Am Fam Physician. 2003 Apr 1;67(7):1438-1439.
to the editor: I read and enjoyed the article, “Intracranial Aneurysms: Current Evidence and Clinical Practice,”1 in American Family Physician and agree with screening the proposed groups: patients with autosomal dominant polycystic kidney disease and patients with a history of aneurysmal subarachnoid hemorrhage (SAH). I also agree with the consensus of not routinely screening for unruptured intracranial aneurysms in relatives of patients with subarachnoid hemorrhage, because of the increased morbidity and mortality associated with elective surgical intervention/repair of unruptured aneurysms. This is based on the result of the International Study of Unruptured Intracranial Aneurysms (ISUIA)2 that shows a decrease in the previously thought rupture rate of intracranial aneurysms: 0.05 percent per year in patients with no previous SAH, and 0.5 percent per year for large (greater than 10 mm diameter) aneurysms, and for all aneurysms in patients with previous SAH, compared with the previously proposed rupture rate of 1 to 2 percent per year.3
Table 1 in the article1 listed the risk factors for intracranial aneurysm formation and SAH; these risk factors could be diminished or eliminated in at-risk patients. While the evidence is strong against routine screening of all relatives of patients with SAH, the issue of careful history taking to identify additional risk factors that could be prevented or corrected was not addressed in the article.
Siblings appear to be the most frequently affected relatives of patients with aneurysmal SAH.1 More aggressive management or elimination of risk factors in this population could reduce both risk of formation and rupture until screening in this population can be tested in a randomized trial.3
1. Vega C, Kwoon JV, Lavine SD. Intracranial aneurysms: current evidence and clinical practice. Am Fam Physician. 2002;66:601–8.
2. Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. The International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med. 1998;339:1725–33.
3. Wardlaw JM, White PM. The detection and management of unruptured intracranial aneurysms. Brain. 2000;123:205–21.
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