Conservative management of 661 patients with unruptured intracranial aneurysms: an observational study over 4 decades

OBJECTIVE: The management of unruptured intracranial aneurysms (UIAs) remains controversial, with a scarcity of long-term natural history data on conservative management. Therefore, the authors attempted to identify risk factors for aneurysm rupture in a cohort of consecutive patients with UIAs. METHODS: In this retrospective observational study, the authors analyzed 661 patients with 767 exclusively UIAs who were conservatively managed at their tertiary referral center between 1984 and 2020. Patient-specific and aneurysm-specific risk factors for hemorrhage and aneurysm-related death were analyzed, including thresholds for the PHASES (population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from another aneurysm, and site of aneurysm) and ELAPSS (earlier subarachnoid hemorrhage, aneurysm location, age, population, aneurysm size and shape) scores that were set at 8 and 15, respectively, prior to the analyses. RESULTS: The median follow-up in the conservative observation period was 4.1 years, with 42% of the patients observed for ≥ 5 years. The overall aneurysm-related mortality rate was 4.4%. In 23 (3.5%) patients, aneurysm rupture was reported during the conservative observation period, resulting in an overall calculated annual hemorrhage rate of 0.6%. Notably, 87% of the hemorrhages occurred in the first 5 years after diagnosis, whereas no single rupture occurred after 10 years. Aneurysm size and PHASES and ELAPSS scores were independent predictors of hemorrhage. Among patients with a PHASES score < 8 or an ELAPSS score < 15, no aneurysm-related death or aneurysm rupture occurred. CONCLUSIONS: The identified PHASES and ELAPSS score thresholds may help identify high-risk patients with UIAs. Individual aneurysm rupture risks must be carefully weighed against center-specific treatment outcomes. For conservatively managed UIAs, lifelong regular follow-up is recommended and seems to be especially important in the first 10 years after diagnosis.