Elsevier

The Lancet Neurology

Volume 4, Issue 2, February 2005, Pages 122-128
The Lancet Neurology

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Intracranial aneurysm screening: indications and advice for practice

https://doi.org/10.1016/S1474-4422(05)00993-2Get rights and content

Summary

The advent of non-invasive methods of imaging intracranial blood vessels has facilitated screening for intracranial aneurysms in people who are at risk. A strong risk factor for intracranial aneurysm, which causes subarachnoid haemorrhage, is a positive family history, defined as two or more first-degree relatives with subarachnoid haemorrhages (relative risk [RR]=6·6). The greatest familial risk is associated with an affected sibling. Another strong risk factor is polycystic kidney disease (RR=4·4). People who have these risk factors are potential candidates for screening. Even if screening does not find abnormality, there is a high risk of new aneurysms 5 years later. Repeated screening might be done, although the optimum interval between screening assessments and the duration of repeated screening is unclear. Patients who have survived a subarachnoid haemorrhage are at increased risk of another from a newly developed aneurysm, but whether screening is beneficial in such patients is not clear. Most occurrences of subarachnoid haemorrhage in the general population are related to the more common risk factors of hypertension (RR=2·8) and smoking (RR=1·9). Therefore, screening of individuals who have a family history of subarachnoid haemorrhage or polycystic kidney disease will have little effect on the incidence of subarachnoid haemorrhage in the general population. When patients present for screening, the construction of a family tree and discussion of the history of relatives with stroke can be revealing. Before referring a patient for non-invasive imaging of the circle of Willis, the physician should discuss the risks and benefits of screening, the implications for holding a licence to drive or fly and for life insurance, and whether or not the patient wants to be informed about other incidental findings.

Section snippets

Risk factors

Factors associated with the risk of intracranial aneurysm and subarachnoid haemorrhage can be classified as modifiable or non-modifiable. Risk factors that can be modified include active smoking, hypertension, excessive alcohol consumption, and possibly the use of oestrogens.1, 2, 3, 4, 5, 6, 7 Some case-control studies also found that intake of coffee and use of cocaine are associated with increased risk,8, 9 but more studies are needed before individuals with additional risk factors for

Risks and consequences for treatment

The goal of screening is not to detect or to treat an aneurysm, but to increase the number of quality years of life. Therefore, before intracranial vessels are imaged, the risks and benefits of screening should be weighed. This process includes calculation of the risks of diagnostic procedures and treatment and the gain in life expectancy by preventive treatment of aneurysms detected by screening. But the assessment of risks should also include the amount of anxiety before screening, the

Search strategy and selection criteria

The MEDLINE database was searched with the terms “intracranial aneurysm”, “subarachnoid hemorrhage”, “screening”, “family”, “polycystic kidney disease”, and “risk factor” for articles published between 2000 and July 2004.

References (69)

  • P Hager et al.

    Identical cerebral aneurysms in siblings: report of two families

    J Clin Neurosci

    (2004)
  • LL Teunissen et al.

    Risk factors for subarachnoid hemorrhage: a systematic review

    Stroke

    (1996)
  • SC Johnston et al.

    Rapid development of giant fusiform cerebral aneurysms in angiographically normal vessels

    Neurology

    (1998)
  • CN Mhurchu et al.

    Hormonal factors and risk of aneurysmal subarachnoid hemorrhage: an international population-based, case-control study

    Stroke

    (2001)
  • AI Qureshi et al.

    Risk factors for subarachnoid hemorrhage

    Neurosurgery

    (2001)
  • BM Kissela et al.

    Subarachnoid hemorrhage: a preventable disease with a heritable component

    Stroke

    (2002)
  • H Ohkuma et al.

    Risk factors for aneurysmal subarachnoid hemorrhage in Aomori, Japan

    Stroke

    (2003)
  • CS Anderson et al.

    Active and passive smoking and the risk of subarachnoid hemorrhage: an international population-based case-control study

    Stroke

    (2004)
  • J Isaksen et al.

    Risk factors for aneurysmal subarachnoid haemorrhage: the Tromso study

    J Neurol Neurosurg Psychiatry

    (2002)
  • JP Broderick et al.

    Major risk factors for aneurysmal subarachnoid hemorrhage in the young are modifiable

    Stroke

    (2003)
  • GJE Rinkel et al.

    Prevalence and risk of rupture of intracranial aneurysms: a systematic review

    Stroke

    (1998)
  • JEC Bromberg et al.

    Subarachnoid haemorrhage in first and second degree relatives of patients with subarachnoid haemorrhage

    BMJ

    (1995)
  • YM Ruigrok et al.

    Attributable risk of common and rare determinants of subarachnoid hemorrhage

    Stroke

    (2001)
  • TWM Raaymakers

    Aneurysms in relatives of patients with subarachnoid hemorrhage: frequency and risk factors

    Neurology

    (1999)
  • YM Ruigrok et al.

    Characteristics of intracranial aneurysms in patients with familial subarachnoid hemorrhage

    Neurology

    (2004)
  • JEC Bromberg et al.

    Familial subarachnoid hemorrhage: distinctive features and patterns of inheritance

    Ann Neurol

    (1995)
  • PM Struycken et al.

    Anticipation in familial intracranial aneurysms in consecutive generations

    Eur J Hum Genet

    (2003)
  • MJ Wermer et al.

    Repeated screening for intracranial aneurysms in familial subarachnoid hemorrhage

    Stroke

    (2003)
  • WI Schievink et al.

    Saccular intracranial aneurysms in autosomal dominant polycystic kidney disease

    J Am Soc Nephrol

    (1992)
  • EW Gieteling et al.

    Characteristics of intracranial aneurysms and subarachnoid haemorrhage in patients with polycystic kidney disease

    J Neurol

    (2003)
  • J Huston et al.

    Value of magnetic resonance angiography for the detection of intracranial aneurysms in autosomal dominant polycystic kidney disease

    J Am Soc Nephrol

    (1993)
  • D Chauveau et al.

    Recurrent rupture of intracranial aneurysms in autosomal dominant polycystic kidney disease

    BMJ

    (1990)
  • MG Pepin et al.

    Clinical and genetic features of Ehlers-Danlos syndrome type IV, the vascular type

    N Engl J Med

    (2000)
  • JSP van den Berg et al.

    Type III collagen deficiency in saccular intracranial aneurysms: defect in gene regulation?

    Stroke

    (1999)
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