Optimal screening strategy for familial intracranial aneurysms: A cost-effectiveness analysis

OBJECTIVE: Individuals with a family history of subarachnoid hemorrhage (SAH), defined as 2 or more affected first-degree relatives, have an increased risk of aneurysm formation and rupture. Screening such individuals for intracranial aneurysms is advocated, but its effectiveness and cost-effectiveness are unknown, as are the optimal age ranges and interval for screening.

METHODS: With a Markov model and Monte Carlo simulations we compared screening with no screening in individuals with a family history of SAH. We varied age ranges (starting screening at 20, 30, or 40 years old, ending screening at 60, 70, or 80 years old) and screening intervals (2-, 3-, 5-, 7-, 10-, and 15-year interval), and analyzed the impact in costs and quality-adjusted life years (QALY).

RESULTS: Screening individuals with a family history of SAH is cost-effective. The strategy with the lowest costs per QALY was to screen only twice, at 40 and 55 years old. Sequentially lengthening the screening period and decreasing the screening interval yielded additional health benefits at acceptable costs up to screening from age 20 to 80 every 7 years. More frequent screening within this age range still provided extra QALYs, with an incremental cost-effectiveness ratio more favorable than €26,308/QALY ($38,410/QALY).

CONCLUSION: This study provides evidence for recommendations to screen individuals with 2 or more first-degree relatives with subarachnoid hemorrhage. The optimal screening strategy according to our model is screening from age 20 until 80 every 7 years given a cost-effectiveness threshold of €20,000/quality-adjusted life year (QALY) ($29,200/ QALY).