• Mohamed M Salem, Mira Salih, Felix Nwajei, Santiago Gomez-Paz, Ajith J Thomas, Christopher S Ogilvy, and Justin M Moore.
• Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: msalem1@bidmc.harvard.edu.
• World Neurosurg. 2022 Feb 1; 158: e206-e213.

BackgroundFlow diversion via a Pipeline embolization device (PED [Medtronic, Dublin, Ireland]) is one of the established modalities for the treatment of unruptured intracranial aneurysms that require a robust follow-up regimen. However, to date, no consensus has been reached regarding the optimal imaging modality and timing intervals for such a strategy. We studied the cost-effectiveness of different neuroimaging follow-up strategies after flow diversion with the PED.MethodsA decision-analytical study using Markov modeling was performed to compare 5 commonly used multistep follow-up strategies with different combinations of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA): 1) DSA at 6 months and MRA at 12 and 24 months; 2) DSA at 6, 12, and 24 months; 3) MRA at 6, 12, and 24 months; 4) DSA at 6 and 12 months and MRA at 24 months; and 5) DSA at 12 months and MRA at 24 months. The input parameters were mainly collected from the latest meta-analysis, and 1-way, 2-way, and probabilistic sensitivity analyses were conducted to assess the robustness of our model.ResultsStrategy 5, incorporating DSA at 12 months and MRA at 24 months, was the most cost-effective strategy for >99% of the 10,000 iterations in the probabilistic sensitivity analysis at a willingness-to-pay threshold of $100,000/quality-adjusted life-year. The result remained robust in the 1- and 2-way sensitivity analyses.ConclusionsGiven the current data, delayed imaging follow-up at 1 year with DSA and 2 years with MRA after PED treatment of unruptured intracranial aneurysms is more cost-effective than early follow-up at 6 months.Copyright © 2021 Elsevier Inc. All rights reserved.

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