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Stroke. 2014 Dec;45(12):3576-82. doi: 10.1161/STROKEAHA.114.006679. Epub 2014 Oct 21.

Cost-effectiveness of angiographic imaging in isolated perimesencephalic subarachnoid hemorrhage.

Author information

1
From the Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT (V.B.K., H.P.F., A.M.); and Timothy Dwight College, Yale University, New Haven, CT (X.W.).
2
From the Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT (V.B.K., H.P.F., A.M.); and Timothy Dwight College, Yale University, New Haven, CT (X.W.). ajay.malhotra@yale.edu.

Abstract

BACKGROUND AND PURPOSE:

The purpose of this study is to perform a comprehensive cost-effectiveness analysis of all possible permutations of computed tomographic angiography (CTA) and digital subtraction angiography imaging strategies for both initial diagnosis and follow-up imaging in patients with perimesencephalic subarachnoid hemorrhage on noncontrast CT.

METHODS:

Each possible imaging strategy was evaluated in a decision tree created with TreeAge Pro Suite 2014, with parameters derived from a meta-analysis of 40 studies and literature values. Base case and sensitivity analyses were performed to assess the cost-effectiveness of each strategy. A Monte Carlo simulation was conducted with distributional variables to evaluate the robustness of the optimal strategy.

RESULTS:

The base case scenario showed performing initial CTA with no follow-up angiographic studies in patients with perimesencephalic subarachnoid hemorrhage to be the most cost-effective strategy ($5422/quality adjusted life year). Using a willingness-to-pay threshold of $50 000/quality adjusted life year, the most cost-effective strategy based on net monetary benefit is CTA with no follow-up when the sensitivity of initial CTA is >97.9%, and CTA with CTA follow-up otherwise. The Monte Carlo simulation reported CTA with no follow-up to be the optimal strategy at willingness-to-pay of $50 000 in 99.99% of the iterations. Digital subtraction angiography, whether at initial diagnosis or as part of follow-up imaging, is never the optimal strategy in our model.

CONCLUSIONS:

CTA without follow-up imaging is the optimal strategy for evaluation of patients with perimesencephalic subarachnoid hemorrhage when modern CT scanners and a strict definition of perimesencephalic subarachnoid hemorrhage are used. Digital subtraction angiography and follow-up imaging are not optimal as they carry complications and associated costs.

KEYWORDS:

angiography; digital subtraction

PMID:
25336513
DOI:
10.1161/STROKEAHA.114.006679
[Indexed for MEDLINE]
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