Serial Screening for Cerebral Aneurysm Fruitful

Megan Brooks

May 05, 2014

Long-term, serial screening for intracranial aneurysms should be considered in adults with at least 2 first-degree relatives with aneurysmal subarachnoid hemorrhage (aSAH), say researchers from the Netherlands.

The yield of long-term screening is "substantial even after more than 10 years of follow-up and 2 initial negative screens," A. Stijntje Bor, MD, from the Department of Neurology, Leiden University Medical Center, and colleagues report.

"Persons with ≥2 first degree relatives with aSAH who wish screening for unruptured intracranial aneurysms, should receive repeated screening rather than a single screening, as an aneurysm was identified in more than 20% of individuals who were screened again at least 10 years after the initial screening," Dr. Bor told Medscape Medical News.

"Screening may be started in early adulthood, and should be repeated regardless the results of previous screening, until the age of around 70 years," Dr. Bor said.

"Best" Available Evidence

The researchers reviewed the results during 20 years (1993–2013) of screening done at University Medical Centre Utrecht for cerebral aneurysms in individuals aged 16 and older with a positive family aSAH (2 or more first-degree relatives who had had aSAH or unruptured intracranial aneurysms).

Dr. A. Stijntje Bor

Screening was offered after a conversation about possible adverse effects and modifiable risk factors and was mostly done with magnetic resonance angiography. After a negative screen, individuals were advised to come back after 5 years for repeated screening, but they were not actively called back.

The study is published in the April issue of Lancet Neurology.

The researchers identified aneurysms in 51 (11%) of 458 individuals at first screening, in 21 (8%) of 261 at second screening, in 7 (5%) of 128 at third screening, and in 3 (5%) of 63 at fourth screening. Five (3%) of 188 individuals without a history of aneurysms and with 2 negative screens had a de novo aneurysm on a follow-up screen.

On multivariate analysis, modifiable risk factors for aneurysm on first screening were smoking (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.2 - 5.9), history of aneurysms (OR, 3.9; 95% CI, 1.2 - 12.7), and high familial burden of aneurysms (OR, 3.5; 95% CI, 1.6 - 8.1).

Dr. Bor told Medscape Medical News that individuals with 2 or more first-degree relatives with aSAH "should be referred to a neurologist/neurosurgeon to be properly informed on their risks of having an aneurysm and aSAH, on the possibility and the pros and cons of screening. If a person with ≥2 first-degree relatives with aSAH decides to start screening for unruptured intracranial aneurysms, screening should be repeated rather than single."

Limitations and Caveats

"This cohort is unique and the information provided by this series represents the best available information about screening for aSAH," writes Andrew J. Molyneux, from Nuffield Department of Surgical Sciences, University of Oxford, United Kingdom, in a linked Comment in Lancet Neurology.

He notes that information about the total number of observational person-years for this cohort is unavailable, "so the risk of aSAH cannot be put into an overall temporal risk context."

In addition, he says a key question that this paper does not address is the potential number of aSAH and the associated morbidity and mortality that might have been prevented by the strategy adopted.

"Future studies from this cohort of relatives might include some estimates of the expected number of aSAH events in the population screened, compared with the actual number, and further refinement of a cost-effectiveness modeling of the strategy," Dr. Molyneux concludes.

Not Standard of Care

Reached for comment, Joseph Broderick, MD, from the Department of Neurology, University of Cincinnati, Ohio, said adults at high risk for cerebral aneurysm are "usually offered at least 1 screening and encouraged strongly to stop smoking and control [blood pressure].  However, repeat screening as in this article is often not done as in this study."

"Family members with more than 1 affected member with intracranial aneurysm should be screened. [It's] less clear about repeat screening but for young people and those who are smoking and have hypertension, repeat screening at 5-year intervals is reasonable but not standard of care," Dr. Broderick said.

In a review article also published in Lancet Neurology, Dr. Broderick and Robert D. Brown Jr, MD, from the Department of Neurology, Mayo Clinic, Rochester, Minnesota, summarize the epidemiology, natural history, management options, and familial screening for unruptured intracranial aneurysms.

The study by Dr. Bor and colleagues was funded by the Dutch Heart Foundation. The authors have disclosed no relevant financial relationships. Disclosures for Dr. Molyneux, Dr. Brown, and Dr. Broderick are listed with original articles.

Lancet Neurol. 2014;13:343-344, 385-392, 393-404. Comment Study abstract Review

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