Cost-effectiveness of treatment of unruptured intracranial aneurysms in patients with a history of subarachnoid hemorrhage

RATIONALE AND OBJECTIVES: The study goal was to evaluate the cost-effectiveness of surgery and endovascular treatment of unruptured intracranial aneurysms in patients with a history of subarachnoid hemorrhage from a previous aneurysm, incorporating the results of the prospective International Study of Unruptured Intracranial Aneurysms. MATERIALS AND METHODS: Using a Markov model, we performed a decision and cost-effectiveness analysis comparing surgery or endovascular treatment with no treatment. Twelve clinical scenarios were defined based on aneurysm size and location. Probabilistic sensitivity analyses were performed for 50- and 40-year-old cohorts. Treatment was considered to be cost-effective at an incremental cost-effectiveness ratio less than $100,000 per quality-adjusted life-year. RESULTS: In 50-year-old patients, no treatment was the most cost-effective strategy for aneurysms located in the cavernous carotid artery. For aneurysms less than 7 mm located in the anterior circulation, no treatment was the most cost-effective strategy. Endovascular treatment was the most cost-effective option for 7- to 24-mm aneurysms, whereas surgery was the most cost-effective option for aneurysms of 25 mm or larger. For aneurysms less than 7 mm and located in the posterior circulation, endovascular treatment was the most cost-effective option, whereas surgery was the most cost-effective option for 7- to 12-mm aneurysms. No treatment was the most cost-effective strategy for aneurysms of 13 mm or larger. CONCLUSION: For 50-year-old patients with a history of aneurysmal subarachnoid hemorrhage, treatment of unruptured aneurysms that are located in the cavernous carotid artery, or small (<7 mm) and located in the anterior circulation, or large (>or=13 mm) and located in the posterior circulation is ineffective or not cost-effective.