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Chebib FT, Tawk RG. All Patients with ADPKD Should Undergo Screening for Intracranial Aneurysms: CON. KIDNEY360 2024; 5:495-498. [PMID: 37990377 PMCID: PMC11093549 DOI: 10.34067/kid.0000000000000322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/15/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Fouad T. Chebib
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
- Mayo Clinic Florida PKD Center of Excellence, Jacksonville, Florida
| | - Rabih G. Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
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2
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Sanchez S, Essibayi MA, Hickerson M, Ojeda DJ, Kasab SA, Yoshimura S, Jabbour PM, Mascitelli J, Levitt MR, Cuellar-Saenz HH, Brinjikji W, Spiotta AM, Shaban A, Samaniego EA. Morphological characteristics of brain aneurysms among age groups. Interv Neuroradiol 2023:15910199231201520. [PMID: 37715650 DOI: 10.1177/15910199231201520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Patient's age is an important factor in determining the risk of aneurysm rupture. However, there is limited data on how aneurysm morphology differs among age groups. We studied morphological characteristics of brain aneurysms among age groups in a large cohort. METHODS Aneurysms from the Stroke Thrombectomy and Aneurysm Registry (STAR) were analyzed. The following parameters were included: location, size, neck, width, height, aspect ratio, and regular versus irregular morphology. The risk of rupture presentation was estimated using logistic regression. RESULTS A total of 1407 unruptured and 607 ruptured saccular aneurysms were included. The most common locations of ruptured aneurysms in patients younger than 70 years-old were the middle cerebral artery (MCA) and the anterior communicating artery (ACOM). The most common location of ruptured aneurysms in patients older than 70 years-old were the posterior communicating artery (PCOM) and ACOM. The size of unruptured aneurysms increased with age (p < .001). Conversely, the size of ruptured aneurysms was similar among age groups (p = .142). Unruptured and ruptured aneurysms became more irregular at presentation with older age (p < .001 and p .025, respectively). Irregular morphology and location were associated with rupture status across all age groups in multivariate regression. CONCLUSIONS Younger patients have small unruptured and ruptured aneurysms, and ruptured aneurysms are mostly located in the MCA and ACOM. Older patients have larger and more irregular unruptured aneurysms, and ruptured aneurysms are mostly located in the PCOM and ACOM. An irregular morphology increases the risk of rupture in all age groups.
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Affiliation(s)
| | | | | | | | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, USA
| | | | | | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, USA
| | | | | | | | | | - Amir Shaban
- Department of Neurology, University of Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa, USA
- Department of Neurosurgery, University of Iowa, USA
- Department of Radiology, University of Iowa, USA
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3
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Hall S, Abouharb A, Anderson I, Bacon A, Bahl A, Brydon H, Dow G, Fouyas I, Galea J, Ghosh A, Gurusinghe N, Kamel M, Minhas P, Mitchell P, Mowle D, Mukerji N, Nair R, Norris J, Patel H, Patel J, Patel K, St George J, Teo M, Toma A, Trivedi R, Uff C, Visca A, Walsh DC, White E, Whitfield P, Bulters D. A survey of the radiological follow-up of unruptured intracranial aneurysms in the United Kingdom. Br J Neurosurg 2023; 37:163-169. [PMID: 34738491 DOI: 10.1080/02688697.2021.1995587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Unruptured intracranial aneurysms (UIA) are common. For many the treatment risks outweigh their risk of subarachnoid haemorrhage and patients undergo surveillance imaging. There is little data to inform if and how to monitor UIAs resulting in widely varying practices. This study aimed to determine the current practice of unruptured UIA surveillance in the United Kingdom. METHODS A questionnaire was designed to address the themes of surveillance protocols for UIA including when surveillance is initiated, how frequently it is performed, and when it is terminated. Additionally, how aneurysm growth is managed and how clinically meaningful growth is defined were explored. The questionnaire was distributed to members of the British Neurovascular Group using probability-based cluster and non-probability purposive sampling methods. RESULTS Responses were received from 30 of the 30 (100.0%) adult neurosurgical units in the United Kingdom of which 27 (90.0%) routinely perform surveillance for aneurysm growth. Only four units had a unit policy. The mean patient age up to which a unit would initiate follow-up of a low-risk UIA was 65.4 ± 9.0 years. The time points at which imaging is performed varied widely. There was an even split between whether units use a fixed duration of follow-up or an age threshold for terminating surveillance. Forty percent of units will follow-up patients more than 5 years from diagnosis. The magnitude in the change in size that was felt to constitute growth ranged from 1 to 3mm. No units routinely used vessel wall imaging although 27 had access to 3T MRI capable of performing it. CONCLUSIONS There is marked heterogeneity in surveillance practices between units in the United Kingdom. This study will help units better understand their practice relative to their peers and provide a framework forplanning further research on aneurysm growth.
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Affiliation(s)
- Samuel Hall
- Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Ashraf Abouharb
- Department of Neurosurgery, Belfast Health and Social Care Trust, Belfast, UK
| | - Ian Anderson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew Bacon
- Sheffield Centre for Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anuj Bahl
- Department of Neurosurgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Howard Brydon
- Department of Neurosurgery, University Hospital of North Midlands NHS Trust, Stoke on Trent, UK
| | - Graham Dow
- Department of Neurosurgery, Queens Medical Centre, Nottingham, UK
| | - Ioannis Fouyas
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - James Galea
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Anthony Ghosh
- Department of Neurosurgery, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - Nihal Gurusinghe
- Department of Neurourgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - Pawan Minhas
- Department of Neurosurgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Patrick Mitchell
- Department of Neurosurgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - David Mowle
- Department of Neurosurgery, Ninewells Hospital and Medical School, Dundee, UK
| | - Nitin Mukerji
- Department of Neurosurgery, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Ramesh Nair
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - John Norris
- Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Hiren Patel
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Jash Patel
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Krunal Patel
- Department of Neurosurgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | | | - Mario Teo
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | - Ahmed Toma
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rikin Trivedi
- Department of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Chris Uff
- Department of Neurosurgery, Barts Health NHS Trust, London, UK
| | - Anna Visca
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Daniel C Walsh
- Department of Neurosurgery, King's College Hospital NHS Trust, London, UK
| | - Edward White
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Peter Whitfield
- Department of Neurosurgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Diederik Bulters
- Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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4
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Small symptomatic anterior communicating artery aneurysms: report of three cases and literature review. Acta Neurochir (Wien) 2023; 165:1001-1006. [PMID: 36826484 DOI: 10.1007/s00701-023-05506-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/20/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE Given the anatomical relationship between the ACom complex and the optic nerve, small aneurysms of the ACom can present with visual symptoms. CASE REPORTS We summarize and illustrate the clinical course of three patients with symptomatic small ACom aneurysms and collect similar other cases reported. RESULTS Ten patients with small unruptured visually symptomatic anterior communicating artery aneurysms were found in the literature. Including three patients herein reported, the mean age at presentation was 56. The most common visual symptoms were bitemporal vision loss and/or a decrease in visual acuity. CONCLUSION Unruptured aneurysms of the anterior communicating artery can present with visual symptoms due to compression of optic pathways, even at a small size. Prompt recognition and treatment of such a condition are paramount as new onset of visual symptoms can signify impending rupture akin to small PCom aneurysms compressing the third nerve. We discuss a few pitfalls of clipping small ACom aneurysms compressing the optic nerve.
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5
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Ikegami M, Kamide T, Ooigawa H, Take Y, Teranishi A, Suzuki K, Kohyama S, Kurita H. Clinical features of ruptured very small intracranial aneurysms (< 3 mm) in patients with subarachnoid hemorrhage. World Neurosurg 2022; 164:e1087-e1093. [DOI: 10.1016/j.wneu.2022.05.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/21/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022]
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6
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Sweid A, El Naamani K, Abbas R, Starke RM, Badih K, El Hajjar R, Saad H, Hammoud B, Andrews C, Rahm SP, Atallah E, Ramesh S, Tjoumakaris S, Gooch MR, Herial N, Hasan D, Rosenwasser RH, Jabbour P. Clipping Could Be the Best Treatment Modality for Recurring Anterior Communicating Artery Aneurysms Treated Endovascularly. Neurosurgery 2022; 90:627-635. [PMID: 35285450 PMCID: PMC9514745 DOI: 10.1227/neu.0000000000001905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The anterior communicating artery (AcoA) is the most common location for intracranial aneurysms. OBJECTIVE To present occlusion outcomes, complication rate, recurrence rate, and predictors of recurrence in a large cohort with AcoA aneurysms treated primarily with endosaccular embolization. We also attempt to present data on the most effective treatment modality for recurrent AcoA aneurysms. METHODS This is a retrospective, single-center study, reviewing the outcomes of 463 AcoA aneurysms treated endovascularly between 2003 and 2018. RESULTS The study cohort consisted of 463 patients. Adequate immediate occlusion was achieved in 418 (90.3%). Independent functional status at discharge was observed in 269 patients (58.0%), and the mortality rate was 6.8% (31). At 6 months, adequate occlusion was achieved in 418 (90.4%). Of all the patients, recurrence was observed in 101 cases (21.8%), and of those, 98 (22.4%) underwent retreatment. The combined frequency of retreatment for the coiling group was 42.4%, which was significantly higher than the 0 incident of retreatment in the clipping group (P < .0001). Among the retreatment cohort, there was a significantly higher subsequent retreatment rate in the endovascular group (0% in the clipping group vs 42.4% in the endovascular group, P < .0001). CONCLUSION Coiling with and without stent/balloon assistance is a relatively safe and effective modality for the treatment of AcoA aneurysms; however, in the setting of recurrence, microsurgical reconstruction leads to improved outcomes regarding durable occlusion, thus avoiding the potential for multiple interventions in the future.
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Affiliation(s)
- Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Hospital, Miami, Florida, USA;
| | - Khodr Badih
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | - Rayan El Hajjar
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA;
| | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA;
| | - Bassel Hammoud
- Department of Biomedical Engineering, American University of Beirut, Beirut, Lebanon;
| | - Carrie Andrews
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Sage P. Rahm
- Department of Neurosurgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA;
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Sunidhi Ramesh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - M. Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA;
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
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7
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Silva MA, Chen S, Starke RM. Unruptured cerebral aneurysm risk stratification: Background, current research, and future directions in aneurysm assessment. Surg Neurol Int 2022; 13:182. [PMID: 35509527 PMCID: PMC9062958 DOI: 10.25259/sni_1112_2021] [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: 11/05/2021] [Accepted: 04/07/2022] [Indexed: 12/04/2022] Open
Abstract
Background: The optimal management of unruptured cerebral aneurysms is widely debated in the medical field. Rapid technology advances, evolving understanding of underlying pathophysiology, and shifting practice patterns have made the cerebrovascular field particularly dynamic in recent years. Despite progress, there remains a dearth of large randomized studies to help guide the management of these controversial patients. Methods: We review the existing literature on the natural history of unruptured cerebral aneurysms and highlight ongoing research aimed at improving our ability to stratify risk in these patients. Results: Landmark natural history studies demonstrated the significance of size, location, and other risk factors for aneurysm rupture, but prior studies have significant limitations. We have begun to understand the underlying pathophysiology behind aneurysm formation and rupture and are now applying new tools such as flow dynamics simulations and machine learning to individualize rupture risk stratification. Conclusion: Prior studies have identified several key risk factors for aneurysmal rupture, but have limitations. New technology and research methods have enabled us to better understanding individual rupture risk for patients with unruptured cerebral aneurysms.
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8
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McGuinness B, Chieng N, Skipworth C, Caldwell J, Molyneux A. Small ruptured cerebral aneurysms-do they rupture on formation or not? Neuroradiology 2021; 64:597-602. [PMID: 34591129 DOI: 10.1007/s00234-021-02738-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Of patients presenting with subarachnoid haemorrhage, most are due to rupture of a small aneurysm. It has been postulated that in most cases, these aneurysms form and rupture rapidly over a short period of time of days to weeks. We evaluated the hypothesis that such aneurysms therefore should never be discoverable as a pre-existing condition on medical imaging studies. METHODS All patients presenting with subarachnoid haemorrhage due to a small cerebral aneurysm over an 11-year period were reviewed for prior imaging studies capable of detecting small aneurysms. In the subgroup that had such imaging studies, these were reviewed for the presence or absence of the index aneurysm. RESULTS Of 851 patients presenting with subarachnoid haemorrhage over an 11-year period, 35 had prior imaging studies capable of detecting small aneurysms. In 18 out of these 35 (51%) patients, the index aneurysm was identified as a small unruptured aneurysm on these prior studies. The median time between prior imaging and aneurysm rupture was 31 months. CONCLUSION The theory that nearly all cases of subarachnoid haemorrhage due to small aneurysms occur as a result of aneurysm formation, and rupture over a short time period is incorrect. Our findings indicate that at least half of all subarachnoid haemorrhage cases arise from the population harbouring small aneurysms as a pre-existing condition.
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Affiliation(s)
- Ben McGuinness
- Radiology Department, Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand.
| | - Nicholas Chieng
- Radiology Department, Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand
| | - Connor Skipworth
- Radiology Department, Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand
| | - James Caldwell
- Radiology Department, Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand
| | - Andrew Molyneux
- Neurovascular and Neuroradiology Research Unit, Nuffield Department of Surgical Sciences, Oxford University, Oxford, Oxfordshire, UK
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Burlakoti A, Kumaratilake J, Taylor DJ, Henneberg M. Quantifying asymmetry of anterior cerebral arteries as a predictor of anterior communicating artery complex aneurysm. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2020; 2:e000059. [PMID: 35047797 PMCID: PMC8749284 DOI: 10.1136/bmjsit-2020-000059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/29/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The aim of this study was to establish an anatomical index for early prediction of the risk of development of aneurysms in anterior communicating arterial complex (AcomAC). The asymmetric diameter of one anterior cerebral artery (ACA) to other could alter haemodynamics and may contribute to formation of aneurysms in AcomAC and be a reliable predictor of the risk of development of aneurysms. DESIGN AND SETTING This is a retrospective, observational and quantitative study, which used cerebral computed tomography angiography (CCTA) scans in South Australia. PARTICIPANTS CCTA scans of 166 adult patients of both sexes were studied. MAIN OUTCOME MEASURES The internal diameters of the proximal segments of ACAs (A1s) were measured. Position and presence or absence of aneurysms in AcomAC were determined. The ratio of A1 diameters was taken as a measure of A1 asymmetry. RESULTS The ratio of diameters of A1s correlated with the occurrence of AcomAC aneurysms. The risk of development of aneurysms in AcomAC was much greater (80%, OR=47.3) when one A1 segment's radius was at least 50% larger (ie, 2.25 times cross-sectional area) than the other. CONCLUSION The general information on asymmetric A1 has been published previously. The present findings have significant contribution since the A1s asymmetry ratios have been categorised in ascending order and matched with the presence of AcomAC aneurysms. The asymmetry ratio of the A1 is a good predictor for the development of AcomAC aneurysms. Reconstruction of the asymmetric A1 could be done if the technology gets advanced.
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Affiliation(s)
- Arjun Burlakoti
- UniSA Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Jaliya Kumaratilake
- Discipline of Anatomy and Pathology, Adelaide Medical School, The University of Adelaide Faculty of Health Sciences, Adelaide, South Australia, Australia
| | - David J Taylor
- SA Medical Imaging, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Maciej Henneberg
- Institute of Evolutionary Medicine, University of Zurich Faculty of Medicine, Zurich, ZH, Switzerland
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Majeed K, Boddu SR, Carnevale J, Cenberlitas EE, Williams N, Patsalides A, Gobin YP, Knopman J, Stieg PE. Intracranial Aneurysms: Does Size Really Matter? NEUROSURGERY OPEN 2020. [DOI: 10.1093/neuopn/okaa015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
To stratify the risk of aneurysmal rupture, size remains the primary criterion as proposed by 2 ISUIA (International Study of Unruptured Intracranial Aneurysms) trials that recommend the observation of ≤7 mm aneurysms because of their low propensity to rupture. These recommendations are controversial, given the severe outcomes following hemorrhage.
OBJECTIVE
To retrospectively assess whether size correlates with aneurysmal rupture, and to analyze outcomes of endovascular and microsurgical procedures.
METHODS
All aneurysms presenting between 2016 and 2019 were reviewed. Age, gender, comorbidities, ruptured status, modes of treatment, and their outcomes were noted. Regression analysis was performed to correlate size with rupture. The type of intervention was based on clinical and aneurysmal characteristics and the likelihood of obliteration.
RESULTS
Of the 668 aneurysms, 116 had ruptured. In size groups 0 to 6 mm, 7 to 12 mm, 13 to 18 mm, 18 to 24 mm, and giant, the ruptured aneurysms were 60.3%, 30.2%, 1.7%, 0.9%, and 6.9%, respectively. The majority (423) were managed endovascularly, of which 84 (19.9%) were ruptured. A total of 97 (14.5%) underwent clipping, of which 31 were ruptured. The mean modified Rankin Scale for both treated groups was zero. One death in each group and a single brainstem stroke in the coiled group were noted. A total of 139 were followed, of which none had ruptured. The mean modified Raymond-Roy classification for endovascular therapy was 1.1, with 380 completely occluded; 15 had a score of 2, and 28 of score 3.
CONCLUSION
The ruptured aneurysms were mostly smaller than reported previously. Surgical clipping was at equipoise with endovascular treatments. Further studies to correlate aneurysmal characteristics to the risk of rupture are needed.
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Affiliation(s)
- Kashif Majeed
- Department of Neurological Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Srikanth R Boddu
- Department of Neurological Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Joseph Carnevale
- Department of Neurological Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | | | - Nicholas Williams
- Department of Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, New York
| | - Athos Patsalides
- Department of Neurological Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Yves Pierre Gobin
- Department of Neurological Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Jared Knopman
- Department of Neurological Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York
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11
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Rinaldo L, Nesvick CL, Rabinstein AA, Lanzino G. Differences in Size Between Unruptured and Ruptured Saccular Intracranial Aneurysms by Location. World Neurosurg 2020; 133:e828-e834. [DOI: 10.1016/j.wneu.2019.10.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
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12
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Yanagawa T, Harada Y, Hatayama T, Kono T. Rupture immediately after growth of unruptured intracranial aneurysms during follow-up. Surg Neurol Int 2019; 10:164. [PMID: 31583161 PMCID: PMC6763665 DOI: 10.25259/sni_262_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/19/2019] [Indexed: 11/20/2022] Open
Abstract
Background: The annual rupture rate of small unruptured intracranial aneurysms (UIAs) <5 mm is generally low; further, small UIAs are often treated conservatively. While the growth of aneurysms during follow-up is associated with a high risk of rupture, the urgency for surgical treatment of asymptomatic enlarged UIAs remains controversial. We experienced two patients in whom UIAs ruptured shortly after asymptomatic growth during follow-up. Case Description: A 1-mm right middle cerebral artery aneurysm was incidentally found in a 63-year-old woman. Preventive surgery was planned because the aneurysm grew rapidly; however, the aneurysm ruptured preoperatively. A 68-year-old woman had a small (4 mm) aneurysm at the left internal carotid-posterior communicating artery. The aneurysm grew rapidly after many years. Several hours after magnetic resonance imaging was performed, she presented to the hospital with loss of consciousness, and a diagnosis of subarachnoid hemorrhage due to the ruptured aneurysm was made. Conclusion: UIAs that rapidly increase during follow-up may be regarded as impending ruptured aneurysms.
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Affiliation(s)
- Taro Yanagawa
- Department of Neurosurgery, Mito Brain Heart Center, Mito, Ibaraki, Japan
| | - Yoichi Harada
- Department of Neurosurgery, Mito Brain Heart Center, Mito, Ibaraki, Japan
| | - Toru Hatayama
- Department of Neurosurgery, Mito Brain Heart Center, Mito, Ibaraki, Japan
| | - Takuji Kono
- Department of Neurosurgery, Mito Brain Heart Center, Mito, Ibaraki, Japan
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13
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Malhotra A, Wu X, Forman HP, Matouk CC, Gandhi D, Sanelli P. Management of Tiny Unruptured Intracranial Aneurysms: A Comparative Effectiveness Analysis. JAMA Neurol 2019; 75:27-34. [PMID: 29159405 DOI: 10.1001/jamaneurol.2017.3232] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Unruptured intracranial aneurysms (UIAs) are relatively common in the general population and are being increasingly diagnosed; a significant proportion are tiny (≤3 mm) aneurysms. There is significant heterogeneity in practice and lack of clear guidelines on the management of incidental, tiny UIAs. It is important to quantify the implications of different management strategies in terms of health benefits to patients. Objective To evaluate the effectiveness of routine treatment (aneurysm coiling) vs 3 strategies for imaging surveillance compared with no preventive treatment or routine follow-up of tiny UIAs. Design, Setting, and Participants A decision-analytic model-based comparative effectiveness analysis was conducted from May 1 to June 30, 2017, using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included 10 000 iterations simulating adult patients with incidental detections of UIAs 3 mm or smaller and no history of subarachnoid hemorrhage. Interventions The following 5 management strategies for tiny UIAs were evaluated: annual magnetic resonance angiography (MRA) screening, biennial MRA screening, MRA screening every 5 years, aneurysm coiling and follow-up, and no treatment or preventive follow-up. Main Outcomes and Measures A Markov decision model for lifetime rupture was constructed from a societal perspective per 10 000 patients with incidental, tiny UIAs. Outcomes were assessed in terms of quality-adjusted life-years. Probabilistic, 1-way, and 2-way sensitivity analyses were performed. Results In this analysis of 10 000 iterations simulating adult patients with a mean age of 50 years, the base-case calculation shows that the management strategy of no treatment or preventive follow-up has the highest health benefit (mean [SD] quality-adjusted life-years, 19.40 [0.31]). Among the management strategies that incorporate follow-up imaging, MRA every 5 years is the best strategy with the next highest effectiveness (mean [SD] quality-adjusted life-years, 18.05 [0.62]). The conclusion remains robust in probabilistic and 1-way sensitivity analyses. No routine follow-up remains the optimal strategy when the annual growth rate and risk of rupture of growing aneurysms are varied. When the annual risk of rupture of nongrowing UIAs is less than 1.7% (0.23% in base case scenario), no follow-up is the optimal strategy. If annual risk of rupture is more than 1.7%, coiling should be performed directly. Conclusions and Relevance Given the current literature, no preventive treatment or imaging follow-up is the most effective strategy in patients with aneurysms that are 3 mm or smaller, resulting in better health outcomes. More aggressive imaging surveillance for aneurysm growth or preventive treatment should be reserved for patients with a high risk of rupture. Given these findings, it is important to critically evaluate the appropriateness of current clinical practices, and potentially determine specific guidelines to reflect the most effective management strategy for patients with incidental, tiny UIAs.
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Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, of Economics, of Management, and of Public Health, Yale School of Medicine, New Haven, Connecticut
| | - Charles C Matouk
- Department of Neurosurgery and of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Dheeraj Gandhi
- Interventional Neuroradiology, Radiology, Nuclear Medicine, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Long Island, New York
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Wu X, Matouk CC, Mangla R, Forman HP, Gandhi D, Sanelli P, Malhotra A. Cost-Effectiveness of Computed Tomography Angiography in Management of Tiny Unruptured Intracranial Aneurysms in the United States. Stroke 2019; 50:2396-2403. [DOI: 10.1161/strokeaha.119.025600] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background and Purpose—
Our study aims to evaluate the cost-effectiveness of computed tomography angiography (CTA) for surveillance of tiny unruptured intracranial aneurysms and the impact of CTA radiation-induced brain tumor on the overall effectiveness of CTA.
Methods—
A Markov decision model was constructed from a societal perspective starting with patients 30-, 40-, or 50-year-old, with incidental detection of unruptured intracranial aneurysm ≤3 mm and no prior history of subarachnoid hemorrhage. Five different management strategies were assessed (1) annual CTA surveillance, (2) biennial CTA, (3) CTA follow-up every 5 years, (4) coiling and subsequent magnetic resonance imaging follow-up, and (5) annual CTA surveillance for the first 2 years, followed by every 5-year CTA follow-up. Probabilistic, 1-way, and 2-way sensitivity analyses were performed.
Results—
The base case calculation shows every 5-year CTA follow-up to be the most cost-effective strategy, and the conclusion remains robust in probabilistic sensitivity analysis. It remains the dominant strategy when the annual rupture risk of nongrowing unruptured intracranial aneurysms is smaller than 2.66% or the rupture risk in growing aneurysms is <57.4%. The radiation-induced brain cancer risk is relatively low, and sensitivity analysis shows that the radiation-induced cancer risk does not influence the conclusions unless the risk exceeds 663-fold of the base case values.
Conclusions—
Given the current literature, every 5-year CTA imaging follow-up is the cost-effective strategy in patients with aneurysms ≤3 mm, resulting in better health outcomes and lower healthcare spending. Patients with aneurysms at high risk of rupture might need more aggressive management.
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Affiliation(s)
- Xiao Wu
- From the Department of Radiology and Biomedical Imaging (X.W., C.C.M., H.P.F.), Yale School of Medicine, New Haven, CT
| | - Charles C. Matouk
- From the Department of Radiology and Biomedical Imaging (X.W., C.C.M., H.P.F.), Yale School of Medicine, New Haven, CT
- Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
| | - Rajiv Mangla
- Department of Radiology, State University of New York, Upstate Medical University (R.M.)
| | - Howard P. Forman
- From the Department of Radiology and Biomedical Imaging (X.W., C.C.M., H.P.F.), Yale School of Medicine, New Haven, CT
- Department of Economics, of Management, and of Public Health (H.P.F.), Yale School of Medicine, New Haven, CT
| | - Dheeraj Gandhi
- University of Maryland School of Medicine, Baltimore (D.G.)
| | - Pina Sanelli
- Department of Radiology, The Imaging Clinical Effectiveness and Outcomes Research, Northwell Health (P.S.)
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Ikawa F, Hidaka T, Yoshiyama M, Ohba H, Matsuda S, Ozono I, Iihara K, Kinouchi H, Nozaki K, Kato Y, Morita A, Michihata N, Yasunaga H, Kurisu K. Characteristics of Cerebral Aneurysms in Japan. Neurol Med Chir (Tokyo) 2019; 59:399-406. [PMID: 31462602 PMCID: PMC6867938 DOI: 10.2176/nmc.ra.2019-0099] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The characteristics of cerebral aneurysms in Japan differ from other countries in the higher incidence of unruptured cerebral aneurysm detected by brain check-up screening, higher rupture rate of unruptured cerebral aneurysm, higher incidence of subarachnoid hemorrhage, and superior outcome after subarachnoid hemorrhage based on meta-analysis. Head shape, genetic features, environmental factors, demographics, and medical system in Japan are also different from other countries. Unruptured cerebral aneurysms are 2.8 times more likely to rupture in Japanese than western aneurysms, resulting in the highest incidence of subarachnoid hemorrhage in the world. The exact and specific mechanisms of de novo, growth, and rupture of cerebral aneurysms have not been elucidated. Investigations will contribute to the understanding of cerebral aneurysms and subarachnoid hemorrhage worldwide. Some features of cerebral aneurysm in Japan are discussed for possible research guidance in the elucidation of the predominance of subarachnoid hemorrhage in Japan.
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Affiliation(s)
- Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital
| | - Toshikazu Hidaka
- Department of Neurosurgery, Shimane Prefectural Central Hospital
| | | | - Hideo Ohba
- Department of Neurosurgery, Shimane Prefectural Central Hospital
| | - Shingo Matsuda
- Department of Neurosurgery, Shimane Prefectural Central Hospital
| | - Iori Ozono
- Department of Neurosurgery, Shimane Prefectural Central Hospital
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences Kyushu University
| | - Hiroyuki Kinouchi
- Department of Neurosurgery, Faculty of Medicine, University of Yamanashi
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School Hospital
| | - Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Kaoru Kurisu
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University
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Lepski G, Lobão CAF, Taylor S, Mesquita Filho PM, Tatagiba M. Bleeding risk of small intracranial aneurysms in a population treated in a reference center. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:300-309. [PMID: 31188992 DOI: 10.1590/0004-282x20190046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 02/05/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Large multicenter studies have shown that small intracranial aneurysms are associated with a minimal risk of bleeding. Nevertheless, other large series have shown that most ruptured aneurysms are, in fact, the smaller ones. In the present study, we questioned whether small aneurysms are indeed not dangerous. METHODS We enrolled 290 patients with newly-diagnosed aneurysms at our institution over a six-year period (43.7% ruptured). We performed multivariate analyses addressing epidemiological issues, cardiovascular diseases, and three angiographic parameters (largest aneurysm diameter, neck diameter and diameter of the nutrition vessel). Risk estimates were calculated using a logistic regression model. Aneurysm size parameters were stratified according to receiver operating characteristic (ROC) curves. Finally, we calculated odds ratios for rupture based on the ROC analysis. RESULTS The mean largest diameter for the ruptured versus unruptured groups was 13.3 ± 1.7 mm versus 22.2 ± 2.2 mm (p < 0.001). Multivariate analysis revealed a positive correlation between rupture and arterial hypertension (p < 0.001) and an inverse correlation with all three angiographic measurements (all p < 0.01). Aneurysms from the anterior cerebral artery bled more often (p < 0.05). According to the ROC curves, at the largest diameter of 15 mm, the sensitivity and specificity to predict rupture were 83% and 36%, respectively. Based on this stratification, we calculated the chance of rupture for aneurysms smaller than 15 mm as 46%, which dropped to 25% for larger aneurysms. CONCLUSION In the population studied at our institution, small aneurysms were more prone to bleeding. Therefore, the need for intervention for small aneurysms should not be overlooked.
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Affiliation(s)
- Guilherme Lepski
- Universitätsklinik für Neurochirurgie, Eberhard Karls University, Tübingen, Deutschland
| | - Carlos A F Lobão
- Universitätsklinik für Neurochirurgie, Eberhard Karls University, Tübingen, Deutschland
| | - Stella Taylor
- Universitätsklinik für Neurochirurgie, Eberhard Karls University, Tübingen, Deutschland
| | | | - Marcos Tatagiba
- Universitätsklinik für Neurochirurgie, Eberhard Karls University, Tübingen, Deutschland
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Malhotra A, Wu X, Forman HP, Matouk CC, Hughes DR, Gandhi D, Sanelli P. Management of Unruptured Intracranial Aneurysms in Older Adults: A Cost-effectiveness Analysis. Radiology 2019; 291:411-417. [PMID: 30888931 DOI: 10.1148/radiol.2019182353] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Unruptured intracranial aneurysms (UIAs) are relatively common and are being increasingly diagnosed, with a significant proportion in older patients (˃ 65 years old). Serial imaging is often performed to assess change in size or morphology of UIAs since growing aneurysms are known to be at high risk for rupture. However, the frequency and duration of surveillance imaging have not been established. Purpose To evaluate the cost-effectiveness of routine treatment (aneurysm coil placement) versus four different strategies for imaging surveillance of UIAs in adults older than 65 years. Materials and Methods A Markov decision-analytic model was constructed from a societal perspective. Age-dependent input parameters were obtained from published literature. Analysis included adults older than 65 years, with incidental detection of UIA and no prior history of subarachnoid hemorrhage. Five different management strategies for UIAs in older adults were evaluated: (a) annual MR angiography, (b) biennial MR angiography, (c) MR angiography every 5 years, (d) coil placement and follow-up, and (e) limited MR angiography follow-up for the first 2 years after detection only. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Probabilistic, one-way, and two-way sensitivity analyses were performed. Results Imaging follow-up for the first 2 years after detection is the most cost-effective strategy (cost = $24 572, effectiveness = 13.73 QALYs), showing the lowest cost and highest effectiveness. The conclusion remains robust in probabilistic and one-way sensitivity analyses. Time-limited imaging follow-up remains the optimal strategy when the annual growth rate and rupture risk of growing aneurysms are varied. If annual rupture risk of nongrowing aneurysms is greater than 7.1%, coil placement should be performed directly. Conclusion Routine preventive treatment or periodic, indefinite imaging follow-up is not a cost-effective strategy in all adults older than 65 years with unruptured intracranial aneurysms. More aggressive management strategies should be reserved for patients with high risk of rupture, such as those with aneurysms larger than 7 mm and those with aneurysms in the posterior circulation. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Cloft in this issue.
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Affiliation(s)
- Ajay Malhotra
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Xiao Wu
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Howard P Forman
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Charles C Matouk
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Danny R Hughes
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Dheeraj Gandhi
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
| | - Pina Sanelli
- From the Departments of Radiology and Biomedical Imaging (A.M., X.W., H.P.F., C.C.M.), Economics (H.P.F.), Management (H.P.F.), Public Health (H.P.F.), and Neurosurgery (C.C.M.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, VA (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (D.G.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.)
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18
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Malhotra A, Wu X, Forman HP, Grossetta Nardini HK, Matouk CC, Gandhi D, Moore C, Sanelli P. Growth and Rupture Risk of Small Unruptured Intracranial Aneurysms: A Systematic Review. Ann Intern Med 2017; 167:26-33. [PMID: 28586893 DOI: 10.7326/m17-0246] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Small unruptured intracranial aneurysms (UIAs) are increasingly diagnosed. Management depends on growth and rupture risks, which may vary by aneurysm size. PURPOSE To summarize evidence about the growth and rupture risk of UIAs 7 mm and smaller and to explore differences in growth and rupture risks of very small (≤3 mm) and small (≤5 mm) aneurysms. DATA SOURCES MEDLINE, EMBASE, Scopus, and the Cochrane Library from inception to 2017 (with no language restrictions). STUDY SELECTION Published case series and observational studies that reported natural history data on UIAs 7 mm and smaller. DATA EXTRACTION 2 reviewers abstracted study information, evaluated study quality, and graded strength of evidence. DATA SYNTHESIS Of 26 studies, 5, 10, and 8 described the growth rate of aneurysms 3 mm and smaller, 5 mm and smaller, and 7 mm and smaller, respectively, whereas rupture rates were reported in 7, 11, and 13 studies for aneurysms 3 mm and smaller, 5 mm and smaller, and 7 mm and smaller, respectively. The annualized growth rate was less than 3% in all but 1 study for all 3 size categories. The annualized rupture rate was 0%, less than 0.5%, and less than 1% for the 3 size categories, respectively. Strength of evidence was very low quality for growth rates and low quality for rupture rates. LIMITATION Heterogeneous definitions of growth; heterogeneous and selective treatment and follow-up methods, particularly in high-risk patients. CONCLUSION Poor-quality evidence suggests that small UIAs have low growth and rupture rates and very small UIAs have little or no risk for rupture. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ajay Malhotra
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Xiao Wu
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Howard P Forman
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Holly K Grossetta Nardini
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Charles C Matouk
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Dheeraj Gandhi
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Christopher Moore
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
| | - Pina Sanelli
- From Yale School of Medicine and Yale University, New Haven, Connecticut; University of Maryland School of Medicine, Baltimore, Maryland; and Northwell Health, Manhasset, New York
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Associations of Endothelin Polymorphisms and Aneurysm Size at Time of Rupture. World Neurosurg 2017; 102:253-257. [DOI: 10.1016/j.wneu.2017.03.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/21/2022]
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20
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Hokari M, Nakayama N, Shimoda Y, Houkin K. Effect of Headache on the Pathologic Findings of Unruptured Cerebral Saccular Aneurysms. World Neurosurg 2017; 103:431-441. [PMID: 28427983 DOI: 10.1016/j.wneu.2017.01.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/15/2017] [Accepted: 01/17/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Some patients with aneurysm exhibit warning headaches without minor bleeding, and this could be caused by stretching of the aneurysm wall. Recently, our pathologic study observed subintimal fibrin deposition in a majority of the ruptured aneurysms. However, these findings also were observed in some unruptured aneurysms. In this report, 2 unruptured aneurysms exhibited subintimal fibrin, and interestingly, one of the patients experienced severe headache within 1 month before neuroimaging. OBJECTIVE We performed pathologic analysis of unruptured aneurysms and collected their various clinical variables, including severe headache, to clarify the clinical characteristics of "dangerous" unruptured aneurysms. METHODS This study included unruptured saccular aneurysm samples (n = 17) that were resected after clipping. We compared the differences in clinical variables, including warning headache, between aneurysms with and without fibrin deposition. RESULTS Fibrin deposition was present in the subintimal layer in 4 patients and in the periouter membrane in 4 patients. Three of the 4 former patients experienced warning headaches, and one presented aneurysm growth. Of the latter 4 patients, one exhibited aneurysm growth, whereas the others presented with relatively large aneurysms. In the remaining 9 aneurysms without fibrin deposition, monocyte infiltration was observed in one, all aneurysms were small, and no patients experienced warning headaches or aneurysm growth. CONCLUSIONS Subintimal fibrin deposition is observed frequently in patients with aneurysm with warning headaches. These pathologic findings are clinically inspiring and may suggest that these aneurysms exhibit rapid stretching by newly formed aneurysms, which can result in rupture at an early stage.
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Affiliation(s)
- Masaaki Hokari
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Naoki Nakayama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yusuke Shimoda
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kiyohiro Houkin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Burlakoti A, Kumaratilake J, Taylor J, Massy-Westropp N, Henneberg M. The cerebral basal arterial network: morphometry of inflow and outflow components. J Anat 2017; 230:833-841. [PMID: 28370065 DOI: 10.1111/joa.12604] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2017] [Indexed: 12/20/2022] Open
Abstract
The aim of this project was to study how the morphology of the incoming and outgoing arterial components of the cerebral basal arterial network influence the blood flow to the brain. The cerebral basal arterial network consists of the circulus arteriosus cerebri anteriorly and the basilar artery posteriorly. Diameters of inflow vessels (bilateral vertebral and internal carotid arteries), connecting vessels (anterior communicating, basilar and bilateral posterior communicating arteries) and outflow vessels (anterior, middle and posterior cerebral arteries) were measured and cross-sectional areas calculated in 51 cadaveric brain specimens. The individual and the average cross-sectional areas of inflow arteries (51.43 mm2 ) were significantly bigger than the major outflow arteries (37.76 mm2 ) but smaller than the combined cross-sectional areas of outflow (37.76 mm2 ) and connecting (25.33 mm2 ) arteries. The difference in the size of arterial cross-sectional area and the presence of the connecting arteries in the cerebral basal arterial network provides a mechanism for lowering peaks in pressure, and demonstrates a function of the cerebral basal arterial network.
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Affiliation(s)
- Arjun Burlakoti
- School of Health Sciences, University of South Australia, Adelaide, SA, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Jaliya Kumaratilake
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Jamie Taylor
- Magnetic Resonance Imaging Centre, Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Maciej Henneberg
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
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Feng X, Ji W, Qian Z, Liu P, Kang H, Wen X, Xu W, Li Y, Jiang C, Wu Z, Liu A. Bifurcation Location Is Significantly Associated with Rupture of Small Intracranial Aneurysms (<5 mm). World Neurosurg 2016; 98:538-545. [PMID: 27888082 DOI: 10.1016/j.wneu.2016.11.055] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/11/2016] [Accepted: 11/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with small (<5 mm) unruptured intracranial aneurysms (UIAs) are at risk of subarachnoid hemorrhage, but risk assessment of these patients remains controversial in daily clinical practice. We aimed to identify the risk factors of aneurysmal rupture in these patients. METHODS We retrospectively analyzed consecutive patients with small UIAs who were admitted to our center between February 2009 and December 2014. The enrolled patients were divided into ruptured and unruptured groups. The risk factors for aneurysmal rupture were determined using multivariate logistic regression analysis. RESULTS A total of 548 patients with 618 small intracranial aneurysms (267 ruptured and 351 unruptured) were included. Univariate analysis showed that rupture of small aneurysms was related to sex, age, smoking, hypertension, aspect ratio, size ratio, irregular shape, aneurysm width, height, and neck diameter, and location at bifurcation or posterior circulation. Multivariate logistic regression showed that rupture was associated with bifurcation location (odds ratio [OR], 5.409; 95% confidence interval [CI], 3.656-8.001; P < 0.001), size ratio (OR, 3.092; 95% CI, 2.002-4.774; P < 0.001), location (OR, 2.624; 95% CI, 1.428-4.824; P = 0.002), hypertension (OR, 1.698; 95% CI, 1.1140-2.527; P = 0.009), and age at diagnosis of UIA (OR, 1.826; 95% CI, 1.225-2.723; P = 0.003). CONCLUSIONS This study showed that 70.4% of small ruptured intracranial aneurysms (<5 mm) were located at parent artery bifurcations and that bifurcation location was a significant independent factor for the risk of rupture of small UIAs (<5 mm). Prophylactic treatment should be recommended for small UIAs in this location.
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Affiliation(s)
- Xin Feng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenjun Ji
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zenghui Qian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huibin Kang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolong Wen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenjuan Xu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongxue Wu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aihua Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Aishima K, Shimizu T, Aihara M, Yoshimoto Y. Lifetime Effects of Small Unruptured Intracranial Aneurysms. World Neurosurg 2016; 95:434-440. [PMID: 27567575 DOI: 10.1016/j.wneu.2016.08.060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/12/2016] [Accepted: 08/13/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent prospective multicenter studies have shown that the probability of rupture of unruptured aneurysms with maximal diameter <7 mm is rather low. However, the overall risks and long-term impact of unruptured aneurysms on lifetime quality of life are still unknown. METHODS A mathematical model of the natural history of intracranial aneurysms was constructed, in which the hypothetical individuals with or without unruptured aneurysm transit between discrete health states. The annual rupture rate of small aneurysms was assumed to be 0.5% in the baseline analysis, followed by the subsequent sensitivity analysis. The analyses were continued until cumulative death rate from subarachnoid hemorrhage or other causes reached 1.0. RESULTS Age-specific ratios of death of subarachnoid hemorrhage in the individuals harboring unruptured aneurysm, if dying at 60 years old, were 25% in men and 43% in women. These ratios decreased rapidly with higher age. Most (more than 90%) patients with small aneurysms were expected to die of diseases other than subarachnoid hemorrhage. In the baseline analysis (60-year-old individuals), lifetime lost to small aneurysms could be estimated as 3.8% for men and 4.2% for women, but a somewhat larger impact could be identified in the young and/or female individuals compared with in the elderly and/or male individuals. CONCLUSIONS Lifetime effects of small unruptured aneurysms without risk factors increasing the probability of rupture are relatively small, and most patients were expected to die of diseases other than subarachnoid hemorrhage.
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Affiliation(s)
- Kaoru Aishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
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24
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Xu T, Lin B, Liu S, Shao X, Xia N, Zhang Y, Xu H, Yang Y, Zhong M, Zhuge Q, Zhao B, Chen W. Larger size ratio associated with the rupture of very small (≤3 mm) anterior communicating artery aneurysms. J Neurointerv Surg 2016; 9:278-282. [DOI: 10.1136/neurintsurg-2016-012294] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/25/2016] [Accepted: 02/26/2016] [Indexed: 11/03/2022]
Abstract
BackgroundAnterior communicating artery (AcoA) aneurysms have a high rupture risk, and ruptured AcoA aneurysms tend to be smaller than other intracranial aneurysms. We aimed to determine the incidence and morphologic predictors of aneurysm rupture of very small AcoA aneurysms.MethodsWe conducted a retrospective analysis of 519 consecutive patients with single AcoA aneurysms between December 2007 and February 2015 in our hospital. Aneurysm morphologies were re-measured using CT angiography images. Very small aneurysms were defined as those with a maximum size ≤3 mm, and small aneurysms were defined as those with a maximum size ≤5 mm. Multivariate regression analyses were used to determine the association between aneurysm morphology and aneurysm rupture status.ResultsOf the 474 ruptured AcoA aneurysms, 134 (28.3%) aneurysms were very small and 278 (58.6%) aneurysms were small. In the univariate analysis for very small aneurysms, larger aneurysm size (p=0.037), larger size ratio (p=0.002), higher aneurysm height (p=0.038), smaller vessel size (p=0.012), and dominant A1 segment configuration (p=0.011) were associated with aneurysm rupture. Multivariate analysis revealed that a larger size ratio was independently associated with the rupture status of the very small aneurysms (OR 3.69, 95% CI 1.5 to 9.0; p=0.004), and larger aneurysm size, larger size ratio, and dominant A1 segment configuration were associated with the rupture of small aneurysms.ConclusionsAbout one-third of ruptured AcoA aneurysms were very small. A larger size ratio, rather than other aneurysm morphologies, was independently associated with the rupture of very small AcoA aneurysms.
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25
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Mukerji N, Cook DJ, Steinberg GK. Temporary Clipping for Unruptured Aneurysms. World Neurosurg 2014; 82:309-11. [DOI: 10.1016/j.wneu.2013.07.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
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26
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Jeon JS, Ahn JH, Huh W, Son YJ, Bang JS, Kang HS, Sohn CH, Oh CW, Kwon OK, Kim JE. A retrospective analysis on the natural history of incidental small paraclinoid unruptured aneurysm. J Neurol Neurosurg Psychiatry 2014; 85:289-94. [PMID: 23781005 DOI: 10.1136/jnnp-2013-305019] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The optimal consensus concerning treatment of incidental small paraclinoid unruptured intracranial aneurysms (UIAs) remains controversial. The aim of this retrospective study was to reveal the natural history of small paraclinoid UIAs with the goal of informing the treatment plan. METHODS 524 patients harbouring 568 paraclinoid UIAs (≤5 mm) were retrospectively evaluated during the mean follow-up of 35.4 months. The aneurysms were divided into two groups with respect to arterial branch: related (ophthalmic and superior hypophyseal artery), and non-related. Medical records were reviewed concerning multiple variables, such as sex, age, hypertension (HTN), diabetes mellitus, smoking and aneurysmal factors (size, arterial relationship, multiplicity and the occurrence of rupture and growth). The cumulative risk and the risk factors of aneurysmal rupture and growth were analysed. RESULTS Two aneurysmal (0.35%) ruptures and 17 growths (3.0%) were observed during the follow-up of 1675.5 aneurysm-years with an annual rupture of 0.12% and an annual growth of 1.01%. The cumulative survival without aneurysmal growth reached a significant difference in aneurysms ≥4 mm (p=0.001), HTN (p=0.002), and arterial branch-related location (p=0.001). Multivariate analysis disclosed that aneurysm ≥4 mm (HR, 4.41; p=0.003), HTN (HR, 5.74; p=0.003), arterial branch-related location (HR, 6.04; p=0.002), and multiplicity (HR, 0.27; p=0.042) were significant predictive factors for aneurysm growth. CONCLUSIONS Although incidental small paraclinoid UIAs have a relatively lower rupture and growth risk, patients with high-risk factors, including aneurysm ≥4 mm, HTN, arterial branch-related aneurysms, and multiple aneurysms must be monitored closely. The limitation of the retrospective nature of this study should be taken into consideration.
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Affiliation(s)
- Jin Sue Jeon
- Department of Neurosurgery, Seoul National University College of Medicine, , Seoul, Korea
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27
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Balakhovsky K, Jabareen M, Volokh KY. Modeling rupture of growing aneurysms. J Biomech 2013; 47:653-8. [PMID: 24359675 DOI: 10.1016/j.jbiomech.2013.11.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/19/2013] [Accepted: 11/27/2013] [Indexed: 11/27/2022]
Abstract
Growth and rupture of aneurysms are driven by micro-structural alterations of the arterial wall yet precise mechanisms underlying the process remain to be uncovered. In the present work we examine a scenario when the aneurysm evolution is dominated by turnover of collagen fibers. In the latter case it is natural to hypothesize that rupture of individual fibers (or their bonds) causes the overall aneurysm rupture. We examine this hypothesis in computer simulations of growing aneurysms in which constitutive equations describe both collagen evolution and failure. Failure is enforced in constitutive equations by limiting strain energy that can be accumulated in a fiber. Within the proposed theoretical framework we find a range of parameters that lead to the aneurysm rupture. We conclude in a qualitative agreement with clinical observations that some aneurysms will rupture while others will not.
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Affiliation(s)
- K Balakhovsky
- Faculty of Civil and Environmental Engineering, Technion - I.I.T., Israel
| | - M Jabareen
- Faculty of Civil and Environmental Engineering, Technion - I.I.T., Israel
| | - K Y Volokh
- Faculty of Civil and Environmental Engineering, Technion - I.I.T., Israel; Department of Structural Engineering, Ben-Gurion University of the Negev, Israel.
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28
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Güresir E, Vatter H, Schuss P, Platz J, Konczalla J, de Rochement RDM, Berkefeld J, Seifert V. Natural History of Small Unruptured Anterior Circulation Aneurysms. Stroke 2013; 44:3027-31. [DOI: 10.1161/strokeaha.113.001107] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The natural history of small unruptured intracranial aneurysms of the anterior circulation in the European population is unclear. Therefore, the management of unruptured intracranial aneurysms <7 mm in the anterior circulation is controversial.
Methods—
Between June 1999 and June 2012, 384 unruptured intracranial aneurysms of the anterior circulation <7 mm in diameter underwent conservative treatment and regular annual follow-up in our institution. Patient- and aneurysm-specific information, as well as information on aneurysm enlargement and rupture, was entered into a prospectively conducted database.
Results—
The mean follow-up duration was 48.5±37 months. Three aneurysms enlarged during the follow-up period and were treated by surgical clipping. Three aneurysms were ruptured during the follow-up period. The overall annual incidence of subarachnoid hemorrhage was 0.2% during the follow-up. In the multivariate Cox proportional hazard regression analysis, hypertension (
P
<0.001; hazard ratio, 2.6; 95% confidence interval, 2.1–3.3) and <50 years of age (
P
=0.04; hazard ratio, 1.3; 95% confidence interval, 1.01–1.7) were significant independent predictors of aneurysm rupture.
Conclusions—
The present data indicate that the annual incidence of subarachnoid hemorrhage associated with small anterior circulation unruptured intracranial aneurysms is low in this single-institution prospective cohort study. The natural course varies according to arterial hypertension and patient age.
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Affiliation(s)
- Erdem Güresir
- From the Departments of Neurosurgery (E.G., H.V., P.S., J.P., J.K., V.S.) and Neuroradiology (R.D.M.d.R., J.B.), Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Hartmut Vatter
- From the Departments of Neurosurgery (E.G., H.V., P.S., J.P., J.K., V.S.) and Neuroradiology (R.D.M.d.R., J.B.), Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Patrick Schuss
- From the Departments of Neurosurgery (E.G., H.V., P.S., J.P., J.K., V.S.) and Neuroradiology (R.D.M.d.R., J.B.), Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Johannes Platz
- From the Departments of Neurosurgery (E.G., H.V., P.S., J.P., J.K., V.S.) and Neuroradiology (R.D.M.d.R., J.B.), Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Jürgen Konczalla
- From the Departments of Neurosurgery (E.G., H.V., P.S., J.P., J.K., V.S.) and Neuroradiology (R.D.M.d.R., J.B.), Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Richard Du Mesnil de Rochement
- From the Departments of Neurosurgery (E.G., H.V., P.S., J.P., J.K., V.S.) and Neuroradiology (R.D.M.d.R., J.B.), Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- From the Departments of Neurosurgery (E.G., H.V., P.S., J.P., J.K., V.S.) and Neuroradiology (R.D.M.d.R., J.B.), Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- From the Departments of Neurosurgery (E.G., H.V., P.S., J.P., J.K., V.S.) and Neuroradiology (R.D.M.d.R., J.B.), Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
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Jagadeesan BD, Delgado Almandoz JE, Kadkhodayan Y, Derdeyn CP, Cross DT, Chicoine MR, Rich KM, Zipfel GJ, Dacey RG, Moran CJ. Size and anatomic location of ruptured intracranial aneurysms in patients with single and multiple aneurysms: a retrospective study from a single center. J Neurointerv Surg 2013; 6:169-74. [PMID: 23539144 DOI: 10.1136/neurintsurg-2012-010623] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The difference in the relationship between the size of intracranial aneurysms (IAs) and their risk of rupture in patients with singe IAs versus those with multiple IAs is unclear. We sought to retrospectively analyze the size of ruptured IAs (RIAs) in patients with single and multiple IAs in order to study this relationship further. METHODS We retrospectively measured the size and location of RIAs in all patients who presented to our institute with an acute subarachnoid hemorrhage between 1 January 2005 and 31 December 2010. The IAs were classified by size into very small IAs or VSAs (≤3 mm), small IAs or SAs (>3 mm but ≤7 mm) and others (>7 mm). RESULTS 379 patients (281 with a single IA, Group 1 and 98 with multiple IAs, Group 2) with 419 treated RIAs were included in the study. VSAs and SAs constituted the majority of RIAs in both groups (33.5% and 45.2% in Group 1 and 24.6% and 50.7% in Group 2) and the mean size of the RIAs was not different between the two groups. VSAs constituted almost two-thirds of all RIAs in certain locations whereas IAs > 7 mm in size did not constitute more than a third of the RIAs at any of the arterial locations. CONCLUSIONS The high incidence of VSAs, particularly in certain locations in both patient subgroups, suggests that current diagnostic, prognostic and therapeutic options in the management of IAs should be more tailored towards the management of these difficult-to-treat lesions.
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30
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Radak D, Sotirovic V, Tanaskovic S, Isenovic ER. Intracranial Aneurysms in Patients With Carotid Disease. Angiology 2013; 65:12-6. [DOI: 10.1177/0003319712468938] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Before the routine use of computed tomography (CT) angiography, decisions for carotid artery treatment were mostly based on ultrasound findings and conventional angiography. Implementation and increasing use of CT angiography provided better visualization of the carotid and vertebrobasilar arteries system leading to an unexpected more frequent detection of unruptured intracranial aneurysms (UIAs). Concomitant presence of intracranial aneurysms in patients with severe carotid stenosis is a potential cause of significant mortality and morbidity. Due to the possible higher risk of aneurysm rupture after carotid procedures and ischemic events after aneurysm repair, the simultaneous presence of both lesions creates several therapeutic dilemmas. We review the prevalence of UIAs in patients with carotid occlusive disease and management difficulties and the current treatment strategies for handling the concomitant presence of these life-threatening diseases.
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Affiliation(s)
- Djordje Radak
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vuk Sotirovic
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Slobodan Tanaskovic
- Vascular Surgery Clinic, “Dedinje” Cardiovascular Institute, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Esma R. Isenovic
- Institute Vinca, Laboratory for Radiobiology and Molecular Genetics, University of Belgrade, Belgrade, Serbia
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31
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Lanzino G. Editorial: Aneurysm geometry. J Neurosurg 2012; 117:911; discussion 911-2. [DOI: 10.3171/2012.3.jns112260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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32
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Inoue T, Shimizu H, Fujimura M, Saito A, Tominaga T. Annual rupture risk of growing unruptured cerebral aneurysms detected by magnetic resonance angiography. J Neurosurg 2012; 117:20-5. [DOI: 10.3171/2012.4.jns112225] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this paper, the authors' goals were to clarify the characteristics of growing unruptured cerebral aneurysms detected by serial MR angiography and to establish the recommended follow-up interval.
Methods
A total of 1002 patients with 1325 unruptured cerebral aneurysms were retrospectively identified. These patients had undergone follow-up evaluation at least twice. Aneurysm growth was defined as an increase in maximum aneurysm diameter by 1.5 times or the appearance of a bleb.
Results
Aneurysm growth was observed in 18 patients during the period of this study (1.8%/person-year). The annual rupture risk after growth was 18.5%/person-year. The proportion of females among patients with growing aneurysms was significantly larger than those without growing aneurysms (p = 0.0281). The aneurysm wall was reddish, thin, and fragile on intraoperative findings. Frequent follow-up examination is recommended to detect aneurysm growth before rupture.
Conclusions
Despite the relatively short period, the annual rupture risk of growing unruptured cerebral aneurysms detected by MR angiography was not as low as previously reported. Surgical or endovascular treatment can be considered if aneurysm growth is detected during the follow-up period.
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Affiliation(s)
| | | | - Miki Fujimura
- 2Department of Neurosurgery, Sendai Medical Center; and
| | | | - Teiji Tominaga
- 3Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Lanzino G, Brown RD. Natural history of unruptured intracranial aneurysms. J Neurosurg 2012; 117:50-1; discussion 51-2. [PMID: 22519431 DOI: 10.3171/2012.1.jns129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Background and Purpose—
Management of asymptomatic unruptured intracranial aneurysms remains controversial, and recent prospective follow-up studies showed that the rupture rate of small aneurysms is very low. These results are inconsistent with the finding that the majority of ruptured aneurysms in patients with subarachnoid hemorrhage are small.
Methods—
A Markov model was constructed to simulate the natural history of intracranial aneurysms. All epidemiological and statistical data obtained from the Portal Site of Official Statistics of Japan (e-Stat) were adjusted to the standardized age distribution. From the selected data of aneurysm formation, the prevalence of unruptured aneurysms was estimated as 1.45% and the incidence of subarachnoid hemorrhage calculated to be 19.7/100 000/year in the whole standardized population.
Results—
The function for rupture rate constant with time was first analyzed. Selected values for annual rupture rates of 0.3%, 0.5%, 0.7%, and 1.0% showed inconsistencies in the relationship between the prevalence of unruptured aneurysm and the incidence of subarachnoid hemorrhage. Next, the function for a short period of high risk followed by a long period of low risk was considered. Annual rupture rates of 0.5%, 0.7%, and 1.0% indicated epidemiological compatibility with additional early rupture rates of 20%, 15%, and 10%, respectively.
Conclusions—
This study suggests that some aneurysms bleed shortly after formation and thus are rarely detected as unruptured aneurysms. Most aneurysms without early rupture remain stable for the remainder of life through some healing process, and prophylactic treatment for incidentally identified small unruptured aneurysms has no rationale.
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Krings T, Mandell DM, Kiehl TR, Geibprasert S, Tymianski M, Alvarez H, terBrugge KG, Hans FJ. Intracranial aneurysms: from vessel wall pathology to therapeutic approach. Nat Rev Neurol 2011; 7:547-59. [DOI: 10.1038/nrneurol.2011.136] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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36
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Affiliation(s)
- Malcolm R. Macleod
- From the Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, UK
| | - Phil M. White
- From the Centre for Clinical Brain Sciences, University of Edinburgh, Scotland, UK
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Roessler K, Cejna M, Zachenhofer I. Aneurysmatic subarachnoidal haemorrhage: Incidence and location of small ruptured cerebral aneurysms – a retrospective population-based study. Wien Klin Wochenschr 2011; 123:444-9. [DOI: 10.1007/s00508-011-1598-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 04/11/2011] [Indexed: 11/25/2022]
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38
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Sonobe M, Yamazaki T, Yonekura M, Kikuchi H. Small Unruptured Intracranial Aneurysm Verification Study. Stroke 2010; 41:1969-77. [PMID: 20671254 DOI: 10.1161/strokeaha.110.585059] [Citation(s) in RCA: 307] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The natural history and optimal management of incidentally found small unruptured aneurysms <5 mm in size remain unclear. A prospective study was conducted to determine the optimal management for incidentally found small unruptured aneurysms.
Methods—
From September 2000 to January, 2004, 540 aneurysms (446 patients) were registered. Four hundred forty-eight unruptured aneurysms <5 mm in size (374 patients) have been followed up for a mean of 41.0 months (1306.5 person-years) to date. We calculated the average annual rupture rate of small unruptured aneurysms and also investigated risk factors that contribute to rupture and enlargement of these aneurysms.
Results—
The average annual risks of rupture associated with small unruptured aneurysms were 0.54% overall, 0.34% for single aneurysms, and 0.95% for multiple aneurysms. Patient <50 years of age (
P
=0.046; hazard ratio, 5.23; 95% CI, 1.03 to 26.52), aneurysm diameter of ≥4.0 mm (
P
=0.023; hazard ratio, 5.86; 95% CI, 1.27 to 26.95), hypertension (
P
=0.023; hazard ratio, 7.93; 95% CI, 1.33 to 47.42), and aneurysm multiplicity (
P
=0.0048; hazard ratio, 4.87; 95% CI, 1.62 to 14.65) were found to be significant predictive factors for rupture of small aneurysms.
Conclusions—
The annual rupture rate associated with small unruptured aneurysms is quite low. Careful attention should be paid to the treatment indications for single-type unruptured aneurysms <5 mm. If the patient is <50 years of age, has hypertension, and multiple aneurysms with diameters of ≥4 mm, treatment should be considered to prevent future aneurysmal rupture.
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Affiliation(s)
- Makoto Sonobe
- From the Department of Neurosurgery (M.S., T.Y.), National Hospital Organization, Mito Medical Center, Ibaraki, Japan; Department of Neurosurgery (M.Y.), National Hospital Organization, Nagasaki Medical Center, Nagasaki, Japan, and the Department of Neurosurgery, Kobe City Hospital (H.K.), Kobe, Japan
| | - Tomosato Yamazaki
- From the Department of Neurosurgery (M.S., T.Y.), National Hospital Organization, Mito Medical Center, Ibaraki, Japan; Department of Neurosurgery (M.Y.), National Hospital Organization, Nagasaki Medical Center, Nagasaki, Japan, and the Department of Neurosurgery, Kobe City Hospital (H.K.), Kobe, Japan
| | - Masahiro Yonekura
- From the Department of Neurosurgery (M.S., T.Y.), National Hospital Organization, Mito Medical Center, Ibaraki, Japan; Department of Neurosurgery (M.Y.), National Hospital Organization, Nagasaki Medical Center, Nagasaki, Japan, and the Department of Neurosurgery, Kobe City Hospital (H.K.), Kobe, Japan
| | - Haruhiko Kikuchi
- From the Department of Neurosurgery (M.S., T.Y.), National Hospital Organization, Mito Medical Center, Ibaraki, Japan; Department of Neurosurgery (M.Y.), National Hospital Organization, Nagasaki Medical Center, Nagasaki, Japan, and the Department of Neurosurgery, Kobe City Hospital (H.K.), Kobe, Japan
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A Stijntje E Bor, Marieke JH Wermer, Gabriel JE Rinkel. Unruptured intracranial aneurysms: initial and follow-up screening. FUTURE NEUROLOGY 2010. [DOI: 10.2217/fnl.10.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm is a devastating disease that causes death or severe disability in half of patients. Intracranial aneurysms are not present at birth but develop during life. Actively searching and treating intracranial aneurysms before rupture may prevent SAH as a result of these aneurysms. The prevalence of intracranial aneurysms is approximately 2% in the general population, but higher in subgroups such as patients who have survived an episode of SAH, persons with a family history of SAH and patients with polycystic kidney disease. Screening for intracranial aneurysms should be considered in these high-risk groups. Some of the intracranial aneurysms detected with screening will be too small to be treated, and may therefore be followed over time, which can cause anxiety in the patient. In this article, we discuss current knowledge, remaining questions and future perspectives in screening and follow-up imaging for unruptured intracranial aneurysms.
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40
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Mitchell P, Jakubowski J. Failure testing cerebral arteries: are branch points weaker than unbranched vessels? Br J Neurosurg 2009. [DOI: 10.1080/02688690209168364] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Koffijberg H, Rinkel G, Buskens E. Do Intraindividual Variation in Disease Progression and the Ensuing Tight Window of Opportunity Affect Estimation of Screening Benefits? Med Decis Making 2009; 29:82-90. [DOI: 10.1177/0272989x08322012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background . The effects of variation in disease progression between individuals on the effectiveness of screening have been assessed extensively in the literature. For several diseases, progression may also vary within individuals over time. The authors study the effects of intraindividual variation and the combined effects of inter- and intraindividual variation in disease progression on the effectiveness of screening. Methods . The authors investigated the risk reduction of aneurysmal subarachnoid hemorrhage (SAH) achieved by screening for intracranial aneurysms in a simulation study as a function of the inter- and intraindividual variation in the risk of aneurysm rupture. They also extended a previously constructed Markov model for the cost-effectiveness analysis of screening for new aneurysms in patients with clipped aneurysms after SAH. A time-varying risk of aneurysm rupture was introduced, and the influence of this variation on cost-effectiveness was assessed. Results . The risk reduction provided by screening decreased with increasing intraindividual variation in disease progression. The expected number of prevented instances of SAH was overestimated by 58% in this simulation study when high degrees of inter- and intraindividual variation were present. Interindividual variation alone resulted in up to 33% overestimation and intraindividual variation in up to 43% overestimation. In the extended Markov model, screening benefits were overestimated by 24% when a high degree of intraindividual variation was present but ignored. Conclusions . If intraindividual variation in disease progression is ignored in decision models, subsequent cost-effectiveness analyses of screening strategies will overestimate the benefits provided by screening. This bias is comparable to, but partially independent of, the bias caused by ignoring interindividual heterogeneity.
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Affiliation(s)
- Hendrik Koffijberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands,
| | - Gabriel Rinkel
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erik Buskens
- Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Rinkel G. Natural history, epidemiology and screening of unruptured intracranial aneurysms. Rev Neurol (Paris) 2008; 164:781-6. [DOI: 10.1016/j.neurol.2008.07.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Accepted: 07/23/2008] [Indexed: 10/21/2022]
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Koffijberg H, Buskens E, Algra A, Wermer MJH, Rinkel GJE. Growth rates of intracranial aneurysms: exploring constancy. J Neurosurg 2008; 109:176-85. [PMID: 18671627 DOI: 10.3171/jns/2008/109/8/0176] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The annual rate of rupture of intracranial aneurysms is often assumed to be constant, but it is unknown whether this assumption is true. Recent case reports have suggested that aneurysms grow fast in a short period of time. The authors of the present report investigated the plausibility of a constant growth rate for intracranial aneurysms. METHODS Assuming a constant aneurysm growth rate within an individual and varying rates between individuals, a hypothetical cohort was simulated. Individuals with high growth rates will display aneurysm formation and rupture at a young age; such persons disappear early from the hypothetical cohort. As a result the mean lesion growth rate varies over time. In hypothetical cohorts with different initial mean growth rates, the authors calculated age-specific incidence rates (per 100,000 person-years) of subarachnoid hemorrhage and compared these rates with population-based data on the incidence of subarachnoid hemorrhage (per 100,000 person-years). RESULTS A hypothetical cohort with a mean initial growth rate of 0.18 mm/year reproduced most closely the incidence rates observed in the population. However, even for this most plausible hypothetical cohort, age-specific incidence rates in the model differed substantially and statistically significantly from those observed in the population. CONCLUSIONS Based on the results of this study, it is unlikely that intracranial aneurysms in general grow at a constant time-independent rate. The authors hypothesized that the actual growth process is irregular and discontinuous, which results in periods with and without aneurysm growth and with high and low risks of rupture.
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Affiliation(s)
- Hendrik Koffijberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.
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Rinkel G. Natural history, epidemiology and screening of unruptured intracranial aneurysms. J Neuroradiol 2008; 35:99-103. [DOI: 10.1016/j.neurad.2007.11.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Proust F, Gérardin E, Chazal J. Anévrisme intracrânien non rompu et exclusion microchirurgicale : justification d’une étude randomisée chirurgie versus histoire naturelle. J Neuroradiol 2008; 35:109-15. [DOI: 10.1016/j.neurad.2008.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mitchell P, Kerr R, Mendelow AD, Molyneux A. Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the International Subarachnoid Aneurysm Trial? J Neurosurg 2008; 108:437-42. [PMID: 18312088 DOI: 10.3171/jns/2008/108/3/0437] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The present purpose is to define the sensitivity of the superiority of coil embolization observed in the International Subarachnoid Aneurysm Trial (ISAT) according to the rate of late rebleeding over a reasonable range, and to find the range of rebleeding rates for which it may be overturned. In the ISAT, coil embolization appears to be safer than clip ligation at 1 year, and clip occlusion has better long-term efficacy at preventing rebleeding. This leaves open the question of which is better in the longer term. METHODS The authors calculate the life expectancy of patients following a subarachnoid hemorrhage (SAH) and compare the life expectancy of those who underwent coil embolization with those who underwent clip ligation in the ISAT cohort. RESULTS The 1-year poor outcome rate following treatment climbs rapidly with advancing age. A consequence is that the absolute difference between the poor outcome rates after coil embolization and clip occlusion is lower in those < 50 years of age (3.3%) than it is for those > 50 years of age (10.1%). This difference may be enough to give clip application the advantage in the < 40-year-old group despite the small size of the difference in 1-year rebleeding rates thus far observed (0.152%). CONCLUSIONS When treating ruptured cerebral aneurysms, the advantage of coil embolization over clip ligation cannot be assumed for patients < 40 years old. In this age range the difference in the safety of the 2 procedures is small, and the better long-term protection from SAH afforded by clip placement may give this treatment an advantage in life expectancy for patients < 40 years of age.
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Affiliation(s)
- Patrick Mitchell
- Department of Neurosurgery, Newcastle General Hospital, Newcastle upon Tyne, UK.
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Humphrey J, Taylor C. Intracranial and abdominal aortic aneurysms: similarities, differences, and need for a new class of computational models. Annu Rev Biomed Eng 2008; 10:221-46. [PMID: 18647115 PMCID: PMC2742216 DOI: 10.1146/annurev.bioeng.10.061807.160439] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Intracranial saccular and abdominal aortic aneurysms (ISAs and AAAs, respectively) result from different underlying disease processes and exhibit different rupture potentials, yet they share many histopathological and biomechanical characteristics. Moreover, as in other vascular diseases, hemodynamics and wall mechanics play important roles in the natural history and possible treatment of these two types of lesions. The goals of this review are twofold: first, to contrast the biology and mechanics of intracranial and abdominal aortic aneurysms to emphasize that separate advances in our understanding of each disease can aid in our understanding of the other disease, and second, to suggest that research on the biomechanics of aneurysms must embrace a new paradigm for analysis. That is, past biomechanical studies have provided tremendous insight but have progressed along separate lines, focusing on either the hemodynamics or the wall mechanics. We submit that there is a pressing need to couple in a new way the separate advances in vascular biology, medical imaging, and computational biofluid and biosolid mechanics to understand better the mechanobiology, pathophysiology, and treatment of these lesions, which continue to be responsible for significant morbidity and mortality. We refer to this needed new class of computational tools as fluid-solid-growth (FSG) models.
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Affiliation(s)
- J.D. Humphrey
- Department of Biomedical Engineering and M.E. DeBakey Institute Texas A&M University, College Station, TX, USA
| | - C.A. Taylor
- Departments of Bioengineering and Surgery Stanford University, Stanford, CA, USA
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Day 1 — September 10, 2007. Interv Neuroradiol 2007. [DOI: 10.1177/15910199070130s206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Mitchell P, Birchall D, Mendelow AD. Blood pressure, fatigue, and the pathogenesis of aneurysmal subarachnoid hemorrhage. ACTA ACUST UNITED AC 2006; 66:574-80; discussion 580. [PMID: 17145314 DOI: 10.1016/j.surneu.2006.06.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Accepted: 06/13/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Endovascular embolization and BP reduction appear to protect cerebral aneurysms from rupture, although they do not totally eliminate aneurysm wall stress as does surgical clipping. We investigate the possible mechanisms of rupture to offer an explanation for this. METHODS Fatigue modeling of cerebral aneurysms using BP as the source of wall stress loading and calculating the increase in cycles to failure produced by a reduction in stress loading. RESULTS A modest reduction in the stress loading of aneurysms leads to a disproportionately large increase in the time taken for them to rupture. This result is based on the following assumptions and is thus restricted to aneurysm for which they may reasonably be true. Fatigue is the dominant mode of failure. The final decline in strength is rapid. The aneurysm lasts at least 6 weeks before rupturing. CONCLUSIONS A slight reduction in the stress on aneurysm walls can dramatically reduce their risk of rupture.
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Affiliation(s)
- Patrick Mitchell
- Neurosurgery (School of Surgical and Reproductive Sciences), Newcastle University, Newcastle General Hospital, NE4 6BE Newcastle upon Tyne, UK.
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Proust F, Derrey S, Debono B, Gérardin E, Dujardin AC, Berstein D, Douvrin F, Langlois O, Verdure L, Clavier E, Fréger P. Anévrismes intracrâniens non rompus : que proposer ? Neurochirurgie 2005; 51:435-54. [PMID: 16327677 DOI: 10.1016/s0028-3770(05)83502-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Intracranial unruptured aneurysm (ICUA) has become a common condition for patient consultation. The mortality rate after fissuration is estimated to be between 52% and 85.7%. The final therapeutic decision results from a balance between the risk of rupture and risks related to the aneurysmal exclusion. Analysis of the risk of rupture risk enables a classification of risk factors. Depending on the circumstances of diagnosis, we considered the ICUA at high risk of rupture for incidental ICUA larger than 7 mm and in the event of associated aneurysms. Classifying by morphologic features, high-risk ICUA were located in the vertebrobasilar system (RR: 4.4; 95%CI: 2.7-6.8), those with a size between 7 and 12 mm (RR: 3.3; 95%CO: 1.3-8.2), larger than 12 mm (RR: 17; 95%CI: 8-36.1), those that were multilobular or a larger size and those ones with a index P/L superior to 3.4 (risk x20). Familial ICUA would expose to a major rupture risk (2 to 7 times sporadic ICUA). Some systemic factors were related to ICUA rupture: arterial hypertension (RR: 1.46; 95%CI: 1.01-2.11) and smoking addiction (RR: 3.04; 95%CI: 1.21-7.66). After microsurgical exclusion, the morbidity and mortality rates were 10% and 2% respectively. Some microsurgical morbidity factors were identified: age (32%>65 years), size (14%>15 mm), vertebrobasilar location and temporary occlusion. The rupture incidence after microsurgical exclusion was estimated 0.26%/year. After endovascular exclusion, the morbidity and mortality rates were 8% and 1% respectively. The complete exclusion rate varied between 47% and 67%. The rupture risk was estimated at 0.9%/year. Treatment recommendations were classified into 3 categories.
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Affiliation(s)
- F Proust
- Service de Neurochirurgie, CHU de Rouen.
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