Cost-effectiveness of advanced neuroimaging for transient and minor neurological events in the emergency department

Ava L. Liberman, Hui Zhang, Sara K. Rostanski, Natalie T. Cheng, Charles C. Esenwa, Neil Haranhalli, Puneet Singh, Daniel L. Labovitz, Richard B. Lipton, Shyam Prabhakaran

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


BACKGROUND: Accurate diagnosis of patients with transient or minor neurological events can be challenging. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in low-risk patients with transient or minor neurological symptoms, but a cost-effective emergency department diagnostic evaluation strategy remains uncertain. METHODS AND RESULTS: We constructed a decision-analytic model to evaluate 2 diagnostic evaluation strategies for patients with low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (magnetic resonance imaging brain and magnetic resonance angiography head and neck) on every patient or (2) current emergency department standard-of-care clinical evaluation with basic neuroimaging. Main probability variables were: proportion of patients with true ischemic events, strategy specificity and sensitivity, and recurrent stroke rate. Direct healthcare costs were included. We calculated incremental cost-effectiveness ratios, conducted sensitivity analyses, and evaluated various diagnostic test parameters primarily using a 1-year time horizon. Cost-effectiveness standards would be met if the incremental cost-effectiveness ratio was less than willingness to pay. We defined willingness to pay as $100 000 US dollars per quality-adjusted life year. Our primary and sensitivity analyses found that the advanced neuroimaging strategy was more cost-effective than emergency department standard of care. The incremental effectiveness of the advanced neuroimaging strategy was slightly less than the standard-of-care strategy, but the standard-of-care strategy was more costly. Potentially superior diagnostic approaches to the modeled advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to standard-of-care strategy’s cost. CONCLUSIONS: Obtaining advanced neuroimaging on emergency department patient with low-risk transient or minor neurological symptoms was the more cost-effective strategy in our model.

Original languageEnglish (US)
Article numbere019001
JournalJournal of the American Heart Association
Issue number12
StatePublished - Jun 15 2021


  • Cost-effectiveness
  • Diagnosis
  • Emergency department
  • Ischemic stroke
  • Transient ischemic attack

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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