Routine angiography after surgery for ruptured intracranial aneurysms: A cost versus benefit analysis

PURPOSE: To assess the cost versus the benefit of routine cerebral angiography after surgery for ruptured aneurysms. METHODS: Decision tree and Markov analyses that used cohort simulation were conducted to determine the incremental cost:benefit ratio of routine postsurgical angiography. Input data for unexpected partially clipped and unclipped cerebral aneurysms were estimated from the literature for the following variables: frequency; annual rate of subsequent hemorrhage; morbidity and mortality rates of subsequent hemorrhage; efficacy and morbidity and mortality rates of subsequent surgery; and costs of subsequent surgery, angiography, subsequent hemorrhage of aneurysm, and rehabilitation. RESULTS: Baseline input variables resulted in an acceptable cost:benefit ratio for routine postsurgical angiography. However, essentially all of the benefit was derived from intervening in cases of unexpected unclipped aneurysms rather than partially clipped aneurysms. Isolated instances of angiography and subsequent surgery for unexpected partially clipped aneurysms yielded unacceptable cost:benefit ratios. Surgical costs had minimal effect on the analysis. CONCLUSIONS: When routine postsurgical angiography was performed primarily to diagnose and to subsequently operate on unexpected partially clipped aneurysms, the cost:benefit ratio was unacceptable. However, even low frequencies of unexpected unclipped aneurysms resulted in favorable cost:benefit ratios.