Patients with saccular untreated ruptured intracranial aneurysms were identified from the Chinese Multicenter Cerebral Aneurysm Database, a multicenter, prospective, observational database registered in China, which involved 32 tertiary medical centers covering 4 northern Chinese provincial regions. Patients with intracranial aneurysms, regardless of ruptured status, shape, age, or comorbidities, were consecutively included in 12 of 32 medical centers between 2017 and 2020. Survival probabilities were computed using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were conducted to determine the risk factors for the cumulative 2-year mortality. We analyzed the reasons for treatment decisions stratified by demographic characteristics and clinical features.
For 941 enrolled patients, 58.6% of patients died within 1 month of symptom onset; and 68.1% within 2 years. 98 patients underwent surgical repair during follow-up. Multivariate Cox regression analysis identified Hunt and Hess grades 3 to 5 (hazard ratio, 1.54 [95% CI, 1.01-2.35]; P=0.047), loss of consciousness at symptom onset (hazard ratio, 1.56 [95% CI, 1.18-2.07]; P=0.002), and largest aneurysm size of ≥5 mm (hazard ratio, 1.29 [95% CI, 1.05-1.59]; P=0.014) as mortality predictors during the 2-year follow-up. Among patients who were successfully followed up, 42.6% (280) of them refused surgical treatment.
Patients with poor Hunt and Hess grades, loss of consciousness at symptom onset, or largest aneurysms ≥5 mm in size showed a high mortality rate. A high number of treatment refusals was present in this study. These findings have implications for medical insurance policy, doctor-patient communication, and popular science education 1)
Cerebrovascular atherosclerotic stenosis (CAS) and intracranial aneurysm (IA) have a common underlying arterial pathology and common risk factors, but the clinical significance of CAS in IA rupture (IAR) is unclear. A study of Feng et al. aimed to investigate the effect of CAS on the risk of IAR.
A total of 336 patients with 507 sacular IAs admitted at our center were included. Univariable and multivariable logistic regression analyses were performed to determine the association between IAR and the angiographic variables for CAS. We also explored the differences in CAS in patients aged <65 and ≥65 years.
In all the patient groups, moderate (50%-70%) cerebrovascular stenosis was significantly associated with IAR (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.8-6.5). Single cerebral artery stenosis was also significantly associated with IAR (OR, 2.3; 95% CI, 1.3-3.9), and intracranial stenosis may be a risk factor for IAR (OR, 1.8; 95% CI, 1.0-3.2). In addition, IAs with lobulation may be at a higher risk for rupture than IAs with regular shape (OR, 2.6; 95% CI, 1.1-5.8; P = 0.026), although the same was not true of aneurysms with a daughter sac (OR, 1.8; 95% CI, 0.9-3.7; P = 0.098). Bifurcation location (OR, 2.4; 95% CI, 1.5-3.8; P < 0.001) was significantly associated with aneurysmal rupture. For the patient subgroup aged <65 years, rupture risk was higher for aneurysms with moderate stenosis (OR, 3.4; 95% CI, 1.8-6.5). For patients aged ≥65 years, single-artery stenosis (OR, 1.9; 95% CI, 1.2-3.0) was statistically associated with IAR.
They observed substantial differences in the severity of atherosclerotic stenosis, parent-artery stenosis, number of stenotic arteries, and intracranial/extracranial stenosis as indicators between ruptured and unruptured aneurysms. CAS is significantly associated with the risk of intracranial aneurysm rupture, whether in patients aged ≥65 years or <65 years. These findings indicate the clinical significance of CAS in IAR 2).
The outcomes at discharge for ruptured cerebral aneurysms after subarachnoid hemorrhage (SAH) were investigated using data from the Japanese stroke databank. Among 101,165 patients with acute stroke registered between 2000 and 2013, 4693 patients had SAH caused by ruptured saccular aneurysm. Of these, 3593 patients (1140 men and 2453 women; mean age 61.3 ± 13.7 years) were treated by surgical clipping (SC) and/or endovascular coiling (EC). The outcomes of modified Rankin scale (mRS) at discharge were compared between the SC and EC groups. There were 2666 cases in the SC group, 881 cases in the EC group, and 46 cases in the SC and EC group. The rates of poor outcome of mRS > 2 were 33.0 and 45.5% in the SC and EC groups (p < 0.05), respectively. Cases were selected using two types of criteria compatible with both treatments. Under the first compatible criteria, the rates of poor outcome of mRS > 2 were 18.9 and 24.8% in the SC and EC groups (p < 0.05), respectively. Under the second compatible criteria, the rates of poor outcome of mRS > 2 were 16.0 and 14.8% in the SC and EC groups (p = 0.22), respectively. No significant differences were found in clinical characteristics or outcomes between the two groups. Multivariate analysis of aneurysmal SAH revealed no significant risk for poor outcome associated with the treatment method. The present study was not a randomized controlled study, but no significant differences in mRS at discharge were found between SC and EC in the Japanese stroke databank 3).
3210 patients underwent treatment for ruptured intracranial aneurysms. Of these patients, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the 1st year after admission for subarachnoid hemorrhage (SAH) were $113,000 (IQR $77,500-$182,000) for surgical clipping and $103,000 (IQR $72,900-$159,000) for endovascular coiling. When the authors adjusted for unmeasured confounding factor by using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI $4492-$34,663).
In this cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, surgical clipping was associated with increased 1-year expenditures in comparison with endovascular coiling 4).