Practises and controversies in the management of asymptomatic aneurysms: Results of an international survey

Alshafai, Nabeel; Falenchuk, Olesya; Cusimano, Michael D.

doi:10.3109/02688697.2015.1096906

Cited by 13 publications

(7 citation statements)

References 37 publications

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“…The development of a true rupture predictor requires longitu- dinal follow-up of unbiased cohorts of UIAs for a sufficiently long time, which is extremely difficult to accomplish because most UIAs eventually receive treatment. 19 Conversely, RRS is derived from consecutively collected cross-sectional data and therefore is unbiased. In current clinical practice, UIAs with an irregular or elongated shape and blebs, which are common features of RIAs, are usually recommended for treatment, regardless of size.…”

Section: Discussionmentioning

confidence: 99%

A data-driven model to identify high-risk aneurysms and guide management decisions: the Rupture Resemblance Score

Rajabzadeh-Oghaz

Waqas

Veeturi

et al. 2020

Journal of Neurosurgery

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OBJECTIVEPrevious studies have found that ruptured intracranial aneurysms (RIAs) have distinct morphological and hemodynamic characteristics, including higher size ratio and oscillatory shear index and lower wall shear stress. Unruptured intracranial aneurysms (UIAs) that possess similar characteristics to RIAs may be at a higher risk of rupture than those UIAs that do not. The authors previously developed the Rupture Resemblance Score (RRS), a data-driven computer model that can objectively gauge the similarity of UIAs to RIAs in terms of morphology and hemodynamics. The authors aimed to explore the clinical utility of RRS in guiding the management of UIAs, especially for challenging cases such as small UIAs.METHODSBetween September 2018 and June 2019, the authors retrospectively collected consecutive challenging cases of incidentally identified UIAs that were discussed during their weekly multidisciplinary neurovascular conference. From patient 3D digital subtraction angiography, they reconstructed the aneurysm geometry and performed computer-assisted 3D morphology analysis and computational fluid dynamics simulation. They calculated RRS for every UIA case and compared it against the treatment decision made at the neurovascular conference as well as the recommendation based on the unruptured intracranial aneurysm treatment score (UIATS).RESULTSForty-seven patients with 79 UIAs, 90% of which were < 7 mm in size, were included in this study. The mean RRS (range 0.0–1.0) was 0.24 ± 0.31. At the conferences, treatment was endorsed for 45 of the UIAs (57%). These cases had significantly higher RRSs than the 34 cases suggested for observation (0.33 ± 0.34 vs 0.11 ± 0.19, p < 0.001). The UIATS-based recommendations were “observation” for 24 UIAs (30%), “treatment” for 21 UIAs (27%), and “not definitive” for 34 UIAs (43%). These “not definitive” cases were stratified by RRS based on similarity to RIAs.CONCLUSIONSAlthough not a rupture predictor, RRS is a data-driven model that gauges the similarity of UIAs to RIAs in terms of morphology and hemodynamics. In cases in which the UIATS-based recommendation is not definitive, RRS provides additional stratification to assist the identification of high-risk UIAs. The current study highlights the clinical utility of RRS in a real-world setting as an adjunctive tool for the management of UIAs.

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Section: Discussionmentioning

confidence: 99%

A data-driven model to identify high-risk aneurysms and guide management decisions: the Rupture Resemblance Score

Rajabzadeh-Oghaz

Waqas

Veeturi

et al. 2020

Journal of Neurosurgery

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“…8 In a 2015 international survey of 203 neurosurgeons, most endorsed treatment of all asymptomatic aneurysms regardless of size. 12 A more recent North American study showed that 11% of treating physicians always or usually recommended treatment of the anterior circulation aneurysms of Ͻ5 mm without a family or personal history of SAH. 13 Another 30% sometimes treated these small aneurysms (40%-60% of the time).…”

Section: Discussionmentioning

confidence: 99%

“…9,11 An increasing number of treating physicians favor preventive treatment of even tiny aneurysms. 12,13 The American Heart Association/American Stroke Associa-tion (AHA/ASA) guidelines for management of patients with UIAs were updated in 2015. 8 However, these do not specify separate recommendations for small (3-7 mm) and tiny aneurysms (Յ3 mm), though their natural history, risk of rupture, and success of treatment might be different from aneurysms measuring Ͼ7 mm.…”

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confidence: 99%

Management of Small Unruptured Intracranial Aneurysms: A Survey of Neuroradiologists

Malhotra

Geng

Hersey

et al. 2018

AJNR Am J Neuroradiol

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The natural history of intracranial aneurysms is not well-understood. A large proportion of incidentally detected, unruptured aneurysms are small (<7 mm). The survey results show significant heterogeneity in practice even among neuroradiologists and underlies the need to standardize imaging practice. Further studies are needed to assess the optimal frequency and duration of surveillance imaging for unruptured intracranial aneurysms. The criteria used to measure aneurysms and define growth on imaging also need to be standardized.

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“…In a 2015 international survey of 203 neurosurgeons, most endorsed treatment of all asymptomatic aneurysms regardless of size. 18 A more recent study showed that 11% of treating physicians always or usually recommend treatment of anterior circulation aneurysms measuring less than 5 mm without a family or personal history of SAH. 19 Another 30% of physicians treated these small aneurysms 40% to 60% of the time.…”

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confidence: 99%

Management of Tiny Unruptured Intracranial Aneurysms

et al. 2018

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UIAs) are relatively common in the general population and are being increasingly diagnosed; a significant proportion are tiny (Յ3 mm) aneurysms. There is significant heterogeneity in practice and lack of clear guidelines on the management of incidental, tiny UIAs. It is important to quantify the implications of different management strategies in terms of health benefits to patients. OBJECTIVE To evaluate the effectiveness of routine treatment (aneurysm coiling) vs 3 strategies for imaging surveillance compared with no preventive treatment or routine follow-up of tiny UIAs. DESIGN, SETTING, AND PARTICIPANTSA decision-analytic model-based comparative effectiveness analysis was conducted from May 1 to June 30, 2017, using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included 10 000 iterations simulating adult patients with incidental detections of UIAs 3 mm or smaller and no history of subarachnoid hemorrhage. INTERVENTIONSThe following 5 management strategies for tiny UIAs were evaluated: annual magnetic resonance angiography (MRA) screening, biennial MRA screening, MRA screening every 5 years, aneurysm coiling and follow-up, and no treatment or preventive follow-up. MAIN OUTCOMES AND MEASURESA Markov decision model for lifetime rupture was constructed from a societal perspective per 10 000 patients with incidental, tiny UIAs. Outcomes were assessed in terms of quality-adjusted life-years. Probabilistic, 1-way, and 2-way sensitivity analyses were performed. RESULTSIn this analysis of 10 000 iterations simulating adult patients with a mean age of 50 years, the base-case calculation shows that the management strategy of no treatment or preventive follow-up has the highest health benefit (mean [SD] quality-adjusted life-years, 19.40 [0.31]). Among the management strategies that incorporate follow-up imaging, MRA every 5 years is the best strategy with the next highest effectiveness (mean [SD] quality-adjusted life-years, 18.05 [0.62]). The conclusion remains robust in probabilistic and 1-way sensitivity analyses. No routine follow-up remains the optimal strategy when the annual growth rate and risk of rupture of growing aneurysms are varied. When the annual risk of rupture of nongrowing UIAs is less than 1.7% (0.23% in base case scenario), no follow-up is the optimal strategy. If annual risk of rupture is more than 1.7%, coiling should be performed directly. CONCLUSIONS AND RELEVANCEGiven the current literature, no preventive treatment or imaging follow-up is the most effective strategy in patients with aneurysms that are 3 mm or smaller, resulting in better health outcomes. More aggressive imaging surveillance for aneurysm growth or preventive treatment should be reserved for patients with a high risk of rupture. Given these findings, it is important to critically evaluate the appropriateness of current clinical practices, and ...

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Practises and controversies in the management of asymptomatic aneurysms: Results of an international survey

Cited by 13 publications

References 37 publications

A data-driven model to identify high-risk aneurysms and guide management decisions: the Rupture Resemblance Score

A data-driven model to identify high-risk aneurysms and guide management decisions: the Rupture Resemblance Score

Management of Small Unruptured Intracranial Aneurysms: A Survey of Neuroradiologists

Management of Tiny Unruptured Intracranial Aneurysms

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