Current controversies for aneurysms Unruptured aneurysms UPDATE ON - - PowerPoint PPT Presentation

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UPDATE ON INTRACRANIAL ANEURYSMS AND SAH

Nerissa U. Ko, MD, MAS Recent Advances in Neurology February 15, 2019

Current controversies for aneurysms

• Unruptured aneurysms
• What to do with small aneurysms?
• Predicting aneurysms at high risk for rupture?
• What treatment is best?
• Ruptured aneurysms
• Treatment trends since ISAT
• Is coiling still the best treatment?
• Are outcomes better?

Guideline recommendations

• Family history > 2 first

degree family members with IA or SAH

• Genetic risk factors
• Polycystic kidney disease
• Ehler’s-Danlos, aortic

coarctation, microcephalic

• steodysplastic primordial

dwarfism

• History of prior SAH
• Non-invasive imaging

initially 6-12 months (CTA/MRA/DSA)

• Follow-up one year or

every other year to determine if:

• Aneurysm size > 7mm
• Aneurysm enlargement
• Consideration for treatment

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Stroke 2018; 49(9): 2268–2275. Current Opinion in Neurology 2019; 32(1): 49–53.

Balancing Risks and Benefits

• Risk of rupture
• Risk paradox of the

small aneurysm

• Risk of complications

with preventative treatment

• Coiling preferred in older

patients

• Coil vs clip for others?
• Medical therapy?
• Quality of life with

aneurysm diagnosis

• Follow-up imaging
• No imaging in <3mm
• Growth predicts rupture

risk, other morphology

• Still overall small risk

increase

• ELAPSS score for

growth risk

Neurology Apr 2017, 88 (17) 1600-1606;

ELAPSS score Unruptured Aneurysm Treatment

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JAMA Neurol. Published online December 28, 2018 Current Opinion in Neurology 2019; 32(1): 36–42.

Updates from ISC 2019

• Trend for rising costs of treatment for UIAs
• Regional variability in aSAH treatment and outcomes
• Predicting high risk aneurysms:
• UIA growth associated with size, multiplicity, HTN
• PHASES, UIATS predictive scores not accurate in age > 58
• Novel Imaging to predict rupture/growth
• Flow dynamics
• Vessel wall imaging with pathology
• Automated CT scan readers
• Biomarkers as predictors
• Inflammatory markers in blood and CSF

Updates from ISC 2019

• Innovations in endovascular treatment
• New hydrogel coils had less recanalization compared to bare

platinum coils (HEAT trial)

• Newer flow diverter with improved outcomes in giant/wide-necked

aneurysm (SCENT trial)

• Preventative treatment for UIAs
• Although more UIAs were treated overall aneurysm mortality is

unchanged

• Japanese study preferred coil to clip for UIAs in elderly
• Less readmissions post procedure with coil vs clip for UIAs
• Pragmatic trial of clipping vs coiling of UIAs is ongoing
• Medical therapy trial PROTECT-U enrolling (asa and SBP <120)

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Summary

• Small aneurysms have a very low risk of

growth and rupture

• Paradox of infrequent/no monitoring in small

aneurysms, but small aneurysms do rupture

• Selecting those at risk remains problematic
• Role for imaging, biomarkers
• Treatment risks for both coiling and clipping
• Medical and interventional treatment trials
• ngoing