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Evidence That a Subset of Aneurysms Less Than 7   mm Warrant Treatment

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The prevalence of cerebral aneurysms (CAs) in the general population is thought to be somewhere between 1% and 7%. 2, 3, 4 However, aneurysmal subarachnoid hemorrhage (SAH) remains a rare event with an incidence of 6 to 20 cases per 100 000 persons per year. 2 This highlights the importance of patient selection for treatment... The standard of care has been to observe these lesions, especially in the absence of high‐risk factors based on patient history or aneurysm characteristics and geometry. 2 A 2012 study evaluating the natural history of unruptured cerebral aneurysm in a Japanese cohort9 showed that larger size, posterior circulation aneurysm, and presence of a daughter sac confers a higher risk of rupture... In contrast to the findings of the ISUIA, several studies10, 11, 12 have reported results showing that the majority of SAHs result from aneurysms <10 mm in size and a significant proportion of patients present with ruptured aneurysms <5 mm in diameter. 2, 9, 13 Korja et al13 evaluated the lifelong rupture risk of intracranial aneurysms in a Finnish cohort and concluded that treatment decisions of UIAs should be based on the risk factor status since even small UIAs still ruptured... In conclusion, all aneurysms with early uptake ruptured and those with no or late uptake did not rupture or change in size/morphology, despite a follow‐up period of 2 years (as of the current time)... Furthermore, the authors found that CAs with early uptake had increased M1 cells and exhibited a more intense inflammation in their walls, similar in magnitude to ruptured aneurysms (harvested tissue from control patients) and significantly higher than patients with late uptake (P<0.05)... To sum up, there were no subarachnoid hemorrhages (SAHs) in 9 patients without uptake compared to all 3 patients with uptake (Figure)... We performed a Fischer exact test and found this difference to be statistically significant (Fischer exact =0.0045)... Ruptured aneurysms (RAs) can have areas with higher than average and more concentrated wall shear stress with smaller impingement zones (where the inflow jet impacts against the aneurysm wall) when compared with unruptured ones. 26, 27, 28 Furthermore, it is reported that hemodynamic variables are dependent on the morphology of the aneurysm and on its feeding vessels. 25, 29, 30 Chronic hypertension seems to play a major role in aneurysm formation since it is more prevalent in patients with CAs compared to the general population. 31 It is also a well‐established independent risk factor. 31 Lin et al introduced the parent–daughter angle parameter,32 which is formed by the vector of flow in the feeding artery with the vector of flow in the aneurysm... This highlights that hypertension may result in an increased intra‐aneurysm pressure and stresses the aneurysm wall... More importantly, the authors found a significant variation in the slopes of this relationship from patient to patient... Mehan et al55 noted that UIA morphology and interval growth are characteristics predictive of a higher risk of subsequent rupture during follow‐up using computed tomographic angiography... Brinjikji et al56 showed that growth of UIAs was associated with a rupture rate of 3.1% per year compared with 0.1% per year for stable UIAs (P<0.01)... Juvela et al57 found that rupture of UIAs was associated (P<0.001) with UIAs growth during follow‐up.

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Early versus late uptake. Twenty‐five aneurysms were imaged to compare early (24 hours) vs late (72 hours) or no uptake. Seven of the 25 aneurysms demonstrated early uptake. Of these 7 aneurysms, 4 were clipped and 3 were observed. All 3 observed aneurysms progressed to rupture, including a <7‐mm aneurysm. On the other hand, 18 of the 25 aneurysms did not show early uptake. Of these, 9 were clipped and 9 were observed. None of the observed progressed to rupture, including a giant aneurysm (The authors elected not to treat the aneurysm due to the patient's age and morbidity).
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jah31689-fig-0001: Early versus late uptake. Twenty‐five aneurysms were imaged to compare early (24 hours) vs late (72 hours) or no uptake. Seven of the 25 aneurysms demonstrated early uptake. Of these 7 aneurysms, 4 were clipped and 3 were observed. All 3 observed aneurysms progressed to rupture, including a <7‐mm aneurysm. On the other hand, 18 of the 25 aneurysms did not show early uptake. Of these, 9 were clipped and 9 were observed. None of the observed progressed to rupture, including a giant aneurysm (The authors elected not to treat the aneurysm due to the patient's age and morbidity).

Mentions: However, some aneurysms showed early uptake (at 24 hours), well before the others. The significance of early uptake, however, was not clear at the time, but the authors thought it might be associated with a more active inflammation and thus linked to a higher risk of rupture. Hence, a subsequent study was conducted to verify this hypothesis,24 where 25 aneurysms were imaged to compare early (24 hours) versus late (72 hours) or no uptake. Seven of the 25 aneurysms demonstrated early uptake. Of these 7 aneurysms, 4 were clipped and 3 were observed. All 3 observed aneurysms progressed to rupture, including a <7‐mm aneurysm. On the other hand, 18 of the 25 aneurysms did not show early uptake. Of these, 9 were clipped and 9 were observed. None of the observed progressed to rupture, including a giant aneurysm (The authors elected not to treat the aneurysm due to the patient age and morbidity). In conclusion, all aneurysms with early uptake ruptured and those with no or late uptake did not rupture or change in size/morphology, despite a follow‐up period of 2 years (as of the current time). Furthermore, the authors found that CAs with early uptake had increased M1 cells and exhibited a more intense inflammation in their walls, similar in magnitude to ruptured aneurysms (harvested tissue from control patients) and significantly higher than patients with late uptake (P<0.05). Interestingly, early MRI signal change was independent of aneurysm size. Late MRI signal change was noted in 50% of aneurysms <7 mm, and 44% in aneurysms 7 to 14 mm. To sum up, there were no subarachnoid hemorrhages (SAHs) in 9 patients without uptake compared to all 3 patients with uptake (Figure). We performed a Fischer exact test and found this difference to be statistically significant (Fischer exact =0.0045). Aneurysms with early uptake of ferumoxytol on MRI may be prone to rupture and thus may warrant early operative intervention, regardless of size.


Evidence That a Subset of Aneurysms Less Than 7   mm Warrant Treatment
Early versus late uptake. Twenty‐five aneurysms were imaged to compare early (24 hours) vs late (72 hours) or no uptake. Seven of the 25 aneurysms demonstrated early uptake. Of these 7 aneurysms, 4 were clipped and 3 were observed. All 3 observed aneurysms progressed to rupture, including a <7‐mm aneurysm. On the other hand, 18 of the 25 aneurysms did not show early uptake. Of these, 9 were clipped and 9 were observed. None of the observed progressed to rupture, including a giant aneurysm (The authors elected not to treat the aneurysm due to the patient's age and morbidity).
© Copyright Policy - creativeCommonsBy-nc-nd
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC5015310&req=5

jah31689-fig-0001: Early versus late uptake. Twenty‐five aneurysms were imaged to compare early (24 hours) vs late (72 hours) or no uptake. Seven of the 25 aneurysms demonstrated early uptake. Of these 7 aneurysms, 4 were clipped and 3 were observed. All 3 observed aneurysms progressed to rupture, including a <7‐mm aneurysm. On the other hand, 18 of the 25 aneurysms did not show early uptake. Of these, 9 were clipped and 9 were observed. None of the observed progressed to rupture, including a giant aneurysm (The authors elected not to treat the aneurysm due to the patient's age and morbidity).
Mentions: However, some aneurysms showed early uptake (at 24 hours), well before the others. The significance of early uptake, however, was not clear at the time, but the authors thought it might be associated with a more active inflammation and thus linked to a higher risk of rupture. Hence, a subsequent study was conducted to verify this hypothesis,24 where 25 aneurysms were imaged to compare early (24 hours) versus late (72 hours) or no uptake. Seven of the 25 aneurysms demonstrated early uptake. Of these 7 aneurysms, 4 were clipped and 3 were observed. All 3 observed aneurysms progressed to rupture, including a <7‐mm aneurysm. On the other hand, 18 of the 25 aneurysms did not show early uptake. Of these, 9 were clipped and 9 were observed. None of the observed progressed to rupture, including a giant aneurysm (The authors elected not to treat the aneurysm due to the patient age and morbidity). In conclusion, all aneurysms with early uptake ruptured and those with no or late uptake did not rupture or change in size/morphology, despite a follow‐up period of 2 years (as of the current time). Furthermore, the authors found that CAs with early uptake had increased M1 cells and exhibited a more intense inflammation in their walls, similar in magnitude to ruptured aneurysms (harvested tissue from control patients) and significantly higher than patients with late uptake (P<0.05). Interestingly, early MRI signal change was independent of aneurysm size. Late MRI signal change was noted in 50% of aneurysms <7 mm, and 44% in aneurysms 7 to 14 mm. To sum up, there were no subarachnoid hemorrhages (SAHs) in 9 patients without uptake compared to all 3 patients with uptake (Figure). We performed a Fischer exact test and found this difference to be statistically significant (Fischer exact =0.0045). Aneurysms with early uptake of ferumoxytol on MRI may be prone to rupture and thus may warrant early operative intervention, regardless of size.

View Article: PubMed Central - PubMed

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

The prevalence of cerebral aneurysms (CAs) in the general population is thought to be somewhere between 1% and 7%. 2, 3, 4 However, aneurysmal subarachnoid hemorrhage (SAH) remains a rare event with an incidence of 6 to 20 cases per 100 000 persons per year. 2 This highlights the importance of patient selection for treatment... The standard of care has been to observe these lesions, especially in the absence of high‐risk factors based on patient history or aneurysm characteristics and geometry. 2 A 2012 study evaluating the natural history of unruptured cerebral aneurysm in a Japanese cohort9 showed that larger size, posterior circulation aneurysm, and presence of a daughter sac confers a higher risk of rupture... In contrast to the findings of the ISUIA, several studies10, 11, 12 have reported results showing that the majority of SAHs result from aneurysms <10 mm in size and a significant proportion of patients present with ruptured aneurysms <5 mm in diameter. 2, 9, 13 Korja et al13 evaluated the lifelong rupture risk of intracranial aneurysms in a Finnish cohort and concluded that treatment decisions of UIAs should be based on the risk factor status since even small UIAs still ruptured... In conclusion, all aneurysms with early uptake ruptured and those with no or late uptake did not rupture or change in size/morphology, despite a follow‐up period of 2 years (as of the current time)... Furthermore, the authors found that CAs with early uptake had increased M1 cells and exhibited a more intense inflammation in their walls, similar in magnitude to ruptured aneurysms (harvested tissue from control patients) and significantly higher than patients with late uptake (P<0.05)... To sum up, there were no subarachnoid hemorrhages (SAHs) in 9 patients without uptake compared to all 3 patients with uptake (Figure)... We performed a Fischer exact test and found this difference to be statistically significant (Fischer exact =0.0045)... Ruptured aneurysms (RAs) can have areas with higher than average and more concentrated wall shear stress with smaller impingement zones (where the inflow jet impacts against the aneurysm wall) when compared with unruptured ones. 26, 27, 28 Furthermore, it is reported that hemodynamic variables are dependent on the morphology of the aneurysm and on its feeding vessels. 25, 29, 30 Chronic hypertension seems to play a major role in aneurysm formation since it is more prevalent in patients with CAs compared to the general population. 31 It is also a well‐established independent risk factor. 31 Lin et al introduced the parent–daughter angle parameter,32 which is formed by the vector of flow in the feeding artery with the vector of flow in the aneurysm... This highlights that hypertension may result in an increased intra‐aneurysm pressure and stresses the aneurysm wall... More importantly, the authors found a significant variation in the slopes of this relationship from patient to patient... Mehan et al55 noted that UIA morphology and interval growth are characteristics predictive of a higher risk of subsequent rupture during follow‐up using computed tomographic angiography... Brinjikji et al56 showed that growth of UIAs was associated with a rupture rate of 3.1% per year compared with 0.1% per year for stable UIAs (P<0.01)... Juvela et al57 found that rupture of UIAs was associated (P<0.001) with UIAs growth during follow‐up.

No MeSH data available.


Related in: MedlinePlus