Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping

Predictors of Extended Length of Stay After Treatment of Unruptured Intracranial Aneurysms

BACKGROUND

Despite their asymptomatic occurrence, unruptured intracranial aneurysms (UIAs) account for a significant proportion of hospital charges and healthcare resource utilization in the United States. Hospital length of stay (LOS) is a reimbursement metric utilized to incentivize value-based care. Our study identifies predictors of extended LOS (eLOS) after elective treatment of UIAs.

METHODS

This was a retrospective study of 525 patients who underwent elective treatment of an UIA at a single institution. Data were collected with regard to demographics, clinical presentation, treatment characteristics, and postoperative outcomes. The primary outcome, eLOS, was defined as hospital stay in the upper quartile of the median (≥75th percentile). Univariate and multivariate analyses were performed to identify factors predictive of eLOS in this cohort.

RESULTS

The average age of the cohort was 61.40, standard deviation=11.41. 77.3% of the cohort was female. The median duration of LOS was 2 days (interquartile range: 1-5). 11.6% experienced eLOS (≥5 days). Multivariate logistic regression identified age (OR: 1.04, 95% confidence interval [CI]: 1.01-1.07), coexistent vascular pathology (OR: 21.33, 95% CI: 8.06-56.39), open surgery (OR: 3.93, 95% CI: 1.85-8.34), and postoperative stroke (OR: 11.72, 95% CI: 3.18-43.18) as independent predictors of eLOS.

CONCLUSIONS

Our study identified predictors of eLOS that could help promote risk stratification prior to treatment of UIAs. Future research that identifies predictors of long-term outcomes based on treatment modality could help identify ways to improve healthcare resource utilization in this cohort.

Risk Factor Analysis of Complications and Mortality Following Coil Procedures in Patients with Intracranial Unruptured Aneurysms Using a Nationwide Health Insurance Database

(1) Background: Unruptured intracranial aneurysm (UIA) occurs in 1-2% of the population and is being increasingly detected. Patients with UIA are treated with close observation, endovascular coiling or surgical clipping. The proportion of endovascular coiling has been rising. However, complications such as cerebral infarction (CI), intracranial hemorrhage (ICRH), and death remain crucial issues after coil treatment. (2) Methods: We analyzed the incidence and risk factors of complications after the use of coil in patients with UIA based on the patients' characteristics. We utilized the Health Insurance Review and Assessment (HIRA) database. Patients treated with coils for UIA between 1 January 2015 and 1 December 2021 were retrospectively analyzed. (3) Results: Of the total 35,140 patients, 1062 developed ICRH, of whom 87 died, with a mortality rate of 8.2%. Meanwhile, 749 patients developed CI, of whom 29 died, with a mortality rate of 3.9%. The overall mortality rate was 1.8%. In a univariate analysis of the risk factors, older age, males, a higher Charlson Comorbidity Index (CCI) score, and diabetes increase the risk of CI. Meanwhile, males with higher CCI scores and hemiplegia or paraplegia show increased ICRH risk. Older age, males and metastatic solid tumors relate to increased mortality risk. (4) Conclusions: This study is significant in that the complications based on the patient's underlying medical condition were analyzed.

The Effect of Age on Peri-Operative Outcomes after FEVAR

INTRODUCTION

Fenestrated endovascular aortic repair (FEVAR) has become a popular custom-made treatment option for juxtarenal and pararenal aneurysms. It has been previously investigated whether octogenarians as a distinct subgroup are at increased risk for adverse outcomes after FEVAR. With diverging results and an inconclusive understanding of age as a risk factor in general, an analysis of the historical data of a single center was conducted to add to the available body of evidence and further investigate the effect of age as a continuous risk factor.

METHODS

A retrospective data analysis of a prospectively maintained single-center database of all patients who underwent FEVAR at a single department of vascular surgery was performed. The main endpoint was post-operative survival. In addition to association analyses, potential confounders such as co-morbidities, complication rates, or aneurysm diameter were examined. In terms of sensitivity analyses, logistic regression models were created for the dependent variables of interest.

RESULTS

During the observation period from April 2013 to November 2020, 40 patients over the age of 80 and 191 patients under the age of 80 were treated by FEVAR. The 30-day survival showed no significant difference between the groups (95.1% in octogenarians and 94.3% in patients under 80 years of age). The sensitivity analyses conducted also showed no difference between the two groups, and complication and technical success rates were comparable. The aneurysm diameter was 67 ± 13 mm in the study group and 61 ± 15 mm in those under 80 years of age. Additionally, the sensitivity analyses showed that age as a continuous variable exhibits no effect on the outcomes of interest.

DISCUSSION

In the present study, age was not associated with adverse peri-operative outcomes after FEVAR, including mortality, lower technical success rates, complications, or length of hospital stay. Essentially, the most highly associated factor with hospital and ICU length of stay was time spent in surgery. However, octogenarians had a significantly larger aortic diameter at the time of treatment, which might indicate the potential introduction of bias by pre-interventional patient selection. Nevertheless, the usefulness of research on octogenarians as a distinct subgroup might be questionable regarding the scalability of results, and future studies might focus on age as a continuous risk factor instead.

Microsurgical clipping and endovascular management of unruptured anterior circulation aneurysms: how age, frailty, and comorbidity indexes influence outcomes

OBJECTIVE

Frailty is one of the important factors in predicting the outcomes of surgery. Many surgical specialties have adopted a frailty assessment in the preoperative period for prognostication; however, there are limited data on the effects of frailty on the outcomes of cerebral aneurysms. The object of this study was to find the effect of frailty on the surgical outcomes of anterior circulation unruptured intracranial aneurysms (UIAs) and compare the frailty index with other comorbidity indexes.

METHODS

A retrospective study was performed utilizing the National Inpatient Sample (NIS) database (2016-2018). The Hospital Frailty Risk Score (HFRS) was used to assess frailty. On the basis of the HFRS, the whole cohort was divided into low-risk (0-5), intermediate-risk (> 5 to 15), and high-risk (> 15) frailty groups. The analyzed outcomes were nonhome discharge, complication rate, extended length of stay, and in-hospital mortality.

RESULTS

In total, 37,685 patients were included in the analysis, 5820 of whom had undergone open surgical clipping and 31,865 of whom had undergone endovascular management. Mean age was higher in the high-risk frailty group than in the low-risk group for both clipping (63 vs 55.4 years) and coiling (64.6 vs 57.9 years). The complication rate for open surgical clipping in the high-risk frailty group was 56.1% compared to 0.8% in the low-risk group. Similarly, for endovascular management, the complication rate was 60.6% in the high-risk group compared to 0.3% in the low-risk group. Nonhome discharges were more common in the high-risk group than in the low-risk group for both open clipping (87.8% vs 19.7%) and endovascular management (73.1% vs 4.4%). Mean hospital charges for clipping were $341,379 in the high-risk group compared to $116,892 in the low-risk group. Mean hospital charges for coiling were $392,861 in the high-risk frailty group and $125,336 in the low-risk group. Extended length of stay occurred more frequently in the high-risk frailty group than in the low-risk group for both clipping (82.9% vs 10.7%) and coiling (94.2% vs 12.7%). Frailty had higher area under the receiver operating characteristic curve values than those for other comorbidity indexes and age in predicting outcomes.

CONCLUSIONS

Frailty affects surgical outcomes significantly and outperforms age and other comorbidity indexes in predicting outcome. It is imperative to include frailty assessment in preoperative planning.

An Analysis of the Incidence and Cost of Intracranial Aneurysm and Subarachnoid Haemorrhage Treatment between 2013 and 2021

The incidence of unruptured intracranial aneurysms (UIAs) amounts to 3.2% among adults. The annual risk of aneurysm rupture is 2-10% and it results in subarachnoid haemorrhage (SAH). The aim of this study is to assess changes in the incidence of unruptured intracranial aneurysms and subarachnoid haemorrhages in Poland between 2013 and 2021 and the cost associated with their in-hospital treatment in the acute phase. The analysis was based on the National Health Fund database. Patients diagnosed with UIA and SAH and hospitalised between 2013 and 2021 were chosen. The statistical analysis was performed with an assumed significance level of α = 0.05. The ratio between the prevalence of SAH and UIA diagnoses was 4:6. The proportion of women in relation to men was higher in both diagnoses. The highest proportions of patients with diagnoses SAH and UIA were found in highly urbanised provinces. The value of medical services in 2021 compared to 2013 increased by 81.8%. The highest values in this period were recorded in Mazowieckie province, and the lowest were recorded in Opolskie province. The overall number of patients hospitalised with diagnosis of UIA or SAH did not decrease, but the risk of aneurysm rupture probably decreased, which resulted in lower incidence of SAH in subsequent years of observation. The recorded changes in the dynamics of the value of medical services per patient or per hospitalisation largely coincided. However, it is difficult to speculate on expected value levels as not all provinces showed linear changes in the value of services provided.

Small intracranial aneurysms of the anterior circulation: A negligible risk?

BACKGROUND AND PURPOSE

According to the International Study of Unruptured Intracranial Aneurysms, small (<7 mm) unruptured intracranial aneurysms (IAs) of the anterior circulation (aC) carry a neglectable 5-year rupture risk. In contrast, some studies report frequencies of >20% of all ruptured IAs being small IAs of the aC. This contradiction was addressed in this study by analyzing the rates and risk factors for rupture of small IAs within the aC.

METHODS

Of the institutional observational cohort, 1676 small IAs of the aC were included. Different demographic, clinical, laboratory, and radiographic characteristics were collected. A rupture risk score was established using all independent prognostic factors. The score performance was checked using receiver operating characteristic curve analysis.

RESULTS

Of all registered small IAs of the aC, 20.1% were ruptured. The developed small IAs of the aC (SIAAC) score (range = -4 to +13 points) contained five major risk factors: IA location and size, arterial hypertension, alcohol abuse, and chronic renal failure. In addition, three putative protective factors were also included in the score: hypothyroidism, dyslipidemia, and peripheral arterial disease. Increasing rates of ruptured IA with increasing SIAAC scores were observed, from 0% (≤-1 points) through >50% (≥8 points) and up to 100% in patients scoring ≥12 points. The SIAAC score achieved excellent discrimination (area under the curve_SIAAC  = 0.803) and performed better than the PHASES (Population,Hypertension, Age, Size of the aneurysm, Earlier SAH from another aneurysm, Site of aneurysm) score.

CONCLUSIONS

Small IAs of the aC carry a considerable rupture risk. After external validation, the proposed rupture risk score might provide a basis for better decision-making regarding the treatment of small unruptured IAs of the aC.

Unruptured cerebral aneurysms in elderly patients: key challenges and management

Unruptured cerebral aneurysms are increasingly identified in elderly patients as the global life expectancy continues to rise and non-invasive vascular imaging becomes more prevalent. The optimal management of unruptured aneurysms in elderly patients remains controversial. Variability in life expectancy, comorbidities and rupture risk coupled with heterogenous endovascular and surgical treatments contribute to a paucity of clear guidelines, and current management is highly individualized. Elderly patients present unique considerations including frailty, cognitive dysfunction, vasculopathy, reduced life expectancy and overall worse prognosis in case of rupture which shape the risks and likelihood of success of endovascular and microsurgical treatment. In this review, we provide a comprehensive overview of unruptured cerebral aneurysms in the elderly, with a particular focus on the natural history, key challenges associated with advanced age, management and future innovations to further refine treatment.Key MessagesThe management of unruptured cerebral aneurysms in elderly patients remains controversial.Key challenges including frailty, cognitive dysfunction, reduced life expectancy, vasculopathy and poor prognosis with aneurysm rupture add complexity to endovascular and surgical decision making not encountered with younger demographics.A thorough understanding of available treatment options, likelihood of treatment success and associated risks weighed against the risk of aneurysm rupture informs patient discussion and management.

Small vs. Large Unruptured Cerebral Aneurysm: Concerns With the Age of Patient

Objective: The coiling and clipping of unruptured cerebral aneurysms (UCAs) in older patients has increased rapidly, and aneurysm size was a significant factor for decision-making in the treatment of UCAs. The purpose of the study was to investigate the impact of age on the functional outcomes of patients between the small versus large UCAs. Methods: We conducted a retrospective study for consecutive cases of UCAs admitted from May 2011 to December 2020. According to the maximum diameter of UCA, patients were divided into small UCAs (≤ 5 mm) group and large UCAs (>5 mm) group. Baseline characteristics, clinical complications, and outcomes of patients between the two groups were analyzed. Results: A total of 564 UCA patients received preventive treatment, including 165 small UCAs and 399 large UCAs. Compared with the small UCA group, the incidence of ischemia event in the large UCA group was significantly higher (7.3 vs. 2.4%; p = 0.029). Multivariable analysis demonstrating age (p = 0.006) and treatment modality (p < 0.001) were independent risk factors associated with poor outcome for patients with large UCAs. Conclusions: Preventive treatment of small UCAs is safe and effective, but older patients with large UCAs are at high risk of poor outcome, and the operations should be more cautious.

Clinical Outcomes of Clipping and Coiling in Elderly Patients with Unruptured Cerebral Aneurysms: a National Cohort Study in Korea

BACKGROUND

We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea.

METHODS

The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases.

RESULTS

A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively).

CONCLUSION

The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care.

Clipping of unruptured intracranial aneurysms in patients older than sixty: An age-based analysis

OBJECTIVE

The diagnosis of unruptured intracranial aneurysms (UIAs) is being made more frequently in elderly patients. The goal of this study is to evaluate complications and clinical outcome in patients ≥ 60 years-old who underwent clipping of UIAs.

METHODS

We performed a retrospective cohort study. Clinical outcome (modified Rankin scale score) was determined at the latest clinical follow-up. Complications and outcomes were compared between age groups (60-69, 70-80) and subgroups (60-64, 65-69, 70-74, and >75).

RESULTS

The study population consisted of 255 patients (range 60-80 years-old) who underwent 262 clipping procedures for UIAs. Mean follow-up duration was 15.6 months (± 27.5). Major complications occurred in 20 patients (7.6%) and mortality in 3 patients (1.1%). Medical complications occurred in 26 patients (10%). Mean length of hospital-stay was 4.7 days (± 5.8). 89.6% were discharged to home. 87.8% had a favorable clinical outcome. The 70-80 age group had significantly more complications (P = 0.03) than the 60-69 group and a significantly longer hospital stay (6.02 vs. 4.3 days, P = 0.04). The older group was less likely to discharge to home and more likely to require rehabilitation (P = 0.002). Favorable clinical outcome did not significantly differ between the two groups (85.7% vs. 88.4%, P = 0.56). There was a trend for increasing complications from the younger to older subgroups (P = 0.008) and a reduction in the likelihood to discharge to home (P < 0.0001). The rate of ultimate favorable clinical outcome did not differ significantly between subgroups (P = 0.79).

CONCLUSION

Although complications, length of hospital-stay, and discharge to non-home destinations increase with older age, the majority of patients ≥ 60 may have favorable clinical outcomes.

Long-Term Medical Resource Consumption between Surgical Clipping and Endovascular Coiling for Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study

Purpose: To estimate long-term medical resource consumption in patients with subarachnoid aneurysmal hemorrhage (SAH) receiving surgical clipping or endovascular coiling. Patients and methods: From Taiwan’s National Health Insurance Research Database, we enrolled patients with aneurysmal SAH who received clipping or coiling. After propensity score matching and adjustment for confounders, a generalized linear mixed model was used to determine significant differences in the accumulative hospital stay (days), intensive care unit (ICU) stay, and total medical cost for aneurysmal SAH, as well as possible subsequent surgical complications and recurrence. Results: The matching process yielded a final cohort of 8102 patients (4051 and 4051 in endovascular coil embolization and surgical clipping, respectively) who were eligible for further analysis. The mean accumulative hospital stay significantly differed between coiling (31.2 days) and clipping (46.8 days; p < 0.0001). After the generalized linear model adjustment of gamma distribution with a log link, compared with the surgical clipping procedure, the adjusted odds ratios (aOR; 95% confidence interval [CI]) of the medical cost of accumulative hospital stay for the endovascular coil embolization procedure was 0.63 (0.60, 0.66; p < 0·0001). The mean accumulative ICU stay significantly differed between the coiling and clipping groups (9.4 vs. 14.9 days; p < 0.0001). The aORs (95% CI) of the medical cost of accumulative ICU stay in the endovascular coil embolization group was 0.61 (0.58, 0.64; p < 0.0001). The aOR (95% CI) of the total medical cost of index hospitalization in the endovascular coil embolization group was 0·85 (0.82, 0.87; p < 0.0001). Conclusions: Medical resource consumption in the coiling group was lower than that in the clipping group.

Cost-effectiveness analysis in patients with an unruptured cerebral aneurysm treated with observation or surgery

OBJECTIVE

The main goal of preventive treatment of unruptured intracranial aneurysms (UIAs) is to avoid the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage. A comparison between the conservative approach and the surgical approach combining endovascular treatment and microsurgical clipping is currently lacking. This study aimed to conduct an updated evaluation of cost-effectiveness comparing the two approaches in patients with UIA.

METHODS

A decision tree with a Markov model was developed. Quality-adjusted life-years (QALYs) associated with living with UIA before and after treatment were prospectively collected from a cohort of patients with UIA at a tertiary center. Other inputs were obtained from published literature. Using Monte Carlo simulation for patients aged 55, 65, and 75 years, the authors modeled the conservative management in comparison with preventive treatment. Different proportions of endovascular and microsurgical treatment were modeled to reflect existing practice variations between treatment centers. Outcomes were assessed in terms of QALYs. Sensitivity analyses to assess the model's robustness and completed threshold analyses to examine the influence of input parameters were performed.

RESULTS

Preventive treatment of UIAs consistently led to higher utility. Models using a higher proportion of endovascular therapy were more cost-effective. Models with older cohorts were less cost-effective than those with younger cohorts. Treatment was cost-effective (willingness to pay < 100,000 USD/QALY) if the annual rupture risk exceeded a threshold between 0.8% and 1.9% in various models based on the proportion of endovascular treatment and cohort age. A higher proportion of endovascular treatments and younger age lowered this threshold, making the treatment of aneurysms with a lower risk of rupture more cost-effective.

CONCLUSIONS

Preventive treatment of aneurysms led to higher utility compared with conservative management. Models with a higher proportion of endovascular treatment and younger patient age were most cost-effective.

Analysis of the Surgical Outcome of Unruptured Intracranial Saccular Aneurysms in Octogenarians (80-89 Years)

Background:

The prevalence of unruptured intracranial aneurysms is increasing in elderly population in Japan. Octogenarians (80–89 years) are more prone to complications due to increased age, comorbidities, increased risk of vasospasm, and treatment risks.

Aim:

The aim is to study the surgical outcome of unruptured intracranial saccular aneurysms in elderly patients aged between 80 and 89 years.

Patients and Methods:

A retrospective study was conducted involving all the cases of unruptured intracranial saccular aneurysms operated surgically in elderly patients aged between 80 and 89 years. All the cases operated between January 2017 and October 2019 were included in the study. The preoperative neurological status was assessed using the Glasgow Coma Scale (GCS). The comorbidities and risk factors involved were assessed. Postoperative neurological status was assessed by (1) postoperative GCS score and by the (2) presence or absence of the motor weakness of limbs.

Results:

Thirty-three aneurysms were operated in 27 patients. Two patients were operated two times at separate occasions for different aneurysms during the study period and hence making a total of 29 surgeries. The age range was 80–88 years, with a mean of 82.4 years ± 2.64 standard deviation (SD). There were 7 (24.1%) males and 22 (75.86%) females. All the patients had a preoperative GCS score of 15/15 without focal neurological deficit. The mean size (mm) of the aneurysms was 6.57 ± 4.04 SD. There were 31 (93.94%) aneurysms in the anterior circulation and 2 (6.06%) aneurysms in the posterior circulation. The comorbidities and risk factors were analyzed and found to be not influencing the outcome of the patients. Clipping was done in 32 aneurysms. One case of posterior inferior cerebellar artery (PICA) aneurysm underwent occipital artery to PICA bypass surgery. The postoperative complications include chronic subdural hematoma (CSDH) in 7 (24.13%) patients, extradural hematoma in 1 (3.4%), meningitis in 1 (3.4%), and lower cranial nerve palsy in 1 (3.4%) patient. All the patients were discharged with GCS score 15/15 without motor weakness of the limbs. The mean duration of stay was 16.62 days ± 9.98 SD.

Conclusion:

Surgery for unruptured saccular aneurysms in octogenarians has got a good result in the tertiary care facility. Advanced age alone should not be considered for preferring coiling over clipping. Octogenarians are more prone to developing postoperative CSDH.

Propensity Score Matching Analysis for the Patients of Unruptured Cerebral Aneurysm from a Post Hoc Analysis of a Nationwide Database in Japan

BACKGROUND

This study aimed to compare the functional outcome at discharge for unruptured cerebral aneurysms (UCAs) between surgical clipping and endovascular coiling in total, nonelderly (<65 years), and elderly (≥65 years) patients by nonbiased analysis based on a national database in Japan.

METHODS

A total of 15,671 patients with UCA were registered in the Diagnosis Procedure Combination, the nationwide database, from 2010 to 2015 in Japan. The outcome of the Barthel Index (BI) at discharge was investigated, and propensity score-matched analysis was conducted in total, nonelderly, and elderly patient groups.

RESULTS

Propensity score-matched analysis found no significant difference for in-hospital mortality between the 2 treatment methods in the total and both age-groups. The rate of morbidity of BI <90 at discharge was higher after surgical clipping than after endovascular coiling in the total (4.9% vs. 3.9%; P = 0.040; risk difference, -1.0%; 95% confidence interval, -3.6 to 2.3%) and the elderly age-group (8.1% vs. 5.0%; P < 0.001; risk difference, -3.1%; -4.8% to 1.5%), however, no significant association between the 2 treatment methods (2.4% vs. 2.6%; P = 0.67; risk difference, 0.22%; -0.79 to 1.22%) was found in the nonelderly group.

CONCLUSIONS

In elderly patients with UCA, a better outcome at discharge after endovascular coiling was found. However, no significantly different functional outcome at discharge between surgical clipping and endovascular coiling for UCA in nonelderly patients was confirmed by propensity score-matched analysis from a nationwide database in Japan.

Evaluation of disease severity and treatment intensity as cost drivers for ruptured intracranial aneurysms

BACKGROUND

Previous studies have not evaluated the impact of illness severity and postrupture procedures in the cost of care for intracranial aneurysms. We hypothesize that the severity of aneurysm rupture and the aggressiveness of postrupture interventions play a role in cost.

METHODS

The Value Driven Outcomes database was used to assess direct patient cost during the treatment of ruptured intracranial aneurysm with clipping, coiling, and Pipeline flow diverters.

RESULTS

One hundred ninety-eight patients (mean age 52.8 ± 14.1 years; 40.0% male) underwent craniotomy (64.6%), coiling (26.7%), or flow diversion (8.6%). Coiling was 1.4× more expensive than clipping (p = .005) and flow diversion was 1.7× more expensive than clipping (p < .001). More severe illness as measured by American Society of Anesthesia, Hunt/Hess, and Fisher scales incurred higher costs than less severe illness (p < .05). Use of a lumbar drain protocol to reduce subarachnoid hemorrhage and use of an external ventricular drain to manage intracranial pressure were associated with reduced (p = .05) and increased (p < .001) total costs, respectively. Patients with severe vasospasm (p < .005), those that received shunts (p < .001), and those who had complications (p < .001) had higher costs. Multivariate analysis showed that procedure type, length of stay, number of angiograms, vasospasm severity, disposition, and year of treatment were independent predictors of cost.

CONCLUSIONS

These results show for the first time that disease and vasospasm severity and intensity of treatment directly impact the cost of care for patients with aneurysms in the USA. Strategies to alter these variables may prove important for cost reduction.

Management of Unruptured Intracranial Aneurysms in Older Adults: A Cost-effectiveness Analysis

Background Unruptured intracranial aneurysms (UIAs) are relatively common and are being increasingly diagnosed, with a significant proportion in older patients (˃ 65 years old). Serial imaging is often performed to assess change in size or morphology of UIAs since growing aneurysms are known to be at high risk for rupture. However, the frequency and duration of surveillance imaging have not been established. Purpose To evaluate the cost-effectiveness of routine treatment (aneurysm coil placement) versus four different strategies for imaging surveillance of UIAs in adults older than 65 years. Materials and Methods A Markov decision-analytic model was constructed from a societal perspective. Age-dependent input parameters were obtained from published literature. Analysis included adults older than 65 years, with incidental detection of UIA and no prior history of subarachnoid hemorrhage. Five different management strategies for UIAs in older adults were evaluated: (a) annual MR angiography, (b) biennial MR angiography, (c) MR angiography every 5 years, (d) coil placement and follow-up, and (e) limited MR angiography follow-up for the first 2 years after detection only. Outcomes were assessed in terms of quality-adjusted life-years (QALYs). Probabilistic, one-way, and two-way sensitivity analyses were performed. Results Imaging follow-up for the first 2 years after detection is the most cost-effective strategy (cost = $24 572, effectiveness = 13.73 QALYs), showing the lowest cost and highest effectiveness. The conclusion remains robust in probabilistic and one-way sensitivity analyses. Time-limited imaging follow-up remains the optimal strategy when the annual growth rate and rupture risk of growing aneurysms are varied. If annual rupture risk of nongrowing aneurysms is greater than 7.1%, coil placement should be performed directly. Conclusion Routine preventive treatment or periodic, indefinite imaging follow-up is not a cost-effective strategy in all adults older than 65 years with unruptured intracranial aneurysms. More aggressive management strategies should be reserved for patients with high risk of rupture, such as those with aneurysms larger than 7 mm and those with aneurysms in the posterior circulation. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Cloft in this issue.

Surgical Management of Unruptured Cerebral Aneurysms in the Elderly: An Institution Experience

Background and Purpose:

The elderly population is increasing in the world, especially in developed countries. The gain in life expectancy is remarkable in Japan, consequently incidence of aneurysms increases in this population. The purpose of this study is to evaluate the surgical treatment and outcome of patients aged more than 75 years treated for unruptured intracranial aneurysms.

Patients and Methods:

We conducted a retrospective study for unruptured cerebral aneurysms operated between September 2014 and August 31, 2018, in Fujita Health University, Banbuntane Hotokukai Hospital, for people aged more than 75 years. A demographic study was done. We also studied aneurysm location, aneurysm size, outcome, duration of stay, and complications.

Results:

About 61 patients aged more than 75 years were operated in 4 years, comprising 12 males and 45 females. The mean age was 79.32 ± 3.29 years. Mean size of the aneurysm was 6.22 ± 3.28. Aneurysm location (P = 0.0037), associated risk factors (P = 0.006), and association of hypertension and diabetes (P = 0.0362) influence outcome. Length of stay is directly correlated with outcome (P = 0.009).

Conclusions:

Elder patients with hypertension and diabetes or associated risk factors having a posterior circulation aneurysm have a poor diagnosis.