Endovascular thrombectomy for ischemic stroke increases disability-free survival, quality of life, and life expectancy and reduces cost

Bruce C. V. Campbell, Peter J. Mitchell, Leonid Churilov, Mahsa Keshtkaran, Keun Sik Hong, Timothy J. Kleinig, Helen M. Dewey, Nawaf Yassi, Bernard Yan, Richard J. Dowling, Mark W. Parsons, Teddy Y. Wu, Mark Brooks, Marion A. Simpson, Ferdinand Miteff, Christopher R. Levi, Martin Krause, Timothy J. Harrington, Kenneth C. Faulder, Brendan S. Steinfort & 18 others Timothy Ang, Rebecca Scroop, P. Alan Barber, Ben McGuinness, Tissa Wijeratne, Thanh G. Phan, Winston Chong, Ronil V. Chandra, Christopher F. Bladin, Henry Rice, Laetitia de Villiers, Henry Ma, Patricia M. Desmond, Atte Meretoja, Dominique A. Cadilhac, Geoffrey A. Donnan, Stephen M. Davis, on behalf of the EXTEND-IA Investigators

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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).

Original languageEnglish
Article number657
Pages (from-to)1-7
Number of pages7
JournalFrontiers in Neurology
Volume8
Issue numberDEC
DOIs
Publication statusPublished - 14 Dec 2017
Externally publishedYes

Bibliographical note

Copyright the Author(s) 2017. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

Keywords

  • CT perfusion
  • Endovascular therapy
  • Intraarterial therapy
  • Ischemic stroke
  • Mechanical thrombectomy
  • Randomized trial
  • Solitaire stent retriever device
  • Thrombolysis

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