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Title: Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.
Austin Authors: Campbell, Bruce C V;Mitchell, Peter J;Churilov, Leonid ;Keshtkaran, Mahsa;Hong, Keun-Sik;Kleinig, Timothy J;Dewey, Helen M;Yassi, Nawaf;Yan, Bernard;Dowling, Richard J;Parsons, Mark W;Wu, Teddy Y;Brooks, Duncan Mark ;Simpson, Marion A ;Miteff, Ferdinand;Levi, Christopher R;Krause, Martin;Harrington, Timothy J;Faulder, Kenneth C;Steinfort, Brendan S;Ang, Timothy;Scroop, Rebecca;Barber, P Alan;McGuinness, Ben;Wijeratne, Tissa;Phan, Thanh G;Chong, Winston;Chandra, Ronil V;Bladin, Christopher F;Rice, Henry;de Villiers, Laetitia;Ma, Henry;Desmond, Patricia M;Meretoja, Atte;Cadilhac, Dominique A;Donnan, Geoffrey A ;Davis, Stephen M
Affiliation: Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
Department of Neurology, Ilsan Paik Hospital, Inje University, Gyeonggi-do, South Korea
Royal Adelaide Hospital, Adelaide, SA, Australia
Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Monash University, Clayton, Victoria, Australia
Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
Austin Health, Heidelberg, Victoria, Australia
Department of Radiology, Royal North Shore Hospital, St Leonards, NSW, Australia
Department of Neurology, Royal North Shore Hospital, Kolling Institute, University of Sydney, St Leonards, NSW, Australia
Centre for Brain Research, University of Auckland, Auckland City Hospital, Auckland, New Zealand
Auckland City Hospital, Auckland, New Zealand
Western Hospital, Footscray, Victoria, Australia
Monash Medical Centre, Monash University, Clayton, Victoria, Australia
Gold Coast University Hospital, Southport, QLD, Australia
Department of Neurology, Helsinki University Hospital, Helsinki, Finland
Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
Issue Date: 2017 2017
Publication information: Frontiers in neurology 2017; 8: 657
Abstract: 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. 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). 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. 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. NCT01492725 (registered 20/11/2011).
DOI: 10.3389/fneur.2017.00657
ORCID: 0000-0001-8162-682X
PubMed URL: 29312109
ISSN: 1664-2295
Type: Journal Article
Subjects: CT perfusion
Solitaire stent retriever device
endovascular therapy
intraarterial therapy
Ischaemic Stroke
mechanical thrombectomy
randomized trial
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