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Ortiz AFH, Suriano ES, Eltawil Y, Sekhon M, Gebran A, Garland M, Cuenca NTR, Cadavid T, Almarie B. Prevalence and risk factors of unruptured intracranial aneurysms in ischemic stroke patients - A global meta-analysis. Surg Neurol Int 2023; 14:222. [PMID: 37404522 PMCID: PMC10316137 DOI: 10.25259/sni_190_2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/31/2023] [Indexed: 07/06/2023] Open
Abstract
Background Unruptured intracranial aneurysms (UIAs) have an estimated global prevalence of 2.8% in the adult population; however, UIA was identified among more than 10% of ischemic stroke patients. Many epidemiological studies and reviews have pointed to the presence of UIA among patients with ischemic stroke; yet, the extent of this association is not fully known. We performed a systematic review and meta-analysis to determine the prevalence of UIA in patients admitted to hospitals with ischemic stroke and transient ischemic attack (TIA) at both global and continental levels and evaluate factors associated with UIA in this population. Methods We identified, in five databases, all studies describing UIA in ischemic stroke and TIA patients between January 1, 2000, and December 20, 2021. Included studies were of observational and experimental design. Results Our search yielded 3581 articles of which 23 were included, with a total of 25,420 patients. The pooled prevalence of UIA was 5% (95% confidence interval [CI] = 4-6%) with stratified results showing 6% (95% CI = 4-9%), 6% (95% CI = 5-7%), and 4% (95% CI = 2-5%) in North America, Asia, and Europe, respectively. Significant risk factors were large vessel occlusion (odds ratios [OR] = 1.22, 95% CI = 1.01-1.47) and hypertension (OR = 1.45, 95% CI = 1.24-1.69), while protective factors were male sex (OR = 0.60, 95% CI = 0.53-0.68) and diabetes (OR = 0.82, 95% CI = 0.72-0.95). Conclusion The prevalence of UIA is notably higher in ischemic stroke patients than the general population. Physicians should be aware of common risk factors in stroke and aneurysm formation for appropriate prevention.
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Affiliation(s)
| | | | - Yasmin Eltawil
- Department of Medicine, San Francisco School of Medicine, San Francisco, California, United States
| | - Manraj Sekhon
- Department of Medicine, University of California, Riverside School of Medicine, Riverside, California, United States
| | - Anthony Gebran
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Mateo Garland
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, United States
| | | | - Tatiana Cadavid
- Department of Nuclear Medicine, Fundación Universitaria Sanitas, Bogotá, Colombia
| | - Bassel Almarie
- Department of Surgery, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Wen D, Chen Y, Zhu W, Peng Z, Ma L. Cerebral hemorrhage after thrombolysis in stroke patients with unruptured intracranial aneurysms: a systemic review and meta-analysis. J Neurol 2023; 270:1931-1944. [PMID: 36547715 DOI: 10.1007/s00415-022-11533-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND For ischemic stroke patients with concomitant unruptured aneurysm, intravenous thrombolysis therapy (IVT) remains a disputable decision. We hence performed a meta-analysis to identify the related brain hemorrhage rate of unruptured aneurysms and the risk ratio for their rupture comparing to stroke patients who do not have aneurysms. METHODS A comprehensive search was conducted to identify the studies from the online database from 2000 to September 1st, 2022. Cohort studies were included and assessed by Newcastle-Ottawa Scale (NOS) for quality. The research procedures were subjected to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Fixed-effects model was used based on the heterogeneity tests. RESULTS In 10 eligible studies, 7238 ischemic stroke patients were screened, a total of 302 patients with 348 aneurysms were included. 10 studies were eligible for ICH rate analysis, 8 for SAH rate analysis and 7 for risk ratio of stroke patients with unruptured aneurysms. The pooled any ICH rate was 16% (95% CI 11-21%), symptomatic ICH rate was 4% (95% CI 1-7%, I2 = 0.00%, p = 0.90), and 0% (95% CI 0-1%) for aneurysm-related ICH. Subarachnoid hemorrhage was as low as 2% (95% CI 0-5%), while 0% (95% CI 0-2%) directly related to the aneurysm rupture. The risk ratio of ICH in stroke patients with aneurysms was 1.18 (95% CI 0.79-1.77). Additionally, the hemorrhage rate difference was not evident between saccular and fusiform aneurysms due to a lack of details. CONCLUSIONS IVT is unlikely to induce hemorrhage of pre-existing unruptured aneurysms in stroke patients. Further randomized control studies are warranted to validate these conclusions.
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Affiliation(s)
- Dingke Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yuqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Wei Zhu
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zongjun Peng
- Department of Neurosurgery, Sichuan Friendship Hospital, Chengdu, 610000, Sichuan, China.
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Virta JJ, Strbian D, Putaala J, Korja M. Risk of Aneurysm Rupture After Thrombolysis in Patients With Acute Ischemic Stroke and Unruptured Intracranial Aneurysms. Neurology 2021; 97:e1790-e1798. [PMID: 34615686 DOI: 10.1212/wnl.0000000000012771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/12/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Unruptured intracranial aneurysms (UIAs) are considered to be a relative contraindication for IV thrombolysis (IVT) in acute ischemic stroke (AIS). Currently, however, data are limited on the risk of UIA rupture after IVT. Our objective was to assess whether IVT for AIS can lead to a UIA rupture and intracranial hemorrhages (ICHs) in patients with unruptured UIAs. METHODS This was a prospective cohort study of consecutive patients treated in a comprehensive stroke center between 2005 and 2019. We assessed radiology reports and records at the Finnish Care Register for Health Care to identify patients with UIAs among all patients with AIS treated with IVT at the center. We analyzed patient angiograms for aneurysm characteristics and other brain imaging studies for ICHs after IVT. The main outcome was in-hospital ICHs attributable to a UIA rupture after IVT. Secondary outcomes were in-hospital symptomatic ICHs (European-Australian Cooperative Acute Stroke Study [ECASS-2] criteria, i.e., NIH Stroke Scale score increase ≥4 points) and any in-hospital ICHs. RESULTS A total of 3,953 patients were treated with IVT during the 15-year study period. One hundred thirty-two (3.3%) of the 3,953 patients with AIS had a total of 155 UIAs (141 saccular and 14 fusiform). The mean diameter of UIAs was 4.7 ± 3.8 mm, with 18.7% being ≥7 mm and 9.7% ≥10 mm in diameter. None of the 141 saccular UIAs ruptured after IVT. Three patients (2.3%, 95% confidence interval [CI] 0.6%-5.8%) with large fusiform basilar artery UIAs had a fatal rupture at 27 hours, 43 hours, and 19 days after IVT. All 3 were administered anticoagulation treatments after IVT, and anticoagulation took effect during the UIA rupture. Any ICHs and symptomatic ICHs were detected in 18.9% (95% CI 12.9%-26.2%) and 8.3% (95% CI 4.4%-13.8%) of all patients with AIS, respectively. DISCUSSION IVT appears to be safe in patients with AIS with saccular UIAs, including larges UIAs (≥10 mm). Anticoagulation after AIS in patients with large fusiform posterior circulation UIAs may increase the risk of aneurysm rupture.
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Affiliation(s)
- Jyri Juhani Virta
- From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland.
| | - Daniel Strbian
- From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland
| | - Jukka Putaala
- From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland
| | - Miikka Korja
- From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland
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Kikuchi J, Takeuchi Y, Sugi K, Negoto T, Yoshitomi M, Hirohata M, Morioka M. Gamma knife surgery-induced aneurysm rupture associated with tissue plasminogen activator injection: A case report and literature review. Surg Neurol Int 2019; 10:150. [PMID: 31528485 PMCID: PMC6744794 DOI: 10.25259/sni_210_2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/23/2019] [Indexed: 11/04/2022] Open
Abstract
Background Cases involving delayed development of intracranial aneurysms related to gamma knife surgery (GKS) have been recently reported. Here, we present a rare case of GKS-induced aneurysm rupture after intravenous injection of tissue plasminogen activator (t-PA) for occlusion of the middle cerebral artery (MCA). To the best of our knowledge, this is the first case in which t-PA-induced rupture of a GKS-related unruptured aneurysm. Case Description A 56-year-old woman underwent GKS for left trigeminal neuralgia. Eighteen years later, she suddenly experienced MCA occlusion with consciousness disturbance and right hemiparesis. She received an intravenous injection of t-PA and then was transferred to our hospital. We confirmed residual thrombus, and she underwent mechanical thrombectomy successfully. A postthrombectomy brain computed tomography scan revealed subarachnoid hemorrhage with a hematoma in the left cerebellar hemisphere. Cerebral angiography revealed a small irregular-shaped aneurysm at the branching site of the left circumflex branch at the distal position of the anterior inferior cerebellar artery, which was not detected on initial imaging. Coil embolization was performed. One month after the ischemic attack, she was transferred to a rehabilitation hospital, with a modified Rankin Scale score of 5. Conclusions The tendency to rupture is greater for GKS-induced aneurysms than for intrinsic unruptured aneurysms, according to previous reports. When performing acute treatment for cerebral infarction in patients with a history of GKS, the presence of aneurysms should be evaluated and we should keep in mind that GKS aneurysms are very small and tend to rupture.
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Affiliation(s)
- Jin Kikuchi
- Department of Neurosurgery, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Yasuharu Takeuchi
- Department of Neurosurgery, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Keisuke Sugi
- Department of Neurosurgery, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Tetsuya Negoto
- Department of Neurosurgery, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Munetake Yoshitomi
- Department of Neurosurgery, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Masaru Hirohata
- Department of Neurosurgery, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
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Beneš V, Jurák L, Jedlička J, Dienelt J, Suchomel P. Fatal intracranial aneurysm rupture after thrombolytic treatment for ischemic stroke: a case report and literature review. Acta Neurochir (Wien) 2019; 161:1337-1341. [PMID: 31065893 DOI: 10.1007/s00701-019-03931-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/24/2019] [Indexed: 01/01/2023]
Abstract
Intravenous thrombolysis is a proven treatment of acute ischemic stroke. Its complications include intracranial hemorrhage; the risk may be increased in the presence of an unruptured aneurysm. We present a case report of a patient who suffered fatal subarachnoid hemorrhage after thrombolysis from a known aneurysm. A history of recent previously inexperienced headaches was revealed retrospectively, suggestive of sentinel bleedings. A similar patient was identified in the literature; we thus propose that this history should be excluded in patients harboring an aneurysm considered for thrombolytic treatment.
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Affiliation(s)
- Vladimír Beneš
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, 460 01, Liberec, Czech Republic.
| | - Lubomír Jurák
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, 460 01, Liberec, Czech Republic
| | - Jaroslav Jedlička
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, 460 01, Liberec, Czech Republic
| | - Jan Dienelt
- Department of Neurology, Regional Hospital Liberec, Husova 10, Liberec, 460 01, Czech Republic
| | - Petr Suchomel
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, 460 01, Liberec, Czech Republic
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