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Approaches to Unruptured Cerebral Aneurysms

Unruptured cerebral aneurysms may be discovered during the evaluation of another aneurysm that has ruptured, in the work-up of symptoms caused by compression of adjacent structures, or incidentally. This cohort study compared surgical clipping and the more recent technique of endovascular coil embolization via a catheter inserted through the femoral artery.

Between 1994 and 1997, a consortium of academic medical centers treated 2,357 surgical cases and 255 endovascular cases. The endovascular group had significantly lower in-hospital mortality (0.4 percent vs. 2.3 percent) and fewer adverse outcomes, defined as death or discharge to a nursing home or rehabilitation facility (10.6 percent vs. 18.5 percent). On multivariate analysis adjusting for baseline differences between groups, the rate of adverse outcomes remained significantly higher with surgery.

Another analysis compared the cost-utility of these two strategies and no treatment, using estimates from the published literature. For an asymptomatic person with no past history of subarachnoid hemorrhage and an aneurysm less than 10 mm in diameter, both treatments would lead to a reduction in quality-adjusted life years, and thus the analysis advises no treatment. For most other scenarios, the model judged both treatments to be cost-effective, with coil embolization slightly better than surgery.

Comment: Because the first study was not a randomized trial, and with the volume of surgical cases far exceeding the endovascular cases, these findings should be regarded tentatively. Nevertheless, both studies can provide some guidance for patients and physicians facing the uncertainty of an unruptured aneurysm.

— AS Brett

Published in Journal Watch General Medicine July 9, 1999

Citation(s):

Johnston SC et al. Surgical and endovascular treatment of unruptured cerebral aneurysms at university hospitals. Neurology 1999 Jun 52 1799-1805.

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• Medline abstract (Free)

Johnston SC et al. Which unruptured cerebral aneurysms should be treated?. A cost-utility analysis. Neurology 1999 Jun 52 1806-1815.

• Original article (Subscription may be required)
• Medline abstract (Free)