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Unruptured Aneurysms
G Narenthiran
L Alakandy
J P Holland
Greater Manchester Neurosciences CentreHope Hospital
Salford
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Tools for estimating the
Life-time risk of rupture
&
Effect of intervention on life-expectancy
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Unruptured aneurysms
• Increasing numbers being diagnosed
• 45% - 80% of patients with ruptured aneurysm may die
• Not all rupture
• Treatment morbidity 0-16%; mortality 0-25%
• Treat those at high risk of rupture
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ISUIA 2003
• Prospective• Multi-centre• 1692 patients did not have treatment• Selection bias• Not randomised• Aneurysms < 2mm not included• Mean duration of follow-up was 4.5 years• Patients who subsequently underwent treatment
excluded from analysis• Included only North America and Europe
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ISUIA, 2003
• The best we have
• Findings of ISUIA (2003), could be incorporated into the global view of UIA
• Considered along with other data pertaining to the patient
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Objective
• Tools for calculating rapidly at:
• Neurovascular MDT meetings• Clinics
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Method
Cumulative risk (%) = 100 x {1- [(1-annual risk)/100]^years}
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Maths of Probability
100
98
2
1.96
96.4
100 × 0.98
100 × 0.98 × 0.98
100 × 0.98 × 0.98 × 0.98
100 × (risk of no-rupture) yearsChance of non-rupture =
Chance of rupture = 100 – chance of no-rupture
Annual risk of rupture = 2%
Annual risk of no-rupture = 98%
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Calculation: Simple Vs Actual
Simple Actual
1% annual risk over 10
years10 9.6
3 % annual risk over 20
years60 46
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Updated ISUIA (2003)< 7 < 7 7-12 13-24 ≥25
Group 1
Group 2
Cavernous carotid
0 0 0 3% 6.4%
AC/MC/IC 0 1.5% 2.6% 14.5% 40%
Post-P comm
2.5% 3.4% 14.5% 18.4 % 50%
5 year cumulative rupture rate. Wiebers DO et al. Lancet 2003; 362: 103-10
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Annual risk of rupture of unruptured aneurysm
< 7 < 7 7-12 13-24 >=25
Group 1
Group 2
Cavernous carotid
0 0 0 0.6 1.3
AC/MC/IC 0 0.3 0.5 3.1 9.7
Post-P comm
0.5 0.7 3.1 4 13
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Risk of Intervention Vs natural history
• The Risk of intervention is immediate
• Risk of natural history is distributed over the life-time
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Need to take into out those who will have a good outcome
following rupture
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Life table
• Life-expectancy tables for 2001-2003
• Constructed abridged life-tables
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Look-up tables
• ‘Actuarial-type’ table
• Gender specific
• Calculations performed using Microsoft® Excel® 2003
• Table laid out using Adobe® Illustrator CS2® and Adobe® InDesign CS2®
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‘Hope’ calculator
• Life-time risk of rupture of unruptured aneurysms
• Effect of intervention on the life-expectancy
• Software developed with Macromedia® Flash 8®
• Both Windows and Mac compatible
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55 year old male with sah with an incidental 5 mm Acomm Aneurysm
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A 50 year old female with 8 mm rt. PICA aneurysm
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A 45 year lady with 8 mm MCA aneurysm
A 60 year male with 13 mm basilar artery aneurysm
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Acknowledgements
• Mr Leggate, Mr King
• Mr Hutchinson, Dr Laitt
• Mr West, Mr Richardson, Miss Pickett, Dr Hughes, Dr Herdwardkar
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Acknowledgements
Mr Kirkpatrick, Mr Laing
Professor Mendelow, Mr MitchellProfessor Harbaugh (Penn State)
Professor Wiebers (Mayo Clinic)
Professor Tamargo (Johns Hopkins)
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Questions?Questions?
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