Multidisciplinary Consensus on Assessment of Unruptured Intracranial Aneurysms Proposal of an International Research Group

Peer reviewe

The unruptured intracranial aneurysm treatment score A multidisciplinary consensus

Objective: We endeavored to develop an unruptured intracranial aneurysm (UIA) treatment score (UIATS) model that includes and quantifies key factors involved in clinical decision-making in the management of UIAs and to assess agreement for this model among specialists in UIA management and research. Methods: An international multidisciplinary (neurosurgery, neuroradiology, neurology, clinical epidemiology) group of 69 specialists was convened to develop and validate the UIATS model using a Delphi consensus. For internal (39 panel members involved in identification of relevant features) and external validation (30 independent external reviewers), 30 selected UIA cases were used to analyze agreement with UIATS management recommendations based on a 5-point Likert scale (5 indicating strong agreement). Interrater agreement (IRA) was assessed with standardized coefficients of dispersion (v(r)*) (v(r)* 5 0 indicating excellent agreement and v(r)* = 1 indicating poor agreement). Results: The UIATS accounts for 29 key factors in UIA management. Agreement with UIATS (mean Likert scores) was 4.2 (95% confidence interval [CI] 4.1-4.3) per reviewer for both reviewer cohorts; agreement per case was 4.3 (95% CI 4.1-4.4) for panel members and 4.5 (95% CI 4.3-4.6) for external reviewers (p = 0.017). Mean Likert scores were 4.2 (95% CI 4.1-4.3) for interventional reviewers (n = 56) and 4.1 (95% CI 3.9-4.4) for noninterventional reviewers (n = 12) (p = 0.290). Overall IRA (v(r)*) for both cohorts was 0.026 (95% CI 0.019-0.033). Conclusions: This novel UIA decision guidance study captures an excellent consensus among highly informed individuals on UIA management, irrespective of their underlying specialty. Clinicians can use the UIATS as a comprehensive mechanism for indicating how a large group of specialists might manage an individual patient with a UIA.Peer reviewe

The impact of hypertension and nicotine on the size of ruptured intracranial aneurysms

International audienceBackground and Purpose The goal of the present study was to analyze retrospectively the impact of risk factors for subarachnoid hemorrhage (SAH) on the size of ruptured intracranial aneurysms in order to identify variables which might influence the discrepancy between average sizes of ruptured and unruptured aneurysms. Methods The records and angiographies of 373 patients treated at our center due to aneurysmal SAH between 2004 and December 2008 were retrospectively analyzed. Modifiable and non-modifiable risk factors for SAH were correlated with exact measurement of aneurysm size using 3-dimensional rotational digital subtraction angiographies (3D-DSA). Results Average maximum aneurysm diameter in patients with combined history of hypertension and cigarette smoking was 5.47±3.22 mm [95% CI 4.71-6.24], thus significantly smaller (p<0.001) than in patients with hypertension only (6.27±3.28 mm, 95% CI 5.75-6.78), with cigarette smoking only (7.61± 4.29 mm, 95% CI 6.43-8.79) and patients with no history for risk factors (8.08±4.73mm, 95% CI 6.96- 9.21). Odds ratio for aneurysm size less than 7mm in patients with combined hypertension and cigarette smoking was 3.63 [95% CI 1.78-7.42], 3.09 [95% CI 1.95-4.92] in patients with hypertension only and 1.02 [95% CI 0.64-1.62] in patients with cigarette smoking only. Conclusions The present analysis demonstrates a distinct correlation between hypertension, smoking and the size of ruptured aneurysms in SAH patients. Arterial hypertension and cigarette smoking appear to destabilize cerebral aneurysms growth. Our data strongly suggests that these factors should also be considered, when treatment indications for small unruptured aneurysms are discussed

Profile and Prognosis of Spontaneous Lobar Intracerebral Hemorrhage: Comparison of 6-month Survival with STICH II and the MISTIE III Lobar Hemorrhage Subset

Background Randomized trials on spontaneous lobar intracerebral hemorrhage (ICH) provided no convincing evidence of the superiority of surgical treatment. Since recruitment in the trials was under the premise of equipoise, a selection bias toward patients who did not need surgery or were in hopeless condition must be suspected. The aim of the actual analysis was to compare outcome and patient profile of an unselected hospital series with recent randomized trials and to develop a prognostic model. Methods Of 821 patients with spontaneous ICH managed at the neurosurgical department of the University Hospital Dusseldorf between 2013 and 2018, 159 had lobar bleedings. Patient characteristics, hematoma volume, treatment modality, and 6-month survival were compared with STICH II and the subset of lobar hemorrhage in the MISTIE III trial. In addition, a prognostic model for 6-month survival in our patients was developed using a random forest classifier. Results One hundred and seven patients were managed by surgical evacuation of the hematoma and 52 without surgical evacuation. Median hemorrhage volume in our surgical cohort was 66 and 42mL in the conservative cohort, compared with 38 and 36mL in the STICH II trial, and 46 and 47mL in the surgical and conservative MISTIE III lobar hemorrhage subset. Median initial Glasgow Coma Scale (GCS) score was 12 in our surgical group and 11 in the conservative group, compared with 13 in the STICH II cohorts and 12 in the MISTIE III lobar hemorrhage subset. Median age in our surgical and conservative cohorts was 73 and 74 years, respectively, compared with 65 years in both STICH II cohorts and 68 years in the MISTIE II subsets. Twenty-nine percent of our surgical cohort and 55% of our conservatively managed patients deceased within the first 6 months, compared with 18 and 24%, respectively, in STICH II and 17 and 24% in the MISTIE III subset. Our prognostic model identified large hemorrhage volumes and low admission GCS score as main unfavorable prognostic factors for 6-month survival. The random forest classifier achieved a predictive accuracy of 78% and an area under curve (AUC)- value of 88% regarding survival at 6 months, on a test set independent of the training set. Conclusions In comparison with our surgical group, the STICH II and MISTIE III cohorts, recruited under the premise of physician equipoise, underrepresented patients with large ICHs. The cohorts in the randomized trials were therefore biased toward patients with a favorable perspective under conservative management. Initial hematoma volume and admission GCS were the main prognostic factors in our patients

Prediction of outcome after aneurysmal subarachnoid haemorrhage using data from patient admission

The pathogenesis leading to poor functional outcome after aneurysmal subarachnoid haemorrhage (aSAH) is multifactorial and not fully understood. We evaluated a machine learning approach based on easily determinable clinical and CT perfusion (CTP) features in the course of patient admission to predict the functional outcome 6 months after ictus.METHODS:Out of 630 consecutive subarachnoid haemorrhage patients (2008-2015), 147 (mean age 54.3, 66.7% women) were retrospectively included (Inclusion: aSAH, admission within 24 h of ictus, CTP within 24 h of admission, documented modified Rankin scale (mRS) grades after 6 months. Exclusion: occlusive therapy before first CTP, previous aSAH, CTP not evaluable). A random forests model with conditional inference trees was optimised and trained on sex, age, World Federation of Neurosurgical Societies (WFNS) and modified Fisher grades, aneurysm in anterior vs. posterior circulation, early external ventricular drainage (EVD), as well as MTT and Tmax maximum, mean, standard deviation (SD), range, 75th quartile and interquartile range to predict dichotomised mRS (≤ 2; > 2). Performance was assessed using the balanced accuracy over the training and validation folds using 20 repeats of 10-fold cross-validation.RESULTS:In the final model, using 200 trees and the synthetic minority oversampling technique, median balanced accuracy was 84.4% (SD 0.7) over the training folds and 70.9% (SD 1.2) over the validation folds. The five most important features were the modified Fisher grade, age, MTT range, WFNS and early EVD.CONCLUSIONS:A random forests model trained on easily determinable features in the course of patient admission can predict the functional outcome 6 months after aSAH with considerable accuracy.KEY POINTS:• Features determinable in the course of admission of a patient with aneurysmal subarachnoid haemorrhage (aSAH) can predict the functional outcome 6 months after the occurrence of aSAH. • The top five predictive features were the modified Fisher grade, age, the mean transit time (MTT) range from computed tomography perfusion (CTP), the WFNS grade and the early necessity for an external ventricular drainage (EVD). • The range between the minimum and the maximum MTT may prove to be a valuable biomarker for detrimental functional outcome

The age of collagen in intracranial saccular aneurysms

BACKGROUND AND PURPOSE: The chronological development and natural history of cerebral aneurysms (CA) remains incompletely understood. We used (14)C birth dating of a main constituent of CAs, i.e. collagen type I, as an indicator for biosynthesis and turnover of collagen in CAs in relation to human cerebral arteries to further investigate this. METHODS: Forty-six ruptured and unruptured CA samples from 43 patients as well 10 cadaveric human cerebral arteries were obtained. The age of collagen, extracted and purified from excised CAs, was estimated using (14)C birth dating and correlated with CA and patient characteristics, including the history of risk factors associated with atherosclerosis and potentially aneurysm growth and rupture. RESULTS: Nearly all CA samples contained collagen type I which was less than 5 years old, irrespective of patient age, aneurysm size, morphology, or rupture status. However, CAs from patients with a history of risk factors (smoking or hypertension), contained significantly younger collagen than CAs from patients with no risk factors (mean 1.6±1.2 years versus 3.9±3.3 years, respectively, p= 0.012). CAs and cerebral arteries did not share one dominant structural protein, such as collagen type I, which would allow comparison of their collagen turnover. CONCLUSIONS: The abundant amount of relatively young collagen type I in CAs suggests that there is on-going collagen remodeling in aneurysms, which is significantly more rapid in patients with risk factors. These findings challenge the concept that cerebral aneurysms are present for decades and that they undergo only sporadic episodes of structural change