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Which unruptured cerebral aneurysms should be treated? A cost-utility analysis
S C Johnston1, D R Gress, J G Kahn
1Department of Neurology, University of California, San Francisco 94143-0114, USA. clayj@itsa.ucsf.edu
Neurology
|June 17, 1999
Summary
Treatment for small, asymptomatic unruptured cerebral aneurysms is not effective or cost-effective. Larger or symptomatic aneurysms, or those in patients with a history of subarachnoid hemorrhage (SAH), benefit from treatment.
Area of Science:
- Neurosurgery
- Medical Economics
- Public Health
Background:
- Unruptured cerebral aneurysms are often treated surgically or endovascularly to prevent subarachnoid hemorrhage (SAH).
- Deciding on treatment involves weighing risks, benefits, and costs.
Purpose of the Study:
- To determine optimal treatment strategies for unruptured cerebral aneurysms.
- To compare the cost-effectiveness of surgical clipping, endovascular coiling, and no treatment.
Main Methods:
- A cost-utility analysis was conducted, modeling health outcomes and costs over a lifetime.
- Eight clinical scenarios were defined based on aneurysm characteristics (size, symptoms, SAH history).
- Quality-adjusted life years (QALYs) and cost per QALY were compared for each treatment option versus no treatment.
Main Results:
- For small (<10 mm), asymptomatic aneurysms without prior SAH, both clipping and coiling resulted in a net loss of QALYs.
- Treatment for larger (≥10 mm), symptomatic aneurysms, or in patients with prior SAH, was found to be cost-effective.
- Endovascular coiling showed greater effectiveness and cost-effectiveness than clipping, though with some model uncertainty.
Conclusions:
- Treating small, asymptomatic unruptured cerebral aneurysms without a history of SAH is not clinically effective or cost-effective.
- Treatment is advisable and cost-effective for aneurysms ≥10 mm, symptomatic aneurysms, or in patients with a history of SAH.