The unruptured intracranial aneurysm treatment score · The unruptured intracranial aneurysm treatment score A multidisciplinary consensus ABSTRACT Objective: We endeavored to develop
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The unruptured intracranial aneurysmtreatment scoreA multidisciplinary consensus
ABSTRACT
Objective We endeavored to develop an unruptured intracranial aneurysm (UIA) treatment score(UIATS) model that includes and quantifies key factors involved in clinical decision-making in themanagement of UIAs and to assess agreement for this model among specialists in UIA managementand research
Methods An international multidisciplinary (neurosurgery neuroradiology neurology clinical epidemi-ology) group of 69 specialists was convened to develop and validate the UIATS model using a Delphiconsensus For internal (39 panel members involved in identification of relevant features) and externalvalidation (30 independent external reviewers) 30 selected UIA cases were used to analyze agree-ment with UIATS management recommendations based on a 5-point Likert scale (5 indicating strongagreement) Interrater agreement (IRA) was assessed with standardized coefficients of dispersion (vr)(vr 5 0 indicating excellent agreement and vr 5 1 indicating poor agreement)
Results The UIATS accounts for 29 key factors in UIA management Agreement with UIATS (meanLikert scores) was 42 (95 confidence interval [CI] 41ndash43) per reviewer for both reviewer cohortsagreement per case was 43 (95 CI 41ndash44) for panel members and 45 (95 CI 43ndash46) forexternal reviewers (p 5 0017) Mean Likert scores were 42 (95 CI 41ndash43) for interventionalreviewers (n 5 56) and 41 (95 CI 39ndash44) for noninterventional reviewers (n 5 12) (p 5 0290)Overall IRA (vr) for both cohorts was 0026 (95 CI 0019ndash0033)
Conclusions This novel UIA decision guidance study captures an excellent consensus amonghighly informed individuals on UIA management irrespective of their underlying specialty Clini-cians can use the UIATS as a comprehensive mechanism for indicating how a large group of spe-cialists might manage an individual patient with a UIA Neurologyreg 201585881ndash889
Unruptured intracranial aneurysms (UIAs) are prevalent in 3 of the adult population and areincreasingly detected due to more frequent cranial imaging12 Previous cohort studies found thatonly a small proportion of UIAs rupture causing subarachnoid hemorrhage (SAH) with a significantcase fatality rate3ndash9 Although partially biased by selection of specific subgroups of UIAs these studiesfound that especially small UIAs generally have a low risk of rupture However because small UIAsare so highly prevalent most instances of SAH are caused by rupture of small aneurysms but itremains unclear which small UIAs are prone to rupture so that preventive treatment could beconsidered Case-control studies have suggested factors (eg UIA morphology family history smok-ing or hypertension) that may increase the risk of UIA rupture but uncertainties remain10ndash13 This isfurther complicated by the fact that there are only a few established risk factors for complicationsduring aneurysm repair (eg patient age) even though numerous factors have been suggested1415
Thus data with varying levels of evidence must be taken into account when counseling patients withUIAs which may lead to high levels of variation in the management of UIA among clinicians1617
Nima Etminan MDRobert D Brown Jr MDKerim Beseoglu MDSeppo Juvela MD PhDJean Raymond MDAkio Morita MD PhDJames C Torner MSc
FRCP Edin PhDDaniel L Barrow MDJoshua Bederson MDAlain Bonafe MDAaron S Dumont MDDavid J Fiorella MD
PhDAndreas Gruber MDGraeme J Hankey MDDavid M Hasan MDBrian L Hoh MDPascal Jabbour MDHidetoshi Kasuya MDMichael E Kelly MDPeter J Kirkpatrick MDNeville Knuckey MDTimo Koivisto MD PhDTimo Krings MD PhDMichael T Lawton MDThomas R Marotta MDStephan A Mayer MDEdward Mee MDVitor Mendes Pereira
MD MScAndrew Molyneux MDMichael K Morgan MD
Author list continued on next page
Author affiliations are provided at the end of the article
Go to Neurologyorg for full disclosures Funding information and disclosures deemed relevant by the authors if any are provided at the end of the articleThe Article Processing Charge was paid by the Department of Neurosurgery Medical Faculty Heinrich-Heine University Duumlsseldorf Germany
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 40 (CC BY-NC-ND)which permits downloading and sharing the work provided it is properly cited The work cannot be changed in any way or used commercially
copy 2015 American Academy of Neurology 881
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
Our aim was to (1) develop a UIA treatmentscore (UIATS) that explicitly summarizes andquantifies recently reported consensus data onfactors UIA specialists consider for appropriatemanagement of UIAs and (2) assess agreementwith management recommendations based onthe UIATS among specialists who were andwere not involved in its development18
METHODS Delphi consensus A multidisciplinary group of
69 cerebrovascular specialists consisting of 43 neurosurgeons
(11 of whom were trained in both neurosurgical and endovascular
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
dispersion (vr) were calculated to determine the degree of
interrater agreement for every case18 vr Values approaching 0
correspond to a high degree of interrater agreement whereas vr
values approaching 1 correspond to a low degree of interrater
agreement The Pearsonrsquo product-moment correlation coefficient
was calculated to analyze the potential association between the level
of agreement among panel members or external reviewers and the
score magnitude The score magnitude defined as the absolute
difference between the UIATS numerical values supporting
ldquoaneurysm repairrdquo and ldquoconservative managementrdquo for each case
(a small score magnitude suggests a less definitive UIATS
recommendation) was used to analyze the relation of the
strength of a UIATS-derived recommendation and the level of
agreement among the reviewers
RESULTS The study flow and participant frequen-cies during the Delphi consensus process are givenin figure 1 The UIATS model was developed basedon the data from rounds 1ndash4 in 3 domains (patient-aneurysm- and treatment-related) comprising 13different categories and 29 different features (figure 2)
The applicability of the preliminary UIATS modelwas initially tested in round 5 Mean agreement withUIATS-derived recommendations based on Likertscores (5 indicating strong agreement and 1 indicatingstrong disagreement) was 37 (95 CI 36ndash38) perpanel member and 37 (95 CI 33ndash41) per caseAfter adjustment of the UIATS for age and aneurysmsize mean agreement with treatment recommenda-tions based on the final UIATS model per reviewerwas 42 (95 CI 41ndash43) for the panel members(p 0001 compared to round 5) and 42 (95 CI41ndash43) for the external reviewers Mean agreementper case was 43 (95 CI 41ndash44) for panel members(p 001 compared to round 5) and 45 (95 CI43ndash46) for external reviewers (figure 3A) Agreementper case was higher among external reviewers thanamong panel members (p 5 0017 Mann-WhitneyU test) Dichotomized overall agreement (agree vs dis-agree) with treatment recommendations based on the
Figure 1 Study flow of the Delphi consensus process
Participant frequencies for each round are given in parentheses The panel member group consisted of 28 neurosurgeons (5of whom were dually trained in endovascular and microsurgical aneurysm repair) 7 interventional neuroradiologists 3 neu-rologists and 1 clinical epidemiologist The external reviewer group consisted of 15 neurosurgeons (7 of whom were duallytrained in endovascular and microsurgical aneurysm repair) 7 interventional neuroradiologists and 8 neurologists CV 5
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
Figure 2 The unruptured intracranial aneurysm treatment scoreThe unruptured intracranialaneurysm treatment score(UIATS) model includes andquantifies the key factorsfor clinical decision-makingin the management of unrup-tured intracranial aneurysms(UIAs) developedbasedon rele-vance rating data from Delphiconsensus rounds 1ndash418 Tocalculate a management rec-ommendation for a UIA thenumber of points correspond-ing to each patient- aneu-rysm- or treatment-relatedfeature on both managementcolumns of the scoring form(ldquoin favor of UIA repairrdquo and ldquoinfavor of UIA conservative man-agementrdquo) are added up Thiswill lead to 2 numerical values1 favoring aneurysm repair(surgical or endovascular) and1 favoring conservative man-agement The definitions foreach category and factor arefound in the Methods sectionFor cases with a score differ-ence of 3 points or more thedirection ie the differencebetween the calculated numer-ical values on each side of therecommendation columns willsuggest an individual manage-ment recommendation (ieaneurysm repair or conserva-tive management) For casesthat have similar aneurysmtreatment and conservativemanagement scores (62 pointdifference or less) the recom-mendation is ldquonot definitiverdquo andeither management approachcould be supported as additionalfactors apart from those used inthe development of UIATSmay be considered in makinga final decision regarding themanagement recommenda-tion and long-term follow-upFor cases with multiple aneur-ysms every aneurysm must beevaluated separately which willthen also result in separate rec-ommendations for each aneu-rysm The minimal intervention-related risk is always added as aconstant factor (5 points)AComA 5 anterior communi-cating artery BasA 5 basilarartery BP 5 blood pressuremultiple 5 multiple selectioncategory PComA 5 poste-rior communicating arterySAH 5 subarachnoid hemor-rhage single 5 single selec-tion category
884 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
UIATS was 95 among panel members and 94among external reviewers Interrater agreement per casewas high for both reviewersrsquo cohorts (vr5 0023 95CI 0018ndash0027 for panel members vr5 0028 95CI 0022ndash0034 for external reviewers) Despite an
unbalanced distribution of specialties among theconsensus group there was no difference (p 5
0290 Mann-Whitney U test) in mean Likert scoresper reviewer between interventional (42 95 CI41ndash43 for neurosurgery interventional neuroradi-ology or both n 5 56) and noninterventional (4195 CI 39ndash44 for neurology and clinical epidemi-ology n5 12) specialties or between individual spe-cialties (p 5 0325 Mann-Whitney U test) Therewas a distinct correlation between the score magni-tude of the recommendation (difference in pointsfor interventional and conservative management)and the level of agreement suggesting that theclearer the recommendation of the UIATS thehigher the level of agreement among the reviewers(figure 3B) A representative set of UIATS examplesand corresponding UIATS recommendations result-ing in the highest and lowest overall agreement areillustrated in figures 4 and 5 respectively
DISCUSSION The key finding of our consensus pro-ject among a large and diverse group of multidisciplinarycerebrovascular specialists is that we were able to developa comprehensive scoring model for management recom-mendations for UIAs Importantly this model is in highagreement with current UIA decision-making in aselected UIA patient population evidenced by thehigh agreement and interrater agreement with UIATS-derived recommendations among the specialist groupThe level of agreement with managementrecommendations based on the UIATS model isindependent from the underlying professionalbackground of the specialists ie interventionalor noninterventional and is even higher amongspecialists who were not involved in the developmentof the scoring model
The UIATS is neither a prognostic study nor apredictive model for UIA rupture as it is derivedfrom consensus on contemporary practice of UIAmanagement among cerebrovascular specialists usingthe Delphi method and only indirectly from pub-lished data In that sense it differs from the recentlydeveloped PHASES score a model based on prospec-tively collected data from 6 cohort studies on risk ofUIA rupture that provides absolute risks of rupturefor the initial 5 years after aneurysm detection using6 easily retrievable baseline characteristics (patientgeographical location and age aneurysm size andlocation presence of arterial hypertension and previ-ous SAH from a different aneurysm)23 Howeversome subgroups in the PHASES score were under-represented such as patients with familial aneurysmsor may have been underrepresented such as youngsmokers Thus the score may not apply to all patientsAlso the score holds true for only the initial 5 yearsafter UIA detection because of limited long-term
Figure 3 Validation of the UIATS
(A) Agreement with unruptured intracranial aneurysm treatment score (UIATS)-derived recom-mendations per case and per rater Means for Likert scores (y-axis) are illustrated for each case(dots) and for each rater (circles) among panel members and the blinded external reviewers(x-axis) A Likert score of 5 indicates strong agreement 4 indicates agreement 3 indicates neu-trality 2 indicates disagreement and 1 indicates strong disagreement Since means for Likertscores did not fall below a score of 3 the y-axis scale does not show disagreement and strongdisagreement Compared to agreement of panel members with UIATS-derived treatment recom-mendations for each case themeanLikert score (y-axis) was significantly higher among the exter-nal reviewers who were completely blinded to the score raw data and the survey developmentand design (indicates p 5 0017) (B) Correlation of Likert scores and UIATS characteristicsThe level of agreement (y-axis) between panel members and external reviewers was correlated(Pearson product-moment) with the UIATS differences between aneurysm repair and conserva-tive management for every UIATS treatment recommendation (x-axis) The score magnitudecorrelated significantly with agreement among the reviewers independently for panel members(r2 5 0323 p 5 0002 solid line) and external reviewers (r2 5 0399 p 0001 dotted line)
Neurology 85 September 8 2015 885
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
follow-up data and many patients have a predicted lifeexpectancy of more than 5 years Moreover severalaneurysm characteristics found or suggested to be riskfactors for rupture in case-control studies could not beincluded in the PHASES score Finally the PHASESscore was developed to predict the risk of rupturewhereas when a clinician recommends repair of aUIA the risk of intervention must also be taken intoaccount which is not done in the PHASES scoreThus many uncertainties due to varying levels of evi-dence remain which have to be accounted for in clin-ical practice when consulting patients with UIAs
The UIATS model was designed to address theseuncertainties and thus to potentially harmonize the
high level of variation among clinicians about the indi-vidual management of patients with UIA The UIATSwas developed partially based on data but also usingconsensus among specialists in the field The merit ofthis model is that it accounts for many different factorsthat often influence clinical decisions but that were notwell studied in previous observational studies egyoung age or long life expectancy coexistent modifiableor nonmodifiable risk factors coexistent morbiditiesmorphologic UIA features or relevance of clinicalsymptoms related to UIAs51011132425 Admittedlythe UIATS model requires more baseline characteris-tics than the PHASES score which makes its applica-tion slightly more time consuming However ourresults highlight that specialists in UIA research andtreatment account for these factors in their decision-making and that these specialists have a high level ofagreement about how to handle these factors for whichdata are currently incomplete or lacking We used theDelphi method to scientifically obtain consensus andsubsequently to systematically categorize potential fac-tors for contemporary decision-making on the appro-priate management of UIAs Studies from othermedical fields have used the Delphi method to system-atically reach consensus or develop treatment scores onsimilar controversial or complex subjects among pro-fessionally andor geographically dispersed special-ists26ndash28 We emphasize that data derived fromconsensus among specialists cannot replace evidencebut rather can complement it specifically in areaswhere there is uncertainty If more observational databecome available and predictors for aneurysm ruptureand treatment complications become more sophisti-cated the UIATS model could be adjusted Howeveruntil such data become available our proposed scoringmodel constitutes an organized and objective means ofcapturing the best consensus possible on UIA manage-ment as a complement to existing UIA rupture riskprediction models
Our study has several limitations Although weincluded a wide variety of multidisciplinary specialistsfrom various predominantly high-income Westerncountries with different health care systems we can-not claim that this ldquopopulationrdquo of specialists is rep-resentative of the general ldquocommunity of UIAspecialists or expertsrdquo if such a group could bedefined Second one important premise in the con-struction of the UIATS is that the management ofUIAs constitutes a comparison between the risk ofrupture vs the risks of treatment in that particularpatient Some have argued that these 2 ldquoquantitiesrdquoone being a risk event rate and the other being a one-time risk cannot validly be compared29 However indaily practice this is what clinicians do ie comparethe risk of aneurysm rupture with the risk of prophy-lactic aneurysm repair Third we used a binary
Figure 4 UIATS case recommendation resulting in the highest agreementamong the internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 47-year-old woman (3points favoring treatment for patient age 41ndash60 years) who previously underwent cranialMRI for chronic headaches with (A) posterior-anterior and (B) lateral projection as well as (C)posterior-anterior and (D) lateral 3-dimensional reconstructions is shown This incidentalirregularly shaped (3 points favoring treatment for irregular morphology) anterior communi-cating artery aneurysm (arrow 2 points favoring treatment for aneurysm location) had amaximum diameter of 76 mm (2 points favoring treatment for aneurysm diameter) with aneck diameter of 35 mm Aspect and size ratios were calculated to be 21 and 38 respec-tively (1 point favoring treatment for aspect or size ratio greater than 16 or 30 respec-tively) Her medical history included arterial hypertension (2 points favoring treatment forrisk factor hypertension) but no other chronic comorbidities The resulting scoring based onthe UIATS was 13 points in favor of aneurysm repair and 7 points in favor of conservativemanagement (1 point for patient age 41ndash60 years 1 point for aneurysm size 6ndash10 mm and5 points for the constant intervention-related risk) The resulting UIATS recommendationwas ldquoaneurysm repairrdquo Overall agreement with this UIATS recommendation was 473 (95confidence interval 462ndash485) for both reviewer cohorts
886 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
decision scenario (treat or not treat) rather than mak-ing distinctions between different possible treatmentmodalities mainly to propose a unifying scoringmodel that would not divide the specialist groupFourth we used pooled data from meta-analyses toincorporate treatment risk percentages into ourmodel However given the lack of more robust dataon risk factors for UIA treatment complications it isunclear whether the individual treatment risk in apatient with a UIA may be distinctly lower or higherdepending on the surgeonrsquos or interventionalistrsquosexperience the treatment modality and the aneu-rysm complexity Lastly the series of cases we vali-dated with the UIATS covered a wide range ofpatients and aneurysms but may not entirely reflectthe complete spectrum of patients and aneurysms
seen in clinical practice As an example in the valida-tion data set 13 of 30 UIAs were larger than 7 mmwhich may not reflect the actual UIA size distributionin the general population In addition the presenta-tion of the actual score values to the external reviewersduring the validation may have introduced some biasif these external experts were somewhat uncertain andtherefore more willing to agree with the proposedrecommendations However given the expertise ofthe external reviewers we do not feel this has influ-enced the results to a large extent
This multidisciplinary consensus project has re-sulted in the UIATSmodel which captures contempo-rary and multifactorial decision-making by specialistson UIA management By applying this scoring modelclinicians can appreciate what highly informed individ-uals in the cerebrovascular field would advise in a par-ticular patient based on current data and uncertaintiesSince the validity of the UIATSmodel was tested basedon theoretical rather than empirical data its applicabil-ity and clinical accuracy remain to be prospectivelyexplored in patients with UIA Thus the current treat-ment recommendations may change if new data fromsuch studies or future observational UIA studiesbecome available Ultimately individual patient factorsbeyond those accounted for in the present scoringmodel may also alter the individual management of apatient with a UIA
AUTHOR AFFILIATIONFrom the Department of Neurosurgery (NE KB AA H-JS DH)
Medical Faculty Heinrich-Heine-University Duumlsseldorf Germany Depart-
ments of Neurology (RDB AAR) and Neurologic Surgery (GL) Mayo
Clinic Rochester MN Department of Clinical Neurosciences (SJ) University
of Helsinki Finland Department of RadiologymdashInterventional Neuroradiol-
ogy (J Raymond) CHUM Research Center Notre-Dame Hospital Montreal
Quebec Canada Department of Neurological Surgery (A Morita) Nippon
Medical School Tokyo Japan Departments of Epidemiology (JCT) and
Neurosurgery (DMH) University of Iowa Iowa City Mallinckrodt Institute
of Radiology (CPD) Washington University School of MedicineBarnes-
Jewish Hospital St Louis MO Department of Neurosurgery (A Raabe)
Inselspital Bern Switzerland Department of Neurological Surgery (JM)
Vanderbilt University Medical Center Nashville TN Department of Neuro-
surgery (MK MN) Helsinki University Central Hospital Helsinki Finland
Department of Neurosurgery (SA-H) University of Illinois at Chicago
Centre for Clinical Brain Sciences (RA-SS) University of Edinburgh
United Kingdom Department of Neurosurgery (DLB) Emory Stroke Cen-
ter Emory University School of Medicine Atlanta GA Department of Neu-
rosurgery (JB) The Mount Sinai Health System New York NY Department
of Neuroradiology (AB) CHUMontpellier Montpellier France Department
of Neurosurgery (ASD) Tulane University School of Medicine New
Orleans LA Department of Neurosurgery (DJK) Cerebrovascular Centre
Stony Brook University Medical Center Stony Brook NY Department of
Neurosurgery (AG) Medical University of Vienna Austria Department of
Neurology (GJH) and Neurosurgery Unit (NK) Sir Charles Gairdner Hos-
pital Nedlands Western Australia Australia School of Medicine and Pharma-
cology (GJH) The University of Western Australia Perth Australia
Department of Neurosurgery (BLH) University of Florida Gainesville
Department of Neurological Surgery (PJ RHR) Thomas Jefferson Univer-
sity Hospital Philadelphia PA Department of Neurosurgery (HK) Tokyo
Womenrsquos Medical University Medical Center East Tokyo Japan Saskatche-
wan Cerebrovascular Centre (MEK) Royal University Hospital University of
Saskatchewan Saskatoon Canada Department of Clinical Neurosciences
Figure 5 UIATS case recommendation resulting in the lowest agreement amongthe internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 25-year-old woman(4 points favoring treatment for patient age younger than 40 years) who previously under-went MRI for persistent headaches vertigo and occasional bitemporal vision disturbances(due to a migraine aura) with (A) posterior-anterior and (B) lateral projection as well as (C) pos-terior-anterior and (D) lateral 3-dimensional reconstructions is shown This left-sided wide-necked paraophthalmic internal carotid artery aneurysm had a maximum diameter of3 mmwith a neck diameter of 27 mm (3 points favoring conservative management for aneu-rysm complexity due to wide neck) The patient did not report any additional risk factors orcomorbidities in her past medical history The resulting scores based on the UIATS were4 points in favor of aneurysm repair and 8 points (including 5 points favoring conservativemanagement for the constant intervention-related risk) in favor of conservative manage-ment The resulting UIATS recommendation was ldquoconservative managementrdquoOverall agree-ment with this UIATS recommendation was 37 (95 confidence interval 344ndash396) forboth reviewer cohorts
Neurology 85 September 8 2015 887
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
(PJK) Cambridge University Hospitals Trust University of Cambridge
United Kingdom NeurosurgeryNeuroCenter (T Koivisto) Kuopio University
Hospital University of Eastern Finland Finland Department of Medical Imag-
ing and Surgery (T Krings VMP) Toronto Western Hospital University
Health Network Toronto Ontario Canada Department of Neurological Sur-
gery (MTL) University of California San Francisco Divisions of Neurora-
diology (TRM) and Neurosurgery (JS RLM) St Michaels Hospital
University of Toronto Ontario Canada Institute for Critical Care Medicine
(SAM) Icahn School of Medicine at Mount Sinai New York NY Depart-
ment of Neurosurgery (EM) Auckland City Hospital Auckland New
Zealand Nuffield Department of Surgical Sciences (A Molyneux) University
of Oxford United Kingdom Division of Neurosurgery (MKM) Australian
School of Advanced Medicine Macquarie University Sydney Australia
Department of Neurosurgery (KM) National Defense Medical College
Tokyo Japan Department of Neurosurgery (YM) JIKEI University School
of Medicine Tokyo Japan Department of Neurosurgery (SN) Institute of
Health Bioscience University of Tokushima Graduate School Tokushima
Japan Department of Neurosurgery (NN) Hokkaido University Graduate
School of Medicine Hokkaido Japan Endovascular and Operative Neurovas-
cular Surgery (CSO) Beth Israel Deaconess Medical Center Harvard Medical
School Boston MA Department of Radiology (LP) University Hospital
Reims France Department of Neurology (YBWEMR) Academic Medical
Center Amsterdam the Netherlands Department of Neurosurgery (J Rinne)
Division of Clinical Neurosciences Turku University Hospital Turku Finland
Department of Neurosurgery (A Ronkainen) Tampere University Hospital
Tampere Finland Department of Neurosurgery (KS) Geneva University
Hospital Switzerland Departments of Neurosurgery (VS) and Neurology
(HS) Goethe University Frankfurt Germany Department of Neurological
Surgery (RAS ESC) New York Presbyterian Hospital Columbia Univer-
sity College of Physicians and Surgeons New York NY Brain Center Rudolf
Magnus (MDIV GJER) Department of Neurology and Neurosurgery
University Medical Centre Utrecht the Netherlands Institute for Diagnostic
and Interventional Radiology and Neuroradiology (IW) University Hospital
of Essen Germany SwissNeuroInstitute (IW DR) Clinic Hirslanden
Zurich Switzerland Department of Neurology (MJHW) Leiden University
Medical Center Leiden the Netherlands Department of Surgery and Neuro-
surgery (GKCW) Prince of Wales Hospital The Chinese University of
Hong Kong Hong Kong China Division of Neurosurgery (JHW) Depart-
ments of Clinical Neurosciences and Diagnostic Imaging University of Calgary
Alberta Canada Departments of Neurological Surgery and Neurology (GJZ)
Washington University School of Medicine St Louis MO Institute of Neu-
rosurgery (AP) Section of Vascular Neurosurgery Verona University amp City
Hospital Verona Italy Department of Neurosurgery (PV) Chariteacute University
Medical Centre Berlin Germany Division of Neurological Surgery (CM)
Barrow Neurological Institute St Josephs Hospital and Medical Center
Phoenix AZ and Brain and Spine Center (PL) Lankenau Medical Center
Wynnewood PA
AUTHOR CONTRIBUTIONSNE RDB KB SJ J Ra A Ra AA ESC HS GL AP
DR PV CM PLR and RLM were involved in the design of
the study NE and KB collected analyzed and interpreted the data
but did not participate in the Delphi consensus NE RDB KB
SJ JRa AkMo JCT CPD ARa JM MK PV DH
GJER and RLM drafted the paper RDB SJ JRa AkMo
JCT CPD ARa JM MK SAH RAlSa DLB JB
AB AD DJF AG GH DMH BLH PJ HK MEK
PJK NK TiKo TiKr MTL TRM SAM EM AnMo
MKM KM YM SN NaNa MN CSO VMP LP
AAR YBWEMR JaRi RHR AnRo KS VS RASo
JS HJS MDIV IW MJHW GKCW JHW GJZ
PV CM DH GJER and RLM participated in the study re-
viewed and commented on the final version of the manuscript
STUDY FUNDINGNo targeted funding reported
DISCLOSUREN Etminan is a scientific advisorofficer for Edge Therapeutics Inc
R Brown K Beseoglu S Juvela J Raymond A Morita and J Torner
report no disclosures relevant to the manuscript C Derdeyn serves on
the Scientific Advisory Board for W L Gore and Associates and Pulse
Therapeutics He is a consultant for Penumbra Inc (DSMB member)
and Microvention (Angio Core Lab for brain aneurysm stent trial)
A Raabe J Mocco M Korja A Abdulazim S Amin-Hanjani
R Al-Shahi Salman D Barrow J Bederson A Bonafe and A Dumont
report no disclosures relevant to the manuscript D Fiorella is a consultant
for Codman Neurovascular CovidienEV3 Sequent Medical and Siemens
Medical Imaging and received research support from Penumbra Inc and
Microvention A Gruber G Hankey D Hasan B Hoh P Jabbour
and H Kasuya report no disclosures relevant to the manuscript M Kelly
is a shareholder of Blockade Medical Inc P Kirkpatrick N Knuckey
T Koivisto T Krings M Lawton and T Marotta report no disclosures
relevant to the manuscript S Mayer is a consultant for Edge Therapeutics
Inc and Actelion Pharmaceuticals E Mee reports no disclosures relevant to
the manuscript V Mendes Pereira is consultant for Covidien A
Molyneux M Morgan K Mori Y Murayama S Nagahiro N
Nakayama M Nimelauml C Ogilvy L Pierot A Rabinstein Y Roos J
Rinne R Rosenwasser A Ronkainen K Schaller V Seifert R Solomon
J Spears H-J Steiger M Vergouwen I Wanke M Wermer G Wong J
Wong G Zipfel E Sander Connolly and H Steinmetz report no disclosures
relevant to the manuscript G Lanzino is a consultant for Covidien Edge
Therapeutics Inc and Codman A Pasqualin D Ruumlfenacht P Vajkoczy
and C McDougall report no disclosures relevant to the manuscript
D Haumlnggi is a scientific advisorofficer for Edge Therapeutics Inc P LeRoux
is a Scientific Advisory Board member for Edge Therapeutics Inc and a
consultant for Integra Codman Synthes Neurologica Brainsgate and Orsan
G Rinkel reports no disclosures relevant to the manuscript R Macdonald is
Chief Scientific Officer of Edge Therapeutics Inc and received grant support
from the Physicians Services Incorporated Foundation Brain Aneurysm Foun-
dation Canadian Institutes for Health Research and the Heart and Stroke
Foundation of Canada Go to Neurologyorg for full disclosures
Received January 5 2015 Accepted in final form April 18 2015
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rate of brain arteriovenous malformations in a large mul-
tiethnic defined population Stroke 20104121ndash26
2 Vlak MH Algra A Brandenburg R Rinkel GJ Prevalence
of unruptured intracranial aneurysms with emphasis on sex
age comorbidity country and time period a systematic
review and meta-analysis Lancet Neurol 201110626ndash636
3 Ishibashi T Murayama Y Urashima M et al Unruptured
intracranial aneurysms incidence of rupture and risk fac-
tors Stroke 200940313ndash316
4 Juvela S Poussa K Lehto H Porras M Natural history of
unruptured intracranial aneurysms a long-term follow-up
study Stroke 2013442414ndash2421
5 Morita A Kirino T Hashi K et al The natural course of
unruptured cerebral aneurysms in a Japanese cohort N
Engl J Med 20123662474ndash2482
6 Nieuwkamp DJ Setz LE Algra A Linn FH de Rooij NK
Rinkel GJ Changes in case fatality of aneurysmal subarach-
noid haemorrhage over time according to age sex and
region a meta-analysis Lancet Neurol 20098635ndash642
7 Sonobe M Yamazaki T Yonekura M Kikuchi H Small
unruptured intracranial aneurysm verification study
SUAVe study Japan Stroke 2010411969ndash1977
8 Wermer MJ van der Schaaf IC Velthuis BK Majoie CB
Albrecht KW Rinkel GJ Yield of short-term follow-up
CTMR angiography for small aneurysms detected at
screening Stroke 200637414ndash418
9 Wiebers DO Whisnant JP Huston J III et al Unrup-
tured intracranial aneurysms natural history clinical out-
come and risks of surgical and endovascular treatment
Lancet 2003362103ndash110
888 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
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Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
ServicesUpdated Information amp
httpnneurologyorgcontent8510881fullincluding high resolution figures can be found at
This article has been cited by 6 HighWire-hosted articles
Subspecialty Collections
httpnneurologyorgcgicollectionstroke_preventionStroke prevention e
httpnneurologyorgcgicollectionall_cerebrovascular_disease_strokAll Cerebrovascular diseaseStrokefollowing collection(s) This article along with others on similar topics appears in the
Permissions amp Licensing
httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in
Reprints
httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online
rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All
reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology
Our aim was to (1) develop a UIA treatmentscore (UIATS) that explicitly summarizes andquantifies recently reported consensus data onfactors UIA specialists consider for appropriatemanagement of UIAs and (2) assess agreementwith management recommendations based onthe UIATS among specialists who were andwere not involved in its development18
METHODS Delphi consensus A multidisciplinary group of
69 cerebrovascular specialists consisting of 43 neurosurgeons
(11 of whom were trained in both neurosurgical and endovascular
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
dispersion (vr) were calculated to determine the degree of
interrater agreement for every case18 vr Values approaching 0
correspond to a high degree of interrater agreement whereas vr
values approaching 1 correspond to a low degree of interrater
agreement The Pearsonrsquo product-moment correlation coefficient
was calculated to analyze the potential association between the level
of agreement among panel members or external reviewers and the
score magnitude The score magnitude defined as the absolute
difference between the UIATS numerical values supporting
ldquoaneurysm repairrdquo and ldquoconservative managementrdquo for each case
(a small score magnitude suggests a less definitive UIATS
recommendation) was used to analyze the relation of the
strength of a UIATS-derived recommendation and the level of
agreement among the reviewers
RESULTS The study flow and participant frequen-cies during the Delphi consensus process are givenin figure 1 The UIATS model was developed basedon the data from rounds 1ndash4 in 3 domains (patient-aneurysm- and treatment-related) comprising 13different categories and 29 different features (figure 2)
The applicability of the preliminary UIATS modelwas initially tested in round 5 Mean agreement withUIATS-derived recommendations based on Likertscores (5 indicating strong agreement and 1 indicatingstrong disagreement) was 37 (95 CI 36ndash38) perpanel member and 37 (95 CI 33ndash41) per caseAfter adjustment of the UIATS for age and aneurysmsize mean agreement with treatment recommenda-tions based on the final UIATS model per reviewerwas 42 (95 CI 41ndash43) for the panel members(p 0001 compared to round 5) and 42 (95 CI41ndash43) for the external reviewers Mean agreementper case was 43 (95 CI 41ndash44) for panel members(p 001 compared to round 5) and 45 (95 CI43ndash46) for external reviewers (figure 3A) Agreementper case was higher among external reviewers thanamong panel members (p 5 0017 Mann-WhitneyU test) Dichotomized overall agreement (agree vs dis-agree) with treatment recommendations based on the
Figure 1 Study flow of the Delphi consensus process
Participant frequencies for each round are given in parentheses The panel member group consisted of 28 neurosurgeons (5of whom were dually trained in endovascular and microsurgical aneurysm repair) 7 interventional neuroradiologists 3 neu-rologists and 1 clinical epidemiologist The external reviewer group consisted of 15 neurosurgeons (7 of whom were duallytrained in endovascular and microsurgical aneurysm repair) 7 interventional neuroradiologists and 8 neurologists CV 5
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
Figure 2 The unruptured intracranial aneurysm treatment scoreThe unruptured intracranialaneurysm treatment score(UIATS) model includes andquantifies the key factorsfor clinical decision-makingin the management of unrup-tured intracranial aneurysms(UIAs) developedbasedon rele-vance rating data from Delphiconsensus rounds 1ndash418 Tocalculate a management rec-ommendation for a UIA thenumber of points correspond-ing to each patient- aneu-rysm- or treatment-relatedfeature on both managementcolumns of the scoring form(ldquoin favor of UIA repairrdquo and ldquoinfavor of UIA conservative man-agementrdquo) are added up Thiswill lead to 2 numerical values1 favoring aneurysm repair(surgical or endovascular) and1 favoring conservative man-agement The definitions foreach category and factor arefound in the Methods sectionFor cases with a score differ-ence of 3 points or more thedirection ie the differencebetween the calculated numer-ical values on each side of therecommendation columns willsuggest an individual manage-ment recommendation (ieaneurysm repair or conserva-tive management) For casesthat have similar aneurysmtreatment and conservativemanagement scores (62 pointdifference or less) the recom-mendation is ldquonot definitiverdquo andeither management approachcould be supported as additionalfactors apart from those used inthe development of UIATSmay be considered in makinga final decision regarding themanagement recommenda-tion and long-term follow-upFor cases with multiple aneur-ysms every aneurysm must beevaluated separately which willthen also result in separate rec-ommendations for each aneu-rysm The minimal intervention-related risk is always added as aconstant factor (5 points)AComA 5 anterior communi-cating artery BasA 5 basilarartery BP 5 blood pressuremultiple 5 multiple selectioncategory PComA 5 poste-rior communicating arterySAH 5 subarachnoid hemor-rhage single 5 single selec-tion category
884 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
UIATS was 95 among panel members and 94among external reviewers Interrater agreement per casewas high for both reviewersrsquo cohorts (vr5 0023 95CI 0018ndash0027 for panel members vr5 0028 95CI 0022ndash0034 for external reviewers) Despite an
unbalanced distribution of specialties among theconsensus group there was no difference (p 5
0290 Mann-Whitney U test) in mean Likert scoresper reviewer between interventional (42 95 CI41ndash43 for neurosurgery interventional neuroradi-ology or both n 5 56) and noninterventional (4195 CI 39ndash44 for neurology and clinical epidemi-ology n5 12) specialties or between individual spe-cialties (p 5 0325 Mann-Whitney U test) Therewas a distinct correlation between the score magni-tude of the recommendation (difference in pointsfor interventional and conservative management)and the level of agreement suggesting that theclearer the recommendation of the UIATS thehigher the level of agreement among the reviewers(figure 3B) A representative set of UIATS examplesand corresponding UIATS recommendations result-ing in the highest and lowest overall agreement areillustrated in figures 4 and 5 respectively
DISCUSSION The key finding of our consensus pro-ject among a large and diverse group of multidisciplinarycerebrovascular specialists is that we were able to developa comprehensive scoring model for management recom-mendations for UIAs Importantly this model is in highagreement with current UIA decision-making in aselected UIA patient population evidenced by thehigh agreement and interrater agreement with UIATS-derived recommendations among the specialist groupThe level of agreement with managementrecommendations based on the UIATS model isindependent from the underlying professionalbackground of the specialists ie interventionalor noninterventional and is even higher amongspecialists who were not involved in the developmentof the scoring model
The UIATS is neither a prognostic study nor apredictive model for UIA rupture as it is derivedfrom consensus on contemporary practice of UIAmanagement among cerebrovascular specialists usingthe Delphi method and only indirectly from pub-lished data In that sense it differs from the recentlydeveloped PHASES score a model based on prospec-tively collected data from 6 cohort studies on risk ofUIA rupture that provides absolute risks of rupturefor the initial 5 years after aneurysm detection using6 easily retrievable baseline characteristics (patientgeographical location and age aneurysm size andlocation presence of arterial hypertension and previ-ous SAH from a different aneurysm)23 Howeversome subgroups in the PHASES score were under-represented such as patients with familial aneurysmsor may have been underrepresented such as youngsmokers Thus the score may not apply to all patientsAlso the score holds true for only the initial 5 yearsafter UIA detection because of limited long-term
Figure 3 Validation of the UIATS
(A) Agreement with unruptured intracranial aneurysm treatment score (UIATS)-derived recom-mendations per case and per rater Means for Likert scores (y-axis) are illustrated for each case(dots) and for each rater (circles) among panel members and the blinded external reviewers(x-axis) A Likert score of 5 indicates strong agreement 4 indicates agreement 3 indicates neu-trality 2 indicates disagreement and 1 indicates strong disagreement Since means for Likertscores did not fall below a score of 3 the y-axis scale does not show disagreement and strongdisagreement Compared to agreement of panel members with UIATS-derived treatment recom-mendations for each case themeanLikert score (y-axis) was significantly higher among the exter-nal reviewers who were completely blinded to the score raw data and the survey developmentand design (indicates p 5 0017) (B) Correlation of Likert scores and UIATS characteristicsThe level of agreement (y-axis) between panel members and external reviewers was correlated(Pearson product-moment) with the UIATS differences between aneurysm repair and conserva-tive management for every UIATS treatment recommendation (x-axis) The score magnitudecorrelated significantly with agreement among the reviewers independently for panel members(r2 5 0323 p 5 0002 solid line) and external reviewers (r2 5 0399 p 0001 dotted line)
Neurology 85 September 8 2015 885
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
follow-up data and many patients have a predicted lifeexpectancy of more than 5 years Moreover severalaneurysm characteristics found or suggested to be riskfactors for rupture in case-control studies could not beincluded in the PHASES score Finally the PHASESscore was developed to predict the risk of rupturewhereas when a clinician recommends repair of aUIA the risk of intervention must also be taken intoaccount which is not done in the PHASES scoreThus many uncertainties due to varying levels of evi-dence remain which have to be accounted for in clin-ical practice when consulting patients with UIAs
The UIATS model was designed to address theseuncertainties and thus to potentially harmonize the
high level of variation among clinicians about the indi-vidual management of patients with UIA The UIATSwas developed partially based on data but also usingconsensus among specialists in the field The merit ofthis model is that it accounts for many different factorsthat often influence clinical decisions but that were notwell studied in previous observational studies egyoung age or long life expectancy coexistent modifiableor nonmodifiable risk factors coexistent morbiditiesmorphologic UIA features or relevance of clinicalsymptoms related to UIAs51011132425 Admittedlythe UIATS model requires more baseline characteris-tics than the PHASES score which makes its applica-tion slightly more time consuming However ourresults highlight that specialists in UIA research andtreatment account for these factors in their decision-making and that these specialists have a high level ofagreement about how to handle these factors for whichdata are currently incomplete or lacking We used theDelphi method to scientifically obtain consensus andsubsequently to systematically categorize potential fac-tors for contemporary decision-making on the appro-priate management of UIAs Studies from othermedical fields have used the Delphi method to system-atically reach consensus or develop treatment scores onsimilar controversial or complex subjects among pro-fessionally andor geographically dispersed special-ists26ndash28 We emphasize that data derived fromconsensus among specialists cannot replace evidencebut rather can complement it specifically in areaswhere there is uncertainty If more observational databecome available and predictors for aneurysm ruptureand treatment complications become more sophisti-cated the UIATS model could be adjusted Howeveruntil such data become available our proposed scoringmodel constitutes an organized and objective means ofcapturing the best consensus possible on UIA manage-ment as a complement to existing UIA rupture riskprediction models
Our study has several limitations Although weincluded a wide variety of multidisciplinary specialistsfrom various predominantly high-income Westerncountries with different health care systems we can-not claim that this ldquopopulationrdquo of specialists is rep-resentative of the general ldquocommunity of UIAspecialists or expertsrdquo if such a group could bedefined Second one important premise in the con-struction of the UIATS is that the management ofUIAs constitutes a comparison between the risk ofrupture vs the risks of treatment in that particularpatient Some have argued that these 2 ldquoquantitiesrdquoone being a risk event rate and the other being a one-time risk cannot validly be compared29 However indaily practice this is what clinicians do ie comparethe risk of aneurysm rupture with the risk of prophy-lactic aneurysm repair Third we used a binary
Figure 4 UIATS case recommendation resulting in the highest agreementamong the internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 47-year-old woman (3points favoring treatment for patient age 41ndash60 years) who previously underwent cranialMRI for chronic headaches with (A) posterior-anterior and (B) lateral projection as well as (C)posterior-anterior and (D) lateral 3-dimensional reconstructions is shown This incidentalirregularly shaped (3 points favoring treatment for irregular morphology) anterior communi-cating artery aneurysm (arrow 2 points favoring treatment for aneurysm location) had amaximum diameter of 76 mm (2 points favoring treatment for aneurysm diameter) with aneck diameter of 35 mm Aspect and size ratios were calculated to be 21 and 38 respec-tively (1 point favoring treatment for aspect or size ratio greater than 16 or 30 respec-tively) Her medical history included arterial hypertension (2 points favoring treatment forrisk factor hypertension) but no other chronic comorbidities The resulting scoring based onthe UIATS was 13 points in favor of aneurysm repair and 7 points in favor of conservativemanagement (1 point for patient age 41ndash60 years 1 point for aneurysm size 6ndash10 mm and5 points for the constant intervention-related risk) The resulting UIATS recommendationwas ldquoaneurysm repairrdquo Overall agreement with this UIATS recommendation was 473 (95confidence interval 462ndash485) for both reviewer cohorts
886 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
decision scenario (treat or not treat) rather than mak-ing distinctions between different possible treatmentmodalities mainly to propose a unifying scoringmodel that would not divide the specialist groupFourth we used pooled data from meta-analyses toincorporate treatment risk percentages into ourmodel However given the lack of more robust dataon risk factors for UIA treatment complications it isunclear whether the individual treatment risk in apatient with a UIA may be distinctly lower or higherdepending on the surgeonrsquos or interventionalistrsquosexperience the treatment modality and the aneu-rysm complexity Lastly the series of cases we vali-dated with the UIATS covered a wide range ofpatients and aneurysms but may not entirely reflectthe complete spectrum of patients and aneurysms
seen in clinical practice As an example in the valida-tion data set 13 of 30 UIAs were larger than 7 mmwhich may not reflect the actual UIA size distributionin the general population In addition the presenta-tion of the actual score values to the external reviewersduring the validation may have introduced some biasif these external experts were somewhat uncertain andtherefore more willing to agree with the proposedrecommendations However given the expertise ofthe external reviewers we do not feel this has influ-enced the results to a large extent
This multidisciplinary consensus project has re-sulted in the UIATSmodel which captures contempo-rary and multifactorial decision-making by specialistson UIA management By applying this scoring modelclinicians can appreciate what highly informed individ-uals in the cerebrovascular field would advise in a par-ticular patient based on current data and uncertaintiesSince the validity of the UIATSmodel was tested basedon theoretical rather than empirical data its applicabil-ity and clinical accuracy remain to be prospectivelyexplored in patients with UIA Thus the current treat-ment recommendations may change if new data fromsuch studies or future observational UIA studiesbecome available Ultimately individual patient factorsbeyond those accounted for in the present scoringmodel may also alter the individual management of apatient with a UIA
AUTHOR AFFILIATIONFrom the Department of Neurosurgery (NE KB AA H-JS DH)
Medical Faculty Heinrich-Heine-University Duumlsseldorf Germany Depart-
ments of Neurology (RDB AAR) and Neurologic Surgery (GL) Mayo
Clinic Rochester MN Department of Clinical Neurosciences (SJ) University
of Helsinki Finland Department of RadiologymdashInterventional Neuroradiol-
ogy (J Raymond) CHUM Research Center Notre-Dame Hospital Montreal
Quebec Canada Department of Neurological Surgery (A Morita) Nippon
Medical School Tokyo Japan Departments of Epidemiology (JCT) and
Neurosurgery (DMH) University of Iowa Iowa City Mallinckrodt Institute
of Radiology (CPD) Washington University School of MedicineBarnes-
Jewish Hospital St Louis MO Department of Neurosurgery (A Raabe)
Inselspital Bern Switzerland Department of Neurological Surgery (JM)
Vanderbilt University Medical Center Nashville TN Department of Neuro-
surgery (MK MN) Helsinki University Central Hospital Helsinki Finland
Department of Neurosurgery (SA-H) University of Illinois at Chicago
Centre for Clinical Brain Sciences (RA-SS) University of Edinburgh
United Kingdom Department of Neurosurgery (DLB) Emory Stroke Cen-
ter Emory University School of Medicine Atlanta GA Department of Neu-
rosurgery (JB) The Mount Sinai Health System New York NY Department
of Neuroradiology (AB) CHUMontpellier Montpellier France Department
of Neurosurgery (ASD) Tulane University School of Medicine New
Orleans LA Department of Neurosurgery (DJK) Cerebrovascular Centre
Stony Brook University Medical Center Stony Brook NY Department of
Neurosurgery (AG) Medical University of Vienna Austria Department of
Neurology (GJH) and Neurosurgery Unit (NK) Sir Charles Gairdner Hos-
pital Nedlands Western Australia Australia School of Medicine and Pharma-
cology (GJH) The University of Western Australia Perth Australia
Department of Neurosurgery (BLH) University of Florida Gainesville
Department of Neurological Surgery (PJ RHR) Thomas Jefferson Univer-
sity Hospital Philadelphia PA Department of Neurosurgery (HK) Tokyo
Womenrsquos Medical University Medical Center East Tokyo Japan Saskatche-
wan Cerebrovascular Centre (MEK) Royal University Hospital University of
Saskatchewan Saskatoon Canada Department of Clinical Neurosciences
Figure 5 UIATS case recommendation resulting in the lowest agreement amongthe internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 25-year-old woman(4 points favoring treatment for patient age younger than 40 years) who previously under-went MRI for persistent headaches vertigo and occasional bitemporal vision disturbances(due to a migraine aura) with (A) posterior-anterior and (B) lateral projection as well as (C) pos-terior-anterior and (D) lateral 3-dimensional reconstructions is shown This left-sided wide-necked paraophthalmic internal carotid artery aneurysm had a maximum diameter of3 mmwith a neck diameter of 27 mm (3 points favoring conservative management for aneu-rysm complexity due to wide neck) The patient did not report any additional risk factors orcomorbidities in her past medical history The resulting scores based on the UIATS were4 points in favor of aneurysm repair and 8 points (including 5 points favoring conservativemanagement for the constant intervention-related risk) in favor of conservative manage-ment The resulting UIATS recommendation was ldquoconservative managementrdquoOverall agree-ment with this UIATS recommendation was 37 (95 confidence interval 344ndash396) forboth reviewer cohorts
Neurology 85 September 8 2015 887
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
(PJK) Cambridge University Hospitals Trust University of Cambridge
United Kingdom NeurosurgeryNeuroCenter (T Koivisto) Kuopio University
Hospital University of Eastern Finland Finland Department of Medical Imag-
ing and Surgery (T Krings VMP) Toronto Western Hospital University
Health Network Toronto Ontario Canada Department of Neurological Sur-
gery (MTL) University of California San Francisco Divisions of Neurora-
diology (TRM) and Neurosurgery (JS RLM) St Michaels Hospital
University of Toronto Ontario Canada Institute for Critical Care Medicine
(SAM) Icahn School of Medicine at Mount Sinai New York NY Depart-
ment of Neurosurgery (EM) Auckland City Hospital Auckland New
Zealand Nuffield Department of Surgical Sciences (A Molyneux) University
of Oxford United Kingdom Division of Neurosurgery (MKM) Australian
School of Advanced Medicine Macquarie University Sydney Australia
Department of Neurosurgery (KM) National Defense Medical College
Tokyo Japan Department of Neurosurgery (YM) JIKEI University School
of Medicine Tokyo Japan Department of Neurosurgery (SN) Institute of
Health Bioscience University of Tokushima Graduate School Tokushima
Japan Department of Neurosurgery (NN) Hokkaido University Graduate
School of Medicine Hokkaido Japan Endovascular and Operative Neurovas-
cular Surgery (CSO) Beth Israel Deaconess Medical Center Harvard Medical
School Boston MA Department of Radiology (LP) University Hospital
Reims France Department of Neurology (YBWEMR) Academic Medical
Center Amsterdam the Netherlands Department of Neurosurgery (J Rinne)
Division of Clinical Neurosciences Turku University Hospital Turku Finland
Department of Neurosurgery (A Ronkainen) Tampere University Hospital
Tampere Finland Department of Neurosurgery (KS) Geneva University
Hospital Switzerland Departments of Neurosurgery (VS) and Neurology
(HS) Goethe University Frankfurt Germany Department of Neurological
Surgery (RAS ESC) New York Presbyterian Hospital Columbia Univer-
sity College of Physicians and Surgeons New York NY Brain Center Rudolf
Magnus (MDIV GJER) Department of Neurology and Neurosurgery
University Medical Centre Utrecht the Netherlands Institute for Diagnostic
and Interventional Radiology and Neuroradiology (IW) University Hospital
of Essen Germany SwissNeuroInstitute (IW DR) Clinic Hirslanden
Zurich Switzerland Department of Neurology (MJHW) Leiden University
Medical Center Leiden the Netherlands Department of Surgery and Neuro-
surgery (GKCW) Prince of Wales Hospital The Chinese University of
Hong Kong Hong Kong China Division of Neurosurgery (JHW) Depart-
ments of Clinical Neurosciences and Diagnostic Imaging University of Calgary
Alberta Canada Departments of Neurological Surgery and Neurology (GJZ)
Washington University School of Medicine St Louis MO Institute of Neu-
rosurgery (AP) Section of Vascular Neurosurgery Verona University amp City
Hospital Verona Italy Department of Neurosurgery (PV) Chariteacute University
Medical Centre Berlin Germany Division of Neurological Surgery (CM)
Barrow Neurological Institute St Josephs Hospital and Medical Center
Phoenix AZ and Brain and Spine Center (PL) Lankenau Medical Center
Wynnewood PA
AUTHOR CONTRIBUTIONSNE RDB KB SJ J Ra A Ra AA ESC HS GL AP
DR PV CM PLR and RLM were involved in the design of
the study NE and KB collected analyzed and interpreted the data
but did not participate in the Delphi consensus NE RDB KB
SJ JRa AkMo JCT CPD ARa JM MK PV DH
GJER and RLM drafted the paper RDB SJ JRa AkMo
JCT CPD ARa JM MK SAH RAlSa DLB JB
AB AD DJF AG GH DMH BLH PJ HK MEK
PJK NK TiKo TiKr MTL TRM SAM EM AnMo
MKM KM YM SN NaNa MN CSO VMP LP
AAR YBWEMR JaRi RHR AnRo KS VS RASo
JS HJS MDIV IW MJHW GKCW JHW GJZ
PV CM DH GJER and RLM participated in the study re-
viewed and commented on the final version of the manuscript
STUDY FUNDINGNo targeted funding reported
DISCLOSUREN Etminan is a scientific advisorofficer for Edge Therapeutics Inc
R Brown K Beseoglu S Juvela J Raymond A Morita and J Torner
report no disclosures relevant to the manuscript C Derdeyn serves on
the Scientific Advisory Board for W L Gore and Associates and Pulse
Therapeutics He is a consultant for Penumbra Inc (DSMB member)
and Microvention (Angio Core Lab for brain aneurysm stent trial)
A Raabe J Mocco M Korja A Abdulazim S Amin-Hanjani
R Al-Shahi Salman D Barrow J Bederson A Bonafe and A Dumont
report no disclosures relevant to the manuscript D Fiorella is a consultant
for Codman Neurovascular CovidienEV3 Sequent Medical and Siemens
Medical Imaging and received research support from Penumbra Inc and
Microvention A Gruber G Hankey D Hasan B Hoh P Jabbour
and H Kasuya report no disclosures relevant to the manuscript M Kelly
is a shareholder of Blockade Medical Inc P Kirkpatrick N Knuckey
T Koivisto T Krings M Lawton and T Marotta report no disclosures
relevant to the manuscript S Mayer is a consultant for Edge Therapeutics
Inc and Actelion Pharmaceuticals E Mee reports no disclosures relevant to
the manuscript V Mendes Pereira is consultant for Covidien A
Molyneux M Morgan K Mori Y Murayama S Nagahiro N
Nakayama M Nimelauml C Ogilvy L Pierot A Rabinstein Y Roos J
Rinne R Rosenwasser A Ronkainen K Schaller V Seifert R Solomon
J Spears H-J Steiger M Vergouwen I Wanke M Wermer G Wong J
Wong G Zipfel E Sander Connolly and H Steinmetz report no disclosures
relevant to the manuscript G Lanzino is a consultant for Covidien Edge
Therapeutics Inc and Codman A Pasqualin D Ruumlfenacht P Vajkoczy
and C McDougall report no disclosures relevant to the manuscript
D Haumlnggi is a scientific advisorofficer for Edge Therapeutics Inc P LeRoux
is a Scientific Advisory Board member for Edge Therapeutics Inc and a
consultant for Integra Codman Synthes Neurologica Brainsgate and Orsan
G Rinkel reports no disclosures relevant to the manuscript R Macdonald is
Chief Scientific Officer of Edge Therapeutics Inc and received grant support
from the Physicians Services Incorporated Foundation Brain Aneurysm Foun-
dation Canadian Institutes for Health Research and the Heart and Stroke
Foundation of Canada Go to Neurologyorg for full disclosures
Received January 5 2015 Accepted in final form April 18 2015
REFERENCES1 Gabriel RA Kim H Sidney S et al Ten-year detection
rate of brain arteriovenous malformations in a large mul-
tiethnic defined population Stroke 20104121ndash26
2 Vlak MH Algra A Brandenburg R Rinkel GJ Prevalence
of unruptured intracranial aneurysms with emphasis on sex
age comorbidity country and time period a systematic
review and meta-analysis Lancet Neurol 201110626ndash636
3 Ishibashi T Murayama Y Urashima M et al Unruptured
intracranial aneurysms incidence of rupture and risk fac-
tors Stroke 200940313ndash316
4 Juvela S Poussa K Lehto H Porras M Natural history of
unruptured intracranial aneurysms a long-term follow-up
study Stroke 2013442414ndash2421
5 Morita A Kirino T Hashi K et al The natural course of
unruptured cerebral aneurysms in a Japanese cohort N
Engl J Med 20123662474ndash2482
6 Nieuwkamp DJ Setz LE Algra A Linn FH de Rooij NK
Rinkel GJ Changes in case fatality of aneurysmal subarach-
noid haemorrhage over time according to age sex and
region a meta-analysis Lancet Neurol 20098635ndash642
7 Sonobe M Yamazaki T Yonekura M Kikuchi H Small
unruptured intracranial aneurysm verification study
SUAVe study Japan Stroke 2010411969ndash1977
8 Wermer MJ van der Schaaf IC Velthuis BK Majoie CB
Albrecht KW Rinkel GJ Yield of short-term follow-up
CTMR angiography for small aneurysms detected at
screening Stroke 200637414ndash418
9 Wiebers DO Whisnant JP Huston J III et al Unrup-
tured intracranial aneurysms natural history clinical out-
come and risks of surgical and endovascular treatment
Lancet 2003362103ndash110
888 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
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Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
ServicesUpdated Information amp
httpnneurologyorgcontent8510881fullincluding high resolution figures can be found at
This article has been cited by 6 HighWire-hosted articles
Subspecialty Collections
httpnneurologyorgcgicollectionstroke_preventionStroke prevention e
httpnneurologyorgcgicollectionall_cerebrovascular_disease_strokAll Cerebrovascular diseaseStrokefollowing collection(s) This article along with others on similar topics appears in the
Permissions amp Licensing
httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in
Reprints
httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online
rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All
reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology
dispersion (vr) were calculated to determine the degree of
interrater agreement for every case18 vr Values approaching 0
correspond to a high degree of interrater agreement whereas vr
values approaching 1 correspond to a low degree of interrater
agreement The Pearsonrsquo product-moment correlation coefficient
was calculated to analyze the potential association between the level
of agreement among panel members or external reviewers and the
score magnitude The score magnitude defined as the absolute
difference between the UIATS numerical values supporting
ldquoaneurysm repairrdquo and ldquoconservative managementrdquo for each case
(a small score magnitude suggests a less definitive UIATS
recommendation) was used to analyze the relation of the
strength of a UIATS-derived recommendation and the level of
agreement among the reviewers
RESULTS The study flow and participant frequen-cies during the Delphi consensus process are givenin figure 1 The UIATS model was developed basedon the data from rounds 1ndash4 in 3 domains (patient-aneurysm- and treatment-related) comprising 13different categories and 29 different features (figure 2)
The applicability of the preliminary UIATS modelwas initially tested in round 5 Mean agreement withUIATS-derived recommendations based on Likertscores (5 indicating strong agreement and 1 indicatingstrong disagreement) was 37 (95 CI 36ndash38) perpanel member and 37 (95 CI 33ndash41) per caseAfter adjustment of the UIATS for age and aneurysmsize mean agreement with treatment recommenda-tions based on the final UIATS model per reviewerwas 42 (95 CI 41ndash43) for the panel members(p 0001 compared to round 5) and 42 (95 CI41ndash43) for the external reviewers Mean agreementper case was 43 (95 CI 41ndash44) for panel members(p 001 compared to round 5) and 45 (95 CI43ndash46) for external reviewers (figure 3A) Agreementper case was higher among external reviewers thanamong panel members (p 5 0017 Mann-WhitneyU test) Dichotomized overall agreement (agree vs dis-agree) with treatment recommendations based on the
Figure 1 Study flow of the Delphi consensus process
Participant frequencies for each round are given in parentheses The panel member group consisted of 28 neurosurgeons (5of whom were dually trained in endovascular and microsurgical aneurysm repair) 7 interventional neuroradiologists 3 neu-rologists and 1 clinical epidemiologist The external reviewer group consisted of 15 neurosurgeons (7 of whom were duallytrained in endovascular and microsurgical aneurysm repair) 7 interventional neuroradiologists and 8 neurologists CV 5
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
Figure 2 The unruptured intracranial aneurysm treatment scoreThe unruptured intracranialaneurysm treatment score(UIATS) model includes andquantifies the key factorsfor clinical decision-makingin the management of unrup-tured intracranial aneurysms(UIAs) developedbasedon rele-vance rating data from Delphiconsensus rounds 1ndash418 Tocalculate a management rec-ommendation for a UIA thenumber of points correspond-ing to each patient- aneu-rysm- or treatment-relatedfeature on both managementcolumns of the scoring form(ldquoin favor of UIA repairrdquo and ldquoinfavor of UIA conservative man-agementrdquo) are added up Thiswill lead to 2 numerical values1 favoring aneurysm repair(surgical or endovascular) and1 favoring conservative man-agement The definitions foreach category and factor arefound in the Methods sectionFor cases with a score differ-ence of 3 points or more thedirection ie the differencebetween the calculated numer-ical values on each side of therecommendation columns willsuggest an individual manage-ment recommendation (ieaneurysm repair or conserva-tive management) For casesthat have similar aneurysmtreatment and conservativemanagement scores (62 pointdifference or less) the recom-mendation is ldquonot definitiverdquo andeither management approachcould be supported as additionalfactors apart from those used inthe development of UIATSmay be considered in makinga final decision regarding themanagement recommenda-tion and long-term follow-upFor cases with multiple aneur-ysms every aneurysm must beevaluated separately which willthen also result in separate rec-ommendations for each aneu-rysm The minimal intervention-related risk is always added as aconstant factor (5 points)AComA 5 anterior communi-cating artery BasA 5 basilarartery BP 5 blood pressuremultiple 5 multiple selectioncategory PComA 5 poste-rior communicating arterySAH 5 subarachnoid hemor-rhage single 5 single selec-tion category
884 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
UIATS was 95 among panel members and 94among external reviewers Interrater agreement per casewas high for both reviewersrsquo cohorts (vr5 0023 95CI 0018ndash0027 for panel members vr5 0028 95CI 0022ndash0034 for external reviewers) Despite an
unbalanced distribution of specialties among theconsensus group there was no difference (p 5
0290 Mann-Whitney U test) in mean Likert scoresper reviewer between interventional (42 95 CI41ndash43 for neurosurgery interventional neuroradi-ology or both n 5 56) and noninterventional (4195 CI 39ndash44 for neurology and clinical epidemi-ology n5 12) specialties or between individual spe-cialties (p 5 0325 Mann-Whitney U test) Therewas a distinct correlation between the score magni-tude of the recommendation (difference in pointsfor interventional and conservative management)and the level of agreement suggesting that theclearer the recommendation of the UIATS thehigher the level of agreement among the reviewers(figure 3B) A representative set of UIATS examplesand corresponding UIATS recommendations result-ing in the highest and lowest overall agreement areillustrated in figures 4 and 5 respectively
DISCUSSION The key finding of our consensus pro-ject among a large and diverse group of multidisciplinarycerebrovascular specialists is that we were able to developa comprehensive scoring model for management recom-mendations for UIAs Importantly this model is in highagreement with current UIA decision-making in aselected UIA patient population evidenced by thehigh agreement and interrater agreement with UIATS-derived recommendations among the specialist groupThe level of agreement with managementrecommendations based on the UIATS model isindependent from the underlying professionalbackground of the specialists ie interventionalor noninterventional and is even higher amongspecialists who were not involved in the developmentof the scoring model
The UIATS is neither a prognostic study nor apredictive model for UIA rupture as it is derivedfrom consensus on contemporary practice of UIAmanagement among cerebrovascular specialists usingthe Delphi method and only indirectly from pub-lished data In that sense it differs from the recentlydeveloped PHASES score a model based on prospec-tively collected data from 6 cohort studies on risk ofUIA rupture that provides absolute risks of rupturefor the initial 5 years after aneurysm detection using6 easily retrievable baseline characteristics (patientgeographical location and age aneurysm size andlocation presence of arterial hypertension and previ-ous SAH from a different aneurysm)23 Howeversome subgroups in the PHASES score were under-represented such as patients with familial aneurysmsor may have been underrepresented such as youngsmokers Thus the score may not apply to all patientsAlso the score holds true for only the initial 5 yearsafter UIA detection because of limited long-term
Figure 3 Validation of the UIATS
(A) Agreement with unruptured intracranial aneurysm treatment score (UIATS)-derived recom-mendations per case and per rater Means for Likert scores (y-axis) are illustrated for each case(dots) and for each rater (circles) among panel members and the blinded external reviewers(x-axis) A Likert score of 5 indicates strong agreement 4 indicates agreement 3 indicates neu-trality 2 indicates disagreement and 1 indicates strong disagreement Since means for Likertscores did not fall below a score of 3 the y-axis scale does not show disagreement and strongdisagreement Compared to agreement of panel members with UIATS-derived treatment recom-mendations for each case themeanLikert score (y-axis) was significantly higher among the exter-nal reviewers who were completely blinded to the score raw data and the survey developmentand design (indicates p 5 0017) (B) Correlation of Likert scores and UIATS characteristicsThe level of agreement (y-axis) between panel members and external reviewers was correlated(Pearson product-moment) with the UIATS differences between aneurysm repair and conserva-tive management for every UIATS treatment recommendation (x-axis) The score magnitudecorrelated significantly with agreement among the reviewers independently for panel members(r2 5 0323 p 5 0002 solid line) and external reviewers (r2 5 0399 p 0001 dotted line)
Neurology 85 September 8 2015 885
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
follow-up data and many patients have a predicted lifeexpectancy of more than 5 years Moreover severalaneurysm characteristics found or suggested to be riskfactors for rupture in case-control studies could not beincluded in the PHASES score Finally the PHASESscore was developed to predict the risk of rupturewhereas when a clinician recommends repair of aUIA the risk of intervention must also be taken intoaccount which is not done in the PHASES scoreThus many uncertainties due to varying levels of evi-dence remain which have to be accounted for in clin-ical practice when consulting patients with UIAs
The UIATS model was designed to address theseuncertainties and thus to potentially harmonize the
high level of variation among clinicians about the indi-vidual management of patients with UIA The UIATSwas developed partially based on data but also usingconsensus among specialists in the field The merit ofthis model is that it accounts for many different factorsthat often influence clinical decisions but that were notwell studied in previous observational studies egyoung age or long life expectancy coexistent modifiableor nonmodifiable risk factors coexistent morbiditiesmorphologic UIA features or relevance of clinicalsymptoms related to UIAs51011132425 Admittedlythe UIATS model requires more baseline characteris-tics than the PHASES score which makes its applica-tion slightly more time consuming However ourresults highlight that specialists in UIA research andtreatment account for these factors in their decision-making and that these specialists have a high level ofagreement about how to handle these factors for whichdata are currently incomplete or lacking We used theDelphi method to scientifically obtain consensus andsubsequently to systematically categorize potential fac-tors for contemporary decision-making on the appro-priate management of UIAs Studies from othermedical fields have used the Delphi method to system-atically reach consensus or develop treatment scores onsimilar controversial or complex subjects among pro-fessionally andor geographically dispersed special-ists26ndash28 We emphasize that data derived fromconsensus among specialists cannot replace evidencebut rather can complement it specifically in areaswhere there is uncertainty If more observational databecome available and predictors for aneurysm ruptureand treatment complications become more sophisti-cated the UIATS model could be adjusted Howeveruntil such data become available our proposed scoringmodel constitutes an organized and objective means ofcapturing the best consensus possible on UIA manage-ment as a complement to existing UIA rupture riskprediction models
Our study has several limitations Although weincluded a wide variety of multidisciplinary specialistsfrom various predominantly high-income Westerncountries with different health care systems we can-not claim that this ldquopopulationrdquo of specialists is rep-resentative of the general ldquocommunity of UIAspecialists or expertsrdquo if such a group could bedefined Second one important premise in the con-struction of the UIATS is that the management ofUIAs constitutes a comparison between the risk ofrupture vs the risks of treatment in that particularpatient Some have argued that these 2 ldquoquantitiesrdquoone being a risk event rate and the other being a one-time risk cannot validly be compared29 However indaily practice this is what clinicians do ie comparethe risk of aneurysm rupture with the risk of prophy-lactic aneurysm repair Third we used a binary
Figure 4 UIATS case recommendation resulting in the highest agreementamong the internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 47-year-old woman (3points favoring treatment for patient age 41ndash60 years) who previously underwent cranialMRI for chronic headaches with (A) posterior-anterior and (B) lateral projection as well as (C)posterior-anterior and (D) lateral 3-dimensional reconstructions is shown This incidentalirregularly shaped (3 points favoring treatment for irregular morphology) anterior communi-cating artery aneurysm (arrow 2 points favoring treatment for aneurysm location) had amaximum diameter of 76 mm (2 points favoring treatment for aneurysm diameter) with aneck diameter of 35 mm Aspect and size ratios were calculated to be 21 and 38 respec-tively (1 point favoring treatment for aspect or size ratio greater than 16 or 30 respec-tively) Her medical history included arterial hypertension (2 points favoring treatment forrisk factor hypertension) but no other chronic comorbidities The resulting scoring based onthe UIATS was 13 points in favor of aneurysm repair and 7 points in favor of conservativemanagement (1 point for patient age 41ndash60 years 1 point for aneurysm size 6ndash10 mm and5 points for the constant intervention-related risk) The resulting UIATS recommendationwas ldquoaneurysm repairrdquo Overall agreement with this UIATS recommendation was 473 (95confidence interval 462ndash485) for both reviewer cohorts
886 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
decision scenario (treat or not treat) rather than mak-ing distinctions between different possible treatmentmodalities mainly to propose a unifying scoringmodel that would not divide the specialist groupFourth we used pooled data from meta-analyses toincorporate treatment risk percentages into ourmodel However given the lack of more robust dataon risk factors for UIA treatment complications it isunclear whether the individual treatment risk in apatient with a UIA may be distinctly lower or higherdepending on the surgeonrsquos or interventionalistrsquosexperience the treatment modality and the aneu-rysm complexity Lastly the series of cases we vali-dated with the UIATS covered a wide range ofpatients and aneurysms but may not entirely reflectthe complete spectrum of patients and aneurysms
seen in clinical practice As an example in the valida-tion data set 13 of 30 UIAs were larger than 7 mmwhich may not reflect the actual UIA size distributionin the general population In addition the presenta-tion of the actual score values to the external reviewersduring the validation may have introduced some biasif these external experts were somewhat uncertain andtherefore more willing to agree with the proposedrecommendations However given the expertise ofthe external reviewers we do not feel this has influ-enced the results to a large extent
This multidisciplinary consensus project has re-sulted in the UIATSmodel which captures contempo-rary and multifactorial decision-making by specialistson UIA management By applying this scoring modelclinicians can appreciate what highly informed individ-uals in the cerebrovascular field would advise in a par-ticular patient based on current data and uncertaintiesSince the validity of the UIATSmodel was tested basedon theoretical rather than empirical data its applicabil-ity and clinical accuracy remain to be prospectivelyexplored in patients with UIA Thus the current treat-ment recommendations may change if new data fromsuch studies or future observational UIA studiesbecome available Ultimately individual patient factorsbeyond those accounted for in the present scoringmodel may also alter the individual management of apatient with a UIA
AUTHOR AFFILIATIONFrom the Department of Neurosurgery (NE KB AA H-JS DH)
Medical Faculty Heinrich-Heine-University Duumlsseldorf Germany Depart-
ments of Neurology (RDB AAR) and Neurologic Surgery (GL) Mayo
Clinic Rochester MN Department of Clinical Neurosciences (SJ) University
of Helsinki Finland Department of RadiologymdashInterventional Neuroradiol-
ogy (J Raymond) CHUM Research Center Notre-Dame Hospital Montreal
Quebec Canada Department of Neurological Surgery (A Morita) Nippon
Medical School Tokyo Japan Departments of Epidemiology (JCT) and
Neurosurgery (DMH) University of Iowa Iowa City Mallinckrodt Institute
of Radiology (CPD) Washington University School of MedicineBarnes-
Jewish Hospital St Louis MO Department of Neurosurgery (A Raabe)
Inselspital Bern Switzerland Department of Neurological Surgery (JM)
Vanderbilt University Medical Center Nashville TN Department of Neuro-
surgery (MK MN) Helsinki University Central Hospital Helsinki Finland
Department of Neurosurgery (SA-H) University of Illinois at Chicago
Centre for Clinical Brain Sciences (RA-SS) University of Edinburgh
United Kingdom Department of Neurosurgery (DLB) Emory Stroke Cen-
ter Emory University School of Medicine Atlanta GA Department of Neu-
rosurgery (JB) The Mount Sinai Health System New York NY Department
of Neuroradiology (AB) CHUMontpellier Montpellier France Department
of Neurosurgery (ASD) Tulane University School of Medicine New
Orleans LA Department of Neurosurgery (DJK) Cerebrovascular Centre
Stony Brook University Medical Center Stony Brook NY Department of
Neurosurgery (AG) Medical University of Vienna Austria Department of
Neurology (GJH) and Neurosurgery Unit (NK) Sir Charles Gairdner Hos-
pital Nedlands Western Australia Australia School of Medicine and Pharma-
cology (GJH) The University of Western Australia Perth Australia
Department of Neurosurgery (BLH) University of Florida Gainesville
Department of Neurological Surgery (PJ RHR) Thomas Jefferson Univer-
sity Hospital Philadelphia PA Department of Neurosurgery (HK) Tokyo
Womenrsquos Medical University Medical Center East Tokyo Japan Saskatche-
wan Cerebrovascular Centre (MEK) Royal University Hospital University of
Saskatchewan Saskatoon Canada Department of Clinical Neurosciences
Figure 5 UIATS case recommendation resulting in the lowest agreement amongthe internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 25-year-old woman(4 points favoring treatment for patient age younger than 40 years) who previously under-went MRI for persistent headaches vertigo and occasional bitemporal vision disturbances(due to a migraine aura) with (A) posterior-anterior and (B) lateral projection as well as (C) pos-terior-anterior and (D) lateral 3-dimensional reconstructions is shown This left-sided wide-necked paraophthalmic internal carotid artery aneurysm had a maximum diameter of3 mmwith a neck diameter of 27 mm (3 points favoring conservative management for aneu-rysm complexity due to wide neck) The patient did not report any additional risk factors orcomorbidities in her past medical history The resulting scores based on the UIATS were4 points in favor of aneurysm repair and 8 points (including 5 points favoring conservativemanagement for the constant intervention-related risk) in favor of conservative manage-ment The resulting UIATS recommendation was ldquoconservative managementrdquoOverall agree-ment with this UIATS recommendation was 37 (95 confidence interval 344ndash396) forboth reviewer cohorts
Neurology 85 September 8 2015 887
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
(PJK) Cambridge University Hospitals Trust University of Cambridge
United Kingdom NeurosurgeryNeuroCenter (T Koivisto) Kuopio University
Hospital University of Eastern Finland Finland Department of Medical Imag-
ing and Surgery (T Krings VMP) Toronto Western Hospital University
Health Network Toronto Ontario Canada Department of Neurological Sur-
gery (MTL) University of California San Francisco Divisions of Neurora-
diology (TRM) and Neurosurgery (JS RLM) St Michaels Hospital
University of Toronto Ontario Canada Institute for Critical Care Medicine
(SAM) Icahn School of Medicine at Mount Sinai New York NY Depart-
ment of Neurosurgery (EM) Auckland City Hospital Auckland New
Zealand Nuffield Department of Surgical Sciences (A Molyneux) University
of Oxford United Kingdom Division of Neurosurgery (MKM) Australian
School of Advanced Medicine Macquarie University Sydney Australia
Department of Neurosurgery (KM) National Defense Medical College
Tokyo Japan Department of Neurosurgery (YM) JIKEI University School
of Medicine Tokyo Japan Department of Neurosurgery (SN) Institute of
Health Bioscience University of Tokushima Graduate School Tokushima
Japan Department of Neurosurgery (NN) Hokkaido University Graduate
School of Medicine Hokkaido Japan Endovascular and Operative Neurovas-
cular Surgery (CSO) Beth Israel Deaconess Medical Center Harvard Medical
School Boston MA Department of Radiology (LP) University Hospital
Reims France Department of Neurology (YBWEMR) Academic Medical
Center Amsterdam the Netherlands Department of Neurosurgery (J Rinne)
Division of Clinical Neurosciences Turku University Hospital Turku Finland
Department of Neurosurgery (A Ronkainen) Tampere University Hospital
Tampere Finland Department of Neurosurgery (KS) Geneva University
Hospital Switzerland Departments of Neurosurgery (VS) and Neurology
(HS) Goethe University Frankfurt Germany Department of Neurological
Surgery (RAS ESC) New York Presbyterian Hospital Columbia Univer-
sity College of Physicians and Surgeons New York NY Brain Center Rudolf
Magnus (MDIV GJER) Department of Neurology and Neurosurgery
University Medical Centre Utrecht the Netherlands Institute for Diagnostic
and Interventional Radiology and Neuroradiology (IW) University Hospital
of Essen Germany SwissNeuroInstitute (IW DR) Clinic Hirslanden
Zurich Switzerland Department of Neurology (MJHW) Leiden University
Medical Center Leiden the Netherlands Department of Surgery and Neuro-
surgery (GKCW) Prince of Wales Hospital The Chinese University of
Hong Kong Hong Kong China Division of Neurosurgery (JHW) Depart-
ments of Clinical Neurosciences and Diagnostic Imaging University of Calgary
Alberta Canada Departments of Neurological Surgery and Neurology (GJZ)
Washington University School of Medicine St Louis MO Institute of Neu-
rosurgery (AP) Section of Vascular Neurosurgery Verona University amp City
Hospital Verona Italy Department of Neurosurgery (PV) Chariteacute University
Medical Centre Berlin Germany Division of Neurological Surgery (CM)
Barrow Neurological Institute St Josephs Hospital and Medical Center
Phoenix AZ and Brain and Spine Center (PL) Lankenau Medical Center
Wynnewood PA
AUTHOR CONTRIBUTIONSNE RDB KB SJ J Ra A Ra AA ESC HS GL AP
DR PV CM PLR and RLM were involved in the design of
the study NE and KB collected analyzed and interpreted the data
but did not participate in the Delphi consensus NE RDB KB
SJ JRa AkMo JCT CPD ARa JM MK PV DH
GJER and RLM drafted the paper RDB SJ JRa AkMo
JCT CPD ARa JM MK SAH RAlSa DLB JB
AB AD DJF AG GH DMH BLH PJ HK MEK
PJK NK TiKo TiKr MTL TRM SAM EM AnMo
MKM KM YM SN NaNa MN CSO VMP LP
AAR YBWEMR JaRi RHR AnRo KS VS RASo
JS HJS MDIV IW MJHW GKCW JHW GJZ
PV CM DH GJER and RLM participated in the study re-
viewed and commented on the final version of the manuscript
STUDY FUNDINGNo targeted funding reported
DISCLOSUREN Etminan is a scientific advisorofficer for Edge Therapeutics Inc
R Brown K Beseoglu S Juvela J Raymond A Morita and J Torner
report no disclosures relevant to the manuscript C Derdeyn serves on
the Scientific Advisory Board for W L Gore and Associates and Pulse
Therapeutics He is a consultant for Penumbra Inc (DSMB member)
and Microvention (Angio Core Lab for brain aneurysm stent trial)
A Raabe J Mocco M Korja A Abdulazim S Amin-Hanjani
R Al-Shahi Salman D Barrow J Bederson A Bonafe and A Dumont
report no disclosures relevant to the manuscript D Fiorella is a consultant
for Codman Neurovascular CovidienEV3 Sequent Medical and Siemens
Medical Imaging and received research support from Penumbra Inc and
Microvention A Gruber G Hankey D Hasan B Hoh P Jabbour
and H Kasuya report no disclosures relevant to the manuscript M Kelly
is a shareholder of Blockade Medical Inc P Kirkpatrick N Knuckey
T Koivisto T Krings M Lawton and T Marotta report no disclosures
relevant to the manuscript S Mayer is a consultant for Edge Therapeutics
Inc and Actelion Pharmaceuticals E Mee reports no disclosures relevant to
the manuscript V Mendes Pereira is consultant for Covidien A
Molyneux M Morgan K Mori Y Murayama S Nagahiro N
Nakayama M Nimelauml C Ogilvy L Pierot A Rabinstein Y Roos J
Rinne R Rosenwasser A Ronkainen K Schaller V Seifert R Solomon
J Spears H-J Steiger M Vergouwen I Wanke M Wermer G Wong J
Wong G Zipfel E Sander Connolly and H Steinmetz report no disclosures
relevant to the manuscript G Lanzino is a consultant for Covidien Edge
Therapeutics Inc and Codman A Pasqualin D Ruumlfenacht P Vajkoczy
and C McDougall report no disclosures relevant to the manuscript
D Haumlnggi is a scientific advisorofficer for Edge Therapeutics Inc P LeRoux
is a Scientific Advisory Board member for Edge Therapeutics Inc and a
consultant for Integra Codman Synthes Neurologica Brainsgate and Orsan
G Rinkel reports no disclosures relevant to the manuscript R Macdonald is
Chief Scientific Officer of Edge Therapeutics Inc and received grant support
from the Physicians Services Incorporated Foundation Brain Aneurysm Foun-
dation Canadian Institutes for Health Research and the Heart and Stroke
Foundation of Canada Go to Neurologyorg for full disclosures
Received January 5 2015 Accepted in final form April 18 2015
REFERENCES1 Gabriel RA Kim H Sidney S et al Ten-year detection
rate of brain arteriovenous malformations in a large mul-
tiethnic defined population Stroke 20104121ndash26
2 Vlak MH Algra A Brandenburg R Rinkel GJ Prevalence
of unruptured intracranial aneurysms with emphasis on sex
age comorbidity country and time period a systematic
review and meta-analysis Lancet Neurol 201110626ndash636
3 Ishibashi T Murayama Y Urashima M et al Unruptured
intracranial aneurysms incidence of rupture and risk fac-
tors Stroke 200940313ndash316
4 Juvela S Poussa K Lehto H Porras M Natural history of
unruptured intracranial aneurysms a long-term follow-up
study Stroke 2013442414ndash2421
5 Morita A Kirino T Hashi K et al The natural course of
unruptured cerebral aneurysms in a Japanese cohort N
Engl J Med 20123662474ndash2482
6 Nieuwkamp DJ Setz LE Algra A Linn FH de Rooij NK
Rinkel GJ Changes in case fatality of aneurysmal subarach-
noid haemorrhage over time according to age sex and
region a meta-analysis Lancet Neurol 20098635ndash642
7 Sonobe M Yamazaki T Yonekura M Kikuchi H Small
unruptured intracranial aneurysm verification study
SUAVe study Japan Stroke 2010411969ndash1977
8 Wermer MJ van der Schaaf IC Velthuis BK Majoie CB
Albrecht KW Rinkel GJ Yield of short-term follow-up
CTMR angiography for small aneurysms detected at
screening Stroke 200637414ndash418
9 Wiebers DO Whisnant JP Huston J III et al Unrup-
tured intracranial aneurysms natural history clinical out-
come and risks of surgical and endovascular treatment
Lancet 2003362103ndash110
888 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
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bull September 29 A Critical Part of the Team Advanced Practice Providers in Neurology
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Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
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Figure 2 The unruptured intracranial aneurysm treatment scoreThe unruptured intracranialaneurysm treatment score(UIATS) model includes andquantifies the key factorsfor clinical decision-makingin the management of unrup-tured intracranial aneurysms(UIAs) developedbasedon rele-vance rating data from Delphiconsensus rounds 1ndash418 Tocalculate a management rec-ommendation for a UIA thenumber of points correspond-ing to each patient- aneu-rysm- or treatment-relatedfeature on both managementcolumns of the scoring form(ldquoin favor of UIA repairrdquo and ldquoinfavor of UIA conservative man-agementrdquo) are added up Thiswill lead to 2 numerical values1 favoring aneurysm repair(surgical or endovascular) and1 favoring conservative man-agement The definitions foreach category and factor arefound in the Methods sectionFor cases with a score differ-ence of 3 points or more thedirection ie the differencebetween the calculated numer-ical values on each side of therecommendation columns willsuggest an individual manage-ment recommendation (ieaneurysm repair or conserva-tive management) For casesthat have similar aneurysmtreatment and conservativemanagement scores (62 pointdifference or less) the recom-mendation is ldquonot definitiverdquo andeither management approachcould be supported as additionalfactors apart from those used inthe development of UIATSmay be considered in makinga final decision regarding themanagement recommenda-tion and long-term follow-upFor cases with multiple aneur-ysms every aneurysm must beevaluated separately which willthen also result in separate rec-ommendations for each aneu-rysm The minimal intervention-related risk is always added as aconstant factor (5 points)AComA 5 anterior communi-cating artery BasA 5 basilarartery BP 5 blood pressuremultiple 5 multiple selectioncategory PComA 5 poste-rior communicating arterySAH 5 subarachnoid hemor-rhage single 5 single selec-tion category
884 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
UIATS was 95 among panel members and 94among external reviewers Interrater agreement per casewas high for both reviewersrsquo cohorts (vr5 0023 95CI 0018ndash0027 for panel members vr5 0028 95CI 0022ndash0034 for external reviewers) Despite an
unbalanced distribution of specialties among theconsensus group there was no difference (p 5
0290 Mann-Whitney U test) in mean Likert scoresper reviewer between interventional (42 95 CI41ndash43 for neurosurgery interventional neuroradi-ology or both n 5 56) and noninterventional (4195 CI 39ndash44 for neurology and clinical epidemi-ology n5 12) specialties or between individual spe-cialties (p 5 0325 Mann-Whitney U test) Therewas a distinct correlation between the score magni-tude of the recommendation (difference in pointsfor interventional and conservative management)and the level of agreement suggesting that theclearer the recommendation of the UIATS thehigher the level of agreement among the reviewers(figure 3B) A representative set of UIATS examplesand corresponding UIATS recommendations result-ing in the highest and lowest overall agreement areillustrated in figures 4 and 5 respectively
DISCUSSION The key finding of our consensus pro-ject among a large and diverse group of multidisciplinarycerebrovascular specialists is that we were able to developa comprehensive scoring model for management recom-mendations for UIAs Importantly this model is in highagreement with current UIA decision-making in aselected UIA patient population evidenced by thehigh agreement and interrater agreement with UIATS-derived recommendations among the specialist groupThe level of agreement with managementrecommendations based on the UIATS model isindependent from the underlying professionalbackground of the specialists ie interventionalor noninterventional and is even higher amongspecialists who were not involved in the developmentof the scoring model
The UIATS is neither a prognostic study nor apredictive model for UIA rupture as it is derivedfrom consensus on contemporary practice of UIAmanagement among cerebrovascular specialists usingthe Delphi method and only indirectly from pub-lished data In that sense it differs from the recentlydeveloped PHASES score a model based on prospec-tively collected data from 6 cohort studies on risk ofUIA rupture that provides absolute risks of rupturefor the initial 5 years after aneurysm detection using6 easily retrievable baseline characteristics (patientgeographical location and age aneurysm size andlocation presence of arterial hypertension and previ-ous SAH from a different aneurysm)23 Howeversome subgroups in the PHASES score were under-represented such as patients with familial aneurysmsor may have been underrepresented such as youngsmokers Thus the score may not apply to all patientsAlso the score holds true for only the initial 5 yearsafter UIA detection because of limited long-term
Figure 3 Validation of the UIATS
(A) Agreement with unruptured intracranial aneurysm treatment score (UIATS)-derived recom-mendations per case and per rater Means for Likert scores (y-axis) are illustrated for each case(dots) and for each rater (circles) among panel members and the blinded external reviewers(x-axis) A Likert score of 5 indicates strong agreement 4 indicates agreement 3 indicates neu-trality 2 indicates disagreement and 1 indicates strong disagreement Since means for Likertscores did not fall below a score of 3 the y-axis scale does not show disagreement and strongdisagreement Compared to agreement of panel members with UIATS-derived treatment recom-mendations for each case themeanLikert score (y-axis) was significantly higher among the exter-nal reviewers who were completely blinded to the score raw data and the survey developmentand design (indicates p 5 0017) (B) Correlation of Likert scores and UIATS characteristicsThe level of agreement (y-axis) between panel members and external reviewers was correlated(Pearson product-moment) with the UIATS differences between aneurysm repair and conserva-tive management for every UIATS treatment recommendation (x-axis) The score magnitudecorrelated significantly with agreement among the reviewers independently for panel members(r2 5 0323 p 5 0002 solid line) and external reviewers (r2 5 0399 p 0001 dotted line)
Neurology 85 September 8 2015 885
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
follow-up data and many patients have a predicted lifeexpectancy of more than 5 years Moreover severalaneurysm characteristics found or suggested to be riskfactors for rupture in case-control studies could not beincluded in the PHASES score Finally the PHASESscore was developed to predict the risk of rupturewhereas when a clinician recommends repair of aUIA the risk of intervention must also be taken intoaccount which is not done in the PHASES scoreThus many uncertainties due to varying levels of evi-dence remain which have to be accounted for in clin-ical practice when consulting patients with UIAs
The UIATS model was designed to address theseuncertainties and thus to potentially harmonize the
high level of variation among clinicians about the indi-vidual management of patients with UIA The UIATSwas developed partially based on data but also usingconsensus among specialists in the field The merit ofthis model is that it accounts for many different factorsthat often influence clinical decisions but that were notwell studied in previous observational studies egyoung age or long life expectancy coexistent modifiableor nonmodifiable risk factors coexistent morbiditiesmorphologic UIA features or relevance of clinicalsymptoms related to UIAs51011132425 Admittedlythe UIATS model requires more baseline characteris-tics than the PHASES score which makes its applica-tion slightly more time consuming However ourresults highlight that specialists in UIA research andtreatment account for these factors in their decision-making and that these specialists have a high level ofagreement about how to handle these factors for whichdata are currently incomplete or lacking We used theDelphi method to scientifically obtain consensus andsubsequently to systematically categorize potential fac-tors for contemporary decision-making on the appro-priate management of UIAs Studies from othermedical fields have used the Delphi method to system-atically reach consensus or develop treatment scores onsimilar controversial or complex subjects among pro-fessionally andor geographically dispersed special-ists26ndash28 We emphasize that data derived fromconsensus among specialists cannot replace evidencebut rather can complement it specifically in areaswhere there is uncertainty If more observational databecome available and predictors for aneurysm ruptureand treatment complications become more sophisti-cated the UIATS model could be adjusted Howeveruntil such data become available our proposed scoringmodel constitutes an organized and objective means ofcapturing the best consensus possible on UIA manage-ment as a complement to existing UIA rupture riskprediction models
Our study has several limitations Although weincluded a wide variety of multidisciplinary specialistsfrom various predominantly high-income Westerncountries with different health care systems we can-not claim that this ldquopopulationrdquo of specialists is rep-resentative of the general ldquocommunity of UIAspecialists or expertsrdquo if such a group could bedefined Second one important premise in the con-struction of the UIATS is that the management ofUIAs constitutes a comparison between the risk ofrupture vs the risks of treatment in that particularpatient Some have argued that these 2 ldquoquantitiesrdquoone being a risk event rate and the other being a one-time risk cannot validly be compared29 However indaily practice this is what clinicians do ie comparethe risk of aneurysm rupture with the risk of prophy-lactic aneurysm repair Third we used a binary
Figure 4 UIATS case recommendation resulting in the highest agreementamong the internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 47-year-old woman (3points favoring treatment for patient age 41ndash60 years) who previously underwent cranialMRI for chronic headaches with (A) posterior-anterior and (B) lateral projection as well as (C)posterior-anterior and (D) lateral 3-dimensional reconstructions is shown This incidentalirregularly shaped (3 points favoring treatment for irregular morphology) anterior communi-cating artery aneurysm (arrow 2 points favoring treatment for aneurysm location) had amaximum diameter of 76 mm (2 points favoring treatment for aneurysm diameter) with aneck diameter of 35 mm Aspect and size ratios were calculated to be 21 and 38 respec-tively (1 point favoring treatment for aspect or size ratio greater than 16 or 30 respec-tively) Her medical history included arterial hypertension (2 points favoring treatment forrisk factor hypertension) but no other chronic comorbidities The resulting scoring based onthe UIATS was 13 points in favor of aneurysm repair and 7 points in favor of conservativemanagement (1 point for patient age 41ndash60 years 1 point for aneurysm size 6ndash10 mm and5 points for the constant intervention-related risk) The resulting UIATS recommendationwas ldquoaneurysm repairrdquo Overall agreement with this UIATS recommendation was 473 (95confidence interval 462ndash485) for both reviewer cohorts
886 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
decision scenario (treat or not treat) rather than mak-ing distinctions between different possible treatmentmodalities mainly to propose a unifying scoringmodel that would not divide the specialist groupFourth we used pooled data from meta-analyses toincorporate treatment risk percentages into ourmodel However given the lack of more robust dataon risk factors for UIA treatment complications it isunclear whether the individual treatment risk in apatient with a UIA may be distinctly lower or higherdepending on the surgeonrsquos or interventionalistrsquosexperience the treatment modality and the aneu-rysm complexity Lastly the series of cases we vali-dated with the UIATS covered a wide range ofpatients and aneurysms but may not entirely reflectthe complete spectrum of patients and aneurysms
seen in clinical practice As an example in the valida-tion data set 13 of 30 UIAs were larger than 7 mmwhich may not reflect the actual UIA size distributionin the general population In addition the presenta-tion of the actual score values to the external reviewersduring the validation may have introduced some biasif these external experts were somewhat uncertain andtherefore more willing to agree with the proposedrecommendations However given the expertise ofthe external reviewers we do not feel this has influ-enced the results to a large extent
This multidisciplinary consensus project has re-sulted in the UIATSmodel which captures contempo-rary and multifactorial decision-making by specialistson UIA management By applying this scoring modelclinicians can appreciate what highly informed individ-uals in the cerebrovascular field would advise in a par-ticular patient based on current data and uncertaintiesSince the validity of the UIATSmodel was tested basedon theoretical rather than empirical data its applicabil-ity and clinical accuracy remain to be prospectivelyexplored in patients with UIA Thus the current treat-ment recommendations may change if new data fromsuch studies or future observational UIA studiesbecome available Ultimately individual patient factorsbeyond those accounted for in the present scoringmodel may also alter the individual management of apatient with a UIA
AUTHOR AFFILIATIONFrom the Department of Neurosurgery (NE KB AA H-JS DH)
Medical Faculty Heinrich-Heine-University Duumlsseldorf Germany Depart-
ments of Neurology (RDB AAR) and Neurologic Surgery (GL) Mayo
Clinic Rochester MN Department of Clinical Neurosciences (SJ) University
of Helsinki Finland Department of RadiologymdashInterventional Neuroradiol-
ogy (J Raymond) CHUM Research Center Notre-Dame Hospital Montreal
Quebec Canada Department of Neurological Surgery (A Morita) Nippon
Medical School Tokyo Japan Departments of Epidemiology (JCT) and
Neurosurgery (DMH) University of Iowa Iowa City Mallinckrodt Institute
of Radiology (CPD) Washington University School of MedicineBarnes-
Jewish Hospital St Louis MO Department of Neurosurgery (A Raabe)
Inselspital Bern Switzerland Department of Neurological Surgery (JM)
Vanderbilt University Medical Center Nashville TN Department of Neuro-
surgery (MK MN) Helsinki University Central Hospital Helsinki Finland
Department of Neurosurgery (SA-H) University of Illinois at Chicago
Centre for Clinical Brain Sciences (RA-SS) University of Edinburgh
United Kingdom Department of Neurosurgery (DLB) Emory Stroke Cen-
ter Emory University School of Medicine Atlanta GA Department of Neu-
rosurgery (JB) The Mount Sinai Health System New York NY Department
of Neuroradiology (AB) CHUMontpellier Montpellier France Department
of Neurosurgery (ASD) Tulane University School of Medicine New
Orleans LA Department of Neurosurgery (DJK) Cerebrovascular Centre
Stony Brook University Medical Center Stony Brook NY Department of
Neurosurgery (AG) Medical University of Vienna Austria Department of
Neurology (GJH) and Neurosurgery Unit (NK) Sir Charles Gairdner Hos-
pital Nedlands Western Australia Australia School of Medicine and Pharma-
cology (GJH) The University of Western Australia Perth Australia
Department of Neurosurgery (BLH) University of Florida Gainesville
Department of Neurological Surgery (PJ RHR) Thomas Jefferson Univer-
sity Hospital Philadelphia PA Department of Neurosurgery (HK) Tokyo
Womenrsquos Medical University Medical Center East Tokyo Japan Saskatche-
wan Cerebrovascular Centre (MEK) Royal University Hospital University of
Saskatchewan Saskatoon Canada Department of Clinical Neurosciences
Figure 5 UIATS case recommendation resulting in the lowest agreement amongthe internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 25-year-old woman(4 points favoring treatment for patient age younger than 40 years) who previously under-went MRI for persistent headaches vertigo and occasional bitemporal vision disturbances(due to a migraine aura) with (A) posterior-anterior and (B) lateral projection as well as (C) pos-terior-anterior and (D) lateral 3-dimensional reconstructions is shown This left-sided wide-necked paraophthalmic internal carotid artery aneurysm had a maximum diameter of3 mmwith a neck diameter of 27 mm (3 points favoring conservative management for aneu-rysm complexity due to wide neck) The patient did not report any additional risk factors orcomorbidities in her past medical history The resulting scores based on the UIATS were4 points in favor of aneurysm repair and 8 points (including 5 points favoring conservativemanagement for the constant intervention-related risk) in favor of conservative manage-ment The resulting UIATS recommendation was ldquoconservative managementrdquoOverall agree-ment with this UIATS recommendation was 37 (95 confidence interval 344ndash396) forboth reviewer cohorts
Neurology 85 September 8 2015 887
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
(PJK) Cambridge University Hospitals Trust University of Cambridge
United Kingdom NeurosurgeryNeuroCenter (T Koivisto) Kuopio University
Hospital University of Eastern Finland Finland Department of Medical Imag-
ing and Surgery (T Krings VMP) Toronto Western Hospital University
Health Network Toronto Ontario Canada Department of Neurological Sur-
gery (MTL) University of California San Francisco Divisions of Neurora-
diology (TRM) and Neurosurgery (JS RLM) St Michaels Hospital
University of Toronto Ontario Canada Institute for Critical Care Medicine
(SAM) Icahn School of Medicine at Mount Sinai New York NY Depart-
ment of Neurosurgery (EM) Auckland City Hospital Auckland New
Zealand Nuffield Department of Surgical Sciences (A Molyneux) University
of Oxford United Kingdom Division of Neurosurgery (MKM) Australian
School of Advanced Medicine Macquarie University Sydney Australia
Department of Neurosurgery (KM) National Defense Medical College
Tokyo Japan Department of Neurosurgery (YM) JIKEI University School
of Medicine Tokyo Japan Department of Neurosurgery (SN) Institute of
Health Bioscience University of Tokushima Graduate School Tokushima
Japan Department of Neurosurgery (NN) Hokkaido University Graduate
School of Medicine Hokkaido Japan Endovascular and Operative Neurovas-
cular Surgery (CSO) Beth Israel Deaconess Medical Center Harvard Medical
School Boston MA Department of Radiology (LP) University Hospital
Reims France Department of Neurology (YBWEMR) Academic Medical
Center Amsterdam the Netherlands Department of Neurosurgery (J Rinne)
Division of Clinical Neurosciences Turku University Hospital Turku Finland
Department of Neurosurgery (A Ronkainen) Tampere University Hospital
Tampere Finland Department of Neurosurgery (KS) Geneva University
Hospital Switzerland Departments of Neurosurgery (VS) and Neurology
(HS) Goethe University Frankfurt Germany Department of Neurological
Surgery (RAS ESC) New York Presbyterian Hospital Columbia Univer-
sity College of Physicians and Surgeons New York NY Brain Center Rudolf
Magnus (MDIV GJER) Department of Neurology and Neurosurgery
University Medical Centre Utrecht the Netherlands Institute for Diagnostic
and Interventional Radiology and Neuroradiology (IW) University Hospital
of Essen Germany SwissNeuroInstitute (IW DR) Clinic Hirslanden
Zurich Switzerland Department of Neurology (MJHW) Leiden University
Medical Center Leiden the Netherlands Department of Surgery and Neuro-
surgery (GKCW) Prince of Wales Hospital The Chinese University of
Hong Kong Hong Kong China Division of Neurosurgery (JHW) Depart-
ments of Clinical Neurosciences and Diagnostic Imaging University of Calgary
Alberta Canada Departments of Neurological Surgery and Neurology (GJZ)
Washington University School of Medicine St Louis MO Institute of Neu-
rosurgery (AP) Section of Vascular Neurosurgery Verona University amp City
Hospital Verona Italy Department of Neurosurgery (PV) Chariteacute University
Medical Centre Berlin Germany Division of Neurological Surgery (CM)
Barrow Neurological Institute St Josephs Hospital and Medical Center
Phoenix AZ and Brain and Spine Center (PL) Lankenau Medical Center
Wynnewood PA
AUTHOR CONTRIBUTIONSNE RDB KB SJ J Ra A Ra AA ESC HS GL AP
DR PV CM PLR and RLM were involved in the design of
the study NE and KB collected analyzed and interpreted the data
but did not participate in the Delphi consensus NE RDB KB
SJ JRa AkMo JCT CPD ARa JM MK PV DH
GJER and RLM drafted the paper RDB SJ JRa AkMo
JCT CPD ARa JM MK SAH RAlSa DLB JB
AB AD DJF AG GH DMH BLH PJ HK MEK
PJK NK TiKo TiKr MTL TRM SAM EM AnMo
MKM KM YM SN NaNa MN CSO VMP LP
AAR YBWEMR JaRi RHR AnRo KS VS RASo
JS HJS MDIV IW MJHW GKCW JHW GJZ
PV CM DH GJER and RLM participated in the study re-
viewed and commented on the final version of the manuscript
STUDY FUNDINGNo targeted funding reported
DISCLOSUREN Etminan is a scientific advisorofficer for Edge Therapeutics Inc
R Brown K Beseoglu S Juvela J Raymond A Morita and J Torner
report no disclosures relevant to the manuscript C Derdeyn serves on
the Scientific Advisory Board for W L Gore and Associates and Pulse
Therapeutics He is a consultant for Penumbra Inc (DSMB member)
and Microvention (Angio Core Lab for brain aneurysm stent trial)
A Raabe J Mocco M Korja A Abdulazim S Amin-Hanjani
R Al-Shahi Salman D Barrow J Bederson A Bonafe and A Dumont
report no disclosures relevant to the manuscript D Fiorella is a consultant
for Codman Neurovascular CovidienEV3 Sequent Medical and Siemens
Medical Imaging and received research support from Penumbra Inc and
Microvention A Gruber G Hankey D Hasan B Hoh P Jabbour
and H Kasuya report no disclosures relevant to the manuscript M Kelly
is a shareholder of Blockade Medical Inc P Kirkpatrick N Knuckey
T Koivisto T Krings M Lawton and T Marotta report no disclosures
relevant to the manuscript S Mayer is a consultant for Edge Therapeutics
Inc and Actelion Pharmaceuticals E Mee reports no disclosures relevant to
the manuscript V Mendes Pereira is consultant for Covidien A
Molyneux M Morgan K Mori Y Murayama S Nagahiro N
Nakayama M Nimelauml C Ogilvy L Pierot A Rabinstein Y Roos J
Rinne R Rosenwasser A Ronkainen K Schaller V Seifert R Solomon
J Spears H-J Steiger M Vergouwen I Wanke M Wermer G Wong J
Wong G Zipfel E Sander Connolly and H Steinmetz report no disclosures
relevant to the manuscript G Lanzino is a consultant for Covidien Edge
Therapeutics Inc and Codman A Pasqualin D Ruumlfenacht P Vajkoczy
and C McDougall report no disclosures relevant to the manuscript
D Haumlnggi is a scientific advisorofficer for Edge Therapeutics Inc P LeRoux
is a Scientific Advisory Board member for Edge Therapeutics Inc and a
consultant for Integra Codman Synthes Neurologica Brainsgate and Orsan
G Rinkel reports no disclosures relevant to the manuscript R Macdonald is
Chief Scientific Officer of Edge Therapeutics Inc and received grant support
from the Physicians Services Incorporated Foundation Brain Aneurysm Foun-
dation Canadian Institutes for Health Research and the Heart and Stroke
Foundation of Canada Go to Neurologyorg for full disclosures
Received January 5 2015 Accepted in final form April 18 2015
REFERENCES1 Gabriel RA Kim H Sidney S et al Ten-year detection
rate of brain arteriovenous malformations in a large mul-
tiethnic defined population Stroke 20104121ndash26
2 Vlak MH Algra A Brandenburg R Rinkel GJ Prevalence
of unruptured intracranial aneurysms with emphasis on sex
age comorbidity country and time period a systematic
review and meta-analysis Lancet Neurol 201110626ndash636
3 Ishibashi T Murayama Y Urashima M et al Unruptured
intracranial aneurysms incidence of rupture and risk fac-
tors Stroke 200940313ndash316
4 Juvela S Poussa K Lehto H Porras M Natural history of
unruptured intracranial aneurysms a long-term follow-up
study Stroke 2013442414ndash2421
5 Morita A Kirino T Hashi K et al The natural course of
unruptured cerebral aneurysms in a Japanese cohort N
Engl J Med 20123662474ndash2482
6 Nieuwkamp DJ Setz LE Algra A Linn FH de Rooij NK
Rinkel GJ Changes in case fatality of aneurysmal subarach-
noid haemorrhage over time according to age sex and
region a meta-analysis Lancet Neurol 20098635ndash642
7 Sonobe M Yamazaki T Yonekura M Kikuchi H Small
unruptured intracranial aneurysm verification study
SUAVe study Japan Stroke 2010411969ndash1977
8 Wermer MJ van der Schaaf IC Velthuis BK Majoie CB
Albrecht KW Rinkel GJ Yield of short-term follow-up
CTMR angiography for small aneurysms detected at
screening Stroke 200637414ndash418
9 Wiebers DO Whisnant JP Huston J III et al Unrup-
tured intracranial aneurysms natural history clinical out-
come and risks of surgical and endovascular treatment
Lancet 2003362103ndash110
888 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
AAN Practice Management WebinarsExclusive discount pricing only for AAN members Live or recorded $149 per session or subscribeto all 14 sessions for only $199
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bull September 29 A Critical Part of the Team Advanced Practice Providers in Neurology
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Nonmembers pay $199 per webinar or $649 for a full subscription
Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
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httpnneurologyorgcontent8510881fullincluding high resolution figures can be found at
This article has been cited by 6 HighWire-hosted articles
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reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology
UIATS was 95 among panel members and 94among external reviewers Interrater agreement per casewas high for both reviewersrsquo cohorts (vr5 0023 95CI 0018ndash0027 for panel members vr5 0028 95CI 0022ndash0034 for external reviewers) Despite an
unbalanced distribution of specialties among theconsensus group there was no difference (p 5
0290 Mann-Whitney U test) in mean Likert scoresper reviewer between interventional (42 95 CI41ndash43 for neurosurgery interventional neuroradi-ology or both n 5 56) and noninterventional (4195 CI 39ndash44 for neurology and clinical epidemi-ology n5 12) specialties or between individual spe-cialties (p 5 0325 Mann-Whitney U test) Therewas a distinct correlation between the score magni-tude of the recommendation (difference in pointsfor interventional and conservative management)and the level of agreement suggesting that theclearer the recommendation of the UIATS thehigher the level of agreement among the reviewers(figure 3B) A representative set of UIATS examplesand corresponding UIATS recommendations result-ing in the highest and lowest overall agreement areillustrated in figures 4 and 5 respectively
DISCUSSION The key finding of our consensus pro-ject among a large and diverse group of multidisciplinarycerebrovascular specialists is that we were able to developa comprehensive scoring model for management recom-mendations for UIAs Importantly this model is in highagreement with current UIA decision-making in aselected UIA patient population evidenced by thehigh agreement and interrater agreement with UIATS-derived recommendations among the specialist groupThe level of agreement with managementrecommendations based on the UIATS model isindependent from the underlying professionalbackground of the specialists ie interventionalor noninterventional and is even higher amongspecialists who were not involved in the developmentof the scoring model
The UIATS is neither a prognostic study nor apredictive model for UIA rupture as it is derivedfrom consensus on contemporary practice of UIAmanagement among cerebrovascular specialists usingthe Delphi method and only indirectly from pub-lished data In that sense it differs from the recentlydeveloped PHASES score a model based on prospec-tively collected data from 6 cohort studies on risk ofUIA rupture that provides absolute risks of rupturefor the initial 5 years after aneurysm detection using6 easily retrievable baseline characteristics (patientgeographical location and age aneurysm size andlocation presence of arterial hypertension and previ-ous SAH from a different aneurysm)23 Howeversome subgroups in the PHASES score were under-represented such as patients with familial aneurysmsor may have been underrepresented such as youngsmokers Thus the score may not apply to all patientsAlso the score holds true for only the initial 5 yearsafter UIA detection because of limited long-term
Figure 3 Validation of the UIATS
(A) Agreement with unruptured intracranial aneurysm treatment score (UIATS)-derived recom-mendations per case and per rater Means for Likert scores (y-axis) are illustrated for each case(dots) and for each rater (circles) among panel members and the blinded external reviewers(x-axis) A Likert score of 5 indicates strong agreement 4 indicates agreement 3 indicates neu-trality 2 indicates disagreement and 1 indicates strong disagreement Since means for Likertscores did not fall below a score of 3 the y-axis scale does not show disagreement and strongdisagreement Compared to agreement of panel members with UIATS-derived treatment recom-mendations for each case themeanLikert score (y-axis) was significantly higher among the exter-nal reviewers who were completely blinded to the score raw data and the survey developmentand design (indicates p 5 0017) (B) Correlation of Likert scores and UIATS characteristicsThe level of agreement (y-axis) between panel members and external reviewers was correlated(Pearson product-moment) with the UIATS differences between aneurysm repair and conserva-tive management for every UIATS treatment recommendation (x-axis) The score magnitudecorrelated significantly with agreement among the reviewers independently for panel members(r2 5 0323 p 5 0002 solid line) and external reviewers (r2 5 0399 p 0001 dotted line)
Neurology 85 September 8 2015 885
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
follow-up data and many patients have a predicted lifeexpectancy of more than 5 years Moreover severalaneurysm characteristics found or suggested to be riskfactors for rupture in case-control studies could not beincluded in the PHASES score Finally the PHASESscore was developed to predict the risk of rupturewhereas when a clinician recommends repair of aUIA the risk of intervention must also be taken intoaccount which is not done in the PHASES scoreThus many uncertainties due to varying levels of evi-dence remain which have to be accounted for in clin-ical practice when consulting patients with UIAs
The UIATS model was designed to address theseuncertainties and thus to potentially harmonize the
high level of variation among clinicians about the indi-vidual management of patients with UIA The UIATSwas developed partially based on data but also usingconsensus among specialists in the field The merit ofthis model is that it accounts for many different factorsthat often influence clinical decisions but that were notwell studied in previous observational studies egyoung age or long life expectancy coexistent modifiableor nonmodifiable risk factors coexistent morbiditiesmorphologic UIA features or relevance of clinicalsymptoms related to UIAs51011132425 Admittedlythe UIATS model requires more baseline characteris-tics than the PHASES score which makes its applica-tion slightly more time consuming However ourresults highlight that specialists in UIA research andtreatment account for these factors in their decision-making and that these specialists have a high level ofagreement about how to handle these factors for whichdata are currently incomplete or lacking We used theDelphi method to scientifically obtain consensus andsubsequently to systematically categorize potential fac-tors for contemporary decision-making on the appro-priate management of UIAs Studies from othermedical fields have used the Delphi method to system-atically reach consensus or develop treatment scores onsimilar controversial or complex subjects among pro-fessionally andor geographically dispersed special-ists26ndash28 We emphasize that data derived fromconsensus among specialists cannot replace evidencebut rather can complement it specifically in areaswhere there is uncertainty If more observational databecome available and predictors for aneurysm ruptureand treatment complications become more sophisti-cated the UIATS model could be adjusted Howeveruntil such data become available our proposed scoringmodel constitutes an organized and objective means ofcapturing the best consensus possible on UIA manage-ment as a complement to existing UIA rupture riskprediction models
Our study has several limitations Although weincluded a wide variety of multidisciplinary specialistsfrom various predominantly high-income Westerncountries with different health care systems we can-not claim that this ldquopopulationrdquo of specialists is rep-resentative of the general ldquocommunity of UIAspecialists or expertsrdquo if such a group could bedefined Second one important premise in the con-struction of the UIATS is that the management ofUIAs constitutes a comparison between the risk ofrupture vs the risks of treatment in that particularpatient Some have argued that these 2 ldquoquantitiesrdquoone being a risk event rate and the other being a one-time risk cannot validly be compared29 However indaily practice this is what clinicians do ie comparethe risk of aneurysm rupture with the risk of prophy-lactic aneurysm repair Third we used a binary
Figure 4 UIATS case recommendation resulting in the highest agreementamong the internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 47-year-old woman (3points favoring treatment for patient age 41ndash60 years) who previously underwent cranialMRI for chronic headaches with (A) posterior-anterior and (B) lateral projection as well as (C)posterior-anterior and (D) lateral 3-dimensional reconstructions is shown This incidentalirregularly shaped (3 points favoring treatment for irregular morphology) anterior communi-cating artery aneurysm (arrow 2 points favoring treatment for aneurysm location) had amaximum diameter of 76 mm (2 points favoring treatment for aneurysm diameter) with aneck diameter of 35 mm Aspect and size ratios were calculated to be 21 and 38 respec-tively (1 point favoring treatment for aspect or size ratio greater than 16 or 30 respec-tively) Her medical history included arterial hypertension (2 points favoring treatment forrisk factor hypertension) but no other chronic comorbidities The resulting scoring based onthe UIATS was 13 points in favor of aneurysm repair and 7 points in favor of conservativemanagement (1 point for patient age 41ndash60 years 1 point for aneurysm size 6ndash10 mm and5 points for the constant intervention-related risk) The resulting UIATS recommendationwas ldquoaneurysm repairrdquo Overall agreement with this UIATS recommendation was 473 (95confidence interval 462ndash485) for both reviewer cohorts
886 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
decision scenario (treat or not treat) rather than mak-ing distinctions between different possible treatmentmodalities mainly to propose a unifying scoringmodel that would not divide the specialist groupFourth we used pooled data from meta-analyses toincorporate treatment risk percentages into ourmodel However given the lack of more robust dataon risk factors for UIA treatment complications it isunclear whether the individual treatment risk in apatient with a UIA may be distinctly lower or higherdepending on the surgeonrsquos or interventionalistrsquosexperience the treatment modality and the aneu-rysm complexity Lastly the series of cases we vali-dated with the UIATS covered a wide range ofpatients and aneurysms but may not entirely reflectthe complete spectrum of patients and aneurysms
seen in clinical practice As an example in the valida-tion data set 13 of 30 UIAs were larger than 7 mmwhich may not reflect the actual UIA size distributionin the general population In addition the presenta-tion of the actual score values to the external reviewersduring the validation may have introduced some biasif these external experts were somewhat uncertain andtherefore more willing to agree with the proposedrecommendations However given the expertise ofthe external reviewers we do not feel this has influ-enced the results to a large extent
This multidisciplinary consensus project has re-sulted in the UIATSmodel which captures contempo-rary and multifactorial decision-making by specialistson UIA management By applying this scoring modelclinicians can appreciate what highly informed individ-uals in the cerebrovascular field would advise in a par-ticular patient based on current data and uncertaintiesSince the validity of the UIATSmodel was tested basedon theoretical rather than empirical data its applicabil-ity and clinical accuracy remain to be prospectivelyexplored in patients with UIA Thus the current treat-ment recommendations may change if new data fromsuch studies or future observational UIA studiesbecome available Ultimately individual patient factorsbeyond those accounted for in the present scoringmodel may also alter the individual management of apatient with a UIA
AUTHOR AFFILIATIONFrom the Department of Neurosurgery (NE KB AA H-JS DH)
Medical Faculty Heinrich-Heine-University Duumlsseldorf Germany Depart-
ments of Neurology (RDB AAR) and Neurologic Surgery (GL) Mayo
Clinic Rochester MN Department of Clinical Neurosciences (SJ) University
of Helsinki Finland Department of RadiologymdashInterventional Neuroradiol-
ogy (J Raymond) CHUM Research Center Notre-Dame Hospital Montreal
Quebec Canada Department of Neurological Surgery (A Morita) Nippon
Medical School Tokyo Japan Departments of Epidemiology (JCT) and
Neurosurgery (DMH) University of Iowa Iowa City Mallinckrodt Institute
of Radiology (CPD) Washington University School of MedicineBarnes-
Jewish Hospital St Louis MO Department of Neurosurgery (A Raabe)
Inselspital Bern Switzerland Department of Neurological Surgery (JM)
Vanderbilt University Medical Center Nashville TN Department of Neuro-
surgery (MK MN) Helsinki University Central Hospital Helsinki Finland
Department of Neurosurgery (SA-H) University of Illinois at Chicago
Centre for Clinical Brain Sciences (RA-SS) University of Edinburgh
United Kingdom Department of Neurosurgery (DLB) Emory Stroke Cen-
ter Emory University School of Medicine Atlanta GA Department of Neu-
rosurgery (JB) The Mount Sinai Health System New York NY Department
of Neuroradiology (AB) CHUMontpellier Montpellier France Department
of Neurosurgery (ASD) Tulane University School of Medicine New
Orleans LA Department of Neurosurgery (DJK) Cerebrovascular Centre
Stony Brook University Medical Center Stony Brook NY Department of
Neurosurgery (AG) Medical University of Vienna Austria Department of
Neurology (GJH) and Neurosurgery Unit (NK) Sir Charles Gairdner Hos-
pital Nedlands Western Australia Australia School of Medicine and Pharma-
cology (GJH) The University of Western Australia Perth Australia
Department of Neurosurgery (BLH) University of Florida Gainesville
Department of Neurological Surgery (PJ RHR) Thomas Jefferson Univer-
sity Hospital Philadelphia PA Department of Neurosurgery (HK) Tokyo
Womenrsquos Medical University Medical Center East Tokyo Japan Saskatche-
wan Cerebrovascular Centre (MEK) Royal University Hospital University of
Saskatchewan Saskatoon Canada Department of Clinical Neurosciences
Figure 5 UIATS case recommendation resulting in the lowest agreement amongthe internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 25-year-old woman(4 points favoring treatment for patient age younger than 40 years) who previously under-went MRI for persistent headaches vertigo and occasional bitemporal vision disturbances(due to a migraine aura) with (A) posterior-anterior and (B) lateral projection as well as (C) pos-terior-anterior and (D) lateral 3-dimensional reconstructions is shown This left-sided wide-necked paraophthalmic internal carotid artery aneurysm had a maximum diameter of3 mmwith a neck diameter of 27 mm (3 points favoring conservative management for aneu-rysm complexity due to wide neck) The patient did not report any additional risk factors orcomorbidities in her past medical history The resulting scores based on the UIATS were4 points in favor of aneurysm repair and 8 points (including 5 points favoring conservativemanagement for the constant intervention-related risk) in favor of conservative manage-ment The resulting UIATS recommendation was ldquoconservative managementrdquoOverall agree-ment with this UIATS recommendation was 37 (95 confidence interval 344ndash396) forboth reviewer cohorts
Neurology 85 September 8 2015 887
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
(PJK) Cambridge University Hospitals Trust University of Cambridge
United Kingdom NeurosurgeryNeuroCenter (T Koivisto) Kuopio University
Hospital University of Eastern Finland Finland Department of Medical Imag-
ing and Surgery (T Krings VMP) Toronto Western Hospital University
Health Network Toronto Ontario Canada Department of Neurological Sur-
gery (MTL) University of California San Francisco Divisions of Neurora-
diology (TRM) and Neurosurgery (JS RLM) St Michaels Hospital
University of Toronto Ontario Canada Institute for Critical Care Medicine
(SAM) Icahn School of Medicine at Mount Sinai New York NY Depart-
ment of Neurosurgery (EM) Auckland City Hospital Auckland New
Zealand Nuffield Department of Surgical Sciences (A Molyneux) University
of Oxford United Kingdom Division of Neurosurgery (MKM) Australian
School of Advanced Medicine Macquarie University Sydney Australia
Department of Neurosurgery (KM) National Defense Medical College
Tokyo Japan Department of Neurosurgery (YM) JIKEI University School
of Medicine Tokyo Japan Department of Neurosurgery (SN) Institute of
Health Bioscience University of Tokushima Graduate School Tokushima
Japan Department of Neurosurgery (NN) Hokkaido University Graduate
School of Medicine Hokkaido Japan Endovascular and Operative Neurovas-
cular Surgery (CSO) Beth Israel Deaconess Medical Center Harvard Medical
School Boston MA Department of Radiology (LP) University Hospital
Reims France Department of Neurology (YBWEMR) Academic Medical
Center Amsterdam the Netherlands Department of Neurosurgery (J Rinne)
Division of Clinical Neurosciences Turku University Hospital Turku Finland
Department of Neurosurgery (A Ronkainen) Tampere University Hospital
Tampere Finland Department of Neurosurgery (KS) Geneva University
Hospital Switzerland Departments of Neurosurgery (VS) and Neurology
(HS) Goethe University Frankfurt Germany Department of Neurological
Surgery (RAS ESC) New York Presbyterian Hospital Columbia Univer-
sity College of Physicians and Surgeons New York NY Brain Center Rudolf
Magnus (MDIV GJER) Department of Neurology and Neurosurgery
University Medical Centre Utrecht the Netherlands Institute for Diagnostic
and Interventional Radiology and Neuroradiology (IW) University Hospital
of Essen Germany SwissNeuroInstitute (IW DR) Clinic Hirslanden
Zurich Switzerland Department of Neurology (MJHW) Leiden University
Medical Center Leiden the Netherlands Department of Surgery and Neuro-
surgery (GKCW) Prince of Wales Hospital The Chinese University of
Hong Kong Hong Kong China Division of Neurosurgery (JHW) Depart-
ments of Clinical Neurosciences and Diagnostic Imaging University of Calgary
Alberta Canada Departments of Neurological Surgery and Neurology (GJZ)
Washington University School of Medicine St Louis MO Institute of Neu-
rosurgery (AP) Section of Vascular Neurosurgery Verona University amp City
Hospital Verona Italy Department of Neurosurgery (PV) Chariteacute University
Medical Centre Berlin Germany Division of Neurological Surgery (CM)
Barrow Neurological Institute St Josephs Hospital and Medical Center
Phoenix AZ and Brain and Spine Center (PL) Lankenau Medical Center
Wynnewood PA
AUTHOR CONTRIBUTIONSNE RDB KB SJ J Ra A Ra AA ESC HS GL AP
DR PV CM PLR and RLM were involved in the design of
the study NE and KB collected analyzed and interpreted the data
but did not participate in the Delphi consensus NE RDB KB
SJ JRa AkMo JCT CPD ARa JM MK PV DH
GJER and RLM drafted the paper RDB SJ JRa AkMo
JCT CPD ARa JM MK SAH RAlSa DLB JB
AB AD DJF AG GH DMH BLH PJ HK MEK
PJK NK TiKo TiKr MTL TRM SAM EM AnMo
MKM KM YM SN NaNa MN CSO VMP LP
AAR YBWEMR JaRi RHR AnRo KS VS RASo
JS HJS MDIV IW MJHW GKCW JHW GJZ
PV CM DH GJER and RLM participated in the study re-
viewed and commented on the final version of the manuscript
STUDY FUNDINGNo targeted funding reported
DISCLOSUREN Etminan is a scientific advisorofficer for Edge Therapeutics Inc
R Brown K Beseoglu S Juvela J Raymond A Morita and J Torner
report no disclosures relevant to the manuscript C Derdeyn serves on
the Scientific Advisory Board for W L Gore and Associates and Pulse
Therapeutics He is a consultant for Penumbra Inc (DSMB member)
and Microvention (Angio Core Lab for brain aneurysm stent trial)
A Raabe J Mocco M Korja A Abdulazim S Amin-Hanjani
R Al-Shahi Salman D Barrow J Bederson A Bonafe and A Dumont
report no disclosures relevant to the manuscript D Fiorella is a consultant
for Codman Neurovascular CovidienEV3 Sequent Medical and Siemens
Medical Imaging and received research support from Penumbra Inc and
Microvention A Gruber G Hankey D Hasan B Hoh P Jabbour
and H Kasuya report no disclosures relevant to the manuscript M Kelly
is a shareholder of Blockade Medical Inc P Kirkpatrick N Knuckey
T Koivisto T Krings M Lawton and T Marotta report no disclosures
relevant to the manuscript S Mayer is a consultant for Edge Therapeutics
Inc and Actelion Pharmaceuticals E Mee reports no disclosures relevant to
the manuscript V Mendes Pereira is consultant for Covidien A
Molyneux M Morgan K Mori Y Murayama S Nagahiro N
Nakayama M Nimelauml C Ogilvy L Pierot A Rabinstein Y Roos J
Rinne R Rosenwasser A Ronkainen K Schaller V Seifert R Solomon
J Spears H-J Steiger M Vergouwen I Wanke M Wermer G Wong J
Wong G Zipfel E Sander Connolly and H Steinmetz report no disclosures
relevant to the manuscript G Lanzino is a consultant for Covidien Edge
Therapeutics Inc and Codman A Pasqualin D Ruumlfenacht P Vajkoczy
and C McDougall report no disclosures relevant to the manuscript
D Haumlnggi is a scientific advisorofficer for Edge Therapeutics Inc P LeRoux
is a Scientific Advisory Board member for Edge Therapeutics Inc and a
consultant for Integra Codman Synthes Neurologica Brainsgate and Orsan
G Rinkel reports no disclosures relevant to the manuscript R Macdonald is
Chief Scientific Officer of Edge Therapeutics Inc and received grant support
from the Physicians Services Incorporated Foundation Brain Aneurysm Foun-
dation Canadian Institutes for Health Research and the Heart and Stroke
Foundation of Canada Go to Neurologyorg for full disclosures
Received January 5 2015 Accepted in final form April 18 2015
REFERENCES1 Gabriel RA Kim H Sidney S et al Ten-year detection
rate of brain arteriovenous malformations in a large mul-
tiethnic defined population Stroke 20104121ndash26
2 Vlak MH Algra A Brandenburg R Rinkel GJ Prevalence
of unruptured intracranial aneurysms with emphasis on sex
age comorbidity country and time period a systematic
review and meta-analysis Lancet Neurol 201110626ndash636
3 Ishibashi T Murayama Y Urashima M et al Unruptured
intracranial aneurysms incidence of rupture and risk fac-
tors Stroke 200940313ndash316
4 Juvela S Poussa K Lehto H Porras M Natural history of
unruptured intracranial aneurysms a long-term follow-up
study Stroke 2013442414ndash2421
5 Morita A Kirino T Hashi K et al The natural course of
unruptured cerebral aneurysms in a Japanese cohort N
Engl J Med 20123662474ndash2482
6 Nieuwkamp DJ Setz LE Algra A Linn FH de Rooij NK
Rinkel GJ Changes in case fatality of aneurysmal subarach-
noid haemorrhage over time according to age sex and
region a meta-analysis Lancet Neurol 20098635ndash642
7 Sonobe M Yamazaki T Yonekura M Kikuchi H Small
unruptured intracranial aneurysm verification study
SUAVe study Japan Stroke 2010411969ndash1977
8 Wermer MJ van der Schaaf IC Velthuis BK Majoie CB
Albrecht KW Rinkel GJ Yield of short-term follow-up
CTMR angiography for small aneurysms detected at
screening Stroke 200637414ndash418
9 Wiebers DO Whisnant JP Huston J III et al Unrup-
tured intracranial aneurysms natural history clinical out-
come and risks of surgical and endovascular treatment
Lancet 2003362103ndash110
888 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
AAN Practice Management WebinarsExclusive discount pricing only for AAN members Live or recorded $149 per session or subscribeto all 14 sessions for only $199
bull July 7 ICD-10 Are you Ready
bull August 5 Using Practice Benchmarking Analytics to Improve Your Bottom Line
bull September 15 From Quality Measurement to Quality Improvement
bull September 29 A Critical Part of the Team Advanced Practice Providers in Neurology
See the full 2015 schedule and register today at AANcomviewpmw15
Nonmembers pay $199 per webinar or $649 for a full subscription
Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
ServicesUpdated Information amp
httpnneurologyorgcontent8510881fullincluding high resolution figures can be found at
This article has been cited by 6 HighWire-hosted articles
Subspecialty Collections
httpnneurologyorgcgicollectionstroke_preventionStroke prevention e
httpnneurologyorgcgicollectionall_cerebrovascular_disease_strokAll Cerebrovascular diseaseStrokefollowing collection(s) This article along with others on similar topics appears in the
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httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in
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rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All
reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology
follow-up data and many patients have a predicted lifeexpectancy of more than 5 years Moreover severalaneurysm characteristics found or suggested to be riskfactors for rupture in case-control studies could not beincluded in the PHASES score Finally the PHASESscore was developed to predict the risk of rupturewhereas when a clinician recommends repair of aUIA the risk of intervention must also be taken intoaccount which is not done in the PHASES scoreThus many uncertainties due to varying levels of evi-dence remain which have to be accounted for in clin-ical practice when consulting patients with UIAs
The UIATS model was designed to address theseuncertainties and thus to potentially harmonize the
high level of variation among clinicians about the indi-vidual management of patients with UIA The UIATSwas developed partially based on data but also usingconsensus among specialists in the field The merit ofthis model is that it accounts for many different factorsthat often influence clinical decisions but that were notwell studied in previous observational studies egyoung age or long life expectancy coexistent modifiableor nonmodifiable risk factors coexistent morbiditiesmorphologic UIA features or relevance of clinicalsymptoms related to UIAs51011132425 Admittedlythe UIATS model requires more baseline characteris-tics than the PHASES score which makes its applica-tion slightly more time consuming However ourresults highlight that specialists in UIA research andtreatment account for these factors in their decision-making and that these specialists have a high level ofagreement about how to handle these factors for whichdata are currently incomplete or lacking We used theDelphi method to scientifically obtain consensus andsubsequently to systematically categorize potential fac-tors for contemporary decision-making on the appro-priate management of UIAs Studies from othermedical fields have used the Delphi method to system-atically reach consensus or develop treatment scores onsimilar controversial or complex subjects among pro-fessionally andor geographically dispersed special-ists26ndash28 We emphasize that data derived fromconsensus among specialists cannot replace evidencebut rather can complement it specifically in areaswhere there is uncertainty If more observational databecome available and predictors for aneurysm ruptureand treatment complications become more sophisti-cated the UIATS model could be adjusted Howeveruntil such data become available our proposed scoringmodel constitutes an organized and objective means ofcapturing the best consensus possible on UIA manage-ment as a complement to existing UIA rupture riskprediction models
Our study has several limitations Although weincluded a wide variety of multidisciplinary specialistsfrom various predominantly high-income Westerncountries with different health care systems we can-not claim that this ldquopopulationrdquo of specialists is rep-resentative of the general ldquocommunity of UIAspecialists or expertsrdquo if such a group could bedefined Second one important premise in the con-struction of the UIATS is that the management ofUIAs constitutes a comparison between the risk ofrupture vs the risks of treatment in that particularpatient Some have argued that these 2 ldquoquantitiesrdquoone being a risk event rate and the other being a one-time risk cannot validly be compared29 However indaily practice this is what clinicians do ie comparethe risk of aneurysm rupture with the risk of prophy-lactic aneurysm repair Third we used a binary
Figure 4 UIATS case recommendation resulting in the highest agreementamong the internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 47-year-old woman (3points favoring treatment for patient age 41ndash60 years) who previously underwent cranialMRI for chronic headaches with (A) posterior-anterior and (B) lateral projection as well as (C)posterior-anterior and (D) lateral 3-dimensional reconstructions is shown This incidentalirregularly shaped (3 points favoring treatment for irregular morphology) anterior communi-cating artery aneurysm (arrow 2 points favoring treatment for aneurysm location) had amaximum diameter of 76 mm (2 points favoring treatment for aneurysm diameter) with aneck diameter of 35 mm Aspect and size ratios were calculated to be 21 and 38 respec-tively (1 point favoring treatment for aspect or size ratio greater than 16 or 30 respec-tively) Her medical history included arterial hypertension (2 points favoring treatment forrisk factor hypertension) but no other chronic comorbidities The resulting scoring based onthe UIATS was 13 points in favor of aneurysm repair and 7 points in favor of conservativemanagement (1 point for patient age 41ndash60 years 1 point for aneurysm size 6ndash10 mm and5 points for the constant intervention-related risk) The resulting UIATS recommendationwas ldquoaneurysm repairrdquo Overall agreement with this UIATS recommendation was 473 (95confidence interval 462ndash485) for both reviewer cohorts
886 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
decision scenario (treat or not treat) rather than mak-ing distinctions between different possible treatmentmodalities mainly to propose a unifying scoringmodel that would not divide the specialist groupFourth we used pooled data from meta-analyses toincorporate treatment risk percentages into ourmodel However given the lack of more robust dataon risk factors for UIA treatment complications it isunclear whether the individual treatment risk in apatient with a UIA may be distinctly lower or higherdepending on the surgeonrsquos or interventionalistrsquosexperience the treatment modality and the aneu-rysm complexity Lastly the series of cases we vali-dated with the UIATS covered a wide range ofpatients and aneurysms but may not entirely reflectthe complete spectrum of patients and aneurysms
seen in clinical practice As an example in the valida-tion data set 13 of 30 UIAs were larger than 7 mmwhich may not reflect the actual UIA size distributionin the general population In addition the presenta-tion of the actual score values to the external reviewersduring the validation may have introduced some biasif these external experts were somewhat uncertain andtherefore more willing to agree with the proposedrecommendations However given the expertise ofthe external reviewers we do not feel this has influ-enced the results to a large extent
This multidisciplinary consensus project has re-sulted in the UIATSmodel which captures contempo-rary and multifactorial decision-making by specialistson UIA management By applying this scoring modelclinicians can appreciate what highly informed individ-uals in the cerebrovascular field would advise in a par-ticular patient based on current data and uncertaintiesSince the validity of the UIATSmodel was tested basedon theoretical rather than empirical data its applicabil-ity and clinical accuracy remain to be prospectivelyexplored in patients with UIA Thus the current treat-ment recommendations may change if new data fromsuch studies or future observational UIA studiesbecome available Ultimately individual patient factorsbeyond those accounted for in the present scoringmodel may also alter the individual management of apatient with a UIA
AUTHOR AFFILIATIONFrom the Department of Neurosurgery (NE KB AA H-JS DH)
Medical Faculty Heinrich-Heine-University Duumlsseldorf Germany Depart-
ments of Neurology (RDB AAR) and Neurologic Surgery (GL) Mayo
Clinic Rochester MN Department of Clinical Neurosciences (SJ) University
of Helsinki Finland Department of RadiologymdashInterventional Neuroradiol-
ogy (J Raymond) CHUM Research Center Notre-Dame Hospital Montreal
Quebec Canada Department of Neurological Surgery (A Morita) Nippon
Medical School Tokyo Japan Departments of Epidemiology (JCT) and
Neurosurgery (DMH) University of Iowa Iowa City Mallinckrodt Institute
of Radiology (CPD) Washington University School of MedicineBarnes-
Jewish Hospital St Louis MO Department of Neurosurgery (A Raabe)
Inselspital Bern Switzerland Department of Neurological Surgery (JM)
Vanderbilt University Medical Center Nashville TN Department of Neuro-
surgery (MK MN) Helsinki University Central Hospital Helsinki Finland
Department of Neurosurgery (SA-H) University of Illinois at Chicago
Centre for Clinical Brain Sciences (RA-SS) University of Edinburgh
United Kingdom Department of Neurosurgery (DLB) Emory Stroke Cen-
ter Emory University School of Medicine Atlanta GA Department of Neu-
rosurgery (JB) The Mount Sinai Health System New York NY Department
of Neuroradiology (AB) CHUMontpellier Montpellier France Department
of Neurosurgery (ASD) Tulane University School of Medicine New
Orleans LA Department of Neurosurgery (DJK) Cerebrovascular Centre
Stony Brook University Medical Center Stony Brook NY Department of
Neurosurgery (AG) Medical University of Vienna Austria Department of
Neurology (GJH) and Neurosurgery Unit (NK) Sir Charles Gairdner Hos-
pital Nedlands Western Australia Australia School of Medicine and Pharma-
cology (GJH) The University of Western Australia Perth Australia
Department of Neurosurgery (BLH) University of Florida Gainesville
Department of Neurological Surgery (PJ RHR) Thomas Jefferson Univer-
sity Hospital Philadelphia PA Department of Neurosurgery (HK) Tokyo
Womenrsquos Medical University Medical Center East Tokyo Japan Saskatche-
wan Cerebrovascular Centre (MEK) Royal University Hospital University of
Saskatchewan Saskatoon Canada Department of Clinical Neurosciences
Figure 5 UIATS case recommendation resulting in the lowest agreement amongthe internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 25-year-old woman(4 points favoring treatment for patient age younger than 40 years) who previously under-went MRI for persistent headaches vertigo and occasional bitemporal vision disturbances(due to a migraine aura) with (A) posterior-anterior and (B) lateral projection as well as (C) pos-terior-anterior and (D) lateral 3-dimensional reconstructions is shown This left-sided wide-necked paraophthalmic internal carotid artery aneurysm had a maximum diameter of3 mmwith a neck diameter of 27 mm (3 points favoring conservative management for aneu-rysm complexity due to wide neck) The patient did not report any additional risk factors orcomorbidities in her past medical history The resulting scores based on the UIATS were4 points in favor of aneurysm repair and 8 points (including 5 points favoring conservativemanagement for the constant intervention-related risk) in favor of conservative manage-ment The resulting UIATS recommendation was ldquoconservative managementrdquoOverall agree-ment with this UIATS recommendation was 37 (95 confidence interval 344ndash396) forboth reviewer cohorts
Neurology 85 September 8 2015 887
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
(PJK) Cambridge University Hospitals Trust University of Cambridge
United Kingdom NeurosurgeryNeuroCenter (T Koivisto) Kuopio University
Hospital University of Eastern Finland Finland Department of Medical Imag-
ing and Surgery (T Krings VMP) Toronto Western Hospital University
Health Network Toronto Ontario Canada Department of Neurological Sur-
gery (MTL) University of California San Francisco Divisions of Neurora-
diology (TRM) and Neurosurgery (JS RLM) St Michaels Hospital
University of Toronto Ontario Canada Institute for Critical Care Medicine
(SAM) Icahn School of Medicine at Mount Sinai New York NY Depart-
ment of Neurosurgery (EM) Auckland City Hospital Auckland New
Zealand Nuffield Department of Surgical Sciences (A Molyneux) University
of Oxford United Kingdom Division of Neurosurgery (MKM) Australian
School of Advanced Medicine Macquarie University Sydney Australia
Department of Neurosurgery (KM) National Defense Medical College
Tokyo Japan Department of Neurosurgery (YM) JIKEI University School
of Medicine Tokyo Japan Department of Neurosurgery (SN) Institute of
Health Bioscience University of Tokushima Graduate School Tokushima
Japan Department of Neurosurgery (NN) Hokkaido University Graduate
School of Medicine Hokkaido Japan Endovascular and Operative Neurovas-
cular Surgery (CSO) Beth Israel Deaconess Medical Center Harvard Medical
School Boston MA Department of Radiology (LP) University Hospital
Reims France Department of Neurology (YBWEMR) Academic Medical
Center Amsterdam the Netherlands Department of Neurosurgery (J Rinne)
Division of Clinical Neurosciences Turku University Hospital Turku Finland
Department of Neurosurgery (A Ronkainen) Tampere University Hospital
Tampere Finland Department of Neurosurgery (KS) Geneva University
Hospital Switzerland Departments of Neurosurgery (VS) and Neurology
(HS) Goethe University Frankfurt Germany Department of Neurological
Surgery (RAS ESC) New York Presbyterian Hospital Columbia Univer-
sity College of Physicians and Surgeons New York NY Brain Center Rudolf
Magnus (MDIV GJER) Department of Neurology and Neurosurgery
University Medical Centre Utrecht the Netherlands Institute for Diagnostic
and Interventional Radiology and Neuroradiology (IW) University Hospital
of Essen Germany SwissNeuroInstitute (IW DR) Clinic Hirslanden
Zurich Switzerland Department of Neurology (MJHW) Leiden University
Medical Center Leiden the Netherlands Department of Surgery and Neuro-
surgery (GKCW) Prince of Wales Hospital The Chinese University of
Hong Kong Hong Kong China Division of Neurosurgery (JHW) Depart-
ments of Clinical Neurosciences and Diagnostic Imaging University of Calgary
Alberta Canada Departments of Neurological Surgery and Neurology (GJZ)
Washington University School of Medicine St Louis MO Institute of Neu-
rosurgery (AP) Section of Vascular Neurosurgery Verona University amp City
Hospital Verona Italy Department of Neurosurgery (PV) Chariteacute University
Medical Centre Berlin Germany Division of Neurological Surgery (CM)
Barrow Neurological Institute St Josephs Hospital and Medical Center
Phoenix AZ and Brain and Spine Center (PL) Lankenau Medical Center
Wynnewood PA
AUTHOR CONTRIBUTIONSNE RDB KB SJ J Ra A Ra AA ESC HS GL AP
DR PV CM PLR and RLM were involved in the design of
the study NE and KB collected analyzed and interpreted the data
but did not participate in the Delphi consensus NE RDB KB
SJ JRa AkMo JCT CPD ARa JM MK PV DH
GJER and RLM drafted the paper RDB SJ JRa AkMo
JCT CPD ARa JM MK SAH RAlSa DLB JB
AB AD DJF AG GH DMH BLH PJ HK MEK
PJK NK TiKo TiKr MTL TRM SAM EM AnMo
MKM KM YM SN NaNa MN CSO VMP LP
AAR YBWEMR JaRi RHR AnRo KS VS RASo
JS HJS MDIV IW MJHW GKCW JHW GJZ
PV CM DH GJER and RLM participated in the study re-
viewed and commented on the final version of the manuscript
STUDY FUNDINGNo targeted funding reported
DISCLOSUREN Etminan is a scientific advisorofficer for Edge Therapeutics Inc
R Brown K Beseoglu S Juvela J Raymond A Morita and J Torner
report no disclosures relevant to the manuscript C Derdeyn serves on
the Scientific Advisory Board for W L Gore and Associates and Pulse
Therapeutics He is a consultant for Penumbra Inc (DSMB member)
and Microvention (Angio Core Lab for brain aneurysm stent trial)
A Raabe J Mocco M Korja A Abdulazim S Amin-Hanjani
R Al-Shahi Salman D Barrow J Bederson A Bonafe and A Dumont
report no disclosures relevant to the manuscript D Fiorella is a consultant
for Codman Neurovascular CovidienEV3 Sequent Medical and Siemens
Medical Imaging and received research support from Penumbra Inc and
Microvention A Gruber G Hankey D Hasan B Hoh P Jabbour
and H Kasuya report no disclosures relevant to the manuscript M Kelly
is a shareholder of Blockade Medical Inc P Kirkpatrick N Knuckey
T Koivisto T Krings M Lawton and T Marotta report no disclosures
relevant to the manuscript S Mayer is a consultant for Edge Therapeutics
Inc and Actelion Pharmaceuticals E Mee reports no disclosures relevant to
the manuscript V Mendes Pereira is consultant for Covidien A
Molyneux M Morgan K Mori Y Murayama S Nagahiro N
Nakayama M Nimelauml C Ogilvy L Pierot A Rabinstein Y Roos J
Rinne R Rosenwasser A Ronkainen K Schaller V Seifert R Solomon
J Spears H-J Steiger M Vergouwen I Wanke M Wermer G Wong J
Wong G Zipfel E Sander Connolly and H Steinmetz report no disclosures
relevant to the manuscript G Lanzino is a consultant for Covidien Edge
Therapeutics Inc and Codman A Pasqualin D Ruumlfenacht P Vajkoczy
and C McDougall report no disclosures relevant to the manuscript
D Haumlnggi is a scientific advisorofficer for Edge Therapeutics Inc P LeRoux
is a Scientific Advisory Board member for Edge Therapeutics Inc and a
consultant for Integra Codman Synthes Neurologica Brainsgate and Orsan
G Rinkel reports no disclosures relevant to the manuscript R Macdonald is
Chief Scientific Officer of Edge Therapeutics Inc and received grant support
from the Physicians Services Incorporated Foundation Brain Aneurysm Foun-
dation Canadian Institutes for Health Research and the Heart and Stroke
Foundation of Canada Go to Neurologyorg for full disclosures
Received January 5 2015 Accepted in final form April 18 2015
REFERENCES1 Gabriel RA Kim H Sidney S et al Ten-year detection
rate of brain arteriovenous malformations in a large mul-
tiethnic defined population Stroke 20104121ndash26
2 Vlak MH Algra A Brandenburg R Rinkel GJ Prevalence
of unruptured intracranial aneurysms with emphasis on sex
age comorbidity country and time period a systematic
review and meta-analysis Lancet Neurol 201110626ndash636
3 Ishibashi T Murayama Y Urashima M et al Unruptured
intracranial aneurysms incidence of rupture and risk fac-
tors Stroke 200940313ndash316
4 Juvela S Poussa K Lehto H Porras M Natural history of
unruptured intracranial aneurysms a long-term follow-up
study Stroke 2013442414ndash2421
5 Morita A Kirino T Hashi K et al The natural course of
unruptured cerebral aneurysms in a Japanese cohort N
Engl J Med 20123662474ndash2482
6 Nieuwkamp DJ Setz LE Algra A Linn FH de Rooij NK
Rinkel GJ Changes in case fatality of aneurysmal subarach-
noid haemorrhage over time according to age sex and
region a meta-analysis Lancet Neurol 20098635ndash642
7 Sonobe M Yamazaki T Yonekura M Kikuchi H Small
unruptured intracranial aneurysm verification study
SUAVe study Japan Stroke 2010411969ndash1977
8 Wermer MJ van der Schaaf IC Velthuis BK Majoie CB
Albrecht KW Rinkel GJ Yield of short-term follow-up
CTMR angiography for small aneurysms detected at
screening Stroke 200637414ndash418
9 Wiebers DO Whisnant JP Huston J III et al Unrup-
tured intracranial aneurysms natural history clinical out-
come and risks of surgical and endovascular treatment
Lancet 2003362103ndash110
888 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
AAN Practice Management WebinarsExclusive discount pricing only for AAN members Live or recorded $149 per session or subscribeto all 14 sessions for only $199
bull July 7 ICD-10 Are you Ready
bull August 5 Using Practice Benchmarking Analytics to Improve Your Bottom Line
bull September 15 From Quality Measurement to Quality Improvement
bull September 29 A Critical Part of the Team Advanced Practice Providers in Neurology
See the full 2015 schedule and register today at AANcomviewpmw15
Nonmembers pay $199 per webinar or $649 for a full subscription
Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
ServicesUpdated Information amp
httpnneurologyorgcontent8510881fullincluding high resolution figures can be found at
This article has been cited by 6 HighWire-hosted articles
Subspecialty Collections
httpnneurologyorgcgicollectionstroke_preventionStroke prevention e
httpnneurologyorgcgicollectionall_cerebrovascular_disease_strokAll Cerebrovascular diseaseStrokefollowing collection(s) This article along with others on similar topics appears in the
Permissions amp Licensing
httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in
Reprints
httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online
rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All
reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology
decision scenario (treat or not treat) rather than mak-ing distinctions between different possible treatmentmodalities mainly to propose a unifying scoringmodel that would not divide the specialist groupFourth we used pooled data from meta-analyses toincorporate treatment risk percentages into ourmodel However given the lack of more robust dataon risk factors for UIA treatment complications it isunclear whether the individual treatment risk in apatient with a UIA may be distinctly lower or higherdepending on the surgeonrsquos or interventionalistrsquosexperience the treatment modality and the aneu-rysm complexity Lastly the series of cases we vali-dated with the UIATS covered a wide range ofpatients and aneurysms but may not entirely reflectthe complete spectrum of patients and aneurysms
seen in clinical practice As an example in the valida-tion data set 13 of 30 UIAs were larger than 7 mmwhich may not reflect the actual UIA size distributionin the general population In addition the presenta-tion of the actual score values to the external reviewersduring the validation may have introduced some biasif these external experts were somewhat uncertain andtherefore more willing to agree with the proposedrecommendations However given the expertise ofthe external reviewers we do not feel this has influ-enced the results to a large extent
This multidisciplinary consensus project has re-sulted in the UIATSmodel which captures contempo-rary and multifactorial decision-making by specialistson UIA management By applying this scoring modelclinicians can appreciate what highly informed individ-uals in the cerebrovascular field would advise in a par-ticular patient based on current data and uncertaintiesSince the validity of the UIATSmodel was tested basedon theoretical rather than empirical data its applicabil-ity and clinical accuracy remain to be prospectivelyexplored in patients with UIA Thus the current treat-ment recommendations may change if new data fromsuch studies or future observational UIA studiesbecome available Ultimately individual patient factorsbeyond those accounted for in the present scoringmodel may also alter the individual management of apatient with a UIA
AUTHOR AFFILIATIONFrom the Department of Neurosurgery (NE KB AA H-JS DH)
Medical Faculty Heinrich-Heine-University Duumlsseldorf Germany Depart-
ments of Neurology (RDB AAR) and Neurologic Surgery (GL) Mayo
Clinic Rochester MN Department of Clinical Neurosciences (SJ) University
of Helsinki Finland Department of RadiologymdashInterventional Neuroradiol-
ogy (J Raymond) CHUM Research Center Notre-Dame Hospital Montreal
Quebec Canada Department of Neurological Surgery (A Morita) Nippon
Medical School Tokyo Japan Departments of Epidemiology (JCT) and
Neurosurgery (DMH) University of Iowa Iowa City Mallinckrodt Institute
of Radiology (CPD) Washington University School of MedicineBarnes-
Jewish Hospital St Louis MO Department of Neurosurgery (A Raabe)
Inselspital Bern Switzerland Department of Neurological Surgery (JM)
Vanderbilt University Medical Center Nashville TN Department of Neuro-
surgery (MK MN) Helsinki University Central Hospital Helsinki Finland
Department of Neurosurgery (SA-H) University of Illinois at Chicago
Centre for Clinical Brain Sciences (RA-SS) University of Edinburgh
United Kingdom Department of Neurosurgery (DLB) Emory Stroke Cen-
ter Emory University School of Medicine Atlanta GA Department of Neu-
rosurgery (JB) The Mount Sinai Health System New York NY Department
of Neuroradiology (AB) CHUMontpellier Montpellier France Department
of Neurosurgery (ASD) Tulane University School of Medicine New
Orleans LA Department of Neurosurgery (DJK) Cerebrovascular Centre
Stony Brook University Medical Center Stony Brook NY Department of
Neurosurgery (AG) Medical University of Vienna Austria Department of
Neurology (GJH) and Neurosurgery Unit (NK) Sir Charles Gairdner Hos-
pital Nedlands Western Australia Australia School of Medicine and Pharma-
cology (GJH) The University of Western Australia Perth Australia
Department of Neurosurgery (BLH) University of Florida Gainesville
Department of Neurological Surgery (PJ RHR) Thomas Jefferson Univer-
sity Hospital Philadelphia PA Department of Neurosurgery (HK) Tokyo
Womenrsquos Medical University Medical Center East Tokyo Japan Saskatche-
wan Cerebrovascular Centre (MEK) Royal University Hospital University of
Saskatchewan Saskatoon Canada Department of Clinical Neurosciences
Figure 5 UIATS case recommendation resulting in the lowest agreement amongthe internal and external reviewer cohorts
Corresponding scores in accordance with unruptured intracranial aneurysm treatment score(UIATS) features are given in parentheses A catheter angiogram of a 25-year-old woman(4 points favoring treatment for patient age younger than 40 years) who previously under-went MRI for persistent headaches vertigo and occasional bitemporal vision disturbances(due to a migraine aura) with (A) posterior-anterior and (B) lateral projection as well as (C) pos-terior-anterior and (D) lateral 3-dimensional reconstructions is shown This left-sided wide-necked paraophthalmic internal carotid artery aneurysm had a maximum diameter of3 mmwith a neck diameter of 27 mm (3 points favoring conservative management for aneu-rysm complexity due to wide neck) The patient did not report any additional risk factors orcomorbidities in her past medical history The resulting scores based on the UIATS were4 points in favor of aneurysm repair and 8 points (including 5 points favoring conservativemanagement for the constant intervention-related risk) in favor of conservative manage-ment The resulting UIATS recommendation was ldquoconservative managementrdquoOverall agree-ment with this UIATS recommendation was 37 (95 confidence interval 344ndash396) forboth reviewer cohorts
Neurology 85 September 8 2015 887
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
(PJK) Cambridge University Hospitals Trust University of Cambridge
United Kingdom NeurosurgeryNeuroCenter (T Koivisto) Kuopio University
Hospital University of Eastern Finland Finland Department of Medical Imag-
ing and Surgery (T Krings VMP) Toronto Western Hospital University
Health Network Toronto Ontario Canada Department of Neurological Sur-
gery (MTL) University of California San Francisco Divisions of Neurora-
diology (TRM) and Neurosurgery (JS RLM) St Michaels Hospital
University of Toronto Ontario Canada Institute for Critical Care Medicine
(SAM) Icahn School of Medicine at Mount Sinai New York NY Depart-
ment of Neurosurgery (EM) Auckland City Hospital Auckland New
Zealand Nuffield Department of Surgical Sciences (A Molyneux) University
of Oxford United Kingdom Division of Neurosurgery (MKM) Australian
School of Advanced Medicine Macquarie University Sydney Australia
Department of Neurosurgery (KM) National Defense Medical College
Tokyo Japan Department of Neurosurgery (YM) JIKEI University School
of Medicine Tokyo Japan Department of Neurosurgery (SN) Institute of
Health Bioscience University of Tokushima Graduate School Tokushima
Japan Department of Neurosurgery (NN) Hokkaido University Graduate
School of Medicine Hokkaido Japan Endovascular and Operative Neurovas-
cular Surgery (CSO) Beth Israel Deaconess Medical Center Harvard Medical
School Boston MA Department of Radiology (LP) University Hospital
Reims France Department of Neurology (YBWEMR) Academic Medical
Center Amsterdam the Netherlands Department of Neurosurgery (J Rinne)
Division of Clinical Neurosciences Turku University Hospital Turku Finland
Department of Neurosurgery (A Ronkainen) Tampere University Hospital
Tampere Finland Department of Neurosurgery (KS) Geneva University
Hospital Switzerland Departments of Neurosurgery (VS) and Neurology
(HS) Goethe University Frankfurt Germany Department of Neurological
Surgery (RAS ESC) New York Presbyterian Hospital Columbia Univer-
sity College of Physicians and Surgeons New York NY Brain Center Rudolf
Magnus (MDIV GJER) Department of Neurology and Neurosurgery
University Medical Centre Utrecht the Netherlands Institute for Diagnostic
and Interventional Radiology and Neuroradiology (IW) University Hospital
of Essen Germany SwissNeuroInstitute (IW DR) Clinic Hirslanden
Zurich Switzerland Department of Neurology (MJHW) Leiden University
Medical Center Leiden the Netherlands Department of Surgery and Neuro-
surgery (GKCW) Prince of Wales Hospital The Chinese University of
Hong Kong Hong Kong China Division of Neurosurgery (JHW) Depart-
ments of Clinical Neurosciences and Diagnostic Imaging University of Calgary
Alberta Canada Departments of Neurological Surgery and Neurology (GJZ)
Washington University School of Medicine St Louis MO Institute of Neu-
rosurgery (AP) Section of Vascular Neurosurgery Verona University amp City
Hospital Verona Italy Department of Neurosurgery (PV) Chariteacute University
Medical Centre Berlin Germany Division of Neurological Surgery (CM)
Barrow Neurological Institute St Josephs Hospital and Medical Center
Phoenix AZ and Brain and Spine Center (PL) Lankenau Medical Center
Wynnewood PA
AUTHOR CONTRIBUTIONSNE RDB KB SJ J Ra A Ra AA ESC HS GL AP
DR PV CM PLR and RLM were involved in the design of
the study NE and KB collected analyzed and interpreted the data
but did not participate in the Delphi consensus NE RDB KB
SJ JRa AkMo JCT CPD ARa JM MK PV DH
GJER and RLM drafted the paper RDB SJ JRa AkMo
JCT CPD ARa JM MK SAH RAlSa DLB JB
AB AD DJF AG GH DMH BLH PJ HK MEK
PJK NK TiKo TiKr MTL TRM SAM EM AnMo
MKM KM YM SN NaNa MN CSO VMP LP
AAR YBWEMR JaRi RHR AnRo KS VS RASo
JS HJS MDIV IW MJHW GKCW JHW GJZ
PV CM DH GJER and RLM participated in the study re-
viewed and commented on the final version of the manuscript
STUDY FUNDINGNo targeted funding reported
DISCLOSUREN Etminan is a scientific advisorofficer for Edge Therapeutics Inc
R Brown K Beseoglu S Juvela J Raymond A Morita and J Torner
report no disclosures relevant to the manuscript C Derdeyn serves on
the Scientific Advisory Board for W L Gore and Associates and Pulse
Therapeutics He is a consultant for Penumbra Inc (DSMB member)
and Microvention (Angio Core Lab for brain aneurysm stent trial)
A Raabe J Mocco M Korja A Abdulazim S Amin-Hanjani
R Al-Shahi Salman D Barrow J Bederson A Bonafe and A Dumont
report no disclosures relevant to the manuscript D Fiorella is a consultant
for Codman Neurovascular CovidienEV3 Sequent Medical and Siemens
Medical Imaging and received research support from Penumbra Inc and
Microvention A Gruber G Hankey D Hasan B Hoh P Jabbour
and H Kasuya report no disclosures relevant to the manuscript M Kelly
is a shareholder of Blockade Medical Inc P Kirkpatrick N Knuckey
T Koivisto T Krings M Lawton and T Marotta report no disclosures
relevant to the manuscript S Mayer is a consultant for Edge Therapeutics
Inc and Actelion Pharmaceuticals E Mee reports no disclosures relevant to
the manuscript V Mendes Pereira is consultant for Covidien A
Molyneux M Morgan K Mori Y Murayama S Nagahiro N
Nakayama M Nimelauml C Ogilvy L Pierot A Rabinstein Y Roos J
Rinne R Rosenwasser A Ronkainen K Schaller V Seifert R Solomon
J Spears H-J Steiger M Vergouwen I Wanke M Wermer G Wong J
Wong G Zipfel E Sander Connolly and H Steinmetz report no disclosures
relevant to the manuscript G Lanzino is a consultant for Covidien Edge
Therapeutics Inc and Codman A Pasqualin D Ruumlfenacht P Vajkoczy
and C McDougall report no disclosures relevant to the manuscript
D Haumlnggi is a scientific advisorofficer for Edge Therapeutics Inc P LeRoux
is a Scientific Advisory Board member for Edge Therapeutics Inc and a
consultant for Integra Codman Synthes Neurologica Brainsgate and Orsan
G Rinkel reports no disclosures relevant to the manuscript R Macdonald is
Chief Scientific Officer of Edge Therapeutics Inc and received grant support
from the Physicians Services Incorporated Foundation Brain Aneurysm Foun-
dation Canadian Institutes for Health Research and the Heart and Stroke
Foundation of Canada Go to Neurologyorg for full disclosures
Received January 5 2015 Accepted in final form April 18 2015
REFERENCES1 Gabriel RA Kim H Sidney S et al Ten-year detection
rate of brain arteriovenous malformations in a large mul-
tiethnic defined population Stroke 20104121ndash26
2 Vlak MH Algra A Brandenburg R Rinkel GJ Prevalence
of unruptured intracranial aneurysms with emphasis on sex
age comorbidity country and time period a systematic
review and meta-analysis Lancet Neurol 201110626ndash636
3 Ishibashi T Murayama Y Urashima M et al Unruptured
intracranial aneurysms incidence of rupture and risk fac-
tors Stroke 200940313ndash316
4 Juvela S Poussa K Lehto H Porras M Natural history of
unruptured intracranial aneurysms a long-term follow-up
study Stroke 2013442414ndash2421
5 Morita A Kirino T Hashi K et al The natural course of
unruptured cerebral aneurysms in a Japanese cohort N
Engl J Med 20123662474ndash2482
6 Nieuwkamp DJ Setz LE Algra A Linn FH de Rooij NK
Rinkel GJ Changes in case fatality of aneurysmal subarach-
noid haemorrhage over time according to age sex and
region a meta-analysis Lancet Neurol 20098635ndash642
7 Sonobe M Yamazaki T Yonekura M Kikuchi H Small
unruptured intracranial aneurysm verification study
SUAVe study Japan Stroke 2010411969ndash1977
8 Wermer MJ van der Schaaf IC Velthuis BK Majoie CB
Albrecht KW Rinkel GJ Yield of short-term follow-up
CTMR angiography for small aneurysms detected at
screening Stroke 200637414ndash418
9 Wiebers DO Whisnant JP Huston J III et al Unrup-
tured intracranial aneurysms natural history clinical out-
come and risks of surgical and endovascular treatment
Lancet 2003362103ndash110
888 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
AAN Practice Management WebinarsExclusive discount pricing only for AAN members Live or recorded $149 per session or subscribeto all 14 sessions for only $199
bull July 7 ICD-10 Are you Ready
bull August 5 Using Practice Benchmarking Analytics to Improve Your Bottom Line
bull September 15 From Quality Measurement to Quality Improvement
bull September 29 A Critical Part of the Team Advanced Practice Providers in Neurology
See the full 2015 schedule and register today at AANcomviewpmw15
Nonmembers pay $199 per webinar or $649 for a full subscription
Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
ServicesUpdated Information amp
httpnneurologyorgcontent8510881fullincluding high resolution figures can be found at
This article has been cited by 6 HighWire-hosted articles
Subspecialty Collections
httpnneurologyorgcgicollectionstroke_preventionStroke prevention e
httpnneurologyorgcgicollectionall_cerebrovascular_disease_strokAll Cerebrovascular diseaseStrokefollowing collection(s) This article along with others on similar topics appears in the
Permissions amp Licensing
httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in
Reprints
httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online
rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All
reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology
(PJK) Cambridge University Hospitals Trust University of Cambridge
United Kingdom NeurosurgeryNeuroCenter (T Koivisto) Kuopio University
Hospital University of Eastern Finland Finland Department of Medical Imag-
ing and Surgery (T Krings VMP) Toronto Western Hospital University
Health Network Toronto Ontario Canada Department of Neurological Sur-
gery (MTL) University of California San Francisco Divisions of Neurora-
diology (TRM) and Neurosurgery (JS RLM) St Michaels Hospital
University of Toronto Ontario Canada Institute for Critical Care Medicine
(SAM) Icahn School of Medicine at Mount Sinai New York NY Depart-
ment of Neurosurgery (EM) Auckland City Hospital Auckland New
Zealand Nuffield Department of Surgical Sciences (A Molyneux) University
of Oxford United Kingdom Division of Neurosurgery (MKM) Australian
School of Advanced Medicine Macquarie University Sydney Australia
Department of Neurosurgery (KM) National Defense Medical College
Tokyo Japan Department of Neurosurgery (YM) JIKEI University School
of Medicine Tokyo Japan Department of Neurosurgery (SN) Institute of
Health Bioscience University of Tokushima Graduate School Tokushima
Japan Department of Neurosurgery (NN) Hokkaido University Graduate
School of Medicine Hokkaido Japan Endovascular and Operative Neurovas-
cular Surgery (CSO) Beth Israel Deaconess Medical Center Harvard Medical
School Boston MA Department of Radiology (LP) University Hospital
Reims France Department of Neurology (YBWEMR) Academic Medical
Center Amsterdam the Netherlands Department of Neurosurgery (J Rinne)
Division of Clinical Neurosciences Turku University Hospital Turku Finland
Department of Neurosurgery (A Ronkainen) Tampere University Hospital
Tampere Finland Department of Neurosurgery (KS) Geneva University
Hospital Switzerland Departments of Neurosurgery (VS) and Neurology
(HS) Goethe University Frankfurt Germany Department of Neurological
Surgery (RAS ESC) New York Presbyterian Hospital Columbia Univer-
sity College of Physicians and Surgeons New York NY Brain Center Rudolf
Magnus (MDIV GJER) Department of Neurology and Neurosurgery
University Medical Centre Utrecht the Netherlands Institute for Diagnostic
and Interventional Radiology and Neuroradiology (IW) University Hospital
of Essen Germany SwissNeuroInstitute (IW DR) Clinic Hirslanden
Zurich Switzerland Department of Neurology (MJHW) Leiden University
Medical Center Leiden the Netherlands Department of Surgery and Neuro-
surgery (GKCW) Prince of Wales Hospital The Chinese University of
Hong Kong Hong Kong China Division of Neurosurgery (JHW) Depart-
ments of Clinical Neurosciences and Diagnostic Imaging University of Calgary
Alberta Canada Departments of Neurological Surgery and Neurology (GJZ)
Washington University School of Medicine St Louis MO Institute of Neu-
rosurgery (AP) Section of Vascular Neurosurgery Verona University amp City
Hospital Verona Italy Department of Neurosurgery (PV) Chariteacute University
Medical Centre Berlin Germany Division of Neurological Surgery (CM)
Barrow Neurological Institute St Josephs Hospital and Medical Center
Phoenix AZ and Brain and Spine Center (PL) Lankenau Medical Center
Wynnewood PA
AUTHOR CONTRIBUTIONSNE RDB KB SJ J Ra A Ra AA ESC HS GL AP
DR PV CM PLR and RLM were involved in the design of
the study NE and KB collected analyzed and interpreted the data
but did not participate in the Delphi consensus NE RDB KB
SJ JRa AkMo JCT CPD ARa JM MK PV DH
GJER and RLM drafted the paper RDB SJ JRa AkMo
JCT CPD ARa JM MK SAH RAlSa DLB JB
AB AD DJF AG GH DMH BLH PJ HK MEK
PJK NK TiKo TiKr MTL TRM SAM EM AnMo
MKM KM YM SN NaNa MN CSO VMP LP
AAR YBWEMR JaRi RHR AnRo KS VS RASo
JS HJS MDIV IW MJHW GKCW JHW GJZ
PV CM DH GJER and RLM participated in the study re-
viewed and commented on the final version of the manuscript
STUDY FUNDINGNo targeted funding reported
DISCLOSUREN Etminan is a scientific advisorofficer for Edge Therapeutics Inc
R Brown K Beseoglu S Juvela J Raymond A Morita and J Torner
report no disclosures relevant to the manuscript C Derdeyn serves on
the Scientific Advisory Board for W L Gore and Associates and Pulse
Therapeutics He is a consultant for Penumbra Inc (DSMB member)
and Microvention (Angio Core Lab for brain aneurysm stent trial)
A Raabe J Mocco M Korja A Abdulazim S Amin-Hanjani
R Al-Shahi Salman D Barrow J Bederson A Bonafe and A Dumont
report no disclosures relevant to the manuscript D Fiorella is a consultant
for Codman Neurovascular CovidienEV3 Sequent Medical and Siemens
Medical Imaging and received research support from Penumbra Inc and
Microvention A Gruber G Hankey D Hasan B Hoh P Jabbour
and H Kasuya report no disclosures relevant to the manuscript M Kelly
is a shareholder of Blockade Medical Inc P Kirkpatrick N Knuckey
T Koivisto T Krings M Lawton and T Marotta report no disclosures
relevant to the manuscript S Mayer is a consultant for Edge Therapeutics
Inc and Actelion Pharmaceuticals E Mee reports no disclosures relevant to
the manuscript V Mendes Pereira is consultant for Covidien A
Molyneux M Morgan K Mori Y Murayama S Nagahiro N
Nakayama M Nimelauml C Ogilvy L Pierot A Rabinstein Y Roos J
Rinne R Rosenwasser A Ronkainen K Schaller V Seifert R Solomon
J Spears H-J Steiger M Vergouwen I Wanke M Wermer G Wong J
Wong G Zipfel E Sander Connolly and H Steinmetz report no disclosures
relevant to the manuscript G Lanzino is a consultant for Covidien Edge
Therapeutics Inc and Codman A Pasqualin D Ruumlfenacht P Vajkoczy
and C McDougall report no disclosures relevant to the manuscript
D Haumlnggi is a scientific advisorofficer for Edge Therapeutics Inc P LeRoux
is a Scientific Advisory Board member for Edge Therapeutics Inc and a
consultant for Integra Codman Synthes Neurologica Brainsgate and Orsan
G Rinkel reports no disclosures relevant to the manuscript R Macdonald is
Chief Scientific Officer of Edge Therapeutics Inc and received grant support
from the Physicians Services Incorporated Foundation Brain Aneurysm Foun-
dation Canadian Institutes for Health Research and the Heart and Stroke
Foundation of Canada Go to Neurologyorg for full disclosures
Received January 5 2015 Accepted in final form April 18 2015
REFERENCES1 Gabriel RA Kim H Sidney S et al Ten-year detection
rate of brain arteriovenous malformations in a large mul-
tiethnic defined population Stroke 20104121ndash26
2 Vlak MH Algra A Brandenburg R Rinkel GJ Prevalence
of unruptured intracranial aneurysms with emphasis on sex
age comorbidity country and time period a systematic
review and meta-analysis Lancet Neurol 201110626ndash636
3 Ishibashi T Murayama Y Urashima M et al Unruptured
intracranial aneurysms incidence of rupture and risk fac-
tors Stroke 200940313ndash316
4 Juvela S Poussa K Lehto H Porras M Natural history of
unruptured intracranial aneurysms a long-term follow-up
study Stroke 2013442414ndash2421
5 Morita A Kirino T Hashi K et al The natural course of
unruptured cerebral aneurysms in a Japanese cohort N
Engl J Med 20123662474ndash2482
6 Nieuwkamp DJ Setz LE Algra A Linn FH de Rooij NK
Rinkel GJ Changes in case fatality of aneurysmal subarach-
noid haemorrhage over time according to age sex and
region a meta-analysis Lancet Neurol 20098635ndash642
7 Sonobe M Yamazaki T Yonekura M Kikuchi H Small
unruptured intracranial aneurysm verification study
SUAVe study Japan Stroke 2010411969ndash1977
8 Wermer MJ van der Schaaf IC Velthuis BK Majoie CB
Albrecht KW Rinkel GJ Yield of short-term follow-up
CTMR angiography for small aneurysms detected at
screening Stroke 200637414ndash418
9 Wiebers DO Whisnant JP Huston J III et al Unrup-
tured intracranial aneurysms natural history clinical out-
come and risks of surgical and endovascular treatment
Lancet 2003362103ndash110
888 Neurology 85 September 8 2015
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
AAN Practice Management WebinarsExclusive discount pricing only for AAN members Live or recorded $149 per session or subscribeto all 14 sessions for only $199
bull July 7 ICD-10 Are you Ready
bull August 5 Using Practice Benchmarking Analytics to Improve Your Bottom Line
bull September 15 From Quality Measurement to Quality Improvement
bull September 29 A Critical Part of the Team Advanced Practice Providers in Neurology
See the full 2015 schedule and register today at AANcomviewpmw15
Nonmembers pay $199 per webinar or $649 for a full subscription
Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
ServicesUpdated Information amp
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httpnneurologyorgcgicollectionall_cerebrovascular_disease_strokAll Cerebrovascular diseaseStrokefollowing collection(s) This article along with others on similar topics appears in the
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10 Etminan N Dreier R Buchholz BA et al Age of col-
lagen in intracranial saccular aneurysms Stroke 2014
451757ndash1763
11 Korja M Lehto H Juvela S Lifelong rupture risk of intra-
cranial aneurysms depends on risk factors a prospective
Finnish cohort study Stroke 2014451958ndash1963
12 Rahman M Smietana J Hauck E et al Size ratio corre-
lates with intracranial aneurysm rupture status a prospec-
tive study Stroke 201041916ndash920
13 Ujiie H Tachibana H Hiramatsu O et al Effects of size
and shape (aspect ratio) on the hemodynamics of saccular
aneurysms a possible index for surgical treatment of intra-
28 Zafar SY Currow DC Cherny N Strasser F Fowler R
Abernethy AP Consensus-based standards for best sup-
portive care in clinical trials in advanced cancer Lancet
Oncol 201213e77ndashe82
29 Raymond J Incidental intracranial aneurysms rationale
for treatment Curr Opin Neurol 20092296ndash102
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Neurology 85 September 8 2015 889
ordf 2015 American Academy of Neurology Unauthorized reproduction of this article is prohibited
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
ServicesUpdated Information amp
httpnneurologyorgcontent8510881fullincluding high resolution figures can be found at
This article has been cited by 6 HighWire-hosted articles
Subspecialty Collections
httpnneurologyorgcgicollectionstroke_preventionStroke prevention e
httpnneurologyorgcgicollectionall_cerebrovascular_disease_strokAll Cerebrovascular diseaseStrokefollowing collection(s) This article along with others on similar topics appears in the
Permissions amp Licensing
httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in
Reprints
httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online
rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All
reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology
DOI 101212WNL0000000000001891201585881-889 Published Online before print August 14 2015Neurology
Nima Etminan Robert D Brown Jr Kerim Beseoglu et al The unruptured intracranial aneurysm treatment score A multidisciplinary consensus
This information is current as of August 14 2015
ServicesUpdated Information amp
httpnneurologyorgcontent8510881fullincluding high resolution figures can be found at
This article has been cited by 6 HighWire-hosted articles
Subspecialty Collections
httpnneurologyorgcgicollectionstroke_preventionStroke prevention e
httpnneurologyorgcgicollectionall_cerebrovascular_disease_strokAll Cerebrovascular diseaseStrokefollowing collection(s) This article along with others on similar topics appears in the
Permissions amp Licensing
httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in
Reprints
httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online
rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2015 American Academy of Neurology All
reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology