Treatment of Unruptured Intracranial Aneurysms: Decision and Cost-effectiveness Analysis

Published Online:Sep 1 2007https://doi.org/10.1148/radiol.2443061278

Abstract

Purpose: To prospectively perform a decision and cost-effectiveness analysis of surgical and endovascular treatments of unruptured intracranial aneurysms, with incorporation of the results of the prospective International Study of Unruptured Intracranial Aneurysms.

Materials and Methods: With use of a Markov model, a decision and cost-effectiveness analysis was performed for comparison of surgical or endovascular treatment with no treatment. Twelve clinical scenarios were defined on the basis of aneurysm size and location. Probabilistic sensitivity analyses were performed for 50- and 40-year-old patient cohorts. Treatment was considered to be cost-effective at an incremental cost-effectiveness ratio less than $100 000 per quality-adjusted life-year.

Results: In 50-year-old patients, no treatment was the most cost-effective strategy for aneurysms located in the cavernous carotid artery. For aneurysms smaller than 7 mm located in the anterior circulation, no treatment was the most cost-effective strategy. Endovascular treatment was the most cost-effective option for 7–24-mm aneurysms, whereas surgical treatment was the most cost-effective option for aneurysms 25 mm or larger. For aneurysms smaller than 7 mm or 25 mm or larger located in the posterior circulation, no treatment was the most cost-effective strategy. Surgical treatment was the most cost-effective option for 7–12-mm aneurysms, whereas endovascular treatment was the most cost-effective option for 13–24-mm aneurysms.

Conclusion: For 50-year-old patients, treatment of aneurysms that are small (<7 mm), that are located in the cavernous carotid artery, or that are large (≥25 mm) and located in the posterior circulation is ineffective or not cost-effective.

References

1 Rinkel GJ, Djibuti M, Algra A, van Gijn J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review. Stroke 1998; 29: 251–256. Crossref, Medline, Google Scholar
2 Donnan GA, Davis SM. Patients with small, asymptomatic, unruptured intracranial aneurysms and no history of subarachnoid hemorrhage should be treated conservatively. Stroke 2005;36:407. Crossref, Medline, Google Scholar
3 Wiebers DO. Patients with small, asymptomatic, unruptured intracranial aneurysms and no history of subarachnoid hemorrhage should generally be treated conservatively: for. Stroke 2005;36:408–409. Crossref, Medline, Google Scholar
4 Weir B. Patients with small, asymptomatic, unruptured intracranial aneurysms and no history of subarachnoid hemorrhage should be treated conservatively: against. Stroke 2005;36:410–411. Crossref, Medline, Google Scholar
5 Wiebers DO, Whisnant JP, Huston J 3rd, et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 2003;362:103–110. Crossref, Medline, Google Scholar
6 Aoki N, Beck JR, Kitahare T, et al. Reanalysis of unruptured intracranial aneurysm management: effect of a new international study on the threshold probabilities. Med Decis Making 2001;21:87–96. Crossref, Medline, Google Scholar
7 Johnston SC, Gress DR, Kahn JG. Which unruptured cerebral aneurysms should be treated? a cost-utility analysis. Neurology 1999;52:1806–1815. Google Scholar
8 Aoki N, Kitahara T, Fukui T, et al. Management of unruptured intracranial aneurysm in Japan: a Markovian decision analysis with utility measurements based on the Glasgow Outcome Scale. Med Decis Making 1998;18:357–364. Crossref, Medline, Google Scholar
9 King JT Jr, Glick HA, Mason TJ, Flamm ES. Elective surgery for asymptomatic, unruptured, intracranial aneurysms: a cost-effectiveness analysis. J Neurosurg 1995;83:403–412. Crossref, Medline, Google Scholar
10 Leblanc R, Worsley KJ. Surgery of unruptured, asymptomatic aneurysms: a decision analysis. Can J Neurol Sci 1995;22:30–35. Crossref, Medline, Google Scholar
11 van Crevel H, Habbema JD, Braakman R. Decision analysis of the management of incidental intracranial saccular aneurysms. Neurology 1986;36:1335–1339. Crossref, Medline, Google Scholar
12 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. http://www.cdc.gov. Accessed February 15, 2006. Google Scholar
13 Hop JW, Rinkel GJE, Algra A, van Gijn J. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systemic review. Stroke 1997;28:660–664. Crossref, Medline, Google Scholar
14 Mayer SA, Kreiter KT, Copeland D, et al. Global and domain-specific cognitive impairment and outcome after subarachnoid hemorrhage. Neurology 2002;59:1750–1758. Crossref, Medline, Google Scholar
15 Kreiter KT, Copeland D, Bernardini GL, et al. Predictors of cognitive dysfunction after subarachnoid hemorrhage. Stroke 2002;33:200–209. Crossref, Medline, Google Scholar
16 Ronkainen A, Niskanen M, Rinne J, Koivisto T, Hernesniemi J, Vapalahti M. Evidence for excess long-term mortality after treated subarachnoid hemorrhage. Stroke 2001;32:2850–2853. Crossref, Medline, Google Scholar
17 Strauss DJ, Shavelle RM, Anderson TW. Long-term survival of children and adolescents after traumatic brain injury. Arch Phys Med Rehabil 1998;79:1095–1100. Crossref, Medline, Google Scholar
18 Gage BF, Cardinalli AB, Albers GW, Owens DK. Cost-effectiveness of warfarin and aspirin for prophylaxis of stroke in patients with nonvalvular atrial fibrillation. JAMA 1995;274:1839–1845. Crossref, Medline, Google Scholar
19 Post PN, Stiggelbout AM, Wakker PP. The utility of health states after stroke: a systematic review of the literature. Stroke 2001;32:1425–1429. Crossref, Medline, Google Scholar
20 Doubilet P, Begg CB, Weinstein MC, Braun P, McNeil BJ. Probabilistic sensitivity analysis using Monte Carlo simulation: a practical approach. Med Decis Making 1985;5:157–177. Crossref, Medline, Google Scholar
21 Vindlacheruvu RR, Mendelow AD, Mitchell P. Risk-benefit analysis of the treatment of unruptured intracranial aneurysms. J Neurol Neurosurg Psychiatry 2005;76:234–239. Crossref, Medline, Google Scholar
22 Mitchell P, Gholkar A, Vindlacheruvu RR, Mendelow AD. Unruptured intracranial aneurysms: benign curiosity or ticking bomb? Lancet Neurol 2004;3:85–92. Crossref, Medline, Google Scholar
23 Tsutsumi K, Ueki K, Usui M, Kwak S, Kirino T. Risk of subarachnoid hemorrhage after surgical treatment of unruptured cerebral aneurysms. Stroke 1999;30:1181–1184. Crossref, Medline, Google Scholar
24 Huang J, van Gelder JM. The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis. Neurosurgery 2002;51:1101–1107. Crossref, Medline, Google Scholar
25 U.S. Department of Labor, Bureau of Labor Statistics. http://www.bls.gov. Accessed March 6, 2006. Google Scholar
26 Hunink MG, Glasziou PP, Siegel JE, et al. Decision making in health and medicine: integrating evidence and values. Cambridge, England: Cambridge University Press, 2001. Google Scholar
27 Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness in health and medicine. New York, NY: Oxford University Press, 1996. Google Scholar
28 Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. New York, NY: Oxford University Press, 2005. Google Scholar
29 Laupacis A, Feeny D, Detsky AS, Tugwell PX. How attractive does a new technology have to be to warrant adoption and utilization? tentative guidelines for using clinical and economic evaluations. CMAJ 1992;146:473–481. Google Scholar
30 Unruptured intracranial aneurysms: risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med 1998;339:1725–1733. [Published correction appears in N Engl J Med 1999;340:744.] Google Scholar

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Published in print: 2007

Vol. 244, No. 3

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