Widespread screening for unruptured intracranial aneurysms among asymptomatic patients is unnecessary, according to recommendations from the American Heart Association's (AHA) Stroke Council. However, screening should be considered on a case-by-case basis in those patients with a family history of aneurysm or in patients with certain genetic syndromes that may increase their susceptibility to aneurysm formation.

"It is difficult to predict which unruptured aneurysms will rupture and which ones will never bleed," commented Joshua Bederson, MD, Director of Cerebrovascular Surgery at Mount Sinai Hospital, New York, and Chairman of the Stroke Council's task force on unruptured intracranial aneurysms. "Since all treatments carry at least some risk of complications, deciding which patients should be treated is crucial," he noted.

"We recommend considering surgery for young patients regardless of aneurysm size, and for anyone with aneurysm symptoms, a previous ruptured aneurysm, or any growth of the aneurysm," Dr. Bederson reported. "We favor observation in older patients with the smallest symptomless aneurysms due to the highest risk of treatment and the shorter life expectancy." Close observation with repeated brain scans is recommended for those who do not undergo surgery.

Before making their recommendations, the AHA Stroke Council task force reviewed the English-language literature regarding unruptured aneurysms. The studies, they pointed out, were retrospective analyses or uncontrolled series of cases. "There are no prospective randomized trials of treatment interventions versus conservative management to date," they explained. As a result, their recommendations were labeled grade C and represent "an array of potential clinical actions, any of which could be considered appropriate."

In the November issue of Stroke,the authors supported the following options in the management of unruptured intracranial aneurysms:

• Treatment of small incidental intracavernous internal carotid artery aneurysms is not generally indicated. For large symptomatic intracavernous aneurysms, treatment decisions should be based on patient age, severity and progression of symptoms, and treatment alternatives.
• Symptomatic intradural aneurysms of all sizes should be considered for treatment, with relative urgency for the treatment of acutely symptomatic aneurysms. When considering surgical treatment of symptomatic large or giant aneurysms, an individualized risk/benefit assessment should be undertaken.
• Coexisting or remaining aneurysms of all sizes in patients with subarachnoid hemorrhage due to another treated aneurysm warrant consideration for treatment. Treatment decisions must take into account patient age, medical and neurologic conditions, and relative risks of repair. If a decision is made for observation, periodic reevaluation with computed tomography/magnetic resonance angiography or selective contrast angiography should be considered.
• Treatment rather than observation cannot be generally advocated for incidental small (<10 mm) aneurysms in patients without previous subarachnoid hemorrhage. However, special consideration for treatment should be given to young patients in this group. Likewise, small aneurysms approaching the 10 mm diameter size, those with daughter sac formation and other unique hemodynamic features, and patients with a positive family history for aneurysms or aneurysmal subarachnoid hemorrhage deserve special consideration for treatment. In cases managed conservatively, periodic imaging should be considered and is necessary if a specific symptom should arise. Changes in aneurysmal size or configuration should lead to special consideration for treatment.

Asymptomatic aneurysms of 10 mm or more in diameter warrant strong consideration for treatment, taking into account patient age, existing medical and neurologic conditions, and relative risks for treatment.

Further studies with clinically relevant outcome measures are needed to fully assess treatment outcomes, the authors said. They also pointed out that the quality of life of those living with the diagnosis of unruptured aneurysm has yet to be adequately evaluated. Research in the next few years, the task force predicts, "will be useful for confirmation or modification of the guidelines."

NR