Factors influencing management of unruptured intracranial aneurysms: an analysis of 424 consecutive patients.

OBJECTIVE The choice between treating and observing unruptured intracranial aneurysms is often difficult, with little guidance on which variables should influence decision making on a patient-by-patient basis. Here, the authors compared demographic variables, aneurysm-related variables, and comorbidities in patients who received microsurgical or endovascular treatment and those who were conservatively managed to determine which factors push the surgeon toward recommending treatment. METHODS A retrospective chart review was conducted of all patients diagnosed with an unruptured intracranial aneurysm at their institution between January 1, 2013, and January 1, 2016. These patients were dichotomized based on whether their aneurysm was treated. Demographic, geographic, socioeconomic, comorbidity, and aneurysm-related information was analyzed to assess which factors were associated with the decision to treat. RESULTS A total of 424 patients were identified, 163 who were treated surgically or endovascularly and 261 who were managed conservatively. In a multivariable model, an age < 65 years (OR 2.913, 95% CI 1.298-6.541, p = 0.010), a lower Charlson Comorbidity Index (OR 1.536, 95% CI 1.274-1.855, p < 0.001), a larger aneurysm size (OR 1.176, 95% CI 1.100-1.257, p < 0.001), multiple aneurysms (OR 2.093, 95% CI 1.121-3.907, p = 0.020), a white race (OR 2.288, 95% CI 1.245-4.204, p = 0.008), and living further from the medical center (OR 2.125, 95% CI 1.281-3.522, p = 0.003) were all associated with the decision to treat rather than observe. CONCLUSIONS Whereas several factors were expected to be considered in the decision to treat unruptured intracranial aneurysms, including age, Charlson Comorbidity Index, aneurysm size, and multiple aneurysms, other factors such as race and proximity to the medical center were unanticipated. Further studies are needed to identify such biases in patient treatment and improve treatment delineation based on patient-specific aneurysm rupture risk.

[1]  A. Zonderman,et al.  Race, Neighborhood Economic Status, Income Inequality and Mortality , 2016, PloS one.

[2]  F. Arikan,et al.  Prognosis of patients in coma after acute subdural hematoma due to ruptured intracranial aneurysm , 2016, Journal of Clinical Neuroscience.

[3]  X. Lv,et al.  Risk Score for Neurological Complications After Endovascular Treatment of Unruptured Intracranial Aneurysms , 2016, Stroke.

[4]  T. Mayer,et al.  The unruptured intracranial aneurysm treatment score: A multidisciplinary consensus , 2016, Neurology.

[5]  A. Molyneux,et al.  Risk Analysis of Unruptured Intracranial Aneurysms: Prospective 10-Year Cohort Study , 2016, Stroke.

[6]  Abby J. Isaacs,et al.  Clipping and Coiling of Unruptured Intracranial Aneurysms Among Medicare Beneficiaries, 2000 to 2010 , 2015, Stroke.

[7]  E. Connolly,et al.  Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2015, Stroke.

[8]  M. Boakye,et al.  Effect of Insurance and Racial Disparities on Outcomes in Traumatic Brain Injury , 2015, Journal of Neurological Surgery—Part A.

[9]  T. Krings,et al.  Natural History and Outcome After Treatment of Unruptured Intradural Fusiform Aneurysms , 2014, Stroke.

[10]  N. Sanossian,et al.  Racial and socioeconomic disparities in incidence of hospital-acquired complications following cerebrovascular procedures. , 2014, Neurosurgery.

[11]  S. Juvela,et al.  Lifelong Rupture Risk of Intracranial Aneurysms Depends on Risk Factors: A Prospective Finnish Cohort Study , 2014, Stroke.

[12]  E. Connolly,et al.  Variability in Outcome After Elective Cerebral Aneurysm Repair in High-Volume Academic Medical Centers , 2014, Stroke.

[13]  J. Raymond,et al.  Uncertainty and agreement in the management of unruptured intracranial aneurysms. , 2014, Journal of neurosurgery.

[14]  T. Schweizer,et al.  Behavioral profile of unruptured intracranial aneurysms: a systematic review , 2014, Annals of clinical and translational neurology.

[15]  D. Flum,et al.  Shared decision-making for cancer care among racial and ethnic minorities: a systematic review. , 2013, American journal of public health.

[16]  V. Seifert,et al.  Natural History of Small Unruptured Anterior Circulation Aneurysms: A Prospective Cohort Study , 2013, Stroke.

[17]  S. Juvela,et al.  Natural History of Unruptured Intracranial Aneurysms: A Long-term Follow-up Study , 2013, Stroke.

[18]  S. Missios,et al.  Regional and socioeconomic disparities in the treatment of unruptured cerebral aneurysms in the USA: 2000–2010 , 2013, Journal of NeuroInterventional Surgery.

[19]  C. Sohn,et al.  A retrospective analysis on the natural history of incidental small paraclinoid unruptured aneurysm , 2013, Journal of Neurology, Neurosurgery & Psychiatry.

[20]  H. Cloft,et al.  Racial and Ethnic Disparities in the Treatment of Unruptured Intracranial Aneurysms: A Study of the Nationwide Inpatient Sample 2001–2009 , 2012, Stroke.

[21]  G. Rinkel,et al.  Quality of Life, Anxiety, and Depression in Patients With an Unruptured Intracranial Aneurysm With or Without Aneurysm Occlusion , 2012, Neurosurgery.

[22]  A. Algra,et al.  Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis , 2011, The Lancet Neurology.

[23]  Ning Lin,et al.  Treatment of ruptured and unruptured cerebral aneurysms in the USA: a paradigm shift , 2011, Journal of NeuroInterventional Surgery.

[24]  A. Molyneux,et al.  A trial on unruptured intracranial aneurysms (the TEAM trial): results, lessons from a failure and the necessity for clinical care trials , 2011, Trials.

[25]  J. Dimick,et al.  Explaining racial disparities in mortality after abdominal aortic aneurysm repair. , 2009, Journal of vascular surgery.

[26]  D. Spiegelhalter,et al.  Risk of intracranial aneurysm bleeding in autosomal-dominant polycystic kidney disease. , 2007, Kidney international.

[27]  B. Horta,et al.  Risk of rupture in unruptured anterior communicating artery aneurysms: meta-analysis of natural history studies. , 2006, Surgical neurology.

[28]  L. Chan,et al.  Geographic access to health care for rural Medicare beneficiaries. , 2006, The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association.

[29]  John Spencer,et al.  The effects of geography and spatial behavior on health care utilization among the residents of a rural region. , 2005, Health services research.

[30]  Brett M. Kissela,et al.  Subarachnoid Hemorrhage: A Preventable Disease With a Heritable Component , 2002, Stroke.

[31]  J. Tu,et al.  Effect of Socioeconomic Status on Treatment and Mortality After Stroke , 2002, Stroke.

[32]  P. Austin,et al.  Effects of socioeconomic status on access to invasive cardiac procedures and on mortality after acute myocardial infarction. , 1999, The New England journal of medicine.

[33]  Didier Martin,et al.  Unruptured intracranial aneurysms--risk of rupture and risks of surgical intervention. , 1998, The New England journal of medicine.

[34]  A. Algra,et al.  Prevalence and risk of rupture of intracranial aneurysms: a systematic review. , 1998, Stroke.

[35]  C. Mackenzie,et al.  A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. , 1987, Journal of chronic diseases.