Guidelines on Management of Patients With Unruptured Intracranial Aneurysms
- Thompson BG, Brown RD Jr, Amin-Hanjani S, et al., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention.
- Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015;Jun 18:[Epub ahead of print].
The following are 10 points to remember about the American Heart Association/American Stroke Association Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms (UIAs):
- Given that smoking appears to increase the risk of UIA formation, patients with UIA should be counseled regarding the importance of smoking cessation (Class I; Level of Evidence B). Given that hypertension may play a role in growth and rupture of IAs, patients with UIA should monitor blood pressure and undergo treatment for hypertension (Class I; Level of Evidence B).
- Aneurysmal growth may increase the risk of rupture, and intermittent imaging studies to follow those UIAs managed conservatively should be considered (Class I; Level of Evidence B).
- Patients with an acute subarachnoid hemorrhage (aSAH) should undergo careful assessment for a coexistent UIA (Class I; Level of Evidence B). Early treatment is generally indicated for patients presenting with cranial nerve palsy caused by a UIA (Class I; Level of Evidence C).
- Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are useful for detection and follow-up of UIA (Class I; Level of Evidence B).
- Patients with ≥2 family members with IA or SAH should be offered aneurysmal screening by CTA or MRA. Risk factors that predict a particularly high risk of aneurysm occurrence in such families include history of hypertension, smoking, and female sex (Class I; Level of Evidence B).
- Patients with aneurysms with documented enlargement during follow-up should be offered treatment in the absence of prohibitive comorbidities (Class I; Level of Evidence B).
- Several factors should be considered in selection of the optimal management of a UIA, including the size, location, and other morphological characteristics of the aneurysm; documented growth on serial imaging; the age of the patient; a history of prior aSAH; family history of cerebral aneurysm; the presence of multiple aneurysms; or the presence of concurrent pathology such as an arteriovenous malformation or other cerebrovascular or inherited pathology that may predispose to a higher risk of hemorrhage (Class I; Level of Evidence C).
- Imaging after surgical intervention, to document aneurysm obliteration is recommended given the differential risk of growth and hemorrhage for completely versus incompletely obliterated aneurysms (Class I; Level of Evidence B).
- Endovascular treatment of UIAs is recommended to be performed at high-volume centers (Class I; Level of Evidence B). The procedural risk of radiation exposure should be explicitly reviewed in the consent process for endovascular procedures (Class I; Level of Evidence C).
- Surgical clipping is an effective treatment for UIAs that are considered for treatment (Class I; Level of Evidence B). Endovascular coiling is an effective treatment for select UIAs that are considered for treatment (Class IIa; Level of Evidence B). Endovascular coiling is associated with a reduction in procedural morbidity and mortality over surgical clipping in selected cases, but has an overall higher risk of recurrence (Class IIb; Level of Evidence B).
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