Partially thrombosed intracranial aneurysms: symptoms, evolution, and therapeutic management

Partially thrombosed intracranial aneurysms (PTIAs) are different from saccular or nonthrombosed giant or large aneurysms, as they are characterized by multiple intramural thrombotic phenomena related to recurrent vessel wall dissections.

We retrospectively reviewed clinical and radiological files of 23 consecutive patients with PTIAs (mean age 49.3 years). Twenty-two lesions were studied by magnetic resonance imaging (MRI). Patients were managed by endovascular treatments, medically with steroids, or conservatively.

Thirteen patients presented with progressive neurological symptoms. Subarachnoid hemorrhage was suspected but not proven in three. At MRI, 90.9% of PTIAs caused mass effect; perilesional T2 hypersignal compatible with edema was evident in 13.6%. Aneurysmal wall enhancement was detectable in 63.2% of the PTIAs and considered a marker of inflammatory processes. Parent artery occlusion was performed in seven patients with clinical improvement in six. Selective coiling was proposed in three patients (one improved, one remained stable, and one experienced symptoms progression). Three patients were treated with steroids and improved. Ten patients were managed conservatively: eight because spontaneous thrombosis of the lesion had been diagnosed and two because of clinical and radiological stability.

The natural history of PTIAs is different from other aneurysms. They most commonly present with progressive neurological symptoms due to mass effect. MRI properly diagnoses PTIAs and allows precise follow-up, more accurately than angiography because it detects prominent "abluminal" features indicating inflammation and neovascularization. Spontaneous thrombosis is part of the natural history of PTIAs and it should be taken in consideration when discussing the therapeutic management.