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Original research
Irregular pulsation of intracranial unruptured aneurysm detected by four-dimensional CT angiography is associated with increased estimated rupture risk and conventional risk factors
  1. Jianjian Zhang1,
  2. Xiao Li1,
  3. Bing Zhao2,
  4. Jin Zhang1,
  5. Beibei Sun1,
  6. Lingling Wang1,
  7. Shenghao Ding2,
  8. Xiangyu Liu1,
  9. Jing Yan3,
  10. Mahmud Mossa-Basha4,
  11. Xiaosheng Liu1,
  12. Jieqing Wan2,
  13. Huilin Zhao1,
  14. Jianrong Xu1,
  15. Chengcheng Zhu4
  1. 1Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
  2. 2Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
  3. 3Research Collaboration, Canon Medical Systems (China) Co., LTD, Shanghai, China
  4. 4Department of Radiology, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Huilin Zhao, Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China; huilinzhao2013{at}; Dr Jianrong Xu, Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China; renjixjr{at}


Background Intracranial aneurysms (IAs) are common in the population and current imaging-based rupture risk assessment needs to be refined. We aimed to use four-dimensional CT angiography (4D-CTA) to investigate the associations of irregular pulsation of IAs with conventional risk factors and the estimated rupture risk.

Methods One hundred and five patients with 117 asymptomatic IAs underwent 4D-CTA. Geometric and morphologic parameters were measured and the presence of irregular pulsation (defined as a temporary focal protuberance ≥1 mm on more than three successive frames) was identified on 4D-CTA movies. One- and 5 year aneurysm rupture risk were estimated using UCAS and PHASES calculators. Univariate and multivariate analyses were performed to investigate the conventional risk factors associated with irregular pulsation.

Results Irregular pulsation was observed in 41.0% (48/117) of IAs. Aneurysm size (OR=1.380, 95% CI 1.165 to 1.634), irregular shape (OR=3.737, 95% CI 1.108 to 12.608), and internal carotid artery location (OR=0.151, 95% CI 0.056 to 0.403) were independently associated with irregular pulsation (P<0.05). Aneurysms with irregular pulsation had more than a 6-fold higher estimated rupture risk (1- and 5-year risk [95% CI], 1.56% [0.42%–3.91%], and 2.40% [1.30%–4.30%], respectively) than aneurysms without irregular pulsation (0.23% [0.14%–0.78%] and 0.40% [0.40%–1.30%], respectively) (P<0.001).

Conclusions IAs with irregular pulsation are associated with larger size, irregular-shape, and non-ICA origin, and have more than a 6-fold higher estimated 1- and 5-year rupture risk than aneurysms without irregular pulsation. Irregular pulsation should be validated in future longitudinal studies to determine its predictive value for aneurysm growth and rupture.

  • aneurysm
  • CT angiography
  • vessel wall

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  • JZ and XL are joint first authors.

  • JZ and XL contributed equally.

  • Contributors JZ and XL conceived and designed the research. JZ, XL, JZ, BS, LW, XL, JY, and HZ collected and reviewed the data. JZ and XL analyzed the data and performed the statistical analysis. XL, BZ, BS, HZ, and JX handled funding and supervision. JZ and XL drafted the manuscript. JZ, HZ, SD, MMB, XL, JW, and CZ made revision of the manuscript for important intellectual content.

  • Funding This study has received funding from the grants by National Natural Science Foundation of China (81801650, 81571630), Shanghai Municipal Health Commission (201940060, 201740080), Renji Hospital Project (RJZZ18-002, 2019NYBSZX01), and SJTU Medical Engineering Cross-cutting Research Foundation (YG2017MS45).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by our institutional ethics committee (Renji hospital [2017] no.093).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Because of the sensitive nature of the data, it is available upon request to the corresponding author.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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