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Despite Low Risk of Rupture, Most Neurologists Would Refer Intracranial Aneurysms to Neurosurgeons: Presented at ISC

By Paula Moyer

SAN DIEGO, CA -- February 9, 2004 -- Although unruptured intracranial aneurysms have less than a 1% annual risk of rupture, most neurologists would refer such patients to neurosurgeons, according to findings presented here February 6^th at the American Stroke Association's 29^th International Stroke Conference.

Because aneurysm repair entails far more risk than does conservative monitoring, physicians need to be more judicious in their referrals, cautioned Seemant Chaturvedi, MD, Associate Professor of Neurology, and Director, Wayne State University Stroke Program, Detroit, Michigan.

Investigators for the International Study of Unruptured Intracranial Aneurysms (ISUIA) previously found that, in patients with no prior history of rupture, less than 1% of unruptured intracranial aneurysms will rupture annually, and that surgery to correct such defects had complications rates ranging from 15% to 20%.

To determine if these findings had affected clinical practice, Dr. Chaturvedi and colleagues investigated whether neurologists were referring fewer patients with intact aneurysms to neurosurgeons. They also wanted to see if neurologists in the United States would cite medicolegal factors as a reason for referral more often than their Canadian counterparts.

The investigators sent a survey to 200 neurologists practicing in the United States and 200 practicing in Canada, with names drawn from the directory of the American Academy of Neurology. The participants were asked to consider three cases of unruptured aneurysm in a 45-year-old woman with chronic headaches: a 5 mm middle cerebral artery aneurysm; an 8 mm MCA aneurysm, and a 12 mm basilar tip aneurysm. They also were asked whether medicolegal factors and the ISUIA findings affected their referral decisions.

Response rates to the survey were 41% among Canadian and 30% among United States neurologists. Of these, 66% of Canadians and 74% of Americans said they would refer the patient with a 5 mm middle cerebral artery aneurysm to a neurosurgeon, rates that were not statistically significantly different (P = .32).

The overwhelming majority (90% of Canadians and 90% of Americans) said they would refer the patient with an 8 mm MCA. Almost all (97% and 98%, respectively) said they would refer the 12 mm aneurysm.

Neurologists practicing in the United States were more concerned about malpractice suits, with 87% citing such concerns as a reason for referral, compared to 48% of their Canadian counterparts (P < .001). Two-thirds of respondents in both countries said they knew about the ISUIA findings. However, ISUIA had led to a decrease in neurosurgical referrals in 29% of Canadian respondents and 16% of U.S. respondents.

The investigators were surprised to see that ISUIA had such a limited impact on the way neurologists respond to these lesions, said Dr. Chaturvedi. He said that annual monitoring with magnetic resonance imaging is sufficient for initial monitoring of stable aneurysms, and that such monitoring can be performed every 2 years subsequently for aneurysms that do not grow.


[Study title: Has the International Study of Unruptured Intracranial Aneurysms Affected Referrals to Neurosurgeons? Abstract P410]

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