Cost-effectiveness of clipping vs coiling of intracranial aneurysms after subarachnoid hemorrhage in a developing country--a prospective study

Surg Neurol. 2009 Oct;72(4):355-60; discussion 360-1. doi: 10.1016/j.surneu.2008.11.003. Epub 2009 Jul 17.


Background: Endovascular coil treatment is being used increasingly as an alternative to clipping for some ruptured intracranial aneurysms. The relative benefits of these 2 approaches have yet to be fully established. The aim of this study was to compare the clinical outcome, resource consumption, and cost-effectiveness of endovascular treatment vs surgical clipping in a developing country.

Methods: The study population consisted of 55 patients with aneurysmal subarachnoid hemorrhage (SAH) identified prospectively from January 2004 to June 2007. Of the 55 patients with ruptured intracranial aneurysms, 31 underwent surgical clipping, whereas 24 were treated via interventional coils. Clinical outcome at 6 months, using the modified Rankin Scale, and cost of treatment related to all aspects of the inpatient stay were evaluated in both groups.

Results: The average age of the patients in the endovascular group was 38 years, whereas in the surgical group, it was 45 years. Most patients (43) were found to be in grades (1 and 2). Of these patients, 18 received coils and 25 were clipped. The remaining 12 patients were of poor grades (3 and 4), of which 6 had coiling and 6 underwent clipping. Most the patients (46/55) had anterior circulation aneurysms, and the rest of the patients (9/55) had posterior circulation aneurysms. The clinical outcome was similar in comparison (good in 81% for clipping and 83% for coiling). The average total cost for patients undergoing endovascular treatment of the aneurysms was $5080, whereas the average total cost of surgical clipping was $3127.

Conclusion: Patients with aneurysmal SAH whom we judged to require coiling had higher charges than patients who could be treated by clipping. The benefits of apparent decrease in length of stay in the endovascular group were offset by higher procedure price and cost of consumables. There was no significant difference in clinical outcome at 6 months. We have proposed a risk scoring system to give guidelines regarding the choice of treatment considering size of aneurysm and resource allocation.

MeSH terms

  • Adult
  • Cost-Benefit Analysis
  • Developing Countries*
  • Embolization, Therapeutic / economics
  • Embolization, Therapeutic / instrumentation
  • Embolization, Therapeutic / methods
  • Female
  • Humans
  • Intracranial Aneurysm / diagnostic imaging
  • Intracranial Aneurysm / pathology
  • Intracranial Aneurysm / surgery*
  • Male
  • Middle Aged
  • Neurosurgical Procedures / economics*
  • Neurosurgical Procedures / instrumentation*
  • Neurosurgical Procedures / methods
  • Outcome Assessment, Health Care / methods
  • Pakistan
  • Postoperative Complications / epidemiology
  • Postoperative Complications / prevention & control
  • Prospective Studies
  • Prostheses and Implants / economics
  • Prostheses and Implants / statistics & numerical data
  • Radiography
  • Risk Factors
  • Subarachnoid Hemorrhage / diagnostic imaging
  • Subarachnoid Hemorrhage / pathology
  • Subarachnoid Hemorrhage / surgery*
  • Surgical Instruments / economics
  • Surgical Instruments / statistics & numerical data
  • Vascular Surgical Procedures / economics*
  • Vascular Surgical Procedures / instrumentation*
  • Vascular Surgical Procedures / methods