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Gottschalk S, König HH, Subtil F, Bonekamp S, Denis A, Aamodt AH, Fuentes B, Gizewski ER, Hill MD, Krajina A, Pierot L, Simonsen CZ, Zeleňák K, Bendszus M, Thomalla G, Dams J. Cost-effectiveness of endovascular thrombectomy for acute ischemic stroke with established large infarct in Germany: a decision tree and Markov model. J Neurointerv Surg 2024:jnis-2024-021837. [PMID: 38906688 DOI: 10.1136/jnis-2024-021837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/02/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Recent studies, including the TENSION trial, support the use of endovascular thrombectomy (EVT) in acute ischemic stroke with large infarct (Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 3-5). OBJECTIVE To evaluate the cost-effectiveness of EVT compared with best medical care (BMC) alone in this population from a German healthcare payer perspective. METHODS A short-term decision tree and a long-term Markov model (lifetime horizon) were used to compare healthcare costs and quality-adjusted life years (QALYs) between EVT and BMC. The effectiveness of EVT was reflected by the 90-day modified Rankin Scale (mRS) outcome from the TENSION trial. QALYs were based on published mRS-specific health utilities (EQ-5D-3L indices). Long-term healthcare costs were calculated based on insurance data. Costs (reported in 2022 euros) and QALYs were discounted by 3% annually. Cost-effectiveness was assessed using incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses were performed to account for parameter uncertainties. RESULTS Compared with BMC, EVT yielded higher lifetime incremental costs (€24 257) and effects (1.41 QALYs), resulting in an ICER of €17 158/QALY. The results were robust to parameter variation in sensitivity analyses (eg, 95% probability of cost-effectiveness was achieved at a willingness to pay of >€22 000/QALY). Subgroup analyses indicated that EVT was cost-effective for all ASPECTS subgroups. CONCLUSIONS EVT for acute ischemic stroke with established large infarct is likely to be cost-effective compared with BMC, assuming that an additional investment of €17 158/QALY is deemed acceptable by the healthcare payer.
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Affiliation(s)
- Sophie Gottschalk
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
- Hamburg Center for Health Economics, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
- Hamburg Center for Health Economics, Hamburg, Germany
| | - Fabien Subtil
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France
- Laboratoire de Biométrie et Biologie Évolutive, Université Lyon 1, Villeurbanne, France
| | - Susanne Bonekamp
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Angelique Denis
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France
- Laboratoire de Biométrie et Biologie Évolutive, Université Lyon 1, Villeurbanne, France
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian University of Science and Technology, Trondheim, Norway
| | - Blanca Fuentes
- Department of Neurology and Stroke Unit, La Paz University Hospital, Madrid, Spain
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Health Science Centre, University of Calgary & Foothills Medical Centre, Calgary, Alberta, Canada
| | - Antonin Krajina
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université de Reims Champagne-Ardenne, Reims, France
| | | | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Judith Dams
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
- Hamburg Center for Health Economics, Hamburg, Germany
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Sun D, Nguyen TN, Pan Y, Wang M, Abdalkader M, Masoud HE, Ma A, Tong X, Ma G, Sun X, Song L, Ma N, Gao F, Mo D, Miao Z, Huo X. Unsuccessful Recanalization versus Medical Management of Patients with Large Ischemic Core : Analysis of the ANGEL-ASPECT Randomized Trial. Clin Neuroradiol 2024; 34:441-450. [PMID: 38319347 DOI: 10.1007/s00062-024-01384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/05/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE The outcomes of patients with large ischemic core who fail to recanalize with endovascular therapy (EVT) compared to medical management (MM) are uncertain. The objective was to evaluate the clinical and safety outcomes of patients who underwent EVT in patients with large ischemic core and unsuccessful recanalization. METHODS This was a post hoc analysis of the ANGEL-ASPECT randomized trial. Unsuccessful recanalization was defined as patients who underwent EVT with eTICI 0-2a. The primary endpoint was 90-day very poor outcome (mRS 5-6). Multivariable logistic regression was conducted controlling for ASPECTS, occlusion location, intravenous thrombolysis, and time to treatment. RESULTS Of 455 patients 225 were treated with MM. Of 230 treated with EVT, 43 (19%) patients had unsuccessful recanalization. There was no difference in 90-day very poor outcomes (39.5% vs. 40%, aOR 0.93, 95% confidence interval, CI 0.47-1.85, p = 0.95), sICH (7.0% vs. 2.7%, aOR 2.81, 95% CI 0.6-13.29, p = 0.19), or mortality (30% vs. 20%, aOR 1.65, 95% CI 0.89-3.06, p = 0.11) between the unsuccessful EVT and MM groups, respectively. There were higher rates of ICH (55.8% vs. 17.3%, p < 0.001), infarct core volume growth (142.7 ml vs. 90.5 ml, β = 47.77, 95% CI 20.97-74.57 ml, p < 0.001), and decompressive craniectomy (18.6% vs. 3.6%, p < 0.001) in the unsuccessful EVT versus MM groups. CONCLUSION In a randomized trial of patients with large ischemic core undergoing EVT with unsuccessful recanalization, there was no difference in very poor outcomes, sICH or death versus medically managed patients. In the unsuccessful EVT group, there were higher rates of any ICH, volume of infarct core growth, and decompressive craniectomy.
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Affiliation(s)
- Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Thanh N Nguyen
- Neurology, Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Mohamad Abdalkader
- Neurology, Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Hesham E Masoud
- Neurology, SUNY Upstate Medical University Hospital, Syracuse, NY, USA
| | - Alice Ma
- Neurosurgery, Royal North Shore Hospital, Sydney, Australia
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China.
| | - Xiaochuan Huo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, 100070, Beijing, China.
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Mujanovic A, Strbian D, Demeestere J, Marto JP, Puetz V, Nogueira RG, Abdalkader M, Nagel S, Raymond J, Ribo M, Michel P, Yoshimura S, Zaidat OO, Winzer S, Ortega-Gutierrez S, Sheth SA, Siegler JE, Dusart A, Haussen DC, Henon H, Serrallach BL, Mohammaden MH, Möhlenbruch MA, Olive-Gadea M, Puri AS, Sakai N, Klein P, Tomppo L, Caparros F, Ramos JN, Jumaa M, Zaidi S, Dobrocky T, Martinez-Majander N, Nannoni S, Bellante F, Rodriguez-Calienes A, Salazar-Marioni S, Virtanen P, Kaiser DP, Ventura R, Jesser J, Castonguay AC, Qureshi MM, Masoud HE, Galecio-Castillo M, Requena M, Lauha R, Hu W, Lin E, Miao Z, Roy D, Yamagami H, Seiffge DJ, Strambo D, Ringleb PA, Lemmens R, Fischer U, Nguyen TN, Kaesmacher J. Safety and clinical outcomes of endovascular therapy versus medical management in late presentation of large ischemic stroke. Eur Stroke J 2024:23969873241249406. [PMID: 38757713 DOI: 10.1177/23969873241249406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION The benefit of endovascular therapy (EVT) among stroke patients with large ischemic core (ASPECTS 0-5) in the extended time window outside of trial settings remains unclear. We analyzed the effect of EVT among these stroke patients in real-world settings. PATIENTS AND METHODS The CT for Late Endovascular Reperfusion (CLEAR) study recruited patients from 66 centers in 10 countries between 01/2014 and 05/2022. The extended time-window was defined as 6-24 h from last-seen-well to treatment. The primary outcome was shift of the 3-month modified Rankin scale (mRS) score. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality. Outcomes were analyzed with ordinal and logistic regressions. RESULTS Among 5098 screened patients, 2451 were included in the analysis (median age 73, 55% women). Of patients with ASPECTS 0-5 (n = 310), receiving EVT (n = 209/310) was associated with lower 3-month mRS when compared to medical management (median 4 IQR 3-6 vs 6 IQR 4-6; aOR 0.4, 95% CI 0.2-0.7). Patients undergoing EVT had higher sICH (11.2% vs 4.0%; aOR 4.1, 95% CI 1.2-18.8) and lower mortality (31.6% vs 58.4%, aOR 0.4; 95% CI 0.2-0.9) compared to medically managed patients. The relative benefit of EVT was comparable between patients with ASPECTS 0 and 5 and 6-10 in the extended time window (interaction aOR 0.9; 95% CI 0.5-1.7). CONCLUSION In the extended time window, patients with ASPECTS 0-5 may have preserved relative treatment benefit of EVT compared to patients with ASPECTS 6-10. These findings are in line with recent trials showing benefit of EVT among real-world patients with large ischemic core in the extended time window. TRIAL REGISTRATION NUMBER clinicaltrials.gov; Unique identifier: NCT04096248.
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Affiliation(s)
- Adnan Mujanovic
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jelle Demeestere
- Neurology, UZ Leuven, Leuven, Belgium
- Laboratory for Neurobiology, KU Leuven, Leuven, Belgium
| | - João Pedro Marto
- Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Volker Puetz
- Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Raul G Nogueira
- Neurology, University of Pittsburgh Medical Center, Pittsburgh, USA
- Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Mohamad Abdalkader
- Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
- Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Simon Nagel
- Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
- Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jean Raymond
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Radiology, Montreal, Canada
| | - Marc Ribo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Patrik Michel
- Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, USA
| | - Simon Winzer
- Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Sunil A Sheth
- Neurology, UTHealth McGovern Medical School, Neurology, Houston, USA
| | | | - Anne Dusart
- Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | | | - Hilde Henon
- Neurology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Bettina L Serrallach
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | | | | | - Ajit S Puri
- Division of Interventional Neuroradiology, University of Massachusetts Memorial Medical Center, Worcester, USA
| | | | - Piers Klein
- Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
- Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Liisa Tomppo
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - João Nuno Ramos
- Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | | | - Syed Zaidi
- Neurology, University of Toledo, Toledo, USA
| | - Tomas Dobrocky
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | | | | | | | | | - Pekka Virtanen
- Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Daniel Po Kaiser
- Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rita Ventura
- Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Jessica Jesser
- Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Muhammad M Qureshi
- Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, USA
- Radiation Oncology, Boston Medical Center, USA
| | | | | | | | - Riikka Lauha
- Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Wei Hu
- Neurology, The First Affiliated Hospital of USTC, China
| | - Eugene Lin
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, USA
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Daniel Roy
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Radiology, Montreal, Canada
| | - Hiroshi Yamagami
- Division of Stroke Prevention and Treatment, University of Tsukuba, Tsukuba, Japan
| | - David J Seiffge
- Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Davide Strambo
- Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Peter A Ringleb
- Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Robin Lemmens
- Neurology, UZ Leuven, Leuven, Belgium
- Laboratory for Neurobiology, KU Leuven, Leuven, Belgium
| | - Urs Fischer
- Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
- Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thanh N Nguyen
- Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
- Neurology, Boston Medical Center, Boston, USA
| | - Johannes Kaesmacher
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
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Sun D, Guo X, Nguyen TN, Pan Y, Ma G, Tong X, Raynald, Wang M, Ma N, Gao F, Mo D, Huo X, Miao Z. Alberta Stroke Program Early Computed Tomography Score, Infarct Core Volume, and Endovascular Therapy Outcomes in Patients With Large Infarct: A Secondary Analysis of the ANGEL-ASPECT Trial. JAMA Neurol 2024; 81:30-38. [PMID: 38010691 PMCID: PMC10682939 DOI: 10.1001/jamaneurol.2023.4430] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/28/2023] [Indexed: 11/29/2023]
Abstract
Importance Endovascular therapy (EVT) demonstrated better outcomes compared with medical management in recent randomized clinical trials (RCTs) of patients with large infarct. Objective To compare outcomes of EVT vs medical management across different strata of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and infarct core volume in patients with large infarct. Design, Setting, and Participants This prespecified secondary analysis of subgroups of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core (ANGEL-ASPECT) RCT included patients from 46 stroke centers across China between October 2, 2020, and May 18, 2022. Participants were enrolled within 24 hours of symptom onset and had ASPECTS of 3 to 5 or 0 to 2 and infarct core volume of 70 to 100 mL. Patients were divided into 3 groups: ASPECTS of 3 to 5 with infarct core volume less than 70 mL, ASPECTS of 3 to 5 with infarct core volume of 70 mL or greater, and ASPECTS of 0 to 2. Interventions Endovascular therapy or medical management. Main Outcomes and Measures The primary outcome was the ordinal 90-day modified Rankin Scale (mRS) score. Results There were 455 patients in the trial; median age was 68 years (IQR, 60-73 years), and 279 (61.3%) were male. The treatment effect did not vary significantly across the 3 baseline imaging subgroups (P = .95 for interaction). The generalized odds ratio for the shift in the 90-day mRS distribution toward better outcomes with EVT vs medical management was 1.40 (95% CI, 1.06-1.85; P = .01) in patients with ASPECTS of 3 to 5 and infarct core volume less than 70 mL, 1.22 (95% CI, 0.81-1.83; P = .23) in patients with ASPECTS of 3 to 5 and infarct core volume of 70 mL or greater, and 1.59 (95% CI, 0.89-2.86; P = .09) in patients with ASPECTS of 0 to 2. Conclusions and Relevance In this study, no significant interaction was found between baseline imaging status and the benefit of EVT compared with medical management in patients with large infarct core volume. However, estimates within subgroups were underpowered. A pooled analysis of large core trials stratified by ASPECTS and infarct core volume strata is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT04551664.
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Affiliation(s)
- Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Guo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Thanh N. Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Egashira S, Shin JH, Yoshimura S, Koga M, Ihara M, Kimura N, Toda T, Imanaka Y. Cost-effectiveness of endovascular therapy for acute stroke with a large ischemic region in Japan: impact of the Alberta Stroke Program Early CT Score on cost-effectiveness. J Neurointerv Surg 2023:jnis-2023-021068. [PMID: 38124199 DOI: 10.1136/jnis-2023-021068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/17/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Although randomized clinical trials (RCTs) demonstrated short-term benefits of endovascular therapy (EVT) for acute ischemic stroke (AIS) with a large ischemic region, little is known about the long-term cost-effectiveness or its difference by the extent of the ischemic areas. We aimed to assess the cost-effectiveness of EVT for AIS involving a large ischemic region from the perspective of Japanese health insurance payers, and analyze it using the Alberta Stroke Program Early CT Score (ASPECTS). METHODS The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT) was a RCT enrolling AIS patients with ASPECTS of 3-5 initially determined by the treating neurologist primarily using MRI. The hypothetical cohort and treatment efficacy were derived from the RESCUE-Japan LIMIT. Costs were calculated using the national health insurance tariff. We stratified the cohort into two subgroups based on ASPECTS of ≤3 and 4-5 as determined by the imaging committee, because heterogeneity was observed in treatment efficacy. EVT was considered cost-effective if the incremental cost-effectiveness ratio (ICER) was below the willingness-to-pay of 5 000 000 Japanese yen (JPY)/quality-adjusted life year (QALY). RESULTS EVT was cost-effective among the RESCUE-Japan LIMIT population (ICER 4 826 911 JPY/QALY). The ICER among those with ASPECTS of ≤3 and 4-5 was 19 396 253 and 561 582 JPY/QALY, respectively. CONCLUSION EVT was cost-effective for patients with AIS involving a large ischemic region with ASPECTS of 3-5 initially determined by the treating neurologist in Japan. However, the ICER was over 5 000 000 JPY/QALY among those with an ASPECTS of ≤3 as determined by the imaging committee.
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Affiliation(s)
- Shuhei Egashira
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jung-Ho Shin
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoto Kimura
- Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka, Iwate, Japan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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6
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Sahoo A, Abdalkader M, Yamagami H, Huo X, Sun D, Jia B, Weyland CS, Diana F, Kaliaev A, Klein P, Bui J, Kasab SA, de Havenon A, Zaidat OO, Zi W, Yang Q, Michel P, Siegler JE, Yaghi S, Hu W, Nguyen TN. Endovascular Therapy for Acute Stroke: New Evidence and Indications. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:232-242. [PMID: 38025253 PMCID: PMC10657733 DOI: 10.5797/jnet.ra.2023-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/25/2023] [Indexed: 12/01/2023]
Abstract
Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke. In the past few years, endovascular treatment indications have expanded to include patients being treated in the extended window, with large ischemic core infarction, basilar artery occlusion (BAO) thrombectomy, as demonstrated by several randomized clinical trials. Intravenous thrombolysis (IVT) bridging to mechanical thrombectomy has also been studied via several randomized clinical trials, with the overall results indicating that IVT should not be skipped in patients who are candidates for both IVT and EVT. Simplification of neuroimaging protocols in the extended window to permit non-contrast CT, CTA collaterals have also expanded access to mechanical thrombectomy, particularly in regions across the world where access to advanced imaging may not be available. Ongoing study of areas to develop include rescue stenting in patients with failed thrombectomy, medium vessel occlusion thrombectomy, and carotid tandem occlusions. In this narrative review, we summarize recent trials and key data in the treatment of patients with large ischemic core infarct, simplification of neuroimaging protocols for the treatment of patients presenting in the late window, bridging thrombolysis, and BAO EVT evidence. We also summarize areas of ongoing study including medium and distal vessel occlusion.
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Affiliation(s)
- Anurag Sahoo
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Hiroshi Yamagami
- Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Xiaochuan Huo
- Cerebrovascular Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | | - Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
- Vall d'Hebron Research Institute, Barcelona, Spain
| | - Artem Kaliaev
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Piers Klein
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jenny Bui
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sami Al Kasab
- Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Wenjie Zi
- Neurology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Qingwu Yang
- Neurology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Patrik Michel
- Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Shadi Yaghi
- Neurology, Rhode Island Hospital, Brown University School of Medicine, Providence, RI, USA
| | - Wei Hu
- Neurology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Thanh N Nguyen
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
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