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Unruptured intracranial aneurysm

Key sources
The following summarized guidelines for the evaluation and management of unruptured intracranial aneurysm are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the European Stroke Organisation (ESO 2022; 2013), and the American Heart Association (AHA/ASA 2015).
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Guidelines

1.Screening and diagnosis

Indications for screening
As per AAFP 2023 guidelines:
Do not obtain screening for intracranial aneurysms in the general population.
D
Consider offering screening in patients with at least one first-degree family member with a history of intracranial aneurysm or aneurysmal subarachnoid hemorrhage or in patients at increased risk of intracranial aneurysm development.
C
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2.Classification and risk stratification

Risk factors
As per AHA 2015 guidelines:
Recognize that cigarette smoking increases the risk of UIAs formations, and hypertension is a risk factor for growth and rupture of intracranial aneurysms.
B
Consider viewing prior history of aneurysmal subarachnoid hemorrhage as an independent risk factor for future hemorrhage secondary to a different small unruptured aneurysm.
C

3.Diagnostic investigations

Diagnostic imaging
As per AHA 2015 guidelines:
Consider obtaining CTA and MRA for detection of UIAs.
B
Consider obtaining digital subtraction angiography over noninvasive imaging for identification and evaluation of cerebral aneurysms, if surgical or endovascular treatment is being considered.
C

4.Medical management

Antihypertensive therapy: as per ESO 2022 guidelines, manage hypertension in adult patients with UIA and increased BP.
B

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  • Antiplatelet therapy

  • Statin therapy

5.Nonpharmacologic interventions

Smoking cessation: as per ESO 2022 guidelines, advise smoking cessation in smoker patients with UIA.
B

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  • Alcohol intake

6.Therapeutic procedures

Endovascular coiling: as per ESO 2022 guidelines, consider performing placement of flow-diverting stents as a treatment option in adult patients with UIA only if no other endovascular or microsurgical options to occlude the aneurysm (complete occlusion or neck remnant only) at a risk lower than the expected 5-year risk of rupture are available and if the risk of rupture outweighs the risk of treatment with flow-diverting stents.
C

7.Perioperative care

Post-intervention imaging: obtain imaging after surgical intervention to document aneurysm obliteration given the differential risk of growth and hemorrhage for completely versus incompletely obliterated aneurysms.
B

8.Surgical interventions

Indications for aneurysm repair
As per ESO 2022 guidelines:
Consider performing preventive aneurysm repair in adult patients with an estimated 5-year risk of aneurysm rupture higher than the risk of the preventive treatment modality.
C
Consider performing preventive aneurysm repair in adult patients with a UIA showing growth on follow-up imaging, weighing the risk of rupture against the risk of treatment complications.
C

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  • Choice of repair technique

9.Patient education

General counseling: inform patients with UIAs considered for treatment about the risks and benefits of both endovascular and microsurgical aneurysm clipping.
B

10.Follow-up and surveillance

Follow-up imaging, managed conservatively, ESO
Obtain radiological monitoring to detect future UIA growth or morphological change in adult patients with UIAs if the risk of treatment complications is higher than the 5-year risk of rupture and if treatment remains an option.
B
Consider performing preventive aneurysm repair in adult patients with a UIA showing growth on follow-up imaging, weighing the risk of rupture against the risk of treatment complications.
C

More topics in this section

  • Follow-up imaging (managed invasively)

11.Quality improvement

Hospital requirements
Treat patients with unrupted intracranial aneurysm, either with endovascular or surgical approach, at higher-volume centers.
B
Perform surgical treatment of UIAs at higher-volume centers, such as performing > 20 cases annually).
B