Is Magnetic Resonance Angiography (MRA) brain screening recommended for a 36-year-old male with a family history of vascular anomalies, including a brother who died from a ruptured cerebral aneurysm, a sister with a cerebral Arteriovenous Malformation (AVM), and a father with a thoracic aortic aneurysm?

MRA Brain Screening for Cerebral Aneurysms in a Patient with Strong Family History

MRA brain screening is strongly recommended for this 36-year-old male with multiple first-degree relatives affected by cerebrovascular anomalies, including a brother who died of ruptured cerebral aneurysm, a sister with cerebral AVM, and a father with thoracic aortic aneurysm. 1

Rationale for Screening

Family History Risk Assessment

• The patient has a significant family history burden that substantially increases his risk:

  • Brother died of ruptured cerebral aneurysm (first-degree relative)
  • Sister with cerebral arteriovenous malformation (AVM) (first-degree relative)
  • Father with thoracic aortic aneurysm (first-degree relative)

• According to the American Heart Association/American Stroke Association guidelines, patients with ≥2 first-degree relatives with intracranial aneurysms or subarachnoid hemorrhage should be offered screening 1

  • This patient has multiple affected first-degree relatives with cerebrovascular anomalies
  • The presence of both aneurysms and AVMs in the family increases concern for inherited vascular fragility

• The American College of Radiology Appropriateness Criteria specifically recommends screening for high-risk populations, noting that certain conditions significantly increase risk of cerebral aneurysm 1

Age Considerations

• At 36 years old, the patient is at an appropriate age for screening:
  • First screening is most beneficial between ages 30-40
  • The patient's brother already experienced a fatal rupture, suggesting potential early manifestation in this family

Recommended Screening Modality

MRA as Preferred Initial Screening Method

• MRA head is the ideal screening modality for this patient because:
  • Non-invasive nature with no radiation exposure
  • High sensitivity (95%) and specificity (89%) for detecting intracranial aneurysms 1
  • Can be performed without contrast if needed
  • Better visualization of small aneurysms when performed at 3T scanner strength 1

Alternative Screening Options

• CTA head could be considered as an alternative with:

  • 90% sensitivity and specificity for aneurysm detection 1

  • However, CTA has decreased sensitivity for aneurysms <3mm and those adjacent to bone 1
  • Involves radiation exposure, which is a disadvantage for potentially repeated screenings

Screening Protocol and Follow-up

Initial Screening

• Complete MRA of the head should be performed as baseline imaging
• If negative, follow-up screening should be considered at 5-7 year intervals 1
• If positive, management would depend on aneurysm characteristics

Risk Factors Requiring More Vigilant Monitoring

• Additional risk factors that would warrant more frequent surveillance if aneurysms are detected:
  • Smoking history (patient should be strongly advised to quit)
  • Hypertension (should be aggressively controlled)
  • Multiple aneurysms if detected

Connection to Thoracic Aortic Disease

• The father's thoracic aortic aneurysm may indicate a broader familial vascular disorder
• According to the 2024 ESC guidelines, patients with a family history of thoracic aortic disease should undergo imaging screening 1
• Consider additional vascular screening beyond cerebral vessels:
  • Echocardiogram to evaluate the aortic root and ascending aorta
  • If abnormalities are found, more comprehensive aortic imaging may be warranted

Cost-Effectiveness Considerations

• Screening has been shown to be cost-effective in families with ≥2 affected first-degree relatives 1
• The optimal screening strategy according to models is screening every 7 years from age 20 to 80 years, with an incremental cost-effectiveness ratio of $29,200 per quality-adjusted life-year 1

Important Caveats

• False positives can occur with MRA, particularly with vessel loops and infundibular origins of vessels 1
• Small aneurysms (<3mm) may be missed even with high-quality imaging
• The patient should be counseled about the implications of positive findings, including potential anxiety and impact on insurance
• Recent research indicates that family history is the strongest predictor of aortic and peripheral aneurysms in patients with intracranial aneurysms 2, further supporting the need for comprehensive vascular screening in this patient