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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
Clinical case

34F; 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?)
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

      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]
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

Multiple aneurysms more common

De novo aneurysms more common

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

Compared to sporadic aneurysms,

   Rupture tends to be 5 years earlier

   Rupture is at a smaller size (1-2mm)
Prospective FIA Series
(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)
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)
Conclusion
34F; 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
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


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



                           TREAT!

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Ebs unruptured aneurysms 2012

  • 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 case 34F; 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]
  • 7. 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
  • 8.
  • 11. Risk of rupture compared to non-FIA cases?
  • 12. FIAs: Other features Multiple aneurysms more common De novo aneurysms more common Rupture tend to occur within same decade of life as that of sibling Compared to sporadic aneurysms, Rupture tends to be 5 years earlier Rupture is at a smaller size (1-2mm)
  • 14. (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)
  • 15. FIA study: Ruptured IAs during prospective follow up
  • 16. ISUIA Data “Family history of SAH does not increase the risk of rupture in this group”
  • 17. SUAVA Data (Prospective, 2000 to 2004; 12 clinical centres in Japan, aneurysms<5mm)
  • 18. Conclusion 34F; 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
  • 19. 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 FIA Study: X=1.2%; Y=40 Risk = 38.30% over next 40 years TREAT!