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OBJECTIVE  It is well known that larger aneurysm size is a risk factor for poor outcome after surgical treatment of unruptured saccular intracranial aneurysms (USIAs). However, the authors have occasionally observed poor outcome in the surgical treatment of small USIAs and hypothesized that size ratio has a negative impact on outcome. The aim of this paper was to investigate the influence of size ratio on outcome in the surgical treatment of USIAs.    METHODS  Prospectively collected clinical and radiological data of 683 consecutive patients harboring 683 surgically treated USIAs were evaluated. Dome-to-neck ratio was defined as the ratio of the maximum width of the aneurysm to the average neck diameter. The aspect ratio was defined as the ratio of the maximum perpendicular height of the aneurysm to the average neck diameter of the aneurysm. The size ratio was calculated by dividing the maximum aneurysm diameter (height or width, mm) by the average parent artery diameter (mm). Neurological worsening was defined as an increase in modified Rankin Scale score of 1 or more points at 12 months. Clinical and radiological variables were compared between patients with and without neurological worsening.    RESULTS  The median patient age was 64 years (IQR 56–71 years), and 528 (77%) patients were female. The median maximum size, dome-to-neck ratio, aspect ratio, and size ratio were 4.7 mm (IQR 3.6–6.7 mm), 1.2 (IQR 1.0–1.4), 1.0 (IQR 0.76–1.3), and 1.9 (IQR 1.4–2.8), respectively. The size ratio was significantly correlated with maximum size (r = 0.83, p &lt; 0.0001), dome-to-neck ratio (r = 0.69, p &lt; 0.0001), and aspect ratio (r = 0.74, p &lt; 0.0001). Multivariate logistic regression analysis showed that the specific USIA location (paraclinoid segment of the internal carotid artery: OR 6.2, 95% CI 2.6–15, p &lt; 0.0001; and basilar artery: OR 8.4, 95% CI 2.8–25, p &lt; 0.0001), size ratio (OR 1.3, 95% CI 1.1–1.6, p = 0.021), and postoperative ischemic lesion (OR 9.4, 95% CI 4.4–19, p &lt; 0.0001) were associated with neurological worsening (n = 52, 7.6%), and other characteristics showed no significant differences.    CONCLUSIONS  The present study showed that size ratio, and not other morphological parameters, was a risk factor for 12-month neurological worsening in surgically treated patients with USIAs. The size ratio should be further studied in a large, prospective observational cohort to predict neurological worsening in the surgical treatment of USIAs.

journal of neurosurgery

Morphological parameters as factors of 12-month neurological worsening in surgical treatment of patients with unruptured saccular intracranial aneurysms: importance of size ratio