European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms

Abstract

Unruptured intracranial aneurysms (UIA) occur in around 3% of the population. Important management questions concern if and how to perform preventive UIA occlusion; if, how and when to perform follow up imaging; and non-interventional means to reduce the risk of rupture. Using the Standard Operational Procedure of ESO we prepared guidelines according to GRADE methodology. Since no completed randomised trials exist, we used interim analyses of trials, and meta-analyses of observational and case-control studies to provide recommendations to guide UIA management. All recommendations were based on very low evidence. We suggest preventive occlusion if the estimated 5-year rupture risk exceeds the risk of preventive treatment. In general, we cannot recommend endovascular over microsurgical treatment, but suggest flow diverting stents as option only when there are no other low-risk options for UIA repair. To detect UIA recurrence we suggest radiological follow up after occlusion. In patients who are initially observed, we suggest radiological monitoring to detect future UIA growth, smoking cessation, treatment of hypertension, but not treatment with statins or acetylsalicylic acid with the indication to reduce the risk of aneurysm rupture. Additionally, we formulated 15 expert-consensus statements. All experts suggest to assess UIA patients within a multidisciplinary setting (neurosurgery, neuroradiology and neurology) at centres consulting >100 UIA patients per year, to use a shared decision-making process based on the team recommendation and patient preferences, and to repair UIA only in centres performing the proposed treatment in >30 patients with (ruptured or unruptured) aneurysms per year per neurosurgeon or neurointerventionalist. These UIA guidelines provide contemporary recommendations and consensus statement on important aspects of UIA management until more robust data come available

RNA Expression Signatures of Intracranial Aneurysm Growth Trajectory Identified in Circulating Whole Blood

“…Aneurysm growth is a significant risk factor for rupture [ 2 , 3 , 4 , 5 , 6 , 7 ]; Brinjijki et al reported growing IAs are more than 30 times more likely to rupture compared to stable IAs [ 5 ]. Aneurysm growth currently is assessed by repeat cerebral vascular imaging, typically by computed tomography angiography, magnetic resonance imaging, or digital subtraction angiography [ 8 ], which can be expensive and depending on the modality, may carry potential risks.…”

Circular RNA hsa_circ_0007990 as a blood biomarker for unruptured intracranial aneurysm with aneurysm wall enhancement

“…Unruptured intracranial aneurysms (UIA) cause subarachnoid hemorrhage once bleeding, resulting in severe poor clinical outcomes. The risk of rupture in UIA significantly decreases after receiving endovascular treatment or surgical clipping in cases of aneurysm growth (1,2). Inflammation plays a vital role in the development and progression of intracranial aneurysms (IA), which can be reflected by aneurysm wall enhancement (AWE) on high-resolution vessel wall magnetic resonance imaging (HR-VWI) (3)(4)(5)(6)(7)(8).…”

The Role of Bypass Surgery for the Management of Complex Intracranial Aneurysms in the Anterior Circulation in the Flow-Diverter Era: A Single-Center Series

“…Thus, decision making regarding the best managing options for patients with UIAs is very difficult. In the very recent European Stroke Organization (ESO) guidelines on management of unruptured intracranial aneurysms, it has been suggested that, in adult patients in whom the estimated 5 years risk of aneurysm rupture is higher than the risk of preventive treatment, the latter should be proposed, considering the most effective and safe modality for that particular aneurysm [ 6 ]. In the same guidelines, the authors suggested considering aneurysm morphology and complexity as important factors when balancing between conservative and preventive treatment [ 6 ].…”

“…In the very recent European Stroke Organization (ESO) guidelines on management of unruptured intracranial aneurysms, it has been suggested that, in adult patients in whom the estimated 5 years risk of aneurysm rupture is higher than the risk of preventive treatment, the latter should be proposed, considering the most effective and safe modality for that particular aneurysm [ 6 ]. In the same guidelines, the authors suggested considering aneurysm morphology and complexity as important factors when balancing between conservative and preventive treatment [ 6 ]. In fact, despite advancement in surgical and endovascular techniques, the treatment of complex intracranial aneurysms still poses significant difficulties for vascular neurosurgeons and interventional neuroradiologists [ 7 , 8 , 9 , 10 ].…”