J Neurosurg 143:1555–1566, 2025
This study evaluates cost-effectiveness of MRI surveillance intervals for conservatively managed cerebral cavernous malformations (CCMs) using a Markov model and Monte Carlo simulations. It compares 0.5-, 1-, 2-, and 3-year follow-up strategies for brainstem versus nonbrainstem CCMs, calculating lifetime costs, QALYs, and net monetary benefit from a US societal perspective.
Results indicate annual MRI is most cost-effective for brainstem CCMs, while a 3-year MRI interval is preferred for nonbrainstem CCMs, with findings robust to sensitivity analyses that varied hemorrhage rates, mortality, and MRI costs. The authors emphasize individualized follow-up based on symptoms, Zabramski grade, family history, and lesion multiplicity, and note model limitations and US-centric cost data.
Optimal MRI Follow-up for Brainstem CCM: Annual MRI follow-up (every 1 year) is the most cost-effective strategy for conservatively managed, unruptured brainstem cerebral cavernous malformations (CCM), balancing cost and quality-adjusted life years (QALYs).
Optimal MRI Follow-up for Nonbrainstem CCM: MRI follow-up every 3 years is the most cost-effective approach for nonbrainstem CCM, with less frequent imaging justified by lower rupture and rehemorrhage rates.
Markov Model and Monte Carlo Simulation: A decision-analytic Markov model with Monte Carlo simulations was used to compare different MRI follow-up intervals (0.5, 1, 2, and 3 years) for both brainstem and nonbrainstem CCM, incorporating costs, effectiveness (QALYs), and net monetary benefit (NMB).
Key Drivers of Cost-effectiveness: The cost-effectiveness of follow-up strategies is highly sensitive to annual rates of CCM rupture, mortality after rupture, and the cost of MRI; higher hemorrhage or mortality rates favor more frequent imaging.
Individualization of Follow-up: Follow-up intervals should be tailored based on lesion location, symptoms, prior hemorrhage, Zabramski grade, family history, and multiplicity, as higher-risk patients may benefit from closer surveillance.
Brainstem Lesion Risks: Brainstem CCMs have higher annual rupture (2.8%) and rehemorrhage rates (32.3%) compared to nonbrainstem lesions, resulting in greater disability and loss of quality of life, justifying more vigilant follow-up.
MRI Cost Thresholds: As the annual MRI cost increases above $6,581 for brainstem CCM and $8,995 for nonbrainstem CCM, less frequent MRI follow-up (every 2 years) becomes more cost-effective than the previously optimal intervals.
Limitations: The model does not distinguish between cerebellar and supratentorial nonbrainstem lesions, does not account for comorbidities or detailed imaging findings (e.g., Zabramski grade), and uses US-based cost data, which may limit generalizability to other healthcare settings.
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