The cost-effective use of 18F-FDG PET in the presurgical evaluation of medically refractory focal epilepsy.
This study applied decision tree analysis to evaluate the sensitivity, specificity, and cost-effectiveness of clinical algorithms that incorporate 18F-FDG PET.


METHODS
A cohort of 176 patients was studied. The localization rate, accuracy, therapeutic impact on the presurgical decision-making process, and correlation with the postsurgical outcome were assessed for the tests commonly performed for seizure localization. Decision tree sensitivity analysis compared 3 imaging strategies with a baseline strategy of medical therapy for all: video-electroencephalography monitoring (VEM)/MRI strategy, in which patients underwent VEM and brain MRI only, and +SPECT and +PET strategies, in which patients with an indeterminate VEM/MRI result underwent ictal SPECT or interictal 18F-FDG PET, respectively.


RESULTS
The localization rates for VEM, MRI, 18F-FDG PET, ictal SPECT, and intracranial electroencephalography (EEG) were 62.2%, 35.8%, 75.0%, 60.0%, and 93.8%. The VEM/MRI strategy had the lowest cost per class I/II outcome, but the additional costs per class I/II outcome for the +PET and +SPECT strategies were always below the minimum reported cost savings for a class I/II outcome. There were no valid conditions in which the +SPECT strategy had a lower cost per class I/II outcome than the +PET strategy. Within the range of cost savings estimated to be associated with a class I/II outcome, all decision strategies produced net cost savings; however, these were significantly higher for the +PET and the +SPECT strategies.


CONCLUSIONS
18F-FDG PET is cost-effective in the presurgical evaluation, particularly when used in patients with a nonlocalizing or nonconcordant VEM or MRI result.
O'Brien
Terence J
TJ
Department of Medicine, Surgery, and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia. obrientj@unimelb.edu.au
Miles
Ken
K
Ware
Robert
R
Cook
Mark J
MJ
Binns
David S
DS
Hicks
Rodney J
RJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D001315:Australia / Q000453:epidemiology; D002908:Chronic Disease; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D004828:Epilepsies, Partial / Q000000981:diagnostic imaging* / Q000191:economics* / Q000453:epidemiology / Q000601:surgery; D005260:Female; D019788:Fluorodeoxyglucose F18 / Q000191:economics*; D006801:Humans; D008297:Male; D008875:Middle Aged; D049268:Positron-Emission Tomography / Q000191:economics*; D011300:Preoperative Care / Q000191:economics*; D015995:Prevalence; D019275:Radiopharmaceuticals / Q000191:economics
D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18