Preventive screening for intracranial aneurysms

Kidney-brain axis in the pathogenesis of cognitive impairment

The kidney-brain axis is a bidirectional communication network connecting the kidneys and the brain, potentially affected by inflammation, uremic toxin, vascular injury, neuronal degeneration, and so on, leading to a range of diseases. Numerous studies emphasize the disruptions of the kidney-brain axis may contribute to the high morbidity of neurological disorders, such as cognitive impairment (CI) in the natural course of chronic kidney disease (CKD). Although the pathophysiology of the kidney-brain axis has not been fully elucidated, epidemiological data indicate that patients at all stages of CKD have a higher risk of developing CI compared with the general population. In contrast to other reviews, we mentioned some commonly used medicines in CKD that may play a pivotal role in the pathogenesis of CI. Revealing the pathophysiology interactions between kidney damage and brain function can reduce the potential risk of future CI. This review will deeply explore the characteristics, indicators, and potential pathophysiological mechanisms of CKD-related CI. It will provide a theoretical basis for identifying CI that progresses during CKD and ultimately prevents and treats CKD-related CI.

Knowledge, attitude, practice and illness perception toward subarachnoid hemorrhage prevention and management among intracranial aneurysm patients

OBJECTIVE

This study aims to explore the knowledge, attitude, practice and illness perception toward prevention and management of subarachnoid hemorrhages (SAH) among intracranial aneurysm (IA) patients.

METHODS

A cross-sectional study was conducted between March 2023 and June 2023; demographic characteristics and KAP scores were collected by a self-administered questionnaire and analyzed by linear regression and path analysis.

RESULTS

A total of 455 patients with IA were included, of them 26.37% experienced SAH before. Mean knowledge, attitude and practice scores were 16.60 ± 5.86, 16.39 ± 1.84, and 35.07 ± 3.51, respectively. The linear regression showed ethnic minority, married, education, family members in healthcare system, monthly per capita household income, experience ruptured intracranial aneurysms, smoking, hypertension, hyperlipidemia, diabetes, and aortic lesion were associated with knowledge scores. Age, ethnic minority, urban residence, education, family members in healthcare system, monthly per capita household income, duration of IA ≥6 months, experience ruptured intracranial aneurysms, smoking, diabetes, and aortic lesion were associated with attitude scores. Age, urban residence, monthly per capita household income, duration of IA ≥6 months, experience of ruptured intracranial aneurysms, smoking, diabetes, and aortic lesion were associated with practice scores. According to the path analysis, knowledge directly affected illness perception (β=0.156, P<0.001) and attitude (β=0.708, P<0.001), while attitude (β=0.909, P<0.001) and illness perception (β=0.039, P=0.027) affected practice.

CONCLUSIONS

Patients had positive attitudes towards SAH prevention and management, but a substantial knowledge gap was found along with notably delayed medical help-seeking behavior.

Early sexual activity lowers the incidence of intracranial aneurysm: a Mendelian randomization investigation

Objective

Investigate the potential correlation between the age of initial sexual contact, the lifetime accumulation of sexual partners, and the occurrence of intracranial aneurysm (IA) employing a two-sample Mendelian randomization approach.

Methods

This research aims to elucidate the causal relationship between intracranial aneurysm (IA) and sexual variables. Two distinct sexual variables, specifically the age had first sexual intercourse (n = 406,457) and the lifetime number of sexual partners (n = 378,882), were employed as representative parameters in a two-sample Mendelian randomization (MR) study. Outcome data from 23 cohorts, comprising 5,140 cases and 71,934 controls, were gathered through genome-wide association studies (GWAS). To bolster analytical rigor, five distinct methodologies were applied, encompassing MR-Egger technique, weighted median, inverse variance weighted, simple modeling, and weighted modeling.

Results

Our investigation unveiled a causal relationship between the age first had sexual intercourse and the occurrence of intracranial aneurysm (IA), employing the Inverse Variance Weighted (IVW) approach [Odds Ratio (OR): 0.609, p-value: 5.684E-04, 95% Confidence Interval (CI): 0.459-0.807]. This association was notably significant in the context of unruptured intracranial aneurysms (uIA) using the IVW approach (OR: 0.392, p-value: 6.414E-05, 95% CI: 0.248-0.621). Conversely, our findings did not reveal any discernible link between the lifetime number of sexual partners and the occurrence of IA (IA group: OR: 1.346, p-value: 0.415, 95% CI: 0.659-2.749; SAH group: OR: 1.042, p-value: 0.943, 95% CI: 0.338-3.209; uIA group: OR: 1.990, p-value: 0.273, 95% CI: 0.581-6.814).

Conclusion

The two-sample Mendelian Randomization (MR) study presented herein provides evidence supporting a correlation between the age of initial engagement in sexual activity and the occurrence of intracranial aneurysm (IA), with a noteworthy emphasis on unruptured intracranial aneurysms (uIA). Nevertheless, our investigation failed to establish a definitive association between IA and the cumulative lifetime number of sexual partners.

Integrative bioinformatics analysis of miRNA and mRNA expression profiles and identification of associated miRNA-mRNA network in intracranial aneurysms

Background

Intracranial aneurysms (IAs) represent protrusions in the vascular wall, with their growth and wall thinning influenced by various factors. These processes can culminate in the rupture of the aneurysm, leading to subarachnoid hemorrhage (SAH). Unfortunately, over half of the patients prove unable to withstand SAH, succumbing to adverse outcomes despite intensive therapeutic interventions, even in premier medical facilities. This study seeks to discern the pivotal microRNAs (miRNAs) and genes associated with the formation and progression of IAs.

Methods

The investigation gathered expression data of miRNAs (from GSE66240) and mRNAs (from GSE158558) within human aneurysm tissue and superficial temporal artery (STA) samples, categorizing them into IA and normal groups. This classification was based on the Gene Expression Omnibus (GEO) database.

Results

A total of 70 differentially expressed microRNAs (DEMs) and 815 differentially expressed mRNAs (DEGs) were pinpointed concerning IA. Subsequently, a miRNA-mRNA network was constructed, incorporating 9 significantly upregulated DEMs and 211 significantly downregulated DEGs. Simultaneously, functional enrichment and pathway analyses were conducted on both DEMs and DEGs. Through protein-protein interaction (PPI) network analysis and functional enrichment, 9 significantly upregulated DEMs (hsa-miR-188-5p, hsa-miR-590-5p, hsa-miR-320b, hsa-miR-423-5p, hsa-miR-140-5p, hsa-miR-486-5p, hsa-miR-320a, hsa-miR-342-3p, and hsa-miR-532-5p) and 50 key genes (such as ATP6V1G1, KBTBD6, VIM, PA2G4, DYNLL1, METTL21A, MDH2, etc.) were identified, suggesting their potential significant role in IA. Among these genes, ten were notably negatively regulated by at least two key miRNAs.

Conclusions

The findings of this study provide valuable insights into the potential pathogenic mechanisms underlying IA by elucidating a miRNA-mRNA network. This comprehensive approach sheds light on the intricate interplay between miRNAs and genes, offering a deeper understanding of the molecular dynamics involved in IA development and progression.

Prediction of aneurysmal subarachnoid hemorrhage in comparison with other stroke types using routine care data

Aneurysmal subarachnoid hemorrhage (aSAH) can be prevented by early detection and treatment of intracranial aneurysms in high-risk individuals. We investigated whether individuals at high risk of aSAH in the general population can be identified by developing an aSAH prediction model with electronic health records (EHR) data. To assess the aSAH model's relative performance, we additionally developed prediction models for acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) and compared the discriminative performance of the models. We included individuals aged ≥35 years without history of stroke from a Dutch routine care database (years 2007-2020) and defined outcomes aSAH, AIS and ICH using International Classification of Diseases (ICD) codes. Potential predictors included sociodemographic data, diagnoses, medications, and blood measurements. We cross-validated a Cox proportional hazards model with an elastic net penalty on derivation cohorts and reported the c-statistic and 10-year calibration on validation cohorts. We examined 1,040,855 individuals (mean age 54.6 years, 50.9% women) for a total of 10,173,170 person-years (median 11 years). 17,465 stroke events occurred during follow-up: 723 aSAH, 14,659 AIS, and 2,083 ICH. The aSAH model's c-statistic was 0.61 (95%CI 0.57-0.65), which was lower than the c-statistic of the AIS (0.77, 95%CI 0.77-0.78) and ICH models (0.77, 95%CI 0.75-0.78). All models were well-calibrated. The aSAH model identified 19 predictors, of which the 10 strongest included age, female sex, population density, socioeconomic status, oral contraceptive use, gastroenterological complaints, obstructive airway medication, epilepsy, childbirth complications, and smoking. Discriminative performance of the aSAH prediction model was moderate, while it was good for the AIS and ICH models. We conclude that it is currently not feasible to accurately identify individuals at increased risk for aSAH using EHR data.

ARISE I Consensus Review on the Management of Intracranial Aneurysms

BACKGROUND

Intracranial aneurysms (IAs) remain a challenging neurological diagnosis associated with significant morbidity and mortality. There is a plethora of microsurgical and endovascular techniques for the treatment of both ruptured and unruptured aneurysms. There is no definitive consensus as to the best treatment option for this cerebrovascular pathology. The Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts discussed best practices and the most promising approaches to improve the management of brain aneurysms.

METHODS

A group of experts from academia, industry, and federal regulators convened to discuss updated clinical trials, scientific research on preclinical system models, management options, screening and monitoring, and promising novel device technologies, aiming to improve the outcomes of patients with IA.

RESULTS

Aneurysm, Arteriovenous Malformation, and Chronic Subdural Hematoma Roundtable Discussion With Industry and Stroke Experts suggested the incorporation of artificial intelligence to capture sequential aneurysm growth, identify predictors of rupture, and predict the risk of rupture to guide treatment options. The consensus strongly recommended nationwide systemic data collection of unruptured IA radiographic images for the analysis and development of machine learning algorithms for rupture risk. The consensus supported centers of excellence for preclinical multicenter trials in areas such as genetics, cellular composition, and radiogenomics. Optical coherence tomography and magnetic resonance imaging contrast-enhanced 3T vessel wall imaging are promising technologies; however, more data are needed to define their role in IA management. Ruptured aneurysms are best managed at large volume centers, which should include comprehensive patient management with expertise in microsurgery, endovascular surgery, neurology, and neurocritical care.

CONCLUSIONS

Clinical and preclinical studies and scientific research on IA should engage high-volume centers and be conducted in multicenter collaborative efforts. The future of IA diagnosis and monitoring could be enhanced by the incorporation of artificial intelligence and national radiographic and biologic registries. A collaborative effort between academic centers, government regulators, and the device industry is paramount for the adequate management of IA and the advancement of the field.

Remodelers of the vascular microenvironment: The effect of biopolymeric hydrogels on vascular diseases

Vascular disease is the leading health problem worldwide. Vascular microenvironment encompasses diverse cell types, including those within the vascular wall, blood cells, stromal cells, and immune cells. Initiation of the inflammatory state of the vascular microenvironment and changes in its mechanics can profoundly affect vascular homeostasis. Biomedical materials play a crucial role in modern medicine, hydrogels, characterized by their high-water content, have been increasingly utilized as a three-dimensional interaction network. In recent times, the remarkable progress in utilizing hydrogels and understanding vascular microenvironment have enabled the treatment of vascular diseases. In this review, we give an emphasis on the utilization of hydrogels and their advantages in the various vascular diseases including atherosclerosis, aneurysm, vascular ulcers of the lower limbs and myocardial infarction. Further, we highlight the importance and advantages of hydrogels as artificial microenvironments.

Circular RNAs in intracranial aneurysms: Emerging roles in pathogenesis, diagnosis and therapeutic intervention

Intracranial aneurysms (IAs) present a substantial health threat, given the potential for catastrophic ruptures and subarachnoid hemorrhages (SAH). Swift and effective measures for diagnosis and treatment are paramount to enhance patient outcomes and alleviate the associated healthcare burden. In this context, circular RNAs (circRNAs) have emerged as an intriguing area of investigation, offering promise as both diagnostic biomarkers and therapeutic targets for IAs. CircRNAs have demonstrated their influence on critical molecular and cellular processes underpinning IAs pathogenesis, revealing their pivotal role in understanding this complex ailment. Beyond their diagnostic potential, circRNAs hold great potential as prognostic markers, providing crucial insights into IAs rupture risk. The unique circular structure and their regulatory functions make circRNAs an enticing avenue for innovative therapeutic approaches. The ongoing study of circRNAs in the context of IAs is an exciting and rapidly evolving field that has the potential to revolutionize approaches to diagnosis, treatment, and prevention of this life-threatening condition. As research continues to unravel the intricate roles of circRNAs, they are poised to become invaluable tools in clinical practice, enhancing patient care and ultimately reducing the impact of cerebral aneurysms on both individuals and healthcare systems. This comprehensive review delves deeply into the world of circRNAs in the realm of IAs, elucidating their multifaceted roles in the onset and progression of this condition. Moreover, this review ventures into the diagnosis and therapeutic potential of circRNAs, exploring their possible applications in gene therapy and as targets for novel treatment modalities.

Changes of serum MMP-9, NSE, MPO levels and prognostic influencing factors in patients with intracranial aneurysm undergoing interventional embolization at different treatment timing

Background

To analyzes the changes in serum levels of matrix metalloproteinase-9 (MMP-9), neuroenolase (NSE), myeloperoxidase (MPO) and prognostic factors in patients with intracranial aneurysm (IA) undergoing interventional embolization at different treatment times.

Methods

A retrospective analysis was made of 200 IA patients admitted to our department from January 2018 to June 2021 was performed. All patients underwent interventional embolization. According to the timing of surgery, the patients were divided into an early group (n=120, onset to surgery ≤72 h) and a delayed group (n=80, onset to surgery >72 h). The effect of embolization, complications and neurological deficit scale (NDS) scores were compared between the two groups. Serum MMP-9, NSE and MPO levels were compared before and after surgery, and the prognosis of all patients within 2 years after surgery was assessed by the Glasgow outcome scale (GOS) and divided accordingly into the good prognosis group (n=147) and the poor prognosis group (n=53) accordingly, and the prognostic factors influencing the patients were analyzed univariately and multifactorially.

Cerebral and Aortic Aneurysms in Electroconvulsive Therapy Patients: A Systematic Review and Results From 12 Years of Screening

INTRODUCTION

Theoretically, the procedural risk of electroconvulsive therapy (ECT) could be increased in the presence of undetected aneurysms due to the hemodynamic changes associated with ECT. However, empirical evidence is limited to few individual case reports and case series.

METHODS

We performed a systematic review of available evidence on ECT treatment in patients with intracranial aneurysms and untreated aortic aneurysms and we retrospectively analyzed data from 252 consecutive patients referred for ECT at the Department of Psychiatry, Psychotherapy and Psychosomatics of Siegen Hospital, Germany, who received magnetic resonance angiographies and abdominal sonographies as part of their routine pre-ECT workup.

RESULTS

Of 252 patients referred for ECT, 5 (2.0%) were found to have an intracerebral aneurysm and 1 (0.4%) was found to have an abdominal aortic aneurysm. These cases are reported in detail together with 2 additional cases of aortic aneurysms from the Central Institute of Mental Health, Mannheim, Germany. Electroconvulsive therapy was performed without complications in all 8 cases.

CONCLUSIONS

Aneurysms might occur in ECT patients at a similar rate as in the general population. The number of ECTs performed annually in mostly unscreened patients suggests that there might be a significant number of patients with undetected aneurysms in whom ECT is performed without reported complications.

Updates on Neuronavigation: Emerging tools for tumor resection

Multiple studies have been conducted to properly elucidate the various tools available to help enhance the resection of tumor tissue, aneurysms, and arteriovenous malformations (AVM). Diffusion tensor imaging (DTI) tractography is useful in providing a map of the tumor borders, allowing the optimal preservation of function and structure of specific regions of the brain. During neurosurgery, especially craniotomies, the possibility of the brain shifting due to swelling or gravity is high. Thus, tools for intraoperative imaging such as high-frequency linear array ultrasound transducers and doppler ultrasonography are utilized for high resolution images and detecting frequency shifts. 4D-digital subtraction angiography (DSA) is another technique used to create spatial resolutions and 3D maps for aneurysms. These similar techniques can also be utilized to assess the integrity of white matter in AVM. By implementing effective evaluation strategies, healthcare professionals can make informed decisions regarding treatment options, preventive measures, and long-term care plans tailored to individual patients.

Risk factor synergism in aneurysmal subarachnoid hemorrhage: a cross-sectional study

BACKGROUND

Spontaneous subarachnoid hemorrhage (SAH) accounts for 5-10% of strokes but a disproportionately large amount of stroke-related morbidity. Several risk factors have been described, including smoking, hypertension, increasing age, and female sex.

METHODS

This cross-sectional study examined all patients with aSAH within a nationally representative catchment from 01/01/2017 to 31/12/2020. Patients with aneurysmal SAH were identified from multiple sources, including a prospective database and death records. The population was estimated from projections from a door-to-door census and risk factors from stratified random sampled surveys conducted on a yearly basis. Poisson regression models were used to estimate the incidence and incidence rate ratios (IRRs) for risk factors with 95% confidence intervals (95% CIs).

RESULTS

We identified 875 cases of aSAH in 11,666,807 patient-years of follow-up, which corresponded to a crude incidence of 7.5 per 100,000 patient-years (95% CI 7-8) and a standardized incidence of 6.1/100,000 (95% CI 5.6-6.5). Smoking was the strongest individual risk factor, with a standardized incidence of 24/100,000 (95% CI 20-27) in smokers compared with 2.6/100,000 (2.1-3.2) in non-smokers (age-adjusted IRR 9.2, 95% CI 6.3-13.6). Hypertension (age-adjusted IRR 3.1, 95% CI 2.2-4.3) and female sex (age-adjusted IRR 1.8, 95% CI 1.4-2.3) were also associated with increased incidence. The highest incidence was observed in hypertensive smokers (standardized incidence 63/100,000, 95% CI 41-84), who had a lifetime risk of aSAH of 6.7% (95% CI 5.4-8.1) after age 35. Compared with participants who were non-smokers without hypertension, the age-adjusted IRR in hypertensive smokers was 27.9 (95% CI 15.9-48.8).

CONCLUSION

Smoking is the most prominent individual risk factor for aSAH. Smoking and hypertension appear to interact to increase the risk of aSAH synergistically.

Clinical findings, underlying pathogenetic processes and treatment of vascular dysfunction in autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder characterized by the development of fluid-filled cysts in the kidneys. The primary cause of ADPKD is mutations in the PKD1 (polycystic kidney disease 1) or PKD2 (polycystic kidney disease 2) gene. Patients with ADPKD often develop a variety of vascular abnormalities, which have a major impact on the structure and function of the blood vessels and can lead to complications such as hypertension, intracranial aneurysm (ICAN), and atherosclerosis. The progression of ADPKD involves intricate molecular and cellular processes that lead to the development of these vascular abnormalities. Our understanding of these processes remains incomplete, and available treatment options are limited. The aim of this review is to delve into the underlying mechanisms of these vascular abnormalities and to explore potential interventions.

Incidence, management, and outcome of incidental meningioma: what has happened in 10 years?

PURPOSE

The aim of this study was to study the use of brain scanning, and the subsequent findings of presumed incidental meningioma in two time periods, and to study differences in follow-up, treatment, and outcome.

METHODS

Records of all performed CT and MRI of the brain during two time periods were retrospectively reviewed in search of patients with presumed incidental meningioma. These patients were further analyzed using medical health records, with the purpose to study clinical handling and outcome during a 3 year follow up.

RESULTS

An identical number of unique patients underwent brain imaging during the two time periods (n = 22 259 vs. 22 013). In 2018-2019, 25% more incidental meningiomas were diagnosed compared to 2008-2009 (n = 161 vs. 129, p = 0.052). MRI was used more often in 2018-2019 (26.1 vs. 12.4%, p = 0.004), and the use of contrast enhancement, irrespective of modality, also increased (26.8 vs. 12.2%, p < 0.001). In the most recent cohort, patients were older (median 79 years vs. 73 years, p = 0.03). Indications showed a significant increase of cancer without known metastases among scanned patients. 29.5 and 35.4% of patients in the cohorts were deceased 3 years after diagnosis for causes unrelated to their meningioma.

CONCLUSIONS

Despite the same number of unique patients undergoing brain scans in the time periods, there was a trend towards more patients diagnosed with an incidental asymptomatic meningioma in the more recent years. This difference may be attributed to more contrast enhanced scans and more scans among the elderly but needs to be further studied. Patients in the cohort from 2018 to 2019 more often had non-metastatic cancer, with their cause of scan screening for metastases. There was no significant difference in management decision at diagnosis, but within 3 years of follow up significantly more patients in the latter cohort had been re-scanned. Almost a third of all patients were deceased within 3 years after diagnosis, due to causes other than their meningioma.

A case for preference-sensitive decision timelines to aid shared decision-making in intensive care: need and possible application

In the intensive care unit, it can be challenging to determine which interventions align with the patients' preferences since patients are often incapacitated and other sources, such as advance directives and surrogate input, are integral. Managing treatment decisions in this context requires a process of shared decision-making and a keen awareness of the preference-sensitive instances over the course of treatment. The present paper examines the need for the development of preference-sensitive decision timelines, and, taking aneurysmal subarachnoid hemorrhage as a use case, proposes a model of one such timeline to illustrate their potential form and value. First, the paper draws on an overview of relevant literature to demonstrate the need for better guidance to (a) aid clinicians in determining when to elicit patient preference, (b) support the drafting of advance directives, and (c) prepare surrogates for their role representing the will of an incapacitated patient in clinical decision-making. This first section emphasizes that highlighting when patient (or surrogate) input is necessary can contribute valuably to shared decision-making, especially in the context of intensive care, and can support advance care planning. As an illustration, the paper offers a model preference-sensitive decision timeline-whose generation was informed by existing guidelines and a series of interviews with patients, surrogates, and neuro-intensive care clinicians-for a use case of aneurysmal subarachnoid hemorrhage. In the last section, the paper offers reflections on how such timelines could be integrated into digital tools to aid shared decision-making.

Cardiovascular Manifestations and Management in ADPKD

Cardiovascular disease (CVD) is the major cause of mortality in autosomal dominant polycystic kidney disease (ADPKD) and contributes to significant burden of disease. The manifestations are varied, including left ventricular hypertrophy (LVH), intracranial aneurysms (ICAs), valvular heart disease, and cardiomyopathies; however, the most common presentation and a major modifiable risk factor is hypertension. The aim of this review is to detail the complex pathogenesis of hypertension and other extrarenal cardiac and vascular conditions in ADPKD drawing on preclinical, clinical, and epidemiological evidence. The main drivers of disease are the renin-angiotensin-aldosterone system (RAAS) and polycystin-related endothelial cell dysfunction, with the sympathetic nervous system (SNS), nitric oxide (NO), endothelin-1 (ET-1), and asymmetric dimethylarginine (ADMA) likely playing key roles in different disease stages. The reported rates of some manifestations, such as LVH, have decreased likely due to the use of antihypertensive therapies; and others, such as ischemic cardiomyopathy, have been reported with increased prevalence likely due to longer survival and higher rates of chronic disease. ADPKD-specific screening and management guidelines exist for hypertension, LVH, and ICAs; and these are described in this review.

Multiphase computed tomography angiography derived from computed tomography perfusion data for the differential diagnosis of intracranial aneurysm and infundibular dilation

Background

As infundibular dilation (ID) is less likely to cause hemorrhage or other clinical sequelae than an intracranial aneurysm (IA) and treating infundibulum itself may put the patient at unnecessary risk for stroke, it is important to distinguish between the ID and IA. Given the limitations of conventional single-phase computed tomography angiography (sCTA) to show small branches of intracranial arteries, the application of multiphase computed tomography angiography (mCTA) for identification seems promising. Our main objective was to evaluate whether using mCTA derived from computed tomography perfusion (CTP) data can improve distinction between IA and ID.

Methods

A total of 35 patients diagnosed with IA or ID of the posterior communicating artery at its junction with the internal carotid artery junction (ICA-PComA) by sCTA at the 8th Medical Center of Chinese PLA General Hospital between January 2019 and May 2022 were retrospectively selected. All patients underwent CTP. The simulated mCTA was reconstructed from 0.75 mm CTP data for assessment of vascular branches. All data were processed separately by 2 CTA post-processors; 2 observers diagnosed IA and ID by source and volume rendering (VR) images of sCTA and VR images of mCTA, and compared the diagnostic efficacy of source and VR images of sCTA with VR images of mCTA.

Results

The quality of the reconstructed images was more consistent between the 2 post-processors mCTA (K=0.856) than sCTA (K=0.648). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the source image for ID identification were 78.9%, 86.7%, 84.2%, 81.3%, and 80.0% for sCTA, 73.7%, 81.2%, 82.3%, 72.2%, and 77.2% for the VR image of sCTA, and 94.7%, 87.5%, 90.0%, 93.3%, and 91.4% for the VR image based on mCTA, respectively. The net reclassification index (NRI) of mCTA for VR and the source image of sCTA was 0.273 and 0.220, respectively. VR base on mCTA was on average better than VR and the source image of sCTA at differentiating ID from IA (P=0.005 and P=0.001, respectively).

Conclusions

Compared to sCTA, mCTA is more helpful in improving the distinction of ID and IA.

Aneurysm Prevalence and Quality of Life During Screening in Relatives of Patients With Unruptured Intracranial Aneurysms: A Prospective Study

BACKGROUND AND OBJECTIVES

Screening for unruptured intracranial aneurysms (UIAs) is effective for first-degree relatives (FDRs) of patients with aneurysmal subarachnoid hemorrhage (aSAH). Whether screening is also effective for FDRs of patients with UIA is unknown. We determined the yield of screening in such FDRs, assessed rupture risk and treatment decisions of aneurysms that were found, identified potential high-risk subgroups, and studied the effects of screening on quality of life (QoL).

METHODS

In this prospective cohort study, we included FDRs, aged 20-70 years, of patients with UIA without a family history of aSAH who visited the Neurology outpatient clinic in 1 of 3 participating tertiary referral centers in the Netherlands. FDRs were screened for UIA with magnetic resonance angiography between 2017 and 2021. We determined UIA prevalence and developed a prediction model for UIA risk at screening using multivariable logistic regression. QoL was evaluated with questionnaires 6 times during the first year after screening and assessed with a linear mixed-effects model.

RESULTS

We detected 24 UIAs in 23 of 461 screened FDRs, resulting in a 5.0% prevalence (95% CI 3.2-7.4). The median aneurysm size was 3 mm (interquartile range [IQR] 2-4 mm), and the median 5-year rupture risk assessed with the PHASES score was 0.7% (IQR 0.4%-0.9%). All UIAs received follow-up imaging, and none were treated preventively. After a median follow-up of 24 months (IQR 13-38 months), no UIA had changed. Predicted UIA risk at screening ranged between 2.3% and 14.7% with the highest risk in FDRs who smoke and have excessive alcohol consumption (c-statistic: 0.76; 95% CI 0.65-0.88). At all survey moments, health-related QoL and emotional functioning were comparable with those in a reference group from the general population. One FDR with a positive screening result expressed regret about screening.

DISCUSSION

Based on the current data, we do not advise screening FDRs of patients with UIA because all identified UIAs had a low rupture risk. We observed no negative effect of screening on QoL. A longer follow-up should determine the risk of aneurysm growth requiring preventive treatment.

Scar Epilepsy as a Complication of Subarachnoid Hemorrhage in a Patient With Adult Polycystic Kidney Disease: A Case Report

Polycystic kidney disease (PKD) is the most common hereditary disorder of kidneys. In adults, PKD1 gene mutation almost always signifies its subtype, autosomal dominant polycystic kidney disease (ADPKD), or adult polycystic kidney disease. ADPKD is a multisystemic disorder giving rise to renal and extra-renal manifestations. The renal shutdown is the most feared renal complication while the development of intracranial aneurysms is considered the most lethal extra-renal feature. This can be attributed to the increased risk of rupture associated with aneurysms leading to a condition called subarachnoid hemorrhage (SAH). While being notorious for the subtle situations SAH often leads to, its association with the onset of seizures is a matter of high clinical significance. We present a patient with a kidney disorder (ADPKD) that has led to the onset of epilepsy. Five years after the diagnosis of ADPKD, he developed an aneurysm in the right internal carotid artery, for which he was treated conservatively. After four months, he presented with the onset of symptoms of SAH, which was confirmed by computed tomography angiography. Clipping was unable to be performed, and the patient was treated conservatively, this time as well. Recently, the patient presented with the onset of generalized tonic-clonic seizures, unable to be controlled with single anti-epileptics. He was stabilized by dual intravenous antiepileptics but on further workup, he was found to have a recurrence of a berry aneurysm for which he was referred to a neurosurgeon for a clipping procedure to be performed. The operation was successful, but the patient was still found to be an epileptic for which he was discharged with a long-term course of double anti-epileptics.

Higher Incidence of Unruptured Intracranial Aneurysms among Black and Hispanic Women on Screening MRA in Large Urban Populations

BACKGROUND AND PURPOSE

Intracranial aneurysms have a reported prevalence of 1%-2% in the general population. Currently, only patients with a strong family history or autosomal dominant polycystic kidney disease are screened for intracranial aneurysms using MRA. The purpose of this study was to determine whether there are other specific patient populations at risk that should be offered screening for intracranial aneurysms.

MATERIALS AND METHODS

This is a retrospective case-control study of adult patients who underwent a screening MRA of their brain at our comprehensive stroke center from 2011 to 2020. Patients with a history of a known brain aneurysm were excluded. Data were extracted on patient demographics and medical comorbidities. Bivariate analyses were performed, followed by multivariable logistic regression, to identify factors associated with a positive MRA screen for incidental aneurysms.

RESULTS

Of 24,397 patients eligible for this study, 2084 screened positive for a possible intracranial aneurysm. On bivariate analysis, significant differences were present in the following categories: age, sex, race and ethnicity, chronic constipation, and hyperlipidemia. On logistic regression analysis, older age (+10 years: OR = 10.01; 95% CI, 10.01-10.02; P = .001), female sex (OR = 1.37; 95% CI, 1.24-1.51; P = .001), non-Hispanic Black (OR = 1.19; 95% CI, 1.02-1.40; P = .031), and Hispanic ethnicity (OR = 1.35; 95% CI, 1.16-1.58; P = .001) versus non-Hispanic White remained significant when adjusted for other factors.

CONCLUSIONS

Targeted screening for high-risk elderly women of Black or Hispanic descent will yield higher positive findings for brain aneurysms, which may mitigate the risk of rupture. Whether this is a cost-effective approach has yet to be determined.

Aneurysmal Subarachnoid Hemorrhage and Clinical Decision-Making: A Qualitative Pilot Study Exploring Perspectives of Those Directly Affected, Their Next of Kin, and Treating Clinicians

BACKGROUND

Exploring the experience and impact of aneurysmal subarachnoid hemorrhage (aSAH) from three perspectives, that of those directly affected (AFs), their next of kin (NoK), and treating clinicians, is a way to support and empower others to make informed medical decisions.

METHODS

In a Swiss neurosurgical intensive care unit (ICU), eleven semi-structured interviews were conducted as part of a Database of Individual Patient Experiences (DIPEx) pilot project and thematically analyzed. Interviews were held with two clinicians, five people experiencing aSAH, and four NoK 14-21 months after the bleeding event.

RESULTS

Qualitative analysis revealed five main themes from the perspective of clinicians: emergency care, diagnosis and treatment, outcomes, everyday life in the ICU, and decision-making; seven main themes were identified for AFs and NoK: the experience of the aSAH, diagnosis and treatment, outcomes, impact on loved ones, identity, faith, religion and spirituality, and decision-making. Perspectives on decision-making were compared, and, whereas clinicians tended to focus their attention on determining treatment, AFs and NoK valued participation in shared decision-making processes.

CONCLUSIONS

Overall, aSAH was perceived as a life-threatening event with various challenges depending on severity. The results suggest the need for tools that aid decision-making and better prepare AFs and NoK using accessible means and at an early stage.

Prevalence of incidental intracranial findings on magnetic resonance imaging: a systematic review and meta-analysis

BACKGROUND

As the volume and fidelity of magnetic resonance imaging (MRI) of the brain increase, observation of incidental findings may also increase. We performed a systematic review and meta-analysis to determine the prevalence of various incidental findings.

METHODS

PubMed/MEDLINE, EMBASE and SCOPUS were searched from inception to May 24, 2021. We identified 6536 citations and included 35 reports of 34 studies, comprising 40,777 participants. A meta-analysis of proportions was performed, and age-stratified estimates for each finding were derived from age-adjusted non-linear models.

RESULTS

Vascular abnormalities were observed in 423/35,706 participants (9.1/1000 scans, 95%CI 5.2-14.2), ranging from 2/1000 scans (95%CI 0-7) in 1-year-olds to 16/1000 scans (95%CI 1-43) in 80-year-olds. Of these, 204/34,306 were aneurysms (3.1/1000 scans, 95%CI 1-6.3), which ranged from 0/1000 scans (95%CI 0-5) at 1 year of age to 6/1000 scans (95%CI 3-9) at 60 years. Neoplastic abnormalities were observed in 456/39,040 participants (11.9/1000 scans, 95%CI 7.5-17.2), ranging from 0.2/1000 scans (95%CI 0-10) in 1-year-olds to 34/1000 scans (95%CI 12-66) in 80-year-olds. Meningiomas were the most common, in 246/38,076 participants (5.3/1000 scans, 95%CI 2.3-9.5), ranging from 0/1000 scans (95%CI 0-2) in 1-year-olds to 17/1000 scans (95%CI 4-37) in 80-year-olds. Chiari malformations were observed in 109/27,408 participants (3.7/1000 scans, 95%CI 1.8-6.3), pineal cysts in 1176/32,170 (9/1000 scans, 95%CI 1.8-21.4) and arachnoid cysts in 414/36,367 (8.5/1000 scans, 95%CI 5.8-11.8).

CONCLUSION

Incidental findings are common on brain MRI and may result in substantial resource expenditure and patient anxiety but are often of little clinical significance.