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

Autor: Joanna Wardlaw, Miriam Brazzelli, Hector Miranda, Francesca Chappell, Paul McNamee, Graham Scotland, Zahid Quayyum, Duncan Martin, Kirsten Shuler, Peter Sandercock, Martin Dennis
Jazyk: angličtina
Rok vydání: 2014
Předmět:
Zdroj: Health Technology Assessment, Vol 18, Iss 27 (2014)
Druh dokumentu: article
ISSN: 1366-5278
2046-4924
DOI: 10.3310/hta18270
Popis: Background: Patients 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. Objectives: Is 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 sources: Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. Review methods: Systematic reviews and meta-analyses of published/unpublished data.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. Results: The 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 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. Limitations: Data 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. Conclusions: Magnetic 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. Funding: The National Institute for Health Research Health Technology Assessment programme.
Databáze: Directory of Open Access Journals
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