It is well known that larger aneurysm size is a risk factor for poor outcome after surgical treatment of unruptured saccular intracranial aneurysms (USIAs). However, the authors have occasionally observed poor outcome in the surgical treatment of small USIAs and hypothesized that size ratio has a negative impact on outcome. The aim of this paper was to investigate the influence of size ratio on outcome in the surgical treatment of USIAs.
Prospectively collected clinical and radiological data of 683 consecutive patients harboring 683 surgically treated USIAs were evaluated. Dome-to-neck ratio was defined as the ratio of the maximum width of the aneurysm to the average neck diameter. The aspect ratio was defined as the ratio of the maximum perpendicular height of the aneurysm to the average neck diameter of the aneurysm. The size ratio was calculated by dividing the maximum aneurysm diameter (height or width, mm) by the average parent artery diameter (mm). Neurological worsening was defined as an increase in modified Rankin Scale score of 1 or more points at 12 months. Clinical and radiological variables were compared between patients with and without neurological worsening.
The median patient age was 64 years (IQR 56–71 years), and 528 (77%) patients were female. The median maximum size, dome-to-neck ratio, aspect ratio, and size ratio were 4.7 mm (IQR 3.6–6.7 mm), 1.2 (IQR 1.0–1.4), 1.0 (IQR 0.76–1.3), and 1.9 (IQR 1.4–2.8), respectively. The size ratio was significantly correlated with maximum size (r = 0.83, p < 0.0001), dome-to-neck ratio (r = 0.69, p < 0.0001), and aspect ratio (r = 0.74, p < 0.0001). Multivariate logistic regression analysis showed that the specific USIA location (paraclinoid segment of the internal carotid artery: OR 6.2, 95% CI 2.6–15, p < 0.0001; and basilar artery: OR 8.4, 95% CI 2.8–25, p < 0.0001), size ratio (OR 1.3, 95% CI 1.1–1.6, p = 0.021), and postoperative ischemic lesion (OR 9.4, 95% CI 4.4–19, p < 0.0001) were associated with neurological worsening (n = 52, 7.6%), and other characteristics showed no significant differences.
The present study showed that size ratio, and not other morphological parameters, was a risk factor for 12-month neurological worsening in surgically treated patients with USIAs. The size ratio should be further studied in a large, prospective observational cohort to predict neurological worsening in the surgical treatment of USIAs.
DenglerJMaldanerNGläskerSEndresMWagnerMMalzahnU: Outcome of surgical or endovascular treatment of giant intracranial aneurysms, with emphasis on age, aneurysm location, and unruptured aneuryms—a systematic review and meta-analysis. Cerebrovasc Dis41:187–1982016
DenglerJ, MaldanerN, GläskerS, EndresM, WagnerM, MalzahnU, : Outcome of surgical or endovascular treatment of giant intracranial aneurysms, with emphasis on age, aneurysm location, and unruptured aneuryms—a systematic review and meta-analysis. 41:187–198, 201610.1159/00044348526764969)| false
GrevingJPWermerMJBrownRDJrMoritaAJuvelaSYonekuraM: Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. Lancet Neurol13:59–662014
GrevingJP, WermerMJ, BrownRDJr, MoritaA, JuvelaS, YonekuraM, : Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies. 13:59–66, 201410.1016/S1474-4422(13)70263-124290159)| false
HauckEF, WohlfeldB, WelchBG, WhiteJA, SamsonD: Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study. 109:1012–1018, 200810.3171/JNS.2008.109.12.101219035713)| false
KassellNF, TornerJC, HaleyECJr, JaneJA, AdamsHP, KongableGL: The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. 73:18–36, 199010.3171/jns.1990.73.1.0018)| false
MatsukawaHKamiyamaHMiyazakiTKinoshitaYNodaKOtaN: Impacts of a size ratio on outcome in patients with surgically treated unruptured nondissecting anterior cerebral artery aneurysms. World Neurosurg111:e250–e2602018
MatsukawaH, KamiyamaH, MiyazakiT, KinoshitaY, NodaK, OtaN, : Impacts of a size ratio on outcome in patients with surgically treated unruptured nondissecting anterior cerebral artery aneurysms. 111:e250–e260, 201810.1016/j.wneu.2017.12.031)| false
MatsukawaH, KamiyamaH, TsuboiT, NodaK, OtaN, MiyataS, : Is age a risk factor for poor outcome of surgical treatment of unruptured intracranial aneurysms?94:222–228, 201610.1016/j.wneu.2016.06.11827392889)| false
TremmelMDharSLevyEIMoccoJMengH: Influence of intracranial aneurysm-to-parent vessel size ratio on hemodynamics and implication for rupture: results from a virtual experimental study. Neurosurgery64:622–6312009
TremmelM, DharS, LevyEI, MoccoJ, MengH: Influence of intracranial aneurysm-to-parent vessel size ratio on hemodynamics and implication for rupture: results from a virtual experimental study. 64:622–631, 20091934982410.1227/01.NEU.0000341529.11231.69)| false
von ElmEAltmanDGEggerMPocockSJGøtzschePCVandenbrouckeJP: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet370:1453–14572007
von ElmE, AltmanDG, EggerM, PocockSJ, GøtzschePC, VandenbrouckeJP: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. 370:1453–1457, 200710.1016/S0140-6736(07)61602-X)| false
WermerMJ, van der SchaafIC, AlgraA, RinkelGJ: Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: an updated meta-analysis. 38:1404–1410, 20071733244210.1161/01.STR.0000260955.51401.cd)| false