Which unruptured cerebral aneurysms should be treated? A cost-utility analysis

Objective: To determine which unruptured, cerebral aneurysms; should be tre ated 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); Me thods: We, performed a cost-utility analysis comparing surgical clipping an d endovascular coil embolization with no treatment for unruptured aneurysms . Eight clinical scenarios were defined based on aneurysm size, symptoms, a nd history of SAH from a different aneurysm. Health outcomes of a hypotheti cal 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 aneu rysm, both procedures resulted in a net loss in QALYs, and confidence inter vals (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 (greater than or equal to 10 nam), those produc ing symptoms by compressing neighboring nerves and brain structures, or in patients: with history of SAH from a different aneurysm, treatment was cost -effective. Coiling appeared more effective and cost-effective than clippin g but these differences depended on relatively uncertain model parameters. Conclusions: Treatment of small, asymptomatic; unruptured cerebral aneurysm s in patients without a history of SAH worsens clinical outcomes and thus i s neither effective nor cost-effective. For aneurysms that are greater than or equal to 10 mm or symptomatic, or in patients with a history of SAH, tr eatment appears to be cost-effective.