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Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.

ABSTRACT: Background:Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. Methods:Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15?years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90?days was prospectively measured and used to estimate procedure and inpatient care costs (US$ reference year 2014). Results:There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15 (IQR 12-19). The median (IQR) disability-weighted utility score at 90?days was 0.65 (0.00-0.91) in the alteplase-only versus 0.91 (0.65-1.00) in the endovascular group (p?=?0.005). Modeled life expectancy was greater in the endovascular versus alteplase-only group (median 15.6 versus 11.2?years, p?=?0.02). The endovascular thrombectomy group had fewer simulated DALYs lost over 15?years [median (IQR) 5.5 (3.2-8.7) versus 8.9 (4.7-13.8), p?=?0.02] and more QALY gained [median (IQR) 9.3 (4.2-13.1) versus 4.9 (0.3-8.5), p?=?0.03]. Endovascular patients spent less time in hospital [median (IQR) 5 (3-11) days versus 8 (5-14) days, p?=?0.04] and rehabilitation [median (IQR) 0 (0-28) versus 27 (0-65) days, p?=?0.03]. The estimated inpatient costs in the first 90?days were less in the thrombectomy group (average US$15,689 versus US$30,569, p?=?0.008) offsetting the costs of interhospital transport and the thrombectomy procedure (average US$10,515). The average saving per patient treated with thrombectomy was US$4,365. Conclusion:Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90?days. There was evidence of clinically relevant improvement in long-term survival and quality of life. Clinical Trial Registration:http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).

SUBMITTER: Campbell BCV

PROVIDER: S-EPMC5735082 | biostudies-literature | 2017

REPOSITORIES: biostudies-literature

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Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.

Campbell Bruce C V BCV Mitchell Peter J PJ Churilov Leonid L Keshtkaran Mahsa M Hong Keun-Sik KS Kleinig Timothy J TJ Dewey Helen M HM Yassi Nawaf N Yan Bernard B Dowling Richard J RJ Parsons Mark W MW Wu Teddy Y TY Brooks Mark M Simpson Marion A MA Miteff Ferdinand F Levi Christopher R CR Krause Martin M Harrington Timothy J TJ Faulder Kenneth C KC Steinfort Brendan S BS Ang Timothy T Scroop Rebecca R Barber P Alan PA McGuinness Ben B Wijeratne Tissa T Phan Thanh G TG Chong Winston W Chandra Ronil V RV Bladin Christopher F CF Rice Henry H de Villiers Laetitia L Ma Henry H Desmond Patricia M PM Meretoja Atte A Cadilhac Dominique A DA Donnan Geoffrey A GA Davis Stephen M SM

Frontiers in neurology 20171214

<h4>Background</h4>Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection.<h4>Methods</h4>Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (m ...[more]

PMID: 29312109

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Project description:ImportanceIntravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) is recommended to treat acute ischemic stroke (AIS) with a large vessel occlusion (LVO). Most hospitals do not have on-site MT facilities, and most patients need to be transferred secondarily after IVT (drip and ship), which may have an effect on the neurologic outcome.ObjectiveTo compare the functional independence at 3 months between patients treated under the drip-and-ship paradigm and those treated on site (mothership).Design, setting, and participantsThis study used a prospectively gathered registry of patients with AIS to select patients admitted through the Saint-Antoine and Tenon (drip and ship) or the Fondation Rothschild (mothership) hospitals from January 1, 2013, through April 30, 2016. The study included patients older than 18 years treated with bridging therapy for AIS with LVO of the anterior circulation. Among the 159 patients who received MT at the mothership, 100 had been transferred after IVT from the drip-and-ship hospitals and 59 had received IVT on site.Main outcomes and measuresThe main outcome was 3-month functional independence (modified Rankin scale score ≤2). Both groups were compared using a multivariate linear model, including variables that were significantly different in the 2 groups.ResultsDuring the study period, 497 patients were hospitalized at the drip-and-ship and mothership hospitals for an AIS eligible to reperfusion therapy; 11 patients had a basilar artery occlusion and were excluded, leaving 100 patients in the drip-and-ship group (mean age, 73 years; age range, 60-81 years; 57 men [57.0%]) and 59 in the mothership group (mean age, 70 years; age range, 58-82 years; 29 men [49.2%]). The proportion of patients with a favorable neurologic outcome at 3 months was similar in both groups (drip and ship, 61 [61.0%]; mothership, 30 [50.8%]; P = .26), even after adjusting the analysis for the baseline National Institutes of Health Stroke Scale score, diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, and general anesthesia (P = .82). Patients had less severe conditions in the drip-and-ship group (median baseline National Institutes of Health Stroke Scale score, 15 vs 17 [P = .03]; median diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, 7.5 vs 7 [P = .05]). Process times were longer in the drip-and-ship group (onset-to-needle time, 150 vs 135 minutes; onset-to-puncture time, 248 vs 189 minutes; and onset-to-recanalization time, 297 vs 240 minutes; P < .001). Both groups were similar in terms of substantial recanalization (Thrombolysis in Cerebral Ischemia scores 2B to 3; drip and ship, 84 [84.0%]; mothership, 47 [79.7%]; P = .49) and symptomatic hemorrhagic transformation (drip and ship, 2 [2.0%]; mothership, 2 [3.4%]; P = .63).Conclusions and relevanceThis study found that patients treated under the drip-and-ship paradigm also benefit from bridging therapy, with no statistically significant difference compared with those treated directly in a comprehensive stroke center.

Dataset Information

Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.

Publications

Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.

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