International Stroke Conference
February 6–8, 2019
Kat Dakay, DO
One of the talks I was most looking forward to at ISC 2019 was the invited symposium titled “What Do I Do with this Aneurysm?” As advanced imaging allows for the detection of smaller and smaller aneurysms, many of them incidental, this is becoming a more challenging and pertinent topic.
This symposium, moderated by Dr. Sepideh Amin-Hanjani, MD, co-director of neurovascular surgery at the University of Illinois, was a lively discussion incorporating both neuroendovascular and open neurosurgical approaches to aneurysm treatment.
First, Dr. Mervyn Vergouwen, MD, PhD, from UMC Utrecht, began the symposium with a lecture titled “What Aneurysms Should I Treat?” He discussed patient-specific factors such as patient preference and life expectancy/comorbidities, as well as the challenging task of weighing the risk of aneurysmal rupture versus the risk of aneurysm treatment complications. One scoring system mentioned during the lecture was the PHASES score (published in Lancet Neurology in 2014 by Greving et al.), a score developed to approximate the five-year risk of rupture in an unruptured aneurysm; this score takes into account both patient-specific characteristics such as age and hypertension, as well as aneurysm-specific characteristics such as size and location. He discussed also considering the risk of the treatment approach — e.g., stent-assisted coiling versus coiling alone — when deciding whether to treat or observe an asymptomatic aneurysm.
Subsequently, Dr. Giuseppe Lanzino from the Mayo Clinic focused on aneurysms in which monitoring may be appropriate ,as well as the paradox that most unruptured aneurysms do not rupture but that most ruptured aneurysms are small. He also spoke about data suggesting that aneurysms may be at their highest risk shortly after their formation, and that may be why small aneurysms rupture and also why the highest rupture risk is in the first year after diagnosis.
Dr. Andrew Ducruet, MD, endovascular neurosurgeon at Barrow Neurological Institute, talked about the role for clipping in certain aneurysms and highlighted diverse neurosurgical and neuroendovascular opinions on treatment approach. Though some notable exceptions were illustrated in examples given in the lecture, some general trends were that MCA aneurysms were often favored for clipping and basilar aneurysms often treated endovascularly; additionally, a difficult spatial orientation for endovascular access and close proximity to branching vessels may influence a decision towards clipping.
To close the symposium, Dr. Vanessa Chalumeau, from the department of neurointerventional radiology at the Rothschild Foundation in Paris, presented on new-generation devices such as the WEB intrasaccular aneurysm device, an ellipsoid device deployed endovascularly into the aneurysm sac, as well as flow-diverting stents.
This was an excellent and interactive discussion on the complexity of decision-making with regards to aneurysm treatment. One striking theme of the four talks was the complexity of this decision-making — there are many features that the treating physician must take into account: patient-specific attributes such as life expectancy and behaviors such as smoking that can increase risk, patient preference, aneurysm characteristics including size and location, and the method and risk of treatment. Additionally, there are aneurysm-specific features that are not easily accounted for in a risk score such as spatial orientation, morphology, proximity to branching vessels, and presence of thrombus, amongst others, that are also important to factor into decision-making.
Further reading:
- PHASES score: https://doi.org/10.1016/S1474-4422(13)70263-1
- Aneurysm Rupture Risk Highest in First Year: https://doi.org/10.3171/2012.3.JNS111221, https://doi.org/10.3171/2012.1.JNS129
- WEB (Woven Endo Bridge) device, a technical note in JNIS: https://doi.org/10.1136/neurintsurg-2018-014343
