Socioeconomic IssuesCost-effectiveness of clipping vs coiling of intracranial aneurysms after subarachnoid hemorrhage in a developing country—a prospective study
Introduction
Aneurysmal subarachnoid hemorrhage (SAH) is a significant cause of mortality and continuing morbidity worldwide. The frequency of SAH due to rupture of intracranial aneurysm is 6 to 8 per 100 000 in most western populations [3,17]. Ruptured aneurysms can be treated by either a microsurgical technique or endovascular coiling. Neurosurgical intervention to clip the aneurysm entails a craniotomy and aims to prevent rebleeding of the aneurysm by placing a clip across its neck, thus, excluding the aneurysm from circulation. This procedure carries a 98% certainty of elimination of the threat of rerupture [10]. In the 1960s, McKissock et al [20], [21] published a series of prospective trials, which showed that, depending on the location of the aneurysm, benefits of surgery outweighed the risks in most of the circumstances. With extensive refinement in microsurgical techniques in the 1970s and 1980s, clipping of intracranial aneurysms became the criterion standard in the treatment of intracranial aneurysms.
In 1990, a detachable platinum coil device, the Guglielmi Detachable Coil (GDC), was introduced. The detachable coil obstructs the aneurysmal lumen and induces secondary thrombosis of the aneurysm. The introduction of an alternative to neurosurgical clipping gave rise to the need for identifying the patient population suitable for receiving endovascular treatment. Globally, the frequency of use of this technique varies widely [13]. Hence, there is a need of high-quality evidence to establish the efficacy and safety of endovascular coiling, especially in a developing country such as Pakistan.
The International Subarachnoid Aneurysm Trial (ISAT) is the first multicenter prospective randomized trial comparing the 2 options [22]. A total of 2143 patients with ruptured intracranial aneurysms were randomly assigned to clipping (n = 1070) or coiling (n = 1073). At 1 year, the outcome was assessed by a modified Rankin Score to determine dependency and death in these patients. A significant difference was found between the groups, and the trial was abandoned; 22.7% of coiled patients were dependent or dead compared with 30.6% of those subjected to surgery. The annualized risk of rebleeding after coiling was 0.16% and zero for clipping.
International Subarachnoid Aneurysm Trial has affected the approach to patients with intracranial aneurysms in neurosurgical centers across the globe. The changes brought about by ISAT will affect not only the mode of treatment but also the resource allocation as well. However, the cost of treatment differs substantially worldwide. These cost variations may assume significant importance in developing countries. In many developing countries with low per capita income and very limited medical insurance, cost-effectiveness greatly influences decision making when choosing between 2 comparable treatment options.
At Aga Khan University Hospital, Karachi, Pakistan, endovascular coiling has been in use since 2004, and we are the only neurosurgical center in Pakistan offering this service. The objective of this study was to compare the clinical outcome and the cost of endovascular coiling vs neurosurgical clipping in this part of the world.
Section snippets
Patients and methods
The study population consisted of 55 patients with proven aneurysmal SAH who were actively treated for ruptured aneurysms at Aga Khan University Hospital between January 2004 and June 2007 by a team of specialists including neurosurgeons who are trained in microvascular surgery and interventional neuroradiologist trained in endovascular surgery. Patients with aneurysmal SAH were identified prospectively. The Department of Neurosurgery at our institution is the only neurosurgical unit in
Results
Of the 55 patients included in our study, 31 patients underwent clipping and 24 received endovascular treatment. The mean age in years for coiling and clipping was 38 and 45, respectively, and the ratio of male to female was 1:1.3.
According to the Hunt and Hess system, most of the patients (43) were found to be in the range of 1 to 2. Of these 43 patients, 18 underwent coiling and 25 were clipped. The remaining 12 patients had a grade ranging from 3 to 4, making them high-risk candidates for
Discussion
The ISAT trial demonstrated that for aneurysms suitable for both endovascular coiling and neurosurgical clipping, endovascular treatment results in better clinical outcomes measured at 2 months and 1 year of follow-up. Because the use of endovascular therapy increases in the treatment of intracranial aneurysms, resource allocation should be based on this new pattern of practice. A few studies have compared the cost of coiling and clipping of ruptured intracranial aneurysms, and none, to the
Conclusion
In our study, there was no significant difference in the clinical outcome of coiling and clipping of ruptured intracranial aneurysms; however, clipping is more cost-effective in our setup than coiling. Because the results of this study reflect the practices of a single institution, a large multicenter study from different developing countries may be required to confirm our findings, and each new technique must be evaluated in careful well-designed studies before generalized use.
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