Serial Screening for Intracranial Aneurysms?

Serial Screening for Intracranial Aneurysms?

Mark J. Alberts, MD

DisclosuresMay 28, 2014

Hello. Welcome to this stroke update. My name is Dr. Mark Alberts, Vice-Chair of Clinical Affairs at UT Southwestern Medical Center in Dallas, Texas. Today I would like to talk to you about a study[1] that was recently published in Lancet Neurology. The first author is Bor, and this study was published online on March 5, 2014. The authors looked at screening for aneurysms in patients with a positive family history, in first-degree relatives, of subarachnoid hemorrhage and cerebral aneurysms. They identified 458 first-degree relatives in families that had 2 or more patients with subarachnoid hemorrhage or a cerebral aneurysm.

For screening, they did voluntary CT angiography or MR angiography every 5 years to identify the development of new cerebral aneurysms. They found that after the first 5 years, they were able to identify new cerebral aneurysms in 11% of patients. At 10 years, an additional 8% of patients had new aneurysms. At 15 and 20 years, an additional 5% of the 458 patients developed new cerebral aneurysms at each interval. Risk factors for the development of aneurysms as identified in the study included smoking and a history of aneurysms.

Interestingly, however, female gender was not a risk factor for aneurysms, and hypertension was not a risk factor for subsequent aneurysm development, which are different from what has been found in other large epidemiologic studies. Another interesting factor is that out of all of these patients with all of these aneurysms, only 3 cases had a new subarachnoid hemorrhage. All of the subarachnoid hemorrhages occurred in patients with small aneurysms (ie, aneurysms < 5 mm that did not look particularly malignant or worrisome).

What does this study tell me at the end of the day? It tells me that patients with a strong family history of cerebral aneurysms or subarachnoid hemorrhage among first-degree relatives have a relatively high risk for developing new aneurysms. What are we going to do about these new aneurysms? Certainly, you want to be aggressive with risk factor control. In terms of prophylactic surgery or coiling or clipping, it remains to be proven whether it is feasible or wise in patients with asymptomatic aneurysms. In this study, the authors reported that some patients did get treated. Some of them did very well, and some of them had periprocedural complications such as bleeding and other neurologic deficits. At the end of the day, this study tells me that in patients with a strong positive family history, screening with a safe, noninvasive technique such as MR angiography or CT angiography does make sense and helps to identify a group of patients who may require more intensive risk factor control, particularly smoking. As our knowledge increases further, we may develop new tools that will help us identify which patients need more aggressive prophylactic therapy in terms of procedures to eliminate the aneurysm.

Thank you very much for joining me for this stroke update. Have a good day.