Screening for intracranial aneurysms in patients with bicuspid aortic valve

Prevalence of Intracranial Aneurysms in Patients With Coarctation of the Aorta: A Systematic Review and Meta-Analysis

Background

Coarctation of the aorta (CoA) is associated with intracranial aneurysms (IAs); however, the prevalence and risk factors (RFs) are not well described. Current practice guidelines offer inconsistent recommendations on screening for IAs in this patient population ranging from "not recommended" (European Society of Cardiology 2020) to "recommended" (American Heart Association 2018).

Objectives

The purpose of this study was to determine the prevalence and RFs for IAs in patients with CoA.

Methods

We completed a systematic review and meta-analysis of studies utilizing computed tomography or magnetic resonance angiographic screening for IAs in patients with CoA.

Results

Five cohort studies were included, representing 442 patients. The pooled prevalence of IAs in patients with CoA was 3.8% [95% CI: 0.1%-12.3%]. The results met our prespecified definition for high heterogeneity. Of 5 RFs evaluated, only hypertension was associated with the development of IAs with an odds ratio of 3.1 [95% CI: 1.1-8.2; P = 0.03]. There was an observed downward trend over time in the prevalence of IAs among the studies included.

Conclusions

The development of IAs is likely multifactorial in etiology and there may be modifiable RFs in their development. Considering the low prevalence of IAs in the pooled result, routine screening of patients with CoA for IAs is likely of low-value.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Prevalence and Outcomes of Bicuspid Aortic Valve in Patients With Aneurysmal Sub-Arachnoid Hemorrhage: A Prospective Neurology Registry Report

Background Intracranial aneurysms are reported in 6%-10% of patients with bicuspid aortic valve (BAV), and routine intracranial aneurysm surveillance has been advocated by some. We assessed the prevalence and features of the most important patient-outcome: aneurysmal sub-arachnoid hemorrhage (aSAH), as compared with controls without aSAH, and tricuspid aortic valve (TAV) with aSAH. Methods and Results Adult patients with accurate diagnosis of aSAH and at least one echocardiogram between 2000 and 2019 were identified from a consecutive prospectively maintained registry of aSAH admissions. Controls without a diagnosis of SAH were age- and sex-matched. BAV prevalence was confirmed echocardiographically. Severity of aSAH was categorized using modified Fisher and World Federation of Neurological Scale. Neurologic outcome was assessed using modified Rankin score. A total 488 aSAH cases and 990 controls were identified and BAV status was confirmed. Prevalence of BAV in patients with aSAH was 1.2% (6/488) versus 3.5% (35/990) in controls, P=0.01. BAV+aSAH were noted to be younger than TAV+aSAH (56±11 versus 68±14; P=0.03) with smaller aneurysms (5±2 versus 7±4; P=0.31). The severity of aSAH was lesser in BAV+aSAH than TAV (modified Fisher grade>2 50% versus 74%; P=0.19, World Federation of Neurological Scale grade>3 17% versus 36%; P=0.43). BAV+aSAH had less severe neurologic disability (modified Rankin score 3%-6 33% versus 49% in TAV; P=0.44) and comparable in-hospital mortality rates (P=0.93). BAV had lower odds for aSAH on multivariate analysis (odds ratio 0.23[CI 0.08-0.65]; P=0.01). Conclusions Prevalence of BAV was 3 times lower in the aSAH registry than in controls without aSAH. BAV+aSAH had clinically smaller aneurysms, clinically smaller bleeds, and better neurologic outcome as compared with TAV+aSAH, which needs to be confirmed in larger studies. These findings argue against routine surveillance for intracranial aneurysms in patients with BAV without aortic coarctation.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Cost effectiveness of screening for intracranial aneurysms among patients with bicuspid aortic valve: a Markov modelling study

OBJECTIVE

Bicuspid aortic valve (BAV) is common and 7.7%-9.8% of patients with BAV have intracranial aneuryms (IAs) which might lead to a devastating subarachnoid haemorrhage (SAH). We aimed to evaluate different screening and follow-up strategies using magnetic resonance angiography for IAs among patients with BAV.

METHODS

A decision-analytic model was built to evaluate the costs and effectiveness of different management strategies from the Chinese healthcare payer's perspective. The evaluated strategies included natural history without screening for possible IAs, regular screening and no follow-up for detected IAs, and regular screening with regular follow-up (Screen strategy/Follow-up strategy). Base case calculation, as well as probabilistic, one-way, and two-way sensitivity analyses, were performed.

RESULTS

According to the base case calculation, natural history had the least cost and effectiveness while Every 5 years (y)/Annual gained the highest cost and effectiveness. Every 10y/Biennial was cost effective when compared with Every 10y/Every 5y under the willingness-to-pay threshold of ¥211 743 (US$30 162). Probabilistic sensitivity analysis showed that Every 10y/Biennial was superior in 88.3% of the cases when compared with Every 10y/Every 5y. One-way and two-way sensitivity analyses proved that Every 10y/Biennial was the dominant strategy under most circumstances.

CONCLUSIONS

Screening for possible IAs among patients with BAV and follow-up for detected IAs would increase the effectiveness. Every 10y/Biennial was the optimal strategy from the Chinese healthcare payer's perspective.

Rare Neurovascular Diseases in Korea: Classification and Related Genetic Variants

Rare neurovascular diseases (RNVDs) have not been well-recognized in Korea. They involve the central nervous system and greatly affect the patients' lives. However, these diseases are difficult to diagnose and treat due to their rarity and incurability. We established a list of RNVDs by referring to the previous literature and databases worldwide to better understand the diseases and their current management status. We categorized 68 RNVDs based on their pathophysiology and clinical manifestations and estimated the prevalence of each disease in Korea. Recent advances in genetic, molecular, and developmental research have enabled further understanding of these RNVDs. Herein, we review each disease, while considering its classification based on updated pathologic mechanisms, and discuss the management status of RNVD in Korea.

Prevalence of Intracranial Aneurysm in Patients With Aortic Disease in Korea: A Nationwide Population-Based Study

Background Patients with aortic disease (AD) might have a higher prevalence of intracranial aneurysm (IA). The present study evaluated the prevalence of IA in patients with AD and identified potential risk factors of IA using nationwide representative cohort sample data. Methods and Results We defined AD as both aortic dissections and aortic aneurysms. This study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database from 1.1million patients. Using χ² or Fisher's exact tests, the prevalence of the IA in patients with AD and potential risk factors for their concurrence were analyzed. The prevalence of IA in patients with AD was 6.8% (155/2285). The adjusted odds ratios (OR) for having concurrent IA in patients with AD was 3.809 (95% CI, 3.191-4.546; P<0.01). Patients with AD and hypertension were >19 times more likely to be affected by IA (adjusted OR, 18.679; 95% CI, 16.555-21.076; P<0.01). Patients with AD and diabetes mellitus, old age (>60 years), and male sex were >4, 3, and 2 times more likely to be affected by IA, respectively (adjusted OR, 4.291, 3.469, and 1.983, respectively; 95% CI, 3.914-4.704, 3.152-3.878, and 1.779-2.112, respectively). Subgroup analysis with socioeconomic status or disability revealed that the prevalence of IA was significantly higher in all groups. Conclusions In the current population-based study, the prevalence of IA in patients with AD was quadrupled compared with that in the general population. Early IA screening might be considered among patients with AD for appropriate management.

Neurologic complications of congenital heart disease in adults

Congenital heart disease (CHD) is a heterogeneous group of structural abnormalities of the cardiovascular system that are present at birth. Advances in childhood medical and surgical treatment have led to increasing numbers of adults with CHD. Neurological complications of CHD in adults are varied and can include an increased risk of stroke not only related to the underlying congenital defect and its surgical management but also due to atherosclerotic disease associated with advancing age. In addition to cerebrovascular events, CHD in adults is also associated with an increased risk of neurodevelopmental disorders, cognitive impairment, psychiatric disease, and epilepsy. Collaborative multidisciplinary care with contributions from neurologists and cardiologists with expertise in adult CHD is necessary to provide optimal long-term care for this complex and rapidly evolving population.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Frequency of intracranial aneurysms and sub-arachnoid hemorrhage is significantly lesser in bicuspid aortic valve than aortic coarctation

BACKGROUND

Bicuspid aortic valve(BAV) is common. Some studies suggest that all BAV patients require screening for intracranial aneurysm(IA) in order to prevent sub-arachnoid hemorrhage(SAH). Aortic coarctation(CoA) carries high-risk of both IA and SAH. Using a nationally-representative population, we assessed the frequency of IA and SAH in admissions with BAV-without-CoA versus admissions with CoA(with or without BAV).

METHODS

Between 2000 and 2016, adult admissions with a primary/secondary diagnosis of BAV and/or CoA were identified using the National Inpatient Sample. Admissions with traumatic SAH and inter-hospital transfers were excluded. Outcomes were frequency of IA and SAH, and in-hospital mortality in BAV-without-CoA versus CoA.

RESULTS

In this 17-year period, 254,675 admissions met inclusion criteria and 236,930(93.0%) had BAV-without-CoA. BAV-with-CoA was present in 2846(1.1%) and isolated-CoA in 14,899(5.9%), for a total of 17,745(7%) with CoA. IA was noted in 405 admissions(0.2%) overall, BAV-without-CoA versus CoA having 293(0.1%) versus 112(0.6%), p < 0.001. SAH was noted in 910 admissions(0.4%) overall, with BAV-without-CoA versus CoA having 760(0.3%) versus 150(0.9%), p < 0.001.

CONCLUSIONS

In this study, BAV-without-CoA admissions had 0.1%(6-times lower than CoA) and 0.3%(3-times lower that CoA) IA and SAH, respectively, which is comparable to the general population. This suggests that BAV-without-CoA patients likely do not require routine surveillance for IA.

Applications of a Specialty Bicuspid Aortic Valve Program: Clinical Continuity and Translational Collaboration

Bicuspid aortic valve (BAV) is a common congenital heart diagnosis and is associated with aortopathy. Current guidelines for aortic resection have been validated but are based on aortic diameter, which is insufficient to predict acute aortic events. Clinical and translational collaboration is necessary to identify biomarkers that can individualize the timing of prophylactic surgery for BAV aortopathy. We describe our multidisciplinary BAV program, including research protocols aimed at biomarker discovery and results from our longitudinal clinical registry. From 2012–2018, 887 patients enrolled in our clinical BAV registry with the option to undergo four dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR) and donate serum plasma or tissue samples. Of 887 patients, 388 (44%) had an elective BAV-related procedure after initial presentation, while 499 (56%) continued with medical management. Of medical patients, 44 (9%) had elective surgery after 2.3 ± 1.4 years. Surgery patients’ biobank donations include 198 (46%) aorta, 374 (86%) aortic valve, and 314 (73%) plasma samples. The 4D flow CMR was completed for 215 (50%) surgery patients and 243 (49%) medical patients. Patients with BAV aortopathy can be safely followed by a multidisciplinary team to detect indications for surgery. Paired tissue and hemodynamic analysis holds opportunity for biomarker development in BAV aortopathy.

Prevalence of Intracranial Aneurysm in Patients with Aortopathy: A Systematic Review with Meta-Analyses

BACKGROUND AND PURPOSE

Patients with aortic disease might have an increased risk of intracranial aneurysm (IA). We conducted this research to assess the prevalence of IA in patients with aortopathy, considering the impact of gender, age, and cardiovascular risk factors.

METHODS

We searched PubMed and Scopus from inception to August 2019 for epidemiological studies reporting the prevalence of IA in patients with aortopathy. Random-effect meta-analyses were performed to calculate the overall prevalence, and the effect of risk factors on the prevalence was also evaluated. Anatomical location of IAs in patients suffered from distinct aortic disease was extracted and further analyzed.

RESULTS

Thirteen cross-sectional studies involving 4,041 participants were included in this systematic review. We reported an estimated prevalence of 12% (95% confidence interval [CI], 9% to 14%) of IA in patients with aortopathy. The pooled prevalence of IA in patients with bicuspid aortic valve, coarctation of the aorta, aortic aneurysm, and aortic dissection was 8% (95% CI, 6% to 10%), 10% (95% CI, 7% to 14%), 12% (95% CI, 9% to 15%), and 23% (95% CI, 12% to 34%), respectively. Gender (female) and smoking are risk factors related to an increased risk of IA. The anatomical distribution of IAs was heterogeneously between participants with different aortic disease.

CONCLUSIONS

According to current epidemiological evidence, the prevalence of IA in patients with aortic disease is quadrupled compared to that in the general population, which suggests that an early IA screening should be considered among patients with aortic disease for timely diagnosis and treatment of IA.

The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Full online-only version

Bicuspid aortic valve disease is the most common congenital cardiac disorder, being present in 1% to 2% of the general population. Associated aortopathy is a common finding in patients with bicuspid aortic valve disease, with thoracic aortic dilation noted in approximately 40% of patients in referral centers. Several previous consensus statements and guidelines have addressed the management of bicuspid aortic valve-associated aortopathy, but none focused entirely on this disease process. The current guidelines cover all major aspects of bicuspid aortic valve aortopathy, including natural history, phenotypic expression, histology and molecular pathomechanisms, imaging, indications for surgery, surveillance, and follow-up, and recommendations for future research. It is intended to provide clinicians with a current and comprehensive review of bicuspid aortic valve aortopathy and to guide the daily management of these complex patients.

Association of Aortic Aneurysms and Dissections With Subarachnoid Hemorrhage

Background It is uncertain whether aortic diseases, such as aneurysm and dissection, are associated with intracranial aneurysm formation and aneurysmal subarachnoid hemorrhage (SAH). Methods and Results We used data on claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. Our exposure variable was hospitalization with an unruptured or ruptured aortic aneurysm or aortic dissection. The outcome was nontraumatic SAH. Variables were ascertained by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnosis codes. Survival statistics were used to calculate incidence rates. Cox proportional hazards analysis was used to examine the association between aortic aneurysm/dissection and SAH while adjusting for demographics, vascular risk factors, and Charlson comorbidities. Among 1 781 917 beneficiaries, 32 551 (1.8%) had a documented aortic aneurysm or dissection. During 4.6±2.2 years of follow-up, 2538 patients (0.14%) developed a nontraumatic SAH. The incidence of SAH was 9 (95% CI, 7-11) per 10 000 patients per year in those with aortic aneurysm/dissection compared with 3 (95% CI, 3-3) per 10 000 patients per year in those without aortic aneurysm/dissection. After adjustment for demographics, stroke risk factors, and Charlson comorbidities, patients with aortic aneurysm/dissection faced an increased risk of SAH (hazard ratio, 1.4; 95% CI, 1.02-1.9; P=0.04). Conclusions In a nationally representative sample of Medicare beneficiaries, aortic aneurysm/dissection was associated with an increased risk of nontraumatic SAH.

Prevalence of thoracic aortic aneurysms and dilatations in patients with intracranial aneurysms

OBJECTIVE

The prevalence of intracranial aneurysms (IAs) is higher in patients with aortic aneurysms. However, there are lack of studies investigating prevalence of thoracic aortic aneurysms (TAAs) in patients with IAs. The objective of this study was to evaluate the prevalence and risk factors for thoracic aortic dilatations (TADs) and TAAs in patients with IAs.

METHODS

We retrospectively reviewed data from 1777 patients with diagnosed IAs at our institution between 2006 and 2016. We included 411 patients with saccular IAs and available imaging studies (computed tomography or magnetic resonance imaging) of all thoracic aortic segments. TAD was defined according to age- and sex-matched normograms, and TAA as a diameter of greater than 4.0 cm.

RESULTS

A total of 83 patients (20%) had TAD or TAA. The prevalence of TADs and TAAs were 18% (n = 74) and 8% (n = 31) without significant difference between unruptured and ruptured IAs (P = .7). Of the 74 patients with TAD, 22 (30%) had multiple TADs and 66% of the TADs located in the aortic arch. Older age (odds ratio [OR], 1.04; P = .006), rheumatic disease (OR, 4.73; P = .009) and alcohol abuse (OR, 4.77; P = .01) were significant risk factors for TAD/TAA.

CONCLUSIONS

The prevalence of TADs and TAAs is considerably greater in patients with IAs compared with reports from the general population, suggesting that IAs might be associated with aortopathy and might share a similar pathogenetic background with TADs/TAAs. Especially patients with IAs and a history of rheumatic disease and/or alcohol abuse are at high risk for TADs/TAAs.

Bicuspid aortic valve-associated aortopathy: Where do we stand?

Herein we summarize the current knowledge on the bicuspid aortic valve (BAV)-associated aortopathy regarding clinical presentation and disease sub-classification, genetic background, hemodynamics, histopathology, cells and signaling, animal models, and biomarkers. Despite enormous efforts in research in all of the above areas, important issues remain unknown: (i) what is the ontogenetic basis of BAV development? (ii) how can we explain the diversity of BAV and associated aortopathy phenotypes? (iii) what are the signaling processes in aortopathy pathogenesis and how can we interfere with these processes? Despite undoubtedly great progress that has been made in the understanding of BAV-associated aortopathy, so far researchers have put together a heap of Lego bricks, but at present it is unclear if the bricks are compatible, how they fit together, and which parts are missing to build the true model of the BAV aorta. A joint approach is needed to accelerate research progress.

Cerebral Aneurysms: Are They Associated with Anatomic Variations of Carotid and Main Cerebral Arteries?

OBJECTIVE

Vascular anatomic variations are very common in the population, but their coexistence with life-threating vascular malformations remains unclear. The objective of the study was to assess the correlation between the presence of anatomic variants of both carotid and main cerebral arteries and the occurrence of cerebral aneurysms.

METHODS

We analyzed examinations of 194 patients who underwent computed tomography angiography of the head and neck between September of 2016 and November of 2017. The assessed parameters were: the variation of the common carotid arteries origin, hypoplasia or duplication of any of the main cerebral arteries, carotid artery kinking, and the presence of cerebral aneurysms.

RESULTS

We found 5.7% of patients had a cerebral aneurysm. Hypoplasia of at least 1 main cerebral artery occurred in 34.5% of patients, with the most frequent being the vertebral artery (21.6%). Duplication of at least 1 main cerebral artery was detected in 2.6%. Cerebral aneurysms occurred more often together with hypoplasia (P = 0.041; OR = 3.175) or duplication (P < 0.001; OR = 18.500) of at least 1 main cerebral artery. In 7.2% of cases, the origin of common carotid arteries created a true bovine arch, and in 4.1% the so-called bovine arch. Patients with alternative variants of aortic arch branching were more likely to have cerebral aneurysms (P = 0.002; OR = 5.903). We found 27.3% of patients had internal carotid arteries affected by kinking. Carotid kinking did not predispose the patient to the formation of a cerebral aneurysm (P = 0.378).

CONCLUSIONS

There is an evident correspondence between the presence of vascular anatomic variants (abnormal origin of the carotid arteries, hypoplasia, or duplication of the main cerebral artery) and the occurrence of cerebral aneurysms.

New Pathophysiological Considerations on Cerebral Aneurysms

Cerebral aneurysm is a common cerebrovascular disease that is sometimes complicated by rupture or an enlarged mass. We are now aggressively evaluating and managing unruptured cerebral aneurysms based on a significant concern for the high morbidity and mortality related to its associated complications. However, the actual rupture rate is very low and the diagnostic and treatment modalities are expensive and invasive, which may lead to unnecessary costs and potential medical complications. This disproportionate situation is related to a poor understanding of the natural course and pathophysiology of cerebral aneurysms. In consideration of the concept that not all cerebral aneurysms must be removed, we need to examine their course and progression more accurately. Cerebral aneurysms may follow a variety of pathophysiological scenarios over their lifetime, from formation to growth and rupture. The disease course and the final outcome can differ depending on the timing and intensity of the pathological signals acting on the cerebral vessel wall. We should delineate a method of predicting the stability and risk of rupture of the lesion based on a comprehensive knowledge of the vessel wall integrity. This review deals with the basic knowledge and advanced concepts underlying the pathophysiology of cerebral aneurysms.

Mid-term Outcome of 100 Consecutive Ross Procedures: Excellent Survival, But Yet to Be a Cure

The Ross procedure offers excellent short-term outcome but the long-term durability is under debate. Reinterventions and follow-up of 100 consecutive patients undergoing Ross Procedure at our centre (1993-2011) were analysed. Follow-up was available for 96 patients (97%) with a median duration of 5.3 (0.1-17.1) years. Median age of the patient cohort was 15.2 (0.04-58.4) years with 76 males. 93% had underlying congenital aortic stenosis. Root replacement technique was applied in all. The most common valved conduits used for reconstruction of the right ventricular outflow tract were homografts (66 patients) and bovine jugular vein (Contegra^R) graft (31 patients). Additional procedures included Ross-Konno procedure (14%), resection of subaortic stenosis/myectomy (11%) and reduction plasty of the ascending aorta (25%). One patient died within the first 30 days (1%). Late deaths occurred in 4 patients (4%) 0.5-4.5 years postoperatively: causes included pulmonary hypertension due to endocardial fibroelastosis (2), subarachnoid haemorrhage (1) and sudden cardiac death (1). Five-year survival was 93.6 (95% CI 88.1-99.1)%. Moderate or severe aortic (autograft) regurgitation needing reoperation occurred in 8 patients with a 5-year freedom from autograft reoperation of 98.5 (95.6-100)%. Five-year freedom from reintervention (surgery or catheter based) on the right ventricular outflow tract conduit was 91.5 (85.5-96.5)%. Univariate predictors of this reinterventions were smaller graft size (p = 0.03) and use of a Contegra^R graft (p = 0.04). Ross procedure can be performed with low mortality and good survival in the long term. Most of the reinterventions are related to the neo-right ventricular outflow tract and may be partly attributed to the lack of growth. While the Ross Procedure remains an invaluable option for aortic valve disease in children, new solutions for the neo-pulmonary valve as well as for the less often occurring problems on the autograft are needed.

Prevalence of Intracranial Aneurysms in Patients with Aortic Dissection

BACKGROUND AND PURPOSE

There is an uncertainty about the association between intracranial aneurysms and aortic dissection. We aimed to determine the prevalence of intracranial aneurysms in patients with aortic dissection and evaluate the independent risk factors for the presence of intracranial aneurysms in these patients.

MATERIALS AND METHODS

Seventy-one patients with a confirmed aortic dissection who underwent additional brain imaging were enrolled as the aortic dissection group, and 2118 healthy individuals with brain imaging, as controls. Demographic data were obtained from their medical records, including age, sex, comorbidities, and arch vessel involvement of aortic dissection. Two readers reviewed all brain images independently regarding the presence, morphology, size, and location of intracranial aneurysms. Baseline characteristics were compared between the aortic dissection group and controls by propensity score matching, and logistic regression analysis was performed for independent risk factors for the presence of intracranial aneurysms.

RESULTS

The prevalence of intracranial aneurysms was 12.96% in the aortic dissection group and 1.85% in controls (P = .022). The mean diameter of intracranial aneurysms was significantly larger in the aortic dissection group (5.79 ± 3.26 mm in aortic dissection versus 3.04 ± 1.57 mm in controls; P = .008), and intracranial aneurysms of >7 mm were also more common in the aortic dissection group (28.6% in aortic dissection versus 5.3% in controls, P = .003). On multivariate analysis, arch vessel involvement of aortic dissection was an independent risk factor for the presence of intracranial aneurysms (odds ratio, 6.246; 95% confidence interval, 1.472-26.50; P = .013).

CONCLUSIONS

Patients with aortic dissection have a high prevalence of intracranial aneurysms, and selective screening for brain vessels could be considered in these patients with arch vessel involvement. A further prospective study is needed to demonstrate a substantial prevalence of intracranial aneurysms.

Prevalence of Intracranial Aneurysms in Patients with Aortic Aneurysms

BACKGROUND AND PURPOSE

Previous studies have suggested an association between aortic aneurysms and intracranial aneurysms with a higher prevalence of intracranial aneurysms in patients with aortic aneurysms. The aims of the present study were to evaluate the incidence of intracranial aneurysms in a large cohort of patients with aortic aneurysms and to identify potential risk factors for intracranial aneurysms in this population.

MATERIALS AND METHODS

We included all patients with aortic aneurysms (either abdominal and/or thoracic) who had available cerebral arterial imaging and were seen at our institution during a 15-year period. We identified patients with intracranial aneurysms. Patient demographics, comorbidities, and aortic aneurysm and intracranial aneurysm sizes and locations were analyzed. Univariate analysis was performed with a χ(2) test for categoric variables and a Student t test or ANOVA for continuous variables.

RESULTS

A total of 1081 patients with aortic aneurysms were included. Of them, 440 (40.7%) had abdominal aortic aneurysms, 446 (41.3%) had thoracic aortic aneurysms, and 195 (18.0%) had both abdominal aortic and thoracic aortic aneurysms. The overall prevalence of associated intracranial aneurysms in patients with aortic aneurysms was 11.8% (128/1081), with 12.7% (56/440), 10.8% (48/446), and 12.3% (24/195), respectively, in patients with abdominal aortic aneurysms, thoracic aortic aneurysms, and both thoracic aortic aneurysms and abdominal aortic aneurysms. Female patients had a higher risk of associated intracranial aneurysms (OR = 2.08; 95% CI, 1.49-3.03; P = .0002). There was a slight association between abdominal aortic aneurysm size and the prevalence of intracranial aneurysms (OR = 1.02; 95% CI, 1.01-1.03; P = .045). There was no significant association between the locations of the aortic and intracranial aneurysms (P = .93).

CONCLUSIONS

The prevalence of intracranial aneurysms is high in patients with aortic aneurysms. Further studies examining the role and cost-effectiveness of intracranial aneurysm screening in patients are warranted.

Extra-cardiac manifestations of adult congenital heart disease

Advancement in correction or palliation of congenital cardiac lesions has greatly improved the lifespan of congenital heart disease patients, resulting in a rapidly growing adult congenital heart disease (ACHD) population. As this group has increased in number and age, emerging science has highlighted the systemic nature of ACHD. Providers caring for these patients are tasked with long-term management of multiple neurologic, pulmonary, hepatic, renal, and endocrine manifestations that arise as syndromic associations with congenital heart defects or as sequelae of primary structural or hemodynamic abnormalities. In this review, we outline the current understanding and recent research into these extra-cardiac manifestations.

Experimental Induction of Cerebral Aneurysms by Developmental Low Copper Diet

Optimal models are needed to understand the pathophysiology of human cerebral aneurysms (CA). We investigated the development of experimental CA by decreasing the activity of lysyl oxidases by dietary copper deficiency from the time of gestation and then augmenting vascular stress by angiotensin II infusion in adulthood. Rats were fed copper-free, low-copper, or normal diets at different time periods from gestation to adulthood. The incidences of CAs were evaluated and autopsies performed to determine the coexistence of cardiovascular diseases. A copper-free diet from gestation was associated with high mortality rates (79.1%) resulting from rupture of ascending aorta aneurysms; a low-copper diet led to acceptable mortality rates (13.6%) and produced CAs and subarachnoid hemorrhage in 46.4% and 3.6% of animals, respectively. Higher proportions of CAs (up to 33.3%) in the rats primed for copper deficiency from gestation ruptured following angiotensin II infusion from adulthood. Gene expression array analyses of the CAs indicated that genes involving extracellular matrix and vascular remodeling were altered in this model. This model enables future research to understand the entire pathogenetic basis of CA development and rupture in association with systemic vasculopathies.

Frequency of Intracranial Aneurysms Determined by Magnetic Resonance Angiography in Children (Mean Age 16) Having Operative or Endovascular Treatment of Coarctation of the Aorta (Mean Age 3)

Coarctation of the aorta (CofA) has been associated with an increased risk of intracranial aneurysm (IA). This magnetic resonance angiography (MRA) study investigates the prevalence of IAs in 80 children treated in early life for CofA. MRA was performed at mean age of 15.7 ± 7.1 years, and surgical or endovascular treatment for CofA occurred at a mean age of 2.6 ± 4.4 years. No IA was found. In contrast with earlier findings in adult patients with late treatment for CofA, this first systematic study of very early treated patients for CofA failed to confirm the association between CofA and IAs. Our results call the abnormal developmental relation between CofA and IAs into question and suggest that modifiable risk factors like hypertension may be responsible for IA development in patients with CofA with adult diagnosis and treatment. In conclusion, our data suggest that early treatment of CofA can reduce the formation of IAs in children so as to make MRA screening less valuable in this young population.

Bicuspid aortic valve aortopathy in adults: Incidence, etiology, and clinical significance

Bicuspid aortic valve is the most common congenital heart defect and is associated with an aortopathy manifested by dilatation of the ascending thoracic aorta. The clinical consequences of this aortopathy are the need for periodic monitoring of aortic diameters, elective prophylactic surgical aortic repair, and the occurrence of aortic dissection or rupture. This review describes the current knowledge of BAV aortopathy in adults, including incidence, pathophysiologic insights into its etiology, contemporary hypothesis-generating observations into its complications, and recommendations for monitoring and intervention.

Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms.

METHODS

Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.

Site-Specific Relationship Between Intracranial Aneurysm and Aortic Aneurysm

BACKGROUND AND PURPOSE

The high prevalence of intracranial aneurysms (IAs) in patients with a bicuspid aortic valve or coarctation of the aorta suggests a link between IA and aortic pathology. However, studies reporting this link do not sufficiently address the heterogeneity of IAs arising from different anatomic locations. This study aimed to explore whether a location-specific relationship exists between the 2 kinds of aneurysms.

METHODS

Retrospective institutional analysis of patients aged ≥18 years with both IA and an aortic aneurysm (AA) was performed from 2005 to 2014. IAs were categorized based on their locations: internal carotid artery, other anterior circulation, and posterior arteries. AAs were classified as ascending, descending, infrarenal, or multiple. We analyzed the clinical characteristics and the distribution of IA in each AA group.

RESULTS

Of 2375 patients, 660 with available intracranial angiography were screened for IA. We identified 71 patients with 97 IAs. The frequency of both anterior circulation-IAs and internal carotid artery-IAs differed significantly among the AA groups (P=0.001 and P=0.01, respectively). Anterior circulation-IAs were most frequently observed in ascending AA group and least frequently in infrarenal AA group. In contrast, internal carotid artery-IAs were found mostly in infrarenal AA group, least in ascending AA group. Proportions of patients having anterior circulation-IA and internal carotid artery-IA were also highest in ascending AA group and infrarenal AA group, respectively. The number of posterior arteries-IAs was too small to characterize.

CONCLUSIONS

The differing distribution patterns of IA among AA groups suggest a site-specific sharing of pathomechanism between the 2 types of aneurysms.

Bicuspid aortic valves and thoracic aortic aneurysms in patients with intracranial aneurysms

OBJECTIVE

The purpose of this study was to determine the prevalence of bicuspid aortic valves (BAVs) and thoracic ascending aortic aneurysms (TAAs) in a retrospective cohort of patients treated for intracranial aneurysms (IAs).

METHODS

Patients treated for IA at our institution between 2002 and 2011 were identified and their clinical records reviewed. Those without an echocardiogram of sufficient quality to assess the aortic valve were excluded. The prevalence of BAVs and TAAs in this remaining cohort was determined based on echocardiography reports, medical records, and cross-sectional chest imaging.

RESULTS

Of 1,047 patients, 317 had adequate echocardiography for assessment of BAV. Of these, 82 also had cross-sectional chest imaging. Of the 317 patients, 2 had BAV and 15 had TAA. The prevalence of BAVs (0.6%, 95% confidence interval 0.2%-2.2%) was similar to population prevalence estimates for this condition; however, the prevalence of TAAs (4.7%, 95% confidence interval 2.9%-7.6%) was larger than expected in a normal age- and sex-matched population.

CONCLUSIONS

Our data demonstrate an association between IA and TAA, but not independently for BAV.

Echocardiographic evidence of innate aortopathy in the human intracranial aneurysm

BACKGROUND

Intracranial aneurysm (IA) is significantly more prevalent in patients with coarctation of the aorta or bicuspid aortic valve than in the general population, suggesting a common pathophysiology connecting IA and aortopathy. Here, we analyzed echocardiographic aortic root dimension (ARD) in patients with IA to confirm this possibility.

METHODS

From January 2008 to December 2010, 260 consecutive patients with IA who were admitted to our institution for coil embolization or for acute stroke management and who also underwent echocardiography were enrolled. We hypothesized that patients with large, ruptured, or multiple IAs are more likely to harbor co-prevalent aortopathy as measured by ARD compared to patients with small, isolated, unruptured IAs. Eccentric group was defined as patients aged <55 years with at least one ruptured aneurysm, an aneurysm ≥7 mm in size, or multiple aneurysms; the remainder was classified into a non-eccentric group. Clinical, angiographic, and echocardiographic findings of the two groups were compared.

RESULTS

ARD was significantly larger in the eccentric group than in the non-eccentric group (P = 0.049), and the difference was confirmed by multivariable analysis (P = 0.02). Subgroup analysis of patients aged <55 years showed similar result for ARD (P = 0.03), whereas hypertension was more associated with the non-eccentric group (P = 0.01). In addition, height was inversely related to aneurysm size after adjustment for age, sex, weight, ARD, smoking status, and number of aneurysms (P = 0.004).

CONCLUSIONS

A certain group of IA patients share a common intrinsic wall defect with aortopathy. Shared neural crest cell origin may give rise to this phenomenon.

Alternative splicing of endothelial fibronectin is induced by disturbed hemodynamics and protects against hemorrhage of the vessel wall

OBJECTIVE

Abnormally low-flow conditions, sensed by the arterial endothelium, promote aneurysm rupture. Fibronectin (FN) is among the most abundant extracellular matrix proteins and is strongly upregulated in human aneurysms, suggesting a possible role in disease progression. Altered FN splicing can result in the inclusion of EIIIA and EIIIB exons, generally not expressed in adult tissues. We sought to explore the regulation of FN and its splicing and their possible roles in the vascular response to disturbed flow.

APPROACH AND RESULTS

We induced low and reversing flow in mice by partial carotid ligation and assayed FN splicing in an endothelium-enriched intimal preparation. Inclusion of EIIIA and EIIIB was increased as early as 48 hours, with negligible increases in total FN expression. To test the function of EIIIA and EIIIB inclusion, we induced disturbed flow in EIIIAB(-/-) mice unable to include these exons and found that they developed focal lesions with hemorrhage and hypertrophy of the vessel wall. Acute deletion of floxed FN caused similar defects in response to disturbed flow, consistent with a requirement for the upregulation of the spliced isoforms, rather than a developmental defect. Recruited macrophages promote FN splicing because their depletion by clodronate liposomes blocked the increase in endothelial EIIIA and EIIIB inclusion in the carotid model.

CONCLUSIONS

These results uncover a protective mechanism in the inflamed intima that develops under disturbed flow, by showing that splicing of FN mRNA in the endothelium, induced by macrophages, inhibits hemorrhage of the vessel wall.

Results of screening for intracranial aneurysms in patients with coarctation of the aorta

BACKGROUND AND PURPOSE

IAs are found in 2.3% of adults; the mean age at detection is 52 years. Prevalence is <0.5% in young adults. Early studies suggest that 10%-50% of patients with aortic coarctation have IAs. Screening recommendations are variable. We sought to examine the prevalence of IAs through screening with MRA.

MATERIALS AND METHODS

Consecutive patients older than 16 years of age with coarctation undergoing brain MRA between May 1999 and October 2007 were included. MRA was performed by using a 1.5T scanner with a 3D time-of-flight protocol; simultaneous MR imaging was performed of the heart and aorta. Cerebral MRAs were double-reported by a neuroradiologist. Statistics are described as mean ± SD and median ± range. Continuous variables were compared by using Student t tests and Mann-Whitney U tests (categoric variables, by using the Fisher exact test).

RESULTS

One hundred seventeen MRAs were double-reported. The median age was 29 ± 11 years (range, 16-59 years). IAs were found in 12 patients (10.3%). The mean diameter of IAs was 3.9 mm (range, 2.0-8.0 mm). Patients with aneurysms were older (median, 37 years; range, 16-50 years) than those without (median, 23 years; range, 16-59 years; Z = -2.01, P = .04). Hypertension was more common in those with IAs (IA 83% versus no IA 43%, P = .01). There was no association between ascending aortopathy, bicuspid aortic valves, and IAs.

CONCLUSIONS

Patients with coarctation have a higher prevalence of IAs, occurring at an earlier age than in population studies. Whether routine screening is appropriate for this group of patients is unclear. Hypertension is likely to be an important pathophysiologic factor.

The case for family screening for intracranial aneurysms

Given that relatives of patients with intracranial aneurysms (IAs) or subarachnoid hemorrhage have a greater risk of harboring an aneurysm, family screening has become a common practice in neurosurgery. Unclear data exist regarding who should be screened and at what age and interval screening should occur. Multiple factors including the natural history of IAs, the risk of treatment, the cost of screening, and the psychosocial impact of finding an aneurysm should be taken into account when family screening is considered. In this paper, the authors review the current literature regarding risk factors and natural history of sporadic and familial aneurysms. Based on these data the authors assess current recommendations for screening and propose their own recommendations.

Frequency of intracranial aneurysms in patients with spontaneous intracranial hypotension

Object

Spontaneous intracranial hypotension (SIH) is a significant cause of new-onset daily persistent headache. A generalized connective tissue disorder also involving the intracranial arteries has been suspected in the population with SIH. Therefore, the authors reviewed angiographic studies for the presence of intracranial aneurysms in a group of patients with SIH.

Methods

Magnetic resonance angiography studies of the brain were performed in 93 patients with SIH (mean age 43 years, range 14–86 years) and in 291 controls (mean age 56 years, range 28–78 years).

Results

Intracranial aneurysms were detected in 8 (8.6%) of the 93 patients with SIH (95% CI 2.9%–14.3%). This incidence was higher than in the control population (3 (1.0%) of 291 (95% CI 0%–2.2%; p = 0.0007). In 7 patients the aneurysms were incidental, and in 1 patient SIH developed 5 weeks after an aneurysmal subarachnoid hemorrhage.

Conclusions

In this retrospective case-control study, the frequency of intracranial aneurysms among patients with SIH was significantly higher than in the control population.

Hereditary connective tissue diseases in young adult stroke: a comprehensive synthesis

Though the genetic background of ischaemic and haemorrhagic stroke is often polygenetic or multifactorial, it can in some cases result from a monogenic disease, particularly in young adults. Besides arteriopathies and metabolic disorders, several connective tissue diseases can present with stroke. While some of these diseases have been recognized for decades as causes of stroke, such as the vascular Ehlers-Danlos syndrome, others only recently came to attention as being involved in stroke pathogenesis, such as those related to Type IV collagen. This paper discusses each of these connective tissue disorders and their relation with stroke briefly, emphasizing the main clinical features which can lead to their diagnosis.