Frontiers in Neurology (Dec 2017)

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,
  • Nawaf Yassi,
  • Bernard Yan,
  • Richard J. Dowling,
  • Mark W. Parsons,
  • Teddy Y. Wu,
  • Mark Brooks,
  • Marion A. Simpson,
  • Ferdinand Miteff,
  • Ferdinand Miteff,
  • Christopher R. Levi,
  • Martin Krause,
  • Timothy J. Harrington,
  • Kenneth C. Faulder,
  • Brendan S. Steinfort,
  • 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,
  • Henry Ma,
  • Patricia M. Desmond,
  • Atte Meretoja,
  • Atte Meretoja,
  • Dominique A. Cadilhac,
  • Dominique A. Cadilhac,
  • Geoffrey A. Donnan,
  • Stephen M. Davis,
  • on behalf of the EXTEND-IA Investigators,
  • Stephen M Davis,
  • Geoffrey A Donnan,
  • Bruce CV Campbell,
  • Peter J Mitchell,
  • Leonid Churilov,
  • Bernard Yan,
  • Richard Dowling,
  • Nawaf Yassi,
  • Thomas J Oxley,
  • Teddy Y Wu,
  • Gabriel Silver,
  • Amy McDonald,
  • Rachael McCoy,
  • Timothy J Kleinig,
  • Rebecca Scroop,
  • Helen M Dewey,
  • Marion Simpson,
  • Mark Brooks,
  • Bronwyn Coulton,
  • Martin Krause,
  • Timothy J Harrington,
  • Brendan Steinfort,
  • Kenneth Faulder,
  • Miriam Priglinger,
  • Susan Day,
  • Thanh Phan,
  • Winston Chong,
  • Michael Holt,
  • Ronil V Chandra,
  • Henry Ma,
  • Dennis Young,
  • Kitty Wong,
  • Tissa Wijeratne,
  • Hans Tu,
  • Elizabeth Mackay,
  • Sherisse Celestino,
  • Christopher F Bladin,
  • Poh Sien Loh,
  • Amanda Gilligan,
  • Zofia Ross,
  • Skye Coote,
  • Tanya Frost,
  • Mark W Parsons,
  • Ferdinand Miteff,
  • Christopher R Levi,
  • Timothy Ang,
  • Neil Spratt,
  • Lara Kaauwai,
  • Monica Badve,
  • Henry Rice,
  • Laetitia de Villiers,
  • P. Alan Barber,
  • Ben McGuinness,
  • Ayton Hope,
  • Maurice Moriarty,
  • Patricia Bennett,
  • Andrew Wong,
  • Alan Coulthard,
  • Andrew Lee,
  • Jim Jannes,
  • Deborah Field,
  • Gagan Sharma,
  • Simon Salinas,
  • Elise Cowley,
  • Barry Snow,
  • John Kolbe,
  • Richard Stark,
  • John King,
  • Richard Macdonnell,
  • John Attia,
  • Cate D’Este

DOI
https://doi.org/10.3389/fneur.2017.00657
Journal volume & issue
Vol. 8

Abstract

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BackgroundEndovascular 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.MethodsLarge 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).ResultsThere 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.ConclusionThrombectomy 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 Registrationhttp://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).

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