European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms

Nima Etminan; Diana Aguiar de Sousa; Cindy Tiseo; Romain Bourcier; Hubert Desal; Anttii Lindgren; Timo Koivisto; David Netuka; Simone Peschillo; Sabrina Lémeret; Avtar Lal; Mervyn DI Vergouwen; Gabriel Je Rinkel

doi:10.1177/23969873221099736

European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms

Eur Stroke J. 2022 Sep;7(3):V. doi: 10.1177/23969873221099736. Epub 2022 Jun 3.

Authors

Nima Etminan¹, Diana Aguiar de Sousa^{2

3}, Cindy Tiseo⁴, Romain Bourcier⁵, Hubert Desal⁵, Anttii Lindgren^{6

7

8}, Timo Koivisto^{7

8}, David Netuka⁹, Simone Peschillo^{10

11}, Sabrina Lémeret¹², Avtar Lal¹², Mervyn DI Vergouwen¹³, Gabriel Je Rinkel^{1

13}

Affiliations

¹ Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
² Stroke Centre, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal.
³ CEEM and Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, Portugal.
⁴ Department of Neurology and Stroke Unit, SS Filippo e Nicola Hospital, Avezzano, Italy.
⁵ Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, INSERM, CNRS, Université de Nantes, l'institut du thorax, France.
⁶ Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland.
⁷ Department of Neurosurgery, Kuopio University Hospital, Kuopio, Finland.
⁸ Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
⁹ Department of Neurosurgery and Neurooncology, 1st Medical Faculty, Charles University, Praha, Czech Republic.
¹⁰ Department of Surgical Medical Sciences and Advanced Technologies 'G.F. Ingrassia' - Endovascular Neurosurgery, University of Catania, Catania, Italy.
¹¹ Endovascular Neurosurgery, Pia Fondazione Cardinale Giovanni Panico Hospital, Tricase, LE, Italy.
¹² European Stroke Organisation, Basel, Switzerland.
¹³ Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.

Abstract

Unruptured intracranial aneurysms (UIA) occur in around 3% of the population. Important management questions concern if and how to perform preventive UIA occlusion; if, how and when to perform follow up imaging and non-interventional means to reduce the risk of rupture. Using the Standard Operational Procedure of ESO we prepared guidelines according to GRADE methodology. Since no completed randomised trials exist, we used interim analyses of trials, and meta-analyses of observational and case-control studies to provide recommendations to guide UIA management. All recommendations were based on very low evidence. We suggest preventive occlusion if the estimated 5-year rupture risk exceeds the risk of preventive treatment. In general, we cannot recommend endovascular over microsurgical treatment, but suggest flow diverting stents as option only when there are no other low-risk options for UIA repair. To detect UIA recurrence we suggest radiological follow up after occlusion. In patients who are initially observed, we suggest radiological monitoring to detect future UIA growth, smoking cessation, treatment of hypertension, but not treatment with statins or acetylsalicylic acid with the indication to reduce the risk of aneurysm rupture. Additionally, we formulated 15 expert-consensus statements. All experts suggest to assess UIA patients within a multidisciplinary setting (neurosurgery, neuroradiology and neurology) at centres consulting >100 UIA patients per year, to use a shared decision-making process based on the team recommendation and patient preferences, and to repair UIA only in centres performing the proposed treatment in >30 patients with (ruptured or unruptured) aneurysms per year per neurosurgeon or neurointerventionalist. These UIA guidelines provide contemporary recommendations and consensus statement on important aspects of UIA management until more robust data come available.

Keywords: Unruptured intracranial aneurysms; aneurysm growth; assessment; clipping; coiling; endovascular repair; grading of recommendations; guidelines; management; medical management; risk factors; risk of rupture.