title: Screening for Pediatric Blunt Cerebrovascular Injury: Review of Literature and a Cost-Effectiveness Analysis.
abstract: 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.
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT 06520-8042. Electronic address: ajay.malhotra@yale.edu.
authors.forename: Ajay
authors.initials: A
authors.lastname: Malhotra
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT 06520-8042. Electronic address: xiao.wu@yale.edu.
authors.forename: Xiao
authors.initials: X
authors.lastname: Wu
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT 06520-8042. Electronic address: vivekkalramd@gmail.com.
authors.forename: Vivek B
authors.initials: VB
authors.lastname: Kalra
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT 06520-8042. Electronic address: rob.goodman@yale.edu.
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Goodman
authors.affiliation: Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT 06520-8042. Electronic address: howard.forman@yale.edu.
authors.forename: Joseph
authors.initials: J
authors.lastname: Schindler
authors.affiliation: Department of Neurology and Neurosurgery, Yale School of Medicine, New Haven, CT 06520-8042. Electronic address: joseph.schindler@yale.edu.
authors.forename: Howard P
authors.initials: HP
authors.lastname: Forman
mesh_terms: D002533:Cerebral Angiography / Q000191:economics*; D020214:Cerebrovascular Trauma / Q000000981:diagnostic imaging*; D002648:Child; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D016489:Head Injuries, Closed / Q000000981:diagnostic imaging*; D006801:Humans; D009010:Monte Carlo Method; D014057:Tomography, X-Ray Computed / Q000191:economics*
keywords: CT angiography; blunt cerebrovascular injury; cost-effectiveness analysis; digital subtraction angiography; pediatric trauma