The purpose was to obtain a reliable scoring for growth of unruptured intracranial aneurysms (UIAs) in a long-term follow-up study from variables known at baseline and to compare it with the ELAPSS ...(Earlier subarachnoid hemorrhage, Location of the aneurysm, Age > 60 years, Population, Size of the aneurysm, and Shape of the aneurysm) score obtained from an individual-based meta-analysis. The series consists of 87 patients with 111 UIAs and 1669 person-years of follow-up between aneurysm size measurements (median follow-up time per patient 21.7, range 1.2 to 51.0 years). These were initially diagnosed between 1956 and 1978, when UIAs were not treated in our country. ELAPSS scores at baseline did not differ between those with and those without aneurysm growth. The area under the curve (AUC) for the receiver operating curve (ROC) of the ELAPSS score for predicting long-term growth was fail (0.474, 95% CI 0.345–0.603), and the optimal cut-off point was obtained at ≥7 vs. <7 points for sensitivity (0.829) and specificity (0.217). In the present series UIA growth was best predicted by female sex (4 points), smoking at baseline (3 points), and age <40 years (2 points). The AUC for the ROC of the new scoring was fair (0.662, 95% CI 0.546–0.779), which was significantly better than that of ELAPSS score (p < 0.05). The optimal cut-off point was obtained at ≥4 vs. <4 points for sensitivity (0.971) and specificity (0.304). A new simple scoring consisting of only female sex, cigarette smoking and age <40 years predicted growth of an intracranial aneurysm in long-term follow-up, significantly better than the ELAPSS score.
Abstract
BACKGROUND: Retrospective studies have suggested that aneurysm morphology is a risk factor for subarachnoid hemorrhage (SAH).
OBJECTIVE: To investigate whether various morphological indices ...of unruptured intracranial aneurysms (UIAs) predict a future rupture.
METHODS: A total of 142 patients with UIAs diagnosed between 1956 and 1978 were followed prospectively until SAH, death, or the last contact. Morphological UIA indices from standard angiographic projections were measured at baseline and adjusted in multivariable Cox proportional hazards regression analyses for established risk factors for SAH.
RESULTS: During a follow-up of 3064 person-years, 34 patients suffered from an aneurysm rupture. In multivariable analyses, aneurysm volume, volume-to-ostium area ratio, and the bottleneck factor separately as continuous variables predicted aneurysm rupture. All the morphological indices were higher (P < .01) after the rupture than before. In final multivariable analyses, current smoking (adjusted hazard ratio 2.50, 95% CI 1.03-6.10, P = .044), location in the anterior communicating artery (4.28, 1.38-13.28, P = .012), age (inversely; 0.95 per year, 0.91-1.00, P = .043), and UIA diameter ≥7 mm at baseline (2.68, 1.16-6.21, P = .021) were independent risk factors for a future rupture. Aneurysm growth during the follow-up was associated with smoking (P < .05) and SAH (P < .001), but not with the aneurysm indices.
CONCLUSION: Of the morphological indices, UIA volume seems to predict a future rupture. However, as volume correlates with the maximum diameter of the aneurysm, it seems to add little to the predictive value of the maximum diameter. Retrospective studies using indices that are measured after rupture are of little value in risk prediction.
The purpose was to study the risk of rupture of unruptured intracranial aneurysms (UIAs) of patients with multiple intracranial aneurysms after subarachnoid hemorrhage (SAH), in a long-term follow-up ...study, from variables known at baseline. Future rupture risk was compared in relation to outcome after SAH. The series consists of 131 patients with 166 UIAs and 2854 person-years of follow-up between diagnosis of UIA and its rupture, death or the last follow-up contact. These were diagnosed before 1979, when UIAs were not treated in our country. Those patients with a moderate or severe disability after SAH, according to the Glasgow Outcome Scale, had lower rupture rates of UIA than those with a good recovery or minimal disability (4/37 or 11%, annual UIA rupture rate of 0.5% (95% confidence interval (CI) 0.1-1.3%) during 769 follow-up years vs. 27/94 or 29%, 1.3% (95% CI 0.9-1.9%) during 2085 years). Those with a moderate or severe disability differed from others by their older age. Those with a moderate or severe disability tended to have a decreased cumulative rate of aneurysm rupture (log rank test,
= 0.066) and lower relative risk of UIA rupture (hazard ratio 0.39, 95% CI 0.14-1.11,
= 0.077). Multivariable hazard ratios showed at least similar results, suggesting that confounding factors did not have a significant effect on the results. The results of this study without treatment selection of UIAs suggest that patients with a moderate or severe disability after SAH have a relatively low risk of rupture of UIAs. Their lower treatment indication may also be supported by their known higher treatment risks.
Summary Background The decision of whether to treat incidental intracranial saccular aneurysms is complicated by limitations in current knowledge of their natural history. We combined individual ...patient data from prospective cohort studies to determine predictors of aneurysm rupture and to construct a risk prediction chart to estimate 5-year aneurysm rupture risk by risk factor status. Methods We did a systematic review and pooled analysis of individual patient data from 8382 participants in six prospective cohort studies with subarachnoid haemorrhage as outcome. We analysed cumulative rupture rates with Kaplan-Meier curves and assessed predictors with Cox proportional-hazard regression analysis. Findings Rupture occurred in 230 patients during 29 166 person-years of follow-up. The mean observed 1-year risk of aneurysm rupture was 1·4% (95% CI 1·1–1·6) and the 5-year risk was 3·4% (2·9–4·0). Predictors were age, hypertension, history of subarachnoid haemorrhage, aneurysm size, aneurysm location, and geographical region. In study populations from North America and European countries other than Finland, the estimated 5-year absolute risk of aneurysm rupture ranged from 0·25% in individuals younger than 70 years without vascular risk factors with a small-sized (<7 mm) internal carotid artery aneurysm, to more than 15% in patients aged 70 years or older with hypertension, a history of subarachnoid haemorrhage, and a giant-sized (>20 mm) posterior circulation aneurysm. By comparison with populations from North America and European countries other than Finland, Finnish people had a 3·6-times increased risk of aneurysm rupture and Japanese people a 2·8-times increased risk. Interpretation The PHASES score is an easily applicable aid for prediction of the risk of rupture of incidental intracranial aneurysms. Funding Netherlands Organisation for Health Research and Development.
We investigated all-cause mortality and risk factors of death of patients with unruptured intracranial aneurysms (UIAs) in a long-term follow-up study.
A total of 142 patients with 181 UIAs diagnosed ...between 1956 and 1978 when UIAs were not treated were included in this study. Patients were followed until death or until 2011 to 2012. Mortality rates and risk factors were studied with Kaplan-Meier survival analysis and the Cox proportional hazards regression models.
During 3,530 person-years, 113 (80%) had died, giving an average annual mortality of 3.2%. Of them, 19 (17%) died of aneurysm rupture from the index UIA, 6 (5%) of other aneurysm-related causes, and 2 (2%) of unspecified subarachnoid hemorrhage. The remaining 86 died of causes unrelated to intracranial aneurysms. The cumulative death rate was 20% (95% confidence interval 14%-27%) at 10 years and 60% (52%-68%) at 30 years. Independent risk factors for subsequent death were patient age (adjusted hazard ratio 1.09 per year, 95% confidence interval 1.05-1.12, p < 0.001), male sex (2.81, 1.59-4.96, p < 0.001), heavy alcohol use (4.22, 2.22-8.02, p < 0.001), and cigarette smoking (1.72, 0.97-3.07, p = 0.064). History of hypertension, family history of subarachnoid hemorrhage, and diameter of UIA predicted death only in univariable analysis.
In patients of working age with a UIA, alcohol consumption and cigarette smoking are modifiable risk factors for untimely death through several causes and should be taken into account when treatment is considered.
Treatment indications in unruptured intracranial aneurysms (UIAs) are challenging because of the lack of prospective natural history studies without treatment selection and the decreasing incidence ...of aneurysm rupture. The purpose of this study was to test whether the population, hypertension, age, size of aneurysm, earlier aneurysm rupture, site of aneurysm (PHASES) score obtained from an individual-based meta-analysis could predict the long-term rupture risk of UIAs.
The series included 142 patients of working age with UIAs diagnosed before 1979, when these were not treated but were followed up until the first rupture, death, or the last contact. PHASES scores were recorded for all patients by using the baseline variables and compared with the new treatment score obtained from a recent cohort, consisting of age, smoking status, and aneurysm size and location.
Of the 142 patients, 34 had an aneurysm rupture during a total follow-up of 3064 person-years. The median time between diagnosis and an aneurysm rupture was 10.6 years. The PHASES score at baseline was higher in those with an aneurysm rupture than in the others (5.3 ± 2.3 vs 4.2 ± 2.2, p = 0.012), and the difference relative to the new treatment score was 5.3 ± 2.4 versus 3.0 ± 2.2 (p < 0.001). The receiver operating characteristic curve of the PHASES score for predicting rupture showed a fair area under the curve (0.674, 95% CI 0.558-0.790) where the optimal cutoff point was obtained at ≥ 6 versus < 6 points for sensitivity (0.500) and specificity (0.811). The area under the curve of the new score was 0.755 (95% CI 0.657-0.853), with the optimal cutoff point at ≥ 5 versus < 5 points for sensitivity (0.607) and specificity (0.789).
The PHASES and the new scores predicted the long-term aneurysm rupture risk moderately well, with the latter, which also included smoking, being slightly better and easier in clinical practice. The findings suggest that treatment decisions about UIAs in patients of working age can be done with an improved cost-effectiveness.
Background and Purpose- The purpose was to obtain a reliable treatment score for unruptured intracranial aneurysms (UIAs) from variables known at baseline. Methods- The series included 142 patients ...with UIAs diagnosed between 1956 and 1978 when UIAs were not treated and were followed up until the first aneurysm rupture, death, or the last contact. Previously published UIA treatment score was recorded, and finally, a new treatment score was constructed. Results- The median follow-up time was 21.0 years (interquartile range, 10.4-31.8 years). A total of 34 patients had an aneurysm rupture during 3064 person-years of follow-up. The UIA treatment score differed slightly between those with and without an aneurysm rupture (9.4±2.8 versus 8.3±3.1, P=0.082). The receiver operating characteristics curve of the UIA treatment score for predicting rupture showed a modest area under the curve (AUC; 0.618, 95% CI, 0.502-0.733; P=0.059). The best new treatment score consisted of 4 variables: age <40 years (2 points), current smoking (2 points), UIA size ≥7 mm (3 points), and location (anterior communicating artery, 5 points; internal carotid bifurcation, 4 points; and posterior communicating artery, 2 points). Scores of 5 to 12 points were associated with high cumulative UIA rupture rates (16%-60% at 10 years and 49%-80% at 30 years), favoring UIA treatment. Scores of 1 to 4 points (3% at 10 years and 18% at 30 years) favored conservative treatment and needed additional indications for treatment. Patients with a score of 0 points should not be treated (no ruptures during 513 follow-up years). The area under the curve for this scoring was 0.755 (95% CI, 0.657-0.853; P<0.001) and was better than that of the UIA treatment score (P=0.02). Conclusions- This new simple and rapid scoring system is reliable for evaluating treatment indications with regard to the lifelong prevention of aneurysm rupture.
By 2010 there had been 14 published trials of surgery for intracerebral hemorrhage reported in systematic reviews or to the authors, but the role and timing of operative intervention remain ...controversial and the practice continues to be haphazard. This study attempted to obtain individual patient data from each of the 13 studies published since 1985 to better define groups of patients that might benefit from surgery.
Authors of identified published articles were approached by mail, e-mail, and at conferences and invited to take part in the study. Data were obtained from 8 studies (2186 cases). Individual patient data included patient's age, Glasgow Coma Score at presentation, volume and site of hematoma, presence of intraventricular hemorrhage, method of evacuation, time to randomization, and outcome.
Meta-analysis indicated that there was improved outcome with surgery if randomization was corrected undertaken within 8 hours of ictus (P=0.003), or the volume of the hematoma was 20 to 50 mL (P=0.004), or the Glasgow Coma Score was between 9 and 12 (P=0.0009), or the patient was aged between 50 and 69 years (P=0.01). In addition, there was some evidence that more superficial hematomas with no intraventricular hemorrhage might also benefit (P=0.09).
There is evidence that surgery is of benefit if undertaken early before the patient deteriorates. This work identifies areas for further research. Ongoing studies in subgroups of patients such as the Surgical Trial in Lobar Intracerebral Hemorrhage (STICH II) will confirm whether these interpretations can be replicated.
The goal of this study was to investigate predictive preictal risk factors for fatal subarachnoid hemorrhage (SAH) in a patient population with verified intracranial aneurysms without surgical ...selection of patients and with complete follow-up.
A total of 142 patients with 181 unruptured aneurysms diagnosed between 1956 and 1978 were followed up for a total of 2577 person-years until death, SAH, or the years 1997 to 2000. The predictive value of several factors known before SAH was tested for case fatality.
During follow-up, 34 first episodes of hemorrhage from a previously verified unruptured aneurysm occurred. Of these bleeding episodes, 17 were fatal. Patients who died after the bleeding had higher blood pressure values (mean+/-SD, 148+/-11/92+/-8 mm Hg; mean pressure, 111+/-9 mm Hg) before hemorrhage than did those with nonfatal bleeding (mean+/-SD, 135+/-15/83+/-11 mm Hg; mean, 101+/-12 mm Hg) (P<0.05). Patients with fatal SAH were also older (54+/-7 versus 47+/-13 years, P=0.068) and had aneurysms larger in diameter (13+/-8 versus 10+/-5 mm) than those who survived. They had a higher prevalence of definite hypertension (56% versus 12%, P<0.05), more frequently used antihypertensive medication (29% versus 6%) by the end of follow-up, and tended to have higher blood pressure at the beginning of follow-up (140+/-21/85+/-11 versus 134+/-17/80+/-9 mm Hg). After adjustment for age, aneurysm size, and sex, the only indisputable significant independent risk factor for fatal SAH compared with nonfatal SAH was systolic blood pressure before aneurysm rupture (odds ratio, 1.11 per 1 mm Hg; 95% CI, 1.01 to 1.23; P=0.032). The adjusted odds ratio of definite hypertension for fatal SAH was 12.67 (95% CI, 1.53 to 104.70; P=0.018).
Increased systolic blood pressure values and long-term hypertension before aneurysm rupture seem to predict fatal SAH independently of aneurysm size or patient age or sex at the time of rupture.
Background A subset of good-grade patients with aneurysmal subarachnoid hemorrhage (aSAH) develop delayed cerebral ischemia (DCI) that may cause permanent disabilities after aSAH. However, little is ...known about the risk factors of DCI among this specific patient group. Methods and Results We obtained a multinational cohort of good-grade (Glasgow Coma Scale 13-15 on admission) patients with aSAH by pooling patient data from 4 clinical trials and 2 prospective cohort studies. We collected baseline data on lifestyle-related factors and the clinical characteristics of aSAHs. By calculating fully adjusted risk estimates for DCI and DCI-related poor outcome, we identified the most high-risk patient groups. The pooled study cohort included 1918 good-grade patients with aSAH (median age, 51 years; 64% women), of whom 21% and 7% experienced DCI and DCI-related poor outcome, respectively. Among men, patients with obesity and (body mass index ≥30 kg/m
) thick aSAH experienced most commonly DCI (33%) and DCI-related poor outcome (20%), whereas none of the normotensive or young (aged <50 years) men with low body mass index (body mass index <22.5 kg/m
) had DCI-related poor outcome. In women, the highest prevalence of DCI (28%) and DCI-related poor outcome (13%) was found in patients with preadmission hypertension and thick aSAH. Conversely, the lowest rates (11% and 2%, respectively) were observed in normotensive women with a thin aSAH. Conclusions Increasing age, thick aSAH, obesity, and preadmission hypertension are risk factors for DCI in good-grade patients with aSAH. These findings may help clinicians to consider which good-grade patients with aSAH should be monitored carefully in the intensive care unit.
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