Dataset Information

Management of Unruptured Small Multiple Intracranial Aneurysms in China: A Comparative Effectiveness Analysis Based on Real-World Data.

ABSTRACT:

Background

Unruptured small aneurysms with a size of <7 mm were often followed conservatively. However, it is unknown whether unruptured small multiple intracranial aneurysms (MIAs) are better to be prophylactically treated or conservatively followed.

Objective

We aim to compare the effectiveness of different strategies regarding their management.

Methods

A decision-analytic Markov model was built over a entire life cycle. The compared strategies include natural history, treat one aneurysm, treat both aneurysms, annual follow-up, biennial follow-up, and follow-up every 5 years. The inputs for the model were obtained from real-world data and related medical literature. Outcomes were measured in terms of quality-adjusted life-years (QALYs).

Results

Treat both aneurysms had the highest effectiveness of 15.36 QALYs and treat one aneurysm had the second-highest effectiveness of 15.11 QALYs. Probabilistic sensitivity analysis with 10,000 iterations showed that treat both aneurysms and treat one aneurysm were optimal in 67.28 and 17.91% of all cases, respectively. One-way and two-way sensitivity analyses showed that the result was sensitive to the proportion of moderate to severe disability after treating two aneurysms, mortality after treating two aneurysms, proportion of moderate to severe disability after treating one aneurysm, and rupture rate of small growing aneurysm. Either treat both aneurysms or treat one aneurysm would be the optimal strategy under most of the circumstances with the variations of these parameters.

Conclusion

For patients with small unruptured MIAs, prophylactic coiling was superior to conservative management and at least one aneurysm should be treated.

SUBMITTER: Chen J

PROVIDER: S-EPMC8830354 | biostudies-literature | 2021

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Management of Unruptured Small Multiple Intracranial Aneurysms in China: A Comparative Effectiveness Analysis Based on Real-World Data.

Chen Jigang J Tong Xin X Feng Xin X Peng Fei F Niu Hao H Han Mingyang M Liu Lang L Zhao Yuanli Y Wang Daming D Pan Yuesong Y Liu Aihua A

Frontiers in neurology 20220127

<h4>Background</h4>Unruptured small aneurysms with a size of <7 mm were often followed conservatively. However, it is unknown whether unruptured small multiple intracranial aneurysms (MIAs) are better to be prophylactically treated or conservatively followed.<h4>Objective</h4>We aim to compare the effectiveness of different strategies regarding their management.<h4>Methods</h4>A decision-analytic Markov model was built over a entire life cycle. The compared strategies include natural history, tr ...[more]

PMID: 35153970

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Project description:Importance:Unruptured intracranial aneurysms (UIAs) are relatively common in the general population and are being increasingly diagnosed; a significant proportion are tiny (≤3 mm) aneurysms. There is significant heterogeneity in practice and lack of clear guidelines on the management of incidental, tiny UIAs. It is important to quantify the implications of different management strategies in terms of health benefits to patients. Objective:To evaluate the effectiveness of routine treatment (aneurysm coiling) vs 3 strategies for imaging surveillance compared with no preventive treatment or routine follow-up of tiny UIAs. Design, Setting, and Participants:A decision-analytic model-based comparative effectiveness analysis was conducted from May 1 to June 30, 2017, using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included 10 000 iterations simulating adult patients with incidental detections of UIAs 3 mm or smaller and no history of subarachnoid hemorrhage. Interventions:The following 5 management strategies for tiny UIAs were evaluated: annual magnetic resonance angiography (MRA) screening, biennial MRA screening, MRA screening every 5 years, aneurysm coiling and follow-up, and no treatment or preventive follow-up. Main Outcomes and Measures:A Markov decision model for lifetime rupture was constructed from a societal perspective per 10 000 patients with incidental, tiny UIAs. Outcomes were assessed in terms of quality-adjusted life-years. Probabilistic, 1-way, and 2-way sensitivity analyses were performed. Results:In this analysis of 10 000 iterations simulating adult patients with a mean age of 50 years, the base-case calculation shows that the management strategy of no treatment or preventive follow-up has the highest health benefit (mean [SD] quality-adjusted life-years, 19.40 [0.31]). Among the management strategies that incorporate follow-up imaging, MRA every 5 years is the best strategy with the next highest effectiveness (mean [SD] quality-adjusted life-years, 18.05 [0.62]). The conclusion remains robust in probabilistic and 1-way sensitivity analyses. No routine follow-up remains the optimal strategy when the annual growth rate and risk of rupture of growing aneurysms are varied. When the annual risk of rupture of nongrowing UIAs is less than 1.7% (0.23% in base case scenario), no follow-up is the optimal strategy. If annual risk of rupture is more than 1.7%, coiling should be performed directly. Conclusions and Relevance:Given the current literature, no preventive treatment or imaging follow-up is the most effective strategy in patients with aneurysms that are 3 mm or smaller, resulting in better health outcomes. More aggressive imaging surveillance for aneurysm growth or preventive treatment should be reserved for patients with a high risk of rupture. Given these findings, it is important to critically evaluate the appropriateness of current clinical practices, and potentially determine specific guidelines to reflect the most effective management strategy for patients with incidental, tiny UIAs.

Project description:BackgroundThe discovery of an unruptured intracranial aneurysm creates a dilemma between observation and treatment. Neurosurgeons' routines for risk assessment and treatment decision-making are unknown. The position of evidence-based medicine in European neurosurgery is considered to be weak, high-grade guidelines do not exist and variations between institutions are probable. We aimed to explore European neurosurgeons' management routines for newly discovered unruptured intracranial aneurysms.MethodsIn cooperation with the European Association of Neurosurgical Societies (EANS), we conducted an online, cross-sectional survey of 420 European neurosurgeons during Spring/Summer 2016 (1533 non-Norwegians invited through the EANS, and 16 Norwegians invited through heads of departments because of the need for additional information for a separate study). We asked about demographic variables, routines for management and risk assessment of newly discovered unruptured intracranial aneurysms and presented a case. We collected information about gross domestic product (GDP) per capita from the International Monetary Fund.ResultsThe response rate to the invite from the EANS was 26%, with respondents from 47 countries. More than half of the respondents (n = 226 [54%]) reported that their department treated less than 25 unruptured aneurysms yearly. Forty percent said their department used aneurysm size cut-off to guide treatment decisions, with a mean size of 6 mm. Presented with a case, respondents from countries with a lower GDP per capita recommended intervention more often than respondents from higher-income countries. Vascular neurosurgeons more commonly recommended observation.ConclusionThe answers to this self-reported survey indicate that many centers have a treatment volume lower than recommended by international guidelines, and that there are socioeconomic differences in care. Better documentation of treatment and outcome, for example with clinical quality registries, is needed to drive improvements of care.

Project description:BackgroundCurrently, endovascular treatment of intracranial aneurysms (ICAs) is limited by low complete occlusion rates. The advent of novel endovascular technology has expanded the applicability of endovascular therapy; however, the superiority of novel embolic devices over the traditional Guglielmi detachable coils (GDCs) is still debated. We performed a systematic review of literature that reported Raymond-Roy occlusion classification (RROC) rates of modern endovascular devices to determine their immediate and follow-up occlusion effectiveness for the treatment of unruptured saccular ICAs.MethodsA search was conducted using electronic databases (PUBMED, Cochrane, ClinicalTrials.gov, Web of Science). We retrieved studies published between 2000-2022 reporting immediate and follow-up RROC rates of subjects treated with different endovascular ICA therapies. We extracted demographic information of the treated patients and their reported angiographic RROC rates.ResultsA total of 80 studies from 15 countries were included for data extraction. RROC rates determined from angiogram were obtained for 21,331 patients (72.5% females, pooled mean age: 58.2 (95% CI: 56.8-59.6), harboring 22,791 aneurysms. The most frequent aneurysm locations were the internal carotid artery (46.4%, 95% CI: 41.9%-50.9%), the anterior communicating artery (26.4%, 95% CI: 22.5%-30.8%), the middle cerebral artery (24.5%, 95% CI:19.2%-30.8%) and the basilar tip (14.4%, 95% CI:11.3%-18.3%). The complete occlusion probability (RROC-I) was analyzed for GDCs, the Woven EndoBridge (WEB), and flow diverters. The RROC-I rate was the highest in balloon-assisted coiling (73.9%, 95% CI: 65.0%-81.2%) and the lowest in the WEB (27.8%, 95% CI:13.2%-49.2%). The follow-up RROC-I probability was homogenous in all analyzed devices.ConclusionsWe observed that the coil-based endovascular therapy provides acceptable rates of complete occlusion, and these rates are improved in balloon-assisted coils. Out of the analyzed devices, the WEB exhibited the shortest time to achieve >90% probability of follow-up complete occlusion (~18 months). Overall, the GDCs remain the gold standard for endovascular treatment of unruptured saccular aneurysms.

Project description:ObjectivesArterial calcification is thought to protect against rupture of intracranial aneurysms, but studies in a representative population of intracranial aneurysm patients have not yet been performed. The aim was to compare the prevalence of aneurysm wall calcification and intracranial carotid artery calcification (ICAC) between patients with an unruptured intracranial aneurysm (UIA) and a ruptured intracranial aneurysm (RIA).Materials and methodsWe matched 150 consecutive UIA patients to 150 RIA patients on age and sex. Aneurysm wall calcification and ICAC were quantified on non-contrast enhanced computed tomography images with the modified Agatston score. We compared the prevalence of aneurysm wall calcification, ICAC, and severe ICAC (defined as a modified Agatston score in the fourth quartile) between UIA and RIA patients using univariate and multivariate conditional logistic regression models adjusted for aneurysm characteristics and cardiovascular risk factors.ResultsAneurysm wall calcification was more prevalent in UIA compared to RIA patients (OR 5.2, 95% CI: 2.0-13.8), which persisted after adjustment (OR 5.9, 95% CI: 1.7-20.2). ICAC prevalence did not differ between the two groups (crude OR 0.9, 95% CI: 0.5-1.8). Severe ICAC was more prevalent in UIA patients (OR 2.0, 95% CI: 1.1-3.6), but not after adjustment (OR 1.0, 95% CI: 0.5-2.3).ConclusionsAneurysm wall calcification but not ICAC was more prevalent in UIAs than in RIAs, which corresponds to the hypothesis that calcification may protect against aneurysmal rupture. Aneurysm wall calcification should be further assessed as a predictor of aneurysm stability in prospective cohort studies.Clinical relevance statementCalcification of the intracranial aneurysm wall was more prevalent in unruptured than ruptured intracranial aneurysms after adjustment for cardiovascular risk factors. Calcification may therefore protect the aneurysm against rupture, and aneurysm wall calcification is a candidate predictor of aneurysm stability.Key pointsAneurysm wall calcification was more prevalent in patients with unruptured than ruptured aneurysms, while internal carotid artery calcification was similar. Aneurysm wall calcification but not internal carotid artery calcification is a candidate predictor of aneurysm stability. Cohort studies are needed to assess the predictive value of aneurysm wall calcification for aneurysm stability.

Dataset Information

Management of Unruptured Small Multiple Intracranial Aneurysms in China: A Comparative Effectiveness Analysis Based on Real-World Data.

Background

Objective

Methods

Results

Conclusion

Publications

Management of Unruptured Small Multiple Intracranial Aneurysms in China: A Comparative Effectiveness Analysis Based on Real-World Data.

Similar Datasets

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