Welcome to the ESOC 2021 Virtual Conference Calendar

Background And Aims

No concensus exists on adequate surveillance of conservatively managed unruptured intracranial aneurysms (UIAs). We aimed to determine optimal, personalized, MRI surveillance strategies for growth of UIAs using cost-effectiveness analysis.

Methods

We designed a microsimulation model from a health care perspective simulating 100,000 55-year old women to estimate costs and quality-adjusted life years (QALYs) over a lifetime horizon in the US, UK, and the Netherlands, using literature-derived model parameters. Strategies were: no follow-up surveillance, follow-up with MRI in the 1st and 5th year after UIA discovery, every 5 years, 2 years, or annually, or immediate intervention (i.e., clipping or coiling). Secondary analyses were performed for men, different ages and different aneurysm characteristics.

Results

Among 55-year old women with UIAs, no surveillance resulted in an annual subarachnoid hemorrhage incidence of 132 cases per 100,000 person-years, whereas annual MRI decreased the incidence to 87 cases per 100,000 person-years (34.3% relative and 0.045% absolute annual risk reduction). No surveillance MRI was most cost-effective in the US (47% of the simulations) and UK (54% of simulations), whereas annual MRI was most cost-effective in the Netherlands (53% of simulations). In the US and UK, surveillance annually or in the 1st and 5th year after discovery was cost-effective in patients <60 years and at increased risk of aneurysm growth.

Conclusions

In the US and UK, no follow-up MRI for untreated UIAs is most cost-effective. Imaging follow-up should be restricted to patients younger than 60 years or at increased risk of aneurysm growth. In the Netherlands, annual surveillance is typically cost-effective.

Trial Registration Number

Not applicable

Background And Aims

Unruptured intracranial aneurysms are increasingly found on vascular imaging; however, decision-making on management can be challenging. The purpose of this study is to determine whether there is a need for decision-support to decide on the management of unruptured intracranial aneurysms from both the perspectives of patients and physicians.

Methods

We conducted a qualitative study, where we asked patients with unruptured intracranial aneurysms and health care providers involved in aneurysm care to complete a needs assessment questionnaire that was developed based on the Ottawa Decision Support Framework.

Results

54 patients and 33 physicians completed the needs assessment. Physicians ranked the rupture risk as being of the highest importance for decision-making, followed by technical feasibility, patient preferences, comorbidity, and age. Most physicians (73%) assumed they discuss and offer all management options; however, most patients (82%) report that only one management option was offered and discussed with them in the clinic. Furthermore, most physicians assume that patients experience negative emotions and difficulty throughout the decision-making process, which is the opposite to what patients report. However, physicians and patients equally believe it would be beneficial for patients to receive more information on intracranial aneurysms (42%), as well as decision support on the management of the intracranial aneurysms (42%).

Conclusions

There are discrepancies between patients and healthcare providers in the perception of the decision-making process on the management of unruptured intracranial aneurysms. However, both believe there is a need for more patient information and decision support to facilitate shared decision-making between physicians and patients.

Trial Registration Number

Not applicable

Background And Aims

Preventive screening for intracranial aneurysms (IAs) in persons with a positive family history of aneurysmal subarachnoid haemorrhage (aSAH) is cost-effective, but not very efficient. We aimed to develop and externally validate a model for predicting the probability of an IA at first screening in persons with a positive family history of aSAH.

Methods

For model development and validation, we studied results from initial screening for IAs in prospective collected persons with ≥2 affected first-degree relatives screened in the Netherlands and France, respectively. We assessed potential predictors of IA presence in multivariable logistic regression analysis. Predictive performance was assessed with the c-statistic and a calibration plot, and we corrected for overfitting.

Results

IAs were present in 79/660 (12%) persons in the development cohort. Predictors were Number of affected relatives, Age, Smoking, and Hypertension (NASH). The NASH score had a c-statistic of 0.68 (95% CI 0.62-0.74) and showed good calibration in the development data. Predicted probabilities of an IA at first screening varied from 5% in persons aged 20-30 years with two affected relatives, without hypertension who never smoked, up to 36% in persons aged 60-70 years with ≥3 affected relatives, who have hypertension and smoke(d). In the external validation data IAs were present in 67/258 (26%) persons, the model had a c-statistic of 0.64 (95% CI 0.57-0.71) and slightly underestimated IA risk.

Conclusions

The NASH score helps to predict the probability of an IA at first screening in persons with ≥2 affected first-degree relatives based on four easily retrievable predictors.

Background And Aims

Spontaneous aneurysmal subarachnoid hemorrhage (SAH) induces blood–brain barrier permeability (BBBp). The aim of the study was to evaluate longitudinally the association between increased BBBp assessed through Dynamic Contrast-Enhanced MRI (DCE-MRI) in the acute phase of SAH and long-term clinical outcome.

Methods

A prospective cohort of 70 SAH patients evaluated longitudinally through DCE-MRI within 72+/-48h (T1) and at 3 months (T90) after clinical onset was analyzed. Permeabilty maps were used to obtain the values of K-trans as a measure of increased BBBp in the whole brain, in the grey and white matter and in arterial territories. Poor clinical outcome was defined as a modified Rankin Scale score >2 at 90 days. The association between K-trans values and clinical outcome was assessed with univariate and multivariate regression models adjusted for age, WFNS and mFisher grades at admission and aneurism size.

Results

A total of 70 patients (63% females, 70% WFNS I-III, 61% modified-Fisher 4, median age 55) were included in the study. K-trans values were significantly higher at T1 in comparison with T90 in the whole brain, grey/white matter and across all arterial territories (p<0.005 for all comparisons). In adjusted models, elevated K-trans values were significantly associated with poor outcome [adjusted-OR (per 10% of unit increase)=2.16, 95%CI=1.30-3.58, p=0.003].

Conclusions

SAH induces a diffuse increase in BBBp in the acute phase of the disease. Increased BBBp is associated with poor clinical outcome. These results support the role of BBB disruption as a potential target for vasculoprotective therapies in SAH.

Trial Registration Number

Not applicable

Group Name

Instituto Medico ENERI-Clinica La Sagrada Familia

Background And Aims

Background: Prospective studies have established the safety and efficacy of the Pipeline^TM Embolization Device(PED) for treatment of intracranial aneurysms(IA).

Aims: To investigate long-term outcomes from the Pipeline Embolization Devices for the Treatment of Intracranial Aneurysms(PEDESTRIAN) Registry.

Methods

Methods: The PEDESTRIAN registry data was retrospectively reviewed, which included patients (March 2006-July2019) with complex IAs treated with PED. Patients with unfavorable anatomy and/or recurrence following previous treatment were included and excluded those with acute subarachnoid hemorrhage. The primary angiographic endpoint was complete occlusion and long-term stability. Clinical and radiological follow-up was performed at 3-6 months, 12 months, and yearly thereafter.

Results

Results: A total of 835 patients (mean age 55.9±14.7 years; 80.0% female) with 1,000 aneurysms were included. Aneurysms varied in size: 64.6% were small (≤10mm), 25.6% were large (11-24mm), and 9.8% were giant (≥25mm). A total of 1,214 PEDs were deployed. Follow-up angiography was available for 85.1% of patients with 776 aneurysms at 24.6±25.0 months (mean). Complete occlusion was demonstrated in 75.8% of aneurysms at 12-months, 92.9% at 2-4 years, and 96.4% at >5 years. During the post-procedural period, modified Rankin Scale scores remained stable or improved in 96.2% of patients, with stability or improvement in 99.1% of patients >5 years. The overall major morbidity and neurological mortality rate was 5.8%.

Conclusions

Conclusion: This study demonstrated high rates of long-term complete aneurysm-occlusion, stable or improved functional outcomes, and low rates of complications and mortality. Clinical and angiographic outcomes improved over long-term follow-up, demonstrating endovascular treatment of IA with PED is safe and effective.

Background And Aims

Small unruptured intracranial aneurysms (SUIAs) are considered to have low risk of rupture. The proportion of SUIAs that rupture by size threshold when managed without repair is not well known. We aimed to determine the proportion of SUIAs that rupture by size threshold, and to determine the level of precision and sources of heterogeneity in the risk estimate.

Methods

The MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials were searched (inception-August 2020). Studies with longitudinal follow-up of patients with SUIAs (≤10 mm) without endovascular or neurosurgical repair were eligible. The primary outcome was synthesised with random-effects meta-analysis; heterogeneity was explored using meta-regression. PROSPERO registration number CRD42019121522.

Results

Thirty-one studies that included 13800 SUIAs were eligible for data synthesis. The pooled proportion of ≤10 mm SUIAs that ruptured when managed without repair was 1.1% (95%CI 0.8–1.5; I²=52.9%) over mean study follow-up of 3.7 years. Rupture occurred in 1.0% [95%CI 0.8–1.3; I²=0%] of 7280 ≤5mm SUIAs and 0.8% [95%CI 0.4–1.5; I²=0%] of 1228 ≤3mm SUIAs. In higher quality studies with lower risk of bias, rupture occurred in 1.8% (95%CI 1.5–2.0; I²=0%) over 3.9 years. In meta-regression, neither aneurysm size nor exposure to prior subarachnoid haemorrhage was identified as sources of heterogeneity.

Conclusions

For every 1000 SUIAs selected for conservative management without repair, between 8 to 15 are estimated to rupture over 3.7 years. Pooled rupture risk estimates are consistent and clinically applicable for ≤5mm SUIAs selected for management on the basis of size.

Trial Registration Number

Not applicable

Background And Aims

Anti-Aβ antibodies have been reported in the CSF of patients with CAA related inflammation (CAA-ri). Since monoclonal anti-Aβ antibody immunotherapies in Alzheimer’s disease cause both hemorrhagic and inflammatory complications, we hypothesized that not only CSF but systemic anti-Aβ antibodies participate in the pathophysiology of either CAA related hemorrhage (CAA-h) and/or CCA-ri. Therefore, we performed a quantitative and qualitative study of anti-Aβ antibodies in both conditions.

Methods

In this case-control study, serum anti-Aβ antibody isotype, concentration, avidity, and reactivity toward soluble or fibrillary Aβ_1-40 and Aβ_1-42 isoforms were assessed using an ELISA-based multiplex analysis. Anti-Aβ serologic patterns were defined in CAA and CAA subgroups using multivariable logistic regression analyses.

Results

Fourty-one healthy aged controls and 64 CAA patients were recruited, including 46 CAA-h and 18 CAA-ri. Compared to controls, CAA-related serological patterns were the following: i) both CAA-h and CAA-ri patients displayed lower binding diversity of anti-soluble Aβ_1-40 IgM (Fig. A) ; ii) CAA-h patients displayed higher anti-soluble Aβ_1-40 / fibrillary Aβ_1-42 IgG4 concentrations ratio and higher anti-soluble Aβ_1-42 IgG4 and IgA avidity (Fig. B); iii) CAA-ri patients displayed higher binding diversity of anti-soluble Aβ_1-40 IgG3 (Fig. C) and higher anti-fibrillary/soluble Aβ_1-42 IgG4 dilution curve steepness ratio.

Conclusions

This proof-of-concept study reveals anti-Aβ antibody variations in CAA patients, some of which were associated to CAA subtypes, unveiling pathophysiological insights regarding CAA hemorrhagic and inflammatory related events. These results open the perspective of blood biomarkers for cerebral amyloid angiopathy.

Background And Aims

Histopathological evidence is the gold standard for diagnosing cerebral amyloid angiopathy (CAA), but neuroimaging with non-contrast CT (Edinburgh criteria) or MR (modified Boston criteria) may provide indirect evidence of CAA. Amyloid PET may aid in diagnosing CAA by visualizing amyloid pathology in the brain.

Methods

We retrospectively studied 41 patients with lobar intracerebral hemorrhage (ICH) who underwent neuroimaging including amyloid PET between 2015-2017. We investigated differences in characteristic CT and MR findings of CAA between amyloid PET negative vs. positive patients. With amyloid PET status as ground truth, we compared the sensitivity and specificity of the existing neuroimaging criteria for CAA.

Results

We observed no difference in subarachnoid hemorrhage, fingerlike projections or deep microbleeds between amyloid negative (n = 15, 37%) vs. positive (n = 26, 63%) patients. In contrast, in the amyloid positive group cortical microbleeds (p = 0.009) and superficial siderosis (p = 0.004) were more frequent. The rule out sensitivity of the CT-based Edinburgh criteria was 69% and the rule in specificity 87%. Probable CAA according to the modified Boston criteria had a sensitivity of 65% and specificity of 47%. Sensitivity was not significantly different for both criteria, but specificity was better for the CT-based Edinburgh criteria (p = 0.04).

Conclusions

Amyloid PET was positive in 63% of lobar ICH patients. Sensitivity of the CT-based Edinburgh criteria and the modified Boston criteria to predict CAA was similar, but the CT-based Edinburgh criteria had better specificity compared to the modified Boston criteria.

Trial Registration Number

Not applicable