Journal of Cerebrovascular and Endovascular Neurosurgery

Korean Society of Cerebravascular Surgeons (대한뇌혈관외과학회)
권호 표지

Guidelines for the Management of Unruptured Intracranial Aneurysm

비파열뇌동맥류 진료지침 - 종설 -

  • Seo, Dae-Hee (Department of Neurosurgery, Kwandong University College of Medicine, Myongji Hospital) ;
  • Kang, Hyun-Seung (Department of Neurosurgery, Seoul National University Hospital) ;
  • Kim, Dae-Won (Department of Neurosurgery, School of Medicine, Wonkwang University Hospital) ;
  • Park, Sukh-Que (Department of Neurosurgery, College of Medicine, Soonchunhyang University Hospital) ;
  • Song, Young (Department of Neurosurgery, Seoul Veterans Hospital) ;
  • Sheen, Seung-Hun (Department of Neurosurgery, College of Medicine, Hallym University Chuncheon Sacred Heart Hospital) ;
  • You, Seung-Hoon (Department of Neurosurgery, University of Ulsan College of Medicine, Gangneung Asan Hospital) ;
  • Kwon, Sun-Uk (Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Rha, Joung-Ho (Department of Neurology, Inha University Hospital) ;
  • Bae, Hee-Joon (Department of Neurology, Seoul National University Bundang Hospital) ;
  • Oh, Chang-Wan (Department of Neurosurgery, Seoul National University Bundang Hospital) ;
  • Yu, Kyung-Ho (Department of Neurology, College of Medicine, Hallym University Sacred Heart Hospital) ;
  • Yoon, Byung-Woo (Department of Neurology, Seoul National University Hospital) ;
  • Lee, Byung-Chul (Department of Neurology, College of Medicine, Hallym University Sacred Heart Hospital) ;
  • Heo, Ji-Hoe (Department of Neurology, Yonsei University Severance Hospital) ;
  • Hong, Keun-Sik (Department of Neurology, Inje University, Ilsan Paik Hospital) ;
  • Hong, Seung-Chyul (Department of Neurosurgery, Sungkyunkwan University Samsung Medical Center) ;
  • Park, In-Sung (Department of Neurosurgery, Gyeongsang National University Hospital)
  • 서대희 (관동대학교 의과대학 명지병원 신경외과) ;
  • 강현승 (서울대학교병원 신경외과) ;
  • 김대원 (원광대학교병원 신경외과) ;
  • 박석규 (순천향대학교 서울병원 신경외과) ;
  • 송영 (서울보훈병원 신경외과) ;
  • 신승훈 (한림대학교 의과대학 춘천성심병원 신경외과) ;
  • 유승훈 (울산대학교 의과대학 강릉아산병원 신경외과) ;
  • 권순억 (울산대학교 의과대학 서울아산병원 신경과) ;
  • 나정호 (인하대학교병원 신경과) ;
  • 배희준 (분당서울대학교병원 신경과) ;
  • 오창완 (분당서울대학교병원 신경외과) ;
  • 유경호 (한림대학교 의과대학 성심병원 신경과) ;
  • 윤병우 (서울대학교병원 신경과) ;
  • 이병철 (한림대학교 의과대학 성심병원 신경과) ;
  • 허지회 (연세대학교 의과대학 세브란스병원 신경과) ;
  • 홍근식 (인제대학교 의과대학 일산백병원 신경과) ;
  • 홍승철 (성균관대학교 의과대학 삼성서울병원 신경외과) ;
  • 박인성 (경상대학교병원 신경외과)
  • Published : 2011.12.30
⟨ Previous Next ⟩

Abstract

Intracranial aneurysmal rupture causes subarachnoid hemorrhage which usually leads to fatality or severe disability. Treatment of unruptured intracranial aneurysms (UIAs) can substantially reduce the risk of rupture and prevent the grave consequences, but the risk of prophylactic treatment cannot be ignored. UIAs have diverse characteristics and management strategy needs to be tailored according to their location, size and clinical status. In the absence of level I evidence, the treatment guidance often relied on expert's opinions and experience. Knowledge of the natural course and management risks of individual aneurysms can help to guide treatment decision, but the natural history is still controversial and risks are not clearly defined. The Korean Society of Cerebrovascular Surgeons (KSCVS) decided to issue a Korean version of UIA management guideline as a framework for the treatment decision and as a basis for future studies, following 'Guideline Development Manual' of the Clinical Research Center for Stroke (CRCS). The organized committee systematically reviewed relevant literature and major guidelines published between January 2000 and July 2010 and took a developmental strategy of adaptation rather than de novo methods. On the basis of interpretation of the published evidences, recommendations were synthesized, and the level of evidence and the grade of recommendation were determined using the methods adapted from those of the US Agency for Healthcare Policy and Research and CRCS. The current guideline focuses on three domains of natural history, diagnosis and treatment of UIAs. The hierarchy of evidence and the recommendation grading indicate the current level by the literature and do not indicate the necessity or the prohibition of a certain clinical practice. Accordingly, this guideline cannot provide the answer for every clinical situation and should not take precedence over the clinical judgment of responsible physicians for individual patients. The final judgment regarding the care of a particular patient must be made by the physician and patient in light of circumstances specific to that patient. This is the first version of the UIA management guideline in Korea and new evidences will be timely and continuously updated in the future guidelines.

Keywords

References

  1. Akyuz M, Tuncer R, Yilmaz S, Sindel T. Angiographic follow- up after surgical treatment of intracranial aneurysms. Acta Neurochir (Wien) 146:245-50, 2004 https://doi.org/10.1007/s00701-003-0206-z
  2. Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC Jr, Brott T et al. Recommendations for the management of patients with unruptured intracranial aneurysms: a statement for healthcare professionals from the stroke council of the american heart association. Stroke 31:2742-50, 2000 https://doi.org/10.1161/01.STR.31.11.2742
  3. Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 40:994-1025, 2009 https://doi.org/10.1161/STROKEAHA.108.191395
  4. Bor AS, Koffijberg H, Wermer MJ, Rinkel GJ. Optimal screening strategy for familial intracranial aneurysm: a cost-effectiveness analysis. Neurology 74:1671-9, 2010 https://doi.org/10.1212/WNL.0b013e3181e04297
  5. Brilstra EH, Rinkel GJ, van der Graaf Y, Sluzewski M, Groen RJ, Lo RT et al. Quality of life after treatment of unruptured intracranial aneurysms by neurosurgical clipping or by embolisation with coils. A prospective, observational study. Cerebrovasc Dis 17:44-52, 2004 https://doi.org/10.1159/000073897
  6. Brilstra EH, Rinkel GJE, van der Graaf Y, van Rooij WJJ, Algra A. Treatment of intracranial aneurysms by embolization with coils: a systematic review. Stroke 30:470-6, 1999 https://doi.org/10.1161/01.STR.30.2.470
  7. Brinjikji W, Lanzino G, Cloft HJ, Rabinstein A, Kallmes DF. Endovascular treatment of very small (3 mm or smaller) intracranial aneurysms: report of a consecutive series and a meta-analysis. Stroke 41:116-21, 2010 https://doi.org/10.1161/STROKEAHA.109.566356
  8. Broderick JP, Brott TG, Duldner JE, Tomsick T, Leach A. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke 25:1342-7, 1994 https://doi.org/10.1161/01.STR.25.7.1342
  9. Broderick JP, Brown RD Jr, Sauerbeck L, Hornung R, Huston J 3rd, Woo D et al, for FIA Study Investigators. Greater rupture risk for familial as compared to sporadic unruptured intracranial aneurysms. Stroke 40:1952-7, 2009 https://doi.org/10.1161/STROKEAHA.108.542571
  10. Brown RD Jr, Huston J III, Hornung R, Foroud T, Kallmes DF, Kleindorfer D et al. Screening for brain aneurysm in the familial intracranial aneurysm study: frequency and predictors of lesion detection. J Neurosurg 108:1132-8, 2008 https://doi.org/10.3171/JNS/2008/108/6/1132
  11. Burns JD, Huston J III, Layton KF, Piepgras DG, Brown RD Jr. Intracranial aneurysm enlargement on serial magnetic resonance angiography: frequency and risk factors. Stroke 40:406-11, 2009 https://doi.org/10.1161/STROKEAHA.108.519165
  12. Clinical research center for stroke. Clinical Practice Guidelines for stroke. 2009 (Korean version), 2010 (Englsh version). https://www.stroke-crc.or.kr/Clinical%20Guidelines%20for%20Stroke_Korean.pdf
  13. Coil embolization of unruptured intracranial aneurysms. Interventional procedure guidance 105. National Institute for Clinical Excellence, January 2005. www.nice.org.uk
  14. Crawley F, Clifton A, Brown MM. Should we screen for familial intracranial aneurysm? Stroke 30:312-6, 1999 https://doi.org/10.1161/01.STR.30.2.312
  15. David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 91:396-401, 1999 https://doi.org/10.3171/jns.1999.91.3.0396
  16. Graves EJ. Detailed diagnoses and procedures. National hospital discharge survey, 1990. Vital Health Stat 113:1-225, 1992
  17. Henkes H, Fischer S, Weber W, Miloslavski E, Felber S, Brew S et al. Endovascular coil occlusion of 1811 intracranial aneurysms: early angiographic and clinical results. Neurosurgery 54:268-85, 2004 https://doi.org/10.1227/01.NEU.0000103221.16671.F0
  18. Im SH, Han MH, Kwon OK, Kwon BJ, Kim SH, Kim JE et al. Endovascular coil embolization of 435 small asymptomatic unruptured intracranial aneurysms: procedural morbidity and patient outcome. Am J Neuroradiol 30:79-84, 2009 https://doi.org/10.3174/ajnr.A1551
  19. Ishibashi T, Murayama Y, Urashima M, Saguchi T, Ebara M, Arakawa H et al. Unruptured intracranial aneurysms: incidence of rupture and risk factors. Stroke 40:313-6, 2009 https://doi.org/10.1161/STROKEAHA.108.521674
  20. Juvela S, Porras M, Poussa K. Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture. J Neurosurg 93:379-87, 2000 https://doi.org/10.3171/jns.2000.93.3.0379
  21. Juvela S, Poussa K, Porras M. Factors affecting formation and growth of intracranial aneurysms: a long-term follow-up study. Stroke 32:485-91, 2001 https://doi.org/10.1161/01.STR.32.2.485
  22. Kim JE, Lim DJ, Hong CK, Joo SP, Yoon SM, Kim BT. Treatment of unruptured intracranial aneurysms in South Korea in 2006: a nationwide multicenter survey from the korean society of cerebrovascular surgery. J Korean Neurosurg Soc 47:112-8, 2010 https://doi.org/10.3340/jkns.2010.47.2.112
  23. King JT, Berlin JA, Flamm ES. Morbidity and mortality from elective surgery for asymptomatic, unruptured, intracranial aneurysms: a meta-analysis. J Neurosurg 81:837-42, 1994 https://doi.org/10.3171/jns.1994.81.6.0837
  24. Komotar RJ, Mocco J, Solomon RA. Guidelines for the surgical treatment of unruptured intracranial aneurysms: the first annual J. Lawrence pool memorial research symposium--controversies in the management of cerebral aneurysms. Neurosurgery 62:183-94, 2008 https://doi.org/10.1227/01.NEU.0000311076.64109.2E
  25. Krisht AF, Gomez J, Partington S. Outcome of surgical clipping of unruptured aneurysms as it compares with a 10-year nonclipping survival period. Neurosurgery 58:207-16, 2006 https://doi.org/10.1227/01.NEU.0000194638.61073.FC
  26. Kuehn BM. FDA warning: CT scans exceeded proper doses. JAMA 303:124, 2010 https://doi.org/10.1001/jama.2009.1906
  27. Lanterna LA, Tredici G, Dimitrov BD, Biroli F. Treatment of unruptured cerebral aneurysms by embolization with Guglielmi detachable coils: case-fatality, morbidity, and effectiveness in preventing bleeding-A systematic review of the literature. Neurosurgery 55:767-78, 2004 https://doi.org/10.1227/01.NEU.0000137653.93173.1C
  28. Magnetic Resonance Angiography in Relatives of Patients with Subarachnoid Hemorrhage Study Group. Risks and benefits of screening for intracranial aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage. N Engl J Med 341:1344-50, 1999 https://doi.org/10.1056/NEJM199910283411803
  29. Matsubara S, Hadeishi H, Suzuki A, Yasui N, Nishimura H. Incidence and risk factors for the growth of unruptured cerebral aneurysms: observation using serial computerized tomography angiography. J Neurosurg 101:908-14, 2004 https://doi.org/10.3171/jns.2004.101.6.0908
  30. Molyneux AJ, Kerr RS, Birks J, Ramzi N, Yarnold J, Sneade M et al. for ISAT Collaborators. Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 8:427-33, 2009 https://doi.org/10.1016/S1474-4422(09)70080-8
  31. Morgan MK, Mahattanakul W, Davidson A, Reid J. Outcome for middle cerebral artery aneurysm surgery. Neurosurgery 67:755-61, 2010 https://doi.org/10.1227/01.NEU.0000378025.33899.26
  32. Morita A, Fujiwara S, Hashi K, Ohtsu H, Kirino T. Risk of rupture associated with intact cerebral aneurysms in the Japanese population: a systematic review of the literature from Japan. J Neurosurg 102:601-6, 2005 https://doi.org/10.3171/jns.2005.102.4.0601
  33. Moroi J, Hadeishi H, Suzuki A, Yasui N. Morbidity and mortality from surgical treatment of unruptured cerebral aneurysms at Research Institute for Brain and Blood Vessels-Akita. Neurosurgery 56:224-31, 2005 https://doi.org/10.1227/01.NEU.0000148897.28828.85
  34. Murayama Y, Nien YL, Duckwiler G, Gobin YP, Jahan R, Frazee J et al. Guglielmi detachable coil embolization of cerebral aneurysms: 11 years' experience. J Neurosurg 98:959-66, 2003 https://doi.org/10.3171/jns.2003.98.5.0959
  35. Naggara ON, White PM, Guilbert F, Roy D, Weill A, Raymond J. Endovascular treatment of intracranial unruptured aneurysms: systematic review and meta-analysis of the literature on safety and efficacy. Radiology 256:887-97, 2010 https://doi.org/10.1148/radiol.10091982
  36. Nakagawa T, Hashi K, Kurokawa Y, Yamamura A. Family history of subarachnoid hemorrhage and the incidence of asymptomatic, unruptured cerebral aneurysms. J Neurosurg 91:391-5, 1999 https://doi.org/10.3171/jns.1999.91.3.0391
  37. Ogilvy CS, Carter BS. Stratification of outcome for surgically treated unruptured intracranial aneurysms. Neurosurgery 52:82-7, 2003
  38. Ohue S, Oka Y, Kumon Y, Ohta S, Sakaki S, Hatakeyama T et al. Importance of neuropsychological evaluation after surgery in patients with unruptured cerebral aneurysms. Surg Neurol 59:269-75, 2003
  39. Otawara Y, Ogasawara K, Ogawa A, Yamadate K. Cognitive function before and after surgery in patients with unruptured intracranial aneurysm. Stroke 36:142-3, 2005 https://doi.org/10.1161/01.STR.0000149925.36914.4e
  40. Pierot L, Spelle L, Vitry F, for the ATENA Investigators. Immediate clinical outcome of patients harboring unruptured intracranial aneurysms treated by endovascular approach: results of the ATENA study. Stroke 39:2497-504, 2008 https://doi.org/10.1161/STROKEAHA.107.512756
  41. Raaymakers TW. Aneurysms in relatives of patients with subarachnoid hemorrhage: frequency and risk factors: MARS study group. Magnetic resonance angiography in relatives of patients with subarachnoid hemorrhage. Neurology 53:982-8, 1999 https://doi.org/10.1212/WNL.53.5.982
  42. Raaymakers TW, Rinkel GJ, Limburg M, Algra A. Mortality and morbidity of surgery for unruptured intracranial aneurysms: a meta-analysis. Stroke 29:1531-8, 1998 https://doi.org/10.1161/01.STR.29.8.1531
  43. Raaymakers TW, Rinkel GJ, Ramos LM. Initial and follow-up screening for aneurysms in families with familial subarachnoid hemorrhage. Neurology 51:1125-30, 1998 https://doi.org/10.1212/WNL.51.4.1125
  44. Rahman M, Smietana J, Hauck E, Hoh B, Hopkins N, Siddiqui A et al. Size ratio correlates with intracranial aneurysm rupture status. A prospective study. Stroke 41:916-20, 2010 https://doi.org/10.1161/STROKEAHA.109.574244
  45. Rinkel GJ, Djibuti M, Algra A, van Gijn J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review. Stroke 29:251-6, 1998 https://doi.org/10.1161/01.STR.29.1.251
  46. Ronkainen A, Hernesniemi J. Tromp G. Special features of familial intracranial aneurysms: report of 215 familial aneurysms. Neurosurgery 37:43-7, 1995 https://doi.org/10.1227/00006123-199507000-00006
  47. Sluzewski M, van Rooij WJ, Beute GN, Nijssen PC. Late rebleeding of ruptured intracranial aneurysms treated with detachable coils. Am J Neuroradiol 26:2542-9, 2005
  48. Sonobe M, Yamazaki T, Yonekura M, Kikuchi H. Small Unruptured Intracranial Aneurysm Verification Study: SUAVe Study, Japan. Stroke 41:1969-77, 2010 https://doi.org/10.1161/STROKEAHA.110.585059
  49. Takao H, Nojo T, Ohtomo K. Screening for familial intracranial aneurysms: decision and cost-effectiveness analysis. Acad Radiol 15:462-71, 2008 https://doi.org/10.1016/j.acra.2007.11.007
  50. The International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms-risk of rupture and risks of surgical intervention. N Engl J Med 339:1725-33, 1998 https://doi.org/10.1056/NEJM199812103392401
  51. The Joint committee on guidelines for the management of stroke. Japanese guideline for the management of Stroke 2009. Tokyo, Kyowa Kikaku, Ltd., 2009. http://www.jsts.gr.jp/jss08.html[Japanese]
  52. Tsutsumi K, Ueki K, Usui M, Kwak S, Kirino T. Risk of subarachnoid hemorrhage after surgical treatment of unruptured cerebral aneurysms. Stroke 30:1181-4, 1999 https://doi.org/10.1161/01.STR.30.6.1181
  53. Wermer MJ, Koffijberg H, van der Schaaf IC, for the ASTRA Study Group. Effectiveness and costs of screening for aneurysms every 5 years after subarachnoid hemorrhage. Neurology 70:2053-62, 2008 https://doi.org/10.1212/01.wnl.0000304372.01248.02
  54. Wermer MJ, van der Schaaf IC, Algra A, Rinkel GJ. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics：an updated meta-analysis. Stroke 38:1404-10, 2007 https://doi.org/10.1161/01.STR.0000260955.51401.cd
  55. White PM, Wardlaw JM, Easton V. Can noninvasive imaging accurately depict intracranial aneurysms? A systemic review. Radiology 217:361-70, 2000
  56. Wiebers DO. Unruptured intracranial aneurysms: natural history and clinical management. Update on the international study of unruptured intracranial aneurysms. Neuroimaging Clin N Am 16:383-90, 2006 https://doi.org/10.1016/j.nic.2006.04.005
  57. Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG et al. for International Study of Unruptured Intracranial Aneurysms Investigators. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103-10, 2003 https://doi.org/10.1016/S0140-6736(03)13860-3
  58. Willinsky RA, Taylor SM, terBrugge K, Farb RI, Tomlinson G, Montanera W. Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature. Radiology 227:522-8, 2003 https://doi.org/10.1148/radiol.2272012071
  59. Wirth FP, Laws ER, Jr., Piepgras D, Scott RM. Surgical treatment of incidental intracranial aneurysms. Neurosurgery 12:507-11, 1983 https://doi.org/10.1227/00006123-198305000-00005
  60. Yamada N, Hayashi K, Murao K, Higashi M, Iihara K. Time-of-flight MR angiography targeted to coiled intracranial aneurysms is more sensitive to residual flow than is digital subtraction angiography. Am J Neuroradiol 25:1154-7, 2004
  61. Yamashiro S, Nishi T, Koga K, Goto T, Kaji M, Muta D et al. Improvement of quality of life in patients surgically treated for asymptomatic unruptured intracranial aneurysms. J Neurol Neurosurg Psychiatry 78:497-500, 2007
  62. Yoshimoto Y, Wakai S. Cost-effectiveness analysis of screening of asymptomatic, unruptured intracranial aneurysms: a mathematical model. Stroke 30:1621-7, 1999 https://doi.org/10.1161/01.STR.30.8.1621