ENS 2009: Screen for Aneurysm in Those With Strong Family History

Allison Gandey

July 07, 2009

July 7, 2009 (Milan, Italy) — Patients with 2 or more first-degree relatives with cerebral aneurysm should be screened, suggest experts. Presenting here at the 19th Meeting of the European Neurological Society, specialists explained that while screening is not always a good idea, it is warranted for higher-risk patients.

Those with autosomal dominant polycystic kidney disease should also be considered good candidates for screening, presenter Gabriel Rinkel, MD, from the University Medical Center in Utrecht, the Netherlands, said at the meeting.

"Unruptured intracranial aneurysms are present in around 2% of the population," Dr. Rinkel said. "They may rupture in the near or distant future, and sometimes these lesions warrant preventive intervention by means of coiling or surgical clipping."

Genetic Determinants

Factors that determine the risk for rupture include size and site of the aneurysm and family history. "Genetic determinants are likely to play a role in the development of intracranial aneurysms," said session chair José Ferro, MD, from the University of Lisbon, in Portugal.

Dr. Ferro is president of the European Neurological Society. "We now know that individuals with 2 or more affected first-degree relatives have a high risk and therefore should be screened. In people with only 1 affected relative, screening seems not to be efficient or effective," he said.

Speaking during the presidential symposium, Dr. Rinkel pointed out that careful counseling and weighing the pros and cons is very important when screening for aneurysms is considered. "Screenees often have unrealistic risk perceptions, and screening for intracranial aneurysms is associated with considerable psychosocial effects, both positive and negative," he said.

Risks include the anxiety before screening and distress that can be caused by finding an aneurysm, Dr. Rinkel explained. If a first screen is negative, repeated screening should be discussed.

"But if an incidental aneurysm is detected," he emphasized, "it is important to refrain from descriptions such as 'a time bomb in your head.' "

Intervention May Do More Harm

Dr. Rinkel pointed out that in many situations, uncertainty abounds. In some cases, intervention will probably do more harm than good, he noted. "Follow-up imaging to detect growth of the aneurysm is often advised, but data on frequency and effectiveness of this strategy are lacking."

Presenters advised that clinicians carefully balance the risks and benefits of all treatment options and take the time to thoughtfully counsel patients. Age, Dr. Rinkel said, is the most important factor, because at a young age the benefit of treatment can be great and the risk relatively small.

But for many patients, he suggests that no intervention is the best option, even though having to live with an untreated aneurysm can impose a threat to quality of life.

Patients with no family history and no polycystic kidney disease who have survived an episode of hemorrhage are at increased risk for a new episode from a new aneurysm or from recurrence of the treated aneurysm, but screening for new aneurysms is not recommended, Dr. Rinkel said. "But it can be considered in patients — especially women — with an initial episode at a very young age and with multiple aneurysms at time of first hemorrhage."

Main risk factors for rupture are female sex, a positive family history, polycystic kidney disease, a previous ruptured aneurysm, increasing age, smoking, hypertension, and alcohol abuse.

The researchers have disclosed no relevant financial relationships.

19th Meeting of the European Neurological Society: Presidential Symposium, Abstract 3. Presented June 22, 2009.