From the Departments of Radiology and Biomedical Imaging (X.W., C.C.M, A.M.), Neurosurgery (C.C.M., K.S., J.S.), Neurology (K.S., J.S.), and Emergency Medicine (C.W.), Yale School of Medicine, 333 Cedar St, Box 208042, Tompkins East 2, New Haven, CT 06520-8042; Harvey L. Neiman Health Policy Institute, Reston, Va (D.R.H.); Department of Radiology, University of Maryland School of Medicine, Baltimore, Md (D.G.); Department of Radiology, Stanford University, Stanford, Calif (M.W.); and Department of Radiology, Northwell Health, Manhasset, NY (P.S.).
Radiology. 2020 Mar;294(3):580-588. doi: 10.1148/radiol.2019191238. Epub 2020 Jan 14.
Background Minor stroke is common and may represent up to two-thirds of cases of acute ischemic stroke. The cost-effectiveness of CT angiography in patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤6) is not well established. Purpose To evaluate cost-effectiveness of CT angiography in the detection of large-vessel occlusion (LVO) in patients with acute minor stroke (NIHSS score ≤6). Materials and Methods A Markov decision-analytic model with a societal perspective was constructed. Three different management strategies were evaluated: no vascular imaging and best medical management, CT angiography for all patients and immediate thrombectomy for LVO after intravenous thrombolysis, and CT angiography for all and best medical management (including intravenous thrombolysis, with rescue thrombectomy for patients with LVO and neurologic deterioration). One-way, two-way, and probabilistic sensitivity analyses were performed. Results Base-case calculation showed that CT angiography followed by immediate thrombectomy had the lowest cost ($346 007) and highest health benefits (9.26 quality-adjusted life-years [QALYs]). CT angiography followed by best medical management with possible rescue thrombectomy for patients with LVO had a slightly higher cost ($346 500) and lower health benefits (9.09 QALYs). No vascular imaging had the highest cost and lowest health benefits. The difference in health benefits compared with the CT angiography and immediate thrombectomy strategy was 0.39 QALY, which corresponds to 142 days in perfect health per patient. The conclusion was robust in a probabilistic sensitivity analysis. CT angiography was cost-effective when the probability of LVO was greater than 0.16% in patients with acute minor stroke. The net monetary benefit of performing CT angiography was higher in younger patients ($68 950 difference between CT angiography followed by immediate thrombectomy and no vascular imaging in 55-year-old patients compared with $20 931 in 85-year-old patients). Conclusion Screening for large-vessel occlusion with CT angiography in patients with acute minor stroke is cost-effective and associated with improved health outcomes. Undetected large-vessel occlusion in the absence of vascular imaging results in worse health outcomes and higher costs. © RSNA, 2020
背景 轻度卒中很常见，可能占急性缺血性卒中病例的三分之二。对于 NIHSS 评分≤6 的轻度卒中患者，CT 血管造影的成本效益尚不清楚。目的 评估 CT 血管造影在急性轻度卒中（NIHSS 评分≤6）患者中检测大血管闭塞（LVO）的成本效益。材料与方法 构建了一个具有社会视角的 Markov 决策分析模型。评估了三种不同的管理策略：不进行血管成像和最佳药物治疗、所有患者进行 CT 血管造影和静脉溶栓后立即进行 LVO 取栓治疗、所有患者进行 CT 血管造影和最佳药物治疗（包括静脉溶栓，对 LVO 和神经功能恶化的患者进行补救性取栓治疗）。进行了单因素、双因素和概率敏感性分析。结果 基于模型计算的结果显示，CT 血管造影后立即取栓治疗的成本最低（346007 美元），健康获益最高（9.26 个质量调整生命年[QALY]）。CT 血管造影后行最佳药物治疗，对 LVO 患者行补救性取栓治疗的成本略高（346500 美元），健康获益略低（9.09 QALY）。不进行血管成像的成本最高，健康获益最低。与 CT 血管造影和立即取栓治疗策略相比，健康获益的差异为 0.39 QALY，相当于每位患者 142 天的完全健康状态。在概率敏感性分析中，结论是稳健的。当急性轻度卒中患者的 LVO 概率大于 0.16%时，CT 血管造影具有成本效益。在 55 岁的患者中，与不进行血管成像相比，行 CT 血管造影后立即取栓治疗的净货币收益更高（68950 美元），而在 85 岁的患者中，这一数字为 20931 美元。结论 在急性轻度卒中患者中使用 CT 血管造影筛查大血管闭塞是具有成本效益的，并可改善健康结局。不进行血管成像导致 LVO 漏诊会导致健康结局恶化和成本增加。
