2/16/2019 Current controversies for aneurysms • Unruptured aneurysms UPDATE ON INTRACRANIAL • What to do with small aneurysms? • Predicting aneurysms at high risk for rupture ? ANEURYSMS AND SAH • What treatment is best? Nerissa U. Ko, MD, MAS • Ruptured aneurysms • Treatment trends since ISAT Recent Advances in Neurology • Is coiling still the best treatment? February 15, 2019 • Are outcomes better? Guideline recommendations • Family history > 2 first • Non-invasive imaging degree family initially 6-12 months members with IA or (CTA/MRA/DSA) SAH • Follow-up one year or • Genetic risk factors every other year to determine if: • Polycystic kidney disease • Ehler’s-Danlos, aortic • Aneurysm size > 7mm coarctation, microcephalic • Aneurysm enlargement osteodysplastic primordial • Consideration for treatment dwarfism • History of prior SAH 1
2/16/2019 Balancing Risks and Benefits • Risk of rupture • Quality of life with aneurysm diagnosis • Risk paradox of the small aneurysm • Follow-up imaging Current Opinion in Neurology 2019; 32(1): 49–53. • Risk of complications • No imaging in <3mm with preventative • Growth predicts rupture treatment risk, other morphology • Coiling preferred in older • Still overall small risk patients increase • Coil vs clip for others? • ELAPSS score for growth risk • Medical therapy? Stroke 2018; 49(9): 2268–2275. ELAPSS score Unruptured Aneurysm Treatment Neurology Apr 2017, 88 (17) 1600-1606; 2
2/16/2019 Current Opinion in Neurology 2019; 32(1): 36–42. JAMA Neurol. Published online December 28, 2018 Updates from ISC 2019 Updates from ISC 2019 • Trend for rising costs of treatment for UIAs • Innovations in endovascular treatment • Regional variability in aSAH treatment and outcomes • New hydrogel coils had less recanalization compared to bare platinum coils (HEAT trial) • Predicting high risk aneurysms: • Newer flow diverter with improved outcomes in giant/wide-necked • UIA growth associated with size, multiplicity, HTN aneurysm (SCENT trial) • PHASES, UIATS predictive scores not accurate in age > 58 • Preventative treatment for UIAs • Novel Imaging to predict rupture/growth • Although more UIAs were treated overall aneurysm mortality is • Flow dynamics unchanged • Vessel wall imaging with pathology • Japanese study preferred coil to clip for UIAs in elderly • Automated CT scan readers • Less readmissions post procedure with coil vs clip for UIAs • Biomarkers as predictors • Pragmatic trial of clipping vs coiling of UIAs is ongoing • Medical therapy trial PROTECT-U enrolling (asa and SBP <120) • Inflammatory markers in blood and CSF 3
2/16/2019 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 ongoing 4
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