Small UIAs, <7 mm in diameter, uncommonly cause aneurysmal symptoms and are the most frequently detected incidentally.

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1 Research grant from Stryker Neurovascular Research grant from Covidien/ Medtronic Consultant and proctor for Stryker Neurovascular Consultant and proctor for Covidien/ Medtronic Consultant for Codman Neurovascular Ajit S. Puri, MD Assistant Professor of Radiology and Neurosurgery Co-Director,Division of Neurointerventional Surgery, University of Massachusetts Medical Center UIAs are relatively common in the general population, found in 3.2% of the adults (mean age 50 years) worldwide, increasingly being discovered incidentally due to use of MRIs. Majority of UIAs will never rupture. For example, of the 1 million adults harbor a UIA, but only 0.25% of these, or 1 in 200 to 400, will rupture. Women had a higher prevalence of UIAs than men, even after adjustment for age and co-morbidities. Prevalence overall higher in people aged 30 years. Schievink N Engl J Med 1997; Hop et al. Stroke 1997; Olafsson et al.neurology 1997; Ellegala/Day 2005

2 Larger UIAs may present with mass effect, cranial nerve deficits (most commonly a 3 rd CN nerve palsy), seizures, motor deficit, or sensory deficit, or they may be detected on imaging for headaches, ischemic disease etc. Small UIAs, <7 mm in diameter, uncommonly cause aneurysmal symptoms and are the most frequently detected incidentally. o

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7 o 1917 patients underwent clipping, and 451 underwent coiling The combined surgical morbidity and mortality at 1 year was 10.1% for patients without prior SAH and 12.6% for patients with prior SAH versus 7.1% and 9.8%, respectively, for the endovascular group.

8 2575 person-years FU, 33 (23%) of the 142 patients suffered an SAH, an approximate annual incidence of 1.3%, with an average annual incidence of SAH by group of 2.6%, 1%, and 1.3% for symptomatic aneurysm, incidental aneurysm, and prior SAH groups, respectively. UIAs should be treated irrespective of size in the case of patients aged <50 years if it is technically possible and the treatment risk is not compounded by concurrent diseases aneurysms studied, 91% were discovered incidentally. Mean (+/-SD) size- 5.7+/-3.6 mm. January 2001-April 2004, 5720 patients, 20 years of age or older (mean age, 62.5 years; 68% women) with UIAs- 3 mm or more in the largest dimension During a FU period of11,660 aneurysm-years, ruptures were documented in 111 patients, with an annual rate of rupture of 0.95%

9 Hospital Mortality and Complications of Electively Clipped or Coiled Unruptured Intracranial Aneurysms* Rupture risk increased with size of the aneurysm. As compared with MCA aneurysms, PCoM and ACoM aneurysms were more likely to rupture. Aneurysms with a daughter sac (an irregular protrusion of the wall of the aneurysm)-more likely to rupture Alshekhlee et al. Stroke 2010 National Inpatient Sample database Elective admitted to US hospitals with diagnosis of un-ruptured aneurysms 3738 clipping 3498 endovascular coiling Basic demographics including race, age, comorbidity indices were similar Alshekhlee et al. Stroke 2010 Clipped Coiled Length of stay 4 d 1 d P< Hospital charges $ 38,166 $ 42,070 P< Hospital mortality 1.6% 0.57% OR, 3.63;95% CI,1.57,8.42 Intraprocedural ICH Postoperative stroke Composite outcome (death, ICH, stroke) 2.38% 1.37% OR, 1.75;95% CI,1.23, % 2.92% OR, 2.39;95% CI,1.89, % 3.69 OR, 2.37;95% CI,1.92,2.93

10 Endovascular Treatment of Giant Aneurysms: General Principles Robert E. Replogle, MD Operative Techniques in Neurosurgery, V. 8, Iss. 2, June 2005, pp Endovascular Treatment of Giant Aneurysms: General Principles Robert E. Replogle, MD Operative Techniques in Neurosurgery, V. 8, Iss. 2, June 2005, pp o o

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16 Its far more important to know what person the disease has than what disease the person has Hippocrate Wall shear stress (WSS), is a frictional force of the blood flow that is tangential to the wall. WSS major determinant of vascular remodeling, with values around 20 dynes/cm 2, going up to about 200 for an apex and 100 for the distal neck. The anatomical configuration of the arterial tree and the aneurysmal sac determines the hemodynamic stresses in connection with the flow Degradation of the extracellular matrix prominent feature. Quantitative PCR and immunohistochemistry show increased expression of cathepsin in the late stage of aneurysm progression

17 Significant differences between the wall of ruptured and unruptured aneurysms. Macrophage infiltration into the wall may play an important role in weakening the aneurysmal structure Ex vitro at 4.7T of samples- iron deposits as well as fresh/ organizing luminal thrombus. Promise as a marker of inflammation in the vascular wall Nicholls et al. Arterioscler Thromb Vasc Biol. 2005

18 Background: individual patient data from prospective cohort studies to estimate 5-year aneurysm rupture risk. Methods: 8382 participants in six prospective cohort studies with subarachnoid hemorrhage as outcome

19 Six predictors: age, hypertension, history of SAH, aneurysm size, aneurysm location, geographical region. Endovascular coiling is associated with a reduction in procedural morbidity and mortality over surgical clipping in selected cases but has an overall higher risk of recurrence (Class IIb; Level of Evidence B). Although studies confirm that larger UIA size portends a worse prognosis in terms of bleeding, strict size cutoffs may be less helpful than previously thought. Available data also continue to suggest that UIAs in certain locations, with certain morphological characteristics, are more likely to rupture. It also appears that growth of a UIA is associated with rupture.

20 Reasonable to more strongly consider repair (1) when the UIA is discovered as a result of a prior SAH from a different lesion, (2) if the aneurysm is symptomatic, causing compressive symptoms, or a likely source of otherwise unexplained embolic stroke, or (3) if the patient has a family history of IA. Nonetheless, the risks, benefits, and alternatives to repair must be considered carefully in each individual case.