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Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative?

ABSTRACT: An increasing number of unruptured intracranial aneurysms (UIAs) has been discovered in elderly patients in recent years, but the optimal treatment strategy for these patients remains controversial. We report our six-year experience treating UIAs in elderly patients (? 70 years old). A retrospective review was conducted of elderly patients who harbored UIAs treated by conservative observation, microsurgical clipping, or endovascular coiling between January 2009 and December 2014. The patients' clinical and imaging information was recorded. Treating methods, procedure-related complications, imaging results, and clinical outcomes were analyzed. A total of 141 consecutive elderly patients with 166 UIAs were enrolled in our study. In all, 64 patients with 79 aneurysms were treated with coiling, and 14 patients with 14 aneurysms were treated with clipping. The remaining 63 patients with 73 aneurysms were placed under conservative observation. The average modified Rankin scale was 0.99 (range 0-6) in the full cohort after a mean follow-up of 50.4 months (range 0-70 months). There was no significant difference of modified Rankin scale in patients with UIAs treated by different methods. Multivariate analysis showed that age (p=0.030) and aneurysm size (p=0.011) were independent risk factors for unfavorable outcome of UIAs in the elderly. Patient age (p=0.010) and aneurysm size (p=0.020) were also significantly associated with unfavorable outcome of UIAs managed with observation initially. Our results indicated that endovascular coil embolization and clipping were both safe and effective treatment methods for UIAs in the elderly. Aggressive treatment for UIAs in elderly patients with risk factors of aneurysm rupture should be considered positively.

SUBMITTER: Yang H

PROVIDER: S-EPMC6686429 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative?

Yang H H Jiang H H Ni W W Leng B B Bin X X Chen G G Tian Y Y Gu Y Y

Cell transplantation 20190116 6

An increasing number of unruptured intracranial aneurysms (UIAs) has been discovered in elderly patients in recent years, but the optimal treatment strategy for these patients remains controversial. We report our six-year experience treating UIAs in elderly patients (≥ 70 years old). A retrospective review was conducted of elderly patients who harbored UIAs treated by conservative observation, microsurgical clipping, or endovascular coiling between January 2009 and December 2014. The patients' c ...[more]

PMID: 30648433

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Project description:BackgroundUnruptured intracranial aneurysms (UIA) are increasingly being treated by endovascular coiling as opposed to open surgical clipping. Unfortunately, endovascular coiling imparts an approximate 25% recanalization rate, leading to additional procedures and increased rupture risk. While a new health technology innovation (HTI) that reduces this recanalization rate would benefit patients, few advancements have been made. We aim to determine whether cost-effectiveness has been a barrier to HTI.MethodsA probabilistic Markov model was constructed from the healthcare payer perspective to compare standard endovascular treatment of UIA to standard treatment plus the addition of a HTI adjunct. Costs were measured in 2018 USD and health outcomes were measured in quality-adjusted life-years (QALY). In the base case, the HTI was a theoretical mesenchymal stem cell therapy which reduced the aneurysm recanalization rate by 50% and cost $10,000 per procedure. All other model inputs were derived from the published scientific literature.ResultsBased on the model results, we found that for a given HTI price (y) and relative risk reduction of aneurysm recanalization (x), the HTI was always cost-effective if the following equation was satisfied: y ≤ 20268 ∙ x, using a willingness-to-pay threshold of $50,000 per QALY. The uncertainty surrounding whether an aneurysm would recanalize was a significant driver within the model. When the uncertainty around the risk of aneurysm recanalization was eliminated, the 10-year projected additional benefit to the United States healthcare system was calculated to be $113,336,994.ConclusionCost-effectiveness does not appear to be a barrier to innovation in reducing the recanalization rate of UIA treated by endovascular coil embolization. Our model can now be utilized by academia and industry to accentuate economically feasible HTI and by healthcare payers to calculate their maximum willingness-to-pay for a new technology. Our results also indicate that predicting a patient's baseline risk of aneurysm recanalization is a critical area of future research.

Project description:Background and purposeStent-assisted coiling was initially invented for wide-neck aneurysms, but is now used for smaller berry aneurysms. The aim of this study was to compare the safety and efficiency of stent-assisted coiling with conventional coiling in treatment of intracranial aneurysms.MethodsA meta-analysis of studies that compared stent-assisted coiling with coiling only was conducted by searching English literatures via Pubmed, Medline and Cochrane Library databases without restricting the publication year. The primary outcomes in this study were immediate occlusion, progressive thrombosis rate, all-complication rate and angiographic recurrence. The secondary outcomes examined were packing density, mortality, permanent complication and thromboembolic complication rate.ResultsTen retrospective cohort studies were included. There is currently only one unfinished randomized study. Although the stent-assisted coiling group tended to show a lower initial occlusion rate than that of the coiling-only group (57.6% versus 68.7%; OR, 0.66; 95% CI, 0.30-1.44; P = 0.30), it achieved a significantly higher progressive thrombosis rate during follow up compared to that of the coiling only group (37.5% versus 19.4%; OR, 2.75; 95% CI, 1.95-3.86; P<0.00001) and a significantly lower recurrence rate (16.2% versus 34.4%; OR, 0.35; 95% CI, 0.25-0.49; P<0.00001). With respect to safety concerns, the all-complication rate (17.6% versus 15.9%; OR, 1.12; 95% CI, 0.77-1.62; P = 0.56), mortality rate (9.1% versus 2.6%; OR, 2.31; 95% CI, 0.68-7.82; P = 0.18), permanent complication rate (5.6% versus 3.9%; OR, 1.52; 95% CI, 0.96-2.41; P = 0.08) and thromboembolic complication rate (4.2% versus 4.9%; OR, 0.99; 95% CI, 0.41-2.38; P = 0.97) did not show significant difference between the two groups.ConclusionsStent-assisted coiling has a lower recurrence rate than conventional coiling. Analysis of complication events did not show any significant difference between the two methods. Despite the findings reported herein, further validation by well-designed prospective studies is needed.

Dataset Information

Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative?

Publications

Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative?

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