Cost-Effectiveness of Intracranial Aneurysm Screening: A Systematic Review

Clinical Snapshot

Key Findings

• P Value: Not applicable — systematic review of health economic modelling studies; no inferential statistics reported

• Effect Size: 12 of 15 modelling studies (80%) reported screening as cost-effective (n=8) or cost-saving (n=4). All 10 studies evaluating high-risk populations found screening cost-effective. Of 6 studies evaluating the general population, 3 found screening not cost-effective or dominated by no screening.

• Primary Outcome: Cost-effectiveness of unruptured intracranial aneurysm (UIA) screening compared with no screening, assessed across general and high-risk populations

• Nnt Or Sensitivity: Not reported in the abstract. Key model input parameters: UIA prevalence ranged from 0.5% to 19% across studies; annual rupture rates ranged from 0.16% to 12.9%. These wide ranges substantially affect modelled cost-effectiveness conclusions and preclude reliable NNT estimation.

• Confidence Interval: Not applicable — no pooled quantitative synthesis performed; individual study ICERs not reported in the abstract

Clinical Application

Feasibility of UIA screening depends on availability of high-resolution MR angiography (MRA) or CT angiography, neuroradiology reporting capacity, and access to neurovascular multidisciplinary teams for management of incidentally detected aneurysms. Screening programmes require clear referral pathways, patient counselling infrastructure, and defined treatment thresholds. The wide variation in modelled rupture rates and prevalence estimates highlights that real-world programme design requires locally validated epidemiological data. Prospective screening registries are needed before widespread implementation. In Australia, there is no nationally endorsed UIA screening programme. The Royal Australian College of General Practitioners (RACGP) does not currently recommend routine intracranial aneurysm screening in the general population. MRA for UIA detection is not listed on the Medicare Benefits Schedule (MBS) as a screening indication; it is available for symptomatic or high-risk clinical indications. Patients with ADPKD — the highest-risk group consistently identified across included studies — may be referred for neurovascular imaging through specialist nephrology or neurology services, but this is not standardised nationally. The Therapeutic Goods Administration (TGA) has approved endovascular coiling devices and flow diverters for aneurysm treatment, meaning treatment infrastructure exists. However, the cost-effectiveness threshold used in Australian health technology assessment (approximately AUD 50,000–70,000 per QALY, as applied by the Pharmaceutical Benefits Advisory Committee [PBAC]) would need to be met by any future screening programme evaluation. Given that all included studies are of low quality and use non-Australian epidemiological inputs, direct application to Australian cost-effectiveness thresholds is not currently possible. Australian neurosurgical and neurovascular societies should consider developing prospective registry data to inform a locally relevant economic analysis. Adults in defined high-risk groups for UIA or SAH, particularly those with ADPKD, a first-degree family history of intracranial aneurysm or SAH, bicuspid aortic valve, or coarctation of the aorta. Evidence for general population screening remains conflicting and insufficient to support routine implementation. Female smokers were also identified as a modelled high-risk group.

Abstract

BACKGROUND AND OBJECTIVES: Subarachnoid hemorrhage (SAH) is associated with high mortality and long-term morbidity, as well as a considerable economic burden. Screening for unruptured intracranial aneurysms (UIAs) has the potential to reduce mortality and disability related to SAH, but whether the related costs are justified and provide true health benefits-either in general or specific high-risk populations-remains unclear. Therefore, we conducted a systematic review to determine whether screening of UIAs has been estimated to be cost-effective in any population. METHODS: We conducted a literature search in PubMed, Scopus, and Web of Science for studies reporting economic analyses of UIA screening. Eligible studies assessed screening in the general population or in populations with an increased risk of SAH or UIAs. Data were extracted on input parameters, type of model, perspective, and cost-effectiveness outcomes. Study quality was assessed using a modified ECOBIAS checklist. RESULTS: We included 15 modelling studies from 8 countries, published during 1996-2025. Nine studies evaluated high-risk populations (autosomal dominant polycystic kidney disease, bicuspid aortic valve, coarctation of the aorta, family history, and female smokers), 5 evaluated the general population and 1 examined both. Model input parameters varied widely across studies; assumed UIA prevalence ranged from 0.5% to 19% and annual rupture rates from 0.16% to 12.9%. Twelve studies reported screening as cost-effective (n = 8) or cost-saving (n = 4). All 10 studies evaluating high-risk populations found screening cost-effective. Of 6 studies analyzing screening of general population, 3 concluded it was not cost-effective or was dominated by no screening. All 15 studies were classified as of low quality according to the risk of bias assessment. DISCUSSION: Current economic analyses suggest that screening is cost-effective for high-risk populations, whereas evidence for general population remains conflicting. However, the evidence consists exclusively of modelling studies, many with important methodologic limitations. Until prospective data better define SAH risk in screened populations and models more accurately reflect the natural history of aneurysms, the economic analyses of screening should be interpreted with caution. Future research should address these limitations and restrict screening strategies to populations with a demonstrated increase in the incidence of SAH rather than with elevated UIA prevalence alone.