title: Evaluation for Blunt Cerebrovascular Injury: Review of the Literature and a Cost-Effectiveness Analysis.
abstract: OBJECTIVE
  Evaluation for blunt cerebrovascular injury has generated immense controversy with wide variations in recommendations regarding the need for evaluation and the optimal imaging technique. We review the literature and determine the most cost-effective strategy for evaluating blunt cerebrovascular injury in trauma patients.
  
  
  METHODS
  A comprehensive literature review was performed with data extracted to create a decision-tree analysis for 5 different strategies: anticoagulation for high-risk (based on the Denver screening criteria) patients, selective DSA or CTA (only high-risk patients), and DSA or CTA for all trauma patients. The economic evaluation was based on a health care payer perspective during a 1-year horizon. Statistical analyses were performed. The cost-effectiveness was compared through 2 main indicators: the incremental cost-effectiveness ratio and net monetary benefit.
  
  
  RESULTS
  Selective anticoagulation in high-risk patients was shown to be the most cost-effective strategy, with the lowest cost and greatest effectiveness (an average cost of $21.08 and average quality-adjusted life year of 0.7231). Selective CTA has comparable utility and only a slightly higher cost (an average cost of $48.84 and average quality-adjusted life year of 0.7229). DSA, whether performed selectively or for all patients, was not optimal from both the cost and utility perspectives. Sensitivity analyses demonstrated these results to be robust for a wide range of parameter values.
  
  
  CONCLUSIONS
  Selective CTA in high-risk patients is the optimal and cost-effective imaging strategy. It remains the dominant strategy over DSA, even assuming a low CTA sensitivity and irrespective of the proportion of patients at high-risk and the incidence of blunt cerebrovascular injury in high-risk patients.
authors.affiliation: From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.) ajay.malhotra@yale.
authors.forename: A
authors.identifier: http://orcid.org/0000-0001-9223-6640
authors.initials: A
authors.lastname: Malhotra
authors.affiliation: From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.).
authors.forename: X
authors.identifier: http://orcid.org/0000-0002-2679-7447
authors.initials: X
authors.lastname: Wu
authors.affiliation: From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.).
authors.forename: V B
authors.identifier: http://orcid.org/0000-0002-6486-5252
authors.initials: VB
authors.lastname: Kalra
authors.affiliation: Neurology (J.S.) Neurosurgery (J.S., C.C.M.), Yale School of Medicine, New Haven, Connecticut.
authors.forename: J
authors.identifier: http://orcid.org/0000-0003-2865-0438
authors.initials: J
authors.lastname: Schindler
authors.affiliation: From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.) Neurosurgery (J.S., C.C.M.), Yale School of Medicine, New Haven, Connecticut.
authors.forename: C C
authors.identifier: http://orcid.org/0000-0003-3234-9541
authors.initials: CC
authors.lastname: Matouk
authors.affiliation: From the Departments of Diagnostic Radiology (A.M., X.W., V.B.K., C.C.M., H.P.F.).
authors.forename: H P
authors.identifier: http://orcid.org/0000-0002-3096-835X
authors.initials: HP
authors.lastname: Forman
mesh_terms: D015901:Angiography, Digital Subtraction / Q000191:economics*; D001930:Brain Injuries / Q000175:diagnosis* / Q000191:economics; D002533:Cerebral Angiography / Q000191:economics* / Q000379:methods*; D002560:Cerebrovascular Circulation; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D005260:Female; D006801:Humans; D019057:Quality-Adjusted Life Years; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000379:methods; D014949:Wounds, Nonpenetrating