International Stroke Conference
January 24–26

Kaustubh Limaye, MD

Management of unruptured aneurysms continues to be a clinical conundrum. This session at ISC 2018 was geared toward identifying better strategies for identifying patients at higher risk of rupture and selecting appropriate management modalities.

The session started with a talk by Dr. Mervyn Vergouwen, who discussed risk factors for aneurysm growth and rupture. He discussed the prevalence of aneurysm to be 3% of the world population. “Growth predicts rupture,” he said. What to do: treat or wait and scan? Weigh risk of rupture and risk of treatment. He discussed the PHACES and ELAPSS studies, highlighting the important features and also the important predictors of aneurysm rupture that were excluded from these studies, like data on smoking, familial history and aneurysm morphology. “Risk predicting scores are the beginning and not the end,” he said. Multiple factors, rather than just diameter or location, should be included in deciding treatment.

This talk was followed by new imaging modalities for evaluation of unruptured aneurysms by Dr. Waleed Brinjikji. He discussed the important pathophysiologic triad of 1. Inflammation 2. Structural degradation 3. Hemodynamics in aneurysm formation and rupture. He talked about aneurysm wall enhancement techniques, which use magnetic resonance imaging as a modality with gadolinium contrast as a tool in predicting stable vs. non-stable unruptured aneurysm with a negative predictive value of 96.2. He also talked about aneurysm flow data while highlighting high wall shear involvement in formation of aneurysm and low wall shear involvement in rupture. He concluded his talk with a discussion on use of optical imaging utility in flow diverter treatment.

Dr. Ajay Wakhloo discussed fundamental principles for newer technologies with relation to hydrodynamic forces, endothelialization and implant fatigue. He went on to discuss current concepts and products like endoluminal implants (flow diverter, covered stents), neck bridging implants (stents, stent-like implants) and endovascular implants (complex coils, endosaccular mesh).

The session’s concluding talk was by Dr. Nima Etminan, who discussed the limited data to guide endovascular vs. surgical repair of unruptured aneurysms. He again highlighted the importance of risk of rupture vs. risk of treatment. He discussed the prospective randomized open-label trial to evaluate risk factor or management in patients with unruptured intracranial aneurysms (PROTECT-U). This study is currently enrolling patients and plans to enroll 776 patients. The primary endpoint of this study is aneurysm rupture or growth on serial imaging at set intervals. In his final remarks, Dr. Etminan emphasized an interdisciplinary team approach and local surgical expertise in addition to other targets like aneurysm wall inflammation and hypertension control of importance in planning care of individual patients.