Neuroradiology (2011) 53:883–889

DOI 10.1007/s00234-010-0804-4

INTERVENTIONAL NEURORADIOLOGY

Analysis of aneurysm rupture in relation to the geometric

indices: aspect ratio, volume, and volume-to-neck ratio
Chang-Woo Ryu & O-Ki Kwon & Jun Seok Koh &
Eui Jong Kim

Received: 9 September 2010 / Accepted: 5 November 2010 / Published online: 24 November 2010
# Springer-Verlag 2010

Abstract and 109 unruptured aneurysms. The five geometric indices

Introduction Geometric indices of cerebral aneurysms have
been widely studied to determine rupture risk. However,
most of these parameters were evaluated based on two-
dimensional (2D) images and could have a measurement
bias. We propose a new three-dimensional geometric index,
an aneurysm volume-to-neck area ratio (VNR). To deter-
mine whether the VNR of ruptured aneurysms is different
from that of unruptured aneurysms, we compared VNR
with other 2D geometric indices in discriminative capacity
for aneurysm rupture status.
Methods Two hundred fourteen aneurysms in 195 patients
(mean age, 57.44±11.21 years; males, 69; females, 126)
were retrospectively evaluated. There were 105 ruptured
C.-W. Ryu (*)
Department of Radiology,
Kyung Hee University Hospital at Gangdong,
College of Medicine, Kyung Hee University,
Sangil-dong 149, Gangdong-gu,
Seoul 134-727, Republic of Korea
e-mail: md.cwryu@gmail.com
O.-K. Kwon
Department of Neurosurgery,
Seoul National University Bundang Hospital,
Sungnam, Republic of Korea
J. S. Koh
Department of Neurosurgery,
Kyung Hee University Hospital at Gangdong,
Sangil-dong 149, Gangdong-gu,
Seoul, Republic of Korea
E. J. Kim
Department of Radiology, Kyung Hee University Hospital,
Sangil-dong 149, Gangdong-gu,
Seoul, Republic of Korea
[aspect ratio (AR), bottleneck ratio (BR), height-width ratio
(HWR), volume, and VNR] were calculated from angio-
graphic data and assessed to determine correlation with
aneurysm rupture (t test). Receiver operating characteristic
(ROC) curve analysis was used for comparison of discrim-
inative capacity between different indices.
Results AR, BR, HWR, and VNR were correlated with
rupture status. Areas under the ROC curve of the aspect
ratio and VNR were significantly larger than that of the
HWR, BR, and volume. However, AR and VNR did not
show a significant difference.
Conclusion A larger aneurysm volume in proportion to the
neck could be one of the geometric indices of aneurysms
that indicate a higher rupture risk. This characteristic is
represented by the aspect ratio.
Keywords Aneurysm . Geometric factor . Aspect ratio .
Volume
Introduction
The decision of whether to actively treat or expectantly
manage unruptured aneurysms has been embroiled in
controversy due to the small rupture rate against the
common occurrence of aneurysms and the risk of major
morbidity during surgical treatment. Therefore, identifying
indicators of high rupture risk has been an interest for many
years [1].
Over the past few decades, a considerable number of
studies have demonstrated that hemodynamics could play an
important role in aneurysm growth and rupture and depend
mainly on the configuration of the aneurysm. Thus, numerous
884
attempts have been made to find a reliable parameter from
aneurysm configurations to predict rupture risk [2–6].
Among many geometric indices, aneurysm size is a well-
documented risk factor for aneurysm rupture. Size is
commonly represented as the maximum length at one viewing
angle of the aneurysm. However, we suggest that aneurysm
size is too simple a measurement to depict real aneurysm
configurations. Aspect ratio, the ratio of the aneurysm’s height
and neck width, first introduced by Ujiie et al. [7], is also well
recognized as a geometric risk factor for aneurysm rupture.
As with size, the aspect ratio uses length that is measured on
two-dimensional (2D) sources. Therefore, measurements
taken with different viewing angles and observers could
provide a potential bias. Additionally, measurements
obtained this way may not reflect the real aneurysm
configuration because it is based on the assumption that
the aneurysm is round or ellipsoid [8]. Therefore, in some
previous studies [3, 9], bi- or multi-lobulated aneurysms
were excluded from subjects to avoid the bias.
Today, we can determine the real aneurysm configura-
tion by use of three-dimensional rotational angiography
(3DRA). The system workstation provides not only 3D
reconstruction of images but also various analysis tools that
are easily used by clinicians. Additionally, 3DRA allows
for the measurement of aneurysm volume [8, 10].
Contrary to aneurysm size, a dimension expressed to the
length, aneurysm volume cannot be influenced by the shape
or projection of view of the aneurysm. The volume is identical
to the amount of blood into the aneurysm and is related to the
volumetric flow rate. The aneurysm neck area, which may
reflect intra-aneurysmal inflow [11], also can be associated
with the hemodynamics of aneurysms. Here we propose a
novel parameter, the ratio of volume to neck area, to describe
the hemodynamic geometrics of intracranial aneurysms. The
basic concept of this index is the same as that of the aspect
ratio. However, we presumed that our novel parameter is free
from the bias that can occur with aspect ratio.
The aim of this study is to determine whether volume
and the volume-to-neck ratio (VNR) is a more reliable
index than 2D indices, including the aspect ratio, to predict
aneurysm rupture status. We compared the discriminative
capacity and interobserver variability of VNR to those of
the aspect ratio using a receiver operating characteristic
(ROC) curve and the interobserver correlation coefficient
(ICC), respectively.
Materials and methods
Subjects
This study was performed according to the ethical standards
of the Institutional Review Board. This study represents a
Neuroradiology (2011) 53:883–889
retrospective review of a prospectively maintained database
of patients presenting to two institutes with aneurysms. The
study protocol included all consecutive patients in whom
aneurysms were diagnosed by DSA and 3DRA in two
institutions [Kyung Hee University Hospital (KUH) from
June 2006 to October 2007 and Kyung Hee University
Hospital at Gangdong (KUHG) from June 2006 to February
2008]. Brain CT, laboratory results, and clinical information
of subjects were retrospectively evaluated for the presence
of subarachnoid hemorrhage.
In patients with multiple aneurysms, ruptured aneurysms
were identified by direct observation at the time of surgery.
Patients with multiple aneurysms were excluded from this
study if ruptured aneurysm was not confirmed by direct
observation in surgery. Aneurysms with poor image quality
of 3DRA and extradural aneurysms located proximal to the
opthalmic segment were also excluded.
Two hundred fourteen aneurysms of 195 patients (mean
age, 57.44±11.21 years; males, 69; females, 126) were
included in this study; 52 patients presented to KUH, and
143 patients presented to KUHG. Multiple aneurysms were
identified in 18 patients. One hundred five aneurysms were
categorized as ruptured, and 109 aneurysms were unrup-
tured. Of the 105 patients with ruptured aneurysms, 96
patients presented with a single ruptured aneurysm, and
nine patients had at least one additional unruptured
aneurysm.
Three-dimensional rotational angiography
All of the 3DRA examinations were performed using a flat
panel angiographic unit (Allura Xper FD 20/10 angiogra-
phy system; Philips Medical Systems, Best, The Nether-
lands) with a field of view of 16×16 cm and a frame rate of
30/s. The ranges of rotation included +110° to −110°. A
volume of 21–35 mL of non-ionic, iso-osmolar contrast
medium (270 mg per I/mL, iodixanol; Visipaque, Nycomed
Imaging, Oslo, Norway) was injected through a 5–6 Fr
catheter by use of an injector with a velocity of 3–5 mL/s.
Image acquisition was started 1–3 s after contrast material
injection. The acquisition time of the images was 4.1 s.
Volume-rendered 3D images were reconstructed with a
50% magnification (a field of 37.56 cm2) and a matrix of
256 pixels3 using the 3DRA volumetric measurement of the
system software. The threshold for the volume-rendering
image was fixed as a default value provided by the
software.
Image analysis
We recorded the aneurysm locations as the anterior cerebral
artery (ACA; ACA and anterior communicating artery);
middle cerebral artery (MCA; MCA trunk and MCA
Neuroradiology (2011) 53:883–889 885

bifurcation); posterior communicating artery (PCoA; PCoA an index's ability to discriminate between ruptured and
and anterior choroidal artery); paraclinoid internal carotid unruptured aneurysms. Thus, the larger the AUC is, the
artery (ICA); and posterior circulation (basilar top, basilar better the discrimination. The cut-point was determined at
trunk, and vertebral artery). the point where the Youden index [12] shows the maximum
Aneurysms were classified into simple-lobed and value (Youden Index=sensitivity+specificity−1). Likewise,
irregular aneurysms according to their shape. The the comparison of the AUC between the aspect ratio and
irregular shape was defined as an aneurysm with the VNR was performed for simple-lobed and irregular
daughter sac and multilobular aneurysms. The relation- aneurysms groups.
ship between aneurysm shape and rupture status was To assess the correlation between values obtained from
analyzed by the χ2 test. two observers, the ICC between two observers was tested
The geometric indices of aneurysms on 3D volume- for VNR and the aspect ratio. The calculated ICCs were
rendering images of the workstation were measured by compared between the VNR and aspect ratio.
two neuroradiologists (CR and EK) independently. The The Pearson correlation coefficient and linear regression
following five dimensions of aneurysms were manually were used to analyze the relationships between VNR and
measured on the volume-rendering 3D images with the the aspect ratio. P <0.05 was considered statistically
ruler tool of the system software: (1) height (H, the significant.
maximum distance between the neck and dome of an
aneurysm), (2) width (W, the longest diameter of an
aneurysm perpendicular to H), (3) depth (D, the longest
diameter of an aneurysm perpendicular to the axis of the
parent artery, (4) neck width (N), and (5) another neck
width (N′) was obtained perpendicular to the axis of the
parent artery. The neck area (Nd) was calculated as
follows: Nd (mm2)=π×(N/2×N′/2). H, W, and N were
measured in the plane parallel to the blood flow of the
parent arteries (Fig. 1).
We calculated the following secondary geometric indi-
ces: (1) aspect ratio, the ratio of H to N; (2) height–width
ratio, the ratio of H to W; and (3) bottleneck factor, the ratio
of W to N. These indices were previously evaluated in the
identification of aneurysm rupture risk [3, 4].
The aneurysm volume was acquired using the aforemen-
tioned 3DRA system software. In the volume-rendering
image, the aneurysm was manually segmented from the
parent artery, and the volume was calculated. The manual
outlining and segmentation of the aneurysm from the parent
artery was performed by the same neuroradiologist. We
calculated the VNR as follows: VNR (mL/cm2)=volume×
100/Nd.

Statistical analysis

To determine the relationship between rupture status and

geometric indices, aneurysms were divided into two
groups according to rupture status. All geometric indices
between the two groups were compared using an
unpaired t test.
To compare the efficacy of the indices in discriminating
between ruptured and unruptured aneurysms, we performed Fig. 1 a Three-dimensional volume rendering image of an aneurysm
a receiver operating characteristic (ROC) analysis. The illustrates the method of dimension measurements: height (H), width
(W), and neck width (N). These are measured in a parallel plane to
ROC curves were plotted, and the area under the curve blood flow of parent arteries. b 3D image projection perpendicular to
(AUC) values for each geometric index were calculated and blood flow where depth (D) and another neck width (N′) are
compared. The ROC curves and AUC indicate the limit of measured. The dotted line represents the axis of the parent artery
886
Results
The locations of the aneurysms were as follows: ACA (n=
66), MCA (n=66), PCoA (n=31), paraclinoid ICA (n=31),
and posterior circulation (n=20). On the basis of size (the
longest diameter among H, W, and D), aneurysms were
classified as small (<5 mm) in 105 (49.1%), medium (5–
10 mm) in 88 (41.1%), and large (11–20 mm) in the last 21
(9.8%), and there was no giant (>20 mm) aneurysm.
Irregular-shaped aneurysms accounted for 99 (46%) of
all aneurysms. Among them, 34 (34.3%) were unruptured,
and 65 (65.7%) were ruptured. Of the 115 simple-lobed
aneurysms, 75 (65.2%) were unruptured, and 40 (34.8%)
were ruptured aneurysms. The χ2 test revealed that there
were significantly more ruptured cases in irregular aneur-
ysms as compared with simple-lobed aneurysms.
The aspect ratios were 1.11±0.45 and 1.61±0.72 for
unruptured and ruptured aneurysms, respectively. The
height–width ratios were 0.84±0.26 and 1.02±0.39, the
bottleneck factors were 1.48±0.42 and 1.85±0.63, and the
VNRs were 0.60±0.65 and 1.07±0.99 for unruptured and
ruptured aneurysms, respectively. These indices were
significantly correlated with rupture status. However, the
volume was not correlated with rupture status (0.086±0.21
for unruptured and 0.13±0.19 for ruptured aneurysms, P=
0.10) (Table 1).
The AUC of the aspect ratio, height–width ratio,
bottleneck factors, volume, and VNR were 0.735 [95%
confidence interval (CI), 0.671–0.793], 0.642 (0.574–
0.706), 0.701 (0.635–0.762), 0.667 (0.599–0.729), and
0.770 (00.707–0.824), respectively. The AUC values of
the aspect ratio and VNR were significantly larger than the
AUC values of the height–width ratio, bottleneck factors,
and volume. However, aspect ratio and VNR did not show
significant difference on AUC (P=0.246). At a cut-off
value of 1.24 for the aspect ratio, the sensitivity was 66.7%,
and the specificity was 71.6%. At a cut-off value of 0.53 for
the VNR, the sensitivity was 80.0%, and the specificity was
68.8% (Table 2).
Within the simple-lobed group, the AUC between aspect
ratio and VNR did not show any significant differences
(Fig. 2 a). ROC curve analysis was repeated for irregularly
shaped aneurysms. The AUC of the VNR (0.801; 95% CI
0.709–0.875) tended to be larger than that of the aspect
ratio (0.721; 95% CI 0.622–0.806), although they did not
reach statistical significance (P=0.072; Fig. 2 b).
Because one observer (EK) did not estimate the
geometric parameter from 14 aneurysms, the indices of
200 aneurysms were enrolled for the analysis of the ICC.
The ICC between two observers was 0.9173 (95% CI
0.8925–0.9366) and 0.9452 (95% CI 0.9284–0.9581) for
aspect ratio and VNR, respectively. There was no signifi-
cant difference of ICC between aspect ratio and VNR.
Neuroradiology (2011) 53:883–889
Figure 3 shows the VNR values plotted against the
aspect ratio values. This graph demonstrates strong linear
correlation between VNR and the aspect ratio (r=0.71, 95%
CI 0.63–0.77).
Discussion
This study demonstrated that VNR, but not volume, was
correlated with aneurysm rupture status. However, contrary
to our expectation outlined in the introduction, VNR was
not superior to the aspect ratio in the discriminating ability
for aneurysm rupture and interobserver reliability of
measurement. We thought that the basic concept of VNR
(volume in proportion to neck) was not so different from
that of the aspect ratio, and this study revealed that the
aspect ratio was linearly correlated with the VNR.
Therefore, if VNR is to replace the aspect ratio, their
discriminating ability and reliability should be superior to
the latter.
Previous experimental studies [7, 13–15] have shown
that intra-aneurysmal flow decreased as the aneurismal
neck decreased and the aneurismal volume increased. The
area of the neck is a factor in limiting blood flow into and
out of the aneurysm. The volume of the aneurysm is
inversely proportional to the velocity of blood within the
aneurysm. Thus, the larger the aneurysm is in proportion to
the neck, the more sluggish the blood flow will be and the
longer the blood will remain within the aneurysm. The
stagnation of blood may contribute to rupture by degrading
the integrity of the aneurismal wall. We regard our clinical
result about VNR as meaningful to support these experi-
mental results.
In this study, an AUC comparison between VNR and
aspect ratio in the irregular shape group showed a tendency
toward a higher AUC of the VNR, rather than that of the
aspect ratio, while the AUC between the VNR and the
aspect ratio did not show a difference in the simple-lobed
aneurysm groups. The cause of this phenomenon could be
explained by the fact that the heights of irregular aneurysms
might be less linearly correlated with aneurysm volumes
rather than the height of simple-lobed aneurysms. In the
measurement of aneurysm geometry, volume is less
influenced by aneurysm shape or projection view than the
height. One disadvantage of the aspect ratio is that the
threshold values, which showed which aneurysms carry a
higher risk of rupture, varied with researchers. Therefore,
VNR may be favorable to acquire a common cut-off value
regardless of aneurysm shape.
Previous reports have showed that the aspect ratio
consistently correlates with aneurysm rupture [2, 16, 17].
When the aspect ratio was first proposed, the height of the
aneurysm was defined as the simplified value of the
Neuroradiology (2011) 53:883–889 887

Table 1 Comparison of geometric indices between unruptured and ruptured aneurysms

Geometric index Unruptured (109) Ruptured (105) Mean difference (95% CI) P value

Height–width ratio 0.8429±0.2634 1.025±0.3893 0.1824 (0.0931–0.2717) <0.0001

Aspect ratio 1.112±0.4494 1.607±0.7204 0.4954 (0.3342–0.6565) <0.0001
Bottleneck factor 1.483±0.4240 1.849±0.6329 0.3661 (0.2214–0.5107) <0.0001
Volume 0.08619±0.2087 0.1307±0.1857 0.0445 (−0.0088–0.09782) 0.1012
VNR 0.5985±0.6464 1.066±0.9913 0.4671 (0.2424–0.6918) <0.0001

CI confidence interval, VNR volume-to-neck ratio

aneurysm size and was based on the assumption that the
aneurysm is a round cavity [7]. Ambiguously, an aneurysm
with a high aspect ratio can be figured two different
configurations; one is an aneurysm with the larger volume
for neck area and the other is a vertically elongated
aneurysm. Which of the two shapes are more related to
the geometrical characteristics of the ruptured aneurysm?
The present results suggest that the larger volume for neck
area could be correlated with rupture. The other geometric
feature, vertically elongated aneurysm, could also be
independently correlated with aneurysm rupture. The
vertical ellipticity of aneurysm can be represented as the
height–width ratio, which we found to be significantly
different between unruptured and ruptured aneurysms.
However, the shape of ruptured aneurysms was almost
spherical (the height–width ratio is near 1.0), and the
height–width ratio had nearly identical mean values
between the ruptured and unruptured aneurysms despite
the statistical difference observed previously [4, 9] and in
the present study. Therefore, the VNR rather than the
vertical ellipticity should be given a great deal of weight on
reading of aspect ratio. We found that, in several previous
reports, the schematic illustrations showing the geometric
characteristic of the aspect ratio were misinterpreted; an
aneurysm with a low aspect ratio is dumpy, and an
aneurysm with a high aspect ratio is lanky [1, 4, 18]. In
the planning of this study we hypothesized that, because
aneurysm volume is a more realistic parameter than height,
VNR would be superior to the aspect ratio in determining
risk factors of aneurysm rupture. However, our result did
not prove this hypothesis. Despite the pitfalls of aspect
ratio, which were outlined in the introduction, this study
demonstrated that the aspect ratio had a reliable discrimi-
nating ability between unruptured and ruptured aneurysms
and had a high interobserver reliability. We suggest that
height would be a reliable substitute for the volume of an
aneurysm and the aspect ratio would be a more simplified
index of the VNR.
We have not analyzed other risk-related factors such as
smoking, hypertension, age, gender, and familial predispo-
sition. The present study evaluated only morphologic
factors related to aneurysm rupture. Morphologic analysis
is a useful way to assess aneurysm characteristics indepen-
dently without patient-level confounding variables. In this
study, however, the discriminating ability of morphologic
analysis was not suitable for the decision-making involved
in the risks associated with observation. The VNR is yet
another variable that at best adds further weight to the array
of variables used to assess the risk of aneurysm rupture. A
more comprehensive multivariate analysis, including the
above parameters, should be performed for additional study.
To determine treatment of an asymptomatic unruptured
aneurysm, other contributing factors, such as the patient’s
age, previous history of subarachnoid hemorrhage, aneu-
rysm location, the patient’s history of smoking and familial
history, and aneurysm shape (multi-lobulation and daughter
sacs), should be taken into account. Another bias of this
study is that the shape or size of ruptured aneurysms might
have changed due to surrounding clots or intra-aneurysmal
thrombus. Therefore, the measured geometric indices of the

Table 2 ROC curve analysis of geometric indices

Geometric index AUC (95% CI) Cut-off value Sensitivity Specificity Positive likelihood ratio Negative likelihood ratio

Height–width ratio 0.642 (0.574–0.706) 0.8728 64.8 67.0 1.96 0.53

Aspect ratio 0.735a (0.671–0.793) 1.2446 66.7 71.6 2.34 0.47
Bottleneck factor 0.701 (0.635–0.762) 1.4458 77.1 56.9 1.79 0.40
Volume 0.667 (0.599–0.729) 0.041 68.6 63.3 1.87 0.50
VNR 0.770a (0.707–0.824) 0.5258 80.0 68.8 2.56 0.29

AUC area under curve, CI confidence interval, VNR volume-to-neck ratio

a
AUCs are significantly larger than the others
888
Fig. 2 a Graph depicting the ROC curves for aspect ratio (bold) and
VNR (dotted line) in the simple-lobed aneurysm group. The ROC area
for aspect ratio is 0.757 and for VNR is 0.734. b Graph depicting the
ROC curves for aspect ratio (bold) and VNR (dotted line) in the
ruptured aneurysms could be underestimated as compared
to the indices immediately before rupture. This concern has
also been presented in a previous study [2].
In conclusion, ruptured aneurysms had a significantly
larger VNR than that of unruptured aneurysms. The
larger volume in proportion to the neck of the aneurysm
would be one of the morphological characteristics of
aneurysms indicating a higher risk of rupture. These
Fig. 3 Graph demonstrating lin-
ear regression between VNR
and aspect ratio. Pearson corre-
lation coefficient is 0.71 (95%
CI 0.63–0.77)
Neuroradiology (2011) 53:883–889
irregular-shaped aneurysm group. The ROC area for VNR (0.735;
95% CI 0.671–0.793) tends to be larger than the AUC of the aspect
ratio (0.735; 95% CI 0.671–0.793; P=0.072)
characteristics could be more simplified by the aspect
ratio, of which the value was not inferior to VNR for
discriminating between the ruptured and unruptured
aneurysms. ROC analysis also revealed that the aspect
ratio had a substantially greater ability than other
secondary geometric indices. Thus, the aspect ratio is as
a good geometric index for the assessment of aneurysm
rupture risk as ever.
Neuroradiology (2011) 53:883–889
Acknowledgment This work was supported by the program of
Kyung Hee University for the Young Researcher in Medical Science
(KHU-2010719).
Conflict of interest statement We declare that we have no conflict
of interest.
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