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Screening for Pediatric Blunt Cerebrovascular Injury: Review of Literature and a Cost-Effectiveness Analysis
Ajay Malhotra1, Xiao Wu1, Vivek B Kalra1
1Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT 06520-8042.
Insights
Selective computed tomography angiography (CTA) is the optimal imaging strategy for identifying pediatric blunt cerebrovascular injury (BCVI). This approach, combined with selective anticoagulation, offers the most cost-effective management to prevent stroke in children.
Area of Science:
- Pediatric neurology
- Vascular imaging
- Health economics
Background:
- Pediatric blunt cerebrovascular injury (BCVI) screening lacks clear criteria, impacting timely stroke prevention.
- Anticoagulation therapy is crucial for managing pediatric BCVI, but optimal screening strategies require definition.
- A systematic review and cost-effectiveness analysis were conducted to determine the best pediatric BCVI management approach.
Purpose of the Study:
- To identify the most cost-effective strategy for screening and managing pediatric blunt cerebrovascular injury (BCVI).
- To compare five different screening strategies for pediatric BCVI from a societal perspective.
- To provide evidence-based recommendations for optimizing pediatric BCVI care.
Main Methods:
- Systematic literature review for pediatric BCVI screening and management data.
- Development of a decision tree model for economic evaluation of five screening strategies over a 1-year horizon.
- Monte Carlo simulation and sensitivity analyses to assess the robustness of cost-effectiveness findings.
Main Results:
- Selective anticoagulation therapy for high-risk patients emerged as the most cost-effective treatment.
- Selective computed tomography angiography (CTA) was identified as the optimal imaging strategy for high-risk pediatric patients.
- Sensitivity analyses confirmed selective CTA and anticoagulation as optimal unless anticoagulation complication risk exceeds 3.9%.
Conclusions:
- Selective CTA is the recommended imaging strategy for assessing pediatric BCVI.
- Further research is needed to establish more precise screening criteria for pediatric BCVI.
- The findings support a targeted approach to BCVI diagnosis and management in children.
Background:
Timely and accurate screening for pediatric blunt cerebrovascular injury (BCVI) is important in order to administer appropriate anticoagulation therapy thus preventing stroke. The recommended criteria for screening in children are not clear. We performed a systematic review of the literature for screening and management of BCVI in children and designed a cost-effectiveness analysis in order to determine the optimal strategy for managing pediatric BCVI from a societal perspective.
Methods:
Comprehensive review of studies citing BCVI in pediatric patients was carried out with data extraction and compilation. An economic evaluation of 5 possible screening strategies was performed by designing a decision tree over a 1-year horizon using parameters derived from literature review. Base case calculations were made to compare cost effectiveness for each strategy. Monte Carlo simulation and extensive sensitivity analyses were performed to examine the robustness of the conclusion against key variables.
Results:
Selective anticoagulation therapy in patients with high-risk factors was found to be the most cost-effective strategy and selective computed tomography angiography (CTA) in high-risk patients was the optimal imaging strategy. This conclusion was corroborated by a Monte Carlo simulation of 10,000 iterations. In all sensitivity analyses, selective anticoagulation and selective CTA continue to be the optimal strategy until the risk of anticoagulation complications rises above 3.9%.
Conclusions:
Our study demonstrated selective CTA to be the optimal imaging strategy in order to assess BCVI in children. Further studies are needed for more clearly defined screening criteria.
