Stability of unruptured intracranial aneurysms in the anterior circulation: nomogram models for risk assessment

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  • 1 Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing;
  • | 2 China National Clinical Research Center for Neurological Diseases, Beijing;
  • | 3 Department of Neurointervention, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; and
  • | 4 Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
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OBJECTIVE

The probable stability of the lesion is critical in guiding treatment decisions in unruptured intracranial aneurysms (IAs). The authors aimed to develop multidimensional predictive models for the stability of unruptured IAs.

METHODS

Patients with unruptured IAs in the anterior circulation were prospectively enrolled and regularly followed up. Clinical data were collected, IA morphological features were assessed, and adjacent hemodynamic features were quantified with patient-specific computational fluid dynamics modeling. Based on multivariate logistic regression analyses, nomograms incorporating these factors were developed in a primary cohort (patients enrolled between January 2017 and February 2018) to predict aneurysm rupture or growth within 2 years. The predictive accuracies of the nomograms were compared with the population, hypertension, age, size, earlier rupture, and site (PHASES) and earlier subarachnoid hemorrhage, location, age, population, size, and shape (ELAPSS) scores and validated in the validation cohort (patients enrolled between March and October 2018).

RESULTS

Among 231 patients with 272 unruptured IAs in the primary cohort, hypertension, aneurysm location, irregular shape, size ratio, normalized wall shear stress average, and relative resident time were independently related to the 2-year stability of unruptured IAs. The nomogram including clinical, morphological, and hemodynamic features (C+M+H nomogram) had the highest predictive accuracy (c-statistic 0.94), followed by the nomogram including clinical and morphological features (C+M nomogram; c-statistic 0.89), PHASES score (c-statistic 0.68), and ELAPSS score (c-statistic 0.58). Similarly, the C+M+H nomogram had the highest predictive accuracy (c-statistic 0.94) in the validation cohort (85 patients with 97 unruptured IAs).

CONCLUSIONS

Hemodynamics have predictive values for 2-year stability of unruptured IAs treated conservatively. Multidimensional nomograms have significantly higher predictive accuracies than conventional risk prediction scores.

ABBREVIATIONS

ACA = anterior cerebral artery; AcomA = anterior communicating artery; AUC = area under the curve; CFD = computational fluid dynamics; C+M = clinical and morphological; C+M+H = clinical, morphological, and hemodynamic; CTA = CT angiography; ELAPSS = earlier subarachnoid hemorrhage, location, age, population, size, and shape; IA = intracranial aneurysm; IARP-CP = Intracranial Aneurysm Rupture Project in the Chinese Population; ICA = internal carotid artery; LSAR = low shear area ratio; MCA = middle cerebral artery; NWSSA = normalized WSSA; OSI = oscillatory shear index; PHASES = population, hypertension, age, size, earlier rupture, and site; RRT = relative resident time; sIA = stable IA; SR = size ratio; uIA = unstable IA; WSS = wall shear stress; WSSA = WSS average.

Supplementary Materials

    • Supplementary Tables and Figs (PDF 4,450 KB)

Schematics of transseptal interforniceal resection of a superiorly recessed colloid cyst. ©Mark Souweidane, published with permission. See the article by Tosi et al. (pp 813–819).

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