Skip to main content

Advertisement

SpringerLink
Log in

Clinical utility and cost-effectiveness of CT-angiography in the diagnosis of nontraumatic subarachnoid hemorrhage

  • Diagnostic Neuroradiology
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Introduction

CT-angiography gains an increasing role in the initial diagnosis of patients with nontraumatic subarachnoid hemorrhage (SAH). However, the implementation of CT-angiography does not always exclude the necessity of conventional angiography. Our objective was to determine the practical utility and cost-effectiveness of CT-angiography.

Methods

All patients with nontraumatic subarachnoid hemorrhage admitted to our university hospital after implementation of CT-angiography between June 1, 2011 and June 30, 2012 were retrospectively analyzed in regard to factors of treatment flow, radiation exposure, harms of contrast medium loading, and diagnostic costs. A control group of the same size was assembled from previously admitted SAH patients, who did not undergo pretreatment CT-angiography. Furthermore, cost-effectiveness analysis was performed.

Results

The final analysis consisted of 93 patients in each group. Of 93 patients with pretreatment CT-angiography, 74 had to undergo conventional angiography for diagnostic and/or therapeutic purposes. CT-angiography had significant impact on the reduction of collective effective radiation dose by 4.419 mSv per person (p = 0.0002) and was not associated with additional harms. Despite the significantly earlier detection of aneurysms with CT-angiography (p < 0.0001), there were no significant differences in the timing of aneurysm repair and duration of ICU and general hospital stay. There was an increase of diagnostic costs—the cost-effectiveness analysis showed, however, that benefits of CT-angiography in respect to radiation exposure and risk of conventional angiography-related complications justify the additional costs of CT-angiography.

Conclusions

Although the implementation of CT-angiography in SAH diagnosis cannot completely replace conventional angiography, it can be approved in regard to radiation hygiene and cost-effectiveness.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. American Heart Association Stroke C, Council on Cardiovascular R, Intervention, Council on Cardiovascular N, Council on Cardiovascular S, Anesthesia, Council on Clinical C, Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P (2012) Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 43(6):1711–1737. doi:10.1161/STR.0b013e3182587839

    Article  PubMed  Google Scholar 

  2. Westerlaan HE, van Dijk JM, Jansen-van der Weide MC, de Groot JC, Groen RJ, Mooij JJ, Oudkerk M (2011) Intracranial aneurysms in patients with subarachnoid hemorrhage: CT angiography as a primary examination tool for diagnosis—systematic review and meta-analysis. Radiology 258(1):134–145. doi:10.1148/radiol.10092373

    Article  PubMed  Google Scholar 

  3. Tomandl BF, Kostner NC, Schempershofe M, Huk WJ, Strauss C, Anker L, Hastreiter P (2004) CT angiography of intracranial aneurysms: a focus on postprocessing. Radiographics 24(3):637–655. doi:10.1148/rg.243035126

    Article  PubMed  Google Scholar 

  4. Agid R, Lee SK, Willinsky RA, Farb RI, terBrugge KG (2006) Acute subarachnoid hemorrhage: using 64-slice multidetector CT angiography to “triage” patients’ treatment. Neuroradiology 48(11):787–794. doi:10.1007/s00234-006-0129-5

    Article  PubMed  CAS  Google Scholar 

  5. Taschner CA, Thines L, Lernout M, Lejeune JP, Leclerc X (2007) Treatment decision in ruptured intracranial aneurysms: comparison between multi-detector row CT angiography and digital subtraction angiography. J Neuroradiol 34(4):243–249. doi:10.1016/j.neurad.2007.07.006

    Article  PubMed  Google Scholar 

  6. Agid R, Andersson T, Almqvist H, Willinsky RA, Lee SK, terBrugge KG, Farb RI, Soderman M (2010) Negative CT angiography findings in patients with spontaneous subarachnoid hemorrhage: when is digital subtraction angiography still needed? AJNR Am J Neuroradiol 31(4):696–705. doi:10.3174/ajnr.A1884

    Article  PubMed  CAS  Google Scholar 

  7. Menke J, Larsen J, Kallenberg K (2011) Diagnosing cerebral aneurysms by computed tomographic angiography: meta-analysis. Ann Neurol 69(4):646–654. doi:10.1002/ana.22270

    Article  PubMed  Google Scholar 

  8. Lubicz B, Levivier M, Francois O, Thoma P, Sadeghi N, Collignon L, Baleriaux D (2007) Sixty-four-row multisection CT angiography for detection and evaluation of ruptured intracranial aneurysms: interobserver and intertechnique reproducibility. AJNR Am J Neuroradiol 28(10):1949–1955. doi:10.3174/ajnr.A0699

    Article  PubMed  CAS  Google Scholar 

  9. Nijjar S, Patel B, McGinn G, West M (2007) Computed tomographic angiography as the primary diagnostic study in spontaneous subarachnoid hemorrhage. J Neuroimaging 17(4):295–299. doi:10.1111/j.1552-6569.2007.00160.x

    Article  PubMed  Google Scholar 

  10. Kaufmann TJ, Kallmes DF (2008) Diagnostic cerebral angiography: archaic and complication-prone or here to stay for another 80 years? AJR Am J Roentgenol 190(6):1435–1437. doi:10.2214/AJR.07.3522

    Article  PubMed  Google Scholar 

  11. Moran CJ (2011) Aneurysmal subarachnoid hemorrhage: DSA versus CT angiography—is the answer available? Radiology 258(1):15–17. doi:10.1148/radiol.101911

    Article  PubMed  Google Scholar 

  12. Diener HC, C. W (2012) Leitlinien für Diagnostik und Therapie in der Neurologie, vol 1. 5 edn. Thieme, 1; pp. 360-367

  13. Committee for Guidelines for Management of Aneurysmal Subarachnoid Hemorrhage JSoSfCS (2012) Evidence-based guidelines for the management of aneurysmal subarachnoid hemorrhage. Neurologia medico-chirurgica 52(6):355–429, English Edition

    Google Scholar 

  14. Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G (2013) European stroke organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 35(2):93–112. doi:10.1159/000346087

    Article  PubMed  Google Scholar 

  15. McDonald JS, Kallmes DF, Lanzino G, Cloft HJ (2013) Use of CT angiography and digital subtraction angiography in patients with ruptured cerebral aneurysm: evaluation of a large multihospital data base. AJNR Am J Neuroradiol. doi:10.3174/ajnr.A3478

    Google Scholar 

  16. Jethwa PR, Punia V, Patel TD, Duffis EJ, Gandhi CD, Prestigiacomo CJ (2013) Cost-effectiveness of digital subtraction angiography in the setting of computed tomographic angiography negative subarachnoid hemorrhage. Neurosurgery 72(4):511–519. doi:10.1227/NEU.0b013e318282a578, discussion 519

    Article  PubMed  Google Scholar 

  17. Ward MJ, Bonomo JB, Adeoye O, Raja AS, Pines JM (2012) Cost-effectiveness of diagnostic strategies for evaluation of suspected subarachnoid hemorrhage in the emergency department. Acad Emerg Med 19(10):1134–1144. doi:10.1111/j.1553-2712.2012.01455.x

    Article  PubMed  Google Scholar 

  18. MSCT quality criteria for multislice computed tomography Results from a European Concerted Action on CT (FIGMCT- 2000-20078). Appendix B: European field survey on MSCT. Published January 2005. Accessible at: http://www.msct.info/PDF_FILES/Appendix%20Field%20Survey.pdf. Accessed 28 May 2006. http://www.msct.info/PDF_FILES/Appendix%20Field%20Survey.pdf

  19. McParland BJ (1998) A study of patient radiation doses in interventional radiological procedures. Br J Radiol 71(842):175–185

    Article  PubMed  CAS  Google Scholar 

  20. Mitchell AM, Jones AE, Tumlin JA, Kline JA (2010) Incidence of contrast-induced nephropathy after contrast-enhanced computed tomography in the outpatient setting. Clin J Am Soc Nephrol 5(1):4–9. doi:10.2215/CJN.05200709

    Article  PubMed  PubMed Central  Google Scholar 

  21. Hunt WE, Hess RM (1968) Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28(1):14–20. doi:10.3171/jns.1968.28.1.0014

    Article  PubMed  CAS  Google Scholar 

  22. Farrell B, Godwin J, Richards S, Warlow C (1991) The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry 54(12):1044–1054

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  23. Rankin J (1957) Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 2(5):200–215

    PubMed  CAS  Google Scholar 

  24. Lewis C (2011) Optimisation of radiation protection in diagnostic radiology. In: Lemoigne Y, Caner A (eds) Radiation protection in medical physics, vol 1. NATO Science for Peace and Security Series B: Physics and Biophysics. Springer Netherlands, p 110. doi:10.1007/978-94-007-0247-9_15

  25. Vandenhove H, Quarch H, Clerc JJ, Lejeune JM, Sweeck L, Sillen X, Mallants D, Zeevaert aT (2003) Remediation of uranium mining and milling tailing in Mailuu-Suu District of Kyrgyzstan -CONSORTIUM SCK•CEN - BELGATOM (GESTER) - H.QUARCH Tacis Project N° SCRE1/N°38; Chapter 5, pp.18. Accessible at: http://gnssn.iaea.org/RTWS/general/Shared%20Documents/Forms/AllItems.aspx?RootFolder=%2FRTWS%2Fgeneral%2FShared%20Documents%2FEnvironmental%20Assessment%2FBackground%20Worldbank%2FECBGINFO%2FTACIS%20Studie%20SCKCEN&

  26. Sohier A (2002) A European manual for ‘Off-site Emergency Planning and Response to Nuclear Accidents’. -The European Commission Directorate-General Environment Contract SUBV/00/277065, Published by the Belgian Nuclear Research Centre, pp.76. Accessible at: http://ec.europa.eu/energy/nuclear/radioprotection/doc/studies/emergency_planning_en.pdf

  27. Smits M, Dippel DW, Nederkoorn PJ, Dekker HM, Vos PE, Kool DR, van Rijssel DA, Hofman PA, Twijnstra A, Tanghe HL, Hunink MG (2010) Minor head injury: CT-based strategies for management—a cost-effectiveness analysis. Radiology 254(2):532–540. doi:10.1148/radiol.2541081672

    Article  PubMed  Google Scholar 

  28. Wall BF JGBR (1988) The application of cost-utility analysis to radiological protection in diagnostic radiology. J Radiol Prot 8(4):221–229. doi:10.1088/0952-4746/8/4/004

    Article  Google Scholar 

  29. ICRP'2007 (2007) Recommendations of the International Commission on Radiological Protection (Users Edition). ICRP Publication 103 (Users Edition). Ann. ICRP 37 (2-4) http://www.icrp.org/ pp. 53

  30. Cloft HJ, Joseph GJ, Dion JE (1999) Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis. Stroke 30(2):317–320

    Article  PubMed  CAS  Google Scholar 

  31. Kohlmann T (2011) Quality of life measurement: a suitable method for benefit-risk assessment? Z Evid Fortbild Qual Gesundhwes 105(3):157–162. doi:10.1016/j.zefq.2011.03.008

    Article  PubMed  Google Scholar 

  32. Beck J, Raabe A, Szelenyi A, Berkefeld J, Gerlach R, Setzer M, Seifert V (2006) Sentinel headache and the risk of rebleeding after aneurysmal subarachnoid hemorrhage. Stroke 37(11):2733–2737. doi:10.1161/01.STR.0000244762.51326.e7

    Article  PubMed  Google Scholar 

  33. Karamessini MT, Kagadis GC, Petsas T, Karnabatidis D, Konstantinou D, Sakellaropoulos GC, Nikiforidis GC, Siablis D (2004) CT angiography with three-dimensional techniques for the early diagnosis of intracranial aneurysms. Comparison with intra-arterial DSA and the surgical findings. Eur J Radiol 49(3):212–223. doi:10.1016/S0720-048X(03)00173-6

    Article  PubMed  Google Scholar 

  34. Miley JT, Taylor RA, Janardhan V, Tummala R, Lanzino G, Qureshi AI (2008) The value of computed tomography angiography in determining treatment allocation for aneurysmal subarachnoid hemorrhage. Neurocrit Care 9(3):300–306. doi:10.1007/s12028-008-9109-4

    Article  PubMed  Google Scholar 

  35. SIEMENS medical - Somatom Sensation 16 - Application guide. -Siemens, pp.72-75. Accessible at: http://www.healthcare.siemens.com/

  36. Bederson JB, Connolly ES, Jr., Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE, Jr., Harbaugh RE, Patel AB, Rosenwasser RH, American Heart A (2009) Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 40(3):994–1025. doi:10.1161/STROKEAHA.108.191395

    Article  Google Scholar 

  37. Starke RM, Connolly ES, Jr., Participants in the International Multi-Disciplinary Consensus Conference on the Critical Care Management of Subarachnoid H (2011) Rebleeding after aneurysmal subarachnoid hemorrhage. Neurocrit Care 15(2):241–246. doi:10.1007/s12028-011-9581-0

    Article  Google Scholar 

  38. Tipper G, U-King-Im JM, Price SJ, Trivedi RA, Cross JJ, Higgins NJ, Farmer R, Wat J, Kirollos R, Kirkpatrick PJ, Antoun NM, Gillard JH (2005) Detection and evaluation of intracranial aneurysms with 16-row multislice CT angiography. Clin Radiol 60(5):565–572. doi:10.1016/j.crad.2004.09.012

    Article  PubMed  CAS  Google Scholar 

  39. Dammert S, Krings T, Moller-Hartmann W, Ueffing E, Hans FJ, Willmes K, Mull M, Thron A (2004) Detection of intracranial aneurysms with multislice CT: comparison with conventional angiography. Neuroradiology 46(6):427–434. doi:10.1007/s00234-003-1155-1

    Article  PubMed  CAS  Google Scholar 

  40. White PM, Teasdale EM, Wardlaw JM, Easton V (2001) Intracranial aneurysms: CT angiography and MR angiography for detection prospective blinded comparison in a large patient cohort. Radiology 219(3):739–749

    Article  PubMed  CAS  Google Scholar 

  41. Westerlaan HE, Gravendeel J, Fiore D, Metzemaekers JD, Groen RJ, Mooij JJ, Oudkerk M (2007) Multislice CT angiography in the selection of patients with ruptured intracranial aneurysms suitable for clipping or coiling. Neuroradiology 49(12):997–1007. doi:10.1007/s00234-007-0293-2

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  42. Wintermark M, Uske A, Chalaron M, Regli L, Maeder P, Meuli R, Schnyder P, Binaghi S (2003) Multislice computerized tomography angiography in the evaluation of intracranial aneurysms: a comparison with intraarterial digital subtraction angiography. J Neurosurg 98(4):828–836. doi:10.3171/jns.2003.98.4.0828

    Article  PubMed  Google Scholar 

  43. MacKinnon AD, Clifton AG, Rich PM (2013) Acute subarachnoid haemorrhage: is a negative CT angiogram enough? Clin Radiol 68(3):232–238. doi:10.1016/j.crad.2012.07.004

    Article  PubMed  CAS  Google Scholar 

  44. Zhang LJ, Wu SY, Niu JB, Zhang ZL, Wang HZ, Zhao YE, Chai X, Zhou CS, Lu GM (2010) Dual-energy CT angiography in the evaluation of intracranial aneurysms: image quality, radiation dose, and comparison with 3D rotational digital subtraction angiography. AJR Am J Roentgenol 194(1):23–30. doi:10.2214/AJR.08.2290

    Article  PubMed  Google Scholar 

  45. Mnyusiwalla A, Aviv RI, Symons SP (2009) Radiation dose from multidetector row CT imaging for acute stroke. Neuroradiology 51(10):635–640. doi:10.1007/s00234-009-0543-6

    Article  PubMed  Google Scholar 

  46. Raelson CA, Kanal KM, Vavilala MS, Rivara FP, Kim LJ, Stewart BK, Cohen WA (2009) Radiation dose and excess risk of cancer in children undergoing neuroangiography. AJR Am J Roentgenol 193(6):1621–1628. doi:10.2214/AJR.09.2352

    Article  PubMed  Google Scholar 

  47. Holder MC, Lewis DA, Winstead PS (2012) Preventing the harm of a closer look: contrast-induced nephropathy in adults. Orthopedics 35(4):298–303. doi:10.3928/01477447-20120327-06

    Article  PubMed  Google Scholar 

  48. Canadian Association of R, Benko A, Fraser-Hill M, Magner P, Capusten B, Barrett B, Myers A, Owen RJ (2007) Canadian Association of Radiologists: consensus guidelines for the prevention of contrast-induced nephropathy. Can Assoc Radiol J 58(2):79–87

    PubMed  Google Scholar 

  49. From AM, Bartholmai BJ, Williams AW, Cha SS, McDonald FS (2008) Mortality associated with nephropathy after radiographic contrast exposure. Mayo Clin Proc 83(10):1095–1100. doi:10.4065/83.10.1095

    Article  PubMed  Google Scholar 

  50. Taliercio CP, Vlietstra RE, Fisher LD, Burnett JC (1986) Risks for renal dysfunction with cardiac angiography. Ann Intern Med 104(4):501–504

    Article  PubMed  CAS  Google Scholar 

  51. Blue Cross-Blue Shield of Michigan Cardiovascular C, Freeman RV, O'Donnell M, Share D, Meengs WL, Kline-Rogers E, Clark VL, DeFranco AC, Eagle KA, McGinnity JG, Patel K, Maxwell-Eward A, Bondie D, Moscucci M (2002) Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose. Am J Cardiol 90(10):1068–1073

    Article  PubMed  Google Scholar 

  52. Ray B, Rickert KL, Welch BG, White JA, Klinger DR, Boudreaux BP, Whittemore BA, Gu E (2013) Development of contrast-induced nephropathy in subarachnoid hemorrhage: a single center perspective. Neurocrit Care 19(2):150–156. doi:10.1007/s12028-013-9850-1

    Article  PubMed  CAS  Google Scholar 

Download references

Ethical standards and patient consent

We declare that all human and animal studies have been approved by the Institutional Board Review of Albert-Ludwig University of Freiburg (register number: 293/13) and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. We declare that all patients gave informed consent prior to inclusion in this study.

Conflict of interest

We declare that we have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University Hospital of Freiburg, Breisacher Straße 64, D-79106, Freiburg/Breisgau, Germany

    Ramazan Jabbarli, Mukesch Shah, Beate Hippchen & Vera Van Velthoven

  2. Department of Neuroradiology, University Hospital of Freiburg, Freiburg, Germany

    Christian Taschner

  3. Institute for Medical Biometry and Medical Informatics, University Hospital of Freiburg, Freiburg, Germany

    Klaus Kaier

Authors
  1. Ramazan Jabbarli
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mukesch Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christian Taschner
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Klaus Kaier
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Beate Hippchen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Vera Van Velthoven
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ramazan Jabbarli.

Additional information

Ramazan Jabbarli and Mukesch Shah contributed equally to this manuscript.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jabbarli, R., Shah, M., Taschner, C. et al. Clinical utility and cost-effectiveness of CT-angiography in the diagnosis of nontraumatic subarachnoid hemorrhage. Neuroradiology 56, 817–824 (2014). https://doi.org/10.1007/s00234-014-1406-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00234-014-1406-3

Keywords

Search

Navigation