Screening for unruptured familial intracranial aneurysms. A decision analysis

Decision analysis is used to assess the decision to screen for unruptured intracranial aneurysms (IAs) in two affected families, and to formulate guide-lines for similar decisions. Four strategies are compared: "no screening", "screening directly", "screening twice", and "screening later". Intravenous and intra-arterial digital subtraction angiography techniques (iv-DSA, ia-DSA) are considered. Life years lived with and without disability are computed for each strategy. Loss of life expectancy with and without discounting and quality correction is used as an outcome measure. "No screening" is the preferred strategy when population based estimates of the prevalence of IAs are used. Thus, the results of this analysis provide no justification for screening patients without a familial history. But a physician who thinks that the risk of an IA is increased may rightly decide for screening, especially when the patient is aged 40 to 60. Ia-DSA is preferable over iv-DSA. A scenario analysis suggests that screening with magnetic resonance angiography is only slightly better than with ia-DSA, because the complication rate of screening plays a minor role in the analysis.