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Abstract
Background and Objectives No consensus exists on adequate surveillance of conservatively managed unruptured intracranial aneurysms (UIAs). We aimed to determine optimal MRI surveillance strategies for the growth of UIAs using cost-effectiveness analysis. A secondary aim was to develop a clinical tool for personalizing UIA surveillance.
Methods We designed a microsimulation model from a health care perspective simulating 100,000 55-year-old women to estimate costs and quality-adjusted life years (QALYs) over a lifetime horizon in the United States, the United Kingdom, and the Netherlands, using literature-derived model parameters. Country-specific costs and willingness-to-pay thresholds ($100,000/QALY for the United States, £30,000/QALY for the United Kingdom, and €80,000/QALY for the Netherlands) were used. Lifetime costs and QALYs were annually discounted at 3% for the United States, 3.5% for the United Kingdom, or 4% (costs) and 1.5% (QALYs) for the Netherlands. Strategies were no follow-up surveillance, follow-up with MRI in the first and fifth year after UIA discovery, every 5 years, every 2 years, or annually, or immediate intervention (i.e., clipping or coiling). Using the microsimulation model, we developed a tool for personalizing UIA surveillance for men and women, with different ages and varying aneurysm characteristics. Uncertainty in the input parameters was modeled with probabilistic sensitivity analysis.
Results Among 55-year-old women, 2,222 individuals in the United States, 1,910 in the United Kingdom, and 2,040 in the Netherlands needed to undergo an annual MRI scan to prevent 1 case of subarachnoid hemorrhage per year. No surveillance MRI was most cost-effective in the United States (in 47% of the simulations) and United Kingdom (in 54% of simulations), whereas annual MRI was most cost-effective in the Netherlands (in 53% of simulations). In the United States and United Kingdom, annual surveillance or surveillance in the first and fifth year after discovery was cost-effective in patients <60 years and at increased risk of aneurysm growth. The optimal, personalized, surveillance strategies were summarized in a look-up table for use in clinical practice.
Discussion Generally, the US and UK physicians should refrain from assigning patients, particularly older patients and those with few risk factors for aneurysm growth or rupture, to frequent MRI surveillance. In the Netherlands, annual follow-up is generally most cost-effective.
Glossary
- AHA=
- American Heart Association;
- ARR=
- absolute risk reduction;
- ASA=
- American Stroke Association;
- CEAC=
- cost-effectiveness acceptability curve;
- CTA=
- CT angiography;
- ELAPSS=
- Earlier subarachnoid hemorrhage, aneurysm Location, Age, Population, aneurysm Size, and Shape;
- EVT=
- endovascular treatment;
- ICER=
- incremental cost-effectiveness ratio;
- ISUIA=
- International Study of Unruptured Intracranial Aneurysms;
- MRA=
- magnetic resonance angiography;
- PSA=
- probabilistic sensitivity analysis;
- QALY=
- quality-adjusted life year;
- SAH=
- subarachnoid hemorrhage;
- UIA=
- unruptured intracranial aneurysm;
- WTP=
- willingness-to-pay
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was José Merino, MD, MPhil, FAAN.
Editorial, page 363
CME Course: NPub.org/cmelist
- Received August 15, 2021.
- Accepted in final form April 11, 2022.
- © 2022 American Academy of Neurology
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