Screening

Screening for asymptomatic cerebral aneurysms is warranted, as rupture is associated with a very poor prognosis and treatment of unruptured aneurysms is associated with a low morbidity and mortality.[8]

Magnetic resonance angiography (MRA) is considered the appropriate first test in cerebral aneurysm screening, as it is noninvasive and safe. The primary limitation is the inability to reliably detect aneurysms <3 mm in diameter.[36] CT angiography (CTA) adds the small risk associated with giving a bolus of nonionic contrast, but it is particularly helpful in visualizing cerebral vasculature with clips in place.

The joint American Heart Association and American Stroke Association guidelines recommend screening for cerebral aneurysms by CT angiography or magnetic resonance angiography in people with two or more family members affected by cerebral aneurysm or subarachnoid hemorrhage.[18] A subsequent systematic review found strong arguments in favor of screening people with one or more first-degree relatives affected.[37]​ For these people, a history of hypertension, smoking, and female sex are risk factors associated with aneurysm occurrence.[18]

Screening is also indicated for people with certain genetic syndromes, such as Ehlers-Danlos syndrome type IV, Marfan syndrome, neurofibromatosis type 1, and autosomal dominant polycystic kidney disease, particularly if they have a family history of cerebral aneurysm.[18] It is also judicious to offer CTA or MRA to patients with coarctation of the aorta, and patients with microcephalic osteodysplastic primordial dwarfism.[18]

Patients with a prior history of cerebral aneurysms also have a higher rate of future de novo aneurysm formation and should be screened at 5-year intervals.[38]

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