patients, respectively. In female patients, internal carotid artery aneurysms were more commonly observed (31.1% vs 17.3%); however, anterior cerebral artery aneurysms were less commonly observed (18.5% vs 33.8%) compared with male patients. Periprocedural cerebral infarction rate was lower in female than male patients (2.4% vs 4.4%; P = .002). The adjusted odds ratio of primary outcome of female to male patients was 0.72 (95% CI, 0.46-1.12). Incidence of periprocedural intracranial hemorrhage and periprocedural mortality and perioperative symptomatic vasospasm and functional outcome was similar in both groups. In subgroup analysis, periprocedural cerebral infarction due to microsurgical treatment occurred frequently in male patients while incidence in endovascular treatment was similar in both groups (interaction P = .005).

CONCLUSION

This large multicenter registry of patients undergoing intracranial aneurysm treatment found that female patients were not at increased risk of perioperative complications.

Retrospective Application of Risk Scores to Unruptured Anterior Communicating Artery Aneurysms

BACKGROUND

Treatment decisions for unruptured intracranial aneurysms (UIAs) pose a challenge for neurosurgeons, prompting the development of clinical scales assessing hemorrhage risk to provide management guidance. This study compares recommendations from the PHASES and UIA treatment scores (UIATS) applied to anterior communicating artery (AComA) UIAs against real-world management.

METHODS

While UIATS recommends management, for PHASES, an aneurysm with score of 10 or more was considered "high-risk". Analysis involved assessing the concordance in each group alongside comparison to real-word management.

RESULTS

Among 129 patients, 46.5% were observed and 53.5% were treated. PHASES scores were significantly higher in the treatment group (p = 0.00002), and UIATS recommendations correlated with real-world decisions (p < 0.001). We observed no difference in the frequencies of UIATS recommendations between high- and low-risk groups. When comparing the UIATS and PHASES, 33% of high-risk aneurysms received a UIATS conservative management recommendation. In 39% of high-risk aneurysms, the UIATS recommendation was not definitive. Conversely, 27% of low-risk aneurysms obtained a UIATS UIA repair recommendation. Overall, concordance between PHASES and UIATS was 32%.

CONCLUSIONS

Significant discordance in therapeutic suggestions underscores the predominant influence of center experience and individual assessments. Future studies should refine and validate decision-making strategies, potentially exploring alternative applications or developing tailored scales.

Comparison of the unruptured intracranial aneurysm treatment score recommendations with clinical treatment results - A series of 322 aneurysms

Intracranial aneurysms occur with a prevalence of 3-5 %. Subarachnoid hemorrhage (SAH) due to aneurysm rupture is a rare but possibly fatal complication, so that occlusion of unruptured intracranial aneurysms (UIA) must be considered. The Unruptured Intracranial Aneurysm Treatment Score (UIATS) offers support for clinical decision making and has been shown to correlate with real life decisions in clinical practice. However, there is no data concerning the correlation of patient outcome and UIATS. Patients presenting to our outpatient clinic between January 1st, 2014 and December 31st, 2017 were retrospectively analyzed. We recorded the Extended Glasgow Outcome Scale (GOS-E) for longest possible follow-up, the choice of treatment, complications and UIATS recommendation. We included 221 patients with 322 UIA. 124 (38.5 %) UIA were observed and 198 (61.5 %) were occluded, of which 62 (31.3 %) underwent open surgery and 136 (68.7 %) were treated endovascularly. Spearman's rank correlation between our treatment choice and conclusive UIATS recommendation was 0.362 (p < 0.001). If UIATS was inconclusive, there were significantly more treatment-associated deteriorations (10/66 versus 7/132, p = 0.020). Otherwise, UIATS was not significantly associated with outcome. Therefore, treatment choice for UIA remains an individual decision. However, inconclusive UIATS must trigger vigilance and may be a negative prognostic marker for complications.