The role of Area Deprivation Index in treatment selection for anterior communicating artery aneurysms

Patient outcomes in medicine vary significantly when stratified by socioeconomic status (SES). In the cerebrovascular area specifically, rates of treatment of intracranial aneurysms (IAs) and overall outcomes after subarachnoid hemorrhage vary significantly by SES. Less is known about the effect of SES on the selection of seemingly equivocal treatment modalities (microsurgery vs endovascular embolization) for IAs. In this study, the authors examined the impact of SES as measured by the Area Deprivation Index (ADI) on selection of the treatment modality for anterior communicating artery (ACoA) aneurysms, which are readily amenable for either microsurgical or endovascular treatment.

A retrospective study was conducted on 136 consecutively treated patients with ACoA aneurysms, unruptured and ruptured, between August 2016 and February 2023 at a large, urban, academic hospital led by dual-trained neurosurgeons. A retrospective review of patient demographics, comorbidities, aneurysm size, morphology, and treatment selection was performed. Univariable and multivariable logistic regression analysis of treatment selection was conducted in the unruptured context, an elective setting, where socioeconomic factors play a strong role in patient-provider shared decision-making, versus the ruptured context, an emergency setting, where the need for expedient intervention diminishes the weight of socioeconomic considerations.

Multivariable logistic regression showed that being a patient in the top 50th ADI percentiles was strongly associated with undergoing microsurgical treatment of an ACoA aneurysm in the unruptured context (OR 10.88, 95% CI 1.37-86.59; p = 0.02). Conversely, in the context of ruptured ACoA aneurysms, ADI was not associated with treatment selection (OR 0.16, 95% CI 0.02-1.27; p = 0.08).

ADI significantly impacts treatment selection in the management of unruptured ACoA aneurysms. This study highlights that there might be indirect socioeconomic barriers biasing patients from lower SES backgrounds away from endovascular treatment of unruptured ACoA aneurysms compared with their higher SES counterparts.