From the University Department of Neurology Utrecht, The Netherlands.
Correspondence to Gabriel J.E. Rinkel, MD, University Department of Neurology, Heidelberglaan 100, 3584 CX Utrecht, Netherlands. E-mail g.j.e.rinkel{at}neuro.azu.nl
Methods—We searched for studies published between 1955 and 1996
by means of a MEDLINE search and a cumulative review of the reference
lists of all relevant publications. Two authors independently assessed
eligibility of all studies and extracted data on study design and on
numbers and characteristics of patients and aneurysms.
Results—For data on prevalence we found 23 studies, totalling
56 304 patients; 6685 (12%) of these patients were from 15
angiography studies. Prevalence was 0.4% (95% confidence interval,
0.4% to 0.5%) in retrospective autopsy studies, 3.6% (3.1 to 4.1)
for prospective autopsy studies, 3.7% (3.0 to 4.4) in retrospective
angiography studies, and 6.0% (5.3 to 6.8) in prospective angiography
studies. For adults without specific risk factors, the prevalence was
2.3% (1.7 to 3.1); it tended to increase with age. The prevalence was
higher in patients with autosomal dominant polycystic kidney disease
(relative risk [RR], 4.4 [2.7 to 7.2]), a familial predisposition
(RR, 4.0 [2.7 to 6.0]), or atherosclerosis (RR, 2.3
[1.7 to 3.1]). Only 8% (5 to 11) of the aneurysms were
>10 mm. For the risk of rupture, we found nine studies, totalling
3907 patient-years. The overall risk per year was 1.9% (1.5 to 2.4);
for aneurysms =10 mm, the annual risk was 0.7% (0.5 to
1.0). The risk was higher in women (RR, 2.1[1.1 to 3.9]) and for
aneurysms that were symptomatic (RR, 8.3 [4.0 to
17]), >10 mm (RR, 5.5 [3.3 to 9.4]), or in the posterior
circulation (RR, 4.1 [1.5 to 11]).
Conclusions—Data on prevalence and risk of rupture vary
considerably according to study design, study population, and
aneurysm characteristics. If all available evidence with
inherent overestimation and underestimation is taken together, for
adults without risk factors for subarachnoid
hemorrhage, aneurysms are found in approximately 2%.
The vast majority of these aneurysms are small (=10 mm)
and have an annual risk of rupture of approximately 0.7%.
We conducted a systematic review of all reports on prevalence of
intracranial aneurysms and classified the data according to
study design, diagnostic methods, and study population. To
assess the accuracy of the data on prevalence, we also systematically
reviewed data on the risk of SAH in patients with unruptured
intracranial aneurysms because prevalence combined with annual
risk of rupture should equal the incidence of SAH. This calculated
incidence can then be compared with the incidence observed in the
population.5
Eligibility Studies
Data Extraction
Data Analysis
The prevalence in the retrospective autopsy studies was much lower than
in prospective autopsy studies or in angiography studies (retrospective
or prospective) (Fig 1
The site of the aneurysm was recorded for 563
aneurysms, from all angiography studies and two autopsy
studies. ICA aneurysms were most commonly found, and posterior
circulation aneurysms least commonly (Table 2
For the analysis of the risk of SAH in patients with unruptured
aneurysms, nine studies, totalling 3907 patient-years,
fulfilled the inclusion criteria (Table 3
The risk of rupture of aneurysms depended more on the
characteristics of the aneurysm than on those of the patient.
Women and patients at higher age tended to have an increased risk of
rupture, but the 95% confidence intervals were wide.
Symptomatic aneurysms, posterior circulation
aneurysms, and large (>10 mm) aneurysms had a
higher risk of rupture. Additional aneurysms also had a higher
risk of rupture than accidentally found asymptomatic
aneurysms, but this difference was not statistically
significant. Data provided in the publications were insufficient for a
multivariate analysis to assess whether these
factors are independent prognosticators.
The methods used to detect the aneurysms markedly influenced
the proportion of aneurysms. In retrospective autopsy studies,
the prevalence was much lower (0.4%) than in prospective autopsy
studies or in angiography studies of either design. A probable
explanation for this low prevalence in retrospective autopsy studies is
that these review old files, rather than original materials, in
contrast to retrospective angiography studies that can review the
actual studies. The data derived from the retrospective autopsy studies
are therefore probably an underestimation of the prevalence. The much
higher prevalence found in prospective angiography studies compared
with prospective autopsy studies is probably explained by selection
bias because patients with ADPKD, a familial predisposition for SAH, or
atherosclerosis are overrepresented in the
prospective angiography series. The prospective angiography series
therefore seem to overestimate the prevalence.
For the risk of rupture, the type of aneurysm is an important
factor. Incidentally found aneurysms tend to have a lower risk
of rupture than aneurysms found additional to a ruptured
aneurysm. Symptomatic aneurysms,
aneurysms larger than 10 mm, and basilar artery
aneurysms were all found to have a markedly increased risk of
rupture. Because symptomatic aneurysms are often
large, size and being symptomatic may not be independent
risk factors, but unfortunately the data provided in the publications
did not allow us to assess the interdependence of these factors.
Despite all these sources of bias, the data seem reasonably accurate. A
hypothetical calculation of the incidence from the data on prevalence
and risk of rupture should approximate the incidence of SAH observed in
the population (6 per 100 000 patient-years).5 If one
assumes a cohort of 100 000, only the proportion (75%) of individuals
older than 20 years is at risk for aneurysms.37
Most of these 75 000 individuals will not have risk factors for the
presence of aneurysms and will therefore have a prevalence
comparable to the subset of patients with "brain tumor and other
indications for angiography" (2.3%). In these 75 000 individuals,
1725 will have an aneurysm. Because 93% of aneurysms
are
Other factors also corroborate the accuracy of the data in this review.
First, women more often had aneurysms than men and their
aneurysms had a greater risk of rupture, which explains the
higher incidence of SAH in women.5 Second, patients with
ADPKD and patients with a familial predisposition for SAH had an
increased risk of aneurysms. This finding is in keeping with
the increased risk of SAH for first-degree relatives of patients with
SAH4 and suggests that at least part of the increased risk
for SAH is explained by a higher frequency of aneurysms and not
only, or not at all, by a higher risk of rupture. Third, patients with
atherosclerosis also had an increased frequency of
aneurysms, which corresponds with the finding that
cardiovascular diseases and SAH share the risk factors
smoking, hypertension, and alcohol abuse.38 Fourth, the
relative risk of ADPKD and familial predisposition was higher than that
of atherosclerosis, which confirms previous findings
that hypertension contributes less to the familial predisposition for
SAH than other, probably genetic, factors.39
In conclusion, data on prevalence vary considerably according to
methods used to detect aneurysms. Retrospective autopsy studies
probably give an underestimation and prospective angiography studies an
overestimation of the actual prevalence. If all available evidence is
taken together, for adults without risk factors for SAH,
aneurysms can be found in approximately 2%; it is possible
that the prevalence increases with age, but we could not convincingly
demonstrate this. The large majority of these aneurysms are
small (<10 mm), and the annual risk of rupture of these small
aneurysms is low (0.7% per year). These data should be kept in
mind when one is confronted with the task of advising patients with an
accidentally found asymptomatic aneurysm. In
patients with atherosclerosis and especially in
patients with familial predisposition or ADPKD, aneurysms are
found more often. Prospective studies should evaluate whether screening
and treating these patients with an increased risk is beneficial.
Received July 21, 1997;
revision received October 23, 1997;
accepted October 24, 1997.
© 1998 American Heart Association, Inc.
Comments, Opinions, and Reviews
Prevalence and Risk of Rupture of Intracranial Aneurysms
A Systematic Review
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background and Purpose—The estimates
on the prevalence and the risk of rupture of intracranial saccular
aneurysms vary widely between studies. We conducted a
systematic review on prevalence and risk of rupture of intracranial
aneurysms and classified the data according to study design,
study population, and aneurysm characteristics.
Key Words: subarachnoid hemorrhage • aneurysms • epidemiology • systematic review
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Uncertainty surrounds
the prevalence of unruptured saccular aneurysms on intracranial
arteries. In angiographic and autopsy studies, estimates for prevalence
vary between 2 and 90 per 1000.1 2 This wide range probably
reflects methodological differences between studies: prospective or
retrospective designs, diagnostic tools (angiography or
autopsy), and study populations. Many studies have included patients
with ruptured aneurysms, which results in too high a
prevalence. On the other hand, studies reviewing routine autopsy
records or angiograms of only a single carotid artery probably
underestimate the prevalence. Accurate data on the prevalence of
intracranial aneurysms are essential in evaluating the results
of screening programs for aneurysms in patients with increased
risk for SAH such as patients with ADPKD3 or first-degree
relatives of patients with SAH.4 Also, the management
strategy for unruptured aneurysms is influenced by the
prevalence; because the incidence of SAH has been properly assessed and
is stable,5 a higher than previously assumed prevalence of
aneurysms would mean that unruptured aneurysms are less
dangerous.
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Identification of Studies
To identify studies published between 1955 and June 1996 on
prevalence and natural history of intracranial saccular
aneurysms, we first performed a MEDLINE search from 1966
onward. Second, we searched the reference lists of all relevant
publications for additional studies. The references of the publications
thus found were checked again for additional studies published between
1955 and June of 1996. This method of cross-checking was continued
until no further publications were found. In case of multiple
publications on the same study population, we used the most recent
publication. Language other than English was not an exclusion
criterion.6
To assess eligibility, two authors independently reviewed all
studies with a set of predefined inclusion criteria. A first inclusion
criterion for all studies was that the presentation of data
included crude numbers or allowed recalculation into crude numbers. In
autopsy studies, additional inclusion criteria were that ruptured
saccular aneurysms and also fusiform and mycotic
aneurysms had to be excluded or separately reported. In
angiography studies on prevalence, additional criteria were (1)
angiography had to be intra-arterial, (2) the indication
for angiography had to be given, and (3) the number of patients had to
be more than 10. In studies that used CT angiography or MR angiography,
the presence of aneurysms had to be confirmed by conventional
angiography. The inclusion criteria for follow-up studies about the
risk of bleeding in patients with unruptured aneurysms were (1)
the type of aneurysm had to be identifiable as one of three
categories: incidental (found by chance), additional (multiple
aneurysms in patients with SAH), or symptomatic but
unruptured; (2) in patients with additional aneurysms, the
ruptured ("index") aneurysm had to have been clipped
(wrapping was considered inadequate to prevent further ruptures); and
(3) in patients with previously clipped aneurysms, the source
of subsequent bleeding had to be identified by CT, surgery, or autopsy,
to exclude rerupture of the previously clipped aneurysm as a
cause for the hemorrhage. In some studies, only subsets of
patients met all inclusion criteria; only those patients were included
in the review.
After the initial assessment for eligibility, two authors
independently extracted the following data for studies on prevalence:
total number of patients; number of patients with aneurysms;
age and sex of all patients and of patients with aneurysms; and
site and size of the aneurysms found. The indications for
angiography were categorized into the following groups: family history
of SAH, ADPKD, atherosclerosis (carotid artery disease
or ischemic heart disease), suspected pituitary adenoma, brain
tumor, and other. The ages of the patients were grouped into decades;
the sites of the aneurysms were grouped into one of four
locations: (1) ICA, (2) ACA or anterior cerebral and pericallosal
artery, (3) MCA, and (4) vertebrobasilar arteries. The sizes of the
aneurysms were categorized into categories of 5-mm increases,
and the size was also dichotomized into 10 mm or larger. For
follow-up studies in patients with unruptured aneurysms, we
recorded the total number of patients, the period of follow-up, and
the number of patients with SAH. When possible, we stratified data
according to age and sex of the patients and to site and size of the
aneurysms.
For calculating the risk of SAH in patients with unruptured
aneurysms, we multiplied the number of patients by the average
period of follow-up to obtain the total number of patient-years of
follow-up. The number of patients with subsequent SAH was then divided
by this number of patient-years, yielding the risk of SAH per
patient-year. We used this method for calculating the risk of SAH in
all patients as well as in the prespecified subgroups (according to age
group and sex or to type, site, and size of aneurysms).
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
For the overview of prevalence of aneurysms, we found 8
autopsy and 15 angiography studies that fulfilled all the inclusion
criteria (Fig 1
).1 2 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
One of these 23 publications was in French,13 another in
Japanese,25 and the remaining 21 were in English. The
number of patients studied in these 23 series totalled 56 304; 49 619
of these patients (88%) were from autopsy studies, and 6685 patients
(12%) were from angiography studies. In 738 patients, one or more
aneurysms were found; 405 of these patients (55%) were from
autopsy studies. Data on whether more than one aneurysm was
found in single patients could be extracted from two autopsy
studies13 18 and from all angiography studies; the number
of extra aneurysms was 23 in the autopsy studies and 69 in the
angiography studies. The total number of aneurysms found was
830.
View larger version (33K):
[in a new window]
Figure 1. Methods, overall prevalence, and subgroups
distinguished for autopsy studies (retrospective and prospective) and
angiography studies (retrospective and prospective). 
). The prevalence in these last three types of
studies combined was 4.3 (95% confidence interval, 4.0 to 4.7) per
100. The prevalence of aneurysms was very low in the first two
decades of life and steadily increased after the third decade; this
increase was statistically significant in a weighted linear regression
(Fig 2). Autopsy studies did not allow
relating the frequency of aneurysms to sex, comorbidity, or
cause of death. In angiography studies, more men (n=1754) than women
(n=1254) were studied; the prevalence was lower in men (Table 1). If subdivided according to the
indication for angiography, patients with ADPKD and patients with a
positive family history had the highest risk for aneurysms, but
patients with a suspected pituitary adenoma (in whom the angiogram was
often specifically done to exclude an aneurysm as cause of
compression on the optic nerve) and patients with
atherosclerosis also had a higher risk than patients
with a brain tumor or other indications for angiography (Table 1).
View larger version (13K):
[in a new window]
Figure 2. Prevalence of aneurysms per age group from
five autopsy studies1 8 9 12 18 and five angiography
studies.2 11 17 21 23
View this table:
[in a new window]
Table 1. Risk Factors for Presence of Intracranial
Aneurysms in Angiography Studies ). The size of the aneurysm
could be studied for categories of 5 mm in 356 aneurysms,
from 10 angiography and 2 autopsy studies (Table 2). The proportions
within these categories were similar in the autopsy and angiography
studies. One study used categories of 10 mm18; when
the 83 aneurysms 
10 mm and the 10 aneurysms
>10 mm from this study were added, the proportion of
aneurysms 10 mm remained essentially the same (8%; 95%
confidence interval, 5% to 11%).
View this table:
[in a new window]
Table 2. Sites and Sizes of Aneurysms1 ).28 29 30 31 32 33 34 35 36
View this table:
[in a new window]
Table 3. Risk of Rupture of
Aneurysms28 29 30 31 32 33 34 35 36
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
The frequency of incidental aneurysms varied considerably
according to the indication for the imaging studies. The prevalence of
2.3 per 100 in patients with brain tumors or miscellaneous indications
may most closely represent the prevalence in the general
population, although this number probably overestimates the actual rate
because the prevalence in patients younger than 20 years is very low
and this age group is obviously underrepresented in this
study sample. The frequency of aneurysms is higher in patients
investigated for ADPKD or with a familial predisposition for SAH,
suspected pituitary adenomas, and atherosclerosis;
moreover, it tends to increase with age in adults. 10 mm, 1605 subjects in the cohort will have an
aneurysm 10 mm, and 120 subjects an aneurysm
>10 mm. If the annual risk of rupture in this cohort (0.7% for
aneurysms <10 mm and 4% for those of 
10 mm) is
corrected on the assumption that in the general population almost all
ruptured aneurysms are previously asymptomatic and
not additional to a ruptured aneurysm (0.8/1.9=0.4) in a single
year, 0.4*0.7% of the 1605 small aneurysms (n=4.6) and
0.4*4% of the 120 large aneurysms (n=1.9) will rupture; the
total number of SAHs within the cohort of 100 000 subjects will
therefore be 6.5. This calculated incidence is similar to the incidence
of 6 per 100 000 patient-years observed in the population.
Selected Abbreviations and Acronyms
ACA
=
anterior communicating artery
ADPKD
=
autosomal dominant polycystic kidney disease
ICA
=
internal carotid artery
MCA
=
middle cerebral artery
SAH
=
subarachnoid hemorrhage
Acknowledgments
This study was partially funded by a clinical investigator grant
from the University Hospital Utrecht to G.J.E. Rinkel and a
NUFFIC grant to M. Djibuti (CN.1942). We would like to thank Fleur
Bominaar for accurate help in preparing the tables and figures and Stef
Koele for excellent secretarial assistance.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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