Cost-Effectiveness of Angiographic Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Kalra, Vivek B.; Wu, Xiao; Forman, Howard P.; Malhotra, Ajay

doi:10.1161/strokeaha.114.006679

Cited by 26 publications

(11 citation statements)

References 31 publications

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“…73 A cost-effectiveness analysis of angiographic imaging in patients with pSAH also shows limited use of multiple follow-up imaging studies. 74 Repeat imaging can be considered in patients in whom the clinical picture is not consistent with pSAH. Vasospasm and hydrocephalus are infrequent with pSAH.…”

Section: Discussionmentioning

confidence: 99%

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Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Kalra

Matouk

et al. 2015

Stroke

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A retrospective keyword search was performed for reports containing the words perimesencephalic, prepontine, or pretruncal in the past 6 years at our single, large, multisite, academic institution after obtaining Institutional Review Board approval with waiver of consent. Inclusion criteria consisted of patients with perimesencephalic pattern of blood on initial noncontrast CT undergoing CTA and DSA within 24 hours of admission and additional follow-up angiographic imaging. Patients with history of trauma, diffuse SAH, thick blood above the perimesencephalic cistern, and intraventricular blood were excluded. Two-hundred fourteen CTA reports met keyword search Background and Purpose-Multiple studies have shown that negative computed tomographic angiograms (CTAs) are reliable in excluding aneurysms in patients with isolated perimesencephalic subarachnoid hemorrhage (pSAH). We evaluate the use of digital subtraction angiography versus CTA for initial diagnosis and of angiographic follow-ups in patients with pSAH by performing an institutional analysis and a meta-analysis of literature. Methods-Retrospective institutional analysis of patients with pSAH was performed from 2008 to 2014. The number and types of follow-up imaging studies were tabulated. Initial and follow-up studies were evaluated by an experienced neuroradiologist for intracranial aneurysm. Meta-analysis of literature was performed to assess the use of initial digital subtraction angiography and of follow-up imaging. Results-Our institutional review revealed no additional use of initial digital subtraction angiography or of any angiographic follow-up after initial negative CTA in patients with pSAH on noncontrast CT. Meta-analysis of 40 studies yielded a total of 1031 patients. Only 8 aneurysms were first diagnosed on follow-ups (0.78%). Careful review showed that some of these aneurysms reported on follow-up are of questionable validity. Initial digital subtraction angiography and follow-up imaging after a negative initial CTA showed no statistically significant benefits. Conclusions-In

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Section: Discussionmentioning

confidence: 99%

“…45,50 Given the excellent sensitivity and the noninvasive nature of CTA, repeat imaging may be performed preferentially using CTA. 74 by guest on May 9, 2018 http://stroke.ahajournals.org/ Downloaded from…”

Section: Discussionmentioning

confidence: 99%

Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Kalra

Matouk

et al. 2015

Stroke

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“…A false‐negative CTA would be a case of nonaneurysmal SAH, 48.2% of which were assumed to be perimesencephalic SAH (pSAH) . A CTA would be performed with no aneurysm detection and no follow‐ups are necessary in this case . In the remaining nonaneurysmal, non‐pSAH cases, a digital subtraction angiography was assumed to be performed according to the recommendation by Agid et al These patients would have a better prognosis than aneurysmal SAH patients with low risk for subsequent SAH …”

Section: Methodsmentioning

confidence: 99%

Cost‐effectiveness Analysis of Follow‐up Strategies for Thunderclap Headache Patients With Negative Noncontrast CT

Malhotra

Kalra

et al. 2016

Academic Emergency Medicine

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Objectives: Accurate diagnosis of acute subarachnoid hemorrhage (SAH) is critical in thunderclap headache patients due to high morbidity and mortality associated with missed aneurysmal bleeds. The objective of this study was to determine the utility of computed tomography angiography (CTA) in managing patients with acute, severe headaches and negative noncontrast CT and assess the costeffectiveness of three different screening strategies-no follow up, CTA, and lumbar puncture (LP).Methods: A modeling-based economic evaluation was performed with a time horizon of 1 year for thunderclap headache patients in the emergency department with negative noncontrast CT for SAH. Sensitivity analyses were performed to determine the effect of sensitivity of CT and the prevalence of SAH on cost-effectiveness.Results: Lumbar puncture follow-up has the lowest cost and the highest utility in the mathematical model. The Monte Carlo simulation shows noncontrast CT with LP follow-up to be the most costeffective strategy in 85.3% of all cases even at a $1 million/quality-adjusted life-years willingness-to-pay. Sensitivity analyses demonstrate that LP follow-up should be performed, except for when CT sensitivity exceeds 99.2% and the SAH prevalence is below 3.2%, where no follow-up may be considered.Conclusions: Although CTA is frequently used for evaluation of thunderclap headache patients, its utility is not clearly defined. LP follow-up is shown to be the most cost-effective strategy for evaluation of thunderclap headache patients in most clinical settings.ACADEMIC EMERGENCY MEDICINE 2016;23:243-250 © 2016 by the Society for Academic Emergency Medicine S evere, acute headache remains a common cause for presentation to the emergency department (ED) and exclusion of subarachnoid hemorrhage (SAH) in these patients is a critical part of the workup.1,2 Nontraumatic SAH is caused by vascular lesions, such as aneurysms or ateriovenous malformation, in 85% cases and false-negative diagnosis can have increased morbidity and mortality.3,4 The conventional workup for thunderclap headache, or for a patient presenting with an acute onset of "the worst headache of his life," is a noncontrast CT. 5,6 In the case of a negative CT for acute SAH, a lumbar puncture (LP) is performed which is sensitive to small amounts of blood and xanthochromia in cerebrospinal fluid. However, LP is invasive with risks for complications and is also operator-dependent.7 Recent ED literature has proposed using a strategy of CT followed by CT angiography (CT/CTA) instead of CT/LP based on mathematical probabilities and CTA has been increasingly used in evaluating thunderclap headache patients with negative initial CTs. 7,8 Computed tomography angiography has become highly accurate for diagnosis of intracranial aneurysms, with 64-detector CTA having over 98% sensitivity and 100% specificity for aneurysm detection in setting of SAH.9 It is particularly sensitive in detection of aneurysms greater than 3 mm. 10 The tiny aneurysms possibly missed by CTA have a very l...

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“…Performing conventional angiography after negative findings on CTA may not be cost-effective and is not without risks. 6 We request that the authors elaborate on how a primitive BVR pattern might affirm the diagnosis of nonaneurysmal perimesencephalic hemorrhage and the utility of looking for it, in the absence of better evidence and based solely on association.…”

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confidence: 99%

Concerning “Nonaneurysmal Perimesencephalic Hemorrhage Is Associated with Deep Cerebral Venous Drainage Anomalies: A Systematic Literature Review and Meta-Analysis”

Liu

2016

AJNR Am J Neuroradiol

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Cost-Effectiveness of Angiographic Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Cited by 26 publications

References 31 publications

Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Cost‐effectiveness Analysis of Follow‐up Strategies for Thunderclap Headache Patients With Negative Noncontrast CT

Concerning “Nonaneurysmal Perimesencephalic Hemorrhage Is Associated with Deep Cerebral Venous Drainage Anomalies: A Systematic Literature Review and Meta-Analysis”

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