Prevalence and Risk of Rupture of Intracranial Aneurysms

A Systematic Review
Gabriel J.E. Rinkel, MD; Mamuka Djibuti, MD; Ale Algra, MD; J. van Gijn, MD, FRCPE

Background and Purpose—The estimates on the prevalence and the risk of rupture of intracranial saccular aneurysms vary
widely between studies. We conducted a systematic review on prevalence and risk of rupture of intracranial aneurysms and
classified the data according to study design, study population, and aneurysm characteristics.
Methods—We searched for studies published between 1955 and 1996 by means of a MEDLINE search and a cumulative
review of the reference lists of all relevant publications. Two authors independently assessed eligibility of all studies and
extracted data on study design and on numbers and characteristics of patients and aneurysms.
Results—For data on prevalence we found 23 studies, totalling 56 304 patients; 6685 (12%) of these patients were from 15
angiography studies. Prevalence was 0.4% (95% confidence interval, 0.4% to 0.5%) in retrospective autopsy studies, 3.6%
(3.1 to 4.1) for prospective autopsy studies, 3.7% (3.0 to 4.4) in retrospective angiography studies, and 6.0% (5.3 to 6.8)
in prospective angiography studies. For adults without specific risk factors, the prevalence was 2.3% (1.7 to 3.1); it tended
to increase with age. The prevalence was higher in patients with autosomal dominant polycystic kidney disease (relative
risk [RR], 4.4 [2.7 to 7.2]), a familial predisposition (RR, 4.0 [2.7 to 6.0]), or atherosclerosis (RR, 2.3 [1.7 to 3.1]). Only
8% (5 to 11) of the aneurysms were .10 mm. For the risk of rupture, we found nine studies, totalling 3907 patient-years.
The overall risk per year was 1.9% (1.5 to 2.4); for aneurysms 510 mm, the annual risk was 0.7% (0.5 to 1.0). The risk
was higher in women (RR, 2.1[1.1 to 3.9]) and for aneurysms that were symptomatic (RR, 8.3 [4.0 to 17]), .10 mm
(RR, 5.5 [3.3 to 9.4]), or in the posterior circulation (RR, 4.1 [1.5 to 11]).
Conclusions—Data on prevalence and risk of rupture vary considerably according to study design, study population, and
aneurysm characteristics. If all available evidence with inherent overestimation and underestimation is taken together, for
adults without risk factors for subarachnoid hemorrhage, aneurysms are found in approximately 2%. The vast majority of
these aneurysms are small (510 mm) and have an annual risk of rupture of approximately 0.7%. (Stroke.
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1998;29:251-256.)
Key Words: subarachnoid hemorrhage n aneurysms n epidemiology n systematic review

U ncertainty surrounds the prevalence of unruptured saccular

aneurysms on intracranial arteries. In angiographic and
autopsy studies, estimates for prevalence vary between 2 and 90
per 1000.1,2 This wide range probably reflects methodological
differences between studies: prospective or retrospective de-
signs, diagnostic tools (angiography or autopsy), and study
populations. Many studies have included patients with rup-
tured aneurysms, which results in too high a prevalence. On
the other hand, studies reviewing routine autopsy records or
angiograms of only a single carotid artery probably underesti-
mate the prevalence. Accurate data on the prevalence of
intracranial aneurysms are essential in evaluating the results of
screening programs for aneurysms in patients with increased
risk for SAH such as patients with ADPKD3 or first-degree
relatives of patients with SAH.4 Also, the management strategy
for unruptured aneurysms is influenced by the prevalence;
because the incidence of SAH has been properly assessed and
is stable,5 a higher than previously assumed prevalence of
aneurysms would mean that unruptured aneurysms are less
dangerous.
We conducted a systematic review of all reports on preva-
lence of intracranial aneurysms and classified the data according
to study design, diagnostic methods, and study population. To
assess the accuracy of the data on prevalence, we also system-
atically reviewed data on the risk of SAH in patients with
unruptured intracranial aneurysms because prevalence com-
bined with annual risk of rupture should equal the incidence of
SAH. This calculated incidence can then be compared with the
incidence observed in the population.5
Methods
Identification of Studies
To identify studies published between 1955 and June 1996 on
prevalence and natural history of intracranial saccular aneurysms, we
first performed a MEDLINE search from 1966 onward. Second, we
searched the reference lists of all relevant publications for additional
studies. The references of the publications thus found were checked

Received July 21, 1997; final revision received October 23, 1997; accepted October 24, 1997.
From the University Department of Neurology Utrecht, The Netherlands.
Correspondence to Gabriel J.E. Rinkel, MD, University Department of Neurology, Heidelberglaan 100, 3584 CX Utrecht, Netherlands.
E-mail g.j.e.rinkel@neuro.azu.nl
© 1998 American Heart Association, Inc.

251
 252 Intracranial Aneurysms: Prevalence and Risk of Rupture
Selected Abbreviations and Acronyms
ACA 5 anterior communicating artery
ADPKD 5 autosomal dominant polycystic kidney disease
ICA 5 internal carotid artery
MCA 5 middle cerebral artery
SAH 5 subarachnoid hemorrhage
again for additional studies published between 1955 and June of 1996.
This method of cross-checking was continued until no further
publications were found. In case of multiple publications on the same
study population, we used the most recent publication. Language
other than English was not an exclusion criterion.6
Eligibility Studies
To assess eligibility, two authors independently reviewed all studies
with a set of predefined inclusion criteria. A first inclusion criterion for
all studies was that the presentation of data included crude numbers or
allowed recalculation into crude numbers. In autopsy studies, addi-
tional inclusion criteria were that ruptured saccular aneurysms and also
fusiform and mycotic aneurysms had to be excluded or separately
reported. In angiography studies on prevalence, additional criteria
were (1) angiography had to be intra-arterial, (2) the indication for
angiography had to be given, and (3) the number of patients had to be
more than 10. In studies that used CT angiography or MR angiog-
raphy, the presence of aneurysms had to be confirmed by conventional
angiography. The inclusion criteria for follow-up studies about the
risk of bleeding in patients with unruptured aneurysms were (1) the
type of aneurysm had to be identifiable as one of three categories:
incidental (found by chance), additional (multiple aneurysms in
patients with SAH), or symptomatic but unruptured; (2) in patients
with additional aneurysms, the ruptured (“index”) aneurysm had to
have been clipped (wrapping was considered inadequate to prevent
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further ruptures); and (3) in patients with previously clipped aneu-
rysms, the source of subsequent bleeding had to be identified by CT,
surgery, or autopsy, to exclude rerupture of the previously clipped
aneurysm as a cause for the hemorrhage. In some studies, only subsets
of patients met all inclusion criteria; only those patients were included
in the review.
Data Extraction
After the initial assessment for eligibility, two authors independently
extracted the following data for studies on prevalence: total number of
patients; number of patients with aneurysms; age and sex of all patients
and of patients with aneurysms; and site and size of the aneurysms
found. The indications for angiography were categorized into the
following groups: family history of SAH, ADPKD, atherosclerosis
(carotid artery disease or ischemic heart disease), suspected pituitary
adenoma, brain tumor, and other. The ages of the patients were
grouped into decades; the sites of the aneurysms were grouped into
one of four locations: (1) ICA, (2) ACA or anterior cerebral and
pericallosal artery, (3) MCA, and (4) vertebrobasilar arteries. The sizes
of the aneurysms were categorized into categories of 5-mm increases,
and the size was also dichotomized into 10 mm or larger. For
follow-up studies in patients with unruptured aneurysms, we recorded
the total number of patients, the period of follow-up, and the number
of patients with SAH. When possible, we stratified data according to
age and sex of the patients and to site and size of the aneurysms.
Data Analysis
For calculating the risk of SAH in patients with unruptured aneu-
rysms, we multiplied the number of patients by the average period of
follow-up to obtain the total number of patient-years of follow-up.
The number of patients with subsequent SAH was then divided by this
number of patient-years, yielding the risk of SAH per patient-year.
We used this method for calculating the risk of SAH in all patients as
well as in the prespecified subgroups (according to age group and sex
or to type, site, and size of aneurysms).
Results
For the overview of prevalence of aneurysms, we found 8
autopsy and 15 angiography studies that fulfilled all the
inclusion criteria (Fig 1).1,2,7–27 One of these 23 publications was
in French,13 another in Japanese,25 and the remaining 21 were
in English. The number of patients studied in these 23 series
totalled 56 304; 49 619 of these patients (88%) were from
autopsy studies, and 6685 patients (12%) were from angiogra-
phy studies. In 738 patients, one or more aneurysms were
found; 405 of these patients (55%) were from autopsy studies.
Data on whether more than one aneurysm was found in single
patients could be extracted from two autopsy studies13,18 and
from all angiography studies; the number of extra aneurysms
was 23 in the autopsy studies and 69 in the angiography studies.
The total number of aneurysms found was 830.
The prevalence in the retrospective autopsy studies was
much lower than in prospective autopsy studies or in angiog-
raphy studies (retrospective or prospective) (Fig 1). The
prevalence in these last three types of studies combined was 4.3
(95% confidence interval, 4.0 to 4.7) per 100. The prevalence
of aneurysms was very low in the first two decades of life and
steadily increased after the third decade; this increase was
statistically significant in a weighted linear regression (Fig 2).
Autopsy studies did not allow relating the frequency of
aneurysms to sex, comorbidity, or cause of death. In angiog-
raphy studies, more men (n51754) than women (n51254)
were studied; the prevalence was lower in men (Table 1). If
subdivided according to the indication for angiography, pa-
tients with ADPKD and patients with a positive family history
had the highest risk for aneurysms, but patients with a
suspected pituitary adenoma (in whom the angiogram was
often specifically done to exclude an aneurysm as cause of
compression on the optic nerve) and patients with atheroscle-
rosis also had a higher risk than patients with a brain tumor or
other indications for angiography (Table 1).
The site of the aneurysm was recorded for 563 aneurysms,
from all angiography studies and two autopsy studies. ICA
aneurysms were most commonly found, and posterior circu-
lation aneurysms least commonly (Table 2). The size of the
aneurysm could be studied for categories of 5 mm in 356
aneurysms, from 10 angiography and 2 autopsy studies (Table
2). The proportions within these categories were similar in the
autopsy and angiography studies. One study used categories of
10 mm18; when the 83 aneurysms #10 mm and the 10
aneurysms .10 mm from this study were added, the propor-
tion of aneurysms 10 mm remained essentially the same (8%;
95% confidence interval, 5% to 11%).
For the analysis of the risk of SAH in patients with
unruptured aneurysms, nine studies, totalling 3907 patient-
years, fulfilled the inclusion criteria (Table 3).28 –36
The risk of rupture of aneurysms depended more on the
characteristics of the aneurysm than on those of the patient.
Women and patients at higher age tended to have an increased
risk of rupture, but the 95% confidence intervals were wide.
Symptomatic aneurysms, posterior circulation aneurysms, and
large (.10 mm) aneurysms had a higher risk of rupture.
Additional aneurysms also had a higher risk of rupture than
accidentally found asymptomatic aneurysms, but this difference
was not statistically significant. Data provided in the publica-
 Rinkel et al
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tions were insufficient for a multivariate analysis to assess
whether these factors are independent prognosticators.
Discussion
The frequency of incidental aneurysms varied considerably
according to the indication for the imaging studies. The
prevalence of 2.3 per 100 in patients with brain tumors or
miscellaneous indications may most closely represent the
prevalence in the general population, although this number
probably overestimates the actual rate because the prevalence
in patients younger than 20 years is very low and this age group
is obviously underrepresented in this study sample. The fre-
quency of aneurysms is higher in patients investigated for
ADPKD or with a familial predisposition for SAH, suspected
pituitary adenomas, and atherosclerosis; moreover, it tends to
increase with age in adults.
The methods used to detect the aneurysms markedly influ-
enced the proportion of aneurysms. In retrospective autopsy
studies, the prevalence was much lower (0.4%) than in
253
Figure 1. Methods, overall prevalence,
and subgroups distinguished for
autopsy studies (retrospective and
prospective) and angiography studies
(retrospective and prospective).
prospective autopsy studies or in angiography studies of either
design. A probable explanation for this low prevalence in
retrospective autopsy studies is that these review old files,
rather than original materials, in contrast to retrospective
angiography studies that can review the actual studies. The data
derived from the retrospective autopsy studies are therefore
probably an underestimation of the prevalence. The much
higher prevalence found in prospective angiography studies
compared with prospective autopsy studies is probably ex-
plained by selection bias because patients with ADPKD, a
familial predisposition for SAH, or atherosclerosis are overrep-
resented in the prospective angiography series. The prospective
angiography series therefore seem to overestimate the
prevalence.
For the risk of rupture, the type of aneurysm is an important
factor. Incidentally found aneurysms tend to have a lower risk
of rupture than aneurysms found additional to a ruptured
aneurysm. Symptomatic aneurysms, aneurysms larger than
10 mm, and basilar artery aneurysms were all found to have a
 254 Intracranial Aneurysms: Prevalence and Risk of Rupture

TABLE 1. Risk Factors for Presence of Intracranial Aneurysms in Angiography Studies

No. No. of Prevalence per Relative Risk
Investigated Aneurysms 100 (95% CI) (95% CI)
Sex
Men 1754 61 3.5 (2.7-4.5) 0.8 (0.5-1.1)
Women 1254 58 4.6 (3.5-5.9) Ref
Indications
Family history 476 45 9.5 (7.0-12) 4.0 (2.7-6.0)
ADPKD 202 21 10 (6.2-15) 4.4 (2.7-7.3)
Atherosclerosis 3676 196 5.3 (4.6-6.1) 2.3 (1.7-3.1)
Pituitary adenoma 183 11 6.0 (3.0-11) 2.6 (1.4-4.9)
Brain tumor1other 2052 48 2.3 (1.7-3.1) Ref
Ref indicates reference category; CI, confidence interval. Data on sex are derived from nine studies, 2,11,14,16,17,19,21,23,24

on family history from three studies,23,26,27 on ADPKD from three studies,16,20,24 on atherosclerosis from five
studies,2,19,21,22,25 on pituitary adenoma from two studies,14,15 and on other (including brain tumor) conditions from five
studies.11,17,21,23,25

markedly increased risk of rupture. Because symptomatic
aneurysms are often large, size and being symptomatic may not
be independent risk factors, but unfortunately the data pro-
vided in the publications did not allow us to assess the
interdependence of these factors.
Despite all these sources of bias, the data seem reasonably
accurate. A hypothetical calculation of the incidence from the
data on prevalence and risk of rupture should approximate the
incidence of SAH observed in the population (6 per 100 000
patient-years).5 If one assumes a cohort of 100 000, only the
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.10 mm. If the annual risk of rupture in this cohort (0.7% for
aneurysms ,10 mm and 4% for those of $10 mm) is corrected
on the assumption that in the general population almost all
ruptured aneurysms are previously asymptomatic and not
additional to a ruptured aneurysm (0.8/1.950.4) in a single
year, 0.4p0.7% of the 1605 small aneurysms (n54.6) and
0.4p4% of the 120 large aneurysms (n51.9) will rupture; the
total number of SAHs within the cohort of 100 000 subjects
will therefore be 6.5. This calculated incidence is similar to the
incidence of 6 per 100 000 patient-years observed in the

proportion (75%) of individuals older than 20 years is at risk for population.

aneurysms.37 Most of these 75 000 individuals will not have
risk factors for the presence of aneurysms and will therefore
have a prevalence comparable to the subset of patients with
“brain tumor and other indications for angiography” (2.3%). In
these 75 000 individuals, 1725 will have an aneurysm. Because
93% of aneurysms are #10 mm, 1605 subjects in the cohort
will have an aneurysm #10 mm, and 120 subjects an aneurysm
Other factors also corroborate the accuracy of the data in
this review. First, women more often had aneurysms than men
and their aneurysms had a greater risk of rupture, which
explains the higher incidence of SAH in women.5 Second,
patients with ADPKD and patients with a familial predisposi-
tion for SAH had an increased risk of aneurysms. This finding
is in keeping with the increased risk of SAH for first-degree
relatives of patients with SAH4 and suggests that at least part of
the increased risk for SAH is explained by a higher frequency

TABLE 2. Sites and Sizes of Aneurysms*

n % (95% CI)
Size of aneurysm, total number
with data on size 356
,6 257 72 (68-77)
6-10 74 21 (17-25)
11-20 23 6.5 (4.1-9.5)
.20 2 0.8 (0.09-2.8)
Site of aneurysm, total number with
data on site 563
ACA 126 24 (20-27)
MCA 159 30 (26-34)
ICA 223 42 (37-46)
PC 55 10 (7.7-13)
PC indicates posterior circulation.
*Sites of aneurysms found in 2 autopsy studies13,18 and 15 angiography
Figure 2. Prevalence of aneurysms per age group from five studies2,11,14-17,19-27 and sizes of aneurysms in 2 autopsy studies12,18 and 10
autopsy studies1,8,9,12,18 and five angiography studies.2,11,17,21,23 angiography studies.2,14,17,19-21,23-25,27
 Rinkel et al 255

TABLE 3. Risk of Rupture of Aneurysms28-36

Risk of Rupture per
Patient-Years No. of 100 Patient-Years Relative Risk
Investigated Ruptures (95% CI) (95% CI)
Overall 3907 75 1.9 (1.5-2.4)
Sex
Male 1027 13 1.3 (0.7-2.1) Ref
Female 1304 34 2.6 (1.8-3.6) 2.1 (1.1-3.9)
Age, y
,20 No data
20-39 26 0 0 (0-13) NA
40-59 203 7 3.5 (1.4-7.0) Ref
60-79 297 17 5.7 (3.4-9.0) 1.7 (0.7-4.0)
.80 No data
Type of aneurysm
Asymptomatic 1145 9 0.8 (0.4-1.5) Ref
Additional 1997 27 1.4 (0.9-2.0) 1.7 (0.8-3.7)
Symptomatic 463 30 6.5 (4.4-9.1) 8.2 (3.9-17)
Site
ACA 464 5 1.1 (0.4-2.5) Ref
MCA 1519 17 1.1 (0.7-1.8) 1.0 (0.4-2.8)
ICA 2449 30 1.2 (0.8-1.7) 1.1 (0.4-2.9)
PC 434 19 4.4 (2.7-6.8) 4.1 (1.5-11)
Size, mm
#10 3742 27 0.7 (0.5-1.0) Ref
.10 675 27 4.0 (2.7-5.8) 5.5 (3.3-9.5)
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Ref indicates category; CI, confidence interval; PC, posterior circulation; and NA, not available.

of aneurysms and not only, or not at all, by a higher risk of Acknowledgments

rupture. Third, patients with atherosclerosis also had an in-
creased frequency of aneurysms, which corresponds with the
finding that cardiovascular diseases and SAH share the risk
factors smoking, hypertension, and alcohol abuse.38 Fourth, the
relative risk of ADPKD and familial predisposition was higher
than that of atherosclerosis, which confirms previous findings
that hypertension contributes less to the familial predisposition
for SAH than other, probably genetic, factors.39
In conclusion, data on prevalence vary considerably accord-
ing to methods used to detect aneurysms. Retrospective
autopsy studies probably give an underestimation and prospec-
tive angiography studies an overestimation of the actual prev-
alence. If all available evidence is taken together, for adults
without risk factors for SAH, aneurysms can be found in
approximately 2%; it is possible that the prevalence increases
with age, but we could not convincingly demonstrate this. The
large majority of these aneurysms are small (,10 mm), and the
annual risk of rupture of these small aneurysms is low (0.7% per
year). These data should be kept in mind when one is
confronted with the task of advising patients with an acciden-
tally found asymptomatic aneurysm. In patients with athero-
sclerosis and especially in patients with familial predisposition
or ADPKD, aneurysms are found more often. Prospective
studies should evaluate whether screening and treating these
patients with an increased risk is beneficial.
This study was partially funded by a clinical investigator grant from the
University Hospital Utrecht to G.J.E. Rinkel and a NUFFIC grant to
M. Djibuti (CN.1942). We would like to thank Fleur Bominaar for
accurate help in preparing the tables and figures and Stef Koele for
excellent secretarial assistance.
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