Observation versus coiling for unruptured intracranial aneurysms in octogenarians: A decision-analytic modeling study
- 1Department of Neurosurgery, Eulji University Hospital, Eulji University College of Medicine, Daejeon, Republic of Korea
- 2Department of Neurology, Eulji University Hospital, Eulji University College of Medicine, Daejeon, Republic of Korea
Abstract
Management of unruptured intracranial aneurysms in patients aged 80 years and older remains uncertain because treatment morbidity, rupture risk, post-rupture outcome, and competing mortality interact. We constructed a competing-risk Markov decision model comparing observation with endovascular coiling in Korean patients at index ages 80, 85, and 90 years; microsurgical clipping and stent-assisted coiling or flow diversion served as additional scenarios. The primary outcome was the undiscounted lifetime cumulative incidence of aneurysm- or treatment-attributable events—treatment morbidity, treatment death, rupture death, or rupture poor outcome—counted as a first-event composite in which all four components carry equal weight regardless of severity, duration, or reversibility. Periprocedural coiling morbidity and mortality were anchored to a U.S. National Inpatient Sample analysis from 2001–2008, and residual post-treatment rupture risk was fixed at 10% of the natural-history rate. Under this original endpoint, median differences favored observation in every age-90 panel and in all male panels at age ≥ 85, and favored coiling in selected age-80 panels and selected age-85 female panels; the probability that coiling was favored ranged from 0.000 to 0.984. A 24-panel, 3%-discounted severity-weighted quality-adjusted analysis was added, together with structural sensitivities for treatment-morbidity recovery, residual rupture risk, and coiling morbidity. Across 30 endpoint-direction comparisons, with each Ma panel mapped to its two legacy marginals, 21 were concordant; all nine discordant comparisons shifted from observation toward coiling, and eight had 95% quality-adjusted uncertainty intervals spanning zero. Median-direction changes under the executed structural sensitivities were confined to modified Rankin Scale-based panels with reference quality-adjusted differences near zero and uncertainty intervals spanning zero. Modeled treatment preference was therefore conditional on endpoint definition and key structural assumptions, including historical treatment-risk estimates and uncalibrated residual post-treatment rupture risk; these model outputs do not establish treatment recommendations for individual patients.
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BibTeX
@article{yoo2026observation,
title = {{Observation versus coiling for unruptured intracranial aneurysms in octogenarians: A decision-analytic modeling study}},
author = {Hyun Dong Yoo and Jae Guk Kim and Seung Young Chung},
journal = {PLOS One},
year = {2026},
month = sep,
doi = {10.1371/journal.pone.0357374},
url = {https://doi.org/10.1371/journal.pone.0357374},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Observation versus coiling for unruptured intracranial aneurysms in octogenarians: A decision-analytic modeling study
AU - Hyun Dong Yoo
AU - Jae Guk Kim
AU - Seung Young Chung
PY - 2026
DA - 2026/09/01
JO - PLOS One
DO - 10.1371/journal.pone.0357374
UR - https://doi.org/10.1371/journal.pone.0357374
AB - Management of unruptured intracranial aneurysms in patients aged 80 years and older remains uncertain because treatment morbidity, rupture risk, post-rupture outcome, and competing mortality interact. We constructed a competing-risk Markov decision model comparing observation with endovascular coiling in Korean patients at index ages 80, 85, and 90 years; microsurgical clipping and stent-assisted coiling or flow diversion served as additional scenarios. The primary outcome was the undiscounted lifetime cumulative incidence of aneurysm- or treatment-attributable events—treatment morbidity, treatment death, rupture death, or rupture poor outcome—counted as a first-event composite in which all four components carry equal weight regardless of severity, duration, or reversibility. Periprocedural coiling morbidity and mortality were anchored to a U.S. National Inpatient Sample analysis from 2001–2008, and residual post-treatment rupture risk was fixed at 10% of the natural-history rate. Under this original endpoint, median differences favored observation in every age-90 panel and in all male panels at age ≥ 85, and favored coiling in selected age-80 panels and selected age-85 female panels; the probability that coiling was favored ranged from 0.000 to 0.984. A 24-panel, 3%-discounted severity-weighted quality-adjusted analysis was added, together with structural sensitivities for treatment-morbidity recovery, residual rupture risk, and coiling morbidity. Across 30 endpoint-direction comparisons, with each Ma panel mapped to its two legacy marginals, 21 were concordant; all nine discordant comparisons shifted from observation toward coiling, and eight had 95% quality-adjusted uncertainty intervals spanning zero. Median-direction changes under the executed structural sensitivities were confined to modified Rankin Scale-based panels with reference quality-adjusted differences near zero and uncertainty intervals spanning zero. Modeled treatment preference was therefore conditional on endpoint definition and key structural assumptions, including historical treatment-risk estimates and uncalibrated residual post-treatment rupture risk; these model outputs do not establish treatment recommendations for individual patients.
SN - 1932-6203
ER -