Neurosurgery notes/Vascular/Haemorrhagic diseases/SAH/Unruptured Aneurysm

Unruptured Aneurysm

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SAH

Unruptured aneurysm

General
  • There is a paucity of true natural data history on IAs because even in the two largest studies conducted so far, the ISUIA study (Wiebers et al., 2003) and the Japanese study (Morita et al., 2012),
    • Due to many patients were treated with either surgery or endovascular treatment based on physician and patient preference
Evaluation
  • Aneurysmal wall enhancement on Black blood MRI sq --> Vessel wall inflammation ?? Higher risk
Important to manage because
  • Numbers
    • 10% of population have incidental aneurysm
      • Incidence: 10/100,000 per year
      • Prevalence: 5%
    • 1%/year for unruptured aneurysm rupturing (from ISUIA 1998 New England journal of medicine)
      • Size matters
        • <10mm
          • No previous hx of SAH: 0.05% yr
          • Previous hx of SAH: 0.5%/yr
        • >10mm: 1%/yr (for both with and without hx of SAH)
        • >25mm (Giant Aneurysm): 6%/yr
  • With widespread utilization of non- invasive imaging, unruptured IAs are being diagnosed with increasing frequency.
Risk of rupture
Factors analysed in the UIATS study (for clinical decision-making in the management of the unruptured IAs), and PHASES study (for the prediction of 5-year risk of rupture)
Factors analysed
UIATS
PHASES
Patients factors
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Age
Yes
Yes
Previous SAH from another IA
Yes
Yes
Familial IAs or SAH
Yes
No
Ethnicity
Yes
Yes
Smoking
Yes
No
Hypertension
Yes
Yes
ADPKD
Yes
No
Drug and Alcohol abuse
Yes
No
Clinical symptoms related to IA
Yes
No
Aneurysms multiplicity
Yes
No
Reduced quality of life due to fear of rupture
Yes
No
Life expectancy (for chronic or malignant disease)
Yes
No
Neuropsychiatric disorders
Yes
No
Coagulopathies
Yes
No
Aneurysm factors
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Size
Yes
Yes
Morphology
Yes
No
Location
Yes
Yes
Evolution
Yes
No
Treatment-related factors
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Risks of treatment related to age, size, and complexity of the IA
Yes
No
PHASES risk prediction score
  • Is a method of calculating the absolute 5-year risk of intracranial aneurysm rupture
      EPOS&amp;trade;
  • If aneurysm grows in size-Van der kamp 2021
    • 1 mm or greater increase in 1 direction at f/u imaging
    • Absolute risk of rupture after growth was
      • 2.9% (95% CI, 0.9-4.9) at 6 months,
      • 4.3% (95% CI, 1.9-6.7) at 1 year,
      • 6.0% (95% CI, 2.9-9.1) at 2 years
  • Predictors of rupture were
        • Features
        Hazard ratio
        Size 7 mm or larger
        3.1
        Shape (irregular
        2.9
        Site
        MCA
        3.6
        ACA, PCOM, or posterior circulation
        2.8
Five-year rupture risk of unruptured aneurysm by ISUIA, International Study of Unruptured Intracranial Aneurysms.
      Location
      Aneurysm size <7mm
      Aneurysm size 7-12mm
      Aneurysm size 13-24mm
      Aneurysm size >24mm
      Cavernous ICA
      0%
      0%
      3%
      6.4%
      Anterior circulation
      0% (1.5% if previous bleed)
      2.6%
      14.5%
      40%
      Posterior circulation
      2.5% (3.5% if previous bleed)
      14.5%
      18.4%
      50%
  • Basilar tip was most predictive of rupture
      A graph showing the number of patients with abnormal AI-generated content may be incorrect.
    • Aneurysm found what is next?
      • Multidisciplinary approach
      • Patient’s factors
      • Radiological factors
      • Availability of expertise
    • Useful scores to help quantifying the risks of aneurysm rupture
      • ISUIA
      • PHASES
      • UCAS
    ANEURYSM FOUND WHAT IS NEXT • Multidisciplinary approach Patient's factors Radiological factors Availability of expertise • Useful scores to help quantifying the risks of aneurysm rupture • ISUIA • UCAS CENTER FOR MICRO NEUROSURGERY HIRSLANDEN A AREAS OF EXPERTISE SURGERY TECHNIQUES CONTACT nden VIRTUAL SURGERY PLANNING HIRSLANDEN HOSPITAL TEAM ANEURISM RISK CALCULATORS PHASES CALCULATOR + ISUIA CALCULATOR
    • Aspirin for protective vs SAH
    No trial yet but there is a unruptured intracranial aneurysm treatment score (UIATS) made by a panel of experts (Etminan 2015 et al )
    A close-up of a survey AI-generated content may be incorrect.
    • When the difference exceeds 3 or more points, one strategy may be preferred over the other.
    Greenberg:
    • Prompt treatment >10mm of any age
    • Prompt treatment 7-9mm of young and middle age pt
    • <7mm Angiographic follow up
      • Annual TOFlight-MRA (no Gd)
        • No contrast like CTA
        • Low risk compared to DSA
      • Unfortunately most aneurysm burst without enlarging
        • Only 10% of enlarged aneurysm ruptured over a period of 4 yrs
    Management
    • Do not consider a preventative repair of unruptured aneurysm unless MDT states so otherwise
    • Monitoring
    • Surgery
      • Indication:
        • Post MDT discussion
          • Treatment recommendations must take into account
            • Risk of treatment
            • Patient’s degree of anxiety about the knowledge of the IA.
      • Generally:
        • Coiling first line then if not able for clipping
      • Clipping
        • Anterior
        • For younger and wide neck
        • Surgery achieves higher rates of complete angiographic occlusion, but it is more invasive.
      • Coiling
        • Coiling has lower perioperative morbidity
        • Should be used as first line
        • Posterior circulation aneurysm
    Surgical outcome
    • Mortality 2.6%
    • Morbidity: 5%
      • Size:
        • <5mm: 2%
        • 6-15mm: 7%
        • 16-25mm: 14%
      • Location
        • PCOM: 5%
        • MCA: 8%
        • Ophthalmic 12%
        • ACOM: 16%
        • Carotid bifurcation: 17%
      • Age:
        • <45: 7%
        • 45-64: 14%
        • >64: 32%
    Unruptured cavernous carotid aneurysm
    • Most developed at the horizontal segment of the artery
    • Presentation
      • Incidental
      • Symptomatic
        • Common
          • H/A
          • Cavernous sinus syndrome: Horner, ophthalmoplegia, sensory loss V1 +V2, pupillary involvement
          • Mono-ocular blindness: if expand from cavernous sinus —> thru the carotid ring —> Subarachnoid space —> compress optic nerve
        • Rare
          • Retroorbital pain
          • Life threatening complications
            • Mostly due to rupture of giant aneurysm
              • SAH: the aneurysm is straddling the carotid ring aka the carotid ring is acting like a belt to “waist” the aneurysm
              • Arterial epistaxis: rupture into sphenoid sinus in a traumatic aneurysm
              • Emboli
    • Treatment
      • Unruptured CCA: detachable guglielmi coils
        • Indicated for
          • Symptomatic
          • Giant aneurysm: esp those straddling
          • Enlarging aneurysm
      • Ruptured CCA: endovascular occlusion
        • Emergent treatment of epistaxis or SAH
        • Urgent treatment of severe eye pain and threat to vision

    Darsaut et al 2017

    • Primary outcome
        • Intent-to-treat analysis
        Surgical
        Endovascular
        ㅤ
        1-year outcome
        n=48
        n=56
        OR
        Treatment failure (composite)
        5
        10
        0.54 (0.13, 1.90), p=0.40
        Failure to treat aneurysm with allocated modality
        1
        3
        0.38 (0.01, 4.91), p=0.62
        Intracranial haemorrhage during first-year FU
        1
        1
        1.17 (0.01, 93.44), p=1.00
        Saccular residual aneurysm
        3
        6
        0.56 (0.09, 2.80), p=0.51

    Facts about paediatric intracranial aneurysm

    Numbers
    • Represents 2.3 % of all intracranial aneurysms (including adults)
    • Occur more commonly in males than females
    Aetiology paediatric aneurysms
    • Most are idiopathic
    • 10% are related to head trauma
    • 15% infection
      • Infectious aneurysms are more common in children than adults
      • Especially common in children with suppressed immune systems.
    • 33% are associated with underlying conditions
      • NF1, connective tissue disorders (Marfan syndrome or the vascular subtype Ehlers-Danlos syndrome), polycystic kidney disease, sickle cell anemia, and malformation of the blood vessels.
    82% are anterior circulatory aneurysms
    • Internal carotid bifurcation aneurysms are the commonest site
    • Posterior circulation aneurysms are more common in children than in adults, they are not more common than anterior circulation aneurysms in children
    There is an association with coarctation of the aorta
    • AHA recommends screen for coarctation if a pt has intracranial aneurysm (cost effective)
      • By middle (50yrs) age risk of
            • intracranial aneurysm
            Coarctation of aorta pt
            10% to 13%
            Normal
            3% to 7%
      • No screening results in 10.1% lifetime incidence of SAH
      • Prophylactic tx of aneurysm prevented 118 deaths from SAH