Management of Tiny Unruptured Intracranial Aneurysms: A Comparative Effectiveness Analysis

Area of Science:

• Neurosurgery
• Radiology
• Health Economics

Background:

• Unruptured intracranial aneurysms (UIAs) are increasingly diagnosed, with a notable proportion being tiny (≤3 mm).
• Current management strategies for incidental, tiny UIAs lack clear guidelines and exhibit significant practice heterogeneity.
• Quantifying the health benefits of different management strategies is crucial for patient care.

Purpose of the Study:

• To evaluate the comparative effectiveness of routine treatment (aneurysm coiling) versus imaging surveillance strategies and no intervention for tiny UIAs.
• To determine the optimal management strategy for incidental UIAs measuring 3 mm or smaller.

Main Methods:

• A decision-analytic model using Markov decision processes was employed for lifetime rupture analysis.
• Comparative effectiveness analysis utilized literature inputs from PubMed searches, focusing on robust clinical data.
• Simulations included 10,000 iterations of adult patients with incidental UIAs (≤3 mm) and no prior subarachnoid hemorrhage history.

Main Results:

• The strategy of no treatment or preventive follow-up yielded the highest health benefit (19.40 quality-adjusted life-years).
• Among surveillance options, magnetic resonance angiography (MRA) every 5 years showed the next highest effectiveness (18.05 quality-adjusted life-years).
• No routine follow-up remained optimal unless the annual rupture risk exceeded 1.7%, in which case coiling was preferred.

Conclusions:

• No preventive treatment or routine imaging follow-up is the most effective strategy for UIAs ≤3 mm, maximizing health outcomes.
• Aggressive surveillance or treatment should be reserved for patients identified as high-risk for aneurysm rupture.
• Findings suggest a critical evaluation of current practices and potential development of specific guidelines for managing incidental, tiny UIAs.