Giant intracranial aneurysms: natural history and 1-year case fatality after endovascular or surgical treatment

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  • 1 Department of Neurosurgery, Charité—Berlin;
  • 2 Department of Neurosurgery, Helios Clinic, Bad Saarow;
  • 3 Brandenburg Medical School Theodor Fontane, Campus Bad Saarow, Germany;
  • 4 Department of Neuroradiology, Clinic Hirslanden, Zurich, Switzerland;
  • 5 Department of Neurosurgery, Technical University of Munich;
  • 6 Department of Neurosurgery, Georg-August-University Goettingen;
  • 7 Department of Neurology, Charité—Berlin;
  • 8 Center for Stroke Research, Berlin;
  • 9 Institute of Clinical Epidemiology and Biometry, University of Würzburg;
  • 10 Department of Neurosurgery, DONAUISAR Klinik Deggendorf;
  • 11 Department of Neurosurgery, Hannover Medical School, Hannover;
  • 12 Department of Neurosurgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany;
  • 13 Department of Neurosurgery, University Hospital Zurich;
  • 14 Department of Neurosurgery, University Hospital Geneva, Switzerland;
  • 15 Department of Neuroradiology, Metropolitan Hospital Niguarda, Milan, Italy;
  • 16 Department of Neuroradiology, University Hospital Toulouse, France;
  • 17 Comprehensive Heart Failure Center Würzburg, University of Würzburg; and
  • 18 Clinical Trial Center Würzburg, University Hospital Würzburg, Germany
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OBJECTIVE

Clinical evidence on giant intracranial aneurysms (GIAs), intracranial aneurysms with a diameter of at least 25 mm, is limited. The authors aimed to investigate the natural history, case fatality, and treatment outcomes of ruptured and unruptured GIAs.

METHODS

In this international observational registry study, patients with a ruptured or unruptured GIA received conservative management (CM), surgical management (SM), or endovascular management (EM). The authors investigated rupture rates and case fatality.

RESULTS

The retrospective cohort comprised 219 patients with GIAs (21.9% ruptured GIAs and 78.1% unruptured GIAs) whose index hospitalization occurred between January 2006 and November 2016. The index hospitalization in the prospective cohort (362 patients with GIAs [17.1% ruptured and 82.9% unruptured]) occurred between December 2008 and February 2017. In the retrospective cohort, the risk ratio for death at a mean follow-up of 4.8 years (SD 2.2 years) after CM, compared with EM and SM, was 1.63 (95% CI 1.23–2.16) in ruptured GIAs and 3.96 (95% CI 2.57–6.11) in unruptured GIAs. In the prospective cohort, the 1-year case fatality in ruptured GIAs/unruptured GIAs was 100%/22.0% during CM, 36.0%/3.0% after SM, and 39.0%/12.0% after EM. Corresponding 1-year rupture rates in unruptured GIAs were 25.0% during CM, 1.2% after SM, and 2.5% after EM. In unruptured GIAs, the HR for death within the 1st year in patients with posterior circulation GIAs was 6.7 (95% CI 1.5–30.4, p < 0.01), with patients with a GIA at the supraclinoid internal carotid artery as reference. Different sizes of unruptured GIAs were not associated with 1-year case fatality.

CONCLUSIONS

Rupture rates for unruptured GIAs were high, and the natural history and treatment outcomes for ruptured GIAs were poor. Patients undergoing SM or EM showed lower case fatality and rupture rates than those undergoing CM. This difference in outcome may in part be influenced by patients in the CM group having been found poor candidates for SM or EM.

Clinical trial registration no.: NCT02066493 (clinicaltrials.gov)

ABBREVIATIONS CM = conservative management; CND = cranial nerve deficit; EM = endovascular management; GCS = Glasgow Coma Scale; GIA = giant intracranial aneurysm; ISAT = International Subarachnoid Aneurysm Trial; ISUIA = International Study of Unruptured Intracranial Aneurysms; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage; SM = surgical management; UCAS Japan = Unruptured Cerebral Aneurysm Study of Japan; UIATS = Unruptured Intracranial Aneurysm Treatment Score; WFNS = World Federation of Neurosurgical Societies.

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Contributor Notes

Correspondence Julius Dengler: Charité, Berlin, Germany. julius.dengler@charite.de.

INCLUDE WHEN CITING Published online December 6, 2019; DOI: 10.3171/2019.8.JNS183078.

Disclosures Dr. Boccardi: consultant for Medtronic, Balt, and MicroVention. Dr. Cognard: consultant for Medtronic, MicroVention, Stryker, and Cerenovus.

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