A data-driven model to identify high-risk aneurysms and guide management decisions: the Rupture Resemblance Score

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  • 1 Canon Stroke and Vascular Research Center and
  • 2 Department of Mechanical and Aerospace Engineering, University at Buffalo; Departments of
  • 3 Neurosurgery,
  • 5 Neurology,
  • 6 Bioinformatics, and
  • 7 Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo; and
  • 4 Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
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OBJECTIVE

Previous studies have found that ruptured intracranial aneurysms (RIAs) have distinct morphological and hemodynamic characteristics, including higher size ratio and oscillatory shear index and lower wall shear stress. Unruptured intracranial aneurysms (UIAs) that possess similar characteristics to RIAs may be at a higher risk of rupture than those UIAs that do not. The authors previously developed the Rupture Resemblance Score (RRS), a data-driven computer model that can objectively gauge the similarity of UIAs to RIAs in terms of morphology and hemodynamics. The authors aimed to explore the clinical utility of RRS in guiding the management of UIAs, especially for challenging cases such as small UIAs.

METHODS

Between September 2018 and June 2019, the authors retrospectively collected consecutive challenging cases of incidentally identified UIAs that were discussed during their weekly multidisciplinary neurovascular conference. From patient 3D digital subtraction angiography, they reconstructed the aneurysm geometry and performed computer-assisted 3D morphology analysis and computational fluid dynamics simulation. They calculated RRS for every UIA case and compared it against the treatment decision made at the neurovascular conference as well as the recommendation based on the unruptured intracranial aneurysm treatment score (UIATS).

RESULTS

Forty-seven patients with 79 UIAs, 90% of which were < 7 mm in size, were included in this study. The mean RRS (range 0.0–1.0) was 0.24 ± 0.31. At the conferences, treatment was endorsed for 45 of the UIAs (57%). These cases had significantly higher RRSs than the 34 cases suggested for observation (0.33 ± 0.34 vs 0.11 ± 0.19, p < 0.001). The UIATS-based recommendations were “observation” for 24 UIAs (30%), “treatment” for 21 UIAs (27%), and “not definitive” for 34 UIAs (43%). These “not definitive” cases were stratified by RRS based on similarity to RIAs.

CONCLUSIONS

Although not a rupture predictor, RRS is a data-driven model that gauges the similarity of UIAs to RIAs in terms of morphology and hemodynamics. In cases in which the UIATS-based recommendation is not definitive, RRS provides additional stratification to assist the identification of high-risk UIAs. The current study highlights the clinical utility of RRS in a real-world setting as an adjunctive tool for the management of UIAs.

ABBREVIATIONS CFD = computational fluid dynamics; DSA = digital subtraction angiography; IA = intracranial aneurysm; ICA = internal carotid artery; ISUIA = International Study of Unruptured Intracranial Aneurysms; MCA = middle cerebral artery; OSI = oscillatory shear index; PComA = posterior communicating artery; PHASES = Population, Hypertension, Age, Size, Earlier SAH, and Site of the Aneurysm; RIA = ruptured IA; RRS = Rupture Resemblance Score; SR = size ratio; UIA = unruptured IA; UIATS = UIA treatment score; WSS = wall shear stress.

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Contributor Notes

Correspondence Hui Meng: Canon Stroke and Vascular Research Center, Clinical Translational Research Center, Buffalo, NY. huimeng@buffalo.edu.

INCLUDE WHEN CITING Published online September 4, 2020; DOI: 10.3171/2020.5.JNS193264.

Disclosures Funding was provided by Canon Medical Systems Corp.

Dr. Snyder: consulting and teaching for Canon Medical Systems Corp., Penumbra Inc., Medtronic, and Jacobs Institute; and cofounder of Neurovascular Diagnostics, Inc. Dr. Davies: shareholder/ownership interests in RIST Neurovascular; ownership in Cerebrotech; consultant for Medtronic; speakers bureau for Penumbra; and honoraria from Neurotrauma Science, LLC. Dr. Siddiqui: research grant as coinvestigator of NIH/NINDS R01NS091075; financial interest/investor/stock options/ownership in Amnis Therapeutics, Apama Medical, Blink TBI Inc., Buffalo Technology Partners Inc., Cardinal Consultants, Cerebrotech Medical Systems, Inc., Cognition Medical, Endostream Medical Ltd., Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics Inc., Q’Apel Medical Inc., Rebound Therapeutics Corp., Rist Neurovascular Inc., Serenity Medical Inc., Silk Road Medical, StimMed, Synchron, Three Rivers Medical Inc., and Viseon Spine Inc.; consultant/advisory board for Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Guidepoint Global Consulting, Imperative Care, Integra LifeSciences Corp., Medtronic, MicroVention, Northwest University–DSMB Chair for HEAT Trial, Penumbra, Q’Apel Medical Inc., Rapid Medical, Rebound Therapeutics Corp., Serenity Medical Inc., Silk Road Medical, StimMed, Stryker, Three Rivers Medical, VasSol, W.L. Gore & Associates; and principal investigator/steering committee of the following trials: Cerenovus NAPA and ARISE II; Medtronic SWIFT PRIME and SWIFT DIRECT; MicroVention FRED & CONFIDENCE; MUSC POSITIVE; and Penumbra 3D Separator, COMPASS, and INVEST. Dr. Levy: shareholder/ownership interests in NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, and Three Rivers Medical; national principal investigator/steering committees of Medtronic (merged with Covidien Neurovascular) SWIFT PRIME and SWIFT DIRECT Trials; honoraria from Medtronic (training and lectures); consultant for Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound Therapeutics, and StimMed; advisory board of Stryker (AIS Clinical Advisory Board), NeXtGen Biologics, MEDX, Cognition Medical, and Endostream Medical; site principal investigator of CONFIDENCE study (MicroVention), STRATIS Study—Sub I (Medtronic); and provider of medical/legal opinion as an expert witness. Dr. Meng: principal investigator of NIH grants R01NS091075 and R03NS090193 and Canon Medical Systems Corp. grants (no grant number); and cofounder of Neurovascular Diagnostics Inc.

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