Faculty Bibliography

Purpose: To determine if direct magnetic resonance arthrography (MRA) is more cost-effective than a non-contrast magnetic resonance imaging (MRI) in the management of superior labral anterior to posterior (SLAP) tears. Materials and Methods: Our base case was a 25-year-old with clinical findings of a SLAP tear in whom an imaging test is being ordered for further management. Decision analysis software (Tree Age Pro) was used to create a model from the healthcare perspective to evaluate the cost effectiveness of 4 imaging strategies: 3-Tesla (T) MRA, 3T MRI, 1.5T MRA and 1.5TMRI. Probability and utility estimates were obtained from published literature. Commercial insurance and Medicaid reimbursements were estimated using 2017 Medicare rates. Effectiveness was measured in quality-adjusted life years (QALY) over a 2-year period and costs were calculated in 2017 U.S. dollars. Results: 3T MRI was the least expensive ($5975) and most effective (1.62278 QALY) strategy for our base case and was dominant to 3T MRA ($6569, 1.61732 QALY), 1.5T MRA ($6790, 1.60517 QALY) and 1.5T MRI ($6823, 1.58544 QALY). The results remained robust and did not change over a reasonable range of costs, utilities and probabilities in 1-way sensitivity analyses. 3T MRA only becomes a cost-effective option if the specificity of 3T MRI drops below 91% with a willingness-to-pay (WTP) threshold of $100,000 or below 88.5% with WTP threshold of $50,000. If 3T is excluded from the analysis, 1.5T MRA is dominant for our base case but 1.5T MRI also becomes a cost effective option if its specificity is higher than 68%. Conclusion: 3TMRI is themost cost-effective option for management of SLAP tears. If a 3T magnet is not available, 1.5T MRA is the most cost effective option. In both circumstances, the most cost effective option is the test with highest specificity

OBJECTIVE:Patients with cortical dysplasia (CD) are difficult to treat because the MRI abnormality may be undetectable. This study determined whether fluorodeoxyglucose (FDG)-PET/MRI coregistration enhanced the recognition of CD in epilepsy surgery patients. METHODS:Patients from 2004-2007 in whom FDG-PET/MRI coregistration was a component of the presurgical evaluation were compared with patients from 2000-2003 without this technique. For the 2004-2007 cohort, neuroimaging and clinical variables were compared between patients with mild Palmini type I and severe Palmini type II CD. RESULTS:Compared with the 2000-2003 cohort, from 2004-2007 more CD patients were detected, most had type I CD, and fewer cases required intracranial electrodes. From 2004-2007, 85% of type I CD cases had normal non-University of California, Los Angeles (UCLA) MRI scans. UCLA MRI identified CD in 78% of patients, and 37% of type I CD cases had normal UCLA scans. EEG and neuroimaging findings were concordant in 52% of type I CD patients, compared with 89% of type II CD patients. FDG-PET scans were positive in 71% of CD cases, and type I CD patients had less hypometabolism compared with type II CD patients. Postoperative seizure freedom occurred in 82% of patients, without differences between type I and type II CD cases. CONCLUSIONS:Incorporating fluorodeoxyglucose-PET/MRI coregistration into the multimodality presurgical evaluation enhanced the noninvasive identification and successful surgical treatment of patients with cortical dysplasia (CD), especially for the 33% of patients with nonconcordant findings and those with normal MRI scans from mild type I CD.