{"id":783,"date":"2016-11-02T16:10:46","date_gmt":"2016-11-02T16:10:46","guid":{"rendered":"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/?p=783"},"modified":"2016-11-03T14:44:41","modified_gmt":"2016-11-03T14:44:41","slug":"intracranial-aneurysms-non-neurosurgical-provider-primer-series-part-2","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/2016\/11\/02\/intracranial-aneurysms-non-neurosurgical-provider-primer-series-part-2\/","title":{"rendered":"Intracranial Aneurysms for the Non-Neurosurgical Provider: Primer Series (Part 2)"},"content":{"rendered":"<div style=\"width: 135px\" class=\"wp-caption alignright authorPic\"><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2016\/08\/AU000_bbelcher.jpg\" alt=\"Bianca Belcher, MPH, PA-C\" width=\"125\" height=\"150\" align=\"left\" \/><p class=\"wp-caption-text\"><\/p>\n<p><\/p>\n<p class=\"wp-caption-text\">Bianca Belcher, MPH, PA-C, practices neurosurgery in Boston, MA.<\/p>\n<p>&nbsp;<\/p>\n<p><\/p><\/div>\n<p>In Part 2 of this primer series on intracranial aneurysms for non-neurosurgical providers, I will discuss modifiable and non-modifiable patient risk factors for subarachnoid hemorrhage (SAH) during intracranial aneurysm treatment.<\/p>\n<p><strong><u>Modifiable Risks:<\/u><\/strong><\/p>\n<p><strong>Hypertension (HTN)[1]<\/strong><\/p>\n<ul>\n<li>Patients with mild-moderate HTN (defined by systolic blood pressure of\u00a0130-169 mmHg) have a hazard risk (HR) of 2.3 for SAH compared with patients with SBP &lt;130.<\/li>\n<li>Patients with severe HTN (SBP &gt;170 mmHg) have an HR of 3.3.<\/li>\n<li>The risk trend is similar for diastolic blood pressure.<\/li>\n<\/ul>\n<p><strong>Smoking[1]<\/strong><\/p>\n<ul>\n<li>Former smokers have an HR of 2.7 compared with patients who have never smoked.<\/li>\n<li>Current smokers have an HR of 6.1 in the same comparison.<\/li>\n<\/ul>\n<p><strong>Cocaine Use[2]<\/strong><\/p>\n<ul>\n<li>Cocaine use is associated with aneurysm risk in a younger population and in small vessels.<\/li>\n<li>Cocaine-related aneurysms have a higher mortality than others.<\/li>\n<\/ul>\n<div id=\"attachment_790\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2016\/11\/Biancas-neuro-team.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-790\" class=\"size-medium wp-image-790\" src=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2016\/11\/Biancas-neuro-team-300x199.jpg\" alt=\"Dr. Ali Aziz Sultan and Dr. Ramsey Ashour preparing for an endovascular procedure\" width=\"300\" height=\"199\" srcset=\"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2016\/11\/Biancas-neuro-team-300x199.jpg 300w, https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2016\/11\/Biancas-neuro-team-768x510.jpg 768w, https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-content\/uploads\/sites\/8\/2016\/11\/Biancas-neuro-team.jpg 960w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-790\" class=\"wp-caption-text\">Dr. Ali Aziz Sultan and Dr. Ramsey Ashour preparing for an endovascular procedure<\/p><\/div>\n<p><strong><u>Non-modifiable Risks:<\/u><\/strong><\/p>\n<p><strong>Age<\/strong><\/p>\n<ul>\n<li>The incidence of SAH increases with age regardless of gender.[3]<\/li>\n<\/ul>\n<p><strong>\u00a0Gender <\/strong><\/p>\n<ul>\n<li>Females have an HR for rupture of 1.9 compared with males.[1]<\/li>\n<\/ul>\n<p><strong>Personal history of rupture<\/strong><\/p>\n<ul>\n<li>As discussed in <a href=\"http:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/2016\/10\/12\/intracranial-aneurysms-non-neurosurgical-provider-primer-series-part-1\/\">Part 1<\/a>, history of SAH secondary to aneurysm rupture puts patients at a great risk of rupture (HR of 7.3 compared with no personal history of SAH).[4]<\/li>\n<\/ul>\n<p><strong>Genetic\/Connective Tissue Disorders<\/strong><\/p>\n<ul>\n<li>Autosomal dominant polycystic kidney disease<\/li>\n<li>Ehlers-Danlos Syndrome, Type IV (Vascular EDS)<\/li>\n<li>Marfan Syndrome<\/li>\n<li>Neurofibromatosis Type 1<\/li>\n<li>Pseudoxantoma Elasticum<\/li>\n<li>Loeys-Dietz Syndrome<\/li>\n<li>\u03b11 \u2013Antitrypsin Deficiency<\/li>\n<\/ul>\n<p><strong>Associated Conditions<\/strong><\/p>\n<ul>\n<li>Fibromuscular Dysplasia (FMD)<\/li>\n<li>Arteriovenous Malformation<\/li>\n<li>Abdominal Aortic Aneurysm<\/li>\n<li>Sickle Cell Anemia<\/li>\n<\/ul>\n<p><strong>Family history of rupture <\/strong><\/p>\n<ul>\n<li>In patients with polycystic kidney disease and at least one relative with aneurysms are 51 times more likely to have an aneurysm rupture compared with those who have no family history.[5]<\/li>\n<\/ul>\n<p><strong><u>Takeaways:<\/u><\/strong><\/p>\n<ul>\n<li>We should counsel our patients heavily on the things that are within their control (the modifiable risks):\n<ul>\n<li><em>Keep systolic blood pressure normotensive.<\/em><\/li>\n<li><em>Quit smoking if you are a current smoker or don\u2019t start if you aren\u2019t.<\/em><\/li>\n<li><em>Stay clear of cocaine.<\/em><\/li>\n<\/ul>\n<\/li>\n<li>The non-modifiable risks are more useful to the provider \u2014 to help inform decision-making.<\/li>\n<li>You might consider screening patients for aneurysms if they have two <strong>primary<\/strong> relatives with known aneurysms (ruptured or unruptured) OR if they have one of the listed genetic conditions or associated conditions.<\/li>\n<li>Magnetic resonance angiogram (MRA) of the head is the preferred screening tool. Unlike computed tomography with angiography, MRA scans do not expose the patient to radiation and do not require a dye injection.<\/li>\n<li>Screening patients with some of the genetic disorders is controversial since their vessels tend to be more friable, making them more difficult and dangerous to treat.<\/li>\n<\/ul>\n<p>The third and final part of this series will cover available treatment options for intracranial aneurysms.<\/p>\n<p>Note: A special thanks to Dr. Thabele M. Leslie-Mazwi (neuroendovascular and neuro critical care specialist at Massachusetts General Hospital) for his help retrieving some of the studies used in this post.<\/p>\n<p><strong>References<\/strong><\/p>\n<ol>\n<li>Sandvei, e.a., <em>Risk Factors for Aneurysmal Subarachnoid Hemorrhage in a Prospective Population Study: The HUNT Study in Norway.<\/em> Stroke, 2009. 40: p. 1958-1962.<\/li>\n<li>Nanda, A., et al, <em>Intracranial Aneurysms and Cocaine Abuse: Analysis of Prognostic Indicators.<\/em> Neurosurgery, 2000. 46(5): p. 1063-1069.<\/li>\n<li>N K de Rooij, e.a., <em>Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends.<\/em> J Neurol Neurosurg Psychiatry, 2007. 78: p. 1365-1372.<\/li>\n<li>Ishibashi, e.a., <em>Unruptured Intracranial Aneurysms Incidence of Rupture and Risk Factors.<\/em> Stroke, 2009. 40: p. 313-316.<\/li>\n<li>Irazabal, e.a., <em>Extended Follow-Up of Unruptured Intracranial Aneurysms Detected by Presymptomatic Screening in Patients with Autosomal Dominant Polycystic Kidney Disease.<\/em> Clin J Am Soc Nephrol, 2011. 6: p. 1274-1285.<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>In Part 2 of this primer series on intracranial aneurysms for non-neurosurgical providers, I will discuss modifiable and non-modifiable patient risk factors for subarachnoid hemorrhage (SAH) during intracranial aneurysm treatment. Modifiable Risks: Hypertension (HTN)[1] Patients with mild-moderate HTN (defined by systolic blood pressure of\u00a0130-169 mmHg) have a hazard risk (HR) of 2.3 for SAH compared [&hellip;]<\/p>\n","protected":false},"author":1259,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[17,20,29],"tags":[207,357,264],"class_list":["post-783","post","type-post","status-publish","format-standard","hentry","category-clinical-implications-of-research","category-education","category-patient-care","tag-diagnostic-test","tag-intracranial-aneurysm","tag-lifestyle-modification"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/posts\/783","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/users\/1259"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/comments?post=783"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/posts\/783\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/media?parent=783"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/categories?post=783"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/frontlines-clinical-medicine\/wp-json\/wp\/v2\/tags?post=783"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}