Safety, efficacy, and cost of surgery for patients with unruptured aneurysms deemed unsuitable for endovascular therapy.
BACKGROUND
Open surgery is a frequent option given to patients with unruptured intracranial aneurysms (UIAs) unsuitable for endovascular repair. Since the risk of rupture of UIAs is generally low, we determined whether the risks and costs of surgery in this patient subset are warranted.


METHODS
The safety, efficacy, and costs of minimally invasive surgery by minicraniotomy were evaluated in 102 consecutive patients with anterior circulation UIAs deemed unsuitable for endovascular repair by an interdisciplinary conference of surgeons and neurointerventionalists. Data from 107 UIA patients treated by endovascular means in the same period were used as the standard.


RESULTS
Surgical patients comprised a different subset of aneurysms, with more MCA and fewer paraophthalmic aneurysms (54 vs. 6, p < 0.0001 and 4 vs. 60, p < 0.0001, for minicraniotomy and endovascular, respectively). However, surgery incurred shorter anesthesia time (197.7 vs. 149.3 min, p < 0.0001), higher rates of complete aneurysm obliteration (94.57 vs. 66.67 %, p < 0.0001), and lower overall hospital costs ($8,287 CAD vs. $17,732 CAD, p < 0.0001) than the endovascular cohort. There were no treatment-related surgical deaths, but one patient had an mRS of 3 after 6 months due to temporal lobe epilepsy and memory problems. This compared favorably with the endovascular cohort in which two patients died due to treatment (mRS = 6) and one suffered a severe stroke (mRS = 5 at 6 months).


CONCLUSIONS
For patients counseled to undergo treatment but have UIAs unsuitable for endovascular repair, surgery is safe, effective, and cost-efficient.
Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada.
Christian
C
Zweifel
Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada.
Raphael Hillel
RH
Sacho
Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada.
Rachel
R
Tymianski
Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada.|Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Ivan
I
Radovanovic
Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada. miketym2@rogers.com.|Department of Surgery, University of Toronto, Toronto, Ontario, Canada. miketym2@rogers.com.
Michael
M
Tymianski
D003365:Costs and Cost Analysis; D004621:Embolization, Therapeutic / Q000009:adverse effects* / Q000191:economics / Q000379:methods; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects* / Q000191:economics / Q000379:methods
Costs; Endovascular treatment; Minicraniotomy and clipping; Outcome; Unruptured aneurysm