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Leon lai feb 2012

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  • 1. Unruptured Familial Intracranial Aneurysms: Are these at greater risk of rupture? Macquarie Neurosurgery Evidence Based Surgery presentation Date:23rd February 2012 Leon Lai EBS presentation 1
  • 2. Clinical case34F; incidental paraclinoid aneurysm (5mm) Non-smoker; No Hypertension Brother died of ruptured aneurysm Is this aneurysm at greater risk of rupture compared to sporadic one? (Treat or not treat?)
  • 3. Searchable question (PICO format)• P = Familial Unruptured Intracranial Aneurysms• I = Observation• C = Sporadic/Non-familial Unruptured Intracranial Aneurysms• O = Rupture; SAH
  • 4. Search strategy P 1. exp Intracranial Aneurysm/ep, ge, pa [Epidemiology, Genetics, Pathology] AND Familial.mp. Or 5. 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]
  • 5. Medline Search results
  • 6. Scopus Search results
  • 7. Summary of search results Year ResultsMedline Search 1950-2012 55 articlesScopus search 1960-2012 57 articlesCochrane Review NA 0 articlesDuplicates References NA 26 articles Subtotal 99 articles Relevance (title/abstract) 32 articles Bibliography/References 6 articles TOTAL 38 articles
  • 8. Retrospective FIA Series
  • 9. Prevalence among aSAHs
  • 10. Risk of rupture compared to non-FIA cases?
  • 11. FIAs: Other featuresMultiple aneurysms more commonDe novo aneurysms more commonRupture tend to occur within same decade of life as that ofsiblingCompared to sporadic aneurysms, Rupture tends to be 5 years earlier Rupture is at a smaller size (1-2mm)
  • 12. Prospective FIA Series
  • 13. (Stroke. 2009;40:1952-1957) Prospective, 26 clinical centres in North America, Australia, NZ. 2 or more affected family members Smoker or Hypertension or both 17x increased risk of rupture (ISUIA 0.069%) 2 ruptures 1.2% per year(96% aneurysms<7mm)
  • 14. FIA study: Ruptured IAs during prospective follow up
  • 15. ISUIA Data“Family history of SAH does not increase the risk of rupture in this group”
  • 16. SUAVA Data(Prospective, 2000 to 2004; 12 clinical centres in Japan, aneurysms<5mm)
  • 17. Conclusion34F; incidental paraclinoid aneurysm (5mm) Non-smoker; No Hypertension Brother died of ruptured aneurysm Is this aneurysm at greater risk of rupture compared to sporadic one?Retrospective data: 2 to 5x increased risk of rupture; rupture is 5 years earlier and at a smaller size (1-2mm) Prospective data (1 study) –17x increased risk of rupture
  • 18. Conclusion X = risk of rupture/year; Y = life expectancy (years)ISUIA: X=0.069%; Y=40  Risk = 2.72% over next 40 yearsSUAVE: X=0.34%; Y=40  Risk = 12.74% over next 40 years FIA Study: X=1.2%; Y=40 Risk = 38.30% over next 40 years TREAT!