Special Issue Article

Aneurysm geometry in predicting the risk of

rupture. A review of the literature
Mario Zanaty, Nohra Chalouhi, Stavropoula I. Tjoumakaris,
L. Fernando Gonzalez, Robert H. Rosenwasser, Pascal M. Jabbour
Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA

The management of unruptured aneurysms (UAs), whose incidence is increasing, is still a controversial
issue. Many studies have been investigating the link between the geometry of the aneurysm and the risk of
future rupture in order to bring forth a clear decision plan. The different estimators studied are the
aneurysm’s geometry and hemodynamic features on one hand, and the patient’s clinical characteristics on
the other. We reviewed the literature while focusing on the different geometrical parameters that have been
used in estimating the future risk of rupture. These include mainly the size ratio (SR), the aspect ratio, the
non-sphericity index (NI), the undulation index (UI), and the vessel aneurysm inclination angle (AA), to
name a few.
Keywords: Aneurysm location, Aneurysm morphology, Aneurysm size, Aspect ratio, Neck type, Rupture risk, Size ratio, Vessel geometry, Undulation
Index, Ellipticity index, Non-sphericity index, Volume-to-neck ratio, Bottleneck factor

Introduction future risk of rupture. It is important to note that

Intracranial aneurysm (IA) is a prevalent disease
estimated to affect around 2–5% of the population.1,2
In the past, IA was discovered when the patient
presented for symptoms related to subarachnoid
bleed. Recently however, the prevalence of unruptured
aneurysms (UAs) or incidental aneurysms has been
largely increasing with the advance in imaging,
its widespread use, and the introduction of family
screening.3 The 1% annual risk of rupture, even
though small, has a tremendous impact on the
patient’s health given its high mortality rate, which
approaches 60%, with a large proportion of the
survivors becoming functionally dependent.4 This risk
of rupture is not absolute, as it may decrease from
0.1 to 0.7% depending on certain characteristics.1,5
The management of UAs may present a dilemma
for the physician who must balance the risk of
future rupture with the morbidity of treatments,
such as coiling or clipping.2 Many observational
studies have been conducted to assess the predictors
of aneurysm rupture and to guide the physician in
his decision. These predictors can be broken down
into three different categories: geometric, hemody-
namic, and clinical characteristics. We conducted a
review of the literature that focuses on the relation-
ship between the geometry of the aneurysm and its
Correspondence to: Pascal Jabbour, Department of Neurological Surgery,
Chief Division of Neurovascular Surgery and Endovascular Neurosurgery,
Thomas Jefferson University Hospital, 909 Walnut St, 2nd Floor,
Philadelphia, PA 19107, USA. Email: pascal.jabbour@jefferson.edu
these indicators are not completely independent, as
discussed later.
Hemodynamic Characteristics
The physiopathology that leads to the development
of aneurysms and their subsequent rupture has been
partially explained by hemodynamic components in a
multitude of studies; high wall shear stress (WSS)
seems to play the predominant role in high flow
aneurysm, whereas high intra-aneurysmal pressure
and low-flow stasis are the main factors in low-flow
aneurysm.6 The lower the flow, the higher the
degenerative changes, and the higher the risk of
rupture. Ruptured aneurysms (RAs) also showed a
higher average, more concentrated WSS, and smaller
impingement zones (where the inflow jet impacts
against the aneurysm wall) than unruptured ones.7–9
The WSS by itself remains controversial since other
studies found that RAs tend to have a lower WSS
that is spread over a larger area.10,11 Takao et al.
indicated that RAs have a significantly lower pressure
loss coefficient (PLC), which can be translated to
lesser resistance to blood flow.9 This facilitation to
flow renders the vessel susceptible to sudden changes
in pressure, increasing thereby the risk of rupture.9 It
has been shown that hemodynamic variables are
dependent on the morphology of the aneurysm
and that of its feeding vessels,6,12,13 making it easier
to predict the risk of rupture by evaluating the
geometry.

ß W. S. Maney & Son Ltd 2014

308 DOI 10.1179/1743132814Y.0000000327 Neurological Research 2014 VOL . 36 NO . 4
 Zanaty et al. Aneurysm geometry in predicting the risk of rupture

Figure 1 A schematic representation of an aneurysm illustrating geometrical variables. h: height of the aneurysm – the
longest perpendicular distance to the neck plane; n: neck width – line that joins the two edges of the neck, but in computation, it
is twice the average radius, the average radius being the average distance between the centroid and the edge; w: aneurysm
width – the longest diameter perpendicular to h; Hmax: maximum aneurysm height – the longest distance from the dome to the
neck, does not have to be perpendicular unlike h; D1: the diameter of the parent vessel at the edge of the neck, perpendicular to
flow; D2: the diameter of the parent vessel perpendicular to flow, measured at 1.5D1 from D1; average diameter: (D1zD2)/2; size
ratio: Hmax/average diameter; h/n: aspect ratio; h/w: bottle neck factor; vessel angle: angle between the flow and n; aneurysm
inclination angle: angle between Hmax and n.

Geometrical Characteristics has on rupture and the underlying hemodynamics.

Generalities
The geometrical predictors can be subdivided into
two-dimensional (2D) variables and the novel three-
dimensional (3D) variables. The 2D variables can be
computed without the need for 3D reconstructive
imaging; they are size, the adjusted ratio (AR), and
the bottleneck factor (BN) among others. The 3D
variables were introduced following the advance in
magnetic resonance angiography (MRA) and 3D
computerized angiography (CTA). The 3D variables
are the ellipticity index (EI), the non-sphericity index
(NI), the undulation index (UI), the writhe number,
the volume-to-neck ratio (VNR), and others. In
addition, by using the 3D rotational angiography
(3DRA), the aneurysm geometry can be recon-
structed and the previously used 2D variables can
be more accurately measured.10,14 Other geometrical
indices incorporate in their definition some parent
vessel characteristics, a factor that has been proven to
influence the distribution of the WSS and other
pressure parameters.6,13 Moreover, parent vessel
characteristics indirectly reflect the vessel location,
another variable associated with RA.12,14–16 In a
study by Szikora et al., the aneurysmal main axis
alignment with the parent artery was an independent
predictor; parallel axis to the parent artery was
associated with a higher rupture rate.17 This finding
may be related to the formation of a jet flow pattern
that results in an unequal pressure distribution.17 We
reviewed each geometrical variable, the influence it
Figure 1 illustrates some of the geometrical variables.
Size and location
Defined as the maximum perpendicular distance
between the dome and the neck plane,18 size is the
most widely used parameter to predict the risk of
rupture. Aneurysm.10 mm in size has a 1.9% annual
risk and at present, size is the most important
geometrical factor used in day-to-day clinical practice
to guide whether to treat or manage expectantly,
along with several other clinical factors such as life
expectancy, family history, and smoking.14,19–21 Even
though size,10 mm has a 0.7% annual risk, the risk
turned out to be non-homogeneous given that a large
percentage of RAs fall in this category, and many are
as small as 5 mm, making the relationship between
size and rupture more sophisticated.2,12,14,18,22,23
Recent studies have also shown that size alone is
not a good predictor, and has a low area under the
curve (AUC) value.14,18 Location also seems to
modify the risk as studies have shown that aneurysm
of the anterior communicating artery (A Com A) are
more often ruptured than not, and that small RA are
more likely to be located at the A Com A.12,14,16
Matsukawa et al. found that size.5 mm was
significantly associated with A Com A RAs.20 On
the other hand, aneurysm of the cavernous part of the
internal carotid artery seldom rupture.12,16 The
location effect on the rupture’s risk could be partially
explained by the fact that distal aneurysms have

Neurological Research 2014 VOL . 36 NO . 4 309

Zanaty et al. Aneurysm geometry in predicting the risk of rupture
thinner membrane and consequently, a lesser pressure
is needed to produce the same wall tension (Laplace’s
law).15 It is not clear if the posterior circulation
aneurysm is more likely to rupture given the
inconsistent results in the literature, and whether
the posterior communicating artery aneurysms were
considered anterior or posterior in location.2,5,24 In
addition, shape seems to play a role in RAs; Ryu et
al. found that irregular aneurysms tend to rupture
more than simple-lobed ones.10 They classified the
aneurysm as irregular if it was multilobular or had
one or more daughter sacs.10 In a multitude of
studies, the daughter sacs were significantly related to
rupture, which may be due to higher shear stress
values present at or adjacent to the blebs.20,25 One
study found that for A Com A aneurysms of size
.5 mm, the presence of blebs and an anterior
direction of the dome are significantly associated
with RAs, and recommended that aneurysm with
these characteristics should be treated.20 This is one
of the few studies that took into consideration the
clinical characteristics such as age, female sex,
diabetes mellitus, smoking, and alcohol consumption.
However, smoking and alcohol consumption were
dichotomous. The study was done on Japanese
patients, which limits its external validity.20 In
conclusion, larger size means higher risk but small
aneurysms need to be carefully evaluated by relying
on different indicators.
Aspect ratio
Another frequently used parameter is the AR, defined
by Ujiie et al. as the maximum perpendicular distance
between the neck and the dome, divided by the neck
width. Therefore the AR reflects the depth-to-neck
ratio.12,26 Most of the studies affirmed its importance
and agreed that a higher AR is correlated with a
higher risk of rupture. The following could explain
the relation between AR and RAs: the smaller the
neck, the slower the flow, thus, a higher AR seems to
reflect a lower intra-aneurysmal blood flow and
subsequently a higher risk of rupture.12,26–28 A
commonly used threshold value is AR 5 1.6, above
which the risk significantly increases.12,28 This value
was chosen by performing a receiver operating
characteristics (ROC) analysis, plotting the AUC,
and then choosing the cut-off point where sensitivi-
tyzspecificity21 is the highest. The threshold of 1,6
seems to vary among different studies, and based on
whether 2D angiography or 3D reconstructed data
was used,14 making this value clinically non-useful. In
addition, the study by Nader-Sepahi et al. showed
that the depth is a stronger predictor than the neck
width, and that the neck width alone is a poor
determinant.26 The AR offers an advantage over the
size that it remains significant regardless of the
310 Neurological Research 2014 VOL . 36 NO .
location.14 What might partially account for the
difficulty in finding a common threshold value across
different studies12,14 could be that the velocity alone
cannot explain the rupture mechanism, since low-
flow velocity may lead to the opposite outcome,
which is aneurysm thrombosis.26 Therefore we can
conclude that AR alone is not a reliable predictor,
and hence other morphological features are needed.
Undulation index, EI, and NI
The UI varies from 0, being a completely convex
aneurysm, to 1. It increases when the surface becomes
more irregular and when more concavities are
present14,29. The EI measures the deviation of the
convex hull (which is the smallest volume that fully
encloses the IA and is convex at all points) from a
perfect sphere. It is a measure of elongation14 and
also varies from 0 to 1, increasing when the ellipticity
increases.29 The NI measures the deviation of the
aneurysm itself, not the convex hull, from a perfect
sphere. It reflects the UI and the EI,14 varying from 0
to 1 and increasing with increased ellipticity or
undulation.29 These indices were proposed by
Raghavan et al. and have been consistently correlated
with RA.14,18 Lauric et al. introduced another
estimator of surface irregularity and torsional forces,
which is the writhe number.29 They were the first to
compare the writhe number between RAs and UAs.
The writhe number measures the twisting or curving
of a coil around itself. The higher the writhe number
the more torsional forces are applied to the surface of
the aneurysm.29 They showed that RAs have
significantly greater writhe number, and that the
results were more accurate in the sidewall aneurysm
group than in the bifurcation aneurysm group,
emphasizing again the importance of morphology.
Even more, Chien et al. examined the ratio of the
aneurysm volume to sphere volume (AVSV), which
was found to be higher in RAs. Aneurysm volume to
sphere volume ratio varies between 0 and 1, the more
spherical the aneurysm, the higher the AVSV and the
higher the stress and stretch acting on the aneurysm
wall.30 In contrast, the ratio of the aneurysm surface
area to sphere surface area (AASA), which is
inversely proportion to the stretch ratio, was found
to be lower in the RA with a value of ,1 in more
than 70% of the cases.30 This suggests again that
irregularity of the surface is linked to a higher
rupture.
Size ratio (SR)
Introduced by Dhar et al., it is defined by the
maximal distance between the center of the neck and
the dome (also called as the height of the aneurysm)
divided by the average parent vessel diameter.14 The
maximal distance, unlike the one used to calculate the
size and the AR, does not have to be perpendicular. It
4

is the longer distance between the aneurysm dome
and the center of the neck.14 The SR, by including the
parent vessel geometry, could be thought of as a
combination of size and location. The SR was found
by Dhar et al. to be a significant predictor of rupture
with a sensitivity of 75% and a specificity of 83%. In
their work, they showed that the SR, the AR, the NI,
the EI, the UI, and the NI were significantly
correlated with rupture, but after a multivariate
logistic regression, only the SR and the UI remained
significant in the model. Additional analysis showed
that the NI, EI, SR, and AR were strongly correlated
with one another and thus, the authors concluded
that the NI, EI, and AR might have served as a
surrogate for the SR.14 It is noteworthy that the
average diameter vessel by itself was not a significant
estimator, indicating again to the importance of the
combination of size and parent vessel characteris-
tics.14 Rahman et al. confirmed this finding and
showed that the SR is strongly correlated with
aneurysmal rupture. The small sample size was a
major limiting factor for both these studies.31 One
study found that the SR was no longer significant in a
multivariate analysis when the aneurysm was in the
middle cerebral artery (MCA) but remained signifi-
cant when the aneurysm was in the A Com A.32 The
authors related the findings to the large diameters of
the MCA branches relative to other vessels, limiting
thereby the effect of the SR.32 Overall, most of the
studies agreed on the SR as a strong estimator of
rupture.10,14,31,33
Volume-to-neck ratio and BN
Using 3DRA, the VNR, introduced by Ryu et al., is
the volume of the aneurysm divided by the neck area.
The VNR was correlated to the rupture status but did
not significantly differ from the AR.10 In fact, the
VNR and the AR showed a linear correlation. The
author related this finding to the previous studies on
hemodynamics; the bigger the volume or the smaller
the neck, the slower the flow, and as previously
discussed, low intra-aneurysmal flow contributes
to the growth and rupture of the aneurysm.10,27,28
The AR in their study was a poorer predictor than
the VNR in the irregular shape group compared
to the simple saccular aneurysm group, nevertheless
this difference was non-significant.10 In conclusion it
might be more adequate to find a common cut-off
point for the VNR since it is less vulnerable to the
shape variation of the aneurysm in contrast to the
AR.10 The BN, which is the longest diameter of an
aneurysm perpendicular to the aneurysm height
divided by the neck width, was significantly higher
in the RA group. However, the AUC value was
significantly lower than the AR and the VNR.10 A
case–control study where the cases were their own
Zanaty et al. Aneurysm geometry in predicting the risk of rupture
control, reported a 25% increase in the likelihood of
rupture for each 0.1 unit rise in the BN.24 Another
parameter related to the neck is the neck type, which
can be classified as deviated (toward one of the
daughter arteries) or classical (arises from midline or
apical). It seems that the neck type also differs between
RAs and UAs. In many studies, a deviated neck type
on its own was a significant risk factor.2,34–36 Even
more, the senior author has shown that the combina-
tion of size, AR, and neck type was significantly more
correlated with RAs than any of the variables in
isolation.2 The strong point of this study was that it
adjusted for age and smoking.2 Finally the clinical
research of Ohshima et al. showed that when the neck
orifice is shifted, .1.5 mm but less than 3 mm, away
from the parent artery (that is to say partial over-
lapping) the risk of rupture increases.35 Complete
overlap or no overlap of the neck orifice with the
parent artery did not significantly differ between UAs
and RAs.35
Vessel angle (VA) and aneurysm inclination
angle (AA)
The VA is the angle between the feeding artery and
the neck plane, whereas the AA is the angle between
the neck and the maximum height of the aneurysm.14
Both heavily depend on the viewing plane, which
needs to be chosen in a way that captures the
incoming flow entering the IA.14 Dhar et al. found
that aneurysm angle was a good predictor of RA;
larger angles have a higher risk with the optimum
threshold being 112u.14 This study however included
only sidewall saccular aneurysm. Dhar et al. explained
that a superior angle could be due to the presence of
blebs,37 or due to the alignment of the growth in the
direction of the incoming flow.14 On the other hand,
despite modifying the flow within the aneurysm, the
VA failed to show a significant effect on the rupture
status.14 The flow angle, which was defined by the
summation of the VA and the AA, was also higher in
RAs.32 Another significant variable that incorporates
the parent vessel geometry is the inflow angle.38 It is the
angle formed between two axes; the first represents
the flow in the aneurysm, defined by a line that joins
the center of the neck to the end of the dome, and the
second represents the flow in the parent vessel at the
level of the aneurysm. When the inflow angle increases,
the velocity of the blood entering the aneurysm in-
creases, intensifying the stress and pressure on the
aneurysm wall.38 One final parameter, introduced by
Lin et al., is the parent–daughter angle formed by the
vector of flow in the feeding artery with the vector of
flow in the aneurysm. A smaller angle was associated
with increased rupture rate, a finding consistent with
previous studies that showed increased WSS when the
angle of bifurcation decreases.32
Neurological Research 2014 VOL . 36 NO . 4 311
Zanaty et al. Aneurysm geometry in predicting the risk of rupture
Clinical Characteristics
Other factors such as family history (two first degree
relatives with RAs), smoking, hypertension, female sex,
connective tissue disorder, and presence of multiple
IAs have been shown to increase the risk of
rupture.2,10,14,21 Morphological features were not
adjusted for these parameters in most of the studies.
Ethnicity also seems to play a role, as the Japanese and
the Finnish patients are at higher risk.39,40 You et al.
conducted a nested case–control study, in which age,
sex, region, and other clinical factors were matched
between the groups; the AR, a positive family history
and a maximum neck diameter of ,3 mm were
significantly associated with rupture.21
Limitations
In most of the studies, the geometrical indicators of
RAs were registered after the rupture, and therefore,
the rupture itself could have affected the size, shape, or
other characteristics. The effect the rupture has on the
aneurysm geometry is poorly understood given the
lack of prospective studies and the difficulty to capture
the parameters before and after the subarachnoid
bleed. However there is some evidence that rupture
does not significantly alter the geometry.14,18,41,42
Most of the studies evaluated the aneurysm morphol-
ogy in isolation, without accounting for the clinical
risk factors, which are proven to influence the
rupture’s risk.10,14 Some of the studies were retro-
spective case–control, in which the UA and RA were
unmatched, and thus, more prone to bias.10 One major
limiting factor that seemed constant throughout most
of the literature is that selection was based on the
admission status of RAs versus UAs, therefore the
aneurysm in the RA group might have a significant
higher duration of exposure than the aneurysm in the
UA group.2 Time was not accounted or adjusted for in
many studies, hence the need of more prospective
cohort studies.2 Novel estimators that reflect the
biological process might also be needed to further
explore the topic.14
Conclusion
In conclusion, there is no single reliable predictor to
estimate the risk of rupture, the clinical decision
should still be based on the patient characteristics as
well as other factors intrinsic to the aneurysm. The
3D factors seem to be more reliable than the 2D
factors, the latter are also more accurate when
captured by 3D reconstruction CT.43 Representing
the geometry as a whole not only helps in risk
estimation, but also in presurgical planning, choice
for coils, and in selecting for each patient the
appropriate procedure.43 Finally, randomized clinical
trial might provide additional insight to the question
and may help generate clinical decision algorithm.
312 Neurological Research 2014 VOL . 36 NO . 4
Disclaimer Statements
Contributors No contributors.
Funding None.
Conflicts of interest None.
Ethics approval Review article, no patients involved
in the study.
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