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Factors affecting formation and rupture of intracranial saccular aneurysms

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Abstract

Unruptured intracranial aneurysms represent a decisional challenge. Treatment risks have to be balanced against an unknown probability of rupture. A better understanding of the physiopathology is the basis for a better prediction of the natural history of an individual patient. Knowledge about the possible determining factors arises from a careful comparison between ruptured versus unruptured aneurysms and from the prospective observation and analysis of unbiased series with untreated, unruptured aneurysms. The key point is the correct identification of the determining variables for the fate of a specific aneurysm in a given individual. Thus, the increased knowledge of mechanisms of formation and eventual rupture of aneurysms should provide significant clues to the identification of rupture-prone aneurysms. Factors like structural vessel wall defects, local hemodynamic stress determined also by peculiar geometric configurations, and inflammation as trigger of a wall remodeling are crucial. In this sense the study of genetic modifiers of inflammatory responses together with the computational study of the vessel tree might contribute to identify aneurysms prone to rupture. The aim of this article is to underline the value of a unifying hypothesis that merges the role of geometry, with that of hemodynamics and of genetics as concerns vessel wall structure and inflammatory pathways.

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Acknowledgments

This work was supported in part by the Umberto Veronesi Foundation (SB). Siemens Medical Solutions supported the start of the project Aneurisk several years ago.

We acknowledge Dr. M. Bacigaluppi for critical revision of the manuscript.

In memory of Dr. M. Collice.

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Authors and Affiliations

  1. Department of Neurosurgery, IRCCS Azienda Ospedaliero-Universitaria San Martino-IST, Genova, Largo Rosanna Benzi 10, Genova, 16132, Italy

    S. Bacigaluppi & G. Zona

  2. Mathematics and Computer Science, Emory University, Atlanta, GA, USA

    M. Piccinelli, A. Veneziani & T. Passerini

  3. Bioengineering, Mario Negri Institute and Orobix srl, Bergamo, Italy

    L. Antiga

  4. Neurosurgery, University of Milan, Milan, Italy

    P. Rampini & M. Zavanone

  5. Neurosurgery, Ospdale Galliera, Genova, Italy

    P. Severi

  6. Neurosciences and Biomedical Technologies, University of Milano-Bicocca, Milano-Monza, Italy

    G. Tredici

  7. Neuroradiology, University of Toronto, Toronto, Canada

    T. Krings

  8. Neuroradiology, Ospedale Niguarda, Milano, Italy

    E. Boccardi

  9. Clinical Genetics, Ospedale Niguarda, Milano, Italy

    S. Penco

  10. Neurosurgery, University of Brescia, Brescia, Italy

    M. Fontanella

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  1. S. Bacigaluppi
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  2. M. Piccinelli
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Comments

Tatsuya Abe, Oita, Japan

Bacigaluppi S. et al. reviewed various factors affecting formation and rupture of intracranial saccular aneurysms, focusing on geometry, hemodynamics, and genetics as concerns vessel wall structure and inflammatory pathways.

Computational fluid dynamics (CFD) technique has the potential to be a useful clinical tool for the prediction of the initiation, growth, and rupture of cerebral aneurysms. Actually, the number of publications about CFD has been growing. The recent application of methods of data assimilation to computational hemodynamics provides a promising approach for improving the reliability and accuracy of CFD studies using clinical data. However, further continuing studies are required.

Uwe Spetzger, Karlsruhe, Germany

On one hand, the raising preventive check-ups with sophisticated MR imaging, lead to an increasing detection rate of unruptured cerebral aneurysms. On the other hand, the ongoing discussion concerning the indication for treatment of innocent aneurysms and especially the adequate treatment strategy are often emotional and polemic discussions. For a proper and precise scientific discussion we need substantiated information and more reliable facts. The simple perspective to indicate the treatment only by the size of an aneurysm is too trivial and is inconsistent to our expertise of many SAH patients with small aneurysms. For decision making we need more evidence-based statistics, but in the future the individualized and patient specific data analysis will gain more importance.

This paper of Susanna Bacigaluppi summarizes the scientific results of a multidisciplinary group of neurosurgeons, neuroradiologists, computer scientists and bioengineers on the important topic of prediction factors for aneurysms rupture. The technique of computational fluid dynamics is an important approach and meanwhile many scientific groups focus on this technique. The systematic review of various factors affecting the formation and also the rupture of saccular aneurysms is comprehensive and clearly represented. The influence of geometry and hemodynamics is a promising approach for patient specific risk estimation to predict aneurysm rupture. However, also the genetic predisposition and inflammatory factors affecting the vessel wall respectively the structural stability of the aneurysm itself are discussed. The paper is of high significance in our daily routine for neurosurgeons dealing with patients with innocent aneurysms.

Computational fluid dynamics seems to become an important tool for the prediction of aneurysm development, growth and rupture. Definitely, further studies to confirm the reliability and clinical feasibility of this method are mandatory. To look ahead, computational fluid dynamics could be beneficial in the treatment algorithm and probably facilitate the decision making for coiling or clipping of an aneurysm. Additionally, follow-up and potential risk estimation of partially coil occluded aneurysms could become possible.

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Bacigaluppi, S., Piccinelli, M., Antiga, L. et al. Factors affecting formation and rupture of intracranial saccular aneurysms. Neurosurg Rev 37, 1–14 (2014). https://doi.org/10.1007/s10143-013-0501-y

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