Imaging of Carotid Arteries in Symptomatic Patients: Cost-effectiveness of Diagnostic Strategies

Buskens, Erik; Nederkoorn, Paul J.; Woude, T Buijs-van der; Mali, Willem P.Th.M.; Kappelle, L. Jaap; Eikelboom, B.C.; Graaf, Yolanda van der; Hunink, M. G. Myriam

doi:10.1148/radiol.2331030863

Cited by 106 publications

(83 citation statements)

References 25 publications

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“…Out of a total of 12 full cost-effectiveness studies that were identified as potentially relevant, four studies were deemed suitable for inclusion in the review: Wardlaw and colleagues, 5,26 Buskens and colleagues, 284 and Tholen and colleagues. 285 Among the eight not considered relevant, one study by the Centre for Evidence-based Purchasing published in 2008 105 concluded that there was no information on which to base a cost-effectiveness assessment of DWI in TIA/minor stroke, and was not considered further.…”

Section: Resultsmentioning

confidence: 99%

“…The study by Buskens and colleagues 284 examined the cost-effectiveness of non-invasive strategies in patients with TIA or minor stroke suspected of having carotid artery stenosis (CAS). The non-invasive strategies in this study included DUS, MRA and the two examinations combined; all were compared against intra-arterial digital subtraction angiography (DSA), which was the reference standard.…”

Section: Cost-effectiveness Analyses Of Imaging In Strokementioning

confidence: 99%

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An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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BackgroundPatients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.ObjectivesIs MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as ‘one-stop’ brain-carotid imaging? What is the current UK availability of services for stroke prevention?Data sourcesPublished literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.Review methodsSystematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.ResultsThe pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35–41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40–45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51–54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with ‘CT scan all patients’ MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. ‘One-stop’ CT/MR angiographic-plus-brain imaging was not cost-effective.LimitationsData on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.ConclusionsMagnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Resultsmentioning

confidence: 99%

Section: Cost-effectiveness Analyses Of Imaging In Strokementioning

confidence: 99%

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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“…33 The annual costs of care for disabled patients after preventive treatment or SAH were taken from data on long-term care in stroke patients. 34 The model does not account for any costs of diagnostic follow-up in the notreatment arm. All cost estimates were updated to 2005 Euros based on Dutch inflation indices (http://statline.cbs.nl).…”

Section: Methods Model Structurementioning

confidence: 99%

Cost-effectiveness of preventive treatment of intracranial aneurysms

et al. 2009

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“…Digital subtraction angiography is still occasionally necessary as an arbiter when the results of noninvasive procedures and the clinical diagnosis are not concordant. Results from cost-effectiveness studies 51,52 showed that duplex sonography as a single examination strategy was both less expensive and more effective than nearly all other strategies, including DSA. The combination strategy of CDDS and MRA has a slight benefit in clinical outcome but at extremely high additional costs, in which DSA is inferior for the associated complications.…”

Section: Comparison Of the Diagnostic Value Of Color Duplex Sonographmentioning

confidence: 99%

“…The combination strategy of CDDS and MRA has a slight benefit in clinical outcome but at extremely high additional costs, in which DSA is inferior for the associated complications. [51][52][53] The main drawback of CDDS is the high dependence on technological factors in both performance and interpretation. For the operator to be familiar with the baseline, about 200 examinations are needed, and a considerable larger number are needed for reliable grading of ICA stenosis and knowledge of pitfalls and limitations of the examination.…”

Section: Comparison Of the Diagnostic Value Of Color Duplex Sonographmentioning

confidence: 99%

Diagnosing Carotid Stenosis by Doppler Sonography

Gaitini

Soudack

2005

Journal of Ultrasound in Medicine

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Objective. The goal of this review article is to present the state of the art in the clinical applications and technical performance and interpretation of carotid sonographic examinations. Methods. Relevant publications regarding color and duplex Doppler sonography (CDDS) of the carotid arteries extracted from a computerized database (MEDLINE) and from references cited in these articles not appearing on the Internet were reviewed. Results. The ability to quickly and efficiently identify stenosis in the carotid artery is an important goal for clinicians and vascular surgeons. Identification of potentially treatable carotid stenosis enables selection of appropriate candidates for endarterectomy or stent implantation. Advances in performance and interpretation of carotid sonographic studies over the last 20 years have been driven by technological improvements in gray scale and CDDS examinations and have made carotid sonography an important means to reach this goal. On the basis of CDDS, intimamedia thickness measurements and plaque location and characterization on gray scale imaging, flow disturbance and areas of stenosis on color Doppler sonography, and flow velocities on spectral Doppler sonography are obtained. The degree of the diameter of a stenosis of the internal carotid artery is the main parameter used for therapeutic approaches. Advantages and limitations of the method are included. Conclusions. Carotid sonography is a unique imaging method for the investigation of carotid abnormalities. Noninvasive, accurate, and cost-effective, it provides morphologic and functional information. It is increasingly becoming the first and often the sole imaging study before endarterectomy, whereas costly and invasive procedures are reserved for special cases.

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Imaging of Carotid Arteries in Symptomatic Patients: Cost-effectiveness of Diagnostic Strategies

Abstract: Duplex US performed without additional imaging is cost-effective in the selection of symptomatic patients suitable for endarterectomy. Adding MR angiography increases effectiveness slightly at disproportionately high costs, whereas DSA is inferior because of associated complications.

Cited by 106 publications

References 25 publications

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Cost-effectiveness of preventive treatment of intracranial aneurysms

Diagnosing Carotid Stenosis by Doppler Sonography

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