Minimally Invasive Stroke Treatment Offers Better Results than Open Surgery

Coils used for minimally invasive endovascular treatment of a ruptured brain aneurysm have proved to be a more effective, but costlier, technique than traditional surgical operation in selected patients, according to a new study.

Researchers at the University of Minnesota Medical School (Minneapolis, USA) compared the cost-effectiveness of both endovascular and neurosurgical treatments in patients with ruptured intracranial aneurysms who were eligible to undergo either type of treatment. The researchers obtained patient data from the International Subarachnoid Aneurysm Trial (ISAT) study, including age, sex, the frequency of retreatment and rebleeding, and quality of life values. The total costs calculated included those associated with disability, hospitalization, retreatment, rebleeding, and incremental cost-effectiveness ratios (ICERs) that were estimated during a one-year period.

The researchers found that the median estimated costs of endovascular and neurosurgical treatments were U.S. $45,493 and $41,769, respectively. The overall quality-adjusted life years (QALY) in the endovascular group was 0.69, and for the neurosurgical group it was 0.64. Thus, the cost per QALY in the endovascular group was $65,424, and in the neurosurgical group it was $64,824. However, the median estimated ICER at one year for endovascular treatment, compared to neurosurgical treatment was higher, at $72,872 per QALY gained. The researchers concluded that while endovascular treatment is more costly, it is associated with better outcomes than the neurosurgical alternative. Also, with the accrual of additional years with a better outcome status, the researchers predict that the ICER for endovascular coiling would be expected to progressively decrease and eventually even reverse. The study was published in the May 2009 issue of the Journal of Neurosurgery.

"The minimally invasive treatment is better tolerated in selected critically ill patients with ruptured brain aneurysms; the procedure is effective in preventing a second rupture but currently limited in terms of cost, due to the need for additional follow-up procedures to treat new aneurysm growth,” said lead author Alberto Maud, M.D. "However, a new generation of devices promises to provide more permanent obliterations for aneurysms. It should be noted that despite additional treatments, patients treated with endovascular treatment continued have lower rates of death and disability than those treated with open surgery.”

The incremental cost-effectiveness ratio of an intervention in health care represents the additional cost of one unit of outcome gained (such as a QALY or infection averted) by a healthcare intervention or strategy, when compared to the next best alternative, mutually exclusive intervention, or strategy. The term "incremental" does not have the standard economic meaning; normally, the effects of an incremental change refer to the effect of an additional unit of a specific measurement--for example, the effect of an additional dollar spent on a public health awareness campaign--but in this case, it is not the effect of an incremental change in some intervention that is being compared, but rather the effect of switching interventions.

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