Association of Diagonal Earlobe Crease (Frank's Sign) with Intracranial Aneurysm Rupture at Small Sizes

The diagonal earlobe crease (DELC), or Frank's sign, has been associated with systemic vascular degeneration. Whether this cutaneous marker correlates with intracranial aneurysm (IA) instability remains unclear.

We conducted a hospital-based observational registry study including 186 consecutive patients with IA. DELC was dichotomized into absent/low-grade versus high-grade creases. Associations between DELC and aneurysm rupture, rupture at small sizes (<7 mm), and clinical outcome were analyzed using multivariate logistic regression models adjusted for demographic and vascular risk factors.

High-grade DELC was significantly associated with overall aneurysm rupture (adjusted OR 3.42, 95% CI 1.39-8.41, p = 0.007). Patients with high-grade DELC harbored ruptured aneurysms at significantly smaller mean sizes than those without the sign (6.11 mm vs. 7.94 mm, p = 0.015). High-grade DELC was also associated with a distinct anatomical shift toward the anterior communicating artery complex (p = 0.021) and was independently associated with rupture at <7 mm (adjusted OR 2.08, 95% CI 1.03-4.21, p = 0.041), even after adjustment for aspect ratio and clinical covariates. DELC was not independently associated with post-hemorrhagic clinical outcome.

Frank's sign may represent a readily observable clinical marker associated with IA instability and rupture at conventionally low-risk sizes (<7 mm). These findings support further investigation into DELC as a potential adjunct for individualized risk stratification in patients with small incidental intracranial aneurysms to prevent catastrophic subarachnoid hemorrhage.