EBS presentation 1

Unruptured Familial Intracranial Aneurysms:

Are these at greater risk of rupture?

Macquarie Neurosurgery

Evidence Based Surgery presentation

Date:23rd February 2012

Leon Lai

Clinical case

34F; incidental paraclinoid aneurysm (5mm)

Brother died of ruptured aneurysm

Non-smoker; No Hypertension

Is this aneurysm at greater risk of rupture compared to sporadic one?

(Treat or not treat?)

Searchable question (PICO format)

• P = Familial Unruptured Intracranial Aneurysms

• I = Observation

• C = Sporadic/Non-familial Unruptured Intracranial Aneurysms

• O = Rupture; SAH

Search strategy

P 1. exp Intracranial Aneurysm/ep, ge, pa [Epidemiology, Genetics, Pathology] AND Familial.mp.

Or

2. exp Intracranial Aneurysm/ep, ge, pa [Epidemiology, Genetics, Pathology] AND Family study.mp.

I NA

C NA

O exp Aneurysm, Ruptured/ep, ge, pa [Epidemiology, Genetics, Pathology]

Or exp Subarachnoid Hemorrhage/ep, ge, pa [Epidemiology, Genetics, Pathology]

Medline Search results

Scopus Search results

Summary of search results

Year Results

Medline Search 1950-2012 55 articles

Scopus search 1960-2012 57 articles

Cochrane Review NA 0 articles

Duplicates References NA 26 articles

Subtotal 99 articles

Relevance (title/abstract) 32 articles

Bibliography/References 6 articles

TOTAL 38 articles

Retrospective FIA Series

Prevalence among aSAHs

Risk of rupture compared to non-FIA cases?

FIAs: Other features

Compared to sporadic aneurysms,

Rupture tends to be 5 years earlier

Rupture is at a smaller size (1-2mm)

Rupture tend to occur within same decade of life as that of sibling

De novo aneurysms more common

Multiple aneurysms more common

Prospective FIA Series

(Stroke. 2009;40:1952-1957)

Prospective, 26 clinical centres in North America, Australia, NZ.

Smoker or Hypertension or both

2 ruptures 1.2% per year

(96% aneurysms<7mm)

17x increased risk of rupture(ISUIA 0.069%)

2 or more affected family members

FIA study: Ruptured IAs during prospective follow up

ISUIA Data

“Family history of SAH does not increase the risk of rupture in this group”

SUAVA Data(Prospective, 2000 to 2004; 12 clinical centres in Japan, aneurysms<5mm)

Brother died of ruptured aneurysm

Non-smoker; No Hypertension

Prospective data (1 study) –17x increased risk of rupture

Conclusion

Retrospective data: 2 to 5x increased risk of rupture; rupture is 5 years earlier and at a smaller size (1-2mm)

Is this aneurysm at greater risk of rupture compared to sporadic one?

34F; incidental paraclinoid aneurysm (5mm)

FIA Study: X=1.2%; Y=40 Risk = 38.30% over next 40 years

Conclusion

X = risk of rupture/year; Y = life expectancy (years)

ISUIA: X=0.069%; Y=40 Risk = 2.72% over next 40 years

SUAVE: X=0.34%; Y=40 Risk = 12.74% over next 40 years

TREAT!