Management of Unruptured Intracranial Aneurysms and Cerebrovascular Malformations

Purpose of Review: Unruptured intracranial aneurysms and vascular malformations are detected more frequently because of the increased use and availability of brain imaging. Management of these entities requires knowledge of which patients are at high risk for hemorrhage and what treatment options are available. This article summarizes the epidemiology, natural history, and management strategies for unruptured intracranial aneurysms, arteriovenous malformations, cavernous malformations, developmental venous anomalies, and capillary telangiectasias. Recent Findings: Pooled cohort studies and meta-analyses have improved the ability to predict hemorrhage for each vascular abnormality. Scores and tools have been developed to aid the practitioner in predicting hemorrhage risk for unruptured intracranial aneurysms. Advances in endovascular techniques for unruptured intracranial aneurysms have improved the ability to treat difficult wide-necked aneurysms. Summary: Unruptured intracranial aneurysms are a common incidental finding. The PHASES (population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from another aneurysm, site of aneurysm) score and Unruptured Intracranial Aneurysm Treatment Score may be useful tools for predicting natural history and treatment recommendations. The overall risk of hemorrhage for both arteriovenous malformations and cavernous malformations is about 2% to 4% per year. With both of these entities, prior hemorrhage predicts future hemorrhage. In addition, other select patient and radiologic factors influence risk of hemorrhage. The risk of future hemorrhage should be compared to the risk of treatment. Developmental venous anomalies and capillary telangiectasias are largely benign entities and rarely symptomatic.