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Long-term, serial screening for intracranial aneurysms in individuals with a family history of aneurysmal subarachnoid haemorrhage: a cohort study

Dr A Stijntje E Bor MD, Prof Gabriel J E Rinkel MD, Jeroen van Norden BSc, Marieke J H Wermer MD

The Lancet Neurology 13:4:385-392, 2014. doi:10.1016/S1474-4422(14)70021-3



Individuals with two or more first-degree relatives who have had aneurysmal subarachnoid haemorrhage (aSAH) have an increased risk of aneurysms and aSAH. We investigated the yield of long-term serial screening for intracranial aneurysms in these individuals.



In a cohort study, we reviewed the results of screening of individuals with a positive family history of aSAH (two or more first-degree relatives who had had aSAH or unruptured intracranial aneurysms) done at the University Medical Centre Utrecht (Utrecht, Netherlands) between April 1, 1993, and April 1, 2013. Magnetic resonance angiography or CT angiography was done from age 16—18 years to 65—70 years. After a negative screen, we advised individuals to contact us after 5 years, but did not actively call them for repeated screening. We recorded familial history of ruptured and unruptured intracranial aneurysms, smoking history, hypertension, previous aneurysms, screening dates, and screening results. We identified risk factors for positive initial and follow-up screens with univariable and multivariable regression analysis.



We identified aneurysms in 51 (11%, 95% CI 9—14) of 458 individuals at first screening, in 21 (8%, 5—12) of 261 at second screening, in seven (5%, 2—11) of 128 at third screening, and three (5%, 1—14) of 63 at fourth screening. Five (3%, 95% CI 1—6) of 188 individuals without a history of aneurysms and with two negative screens had a de-novo aneurysm in a follow-up screen. Smoking (odds ratio 2·7, 95% CI 1·2—5·9), history of previous aneurysms (3·9, 1·2—12·7), and familial history of aneurysms (3·5, 1·6—8·1) were significant risk factors for aneurysms at first screening in the multivariable analysis. History of previous aneurysms was the only significant risk factor for aneurysms at follow-up screening (hazard ratio 4·5, 1·1—18·7). Aneurysms were identified in six (5%, 95% CI 2—10) of 129 individuals who were screened before age 30 years. One patient developed a de-novo aneurysm that ruptured 3 years after the last negative screen.



In individuals with a family history of aSAH, the yield of long-term screening is substantial even after more than 10 years of follow-up and two initial negative screens. We advocate long-term serial screening in these individuals, although the risk of aSAH within screening intervals is not eliminated.



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Buy full article here: http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(14)70021-3/fulltext

Comments (4)Add Comment

Need for long-term screening in individuals with family history of aSAH
written by Thomas S, March 19, 2014
Individuals with two or more first-degree relatives, who have had an aSAH, have an increased risk of aSAH. Bor et al present the results from their long-term screening of individuals with a positive family history of cerebral aneurysms.

A positive family history was de“fined as two or more “first-degree relatives (parents, siblings, or children) who had had definite or probable aSAH, or unruptured intracranial aneurysms.

The screenings were done with an interval of five years, i.e. up to 15 years after initial screening.

At first screening aneurysms were found in 11%.
In the second screening aneurysms were found in 8%
Third screening - 5%
Fourth screening - 5%

The authors conclude that the yield in screening in these individuals was about 5% for each follow-up screening in more than 10 years.

How do you do? For individuals with a family history of aneurysm, do you recommend aneurysm screening? Please answer our poll to the right (March -14).
written by Michael Thomas, March 20, 2014
I have had several patients with the genetics of familial aneurysms. In one family mother and two daughters and two sons (4/5 children) had aneurysms that I treated. I screened the entire family when I discovered the mother and daughter both had aneurysms.
written by sharmakchand, March 22, 2014
Aneurysms in brain need more emphasis than what has been done to detect to them. Since first haemorrhage could be fatal, may be a screening by CT Angio or MR angio is must in close relatives. People employed in military or police should have that screening. You do not remain same after subarachnoid haemorrhage. Each aneurysm in an indivisual is like a finger print and there will always be no 2 similar aneurysms.
We got the following comment via mail:
written by admin, March 31, 2014
very useful inputs from senior surgeons here.

the scenario for me is : one person in the family has aneurysm (not 2)

1. i would do counseling for genetic test in the first generation relatives
2. If on genetic studies the
gene is positive - obviously in the affected patient then what would u do?
3.affected patient and 1 first generation relative - what would you do
4. obviously now 2 first generation relatives are positive now I WOULD DEFINITELY FOLLOW THE SCAN GUIDELINES MENTIONED ABOVE?
5. NOW 2 first generation relatives have positive aneurysms on SCANS, then every one should do MRA/CTA in all the relatives
5. duration only 15 years?

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