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Guidelines for the Management of Patients with Unruptured AHA/ASA Guideline Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Endorsed by the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the Society of NeuroInterventional Surgery B. Gregory Thompson, MD, Chair; Robert D. Brown, Jr, MD, MPH, FAHA, Co-Chair; Sepideh Amin-Hanjani, MD, FAHA; Joseph P. Broderick, MD, FAHA; Kevin M. Cockroft, MD, MSc, FAHA; E. Sander Connolly, Jr, MD, FAHA; Gary R. Duckwiler, MD, FAHA; Catherine C. Harris, PhD, RN, MBA, CRNP; Virginia J. Howard, PhD, MSPH, FAHA; S. Claiborne (Clay) Johnston, MD, PhD; Philip M. Meyers, MD, FAHA; Andrew Molyneux, MD; Christopher S. Ogilvy, MD; Andrew J. Ringer, MD; James Torner, PhD, MS, FAHA; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention Purpose—The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. Downloaded from http://ahajournals.org by on July 17, 2019 Methods—Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. Results—Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment. (Stroke. 2015;46:2368-2400. DOI: 10.1161/STR.0000000000000070.) Key Words: AHA Scientific Statements ◼ cerebral aneurysm ◼ epidemiology ◼ imaging ◼ natural history ◼ outcome ◼ risk factors ◼ treatment The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This guideline was approved by the American Heart Association Science Advisory and Coordinating Committee on January 28, 2015, and the American Heart Association Executive Committee on February 16, 2015. A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail [email protected]. The American Heart Association requests that this document be cited as follows: Thompson BG, Brown RD Jr, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES Jr, Duckwiler GR, Harris CC, Howard VJ, Johnston SC, Meyers PM, Molyneux A, Ogilvy CS, Ringer AJ, Torner J; 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;46:2368–2400. Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page. © 2015 American Heart Association, Inc. Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STR.0000000000000070 2368 Thompson et al Management of Unruptured Intracranial Aneurysms 2369 nruptured intracranial aneurysms (UIAs) are relatively 1692 prospective unoperated patients. Similarly, with a mean Ucommon in the general population, found in ≈3.2% (95% observation period of 3.5 years and 11 660 patient-years of confidence interval [CI], 1.9%–5.2%) of the adult population follow-up in a large Japanese study of unruptured aneurysms (mean age 50 years) worldwide, and they are being discov- (the Unruptured Cerebral Aneurysm Study [UCAS]),5 only ered incidentally with an increasing frequency because of the 110 aneurysmal ruptures were reported. To date, there has widespread use of high-resolution magnetic resonance imag- been no completed randomized comparison of either clipping ing (MRI) scanning. The large majority of UIAs will never or coiling treatment with regard to natural history to evalu- rupture. For example, of the 1 million adults in the general ate its risk/benefit ratio. The Trial of Endovascular Aneurysm population with a mean age of 50 years, ≈32 000 harbor a Management (TEAM) was initiated by Canadian researchers UIA, but only 0.25% of these, or 1 in 200 to 400, will rup- to examine this issue, but the study failed to recruit patients, ture.1–3 To put these numbers in perspective, in any given year, and the trial grant was withdrawn on grounds of futility.6 A ≈80 of 32 000 of these UIAs would be expected to present new Canadian trial has since commenced recruiting in a pilot with subarachnoid hemorrhage (SAH). Complicating matters study to compare endovascular treatment with clip ligation.7 further is the fact that aneurysms that rupture may not be the same as the ones found incidentally. Physicians are now often Changes in the Treatment of faced with the dilemma of whether to treat patients who pres- Unruptured Aneurysms ent with an incidental finding of an unruptured aneurysm or to Since the last recommendation document in 2000, major manage them conservatively. Patients and families may push changes have emerged in the treatment of UIA, largely in the for the surgical or endovascular management of an incidental widespread use of endovascular techniques. The use of coil UIA out of fear of the unknown and potentially catastrophic embolization increased substantially after publication of the outcome that could occur. However, no treatment comes with- results of the International Subarachnoid Aneurysm Trial out risk, and the benefit of treating an incidental UIA must (ISAT) in 2002 and 2005.8,9 ISAT was a randomized trial com- outweigh the potential risks of treating it. paring clip ligation to coil occlusion in ruptured aneurysms; Despite the relatively small number of rupture events that it showed improved clinical outcomes in the coiling arm at occur, many uncertainties remain. There are still concerns 1 year. Although trials of UIAs and ruptured aneurysms can- regarding the risk of rupture for particular aneurysm types not be compared on the basis of outcomes or future risk, the such as multilobed aneurysms, those with irregularity of the relative safety and medium-term efficacy of both coiling aneurysm dome, those with selected morphological charac- and surgical clipping in preventing future hemorrhage from Downloaded from http://ahajournals.org by on July 17, 2019 teristics (such as size relative to the parent artery), those in the treated aneurysm has been better established after ISAT. selected locations, and those of larger diameter. Other con- Furthermore, experience in treating aneurysms continues to cerns include presentations that may mimic sentinel head- increase, with an improved measure of safety and with better aches, patients who smoke or have hypertension, those who devices. have a family history of aneurysmal rupture, and those with This guideline is the result of a collaborative effort of an an enlarging aneurysm. How do these factors play a role in expert committee researching the best available evidence in the natural history of incidental UIA, and should they alter the English language on the prevalence, natural history, and management strategies? Should subsets of incidental UIAs be management of UIA. The committee was composed of experts treated differently or more aggressively? in the field with an interest in developing practice guidelines. The purpose of this statement is to provide guidance for This guideline is the continued review of existing literature physicians, other healthcare professionals, and patients and to that builds on the foundations of the recommendations made serve as a framework for decision making in determining the by the first consensus committee in 2000.10 best course of action when a UIA is discovered. The committee chair nominated writing group members
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