Management Of Unruptured Aneurysms Research Articles

Management of unruptured brain aneurysms during pregnancy and puerperium

Aneurysms are sac-like dilatations of weakened wall areas within blood vessels. Cardiovascular related issues, such as hypertension, can put one at risk of developing such complications, with the possibility of rupturing. In the case of intracranial aneurysms, an outpouching forms where there is turbulent blood flow, often at the bifurcation of arteries. Depending on the morphology and location, different treatments need to be considered, but during pregnancy, further physiological changes also factor into decision making. In pregnant patients, intracranial hemorrhage cases are relatively low, yet they cause a high mortality rate amongst women, hence early detection and management of unruptured aneurysms is of significant importance.

A preliminary investigation of radiomics differences between ruptured and unruptured intracranial aneurysms.

Prediction of intracranial aneurysm rupture is important in the management of unruptured aneurysms. The application of radiomics in predicting aneurysm rupture remained largely unexplored. This study aims to evaluate the radiomics differences between ruptured and unruptured aneurysms and explore its potential use in predicting aneurysm rupture. One hundred twenty-two aneurysms were included in the study (93 unruptured). Morphological and radiomics features were extracted for each case. Statistical analysis was performed to identify significant features which were incorporated into prediction models constructed with a machine learning algorithm. To investigate the usefulness of radiomics features, three models were constructed and compared. The baseline model A was constructed with morphological features, while model B was constructed with addition of radiomics shape features and model C with more radiomics features. Multivariate analysis was performed for the ten most important variables in model C to identify independent risk factors. A simplified model based on independent risk factors was constructed for clinical use. Five morphological features and 89 radiomics features were significantly associated with rupture. Model A, model B, and model C achieved the area under the receiver operating characteristic curve of 0.767, 0.807, and 0.879, respectively. Model C was significantly better than model A and model B (p < 0.001). Multivariate analysis identified two radiomics features which were used to construct the simplified model showing an AUROC of 0.876. Radiomics signatures were different between ruptured and unruptured aneurysms. The use of radiomics features, especially texture features, may significantly improve rupture prediction performance. • Significant radiomics differences exist between ruptured and unruptured intracranial aneurysms. • Radiomics shape features can significantly improve rupture prediction performance over conventional morphology-based prediction model. The inclusion of histogram and texture radiomics features can further improve the performance. • A simplified model with two variables achieved a similar level of performance as the more complex ones. Our prediction model can serve as a promising tool for the risk management of intracranial aneurysms.

Small Aneurysms with Low PHASES Scores Account for Most Subarachnoid Hemorrhage Cases

Management of small unruptured aneurysms is controversial. Small aneurysms and those with low PHASES scores are often observed. The primary aim of this study was to assess whether the PHASES score classified the patients with subarachnoid hemorrhage as high risk for rupture. We retrospectively reviewed a consecutive series of 628 aneurysmal subarachnoid hemorrhage neurosurgical cases over a 10-year period between 2008 and 2018. We collected patient and aneurysm characteristics and calculated PHASES scores. The median aneurysm size was 5.3 mm (interquartile range, 3.5-7). Of the aneurysms, 75% (473/628) were less than 7 mm in size. Nearly half of the aneurysms were less than 5 mm (48%, 302/628). The median PHASES score was 5 (interquartile range, 4-6), corresponding to a 5-year risk of rupture of only 1.3%. Most ruptured aneurysms in our series were small with low PHASES scores, suggesting a low risk of rupture. Many of these patients would have been conservatively managed. PHASES is inadequate in management of unruptured aneurysms because it fails to identify many patients at risk for subarachnoid hemorrhage. A more nuanced assessment of rupture risk should be undertaken.

Clipping Versus Coiling in the Management of Unruptured Aneurysms with Multiple Risk Factors

We investigated the outcomes of patients with an unruptured intracranial aneurysm (UIA) and >2 risk factors concerning complications, obliteration rate, and other factors after surgical or endovascular treatment. Coiling and clipping were compared in patients with UIAs treated in West China Hospital from January 2015 to May 2017. Patient survival, dependency, retreatment, complications, and other clinical outcome indexes were compared between the 2 groups. A total of 82 patients (92 aneurysms) had undergone treatment for UIAs with multiple risk factors. Of these 82 patients, 45 (54.9%) had undergone clipping and 37 (45.1%) had undergone coiling. No deaths were related to either treatment. Morbidity (modified Rankin scale score >2) at 1 year had developed in 1 of 45 and 1 of 37 patients in the clipping and coiling groups, without a statistically significant difference. Hospitalization >5 days (30 of 45 vs. 12 of 37; P < 0.05) was less frequent after coiling. The number of aneurysms with complete occlusion (48 of 51 vs. 33 of 41; P < 0.05) was greater in the surgical group. No differences in peritreatment complications were found in the surgical and endovascular groups (8 of 45 vs. 6 of 37; P > 0.05). In our study, clipping and coiling showed advantages for the treatment of UIAs with multiple risk factors. Surgical clipping of UIAs is achievable with a low rate of unfavorable outcomes and a high rate of complete obliteration for patients with multiple risk factors. However, endovascular treatment was also successful, with a shorter length of stay and low procedure-related morbidity. Additional randomized evidence are required to support the superior efficacy of clipping.

Aneurysm geometry in predicting the risk of rupture. A review of the literature

The management of unruptured aneurysms (UAs), whose incidence is increasing, is still a controversial issue. Many studies have been investigating the link between the geometry of the aneurysm and the risk of future rupture in order to bring forth a clear decision plan. The different estimators studied are the aneurysm’s geometry and hemodynamic features on one hand, and the patient’s clinical characteristics on the other. We reviewed the literature while focusing on the different geometrical parameters that have been used in estimating the future risk of rupture. These include mainly the size ratio (SR), the aspect ratio, the non-sphericity index (NI), the undulation index (UI), and the vessel aneurysm inclination angle (AA), to name a few.

Computational Fluid Dynamic Analysis of Intracranial Aneurysmal Bleb Formation

The management of unruptured aneurysms is controversial, with the decision to treat influenced by aneurysm characteristics including size and morphology. Aneurysmal bleb formation is thought to be associated with an increased risk of rupture. To correlate computational fluid dynamic (CFD) indices with bleb formation. Anatomic models were constructed from 3-dimensional rotational angiography data in 27 patients with cerebral aneurysms harboring a single bleb. Additional models representing the aneurysm before bleb formation were constructed by digitally removing the bleb. We characterized hemodynamic features of models both with and without the blebs using CFDs. Flow structure, wall shear stress (WSS), pressure, and oscillatory shear index (OSI) were analyzed. There was a statistically significant association between bleb location at or adjacent to the point of maximal WSS (74%, P = .019), irrespective of rupture status. Aneurysmal blebs were related to the inflow or outflow jet in 89% of cases (P < .001), whereas 11% were unrelated. Maximal wall pressure and OSI were not significantly related to bleb location. The bleb region attained a lower WSS after its formation in 96% of cases (P < .001) and was also lower than the average aneurysm WSS in 86% of cases (P < .001). Cerebral aneurysm blebs generally form at or adjacent to the point of maximal WSS and are aligned with major flow structures. Wall pressure and OSI do not contribute to determining bleb location. The measurement of WSS using CFD models may potentially predict bleb formation and thus improve the assessment of rupture risk in unruptured aneurysms.

Hypertension, Age, and Location Predict Rupture of Small Intracranial Aneurysms

Although current guidelines for the management of unruptured intracranial aneurysms (IAs) suggest aneurysms larger than 7 mm should be considered for treatment, a significant number of subarachnoid hemorrhages are caused by IAs 7 mm or smaller. Thus, we sought to identify risk factors associated with the rupture of IAs 7 mm or smaller. We identified 100 patients with subarachnoid hemorrhage resulting from IAs 7 mm or smaller between January 2001 and 2004. Patients were compared with controls (n = 51) with unruptured IAs 7 mm or smaller, diagnosed by conventional angiography or three-dimensional computerized angiography, with respect to aneurysm characteristics (size, location, and age of presentation) and risk factors (hypertension, smoking, cocaine use, and family history). Hypertensive patients with IAs 7 mm or smaller were 2.6 times more likely to experience rupture (P = 0.01; 95% confidence interval, 1.21-5.53) than patients with normal blood pressure. Posterior circulation aneurysms were 3.5 times more likely to rupture than anterior circulation aneurysms (P = 0.048; 95% confidence interval, 0.95-19.4). After adjustment for location and hypertension, the age of patient on presentation was associated with a trend toward inverse correlation with aneurysmal rupture risk (P = 0.07). Hypertension and posterior location remained significant independent predictors in the logistic regression model. Among patients with small aneurysms (< or = 7 mm), hypertension, relatively young age, and posterior circulation were significant risk factors for rupture. Given the minimal long-term morbidity and mortality of treatment of unruptured aneurysms in large, tertiary medical centers, management of unruptured aneurysms 7 mm or smaller should be governed by factors other than size, specifically age, history of hypertension, and location.

Hypertension, Age, and Location Predict Rupture of Small Intracranial Aneurysms

BACKGROUND: Although current guidelines for the management of unruptured intracranial aneurysms (IAs) suggest aneurysms larger than 7 mm should be considered for treatment, a significant number of subarachnoid hemorrhages are caused by IAs 7 mm or smaller. Thus, we sought to identify risk factors associated with the rupture of IAs 7 mm or smaller. METHODS: We identified 100 patients with subarachnoid hemorrhage resulting from IAs 7 mm or smaller between January 2001 and 2004. Patients were compared with controls (n = 51) with unruptured IAs 7 mm or smaller, diagnosed by conventional angiography or three-dimensional computerized angiography, with respect to aneurysm characteristics (size, location, and age of presentation) and risk factors (hypertension, smoking, cocaine use, and family history). RESULTS: Hypertensive patients with IAs 7 mm or smaller were 2.6 times more likely to experience rupture (P = 0.01; 95% confidence interval, 1.21–5.53) than patients with normal blood pressure. Posterior circulation aneurysms were 3.5 times more likely to rupture than anterior circulation aneurysms (P = 0.048; 95% confidence interval, 0.95–19.4). After adjustment for location and hypertension, the age of patient on presentation was associated with a trend toward inverse correlation with aneurysmal rupture risk (P = 0.07). Hypertension and posterior location remained significant independent predictors in the logistic regression model. CONCLUSION: Among patients with small aneurysms (≤7 mm), hypertension, relatively young age, and posterior circulation were significant risk factors for rupture. Given the minimal long-term morbidity and mortality of treatment of unruptured aneurysms in large, tertiary medical centers, management of unruptured aneurysms 7 mm or smaller should be governed by factors other than size, specifically age, history of hypertension, and location.

Surgical management of unruptured basilar artery bifurcation aneurysms

The basilar artery (BA) bifurcation is the most common site for aneurysms arising from the posterior circulation. Their inhospitable location, nested within the narrow confines of the interpeduncular fossa anterior to the brainstem, coupled with the rich network of adjacent critical thalamoperforating arteries irrigating the midbrain and thalamus, pose difficult anatomical obstacles for the surgeon. The age old adage that the only cure for intracranial aneurysms remains exclusion from circulation before rupture still holds true. Although management of unruptured aneurysms in general is still controversial, unruptured aneurysms of the BA bifurcation can be treated surgically with acceptable rates of morbidity. The clinician must gather and weigh all clinical, pathological, and radiological data when formulating recommendations for the individual patient. In the present report the authors describe their current technique for the surgical management of unruptured BA bifurcation aneurysms; this represents the culmination of the senior author's (N.K.) experience in the management of both ruptured and unruptured BA bifurcation aneurysms. A modified, right-sided subtemporal transtentorial approach has been adopted in all cases of isolated unruptured BA bifurcation aneurysms. Technical nuances are described.

Treatment of Asymptomatic Unruptured Intracranial Aneurysms

The indication of preventive surgery for patients who harbor asymptomatic un ruptured intracranial aneurysms remains controversial. To evaluate the benefit of this treatment, we investigated the management outcome in 128 patients with 157 unruptured aneurysms. Surgery was planned in patients 70 years old or younger without serious systemic complications. A total of 77 patients underwent surgery including four endovascular interventions, and conservative management was chosen in 51 patients. There was no mortality and 6.5% morbidity as postoperative results, and no complication was found after endovascular treatment. Among the patients in conservative management, four patients suffered from subsequent rupture during the total follow-up period of 148 person-years. The annual rupture rate was estimated at 2.7%. According to the clinical decision analysis based on our data, preventive surgery is beneficial for a Japanese 70 years old or younger. However, the expected utility decreases if the rupture rate is set at 0.5% or 0.05%, posing a doubt about the benefit of the surgery. Decision analysis provides an aid for logical and objective choice in the management of unruptured aneurysms. The actual risk of rupture has a major impact on decision making in therapeutic strategy.

直達手術の立場から(内頸動脈C3部未破裂脳動脈瘤)

直達手術の立場から(内頸動脈C3部未破裂脳動脈瘤)

Importance of management of unruptured cerebral aneurysms

Since excellent recovery is hardly expected in patients with severe subarachnoid hemorrhage, management of unruptured aneurysms is essential in reducing the overall mortality and morbidity rates. The widespread use of less invasive imaging tools such as magnetic resonance angiography (MRA) has made "Brain Check-up Systems" very popular in Japan. Therefore, unruptured aneurysms have been found much more often than before. During the 1-year period of 1994, 80 patients underwent radical surgery for aneurysms in our institute. Thirty-two patients (40%) underwent surgery for unruptured aneurysms, while 48 patients (60%) underwent surgery for ruptured aneurysms. In patients with unruptured aneurysms, we have operated when the aneurysm is larger than approximately 5 mm in diameter, arising from the common sites in the circle of Willis, and when the patient's age is under 70 years. To prevent surgical complications in unruptured aneurysms, we often use a wrapping technique with Bemsheets (cotton) and adhesives. The outcomes were good in all 32 cases of unruptured aneurysms. We believe that early detection and prophylactic surgery for unruptured aneurysms will improve the overall outcome of aneurysm treatment in the future.

Management of Unruptured Aneurysms

The management of unruptured aneurysms is a complicated one. Few definitive data exist to guide us and sensible people often disagree about the best recommendations for a given patient. There are some data and much clinical experience. In these circumstances it seems reasonable to turn to recognized authorities for advice. We asked three experts to offer their opinions on the subject. Each was informed that he was not expected to provide new data, an authoritative review or detailed analyses. Rather, we wanted his concise opinion on the subject. The three opinions follow.

8. Management of unruptured aneurysms

8. Management of unruptured aneurysms

虚血性脳血管障害に合併した未破裂脳動脈瘤の手術管理

虚血性脳血管障害に合併した未破裂脳動脈瘤の手術管理