Key Takeaways
- About 3-5% of the U.S. population has an unruptured brain aneurysm
- Globally, brain aneurysms affect approximately 3.5% of the population
- Incidence of subarachnoid hemorrhage from aneurysm rupture is 6-10 per 100,000 person-years
- Smoking increases aneurysm risk by 4.3 times
- Hypertension is present in 60-70% of ruptured aneurysm cases
- Family history increases risk 4-6 fold
- Symptomatic aneurysm rupture warning headache in 40-50%
- Sudden severe headache ("thunderclap") in 70-80% of ruptures
- Nausea/vomiting occurs in 70% of subarachnoid hemorrhage cases
- Coiling treats 70-80% of aneurysms endovascularly
- Clipping success rate 90-95% for accessible aneurysms
- EVAR reduces perioperative mortality to 1.2% vs 4.4% open repair
- Mortality 40-50% for ruptured brain aneurysms
- 50% of ruptured AAA patients die before hospital
- Good outcome (mRS 0-2) in 66% coiled vs 53% clipped (ISAT)
Aneurysms are surprisingly common but their rupture risk varies widely.
Epidemiology
- About 3-5% of the U.S. population has an unruptured brain aneurysm
- Globally, brain aneurysms affect approximately 3.5% of the population
- Incidence of subarachnoid hemorrhage from aneurysm rupture is 6-10 per 100,000 person-years
- Aortic aneurysms account for about 1-2% of deaths in men over 65
- Prevalence of abdominal aortic aneurysm (AAA) in men aged 65-74 is 5.5%
- Unruptured intracranial aneurysms are found in 3.6-6% of autopsies
- Annual rupture rate for unruptured aneurysms is 0.5-1%
- AAA prevalence in smokers is 4 times higher than non-smokers
- Brain aneurysms are more common in women (2:1 ratio)
- Incidence of ruptured brain aneurysms peaks between ages 40-60
- About 30,000 people in the U.S. suffer aneurysm ruptures annually
- Global incidence of aneurysmal subarachnoid hemorrhage is 10.5 per 100,000
- Thoracic aortic aneurysms prevalence is 0.1% in general population
- Mycotic aneurysms occur in 2-4% of infective endocarditis cases
- Familial intracranial aneurysms in 10-20% of cases
- AAA screening detects aneurysms in 1.3% of screened men 65-74
- Unruptured aneurysm prevalence on angiography is 2-4%
- Rupture risk increases with aneurysm size >7mm (3-15%)
- Popliteal artery aneurysms in 0.1-2.8% of peripheral aneurysms
- Brain aneurysm rupture causes 10% of all strokes
- AAA rupture incidence is 5-10 per 100,000
- Women have higher rupture risk for same size aneurysms
- Prevalence of intracranial aneurysms in hypertensive patients is 6.9%
- Annual detection rate of unruptured aneurysms rising due to imaging
- Splenic artery aneurysms in 0.04-0.1% population
- Renal artery aneurysms prevalence 0.65%
- Cavernous carotid aneurysms in 2-9% of intracranial aneurysms
- Incidence of pediatric aneurysms is 0.5-2 per million
- HIV-associated aneurysms in 4.5% of cases
- Overall aneurysm prevalence in adults >30 is ~2%
Epidemiology Interpretation
Prognosis and Mortality
- Mortality 40-50% for ruptured brain aneurysms
- 50% of ruptured AAA patients die before hospital
- Good outcome (mRS 0-2) in 66% coiled vs 53% clipped (ISAT)
- 30-day mortality post-EVAR 1.8%
- Case fatality for SAH 45%
- Rebleeding mortality 20-30% if untreated
- Delayed cerebral ischemia causes 25% poor outcomes
- 5-year survival post-AAA repair 70%
- WFNS grade 5 has 70% mortality
- Unruptured aneurysm repair morbidity 10-15%
- Ruptured thoracic aneurysm mortality 70-90%
- 1-year mortality post-SAH 50% in elderly
- Vasospasm mortality contribution 15%
- EVAR rupture prevention reduces mortality 50-70%
- Hydrocephalus increases mortality 20%
- Seizures worsen prognosis (OR 2.3)
- Fisher grade 4 SAH has 60% poor outcome
- Long-term cognitive impairment in 50% SAH survivors
- AAA >5.5cm rupture risk 10%/year
- Pediatric aneurysm mortality 20-40%
- Re-rupture after coiling 1-2%/year
Prognosis and Mortality Interpretation
Risk Factors
- Smoking increases aneurysm risk by 4.3 times
- Hypertension is present in 60-70% of ruptured aneurysm cases
- Family history increases risk 4-6 fold
- Smoking doubles the risk of AAA development
- Age >55 is a major risk factor for aortic aneurysms
- Female sex increases rupture risk for brain aneurysms
- Polycystic kidney disease associated with 10-20% aneurysm prevalence
- Atherosclerosis contributes to 90% of AAAs
- Connective tissue disorders like Marfan syndrome increase risk 15-fold
- Hypercholesterolemia raises AAA risk by 2.5 times
- Alcohol consumption >2 drinks/day triples risk
- Cocaine use associated with 1.5-3.6% mycotic aneurysms
- Ehlers-Danlos syndrome type IV has 25-50% aneurysm risk
- Obesity increases AAA growth rate by 20%
- African American ethnicity higher rupture risk for same size
- Prior aneurysm doubles risk for new ones
- Diabetes may protect against AAA (OR 0.6)
- Loeys-Dietz syndrome has 50% aortic aneurysm risk
- Bicuspid aortic valve increases thoracic aneurysm risk 20-fold
- Estrogen deficiency post-menopause raises risk
- Chronic obstructive pulmonary disease (COPD) increases AAA risk 2.7-fold
- Radiation exposure elevates risk by 2-3 times
- Antihypertensive use reduces rupture risk by 30%
Risk Factors Interpretation
Symptoms and Diagnosis
- Symptomatic aneurysm rupture warning headache in 40-50%
- Sudden severe headache ("thunderclap") in 70-80% of ruptures
- Nausea/vomiting occurs in 70% of subarachnoid hemorrhage cases
- Neck stiffness in 30-40% post-rupture
- Visual disturbances in 20-30% with unruptured aneurysms
- Cranial nerve palsies (III, IV, VI) in 15-20%
- Photophobia common in 25% of cases
- Altered consciousness in 50% at rupture
- Seizures in 10-25% post-rupture
- Back/abdominal pain in 50% of AAA ruptures
- Pulsatile abdominal mass in 30-50% of intact AAAs
- Facial pain or numbness if cavernous sinus involvement
- CTA detects 95% of aneurysms >3mm
- MRI/MRA sensitivity 85-95% for unruptured aneurysms
- DSA gold standard with 95-99% sensitivity
- Ultrasound screens AAA with 95% sensitivity >3cm
- WFNS grade predicts outcome; grade 1 has 93% good recovery
- Sentinel bleed (warning leak) in 40-50% before major rupture
- Hydrocephalus in 20-30% post-SAH
- Loss of consciousness at ictus in 45%
- Focal deficits like hemiparesis in 15%
- Fundoscopic exam shows subhyaloid hemorrhage in 20%
- CT shows hyperdensity in 95% within 24h of SAH
- Lumbar puncture xanthochromia after 12h in 100%
- Mass effect symptoms in giant aneurysms (>25mm) 50%
- Claudication or embolism in peripheral aneurysms 30%
- Sudden hypotension/shock in 80% AAA rupture
Symptoms and Diagnosis Interpretation
Treatment
- Coiling treats 70-80% of aneurysms endovascularly
- Clipping success rate 90-95% for accessible aneurysms
- EVAR reduces perioperative mortality to 1.2% vs 4.4% open repair
- ISAT trial: coiling better than clipping (23% vs 30% mortality/disability)
- Flow diversion success 75-90% for large aneurysms
- Beta-blockers reduce aortic growth by 25-40%
- Nimodipine reduces poor outcome by 30% post-SAH
- Endovascular repair for thoracic aneurysms 85% success
- Stent-assisted coiling in 20-30% complex cases
- Watchful waiting for <7mm unruptured aneurysms
- Statins slow AAA expansion by 0.5mm/year less
- Decompressive craniectomy in 10-15% severe SAH
- Pipeline embolization device occludes 90% at 1 year
- Open repair durability 95% at 5 years for AAA
- Vasospasm prophylaxis with nimodipine in 100% SAH patients
- TEVAR mortality <2% in high-volume centers
- Aspirin reduces growth in small aneurysms 20%
- Intra-arterial milrinone for vasospasm 70% improvement
- Rebleeding prevention with antifibrinolytics controversial
- Radiation therapy for inoperable aneurysms 50-70% occlusion
- Angioplasty for vasospasm 60-80% angiographic success
- Surveillance ultrasound every 6-12 months for small AAA
Treatment Interpretation
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