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From the Neurovascular Service, Department of Neurology (Drs. Johnston and Gress), and Institute for Health Policy Studies (Dr. Kahn), University of California, San Francisco, CA.
Address correspondence and reprint requests to Dr. S. Claiborne Johnston, Department of Neurology, Box 0114, University of California, San Francisco, 505 Parnassus Ave., San Francisco, CA 94143-0114; e-mail: clayj{at}itsa.ucsf.edu
OBJECTIVE: To determine which unruptured cerebral aneurysms should be treated considering the risks, benefits, and costs.
BACKGROUND: Asymptomatic unruptured cerebral aneurysms are commonly treated by surgical clipping or endovascular coil embolization to prevent subarachnoid hemorrhage (SAH).
METHODS: We performed a cost–utility analysis comparing surgical clipping and endovascular coil embolization with no treatment for unruptured aneurysms. Eight clinical scenarios were defined based on aneurysm size, symptoms, and history of SAH from a different aneurysm. Health outcomes of a hypothetical cohort of 50-year-old women were modeled over the projected lifetime of the cohort. Costs were assessed from the societal perspective. We compared net quality-adjusted life years (QALYs) and cost per QALY of each therapy to no treatment.
RESULTS: For an asymptomatic unruptured aneurysm less than 10 mm in diameter in patients with no history of SAH from a different aneurysm, both procedures resulted in a net loss in QALYs, and confidence intervals (CI) were not compatible with a benefit from treatment (clipping, loss of 1.6 QALY [95% CI 1.1 to 2.1]; coiling, loss of 0.6 QALY [95% CI 0.2 to 0.8]). For larger aneurysms (
10 mm), those producing symptoms by compressing neighboring nerves and brain structures, or in patients with a history of SAH from a different aneurysm, treatment was cost-effective. Coiling appeared more effective and cost-effective than clipping but these differences depended on relatively uncertain model parameters.
CONCLUSIONS: Treatment of small, asymptomatic, unruptured cerebral aneurysms in patients without a history of SAH worsens clinical outcomes, and thus is neither effective nor cost-effective. For aneurysms that are 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective.
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