Diagnostic imaging in the management of patients with possible cerebral venous thrombosis: a cost-effectiveness analysis

Imaging is crucial for management of patients with possible cerebral venous thrombosis (CVT). To evaluate the cost-effectiveness of different noninvasive imaging strategies in patients with possible CVT. A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALY) associated with the following imaging strategies: non-contrast CT (NCCT), NCCT plus CT venography (CTV), routine MRI without vascular imaging (R-MRI), and MRI with venography (MRV). The analysis was performed from a US healthcare perspective. Model input was based on best available and most recent evidence, including outcome data from the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT). Starting age was 37 years; both high and low pre-test probabilities of CVT were evaluated. Probabilistic sensitivity analyses (PSA) estimated model uncertainty. In the base-case analysis, NCCT and CTV were dominant over R-MRI and MRV. CTV led to incremental lifetime QALYs compared with NCCT (23.385 QALYs vs. 23.374 QALYs) at slightly higher lifetime costs ($\$$ 5210 vs. $\$$ 5057). In PSA, CTV was the strategy with the highest percentage of cost-effective iterations if willingness-to-pay (WTP) thresholds were higher than $\$$ 13,750/QALY. Complying with contemporary WTP thresholds, CTV was thus identified as the most cost-effective strategy. When the pre-test probability was set to 50%, CTV was also preferred. In patients at the peak age of CVT incidence yet low clinical pre-test probability, diagnostic imaging with CTV is the most cost-effective strategy.