Sauvigny Jennifer, Muzaiek Safouh, Czorlich Patrick, Ricklefs Franz L, Bester Maxim, Sauvigny Thomas, Dührsen Lasse
1Departments of Neurosurgery.
2Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
J Neurosurg. 2025 May 23;143(3):634-640. doi: 10.3171/2025.2.JNS242537. Print 2025 Sep 1.
Tiny intracranial aneurysms (tiAs) pose challenges in detection and management. Recent advances in neuroimaging have improved the detection rates of these diminutive lesions, yet the decision-making process regarding their treatment remains controversial. While larger aneurysm size is a relevant risk factor for a possible rupture in common risk scores, the rupture of tiAs leading to subarachnoid hemorrhage (SAH) is also reported frequently. However, a heterogeneity in practice exists, and clear guidelines for the treatment of incidental tiAs are lacking. The aim of this study was to investigate clinical decision-making for aneurysm repair by investigating the risk factors for rupture in tiny aneurysms.
This retrospective analysis utilized data from patients admitted to the University Medical Center Hamburg-Eppendorf for aneurysmal SAH (n = 427) between 2010 and 2020 and patients with unruptured intracranial aneurysm (UIAs) discussed by the medical center's aneurysm board (n = 743) between 2012 and 2022. Patients with single tiAs, defined as a maximum diameter of 3 mm, were selected for further analysis. Patient demographics, aneurysm characteristics, and risk factors were compared between the SAH and UIA groups. A modified UIA treatment score (UIATS*) and the PHASES (population, hypertension, age, size of aneurysm, earlier SAH from another aneurysm, site of aneurysm) score were collected in UIA patients and applied retrospectively in SAH patients for the time of admission.
The authors identified 79 tiAs in the SAH cohort and 109 tiAs in the UIA cohort. Irregular morphology (OR 4.53, 95% CI 1.84-11.16; p < 0.001) and a high size ratio/aspect ratio (> 3/1.6; OR 14.73, 95% CI 3.55-61.17; p < 0.001) were significantly associated with rupture when comparing tiAs of the SAH and UIA groups. When applying the UIATS* to tiny aneurysms retrospectively, intervention would have been recommended in 20.3% of SAH cases compared with 0.9% of UIA cases (p < 0.001). Comparatively, for nontiny aneurysms, intervention would have been recommended in 33.9% of SAH cases compared with 15.6% of UIA cases (p < 0.001).
In the present collective, several ruptured tiAs could be identified. Nevertheless, only a few would have been recommended for treatment. Especially tiAs with irregular morphology and abnormal configurations should be critically evaluated for rupture risk. Current scoring systems provide valuable guidance but should be used in conjunction with individualized, multidisciplinary treatment approaches.
微小颅内动脉瘤（tiA）在检测和管理方面存在挑战。神经影像学的最新进展提高了这些微小病变的检测率，但其治疗的决策过程仍存在争议。虽然在常见风险评分中，较大的动脉瘤尺寸是可能破裂的相关危险因素，但也经常有tiA破裂导致蛛网膜下腔出血（SAH）的报道。然而，实际操作中存在异质性，且缺乏针对偶然发现的tiA治疗的明确指南。本研究的目的是通过调查微小动脉瘤破裂的危险因素来研究动脉瘤修复的临床决策。
这项回顾性分析利用了2010年至2020年期间因动脉瘤性SAH入住汉堡-埃彭多夫大学医学中心的患者数据（n = 427），以及2012年至2022年期间该医学中心动脉瘤委员会讨论的未破裂颅内动脉瘤（UIA）患者数据（n = 743）。选择最大直径为3 mm的单发tiA患者进行进一步分析。比较SAH组和UIA组患者的人口统计学、动脉瘤特征和危险因素。收集UIA患者的改良UIA治疗评分（UIATS*）和PHASES（人群、高血压、年龄、动脉瘤大小、另一动脉瘤先前的SAH、动脉瘤部位）评分，并在SAH患者入院时进行回顾性应用。
作者在SAH队列中识别出79个tiA，在UIA队列中识别出109个tiA。比较SAH组和UIA组的tiA时，不规则形态（OR 4.53，95% CI 1.84 - 11.16；p < 0.001）和高尺寸比/纵横比（> 3/1.6；OR 14.73，95% CI 3.55 - 61.17；p < 0.001）与破裂显著相关。将UIATS*回顾性应用于微小动脉瘤时，20.3%的SAH病例会建议进行干预，而UIA病例为0.9%（p < 0.001）。相比之下，对于非微小动脉瘤，33.9%的SAH病例会建议进行干预，而UIA病例为15.6%（p < 0.001）。
在本研究群体中，可以识别出几个破裂的tiA。然而，只有少数会被建议进行治疗。特别是形态不规则和构型异常的tiA应严格评估破裂风险。当前的评分系统提供了有价值的指导，但应与个体化的多学科治疗方法结合使用。
