Should a patient be screened for brain aneurysm if her sister died of an aneurysm at a young age?

Screening for Brain Aneurysm in Patients with Family History

Screening for brain aneurysm is strongly recommended for patients who have a first-degree relative (such as a sister) who died of an aneurysm, especially at a young age like 28. 1, 2

Risk Assessment for Familial Aneurysms

The risk of harboring an unruptured intracranial aneurysm (UIA) is significantly elevated in first-degree relatives of individuals with aneurysms:

• First-degree relatives have a prevalence of 4-8.7% of harboring UIAs 2
• Siblings have a higher likelihood of detection than children of affected individuals 2
• The American Heart Association/American Stroke Association guidelines specifically identify family history of intracranial aneurysm as a reason to more strongly consider evaluation 1

Screening Recommendations

Who Should Be Screened

• First-degree relatives (siblings, children, parents) of individuals who had aneurysmal subarachnoid hemorrhage
• Risk is particularly high if:
  • Multiple family members are affected (having ≥2 affected relatives) 1, 2
  • Additional risk factors are present: female sex, smoking history, or hypertension 2, 3

Screening Method

1. MRA (Magnetic Resonance Angiography) is the preferred initial screening tool:

   • Non-invasive with sensitivity rates of 69-93% 1, 2
   • Particularly useful for aneurysms >3-5mm 1
   • No radiation exposure

2. CTA (Computed Tomography Angiography) is an acceptable alternative:

   • Sensitivity of >90% for detecting aneurysms 1
   • Less ideal for repeated surveillance due to radiation exposure 1

3. DSA (Digital Subtraction Angiography) should be used:

   • If MRA/CTA findings are positive or questionable 1
   • When planning treatment 1

Timing and Frequency

• Initial screening should begin around age 30 2
• For your patient with a sister who died at age 28, screening should be initiated promptly
• If initial screening is negative, repeat screening is recommended every 5-7 years 2
• Screening should continue throughout adulthood 2, 4

Additional Considerations

Risk Modification

All patients with family history of aneurysm should be advised to:

• Quit smoking (smoking increases risk significantly) 2, 3
• Control blood pressure 2
• Be educated about warning signs of aneurysm rupture 2

Treatment Decisions

If an aneurysm is detected:

• Treatment decisions should consider aneurysm size, location, patient age, and comorbidities 1
• Small aneurysms (<7mm) in the anterior circulation generally have low rupture rates 2
• The treating physician should consider both their own experience and the volume of cases at their center when making recommendations 1

Potential Pitfalls and Caveats

1. False negatives: Both MRA and CTA have limitations in detecting small aneurysms (<3mm) 1

2. Psychological impact: Screening may cause anxiety; patients should be counseled about this before testing 5

3. Insurance implications: Detection of an aneurysm may affect life insurance eligibility 5

4. Treatment risks: If an aneurysm is detected, treatment carries its own risks that must be weighed against the natural history of the aneurysm 1

5. Center expertise: For both screening interpretation and potential treatment, high-volume centers (>20 cases annually) have better outcomes 1

In summary, given your patient's family history of a sister who died from an aneurysm at age 28, screening with MRA is strongly recommended, with follow-up screening at regular intervals if the initial screen is negative.