Antihyperglycemic Agents Are Inversely Associated With Intracranial Aneurysm Rupture

Prescribed Drug Use and Aneurysmal Subarachnoid Hemorrhage Incidence: A Drug-Wide Association Study

BACKGROUND AND OBJECTIVES

Current benefits of invasive intracranial aneurysm treatment to prevent aneurysmal subarachnoid hemorrhage (aSAH) rarely outweigh treatment risks. Most intracranial aneurysms thus remain untreated. Commonly prescribed drugs reducing aSAH incidence may provide leads for drug repurposing. We performed a drug-wide association study (DWAS) to systematically investigate the association between commonly prescribed drugs and aSAH incidence.

METHODS

We defined all aSAH cases between 2000 and 2020 using International Classification of Diseases codes from the Secure Anonymised Information Linkage databank. Each case was matched with 9 controls based on age, sex, and year of database entry. We investigated commonly prescribed drugs (>2% in study population) and defined 3 exposure windows relative to the most recent prescription before index date (i.e., occurrence of aSAH): current (within 3 months), recent (3-12 months), and past (>12 months). A logistic regression model was fitted to compare drug use across these exposure windows vs never use, controlling for age, sex, known aSAH risk factors, and health care utilization. The family-wise error rate was kept at p < 0.05 through Bonferroni correction.

RESULTS

We investigated exposure to 205 commonly prescribed drugs between 4,879 aSAH cases (mean age 61.4, 61.2% women) and 43,911 matched controls. We found similar trends for lisinopril and amlodipine, with a decreased aSAH risk for current use (lisinopril odds ratio [OR] 0.63, 95% CI 0.44-0.90, amlodipine OR 0.82, 95% CI 0.65-1.04) and an increased aSAH risk for recent use (lisinopril OR 1.30, 95% CI 0.61-2.78, amlodipine OR 1.61, 95% CI 1.04-2.48). A decreased aSAH risk in current use was also found for simvastatin (OR 0.78, 95% CI 0.64-0.96), metformin (OR 0.58, 95% CI 0.43-0.78), and tamsulosin (OR 0.55, 95% CI 0.32-0.93). By contrast, an increased aSAH risk was found for current use of warfarin (OR 1.35, 95% CI 1.02-1.79), venlafaxine (OR 1.67, 95% CI 1.01-2.75), prochlorperazine (OR 2.15, 95% CI 1.45-3.18), and co-codamol (OR 1.31, 95% CI 1.10-1.56).

DISCUSSION

We identified several drugs associated with aSAH, of which 5 drugs (lisinopril and possibly amlodipine, simvastatin, metformin, and tamsulosin) showed a decreased aSAH risk. Future research should build on these signals to further assess the effectiveness of these drugs in reducing aSAH incidence.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that some commonly prescribed drugs are associated with subsequent development of aSAH.

Combining Machine-Measured Morphometric, Geometric, and Hemodynamic Factors to Predict the Risk of Aneurysm Rupture at the Middle Cerebral Artery Bifurcation

BACKGROUND

Middle Cerebral Artery Bifurcation Aneurysm (MbifA) is associated with a high risk of rupture and poor overall prognosis in patients once it ruptures. Morphological, geometric, and hemodynamic parameters have been identified as factors contributing to the rupture of intracranial aneurysms. However, there are no studies that combine these 3 types of parameters to specifically target MbifA rupture.

METHODS

This study enrolled all patients with MbifAs diagnosed at our treatment center from 1 April 2021 to 31 July 2023 who met the study criteria. All patients underwent digital subtraction angiography examination to obtain 3D rotational angiography data. We imported the complete image data into the Aneurysm/Artery Reconstruction and Analysis machine to obtain 13 morphological parameters (Dneck, Ddome, Height, Dmax, Dartery, aspect ratio [AR], size ratio, dome-neck-ratio [DNR], height-artery-ratio, bottleneck factor, Inflow Angle, Incline Angle, Arterial Angle), 5 geometric parameters (V,S,undulation index [UI], ellipticity index [EI],nonsphericity index [NSI]), and 5 hemodynamic parameters (wall shear stress [WSS], the maximum WSS, the parent artery WSS, the normalized WSS [NWSS], oscillatory shear index [OSI]). All the above significant parameters were tested by univariate and multivariate analyses to find out the independent discriminatory factors.

RESULTS

A total of 49 MbifAs (16 ruptured and 33 unruptured) from 44 patients were included in the study. Height (P = 0.033), AR (P = 0.007), DNR (P = 0.011), EI (P = 0.042), NSI(P = 0.030), UI(P = 0.027), WSS(P = 0.033), and NWSS(P = 0.002) were all associated with MbifA rupture in univariate analyses, but only NWSS was an independent risk factor (P = 0.036, OR = 0.046, 95% CI: 0.003-0.815) in multivariate logistic regression analysis.

CONCLUSIONS

Height, AR, DNR, EI, UI, NSI, WSS, and NWSS may be correlated with MbifA rupture, but only NWSS was an independent risk factor. A lower NWSS was associated with a higher risk of MbifA rupture. No significant differences were observed in the angle parameters, including the Inflow Angle, between ruptured and unruptured MbifAs. OSI was significantly increased at the dome of the aneurysm but the mean OSI was not found to be associated with MbifA rupture.

Associations Between Drug Treatments and the Risk of Aneurysmal Subarachnoid Hemorrhage: a Systematic Review and Meta-analysis

There is increasing interest in drug therapy for preventing aneurysmal subarachnoid hemorrhage (aSAH). We aimed to comprehensively evaluate the association between drug use and the risk of aSAH. We searched PubMed and Scopus from the databases' inception until December 2021. Observational studies reporting the association between any drug therapy and aSAH were included. The odds ratios (ORs) for each drug used in aSAH were meta-analyzed with a random-effect model. According to the systematic review, 25 observational studies were eligible for the present study. Four therapeutic purpose-based classes (e.g., lipid-lowering agents) and 14 mechanism-based classes (e.g., statins) were meta-analyzed. Anti-hypertensive agents (OR, 0.50; 95% confidence interval [95% CI], 0.33-0.74), statins (OR, 0.55; 95% CI, 0.35-0.85), biguanides (OR, 0.57; 95% CI, 0.34-0.96), and acetylsalicylic acid (ASA) (OR, 0.62; 95% CI, 0.41-0.94) were inversely associated with the risk of aSAH. Non-ASA non-steroidal anti-inflammatory drugs (OR, 1.73; 95% CI, 1.07-2.79), selective cyclooxygenase-2 inhibitors (OR, 2.04; 95% CI, 1.24-3.35), vitamin K antagonists (OR, 1.50; 95% CI, 1.18-1.91), and dipyridamole (OR, 1.77; 95% CI, 1.23-2.54) were positively associated with the incidence of aSAH. There was also a trend toward a positive association between glucocorticoids (OR, 1.38; 95% CI, 0.97-1.94) and aSAH. The present study suggests that anti-hypertensive agents, statins, biguanides, and ASA are candidate drugs for preventing aSAH. By contrast, several drugs (e.g., anti-thrombotic drugs) may increase the risk of aSAH. Thus, the indications of these drugs in patients with intracranial aneurysms should be carefully determined.

Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage Receiving Sulfonylureas: A Propensity-Adjusted Analysis

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased blood-brain barrier permeability, disrupted tight junctions, and increased cerebral edema. Sulfonylureas are associated with reduced tight-junction disturbance and edema and improved functional outcome in aSAH animal models, but human data are scant. We analyzed neurological outcomes in aSAH patients prescribed sulfonylureas for diabetes mellitus.

METHODS

Patients treated for aSAH at a single institution (August 1, 2007-July 31, 2019) were retrospectively reviewed. Patients with diabetes were grouped by presence or absence of sulfonylurea therapy at hospital admission. The primary outcome was favorable neurologic status at last follow-up (modified Rankin Scale score ≤2). Variables with an unadjusted P-value of <0.20 were included in a propensity-adjusted multivariable logistic regression analysis to identify predictors of favorable outcomes.

RESULTS

Of 1013 aSAH patients analyzed, 129 (13%) had diabetes at admission, and 16 of these (12%) were receiving sulfonylureas. Fewer diabetic than nondiabetic patients had favorable outcomes (40% [52/129] vs. 51% [453/884], P = 0.03). Among diabetic patients, sulfonylurea use (OR 3.90, 95% CI 1.05-15.9, P = 0.046), Charlson Comorbidity Index <4 (OR 3.66, 95% CI 1.24-12.1, P = 0.02), and absence of delayed cerebral infarction (OR 4.09, 95% CI 1.20-15.5, P = 0.03) were associated with favorable outcomes in the multivariable analysis.

CONCLUSIONS

Diabetes was strongly associated with unfavorable neurologic outcomes. An unfavorable outcome in this cohort was mitigated by sulfonylureas, supporting some preclinical evidence of a possible neuroprotective role for these medications in aSAH. These results warrant further study on dose, timing, and duration of administration in humans.

Prevalence and risk factors of unruptured intracranial aneurysms in ischemic stroke patients - A global meta-analysis

Background

Unruptured intracranial aneurysms (UIAs) have an estimated global prevalence of 2.8% in the adult population; however, UIA was identified among more than 10% of ischemic stroke patients. Many epidemiological studies and reviews have pointed to the presence of UIA among patients with ischemic stroke; yet, the extent of this association is not fully known. We performed a systematic review and meta-analysis to determine the prevalence of UIA in patients admitted to hospitals with ischemic stroke and transient ischemic attack (TIA) at both global and continental levels and evaluate factors associated with UIA in this population.

Methods

We identified, in five databases, all studies describing UIA in ischemic stroke and TIA patients between January 1, 2000, and December 20, 2021. Included studies were of observational and experimental design.

Results

Our search yielded 3581 articles of which 23 were included, with a total of 25,420 patients. The pooled prevalence of UIA was 5% (95% confidence interval [CI] = 4-6%) with stratified results showing 6% (95% CI = 4-9%), 6% (95% CI = 5-7%), and 4% (95% CI = 2-5%) in North America, Asia, and Europe, respectively. Significant risk factors were large vessel occlusion (odds ratios [OR] = 1.22, 95% CI = 1.01-1.47) and hypertension (OR = 1.45, 95% CI = 1.24-1.69), while protective factors were male sex (OR = 0.60, 95% CI = 0.53-0.68) and diabetes (OR = 0.82, 95% CI = 0.72-0.95).

Conclusion

The prevalence of UIA is notably higher in ischemic stroke patients than the general population. Physicians should be aware of common risk factors in stroke and aneurysm formation for appropriate prevention.

Effect of Renin-Angiotensin-Aldosterone System Inhibitors on the Rupture Risk Among Hypertensive Patients With Intracranial Aneurysms

BACKGROUND

Mounting experimental evidence supports the concept that the RAAS (renin-angiotensin-aldosterone system) is involved in the pathogenesis of intracranial aneurysm rupture. However, whether RAAS inhibitors could reduce the rupture risk of intracranial aneurysms remains unclear.

METHODS

We performed a chart review of a multicenter, prospectively maintained database of 3044 hypertensive patients with intracranial aneurysms from 20 medical centers in China. The patients were separated into ruptured and unruptured groups. Univariable and multivariable logistical regression analyses were performed to determine the association between the use of RAAS inhibitors and the rupture risk. Sensitivity analyses and subgroup analyses were performed to verify the robustness of the results.

RESULTS

In multivariable analyses, female sex, passive smoking, uncontrolled, or unmonitored hypertension, use of over 2 antihypertensive medications, RAAS inhibitors use, antihyperglycemic agents use, hyperlipidemia, ischemic stroke, and aneurysmal location were independently associated with the rupture risk. The use of RAAS inhibitors was significantly associated with a reduced rupture risk compared with the use of non-RAAS inhibitors (odds ratio, 0.490 [95% CI, 0.402-0.597]; P=0.000). Compared with the use of non-RAAS inhibitors, the use of ACE (angiotensin-converting enzyme) inhibitors (odds ratio, 0.559 [95% CI, 0.442-0.709]; P=0.000) and use of ARBs (angiotensin receptor blockers; odds ratio, 0.414 [95% CI, 0.315-0.542]; P=0.000) were both significantly associated with a reduced rupture risk. The negative association of the rupture risk with RAAS inhibitors was consistent across 3 analyzed data and the predefined subgroups (including controlled hypertension).

CONCLUSIONS

The use of RAAS inhibitors was significantly associated with a decreased rupture risk independent of blood pressure control among hypertensive patients with intracranial aneurysms.

Nonlinear Association of Glycosylated Hemoglobin With Single Intracranial Aneurysm Rupture in Patients With Diabetes Mellitus: A Cross-Sectional Study

Background

The published literature linking diabetes mellitus (DM) to intracranial aneurysm (IA) ruptured has been controversial and limited by methodology. Thus, this study was performed to examine whether hyperglycemia control status is independently associated with single IA rupture in patients with DM.

Methods

We conducted a cross-sectional study on two Chinese hospitals between January 2010 and November 2017. Medical records of 223 patients with single IA and DM were reviewed and analyzed. We used glycosylated hemoglobin (GHB) as the independent variable of interest, and the outcome variable was ruptured status of IA. Covariates included data on demographics, morphological parameters, lifestyle habits, clinical features, and comorbidities.

Results

Multivariable adjusted binary logistic regression and sensitivity analyses indicated that GHB was not associated with IA rupture (odds ratio OR, = 1.07, 95% CI 0.84-1.35). A nonlinear association between GHB and IA rupture was observed, whose inflection points were 5.5 and 8.9. The OR values (95% confidence intervals) were 0.38 (0.16-0.9) at the range of 1.88-5.5% of GHB, 1.6 (1.03, 2.5) at the range of 5.5-8.9%, and 0.56 (0.06-5.34) at the range of 8.9-10.1, respectively.

Conclusion

The independent correlation between GHB and risk of IA rupture presented is nonlinear. The good glycemic control in single IA patients with DM can reduce the risk of IA rupture, and vice versa.

Development and External Validation of a Dynamic Nomogram With Potential for Risk Assessment of Ruptured Multiple Intracranial Aneurysms

Background and Purpose

About 20.1% of intracranial aneurysms (IAs) carriers are multiple intracranial aneurysms (MIAs) patients with higher rupture risk and worse prognosis. A prediction model may bring some potential benefits. This study attempted to develop and externally validate a dynamic nomogram to assess the rupture risk of each IA among patients with MIA.

Method

We retrospectively analyzed the data of 262 patients with 611 IAs admitted to the Hunan Provincial People's Hospital between November 2015 and November 2021. Multivariable logistic regression (MLR) was applied to select the risk factors and derive a nomogram model for the assessment of IA rupture risk in MIA patients. To externally validate the nomogram, data of 35 patients with 78 IAs were collected from another independent center between December 2009 and May 2021. The performance of the nomogram was assessed in terms of discrimination, calibration, and clinical utility.

Result

Size, location, irregular shape, diabetes history, and neck width were independently associated with IA rupture. The nomogram showed a good discriminative ability for ruptured and unruptured IAs in the derivation cohort (AUC = 0.81; 95% CI, 0.774–0.847) and was successfully generalized in the external validation cohort (AUC = 0.744; 95% CI, 0.627–0.862). The nomogram was calibrated well, and the decision curve analysis showed that it would generate more net benefit in identifying IA rupture than the “treat all” or “treat none” strategies at the threshold probabilities ranging from 10 to 60% both in the derivation and external validation set. The web-based dynamic nomogram calculator was accessible on https://wfs666.shinyapps.io/onlinecalculator/.

Conclusion

External validation has shown that the model was the potential to assist clinical identification of dangerous aneurysms after longitudinal data evaluation. Size, neck width, and location are the primary risk factors for ruptured IAs.

U-Shaped Association of Aspect Ratio and Single Intracranial Aneurysm Rupture in Chinese Patients: A Cross-Sectional Study

Background: Previous studies have analyzed the association of aspect ratio (AR) on the ruptured intracranial aneurysm (IA), but the findings are inconclusive and controversial. Therefore, the study aimed to derive a more detailed estimation of this association between AR and ruptured IA in Chinese IA patients. Methods: The present work was a cross-sectional study. We retrospectively collected 1,588 Chinese patients with a single IA from January 2010 to November 2017. The relationship was examined between AR at diagnosis and ruptured IA. Covariates included data of demographics, morphological parameters, lifestyle habits, clinical features, and comorbidities. Binary logistic regression and two-piecewise linear models were used to analyze independent associations of AR with ruptured IA. Results: The results suggest that the association between AR and IA rupture was U-shaped. In the AR range of 1.08-1.99, the prevalence of IA rupture was 13% lower for each 0.1-unit increment in AR [odds ratio 0.87, 95% confidence interval (CI) 0.80-0.98]. Conversely, for every 0.1-unit increase in AR, the prevalence of IA rupture increased by ~3% (odds ratio 1.03, 95% CI 1.01-1.06) in the AR range of 3.42-4.08. Conclusion: The relationship between AR and ruptured IA was U-shaped, with the negative association at AR of 1.08-1.99 and positive association at AR of 3.42-4.08.

Candidate drugs for preventive treatment of unruptured intracranial aneurysms: A cross-sectional study

Background and purpose

Establishment of drug therapy to prevent rupture of unruptured intracranial aneurysms (IAs) is needed. Previous human and animal studies have gradually clarified candidate drugs for preventive treatment of IA rupture. However, because most of these candidates belong to classes of drugs frequently co-administered to prevent cardiovascular diseases, epidemiological studies evaluating these drugs simultaneously should be performed. Furthermore, because drugs included in the same class may have different effects in terms of disease prevention, drug-by-drug assessments are important for planning intervention trials.

Materials and methods

We performed a cross-sectional study enrolling patients diagnosed with IAs between July 2011 and June 2019 at our institution. Patients were divided into ruptured or unruptured groups. The drugs investigated were selected according to evidence suggested by either human or animal studies. Univariate and multivariate logistic regression analyses were performed to assess the association of drug treatment with rupture status. We also performed drug-by-drug assessments of the association, including dose-response relationships, with rupture status.

Results

In total, 310 patients with ruptured and 887 patients with unruptured IAs were included. Multivariate analysis revealed an inverse association of statins (odds ratio (OR), 0.54; 95% confidence interval (CI) 0.38–0.77), calcium channel blockers (OR, 0.41; 95% CI 0.30–0.58), and angiotensin II receptor blockers (ARBs) (OR, 0.67; 95% CI 0.48–0.93) with ruptured IAs. Moreover, inverse dose-response relationships with rupture status were observed for pitavastatin and rosuvastatin among statins, benidipine, cilnidipine, and amlodipine among calcium channel blockers, and valsartan, azilsartan, candesartan, and olmesartan among ARBs. Only non-aspirin non-steroidal anti-inflammatory drugs were positively associated with ruptured IAs (OR, 3.24; 95% CI 1.71–6.13).

Conclusions

The present analysis suggests that several types of statins, calcium channel blockers, and ARBs are candidate drugs for preventive treatment of unruptured IAs.

Morphological Variables Associated With Ruptured Middle Cerebral Artery Aneurysms

BACKGROUND

Geometric factors of intracranial aneurysms and surrounding vasculature could affect the risk of aneurysm rupture. However, large-scale assessments of morphological parameters correlated with intracranial aneurysm rupture in a location-specific manner are scarce.

OBJECTIVE

To investigate the morphological characteristics associated with ruptured middle cerebral artery (MCA) aneurysms.

METHODS

Five hundred sixty-one patients with 638 MCA aneurysms diagnosed between 1990 and 2016 who had available computed tomography angiography (CTA) were included in this study. CTAs were evaluated using the Vitrea Advanced Visualization software for 3-dimensional (3D) reconstruction. Morphological parameters examined in each model included aneurysm projection, wall irregularity, presence of a daughter dome, presence of hypoplastic or aplastic A1 arteries and hypoplastic or fetal posterior communicating arteries (PCoA), aneurysm height and width, neck diameter, bottleneck factor, aspect and size ratio, height/width ratio, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine the association of morphological characteristics with rupture of MCA aneurysms. Logistic regression was used to build a predictive MCA score.

RESULTS

Greater bottleneck and size ratio, and irregular, multilobed, temporally projecting MCA aneurysms are associated with higher rupture risk, whereas higher M1/M2 ratio, larger width, and the presence of an ipsilateral or bilateral hypoplastic PCoA were inversely associated with rupture. The MCA score had good predictive capacity with area under the receiver operating curve = 0.88.

CONCLUSION

These practical morphological parameters specific to MCA aneurysms are easy to assess when examining 3D reconstructions of unruptured aneurysms and could aid in risk evaluation in these patients.

Decreased Total Iron Binding Capacity May Correlate with Ruptured Intracranial Aneurysms

Iron and its derivatives play a significant role in various physiological and biochemical pathways, and are influenced by a wide variety of inflammatory, infectious, and immunological disorders. We hypothesized that iron and its related factors play a role in intracranial aneurysm pathophysiology and investigated if serum iron values are associated with ruptured intracranial aneurysms. 4,701 patients with 6,411 intracranial aneurysms, including 1201 prospective patients, who were diagnosed at the Massachusetts General Hospital and Brigham and Women’s Hospital between 1990 and 2016 were evaluated. A total of 366 patients with available serum iron, ferritin and total iron binding capacity (TIBC) values were ultimately included in the analysis. 89% of included patients had anemia. Patients were categorized into ruptured and non-ruptured groups. Univariable and multivariable logistic regression analyses were performed to determine the association between ruptured aneurysms and iron, ferritin, and TIBC. TIBC values (10⁻³ g/L) within 1 year of diagnosis (OR 0.41, 95% CI 0.28–0.59) and between 1 and 3 years from diagnosis (OR 0.52, 95% CI 0.29–0.93) were significantly and inversely associated with intracranial aneurysm rupture. In contrast, serum iron and ferritin were not significant. In this case-control study, low TIBC was significantly associated with ruptured aneurysms, both in the short- and long term. However, this association may not apply to the general population as there may be a selection bias as iron studies were done in a subset of patients only.