A low-cost and shielding-free ultra-low-field brain MRI scanner.

Magnetic resonance imaging is a key diagnostic tool in modern healthcare, yet it can be cost-prohibitive given the high installation, maintenance and operation costs of the machinery. There are approximately seven scanners per million inhabitants and over 90% are concentrated in high-income countries. We describe an ultra-low-field brain MRI scanner that operates using a standard AC power outlet and is low cost to build. Using a permanent 0.055 Tesla Samarium-cobalt magnet and deep learning for cancellation of electromagnetic interference, it requires neither magnetic nor radiofrequency shielding cages. The scanner is compact, mobile, and acoustically quiet during scanning. We implement four standard clinical neuroimaging protocols (T1- and T2-weighted, fluid-attenuated inversion recovery like, and diffusion-weighted imaging) on this system, and demonstrate preliminary feasibility in diagnosing brain tumor and stroke. Such technology has the potential to meet clinical needs at point of care or in low and middle income countries.

Portable, bedside, low-field magnetic resonance imaging for evaluation of intracerebral hemorrhage.

Radiological examination of the brain is a critical determinant of stroke care pathways. Accessible neuroimaging is essential to detect the presence of intracerebral hemorrhage (ICH). Conventional magnetic resonance imaging (MRI) operates at high magnetic field strength (1.5-3 T), which requires an access-controlled environment, rendering MRI often inaccessible. We demonstrate the use of a low-field MRI (0.064 T) for ICH evaluation. Patients were imaged using conventional neuroimaging (non-contrast computerized tomography (CT) or 1.5/3 T MRI) and portable MRI (pMRI) at Yale New Haven Hospital from July 2018 to November 2020. Two board-certified neuroradiologists evaluated a total of 144 pMRI examinations (56 ICH, 48 acute ischemic stroke, 40 healthy controls) and one ICH imaging core lab researcher reviewed the cases of disagreement. Raters correctly detected ICH in 45 of 56 cases (80.4% sensitivity, 95%CI: [0.68-0.90]). Blood-negative cases were correctly identified in 85 of 88 cases (96.6% specificity, 95%CI: [0.90-0.99]). Manually segmented hematoma volumes and ABC/2 estimated volumes on pMRI correlate with conventional imaging volumes (ICC = 0.955, p = 1.69e-30 and ICC = 0.875, p = 1.66e-8, respectively). Hematoma volumes measured on pMRI correlate with NIH stroke scale (NIHSS) and clinical outcome (mRS) at discharge for manual and ABC/2 volumes. Low-field pMRI may be useful in bringing advanced MRI technology to resource-limited settings.

Cost-Effectiveness of Advanced Neuroimaging for Transient and Minor Neurological Events in the Emergency Department.

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.

PriMa: A low-cost, modular, open hardware, and 3D-printed fMRI manipulandum.

Motor actions in fMRI settings require specialized hardware to monitor, record, and control the subjects behavior. Commercially available options for such behavior tracking or control are very restricted and costly. We present a novel grasp manipulandum in a modular design, consisting of MRI-compatible, 3D printable buttons and a chassis for mounting. Button presses are detected by the interruption of an optical fiber path, which is digitized by a photodiode and subsequent signal amplification and thresholding. Two feedback devices (manipulanda) are constructed, one for macaques (Macaca mulatta) and one for human use. Both devices have been tested in their specific experimental setting and possible improvements are reported. Design files are shared under an open hardware license.

An assessment of prevalence and expenditure associated with discharge brain MRI in preterm infants.

To assess national expenditure associated with preterm-infant brain MRI and potential impact of reduction per Choosing Wisely campaign 2015 recommendation to "avoid routine screening term-equivalent or discharge brain MRIs in preterm-infants". Cross-sectional U.S. trend data from the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) database (2006, 2009, 2012, 2016) was used to estimate overall national expenditure associated with brain MRI among infants with gestational age (GA) ≤36 weeks, and also when classified as 'not indicated' (NI-MRI) i.e., equivalent to routine use without clinical indications and regarded as low-value service (LVS). Associated cost was determined by querying CMS-database for physician-fee-schedules to find the highest global procedure-cost per cycle, then adjusting for inflation. Sensitivity-analyses were conducted to account for additional clinical charges associated with NI-MRI. 3,768 (0.26%) of 1,472,236 preterm-infants had brain MRI across all cycles (inflation-adjusted total $3,690,088). Overall proportion of brain MRIs increased across 2006-2012 from 0.25%-0.33% but decreased in 2016 to 0.16% (P<0.001). Inflation-adjusted overall expenditure by cycle was: 2006, $1,299,130 (95% CI: $987,505, $1,610,755); 2009, $1,194,208 (95% CI: $873,487, $1,516,154); 2012, $931,836 (95% CI: $666,114, $1,197,156); and 2016, $264,648 (95% CI: $172,061, $357,280). Prevalence for NI-MRI in 2006, 2009, 2012 and 2016 was 86% (n = 809), 88% (n = 940), 89% (n = 1028) and 50% (n = 299), respectively; and 70% were in infants 35-36 weeks GA. NI-MRI prevalence was not different over time by payer-type (Medicaid, private), sex or race/ethnicity (white, black, Hispanic); larger hospital size was significantly associated across 2006-2012 but this declined for all sizes in 2016, with most decline in larger hospitals (P for interaction <0.05). NI-MRI expenditure sensitivity-analysis with addition of cycle median total-admission-charge to inflation-adjusted CMS-fee was $1,190,919/$518,343, for 2012/2016 cycles respectively. National MRI prevalence in preterm infants (both overall and LVS) and associated expenditure decreased substantially post recommendation; however, annual savings are modest and unlikely to be >$1.2 million.

Mind the brain gap: The worldwide distribution of neuroimaging research on adolescent depression.

Adolescents comprise one fourth of the world's population, with about 90% of them living in low- and middle-income countries (LMICs). The incidence of depression markedly increases during adolescence, making the disorder a leading cause of disease-related disability in this age group. However, most research on adolescent depression has been performed in high-income countries (HICs). To ascertain the extent to which this disparity operates in neuroimaging research, a systematic review of the literature was performed. A total of 148 studies were identified, with neuroimaging data available for 4,729 adolescents with depression. When stratified by income group, 122 (82%) studies originated from HICs, while 26 (18%) were conducted in LMICs, for a total of 3,705 and 1,024 adolescents with depression respectively. A positive Spearman rank correlation was observed between country per capita income and sample size (rs=0.673, p = 0.023). Our results support the previous reports showing a large disparity between the number of studies and the adolescent population per world region. Future research comparing neuroimaging findings across populations from HICs and LMICs may provide unique insights to enhance our understanding of the neurobiological processes underlying the development of depression.

Increasing Out-of-Pocket Costs for Neurologic Care for Privately Insured Patients.

OBJECTIVE: To measure the out-of-pocket (OOP) costs of evaluation and management (E/M) services and common diagnostic testing for neurology patients. METHODS: Using a large, privately insured health care claims database, we identified patients with a neurologic visit or diagnostic test from 2001 to 2016 and assessed inflation-adjusted OOP costs for E/M visits, neuroimaging, and neurophysiologic testing. For each diagnostic service each year, we estimated the proportion of patients with OOP costs, the mean OOP cost, and the proportion of the total service cost paid OOP. We modeled OOP cost as a function of patient and insurance factors. RESULTS: We identified 3,724,342 patients. The most frequent neurologic services were E/M visits (78.5%), EMG/nerve conduction studies (NCS) (7.7%), MRIs (5.3%), and EEGs (4.5%). Annually, 86.5%-95.2% of patients paid OOP costs for E/M visits and 23.1%-69.5% for diagnostic tests. For patients paying any OOP cost, the mean OOP cost increased over time, most substantially for EEG, MRI, and E/M. OOP costs varied considerably; for an MRI in 2016, the 50th percentile paid $103.10 and the 95th percentile paid $875.40. The proportion of total service cost paid OOP increased. High deductible health plan (HDHP) enrollment was associated with higher OOP costs for MRI, EMG/NCS, and EEG. CONCLUSION: An increasing number of patients pay OOP for neurologic diagnostic services. These costs are rising and vary greatly across patients and tests. The cost sharing burden is particularly high for the growing population with HDHPs. In this setting, neurologic evaluation might result in financial hardship for patients.

Headache and Neuroimaging: Why We Continue to Do It.

The appropriate imaging of patients with headache presents a number of important and vexing challenges for clinicians. Despite a number of guidelines and studies demonstrating a lack of cost-effectiveness, clinicians continue to image patients with chronic nonfocal headaches, and the trend toward imaging is increasing. The reasons are complex and include the fear of missing a clinically significant lesion and litigation, habitual and standard of care practices, lack of tort reform, regulatory penalties and potential impact on one's professional reputation, patient pressures, and financial motivation. Regulatory and legislative reforms are needed to encourage best practices without fear of professional sanctions when following the guidelines. The value of negative findings on imaging tests requires better understanding because they appear to provide some measure of societal value. Clinical decision support tools and machine intelligence may offer additional guidance and improve quality and cost-efficient management of this challenging patient population.

The CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Research Collaborative.

In traumatic brain injury (TBI), future integration of multimodal monitoring of cerebral physiology and high-frequency signal processing techniques, with advanced neuroimaging, proteomic and genomic analysis, provides an opportunity to explore the molecular pathways involved in various aspects of cerebral physiologic dysfunction in vivo. The main issue with early and rapid discovery in this field of personalized medicine is the expertise and complexity of data involved. This brief communication highlights the CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Research Collaborative, which has been formed from centers with specific expertise in the area of high-frequency physiologic monitoring/processing, and outlines its objectives.

Children With Minor Blunt Head Trauma Presenting to the Emergency Department.

In our state-of-the-art review, we summarize the best-available evidence for the optimal emergency department management of children with minor blunt head trauma. Minor blunt head trauma in children is a common reason for emergency department evaluation, although clinically important traumatic brain injuries (TBIs) as a result are uncommon. Cranial computed tomography (CT) scanning is the reference standard for the diagnosis of TBIs, although they should be used judiciously because of the risk of lethal malignancy from ionizing radiation exposure, with the greatest risk to the youngest children. Available TBI prediction rules can assist with CT decision-making by identifying patients at either low risk for TBI, for whom CT scans may safely be obviated, or at high risk, for whom CT scans may be indicated. For clinical prediction rules to change practice, however, they require active implementation. Observation before CT decision-making in selected patients may further reduce CT rates without missing children with clinically important TBIs. Future work is also needed to incorporate patient and family preferences into these decision-making algorithms when the course of action is not clear.

[What do MRI and CT scan provide us in patients with vertigo and dizziness? A cost-utility analysis]. / Que aporta la neuroimagen en pacientes con vertigo y mareo? Analisis coste-utilidad.

INTRODUCTION: Vertigo and dizziness are symptoms with a significant burden in the hospital and involve several specialties. There are few guidelines of radiological tests for these symptoms. AIMS: To know which profile of patients with vertigo and dizziness has neuroimaging tests, quantify and describe the radiological findings. To analyze the cost-utility of CT and MRI in the study of these patients. PATIENTS AND METHODS: Descriptive study, we selected patients referred to the hospital for vertigo and dizziness. We analyze demographic and clinical characteristics and quantify the neuroimaging tests requested. We describe the radiological findings, assess their relevance in the diagnosis and detail the cost-benefit. RESULTS: We identified 493 patients, those with neuroimaging test (60%) are older, depressed and frequented the emergency department because of vertigo. The most requested test was the cranial CT scan (5% identifies the cause of the symptom). MRI of the inner ear and cerebellopontine angle was the test that presented the most significant findings (17.7%). The 286 image tests requested for vertigo cost 56,741 euros. The cost for a positive test was 1,576 euros. CONCLUSIONS: A large number of head CT and MRI are made in patients with vertigo and dizziness. A clinical suspicion is recommended from the anamnesis and exploration to make a good selection of test to request. In more than 90% of cases, radiological findings are not shown in relation to vertigo.

TITLE: Que aporta la neuroimagen en pacientes con vertigo y mareo? Analisis coste-utilidad.Introduccion. Vertigo y mareo son sintomas que suponen una carga significativa en el hospital e involucran a varias especialidades. Existen pocas guias sobre la solicitud de pruebas radiologicas ante estos sintomas. Objetivos. Conocer que perfil de pacientes con vertigo y mareo tiene realizadas pruebas de neuroimagen, cuantificar y describir los hallazgos radiologicos, y analizar el coste-utilidad de la tomografia computarizada (TC) y la resonancia magnetica (RM) en pacientes con estos sintomas. Pacientes y metodos. Estudio descriptivo en el que se seleccionan pacientes remitidos al hospital por vertigo y mareo. Se analizan caracteristicas demograficas y clinicas y se cuantifican las pruebas de neuroimagen solicitadas. Se describen los hallazgos radiologicos, se valora su relevancia en el diagnostico y se detalla el coste. Resultados. Se identifica a 493 pacientes, el 60% tiene realizada una prueba de neuroimagen; son pacientes de mas edad, depresivos y que han acudido a urgencias por vertigo. La prueba mas realizada fue la TC de craneo sin contraste (el 5% identifica la causa del sintoma). La que presento mas hallazgos significativos fue la RM de la base del craneo (17,7%). Las 286 pruebas de imagen solicitadas por vertigo costaron 56.741 euros. El gasto para obtener un diagnostico radiologico fue de 1.576 euros. Conclusiones. Se realiza un gran numero de TC y RM de cabeza en pacientes con vertigo y mareo. Es recomendable tener un diagnostico de sospecha previo a partir de la anamnesis y la exploracion para hacer una buena seleccion de las pruebas que hay que solicitar. En mas del 90% de los casos no se muestran hallazgos radiologicos en relacion con el vertigo.

Neuroimaging of Adults with Headache: Appropriateness, Utilization, and an Economical Overview.

One of the most common reasons that a patient seeks out a health care provider for a neuroscience-related issue is headache. Not all patients can, or probably should, be imaged with headache. We must use an approach that attends to scientific evidence, accepted guidelines, and available resources. This approach should focus on quality, safety, appropriateness, and utilization. This article reviews and discusses the consideration of imaging adult patients with headache.

Impact of early headache neuroimaging on time to malignant brain tumor diagnosis: A retrospective cohort study.

BACKGROUND: Neuroimaging for headaches is both common and costly. While the costs are well quantified, little is known about the benefit in terms of diagnosing pathology. Our objective was to determine the role of early neuroimaging in the identification of malignant brain tumors in individuals presenting to healthcare providers with headaches. METHODS: This was a retrospective cohort study using administrative claims data (2001-2014) from a US insurer. Individuals were included if they had an outpatient visit for headaches and excluded for prior headache visits, other neurologic conditions, neuroimaging within the previous year, and cancer. The exposure was early neuroimaging, defined as neuroimaging within 30 days of the first headache visit. A propensity score-matched group that did not undergo early neuroimaging was then created. The primary outcome was frequency of malignant brain tumor diagnoses and median time to diagnosis within the first year after the incident headache visit. The secondary outcome was frequency of incidental findings. RESULTS: 22.2% of 180,623 individuals had early neuroimaging. In the following year, malignant brain tumors were found in 0.28% (0.23-0.34%) of the early neuroimaging group and 0.04% (0.02-0.06%) of the referent group (P<0.001). Median time to diagnosis in the early neuroimaging group was 8 (3-19) days versus 72 (39-189) days for the referent group (P<0.001). Likely incidental findings were discovered in 3.17% (3.00-3.34%) of the early neuroimaging group and 0.66% (0.58-0.74%) of the referent group (P<0.001). CONCLUSIONS: Malignant brain tumors in individuals presenting with an incident headache diagnosis are rare and early neuroimaging leads to a small reduction in the time to diagnosis.

Brain imaging in preterm infants <32 weeks gestation: a clinical review and algorithm for the use of cranial ultrasound and qualitative brain MRI.

The aim is to review the evidence about the utility of term-equivalent age (TEA) magnetic resonance imaging (MRI) in predicting neurodevelopmental outcomes for preterm neonates. Preterm birth accounts for ~12% of all deliveries in the United States and is the leading cause of neurologic disabilities in children. From the neonatologist perspective, it is critically important to identify preterm infants at risk of subsequent neurodevelopmental disability who may benefit from early intervention services. However "the choose wisely campaign" also emphasizes the need to have ongoing cost/benefit discussions regarding care of preterm newborns to avoid waste that comes from subjecting infants to procedures that do not help. We performed a MEDLINE EMBASE database review from 2000 to 2018 to account for the technical evolution in the cranial ultrasound machines and introduction of MRI imaging in the NICU. Studies were graded based on the strength of their design using the GRADE guidelines and summarized with respect to brain MRI vs. cranial US (1) detection of white matter injury; (2) cerebellar hemorrhage; (3) long-term neurodevelopmental outcomes and impact on parental anxiety. We conclude with a hospital-specific guideline algorithm for performing TEA MRI based on risk evaluations ≤32 weeks.

Clinical results and costs of endovascular treatment in comparison with surgery in non ruptured aneurysms. / Resultados clínicos y de costes del tratamiento endovascular frente al quirúrgico en aneurismas incidentales.

OBJECTIVE: to evaluate the results and costs of surgical treatment against endovascular in non ruptured aneurysms. MATERIAL AND METHODS: retrospective study of a consecutive series non ruptured aneurysms from a single-center treated endovascularly (EV) and surgically (SC). A descriptive study of demographic (age, sex) charqacteristics of the patients and the radiological aspects of the aneurysms have been carried out. Clinical results (GOS at 6 months), angiographic data (occlusion classification) and economic costs have been evaluated in both globally, and in each of the groups. RESULTS: 89 patients treated between 2010 and 2015 were reviewed. Most of them were treated endovascularly (74%). There were no statiscally significant differences between EV and SC groups. 89% of the patients presented favourable GOS (4-5) at six months, being this percentage similar in both groups. Complete occlusion was much higher in SC group (96%) than in EV (55%). Retreatment rate was 24% in EV group and 0% in SC group. The retreatments were more frequent in anterior circulation aneurysms and bigger aneurysms (> 10 mm). The expenses in the SC group come mainly from hospital stay, meanwhile in the EV group is due to embolisation materials. The average length of stay (ALOS) are higher in SC group but costs of first admission are higher in EV group (14% more). When the costs of retreatments and follow up are included the costs of endovascular treatment is much higher than the surgical (61% more expensive). CONCLUSIONS: results of both types of treatment are comparable. The grade of aneurysmal occlusion of the SC group was higher than the EV, as well as the stability of the treatment, requiring fewer retreatments. Althoug the ALOS in SC group were longer, the costs of the EV group were significantly higher than the SC group due to the costs of embolisation materials, follow up that they need and the rate of retreatment. Adequate selection of candidates for endovascular coiling could improve angiographic outcomes, reduce retraction rates, and save costs.

Cost burden of neuroimaging during one-time admission for first-ever acute stroke in Nigeria.

OBJECTIVE: To determine the cost burden of Neuroimaging and its contribution to direct total hospitalization costs (HCs) during one-time admission for first-ever stroke. METHODS: The clinical characteristics, direct itemised costs and total HCs for 170 consecutive patients with first-ever stroke, admitted at our public tertiary health facility over a 15-month period were evaluated. RESULTS: The records of 170 stroke subjects were reviewed. The median total HCs for one-time admission per stroke patient was $183.30 with a median daily cost of $15.86. Median cost of radiological investigations was the highest among the categorized hospital costs. Among the radiological investigations, neuroimaging accounted for at least 99% of cost to patients. CONCLUSION: The financial burden of radiological investigations, particularly neuroimaging, is high during one-time admission of patients with first-ever stroke in our environment.