Endovascular thrombectomy in patients with large core ischemic stroke: a cost-effectiveness analysis from the SELECT study

Sarraj, Amrou; Pizzo, Elena; Lobotesis, Kyriakos; Grotta, James C.; Hassan, Ameer E.; Abraham, Michael; Blackburn, Spiros; Day, Arthur L.; Dannenbaum, Mark J.; Hicks, William; Vora, Nirav; Budzik, Ronald F; Sharrief, Anjail; Martin‐Schild, Sheryl; Sitton, Clark; Pujara, Deep; Lansberg, Maarten G; Gupta, Rishi; Albers, Gregory W.; Kunz, Wolfgang G.; Investigators, Select

doi:10.1136/neurintsurg-2020-016766

Cited by 25 publications

(27 citation statements)

References 38 publications

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“…The results of ongoing RCTs testing EVT in patients with low ASPECTS in a 0-24 hours time window, regardless of the imaging modality, will be of particular interest to assess the relative effect of low ASPECTS and the delay from onset to reperfusion on the PH risk and its impact on functional recovery. 18,19 Overall, our results underline the importance of an expedited transfer of patients with suspected LVO-AIS to the cath lab to reduce the delay from onset to reperfusion, encouraging the use mobile stroke unit and the completion of RCT testing direct transfer to the angio suite. 20,21 Our study suffers from several limitations inherent to its design.…”

Section: Discussionmentioning

confidence: 62%

“…They also suggest that initial imaging by CT was by comparison with MRI associated with an higher rate of PH after adjustment on ASPECTS. The results of ongoing RCTs testing EVT in patients with low ASPECTS in a 0–24 hours time window, regardless of the imaging modality, will be of particular interest to assess the relative effect of low ASPECTS and the delay from onset to reperfusion on the PH risk and its impact on functional recovery 18,19 …”

Section: Discussionmentioning

confidence: 99%

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Parenchymal Hemorrhage Rate Is Associated with Time to Reperfusion and Outcome

Olivot¹,

Finitsis

Lapergue

et al. 2022

Annals of Neurology

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Objective Despite a 90% reperfusion rate, only 50% of patients with anterior circulation large vessel occlusion‐related acute ischemic stroke (LVO‐AIS) have a functional recovery at 3 months. Parenchymal hematoma (PH) is a predictor of poor outcome after endovascular treatment (EVT). We aim to investigate the relationship between the delay from onset to reperfusion, the occurrence of PH, and functional outcome. Methods The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing prospective observational study. Data were analyzed from the subgroup of patients who underwent a successful EVT defined by a modified Thrombolysis in Cerebral Infarction (mTICI) score 2b‐3. We assessed the factors associated with PH, (ie, PH1 or PH2 grade according to the European Collaborative Acute Stroke Study 2 (ECASS) classification of hemorrhagic transformation), then evaluated the relationships between PH, delay from onset to reperfusion, and functional recovery defined by a modified Rankin Scale (mRS) of 0–2. Results We analyzed 2,919 patients with an LVO‐related AIS who underwent a successful EVT. Overall, 13.3% of the participant experienced a PH. The rate of PH increased by 2.5% (95% CI 1.5%–3.6%, p < 0.001) for every additional hour of onset to reperfusion delay and was, by comparison with the other study patients, consistently associated with a lower rate of functional recovery 19.7% (95% CI 11.6%–27.7%, p < 0.001) irrespective of time from onset to reperfusion. Interpretation Our results demonstrate that PH rate is associated with the delay from onset to reperfusion and participates in the relationship between time to reperfusion and outcome. Time is Bleeding. ANN NEUROL 2022;92:882–887

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Section: Discussionmentioning

confidence: 62%

Section: Discussionmentioning

confidence: 99%

Parenchymal Hemorrhage Rate Is Associated with Time to Reperfusion and Outcome

Olivot¹,

Finitsis

Lapergue

et al. 2022

Annals of Neurology

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“…However, reperfusion failed to reach statistical significance with regards to absolute NIHSS score change if rCBV was high. These findings underline the ongoing debate on how and when to apply different neuroimaging tools for selection of patients who may benefit from EVT in the subgroup of those with low ASPECTS [13–15]. The HERMES meta‐analysis observed a benefit of EVT only in the subgroup of patients with ASPECTS of 3, whereas no treatment effect of MT was observed in patients with ASPECTS 0–2 or ASPECTS 4–5 [16], emphasizing the need for further diagnostic tools to reliably identify patients with low ASPECTS who are likely to benefit from EVT [3, 17].…”

Section: Discussionmentioning

confidence: 93%

Impact of relative cerebral blood volume reduction on early neurological improvement in extensive ischemic stroke

Broocks

Haupt

McDonough

et al. 2022

Euro J of Neurology

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Background and purpose The benefit of endovascular treatment (EVT) for patients with low Alberta Stroke Program early computed tomography score (ASPECTS) is still ambiguous and is currently being investigated in randomized trials. Computed tomography (CT) perfusion, used to estimate infarct extent and progression, might predict early neurological improvement (ENI) after EVT. We hypothesized that the degree of relative cerebral blood volume (rCBV) reduction is directly associated with ENI in low ASPECTS patients undergoing EVT. Methods Ischemic stroke patients with ASPECTS ≤ 5 who received multimodal CT and underwent thrombectomy were analyzed. rCBV reduction was defined as the ratio of cerebral blood volume (CBV), measured in the ischemic lesion to contralateral CBV. Complete reperfusion was defined as an expanded Thrombolysis in Cerebral Infarction score 2c‐3. The clinical endpoint was ENI at 24 h, defined continuously (National Institutes of Health Stroke Scale [NIHSS] score change from baseline to 24 h) and binarized (NIHSS score at 24 h ≤ 8). Results A total of 102 patients were included. Lower rCBV reduction and complete EVT were independently associated with ENI (−11.4 NIHSS points, p = 0.04; −7.3 points, p < 0.0001, respectively). The effect of complete EVT on ENI was directly linked to the degree of rCBV reduction: the probability for binary ENI was +34.6% (p = 0.004) in patients with low rCBV reduction versus +8.2% (p = 0.28) in patients with high rCBV reduction). Conclusion In patients with ischemic stroke with low ASPECTS, ENI was directly linked to the degree of rCBV reduction, a potential indicator of ischemia depth in extensive baseline infarction. Lower rCBV reduction was associated with higher probability of ENI after complete reperfusion, suggesting less pronounced lesion progression despite its large extent and hence, a higher susceptibility to EVT.

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“…A previous systematic review25 and two recent studies in the USA26 27 have demonstrated cost-effectiveness of endovascular thrombectomy for acute ischemic stroke. The ICER of coiling found in our study on aSAH was slightly higher than that (US$1236) of video-electroencephalography monitoring, which has been adopted for insurance coverage in epilepsy surgery candidates in Thailand 28.…”

Section: Discussionmentioning

confidence: 99%

Cost-effectiveness analysis of endovascular coiling and neurosurgical clipping for aneurysmal subarachnoid hemorrhage in Thailand

Duangthongphon

Kitkhuandee

Munkong

et al. 2021

J NeuroIntervent Surg

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BackgroundFor patients with aneurysmal subarachnoid hemorrhage (aSAH), the Universal Coverage Scheme in Thailand covers the full costs of surgical and endovascular procedures except for those of embolization coils and assisting devices. Costs and effectiveness were compared between endovascular coiling and neurosurgical clipping to inform reimbursement policy decisions.MethodsCosts and quality-adjusted life years (QALYs) were compared between coiling and clipping using the decision tree and Markov models. Mortality and functional outcomes of clipping were derived from national and hospital databases, and relative efficacies of coiling were obtained from meta-analyses of randomized controlled trials. Risks of rebleeding were abstracted from the International Subarachnoid Aneurysm Trial. Costs of the primary treatments, retreatments and follow-up care as well as utilities were obtained from hospital-based data. Non-health and indirect costs were abstracted from standard cost lists.ResultsCoiling and clipping contributed 10.59 and 9.28 QALYs to patients aged in their 50s. Under the societal and healthcare perspectives, the incremental costs incurred by coiling compared with clipping were US$1923 and $4343, respectively, which were equal to the incremental cost-effectiveness ratio of US$1470 and $3321 per QALY gained, respectively. Coiling became a cost-saving option when the costs of coil devices were reduced by 65.7%. At the country’s cost-effectiveness threshold of US$5156, the probability of coiling being cost-effective was 71.3% and 65.6%, under the societal and healthcare perspectives, respectively.ConclusionEndovascular treatment for aSAH is cost-effective and this evidence supports coverage by national insurance.

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Endovascular thrombectomy in patients with large core ischemic stroke: a cost-effectiveness analysis from the SELECT study

Cited by 25 publications

References 38 publications

Parenchymal Hemorrhage Rate Is Associated with Time to Reperfusion and Outcome

Parenchymal Hemorrhage Rate Is Associated with Time to Reperfusion and Outcome

Impact of relative cerebral blood volume reduction on early neurological improvement in extensive ischemic stroke

Cost-effectiveness analysis of endovascular coiling and neurosurgical clipping for aneurysmal subarachnoid hemorrhage in Thailand

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