Unruptured intracranial aneurysm treatment

Unruptured intracranial aneurysm treatment

Establishment of drug therapy to prevent rupture of unruptured intracranial aneurysms (IAs) is needed. Previous human and animal studies have gradually clarified candidate drugs for the prevention of intracranial aneurysm rupture. However, because most of these candidates belong to classes of drugs frequently co-administered to prevent cardiovascular diseases, epidemiological studies evaluating these drugs simultaneously should be performed. Furthermore, because drugs included in the same class may have different effects in terms of disease prevention, drug-by-drug assessments are important for planning intervention trials.

Shimizu et al. performed a cross-sectional study enrolling patients diagnosed with IAs between July 2011 and June 2019. Patients were divided into ruptured or unruptured groups. The drugs investigated were selected according to evidence suggested by either human or animal studies. Univariate and multivariate logistic regression analyses were performed to assess the association of drug treatment with rupture status. They also performed drug-by-drug assessments of the association, including dose-response relationships, with rupture status.

In total, 310 patients with ruptured and 887 patients with unruptured IAs were included. Multivariate analysis revealed an inverse association of statins (odds ratio (OR), 0.54; 95% confidence interval (CI) 0.38-0.77), calcium channel blockers (OR, 0.41; 95% CI 0.30-0.58), and angiotensin II receptor blockers (ARBs) (OR, 0.67; 95% CI 0.48-0.93) with ruptured IAs. Moreover, inverse dose-response relationships with rupture status were observed for pitavastatin and rosuvastatin among statins, benidipinecilnidipine, and amlodipine among calcium channel blockers, and valsartanazilsartancandesartan, and olmesartan among ARBs. Only non-aspirin non-steroidal anti-inflammatory drugs were positively associated with ruptured IAs (OR, 3.24; 95% CI 1.71-6.13).

The present analysis suggests that several types of statins, calcium channel blockers, and ARBs are candidate drugs for the preventive treatment of unruptured IAs 1).

see Unruptured intracranial aneurysm treatment decision.

In the early 1990’s, endovascular treatment using embolic coils for the treatment of intracranial aneurysms was established. Since then, there has been a significant body of peer-reviewed literature written by medical experts regarding the use, safety, and efficacy of these detachable embolic coils. With the publishing of the ISAT (Intracranial Subarachnoid Aneurysm Trial) trial data in 2005, which compared clinical outcomes of neurosurgical clipping and endovascular coiling, embolic coiling became the preferred method for treatment of the majority of unruptured intracranial aneurysm2).

see Unruptured intracranial aneurysm surgery.

see Unruptured intracranial aneurysm endovascular treatment.


1)

Shimizu K, Imamura H, Tani S, Adachi H, Sakai C, Ishii A, Kataoka H, Miyamoto S, Aoki T, Sakai N. Candidate drugs for preventive treatment of unruptured intracranial aneurysms: A cross-sectional study. PLoS One. 2021 Feb 12;16(2):e0246865. doi: 10.1371/journal.pone.0246865. PMID: 33577580.
2)

Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005 Sep 3-9;366(9488):809-17. PubMed PMID: 16139655.

Unruptured anterior communicating artery aneurysm treatment

Unruptured anterior communicating artery aneurysm treatment

see also Anterior communicating artery aneurysm treatment.


The risk associated with treating unruptured anterior communicating artery aneurysms in patients age <65 years is low. Comparing risk with natural history studies, these patients can be expected to outperform natural history within 5 years. Recognizing the risk of smaller anterior communicating artery aneurysms, these findings suggest that treatment of even small lesions may be beneficial 1).


Anterior communicating artery aneurysm treatment requires more collaboration between microsurgical clipping and endovascular therapy. Evaluation of patient and anterior communicating artery aneurysm characteristics by considering the advantages and disadvantages of both techniques could provide an optimal treatment modality. A hybrid vascular neurosurgeon is expected to be a proper solution for the management of these conditions 2).

1)
Schmalz PGR, Enriquez-Marulanda A, Alturki A, Stapleton CJ, Thomas AJ, Ogilvy CS. Combined Outcomes of Endovascular or Surgical Treatment of Unruptured Anterior Communicating Artery Aneurysms: Is a More Aggressive Management Strategy Warranted? World Neurosurg. 2018 Jul;115:e331-e336. doi: 10.1016/j.wneu.2018.04.046. Epub 2018 Apr 17. PMID: 29673817.
2)
Moon JS, Choi CH, Lee TH, Ko JK. Result of coiling versus clipping of unruptured anterior communicating artery aneurysms treated by a hybrid vascular neurosurgeon. J Cerebrovasc Endovasc Neurosurg. 2020 Oct 6. doi: 10.7461/jcen.2020.E2020.06.005. Epub ahead of print. PMID: 33017881.

NSQIP unruptured aneurysm scale

NSQIP unruptured aneurysm scale

Data on patients who underwent surgical clipping of an unruptured aneurysm were extracted from the prospective National Surgical Quality Improvement Program registry (NSQIP; 2007-2014); NSQIP does not systematically collect data on patients undergoing intracranial endovascularinterventionMultivariable logistic regression evaluated predictors of any 30-day adverse event; variables screened included patient demographicscomorbiditiesfunctional status, preoperative laboratory values, aneurysm location/complexity, and operative time. A predictive scale was constructed based on statistically significant independent predictors, which was validated using both NSQIP (2015-2016) and the Nationwide Inpatient Sample (NIS; 2002-2011).

The NSQIP unruptured aneurysm scale was proposed: 1 point was assigned for a bleeding disorder; 2 points for age 51-60 years, cardiac disease, diabetes mellitus, morbid obesity, anemia (hematocrit < 36%), operative time 240-330 minutes; 3 points for leukocytosis (white blood cell count > 12,000/μL) and operative time > 330 minutes; and 4 points for age > 60 years. An increased score was predictive of postoperative stroke or coma (NSQIP: p = 0.002, C-statistic = 0.70; NIS: p < 0.001, C-statistic = 0.61), a medical complication (NSQIP: p = 0.01, C-statistic = 0.71; NIS: p < 0.001, C-statistic = 0.64), and a nonroutine discharge (NSQIP: p < 0.001, C-statistic = 0.75; NIS: p < 0.001, C-statistic = 0.66) in both validation populations. Greater score was also predictive of increased odds of any adverse event, a major complication, and an extended hospitalization in both validation populations (p ≤ 0.03).

The NSQIP unruptured aneurysm scale may augment the risk stratification of patients undergoing microsurgical clipping of unruptured cerebral aneurysm1).

1)

Dasenbrock HH, Rudy RF, Smith TR, Gormley WB, Patel NJ, Frerichs KU, Aziz-Sultan MA, Du R. Adverse events after clipping of unruptured intracranial aneurysms: the NSQIP unruptured aneurysm scale. J Neurosurg. 2019 Mar 15:1-10. doi: 10.3171/2018.12.JNS182873. [Epub ahead of print] PubMed PMID: 30875693.
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