title: Factors influencing management of unruptured intracranial aneurysms: an analysis of 424 consecutive patients.
abstract: OBJECTIVE The choice between treating and observing unruptured intracranial aneurysms is often difficult, with little guidance on which variables should influence decision making on a patient-by-patient basis. Here, the authors compared demographic variables, aneurysm-related variables, and comorbidities in patients who received microsurgical or endovascular treatment and those who were conservatively managed to determine which factors push the surgeon toward recommending treatment. METHODS A retrospective chart review was conducted of all patients diagnosed with an unruptured intracranial aneurysm at their institution between January 1, 2013, and January 1, 2016. These patients were dichotomized based on whether their aneurysm was treated. Demographic, geographic, socioeconomic, comorbidity, and aneurysm-related information was analyzed to assess which factors were associated with the decision to treat. RESULTS A total of 424 patients were identified, 163 who were treated surgically or endovascularly and 261 who were managed conservatively. In a multivariable model, an age < 65 years (OR 2.913, 95% CI 1.298-6.541, p = 0.010), a lower Charlson Comorbidity Index (OR 1.536, 95% CI 1.274-1.855, p < 0.001), a larger aneurysm size (OR 1.176, 95% CI 1.100-1.257, p < 0.001), multiple aneurysms (OR 2.093, 95% CI 1.121-3.907, p = 0.020), a white race (OR 2.288, 95% CI 1.245-4.204, p = 0.008), and living further from the medical center (OR 2.125, 95% CI 1.281-3.522, p = 0.003) were all associated with the decision to treat rather than observe. CONCLUSIONS Whereas several factors were expected to be considered in the decision to treat unruptured intracranial aneurysms, including age, Charlson Comorbidity Index, aneurysm size, and multiple aneurysms, other factors such as race and proximity to the medical center were unanticipated. Further studies are needed to identify such biases in patient treatment and improve treatment delineation based on patient-specific aneurysm rupture risk.
authors.affiliation: Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.
authors.forename: Jian
authors.initials: J
authors.lastname: Guan
authors.affiliation: Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.
authors.forename: Michael
authors.initials: M
authors.lastname: Karsy
authors.affiliation: Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.
authors.forename: William T
authors.initials: WT
authors.lastname: Couldwell
authors.affiliation: Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Schmidt
authors.affiliation: Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.
authors.forename: Philipp
authors.initials: P
authors.lastname: Taussky
authors.affiliation: Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.
authors.forename: Joel D
authors.initials: JD
authors.lastname: MacDonald
authors.affiliation: Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.
authors.forename: Min S
authors.initials: MS
authors.lastname: Park
mesh_terms: D000368:Aged; D000066491:Clinical Decision-Making; D000072700:Conservative Treatment; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000628:therapy*; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D012189:Retrospective Studies
keywords: CCI = Charlson Comorbidity Index; aneurysm clipping; endovascular treatment; health care disparities; intracranial aneurysm; treatment decisions; vascular disorders