1. Home>
2. Specialties>
3. Neurology>
4. Summary and Comment

Screening for Intracranial Aneurysms in First-Degree Relatives

Aneurysmal subarachnoid hemorrhage (SAH) is associated with high case fatality rates and high rates of functional dependence. The dismal outcome and disproportionately earlier age of onset of SAH compared with most other stroke subtypes underscore the need for prevention. Early detection through screening of those at high risk followed by surgical ablation could be a safe and effective means of prevention.

In this study, 626 first-degree relatives (mean age, 41) of 160 patients with sporadic SAH were screened using MRA, and aneurysms were confirmed by conventional cerebral angiography. MRA revealed 33 unruptured in 25 relatives (4%); most were detected in siblings (88%). Six individuals had multiple aneurysms. Of 23 relatives who had aneurysms confirmed at angiography, 18 had elective surgery. (Five had aneurysms 5 to 11 mm in diameter; 11 had aneurysms smaller than 5 mm; and 2 had both small and medium-sized.)

At 6 months postoperatively, the Rankin disability score had increased in 11 of 18 patients (61%). One patient had complications of angiography that resulted in infarcts of the brainstem and cerebellum, 4 had focal neurologic deficits, and 6 had nonspecific symptoms, such as headache, fatigue, impaired concentration, and emotional disturbance. Estimated life expectancy increased slightly for those who underwent surgery (0.9 month per person screened), but this was at the expense of 19 years of functional loss per person. The number of relatives who would need to be screened to prevent 1 SAH and 1 fatal SAH over a lifetime was estimated to be 149 and 298, respectively.

Comment: This study does not support the use of a screening program to detect unruptured aneurysms among first-degree relatives of patients with sporadic SAH. The slight increase in life expectancy was offset by the high risk for disability. A Markov decision model was used to estimate survival and functional outcome. Different estimates for the annual risk of rupture for asymptomatic aneurysms might alter the results. Persons at higher risk for aneurysmal rupture might benefit from screening and ablation of asymptomatic intracranial aneurysms. Estimates of the cost of screening, treatment, and disability--a perspective that might be useful--were not included. For screening programs to be successful, safe and effective preventative treatments are needed. Advances in the endovascular technique for ablation of cerebral aneurysms may provide such a prevention avenue in the future.

— PB Gorelick

Philip B. Gorelick, MD, is Professor and Director, Section of Cerebrovascular Disease and Neurologic Critical Care, Rush Medical College, Chicago IL.

Published in Journal Watch Neurology February 1, 2000

Citation(s):

The Magnetic Resonance Angiography in Relatives of Patients with Subarachnoid Hemorrhage Study Group. Risks and benefits of screening for intracranial aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage. N Engl J Med 1999 Oct 28 341 1344 -1350.

• Original article (Subscription may be required)
• Medline abstract (Free)