From the Department of Radiology and Biomedical Imaging (X.W., C.C.M., H.P.F.), Yale School of Medicine, New Haven, CT.
Department of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT.
Stroke. 2019 Sep;50(9):2396-2403. doi: 10.1161/STROKEAHA.119.025600. Epub 2019 Jul 25.
Background and Purpose- Our study aims to evaluate the cost-effectiveness of computed tomography angiography (CTA) for surveillance of tiny unruptured intracranial aneurysms and the impact of CTA radiation-induced brain tumor on the overall effectiveness of CTA. Methods- A Markov decision model was constructed from a societal perspective starting with patients 30-, 40-, or 50-year-old, with incidental detection of unruptured intracranial aneurysm ≤3 mm and no prior history of subarachnoid hemorrhage. Five different management strategies were assessed (1) annual CTA surveillance, (2) biennial CTA, (3) CTA follow-up every 5 years, (4) coiling and subsequent magnetic resonance imaging follow-up, and (5) annual CTA surveillance for the first 2 years, followed by every 5-year CTA follow-up. Probabilistic, 1-way, and 2-way sensitivity analyses were performed. Results- The base case calculation shows every 5-year CTA follow-up to be the most cost-effective strategy, and the conclusion remains robust in probabilistic sensitivity analysis. It remains the dominant strategy when the annual rupture risk of nongrowing unruptured intracranial aneurysms is smaller than 2.66% or the rupture risk in growing aneurysms is <57.4%. The radiation-induced brain cancer risk is relatively low, and sensitivity analysis shows that the radiation-induced cancer risk does not influence the conclusions unless the risk exceeds 663-fold of the base case values. Conclusions- Given the current literature, every 5-year CTA imaging follow-up is the cost-effective strategy in patients with aneurysms ≤3 mm, resulting in better health outcomes and lower healthcare spending. Patients with aneurysms at high risk of rupture might need more aggressive management.
背景与目的- 本研究旨在评估计算机断层血管造影（CTA）在监测微小未破裂颅内动脉瘤方面的成本效益，以及 CTA 辐射诱发脑肿瘤对 CTA 整体效果的影响。方法- 从社会角度出发，构建了一个马尔可夫决策模型，纳入的患者为 30 岁、40 岁或 50 岁，偶然发现未破裂颅内动脉瘤≤3mm，且无蛛网膜下腔出血史。评估了五种不同的管理策略：（1）每年进行 CTA 监测，（2）每两年进行 CTA，（3）每 5 年进行 CTA 随访，（4）进行弹簧圈栓塞并随后进行磁共振成像随访，以及（5）前 2 年每年进行 CTA 监测，随后每 5 年进行一次 CTA 随访。进行了概率性、单向和双向敏感性分析。结果- 基础案例计算表明，每 5 年进行一次 CTA 随访是最具成本效益的策略，且在概率敏感性分析中该结论仍然稳健。当未生长的未破裂颅内动脉瘤的每年破裂风险小于 2.66%或生长的动脉瘤的破裂风险<57.4%时，该策略仍然是主导策略。辐射诱发脑癌的风险相对较低，敏感性分析表明，除非风险超过基础案例值的 663 倍，否则辐射诱发癌症风险不会影响结论。结论- 根据目前的文献，对于直径≤3mm 的动脉瘤患者，每 5 年进行一次 CTA 成像随访是具有成本效益的策略，可获得更好的健康结果并降低医疗保健支出。破裂风险较高的患者可能需要更积极的管理。
