The management of unruptured intracranial aneurysms (UIAs) in individuals aged 80 and older poses significant challenges due to interactions between treatment-related morbidity, rupture risks, and competing mortality from unrelated causes. With an increasing elderly population and advances in imaging, clinicians in Korea are prompted to evaluate whether preventive treatment offers a net benefit when observing incidentally detected UIAs.
Recent studies have sought to fill the knowledge gap for octogenarians, yet the data remains varied and at times contradictory. For instance, analyses from the National Inpatient Sample provided some estimates for periprocedural complications but often focus on short-term rather than long-term outcomes. Other studies have limitations in their heterogeneous definitions of outcomes, making it difficult to draw definitive conclusions applicable across the elderly cohort.
To create a framework for understanding the outcomes associated with treatment versus observation, a competing-risk Markov decision model was constructed to analyze varying scenarios for patients aged 80, 85, and 90. This model will clarify how different treatment approaches might influence long-term patient management.
The primary aim of this study was to compare observation against endovascular coiling for treating UIAs in octogenarian patients within a decision-analytic model. Three index ages (80, 85, and 90 years) and two sexes were utilized to develop demographic panels for analysis. The model's perspective was strictly patient-centered, assessing outcomes through the lens of treatment morbidity, mortality, and the chance of aneurysm rupture.
The model considered two additional treatment strategies, microsurgical clipping and stent-assisted coiling, making it possible to evaluate a broader clinical context. Both strategies were included to provide comparative insights on their respective risks and benefits relative to coiling versus observation.
The structure of the Markov model included several states representing varying health outcomes after treatment. These comprised:
Each patient cohort began in a well-survival state and could transition to various other states based on their treatment outcomes or complications arising from either ruptures or treatment procedures.
The decision model revealed nuanced findings. In median comparisons across multiple panels, observation consistently demonstrated favorable outcomes in patients aged 90 and in many male panels aged 85 and older. On the other hand, coiling was more beneficial in specific panels among the 80 and 85 age groups, particularly among selected females.
Moreover, the probabilities that coiling was favored varied significantly across different scenarios, ranging from as low as 0.000 to as high as 0.984, indicating that treatment preferences were highly conditional and dependent on patient demographics and specific model parameters.
A broader sensitivity analysis, which factored in quality-adjusted life years (QALYs) and structural variables affecting outcomes, illustrated that treatment preferences are heavily influenced by the choice of endpoint definitions and historical treatment-risk estimates.
The findings emphasize the complexities in managing UIAs among the elderly, particularly as treatment risks and expected outcomes evolve with patient age and health status. The varied results underline the importance of engaging in shared decision-making, considering both clinical evidence and patient values in determining the optimal approach for each individual.
Furthermore, the data highlights the necessity for more concentrated studies focused on the elderly cohort to establish a clearer treatment pathway tailored to their unique health considerations, ultimately improving care standards in this often-overlooked demographic.
In conclusion, while this decision-analytic modeling study provides valuable insights into the management of UIAs in elderly patients, it does not yield direct recommendations for individual treatment. Instead, it serves as a framework for understanding the relative benefits of observation versus coiling, guiding clinical consensus on the appropriate management of UIAs in octogenarians. The work reinforces the need for future research to build a more cohesive understanding of treatment efficacy in this vulnerable patient group.