For those of you who were told that clipping was permanent, and didn't need follow-up, please ask for follow-up. 30% develop new aneurysms. JulieNH
Long-term follow-up survey reveals a high yield, up to 30% of patients presenting newly detected aneurysms more than 10 years after ruptured intracranial aneurysms clipping. Neurosurg Rev. 2011; 34(4):485-96 (ISSN: 1437-2320) Bruneau M; Rynkowski M; Smida-Rynkowska K; Brotchi J; De Witte O; Lubicz B Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium. ■■■■■■■■■■■■■■■■■■ The need to pursue long-term follow-up in patients treated for a ruptured aneurysm remains debated. New aneurysms development is a crucial element to consider but remains scarcely analyzed especially after a mean follow-up longer than 10 years. Our study was designed to provide rates of newly developed aneurysms in patients who have undergone prior clipping who were not followed with serial imaging. Patients were included if they were (1) treated more than 10 years ago by clipping of a ruptured aneurysm, (2) independent at time of discharge, (3) presently younger than 65 years, and if (4) they agreed to undergo a late digital subtraction angiography (DSA) control or to transmit results of a recent one performed elsewhere. Twenty patients were included with a mean delay between aneurysm treatment and late DSA of 18.0 years (10-26.5 years). Out of these patients, six (30%) harbored new aneurysms. Of these six individuals, four (66.6%) presented multiple aneurysms with a total of 15 newly discovered aneurysms. Aneurysm sizes ranged from 1 to 10 mm. One patient suffered from a de novo aneurysm rupture. Multiple aneurysms at the time of the first hemorrhage were a risk factor in developing de novo aneurysm (p=0.0175). In conclusion, based on a 30% rate of new aneurysm formation in patients clipped more than a decade ago, close screening on a very long-term perspective is encouraged. This study suggests aneurysm formation to be a continuous process. http://reference.medscape.com/medline/abstract/21643681
Julie, thanks for sharing. It's kind of scary. My annie did not rupture but I did have an MRI 14 years ago and no annies were detected. Yet, this past year one was. At the time, they told me that there are no others and my neuro surgeon said he didn't think it would be necessary to recheck in 10 years -- that might be because I am now 64 years old. Still seems scary that one could form at anytime.
When my rupture first occured in 2006, many, many people asked why my family hadn't had my aneurysm clipped, because, afterall, it was permanent and I wouldn't need any more follow up. We now know that for 30% of all clipping cases this is not true. I am VERY thankful that I was coiled BECAUSE I receive follow-up testing, (either 3T MRI/MRAs or Angiograms). Another aneurysm was found in my brain, which is being watched.
So, if you have had an aneurysm clipping, please insist on follow-up testing.
I had aneurysm rupture in September 2002 and had mri/mra October last year was supposed to be getting results 17th Jan its been put back to the 7th Feb can’t be to serious cause they would of been in touch. Jess.xxx
I missed this posting before. Thanks for the info.
My personal history supports the findings of this study, i.e., I did develop new aneursyms after my clipping, and I had more than one aneurysm at the time of my rupture. The good news is there have been no new aneurysms in 35 years! For this I give thanks to God.
P.S. Dr Jacques Brotchi whose name is listed in the credits is the neurosurgeon to whose care I was entrusted while I lived in Brussels :-)
I thought these statistics were a little alarming, so I asked Dr. Bob Brown, Mayo Clinic to comment on this. He is world renowned in the field of brain aneurysms. He said:
Following surgical clip ligation of the aneurysm, there typically is no routine maintenance of the aneurysm, particularly if intraoperative imaging documented complete obliteration of the aneurysm. However, for younger patients, those known to have multiple aneurysms, and those with a strong family history of aneurysms, given that they may be at higher risk of the development of de novo aneurysms, some routine surveillance imaging may be recommended.
He noted that this was a very small study in a not well known medical journal. So, for now, unless you fit in to one of the categories above, routine surveillance imaging is not typically required after clipping surgery.
There are two interesting coincidences in my life. First, my own history matches the findings of this study and I was seen by one of the surgeons credited. Second, an more importantly, though, my husband's life was probably saved when what was thought to be Polyarteritis nodosa, a pretty nasty disease, http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002410/ was identified as an allergy to "allergy shots". This diagnosis was made based on the findings of another 20 person study done in Europe. My husband was advised to stop taking the allergy shots and the symptoms went away. We are forever grateful to the young man at Baylor College of Medicine who found the study (pre-internet days) after my husband's mysterious case was assigned to his neurology class.
In a follow-up visit, the allergist who prescribed the allergy shots for my husband later told us that he was aware of the study but that it was not considered to be significant because of its small size.
Julie ,thank you for such great information i was getting checked every year since o7 near its every two because I still have a Sinus canveous ANEURSYM , Great to know and to beware of any signs,
thank you so much,
I have been told all my life how "rare" each and every medical occurance in my life has been (i.e. an odontoma containing 51 baby teeth in my upper jaw, a double ruptured aneurysm, a pituitary tumor, a very rare form of breast cancer, etc.). "Rare" things happen to someone ( I seem to have had more than my share). I will continue to try to avoid another rupture, so yes, I would, and have, insisted on being checked with routine surveillance imaging (MRI in my case). It is my life.
1Department of Neurology, Rudolf Magnus Institute of Neuroscience, 2Department of Radiology and 3Julius Centre for General Practice and Patient Oriented Research, University Medical Centre Utrecht, Utrecht, The Netherlands
*On behalf of the ASTRA Study Group. The members of the ASTRA Study Group are listed in the Addendum. Correspondence to: M. J. H. Wermer, MD, Department of Neurology, G03.228, University Medical Centre Utrecht, Heidelberglaan 100, 3500 GA Utrecht, The Netherlands E-mail: ■■■■■■■■■■■■■■■■■■■■■
Intracranial aneurysms have long been considered a once in a lifetime event. Nevertheless, patients who survive after subarachnoid haemorrhage (SAH) may be at risk for new aneurysms. In a cohort of patients with clipped aneurysms, we studied the yield of screening in the years after the SAH and we tried to identify risk factors for formation of new aneurysms as well as enlargement of aneurysms that were already present at the time of the SAH. We screened 610 patients who had been admitted between 1985 and 2001 for SAH by means of CT-angiography. Risk factors were evaluated by Cox regression analyses. With screening we detected 129 aneurysms in 96 (16%) patients, after a mean interval of 8.9 years. Of these, 24 (19%) were located at the site of the previously ruptured and clipped aneurysm and 105 (81%) at a site remote from the clip site. Of the aneurysms at a remote site 59 could be compared with the initial (CT)-angiogram. Of these, 19 were truly de novo (32%) and 40 (68%) were already visible in retrospect. Of the 53 aneurysms that were followed over time 13 (25%) had enlarged. Risk factors for aneurysm formation and growth were presence of multiple aneurysms at time of SAH (HR 3.2, 95% CI 1.2–8.6), current smoking (HR 3.8, 95% CI 1.5–9.4) and hypertension (HR 2.3, 95% CI 1.1–4.9). These results suggest that intracranial aneurysms should not be considered as a single event in a lifetime but rather as a continuous process. Patients with a previous SAH have a substantial risk for new aneurysm formation and enlargement of untreated aneurysms. Screening these patients might be beneficial, especially in patients with multiple aneurysms, hypertension and a history of smoking. The risks and benefits of screening, however, should be carefully weighed, for example, in a decision model.
Risk of aneurysm recurrence in patients with clipped cerebral aneurysms: results of long-term follow-up angiography.
Department of Neurosurgery, Aizu Chuou Hospital, Aizuwakamatsu, Japan. ■■■■■■■■■■■■■■■■■■■■
Abstract
BACKGROUND AND PURPOSE:
With many patients living long after microsurgical aneurysm clipping for subarachnoid hemorrhage (SAH) and with the evolution of intravascular procedures as less invasive alternatives, knowledge of the long-term results of clipping is becoming important.
METHODS:
Of 412 patients who underwent clipping of ruptured or unruptured cerebral aneurysms at our institution between 1976 and 1994 and who survived >3 years after surgery, 225 patients who were in good general condition and younger than 80 years were offered follow-up angiography to detect newly formed aneurysms. Of the 225, 80 patients (35.6%) agreed to undergo angiography. In addition, 32 patients underwent angiography for new medical indications other than SAH. Therefore, 112 patients underwent angiography, representing a total of 140 clipped aneurysms.
RESULTS:
The mean interval from surgery was 9.3 years for all patients and 9.0 years for the clipped aneurysms (range 3 to 21 years). Four aneurysm regrowths were detected of the 140 (2.9%) clipped aneurysms, representing 3 of 125 completely clipped aneurysms, 1 of 14 incompletely clipped aneurysms, and 0 of 1 aneurysm not studied with postoperative angiography. De novo aneurysms were detected in 9 of 112 (8.0%) patients. The annual rate of de novo aneurysm formation was 0.89%.
CONCLUSIONS:
This study shows that the annual rate of de novo aneurysm formation is relatively high (0.89%) and that the cumulative risk becomes significant after 9 years. In consideration of the fatality rate of SAH, follow-up angiography may be indicated for patients with clipped aneurysms 9 to 10 years after surgery.
This really sends a strong message to NOT smoke, keep your blood pressure controlled, and if you have been diagnosed with multiple aneurysms, you are more at risk for future aneurysms. Thanks for providing this info here, Julie!
Thanks for this posting and starting this discussion. It is one of the most beneficial discussions that I've seen since becoming a member last December.
Neither of these studies include anyone with a long term aneurysm history such as mine so it's hard for me to extrapolate, for example: "This study shows that the annual rate of de novo aneurysm formation is relatively high (0.89%) and that the cumulative risk becomes significant after 9 years." Should one conclude that there should be follow-up on 9 year cycles, post op or every year after the first 9 year period?
Thankfully, I have never been a smoker and I have well controlled blood pressure. When it was discovered that I had three aneurysms, I was told that it was crucial to keep my blood pressure in check to avoid aneurysm rupture. Tuesday's reading was 118/76. I take 1/2 of the minimum dosage of a beta blocker which was started 6 years ago to keep my pressure in check during a period high stress at work exacerbated by my serving simultaneously as the project manager for my new church, traveling internationally 50% of the time and my husband's serious illness. Today, all of this stress is behind me and maybe I will soon be able to eliminate the blood pressure medicine entirely. However, continuing it would certainly be worth it if it is providing additional protection against rupture and does not cause me to have "low" blood pressure issues.
What I do know is that I should continue to give thanks to God for my good experience over these almost 43 years post op and pray for his continued blessings.
Hello, I am a good example of what this article is talking about. Had an UNRUPTURED aneurysm 21 years ago. About 5 weeks ago discovered I have 2 new aneurysm - both approx. 5MM. I thought I was done after the initial clipping, but 2 decades later... I was not told that any follow-up was necessary. I don't think the surgeons knew at that time. Medicine has really come a long way, and it is good news that there is follow-up recommended now. It wasn't fun 21 years ago, and I'm sure it won't be this time, but I thank God I'm alive everyday, and we'll see what can be done this time... Thanks for posting this article!
thanks for posting Julie. Informative and interesting. Applies to me as I had a clipped, ruptured anny about 14 years ago and am under 65. Maybe when I get back to Australia and testing is free, I’ll go get a test. Cheers! Scharyn.
Julie,
Thanks so much for posting this. I also fall into this 30% category.
I had surgery in 2006 for an aneurysm that ruptured in 2001. (On April Fool’s Day if you can believe it!!!) I had that one coiled twice and it kept growing.I had angiograms from 2001 to 2006 every 6 months to a year because of the growth. In 2006…had to have it clipped.
I have chronic pain at the surgical area from that clipping. I was/am so lucky, though. The coils had already pushed through the head of the aneurysm and had attached to scar tissue in my brain.
Since 2007 I’ve been in the Pain and Palliative Clinic at Duke Univ. In mid 2015 the pain was getting worse. In Nov of that year, my neurologist ordered a CT scan w/contrast…and they found another aneurysm. ACoA again.
I had that one clipped in 2017. Both of my surgeries were at UNC-CH and I’m now having angios once a year. My next is coming up as soon as I get it scheduled.
I was 38 when I had the rupture and 44 when it was clipped. I was 54 when we elected to have the 2nd one clipped.
Once one has been through brain surgery…it is so hard to elect to have it again. And I was 54. The aneurysm was not a candidate for coiling. It was shaped like the top part of a valentine heart. I don’t have a complete circle of willis and that creates complications during surgery if something goes wrong. That’s the reason I had 2 coilings. My Neuroradiologist was was very conservative with the amount of coils the 1st time. There were just so many pros for having the surgery except…having to have surgury on one’s brain!
And I’m here!!
This is all a bit scary when my neorosurgeon was adamant that aneurisms dont develop after the age of 45 so i dont need any further follow up. What ages have others found they developed further aneurisms ? I now know i can request my GP to do scans so i wil. But i want to research and understand how often this may be necessary.
I have smoked socially between the ages of 41-43 but not full on smoker , my blood pressure is controlled as i am on a beta blocker for migraine prevention however my dad had AVM burst at 37 years of age and successfully operated on and then at age 50 died of SAH. So do have history.