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A mathematical model of utility for single screening of asymptomatic unruptured intracranial aneurysms at the age of 50 years

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Abstract

Background

Although rupture of intracranial aneurysms carries high mortality and morbidity rates, the clinical and financial benefit of screening certain high-risk groups is uncertain. We designed a mathematical model to interrogate the clinical benefit and cost-effectiveness of screening.

Methods

A decision tree analysis model was used to calculate the outcome and cost of two scenarios applied to the same population: one-off screening for intracranial aneurysms versus not screening. Each scenario had an associated gain or loss of Quality Adjusted Life Years (QALY) and cost; the difference between the two scenarios was calculated. The variable inputs were the aneurysm prevalence and risk of rupture after 5 years. Sensitivity analyses were performed to determine the effects of altering various factors on outcomes.

Results

Screening of the asymptomatic general population results in a QALY loss, equating to a negative clinical impact. The threshold 5-year risk of rupture at which screening resulted in a gain in QALYs was 13 %. This held true for any prevalence between 1 and 25 %. Risk of rupture had a greater impact on outcome than prevalence. Halving the risk of intervention (either surgery or coiling) reduced the threshold 5-year risk of rupture at which screening results in gain of QALYs to 6 %. The age of screening also had important effects on outcome.

Conclusions

The QALY benefit and cost-effectiveness of screening are most sensitive to the 5-year risk of rupture. Screening is beneficial only in populations with a high risk of rupture; this should be the focus of future research.

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References

  1. Belz MM, Fick-Brosnahan GM, Hughes RL, Rubinstein D, Chapman AB, Johnson AM, McFann KK, Kaehny WD, Gabow PA (2003) Recurrence of intracranial aneurysms in autosomal-dominant polycystic kidney disease. Kidney Int 63:1824–1830

    Article  PubMed  Google Scholar 

  2. Bor AS, Velthuis BK, Majoie CB, Rinkel GJ (2008) Configuration of intracranial arteries and development of aneurysms: a follow-up study. Neurology 70:700–705

    Article  PubMed  Google Scholar 

  3. Brown RD, Huston J, Hornung R, Foroud T, Kallmes DF, Kleindorfer D, Meissner I, Woo D, Sauerbeck L, Broderick J (2008) Screening for brain aneurysm in the Familial Intracranial Aneurysm study: frequency and predictors of lesion detection. J Neurosurg 108:1132–1138

    Article  PubMed  Google Scholar 

  4. Burns JD, Huston J, Layton KF, Piepgras DG, Brown RD (2009) Intracranial aneurysm enlargement on serial magnetic resonance angiography: frequency and risk factors. Stroke 40:406–411

    Article  PubMed  Google Scholar 

  5. Chauveau D, Pirson Y, Verellen-Dumoulin C, Macnicol A, Gonzalo A, Grünfeld JP (1994) Intracranial aneurysms in autosomal dominant polycystic kidney disease. Kidney Int 45:1140–1146

    Article  PubMed  CAS  Google Scholar 

  6. Chen W, Wang J, Xin W, Peng Y, Xu Q (2008) Accuracy of 16-row multislice computed tomographic angiography for assessment of small cerebral aneurysms. Neurosurgery 62:113–121, discussion 121–112

    Article  PubMed  Google Scholar 

  7. Cosford PA, Leng GC (2007) Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev:CD002945

  8. Deka R, Koller DL, Lai D, Indugula SR, Sun G, Woo D, Sauerbeck L, Moomaw CJ, Hornung R, Connolly ES, Anderson C, Rouleau G, Meissner I, Bailey-Wilson JE, Huston J, Brown RD, Kleindorfer DO, Flaherty ML, Langefeld CD, Foroud T, Broderick JP, Investigators FS (2010) The relationship between smoking and replicated sequence variants on chromosomes 8 and 9 with familial intracranial aneurysm. Stroke 41:1132–1137

    Article  PubMed  Google Scholar 

  9. Excellence NIfC (2008) Guide to the Methods of Technology Approval. In: Excellence NIoC (ed) London, UK, p 45

  10. Foroud T, Sauerbeck L, Brown R, Anderson C, Woo D, Kleindorfer D, Flaherty ML, Deka R, Hornung R, Meissner I, Bailey-Wilson JE, Rouleau G, Connolly ES, Lai D, Koller DL, Huston J, Broderick JP, Investigators FS (2008) Genome screen to detect linkage to intracranial aneurysm susceptibility genes: the Familial Intracranial Aneurysm (FIA) study. Stroke 39:1434–1440

    Article  PubMed  CAS  Google Scholar 

  11. Foroud T, Sauerbeck L, Brown R, Anderson C, Woo D, Kleindorfer D, Flaherty ML, Deka R, Hornung R, Meissner I, Bailey-Wilson JE, Langefeld C, Rouleau G, Connolly ES, Lai D, Koller DL, Huston J, Broderick JP, Investigators FIAS (2009) Genome screen in familial intracranial aneurysm. BMC Med Genet 10:3

    Article  PubMed  Google Scholar 

  12. Irazabal MV, Huston J, Kubly V, Rossetti S, Sundsbak JL, Hogan MC, Harris PC, Brown RD, Torres VE (2011) Extended follow-up of unruptured intracranial aneurysms detected by presymptomatic screening in patients with autosomal dominant polycystic kidney disease. Clin J Am Soc Nephrol 6:1274–1285

    Article  PubMed  Google Scholar 

  13. Kingdom) NOoSU (21st October 2009) Interim Life Tables 2007–2009. National Office of Statistics

  14. Korja M, Sen C, Langer D (2010) Operative nuances of side-to-side in situ posterior inferior cerebellar artery-posterior inferior cerebellar artery bypass procedure. Neurosurgery 67:471–477

    Article  PubMed  Google Scholar 

  15. Leblanc R (1997) Familial cerebral aneurysms. Can J Neurol Sci 24:191–199

    PubMed  CAS  Google Scholar 

  16. Lee JS, Park IS, Park KB, Kang DH, Lee CH, Hwang SH (2008) Familial intracranial aneurysms. J Kor Neurosurg Soc 44:136–140

    Article  Google Scholar 

  17. Mason H, Jones-Lee M, Donaldson C (2009) Modelling the monetary value of a QALY: a new approach based on UK data. Health Econ 18:933–950

    Article  PubMed  Google Scholar 

  18. Nakagawa T, Hashi K, Kurokawa Y, Yamamura A (1999) Family history of subarachnoid hemorrhage and the incidence of asymptomatic, unruptured cerebral aneurysms. J Neurosurg 91:391–395

    Article  PubMed  CAS  Google Scholar 

  19. Pirson Y, Chauveau D, Torres V (2002) Management of cerebral aneurysms in autosomal dominant polycystic kidney disease. J Am Soc Nephrol 13:269–276

    PubMed  Google Scholar 

  20. Rahman M, Smietana J, Hauck E, Hoh B, Hopkins N, Siddiqui A, Levy EI, Meng H, Mocco J (2010) Size ratio correlates with intracranial aneurysm rupture status: a prospective study. Stroke 41:916–920

    Article  PubMed  Google Scholar 

  21. Rahman M, Ogilvy CS, Zipfel GJ, Derdeyn CP, Siddiqui AH, Bulsara KR, Kim LJ, Riina HA, Mocco J, Hoh BL (2011) Unruptured cerebral aneurysms do not shrink when they rupture: multicenter collaborative aneurysm study group. Neurosurgery 68:155–160, discussion 160–151

    Article  PubMed  Google Scholar 

  22. Ruigrok YM, Rinkel GJ, Algra A, Raaymakers TW, Van Gijn J (2004) Characteristics of intracranial aneurysms in patients with familial subarachnoid hemorrhage. Neurology 62:891–894

    Article  PubMed  CAS  Google Scholar 

  23. Towse A (2009) Should NICE's threshold range for cost per QALY be raised? Yes. BMJ 338:b181

    Article  PubMed  Google Scholar 

  24. van Gijn J, Kerr RS, Rinkel GJ (2007) Subarachnoid haemorrhage. Lancet 369:306–318

    Article  PubMed  Google Scholar 

  25. Vindlacheruvu RR, Mendelow AD, Mitchell P (2005) Risk-benefit analysis of the treatment of unruptured intracranial aneurysms. J Neurol Neurosurg Psychiatry 76:234–239

    Article  PubMed  CAS  Google Scholar 

  26. Vlak MH, Algra A, Brandenburg R, Rinkel GJ (2011) Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol 10:626–636

    Article  PubMed  Google Scholar 

  27. Wardlaw JM, White PM (2000) The detection and management of unruptured intracranial aneurysms. Brain 123(Pt 2):205–221

    Article  PubMed  Google Scholar 

  28. Wermer MJ, van der Schaaf IC, Velthuis BK, Algra A, Buskens E, Rinkel GJ, Group AS (2005) Follow-up screening after subarachnoid haemorrhage: frequency and determinants of new aneurysms and enlargement of existing aneurysms. Brain 128:2421–2429

    Article  PubMed  CAS  Google Scholar 

  29. Wermer MJ, Koffijberg H, van der Schaaf IC, Group AS (2008) Effectiveness and costs of screening for aneurysms every 5 years after subarachnoid hemorrhage. Neurology 70:2053–2062

    Article  PubMed  Google Scholar 

  30. White PM, Wardlaw JM, Easton V (2000) Can noninvasive imaging accurately depict intracranial aneurysms? A systematic review. Radiology 217:361–370

    PubMed  CAS  Google Scholar 

  31. White PM, Teadsale E, Wardlaw JM, Easton V (2001) What is the most sensitive non-invasive imaging strategy for the diagnosis of intracranial aneurysms? J Neurol Neurosurg Psychiatry 71:322–328

    Article  PubMed  CAS  Google Scholar 

  32. White PM, Teasdale EM, Wardlaw JM, Easton V (2001) Intracranial aneurysms: CT angiography and MR angiography for detection prospective blinded comparison in a large patient cohort. Radiology 219:739–749

    PubMed  CAS  Google Scholar 

  33. Wiebers DO, Whisnant JP, Huston J, Meissner I, Brown RD, Piepgras DG, Forbes GS, Thielen K, Nichols D, O'Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC, Investigators ISoUIA (2003) Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103–110

    Article  PubMed  Google Scholar 

  34. Wilson JM, Jungner YG (1968) Principles and practice of mass screening for disease. Bol Oficina Sanit Panam 65:281–393

    PubMed  CAS  Google Scholar 

  35. Xu HW, Yu SQ, Mei CL, Li MH (2011) Screening for intracranial aneurysm in 355 patients with autosomal-dominant polycystic kidney disease. Stroke 42:204–206

    Article  PubMed  CAS  Google Scholar 

  36. Yoshimoto Y, Wakai S (1999) Cost-effectiveness analysis of screening for asymptomatic, unruptured intracranial aneurysms. A mathematical model. Stroke 30:1621–1627

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

We thank Stephen Peebles for his help in sourcing national tariffs.

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Authors and Affiliations

  1. Division of Neurosurgery, Addenbrooke’s Hospital & University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK

    Lucia M. Li, Diederik O. Bulters & Ramez W. Kirollos

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  1. Lucia M. Li
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  2. Diederik O. Bulters
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  3. Ramez W. Kirollos
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Correspondence to Lucia M. Li.

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Li, L.M., Bulters, D.O. & Kirollos, R.W. A mathematical model of utility for single screening of asymptomatic unruptured intracranial aneurysms at the age of 50 years. Acta Neurochir 154, 1145–1152 (2012). https://doi.org/10.1007/s00701-012-1371-8

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  • DOI: https://doi.org/10.1007/s00701-012-1371-8

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