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ECONOMIC EVALUATION OF INTRAVENOUS IODINATED CONTRAST MEDIA IN ITALY
- Sergio Iannazzo, Stijn Vandekerckhove, Maria De Francesco, Akash Nayak, Claudio Ronco, Giovanni Morana, Massimo Valentino
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- Journal:
- International Journal of Technology Assessment in Health Care / Volume 30 / Issue 1 / January 2014
- Published online by Cambridge University Press:
- 31 January 2014, pp. 69-77
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Background: Contrast-induced acute kidney injury (CI-AKI) is defined as a deterioration in renal function after administration of radiologic iodinated contrast media (CM). Iodixanol, showed a lower CI-AKI incidence than low-osmolar contrast media (LOCM). A cost-effectiveness analysis was performed comparing iodixanol and LOCM in intravenous (IV) setting in Italy.
Methods: A Markov model was developed. Patients moved across four health states: CI-AKI free, CI-AKI, myocardial infarction, and death. The simulation horizon was lifetime with 1-month cycles. Costs and outcomes were discounted at 3.5 percent rate. CI-AKI incidence was considered from published literature across different definitions. Cost-effectiveness of iodixanol was assessed in terms of incremental cost per life-year gained. Net monetary benefit (NMB) was also calculated. Both deterministic and probabilistic sensitivity analyses were performed.
Results: Base-case results showed an average survival increase of 0.51 life-years and a savings of €7.25 for iodixanol versus LOCM. The cost-effectiveness of iodixanol was confirmed when other scenarios were explored, such as varying CI-AKI definition, sub-populations with specified risk factors, CM hospital bids prices, and inclusion of adverse drug reactions of allergic nature. An NMB ranging between €6,007.25 and €30,007.25 was calculated.
Conclusion: Base-case results show that IV iodixanol is cost-effective compared with LOCM in the Italian clinical setting of a hospital computed tomography radiology practice. However, some caution is due, mainly linked to inherent limitations of the modeling technique and to the lack of agreement on CI-AKI incidence data in the clinical literature.
146 - Ependymal Cyst
- from Section 5 - Primarily Extra-Axial Focal Space-Occupying Lesions
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- By Giovanni Morana, Children’s Research Hospital, Genoa, Italy
- Edited by Zoran Rumboldt, Medical University of South Carolina, Mauricio Castillo, University of North Carolina, Chapel Hill, Benjamin Huang, University of North Carolina, Chapel Hill, Andrea Rossi
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- Book:
- Brain Imaging with MRI and CT
- Published online:
- 05 August 2013
- Print publication:
- 08 November 2012, pp 301-302
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Summary
Specific Imaging Findings
Ependymal cysts (EC) are rounded or oval cysts with thin walls that are located within the lateral ventricles or subependymally, the most common site being the atrium. On CT they appear hypodense to the brain and of same attenuation as the CSF. Calcifications are usually not present. On MRI, the signal intensity of EC is similar to the CSF on all pulse sequences. Sometimes a slightly hyperintense signal relative to CSF on T1 and FLAIR sequences may be found due to increased protein content. The cyst wall is usually not visible on CT, but it is detectable on MR images, especially with 3D high-resolution heavily T2-weighted sequences (such as CISS, FIESTA, and DRIVE). The cysts do not enhance with contrast and show the same signal as the CSF on diffusion imaging. Post-contrast images may be useful as they demonstrate tiny venous vessels that are located around the margins of the cyst and this information can help in the surgical approach planning.
Pertinent Clinical Information
EC is usually asymptomatic, discovered incidentally, and typically stable on follow-up examinations. In rare instances they may cause entrapment of the ventricle or obstructive hydrocephalus and then may manifest with headache and seizures. The management is typically conservative, it depends on the size of the cyst and the presence of symptoms. Surgical treatment is required only in very large cysts or in symptomatic patients.
189 - Meningioangiomatosis
- from Section 7 - Intracranial Calcifications
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- By Giovanni Morana, Children’s Research Hospital, Genoa, Italy
- Edited by Zoran Rumboldt, Medical University of South Carolina, Mauricio Castillo, University of North Carolina, Chapel Hill, Benjamin Huang, University of North Carolina, Chapel Hill, Andrea Rossi
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- Book:
- Brain Imaging with MRI and CT
- Published online:
- 05 August 2013
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- 08 November 2012, pp 391-392
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Summary
Specific Imaging Findings
On non-enhanced CT scans, meningioangiomatosis (MA) may appear as a nodular calcification, as a thickened gyriform mass with or without surrounding hypodense edema, or as hypodense lesion with central calcification. On MRI it is of either low T1 signal, or shows a mixed signal on both T1- and T2-weighted images, depending primarily on the amount of calcific deposition. A pattern of gyriform hyperintensity has been recently reported as a characteristic feature on FLAIR. Contrast enhancement is usually very prominent and may show a gyriform distribution. Surrounding vasogenic edema involving the adjacent white matter is quite common, and the lesion may cause mass effect. Advanced imaging techniques such as MRS may be degraded by contamination artifacts due to calcific deposition; nevertheless, increase in the choline peak with loss of the n-acetyl aspartate peak have been described. Imaging findings are often nonspecific and do not allow for a definite diagnosis.
Pertinent Clinical Information
MA usually affects children and young adults, with a male predominance; it may occur sporadically (most of reported cases) or in association with NF2 (approximately 20%), when it is often multifocal. Sporadic and NF2-associated forms are histologically similar but clinically different. The sporadic type typically presents with partial seizures that are difficult to control, whereas lesions associated with NF2 are often asymptomatic and discovered incidentally. The genetic basis of the sporadic form is not well clarified.
166 - Ganglioglioma
- from Section 6 - Primarily Intra-Axial Masses
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- By Giovanni Morana, Children’s Research Hospital, Genoa, Italy, Mauricio Castillo, University of North Carolina School of Medicine
- Edited by Zoran Rumboldt, Medical University of South Carolina, Mauricio Castillo, University of North Carolina, Chapel Hill, Benjamin Huang, University of North Carolina, Chapel Hill, Andrea Rossi
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- Book:
- Brain Imaging with MRI and CT
- Published online:
- 05 August 2013
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- 08 November 2012, pp 343-344
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Summary
Specific Imaging Findings
The classic imaging appearance of ganglioglioma (GG) is a cystic mass with a solid tumor nodule which may or may not enhance after contrast administration (about 50% show some enhancement on CT and MRI). This appearance probably occurs in only one-half of the tumors, more commonly in children. Another characteristic feature is the presence of calcifications, which are typically peripheral and shell-like; this is again found in about half of cases. Most GGs occur in the temporal lobes and involve the cortex (and thereby cause seizures). Unfortunately, most GGs have nonspecific imaging features and may be found anywhere in the brain, more likely in the cerebellum, brainstem, spinal cord, optic chiasm, pineal gland, and inside the ventricular system. The lesion size is usually between 3 and 6 cm at the time of discovery. Other imaging appearances include a solid mass (without or with contrast enhancement) and an infiltrating lesion. GGs do show relatively high diffusion, being bright on ADC maps, reflecting their low cellularity. Superficially located tumors tend to expand the overlying cortex and at times MRI may show a discreet cortical dysplasia associated with the tumor. Because they are longstanding, the overlying skull may demonstrate remodeling of its inner table. On nuclear medicine studies with both FDG and thallium, GGs show increased uptake. On MRS they demonstrate nonspecific findings with low n-acetyl aspartate, mildly elevated choline, normal creatine and high myo-inositol on short echo time studies. Lactate may be present, often related to recent seizure activity.
108 - Dysembroplastic Neuroepithelial Tumor (DNT, DNET)
- from Section 4 - Abnormalities Without Significant Mass Effect
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- By Giovanni Morana, Children’s Research Hospital, Genoa, Italy
- Edited by Zoran Rumboldt, Medical University of South Carolina, Mauricio Castillo, University of North Carolina, Chapel Hill, Benjamin Huang, University of North Carolina, Chapel Hill, Andrea Rossi
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- Book:
- Brain Imaging with MRI and CT
- Published online:
- 05 August 2013
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- 08 November 2012, pp 223-224
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Summary
Specific Imaging Findings
On CT, dysembryoplastic neuroepithelial tumor (DNT or DNET) appears as a low density cortico-subcortical supratentorial area. Calcifications are rare. Remodeling of the adjacent calvarium is frequent with superficially located tumors. On MRI, the classic appearance is of a well-demarcated pseudocystic lesion, strongly T2 hyperintense and T1 hypointense with variable signal on FLAIR images. Mass effect is minimal to absent, there is no surrounding vasogenic edema. DNTs may have a triangular-shaped pattern with the base along the cortical surface with preserved gyral pattern. Thin hyperintense signal on FLAIR images is visible both along the surface (bright rim) and as stripes along thin internal septa, resulting in a very characteristic multicystic, “bubbly” appearance. Additional small cysts, separated from the main mass, are often located in the neighboring cortex or subcortical white matter. Some lesionsmay show a more heterogeneous signal consistent with solid, cystic, or semiliquid structures. Solid components may either be solitary or form a multinodular pattern interspersed within a cystic frame. Contrast enhancement is rare, variable, and more often ringlike. Bleeding is also rare. Tumors show increased diffusivity with high ADC values and low rCBV on perfusion imaging. The MRS pattern is nonspecific with increase in mI/Cr and Cho/NAA ratios. Lactate and lipid peaks are usually absent.
139 - Desmoplastic Infantile Ganglioglioma
- from Section 5 - Primarily Extra-Axial Focal Space-Occupying Lesions
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- By Giovanni Morana, Children’s Research Hospital, Genoa, Italy
- Edited by Zoran Rumboldt, Medical University of South Carolina, Mauricio Castillo, University of North Carolina, Chapel Hill, Benjamin Huang, University of North Carolina, Chapel Hill, Andrea Rossi
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- Book:
- Brain Imaging with MRI and CT
- Published online:
- 05 August 2013
- Print publication:
- 08 November 2012, pp 287-288
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Summary
Specific Imaging Findings
Desmoplastic infantile ganglioglioma (DIG) is an extra-axial mass consisting of a large cyst with a solid superficial component. The cystic portion is hypodense on CT, T1 hypointense and T2 hyperintense, with variable signal intensity on FLAIR images (isointense or slightly hyperintense to CSF). The cystic component is invariably associated with a mural, meningeal-based mass or plaque, which is iso- to slightly hyperdense on CT, isointense to gray matter on T1, with a typical very low signal intensity on T2-weighted images (due to its fiber-rich content). Post-contrast images show marked enhancement of the solid portion along with enhancement extending to the adjacent leptomeninges and dura. Typically it shows non-enhancing walls and may appear multilobulated due to the presence of septations; areas of enhancement may at times be present within the cystic septa. Calcification and hemorrhagic foci are usually absent whereas perifocal edema is variable and often very prominent. Diffusion imaging can demonstrate reduced diffusivity in the solid portion whereas MR spectroscopy shows elevated choline and reduced NAA peaks with near-normal myo-inositol levels. In rare cases, diffuse dissemination may be present at the time of diagnosis.
Pertinent Clinical Information
Affected infants present with asymmetric macrocrania, bulging of the fontanels and other nonspecific symptoms such as seizures and vomiting. DIG typically has a favorable prognosis, confirmed by absence of recurrence following surgical removal. However, incomplete excision occurs in about 30% of cases due to the lack of a definite cleavage between the tumor and the surrounding brain and sometimes due to infiltration of eloquent CNS structures.
168 - Dilated Perivascular Spaces
- from Section 6 - Primarily Intra-Axial Masses
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- By Giovanni Morana, Children’s Research Hospital, Genoa, Italy
- Edited by Zoran Rumboldt, Medical University of South Carolina, Mauricio Castillo, University of North Carolina, Chapel Hill, Benjamin Huang, University of North Carolina, Chapel Hill, Andrea Rossi
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- Book:
- Brain Imaging with MRI and CT
- Published online:
- 05 August 2013
- Print publication:
- 08 November 2012, pp 347-348
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Summary
Specific Imaging Findings
Perivascular spaces (PVS) show a well-defined oval, rounded, or tubular configuration with smooth margins and are commonly seen bilaterally in the supratentorial white matter with a radial orientation and in the basal nuclei (around the anterior commissure and in the midbrain). PVS appear on CT as hypodense areas, with similar attenuation as CSF. Calcifications or other associated abnormalities are not present. On MRI, their signal intensity also follows the CSF, being hypointense on FLAIR images, typically without any bright rim. Contrast enhancement is absent and there is water-like diffusivity on ADC maps. MR spectroscopy around dilated PVS shows normal spectra. In rare cases PVS may continuously enlarge to over 2 cm in size, frequently containing internal septations. The surrounding brain parenchyma generally has normal signal intensity; however, adjacent to dilated and enlarging PVS, hyperintense signal on FLAIR images may be present, likely representing reactive gliosis or spongiosis.
Pertinent Clinical Information
Small PVS (≤ 5 mm) are seen on high-resolution MRI in all age groups. Dilatation of PVS has been associated with aging. In healthy children, they are present in 25–30% of cases and must be considered a benign normal variant. They are usually asymptomatic and discovered incidentally. However, in the pediatric age group, prominent PVS are also well-known findings of mucopolysaccharidoses (types I and II). In those cases, PVS dilation specifically involves the corpus callosum, in addition to the periventricular white matter.