Occult intracranial aneurysms in polycystic kidney disease. When is cerebral arteriography indicated?

Patients with polycystic kidney disease are at increased risk of subarachnoid hemorrhage from rupture of intracranial aneurysms. We used decision analysis to assess whether or not patients with polycystic kidney disease should undergo routine cerebral arteriography for intracranial aneurysms and prophylactic surgery, if an aneurysm is detected. We incorporated published data on the prevalence of intracranial aneurysms in patients with polycystic kidney disease, the annual rate of aneurysmal rupture, the risk of grave complications of rupture, and the likelihood of grave complications of arteriography and prophylactic surgery. Outcomes were assessed as years of survival, and benefit was calculated as the gain in survival. Our analysis shows that arteriography should not be carried out routinely because its benefit exceeds one year only if the prevalence of aneurysm exceeds 30 per cent, if the surgical complication rate is 1 per cent or less, and if the patient is under 25 years of age. If newer noninvasive tests, such as digital-subtraction angiography, prove to identify reliably patients who are highly likely to have a cerebral aneurysm, routine screening with these tests will be warranted in patients with polycystic kidney disease.