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Semin Neurol 2010; 30(5): 537-544
DOI: 10.1055/s-0030-1268858
© Thieme Medical Publishers

Unruptured Intracranial Aneurysms

Robert D. Brown1
  • 1Mayo Clinic College of Medicine, Rochester, Minnesota
Further Information

Publication History

Publication Date:
04 January 2011 (online)

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ABSTRACT

Intracranial aneurysms (IAs) are acquired lesions, with a genetic predisposition in selected patients. They are very common in the population, occurring in ~2% of people in the United States. Intracranial aneurysms may present with subarachnoid hemorrhage, the most feared complication of IA, but most commonly they are detected on brain imaging performed for reasons unrelated to the IA. Once detected, the key question is whether the unruptured intracranial aneurysm needs to be treated, or can safely be left alone. This decision is complex and is dependent on numerous factors, including the natural history of the unruptured intracranial aneurysm, in comparison to the risk of unruptured intracranial aneurysm treatment. For those not treated with interventional treatment, repeat imaging at some intermittency may be recommended. In this article, the data regarding the natural history of unruptured intracranial aneurysm and the procedure-associated morbidity and mortality are reviewed, as well as the predictors of hemorrhage, and the likelihood of unruptured intracranial aneurysm growth should conservative management with intermittent repeat imaging be recommended.

KEYWORDS

Intracranial aneurysm - natural history - screening - epidemiology

REFERENCES

  • 1 Atkinson J L, Sundt Jr T M, Houser O W, Whisnant J P. Angiographic frequency of anterior circulation intracranial aneurysms.  J Neurosurg. 1989;  70 551-555
    CrossrefPubMedGoogle Scholar
  • 2 Winn H R, Jane Sr J A, Taylor J, Kaiser D, Britz G W. Prevalence of asymptomatic incidental aneurysms: review of 4568 arteriograms.  J Neurosurg. 2002;  96 (1) 43-49
    CrossrefPubMedGoogle Scholar
  • 3 Vernooij M W, Ikram M A, Tanghe H L et al.. Incidental findings on brain MRI in the general population.  N Engl J Med. 2007;  357 (18) 1821-1828
    CrossrefPubMedGoogle Scholar
  • 4 Jakubowski J, Kendall B. Coincidental aneurysms with tumours of pituitary origin.  J Neurol Neurosurg Psychiatry. 1978;  41 (11) 972-979
    CrossrefPubMedGoogle Scholar
  • 5 Jellinger K. Pathology of intracerebral hemorrhage.  Zentralbl Neurochir. 1977;  38 (1) 29-42
    PubMedGoogle Scholar
  • 6 Menghini V V, Brown Jr R D, Sicks J D, O'Fallon W M, Wiebers D O. Incidence and prevalence of intracranial aneurysms and hemorrhage in Olmsted County, Minnesota, 1965 to 1995.  Neurology. 1998;  51 405-411
    PubMedGoogle Scholar
  • 7 Menghini V V, Brown Jr R D, Sicks J D, O'Fallon W M, Wiebers D O. Clinical manifestations and survival rates among patients with saccular intracranial aneurysms: population-based study in Olmsted County, Minnesota, 1965 to 1995.  Neurosurgery. 2001;  49 (2) 251-256, discussion 256–258
    CrossrefPubMedGoogle Scholar
  • 8 Inagawa T, Hirano A. Autopsy study of unruptured incidental intracranial aneurysms.  Surg Neurol. 1990;  34 (6) 361-365
    CrossrefPubMedGoogle Scholar
  • 9 Meyer F B, Sundt Jr T M, Fode N C, Morgan M K, Forbes G S, Mellinger J F. Cerebral aneurysms in childhood and adolescence.  J Neurosurg. 1989;  70 (3) 420-425
    CrossrefPubMedGoogle Scholar
  • 10 Storrs B B, Humphreys R P, Hendrick E B, Hoffman H J. Intracranial aneurysms in the pediatric age-group.  Childs Brain. 1982;  9 (5) 358-361
    PubMedGoogle Scholar
  • 11 Chason J L, Hindman W M. Berry aneurysms of the circle of Willis; results of a planned autopsy study.  Neurology. 1958;  8 (1) 41-44
    PubMedGoogle Scholar
  • 12 International Study of Unruptured Intracranial Aneurysms Investigators . Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention.  N Engl J Med. 1998;  339 (24) 1725-1733
    CrossrefPubMedGoogle Scholar
  • 13 Wiebers D O, Torner J C, Meissner I. Impact of unruptured intracranial aneurysms on public health in the United States.  Stroke. 1992;  23 (10) 1416-1419
    CrossrefPubMedGoogle Scholar
  • 14 Gibbs G F, Huston III J, Bernstein M A, Riederer S J, Brown Jr R D. Improved image quality of intracranial aneurysms: 3.0-T versus 1.5-T time-of-flight MR angiography.  AJNR Am J Neuroradiol. 2004;  25 (1) 84-87
    PubMedGoogle Scholar
  • 15 Gibbs G F, Huston III J, Bernstein M A, Riederer S J, Brown Jr R D. 3.0-Tesla MR angiography of intracranial aneurysms: comparison of time-of-flight and contrast-enhanced techniques.  J Magn Reson Imaging. 2005;  21 (2) 97-102
    CrossrefPubMedGoogle Scholar
  • 16 Schwartz R B, Tice H M, Hooten S M, Hsu L, Stieg P E. Evaluation of cerebral aneurysms with helical CT: correlation with conventional angiography and MR angiography.  Radiology. 1994;  192 (3) 717-722
    PubMedGoogle Scholar
  • 17 van Gelder J M. Computed tomographic angiography for detecting cerebral aneurysms: implications of aneurysm size distribution for the sensitivity, specificity, and likelihood ratios.  Neurosurgery. 2003;  53 (3) 597-605, discussion 605–606
    CrossrefPubMedGoogle Scholar
  • 18 Juvela S, Hillbom M, Numminen H, Koskinen P. Cigarette smoking and alcohol consumption as risk factors for aneurysmal subarachnoid hemorrhage.  Stroke. 1993;  24 (5) 639-646
    CrossrefPubMedGoogle Scholar
  • 19 Bonita R. Cigarette smoking, hypertension and the risk of subarachnoid hemorrhage: a population-based case-control study.  Stroke. 1986;  17 (5) 831-835
    CrossrefPubMedGoogle Scholar
  • 20 Knekt P, Reunanen A, Aho K et al.. Risk factors for subarachnoid hemorrhage in a longitudinal population study.  J Clin Epidemiol. 1991;  44 (9) 933-939
    CrossrefPubMedGoogle Scholar
  • 21 Longstreth Jr W T, Nelson L M, Koepsell T D, van Belle G. Cigarette smoking, alcohol use, and subarachnoid hemorrhage.  Stroke. 1992;  23 (9) 1242-1249
    CrossrefPubMedGoogle Scholar
  • 22 Adamson J, Humphries S E, Ostergaard J R, Voldby B, Richards P, Powell J T. Are cerebral aneurysms atherosclerotic?.  Stroke. 1994;  25 (5) 963-966
    CrossrefPubMedGoogle Scholar
  • 23 Klatsky A L, Armstrong M A, Friedman G D. Alcohol use and subsequent cerebrovascular disease hospitalizations.  Stroke. 1989;  20 (6) 741-746
    CrossrefPubMedGoogle Scholar
  • 24 Schievink W I. Genetics of intracranial aneurysms.  Neurosurgery. 1997;  40 (4) 651-662, discussion 662–663
    CrossrefPubMedGoogle Scholar
  • 25 Chapman A B, Rubinstein D, Hughes R et al.. Intracranial aneurysms in autosomal dominant polycystic kidney disease.  N Engl J Med. 1992;  327 (13) 916-920
    CrossrefPubMedGoogle Scholar
  • 26 Gibbs G F, Huston III J, Qian Q et al.. Follow-up of intracranial aneurysms in autosomal-dominant polycystic kidney disease.  Kidney Int. 2004;  65 (5) 1621-1627
    CrossrefPubMedGoogle Scholar
  • 27 Yaşargil M G, Smith R D. Association of middle cerebral artery anomalies with saccular aneurysms and moyamoya disease.  Surg Neurol. 1976;  6 (1) 39-43
    PubMedGoogle Scholar
  • 28 Batjer H H, Adamson T E, Bowman G W. Sickle cell disease and aneurysmal subarachnoid hemorrhage.  Surg Neurol. 1991;  36 (2) 145-149
    CrossrefPubMedGoogle Scholar
  • 29 Palubinskas A J, Perloff D, Newton T H. Fibromuscular hyperplasia, an arterial dysplasia of increasing clinical importance.  Am J Roentgenol Radium Ther Nucl Med. 1966;  98 (4) 907-913
    PubMedGoogle Scholar
  • 30 Nagayama Y, Okamoto S, Konishi T, Suzuki H, Hamanaka H. Cerebral berry aneurysms and systemic lupus erythematosus.  Neuroradiology. 1991;  33 (5) 466
    CrossrefPubMedGoogle Scholar
  • 31 Ostergaard J R, Oxlund H. Collagen type III deficiency in patients with rupture of intracranial saccular aneurysms.  J Neurosurg. 1987;  67 (5) 690-696
    CrossrefPubMedGoogle Scholar
  • 32 Connolly H M, Huston III J, Brown Jr R D, Warnes C A, Ammash N M, Tajik A J. Intracranial aneurysms in patients with coarctation of the aorta: a prospective magnetic resonance angiographic study of 100 patients.  Mayo Clin Proc. 2003;  78 (12) 1491-1499
    CrossrefPubMedGoogle Scholar
  • 33 Brown Jr R D, Wiebers D O, Forbes G S. Unruptured intracranial aneurysms and arteriovenous malformations: frequency of intracranial hemorrhage and relationship of lesions.  J Neurosurg. 1990;  73 (6) 859-863
    CrossrefPubMedGoogle Scholar
  • 34 Schievink W I. Genetics and aneurysm formation.  Neurosurg Clin N Am. 1998;  9 (3) 485-495
    PubMedGoogle Scholar
  • 35 Mariani L, Bianchetti M G, Schroth G, Seiler R W. Cerebral aneurysms in patients with autosomal dominant polycystic kidney disease—to screen, to clip, to coil?.  Nephrol Dial Transplant. 1999;  14 (10) 2319-2322
    CrossrefPubMedGoogle Scholar
  • 36 Pirson Y, Chauveau D, Torres V. Management of cerebral aneurysms in autosomal dominant polycystic kidney disease.  J Am Soc Nephrol. 2002;  13 (1) 269-276
    PubMedGoogle Scholar
  • 37 Schievink W I. Marfan syndrome and intracranial aneurysms.  Stroke. 1999;  30 (12) 2767-2768
    PubMedGoogle Scholar
  • 38 Maher C O, Piepgras D G, Brown Jr R D, Friedman J A, Pollock B E. Cerebrovascular manifestations in 321 cases of hereditary hemorrhagic telangiectasia.  Stroke. 2001;  32 (4) 877-882
    CrossrefPubMedGoogle Scholar
  • 39 Edwards A, Taylor G W. Ehlers-Danlos syndrome with vertebral artery aneurysm.  Proc R Soc Med. 1969;  62 (7) 734-735
    PubMedGoogle Scholar
  • 40 Brown R D. Unruptured intracranial aneurysms. In: Noseworthy J H, ed. Neurological Therapeutics: Principals and Practice. Abingdon, UK: Informa Healthcare; 2006: 584-593
    Google Scholar
  • 41 Kissela B M, Sauerbeck L, Woo D et al.. Subarachnoid hemorrhage: a preventable disease with a heritable component.  Stroke. 2002;  33 (5) 1321-1326
    CrossrefPubMedGoogle Scholar
  • 42 Raaymakers T W. Aneurysms in relatives of patients with subarachnoid hemorrhage: frequency and risk factors. MARS Study Group. Magnetic resonance angiography in relatives of patients with subarachnoid hemorrhage.  Neurology. 1999;  53 (5) 982-988
    PubMedGoogle Scholar
  • 43 Magnetic Resonance Angiography in Relatives of Patients with Subarachnoid Hemorrhage Study Group . Risks and benefits of screening for intracranial aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage.  N Engl J Med. 1999;  341 (18) 1344-1350
    CrossrefPubMedGoogle Scholar
  • 44 Ronkainen A, Hernesniemi J, Puranen M et al.. Familial intracranial aneurysms.  Lancet. 1997;  349 (9049) 380-384
    CrossrefPubMedGoogle Scholar
  • 45 Ronkainen A, Miettinen H, Karkola K et al.. Risk of harboring an unruptured intracranial aneurysm.  Stroke. 1998;  29 (2) 359-362
    CrossrefPubMedGoogle Scholar
  • 46 Brown Jr R D, Huston J, Hornung R et al.. Screening for brain aneurysm in the Familial Intracranial Aneurysm Study: frequency and predictors of lesion detection.  J Neurosurg. 2008;  108 (6) 1132-1138
    CrossrefPubMedGoogle Scholar
  • 47 Raps E C, Rogers J D, Galetta S L et al.. The clinical spectrum of unruptured intracranial aneurysms.  Arch Neurol. 1993;  50 (3) 265-268
    CrossrefPubMedGoogle Scholar
  • 48 Phan T G, Huston III J, Brown Jr R D, Wiebers D O, Piepgras D G. Intracranial saccular aneurysm enlargement determined using serial magnetic resonance angiography.  J Neurosurg. 2002;  97 (5) 1023-1028
    CrossrefPubMedGoogle Scholar
  • 49 Brown R D, Whisnant J P, Sicks J D, O'Fallon W M, Wiebers D O. Stroke incidence, prevalence, and survival: secular trends in Rochester, Minnesota, through 1989.  Stroke. 1996;  27 (3) 373-380
    PubMedGoogle Scholar
  • 50 Broderick J P, Brott T, Tomsick T, Huster G, Miller R. The risk of subarachnoid and intracerebral hemorrhages in blacks as compared with whites.  N Engl J Med. 1992;  326 (11) 733-736
    CrossrefPubMedGoogle Scholar
  • 51 Broderick J P, Brott T, Tomsick T, Miller R, Huster G. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage.  J Neurosurg. 1993;  78 (2) 188-191
    CrossrefPubMedGoogle Scholar
  • 52 Wiebers D O, Whisnant J P, O'Fallon W M. The natural history of unruptured intracranial aneurysms.  N Engl J Med. 1981;  304 (12) 696-698
    CrossrefPubMedGoogle Scholar
  • 53 Wiebers D O, Whisnant J P, Sundt Jr T M, O'Fallon W M. The significance of unruptured intracranial saccular aneurysms.  J Neurosurg. 1987;  66 (1) 23-29
    CrossrefPubMedGoogle Scholar
  • 54 Juvela S, Porras M, Poussa K. Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture.  J Neurosurg. 2000;  93 (3) 379-387
    CrossrefPubMedGoogle Scholar
  • 55 Wermer M J, van der Schaaf I C, Algra A, Rinkel G J. Risk of rupture of unruptured intracranial aneurysms in relation to patient and aneurysm characteristics: an updated meta-analysis.  Stroke. 2007;  38 (4) 1404-1410
    CrossrefPubMedGoogle Scholar
  • 56 Wiebers D O, Whisnant J P, Huston III J International Study of Unruptured Intracranial Aneurysms Investigators et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment.  Lancet. 2003;  362 (9378) 103-110
    CrossrefPubMedGoogle Scholar
  • 57 Macdonald R L, Wallace M C, Kestle J R. Role of angiography following aneurysm surgery.  J Neurosurg. 1993;  79 (6) 826-832
    CrossrefPubMedGoogle Scholar
  • 58 David C A, Vishteh A G, Spetzler R F, Lemole M, Lawton M T, Partovi S. Late angiographic follow-up review of surgically treated aneurysms.  J Neurosurg. 1999;  91 (3) 396-401
    CrossrefPubMedGoogle Scholar
  • 59 King Jr J T, Berlin J A, Flamm E S. Morbidity and mortality from elective surgery for asymptomatic, unruptured, intracranial aneurysms: a meta-analysis.  J Neurosurg. 1994;  81 (6) 837-842
    CrossrefPubMedGoogle Scholar
  • 60 Raaymakers T W, Rinkel G J, Limburg M, Algra A. Mortality and morbidity of surgery for unruptured intracranial aneurysms: a meta-analysis.  Stroke. 1998;  29 (8) 1531-1538
    CrossrefPubMedGoogle Scholar
  • 61 Yoshimoto Y. Publication bias in neurosurgery: lessons from series of unruptured aneurysms.  Acta Neurochir (Wien). 2003;  145 (1) 45-48
    CrossrefPubMedGoogle Scholar
  • 62 Wiebers D O, Whisnant J P, Huston III J International Study of Unruptured Intracranial Aneurysms Investigators et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment.  Lancet. 2003;  362 (9378) 103-110
    CrossrefPubMedGoogle Scholar
  • 63 Strother C M. Interventional neuroradiology.  AJNR Am J Neuroradiol. 2000;  21 (1) 19-24
    PubMedGoogle Scholar
  • 64 Johnston S C, Zhao S, Dudley R A, Berman M F, Gress D R. Treatment of unruptured cerebral aneurysms in California.  Stroke. 2001;  32 (3) 597-605
    CrossrefPubMedGoogle Scholar
  • 65 Johnston S C, Dudley R A, Gress D R, Ono L. Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospitals.  Neurology. 1999;  52 (9) 1799-1805
    CrossrefPubMedGoogle Scholar
  • 66 Eskridge J M, Song J K. Endovascular embolization of 150 basilar tip aneurysms with Guglielmi detachable coils: results of the Food and Drug Administration multicenter clinical trial.  J Neurosurg. 1998;  89 (1) 81-86
    CrossrefPubMedGoogle Scholar
  • 67 Bavinzski G, Killer M, Gruber A, Reinprecht A, Gross C E, Richling B. Treatment of basilar artery bifurcation aneurysms by using Guglielmi detachable coils: a 6-year experience.  J Neurosurg. 1999;  90 (5) 843-852
    CrossrefPubMedGoogle Scholar
  • 68 Lee T, Baytion M, Sciacca R, Mohr J P, Pile-Spellman J. Aggregate analysis of the literature for unruptured intracranial aneurysm treatment.  AJNR Am J Neuroradiol. 2005;  26 (8) 1902-1908
    PubMedGoogle Scholar
  • 69 Lanterna L A, Tredici G, Dimitrov B D, Biroli F. Treatment of unruptured cerebral aneurysms by embolization with Guglielmi detachable coils: case-fatality, morbidity, and effectiveness in preventing bleeding—a systematic review of the literature.  Neurosurgery. 2004;  55 (4) 767-775, discussion 775–778
    CrossrefPubMedGoogle Scholar
  • 70 Molyneux A, Kerr R, Stratton I International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial.  Lancet. 2002;  360 (9342) 1267-1274
    CrossrefPubMedGoogle Scholar
  • 71 Higashida R T, Lahue B J, Torbey M T, Hopkins L N, Leip E, Hanley D F. Treatment of unruptured intracranial aneurysms: a nationwide assessment of effectiveness.  AJNR Am J Neuroradiol. 2007;  28 (1) 146-151
    PubMedGoogle Scholar
  • 72 Qureshi A I, Janardhan V, Hanel R A, Lanzino G. Comparison of endovascular and surgical treatments for intracranial aneurysms: an evidence-based review.  Lancet Neurol. 2007;  6 (9) 816-825
    CrossrefPubMedGoogle Scholar
  • 73 Burns J D, Brown Jr R D. Treatment of unruptured intracranial aneurysms: surgery, coiling, or nothing?.  Curr Neurol Neurosci Rep. 2009;  9 (1) 6-12
    CrossrefPubMedGoogle Scholar
  • 74 Zuccarello M. Treatment strategy for patients with unruptured intracranial aneurysms.  Neurol Med Chir (Tokyo). 2001;  41 (12) 571-575
    CrossrefPubMedGoogle Scholar
  • 75 da Costa L B, Gunnarsson T, Wallace M C. Unruptured intracranial aneurysms: natural history and management decisions.  Neurosurg Focus. 2004;  17 (5) E6
    CrossrefPubMedGoogle Scholar
  • 76 Bederson J B, Awad I A, Wiebers D O et al.. Recommendations for the management of patients with unruptured intracranial aneurysms: A Statement for Healthcare Professionals from the Stroke Council of the American Heart Association.  Stroke. 2000;  31 (11) 2742-2750
    CrossrefPubMedGoogle Scholar
  • 77 Brennan J W, Schwartz M L. Unruptured intracranial aneurysms: appraisal of the literature and suggested recommendations for surgery, using evidence-based medicine criteria.  Neurosurgery. 2000;  47 (6) 1359-1371, discussion 1371–1372
    CrossrefPubMedGoogle Scholar
  • 78 Dorsch N W, Jacobson E E. Unruptured aneurysms should generally be clipped.  J Clin Neurosci. 2000;  7 (4) 346-347
    CrossrefPubMedGoogle Scholar
  • 79 Bladin C. Unruptured aneurysms should generally not be clipped.  J Clin Neurosci. 2000;  7 (4) 347-348
    CrossrefPubMedGoogle Scholar
  • 80 Chen P R, Frerichs K, Spetzler R. Current treatment options for unruptured intracranial aneurysms.  Neurosurg Focus. 2004;  17 (5) E5
    PubMedGoogle Scholar
  • 81 Juvela S. Treatment options of unruptured intracranial aneurysms.  Stroke. 2004;  35 (2) 372-374
    CrossrefPubMedGoogle Scholar
  • 82 Zipfel G J, Dacey R G. Update on the management of unruptured intracranial aneurysms.  Neurosurg Focus. 2004;  17 (5) E2
    PubMedGoogle Scholar
  • 83 White P M, Wardlaw J. Unruptured intracranial aneurysms: prospective data have arrived.  Lancet. 2003;  362 (9378) 90-91
    CrossrefPubMedGoogle Scholar
  • 84 Burns J D, Huston III J, Layton K F, Piepgras D G, Brown Jr R D. Intracranial aneurysm enlargement on serial magnetic resonance angiography: frequency and risk factors.  Stroke. 2009;  40 (2) 406-411
    CrossrefPubMedGoogle Scholar
  • 85 Miyazawa N, Akiyama I, Yamagata Z. Risk factors for growth of unruptured intracranial aneurysms: follow-up study by serial 0.5-T magnetic resonance angiography.  Neurosurgery. 2006;  58 (6) 1047-1053 discussion 1047-1053
    CrossrefPubMedGoogle Scholar
  • 86 Matsubara S, Hadeishi H, Suzuki A, Yasui N, Nishimura H. Incidence and risk factors for the growth of unruptured cerebral aneurysms: observation using serial computerized tomography angiography.  J Neurosurg. 2004;  101 (6) 908-914
    CrossrefPubMedGoogle Scholar
  • 87 Juvela S, Poussa K, Porras M. Factors affecting formation and growth of intracranial aneurysms: a long-term follow-up study.  Stroke. 2001;  32 (2) 485-491
    CrossrefPubMedGoogle Scholar
  • 88 Kappelle L J, Eliasziw M, Fox A J, Barnett H J. North American Symptomatic Carotid Endarterectomy Trial Group . Small, unruptured intracranial aneurysms and management of symptomatic carotid artery stenosis.  Neurology. 2000;  55 (2) 307-309
    PubMedGoogle Scholar
  • 89 Dippel D W, Vermeulen M, Braakman R, Habbema J D. Transient ischemic attacks, carotid stenosis, and an incidental intracranial aneurysm. A decision analysis.  Neurosurgery. 1994;  34 (3) 449-457, discussion 457–458
    CrossrefPubMedGoogle Scholar

Robert D BrownJr. M.D. M.P.H. 

Professor of Neurology, Mayo Clinic College of Medicine

200 First Street Southwest, Rochester, MN 55905

Email: Brown@mayo.edu

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