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Effectiveness and costs of screening for aneurysms every 5 years after subarachnoid hemorrhage

From the Departments of Neurology, Neurosurgery and Radiology of the University Medical Center Utrecht and the Academic Medical Center Amsterdam and the Julius Center for Health Sciences and Primary Care Utrecht, The Netherlands.

Address correspondence and reprint requests to DrH. Wermer, Department of Neurology: G03.228, University Medical Center Utrecht, Heidelberglaan 100, 3500 GA Utrecht, The Netherlands m.wermer{at}umcutrecht.nl

Background: Patients who survive after subarachnoid hemorrhage (SAH) are at risk for a recurrence despite successful treatment of the ruptured aneurysm and may therefore benefit from screening for new aneurysms.

Methods: We screened 610 patients with SAH with CT angiography 2–18 years after clipping of the aneurysms. Results of screening were used as input for a Markov decision model. We compared the expected number of recurrent hemorrhages, life expectancy, quality-adjusted life-years (QALYs), and costs associated with the strategies "screening every 5 years" and "no screening."

Results: Screening individuals with previous SAH prevented almost half of the recurrences, slightly increased life expectancy (from 21.06 to 21.08 years), but reduced QALYs (from 12.18 to 12.04) and increased costs (from $2,750 to $4,165 per patient). Screening was cost-saving without increasing QALYs in patients with a more than twofold risk above baseline of both aneurysm formation and rupture and it was cost-saving while increasing QALYs if both risks were at least 4.5 times higher. In patients with reduced quality of life because of fear for a recurrence, screening increased QALYs at a maximum cost of $17,422 per QALY.

Conclusions: In general, screening patients with previous subarachnoid hemorrhage (SAH) cannot be recommended. Screening can save costs and increase quality-adjusted life-years (QALYs) in patients with a relatively high risk of both aneurysm formation and rupture, and increases QALYs at acceptable costs in patients with fear for a recurrence. More data are needed on risk factors for aneurysm formation and rupture in patients with previous SAH and on management of fear for a recurrence to identify patients who can benefit from screening.

Abbreviations: ASTRA = Aneurysm Screening after Treatment for Ruptured Aneurysms; CEAC = cost-effectiveness acceptability curve; CTA = CT angiography; IA-A = intra-arterial angiography; ICER = incremental cost effectiveness ratio; QALYs = quality-adjusted life-years; SAH = subarachnoid hemorrhage.

Supplemental data at www.neurology.org

Editorial, page 2022

e-Pub ahead of print on April 19, 2008, at www.neurology.org.

*Members of the ASTRA Study Group are listed in the appendix.

Supported by a grant from the Netherlands Organization for Scientific Research/ZonMw (grant 945-02-007).

Disclosure: The authors report no disclosures.

Received April 12, 2007. Accepted in final form October 18, 2007.

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