TY - JOUR
T1 - Endovascular thrombectomy for ischemic stroke increases disability-free survival, quality of life, and life expectancy and reduces cost
AU - Campbell, Bruce C.V.
AU - Mitchell, Peter J.
AU - Churilov, Leonid
AU - Keshtkaran, Mahsa
AU - Hong, Keun Sik
AU - Kleinig, Timothy J.
AU - Dewey, Helen M.
AU - Yassi, Nawaf
AU - Yan, Bernard
AU - Dowling, Richard J.
AU - Parsons, Mark W.
AU - Wu, Teddy Y.
AU - Brooks, Mark
AU - Simpson, Marion A.
AU - Miteff, Ferdinand
AU - Levi, Christopher R.
AU - Krause, Martin
AU - Harrington, Timothy J.
AU - Faulder, Kenneth C.
AU - Steinfort, Brendan S.
AU - Ang, Timothy
AU - Scroop, Rebecca
AU - Barber, P. Alan
AU - McGuinness, Ben
AU - Wijeratne, Tissa
AU - Phan, Thanh G.
AU - Chong, Winston
AU - Chandra, Ronil V.
AU - Bladin, Christopher F.
AU - Rice, Henry
AU - de Villiers, Laetitia
AU - Ma, Henry
AU - Desmond, Patricia M.
AU - Meretoja, Atte
AU - Cadilhac, Dominique A.
AU - Donnan, Geoffrey A.
AU - Davis, Stephen M.
AU - on behalf of the EXTEND-IA Investigators
PY - 2017/12/14
Y1 - 2017/12/14
N2 - 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$4,365. Conclusion: Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90 days. There was evidence of clinically relevant improvement in long-term survival and quality of life. Clinical Trial Registration: http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).
AB - Background: Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. Methods: Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15 years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90 days was prospectively measured and used to estimate procedure and inpatient care costs (US$ 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).
KW - CT perfusion
KW - Endovascular therapy
KW - Intraarterial therapy
KW - Ischemic stroke
KW - Mechanical thrombectomy
KW - Randomized trial
KW - Solitaire stent retriever device
KW - Thrombolysis
UR - http://www.scopus.com/inward/record.url?scp=85038220351&partnerID=8YFLogxK
M3 - Article
AN - SCOPUS:85038220351
SN - 1664-2295
VL - 8
JO - Frontiers in Neurology
JF - Frontiers in Neurology
IS - DEC
M1 - 657
ER -
