The future of endovascular treatment: Insights from the ESCAPE investigators

Tracking elemental changes in an ischemic stroke model with X-ray fluorescence imaging

Stroke is a leading cause of long-term disability in adults and a leading cause of death in developed nations. The cascade of cellular events and signalling that occur after cerebral ischemia are complex, however, analyzing global element markers of metabolic state affords the means to monitor stroke severity, status of injury, and recovery. These markers provide a multi-parameter method for assessing changes through the post-stroke time course. We employ synchrotron-based elemental mapping to follow elemental changes in the brain at 1 h, 1-, 2-, and 3-days, and at 1-, 2-, 3-, and 4-weeks post-stroke in a photothrombotic stroke model in mice. Our analysis reveals a highly consistent metabolic penumbra that can be readily identified based on the level of dysregulated potassium and other key elements. Maps of elemental distributions are also useful to demarcate events in the cellular response to the inflammatory cascade, including ion dysregulation, recruitment of cells to the lesion, and glial scar formation.

Health Technology Optimization Analysis: Conceptual Approach and Illustrative Application

We present a conceptual approach to determine the optimal solution to delivering a health technology, consistent with the objective of maximizing patient outcomes subject to resources available to a publicly funded health system. The article addresses two key policy questions: 1) adding system values through appropriate planning of health services delivery and 2) considering the tradeoff between patient outcomes and costs to the health system through appropriate use of health technologies for conditions with time-dependent treatment outcomes. We develop a health technology optimization framework that considers geographical variation and searches for the best delivery method through a pairwise comparison of all possible strategies, factoring in controlled variables including disease epidemiology, time or distance to hospitals, available medical services, treatment eligibility, treatment efficacy, and costs. Taking variations of these factors into account would help support a more efficient allocation of health resources. Drawing identified strategies together then creates a map of optimal strategies. We apply the proposed method to a policy-relevant health technology assessment of endovascular therapy (EVT) for treating acute ischemic stroke. The best strategy for providing EVT relies on the geographical location of stroke onset and the decision maker’s preference for either patient outcomes or economic efficiency. The proposed method produced an optimization map showing the optimal strategy for EVT delivery, which maximizes patient outcomes while minimizing health system costs. In the illustrative case study, there were no tradeoffs between health outcomes and costs, meaning that the delivery strategies that were clinically optimal for patients were also the most cost-effective. In conclusion, the health technology optimization approach is a useful tool for informing implementation decisions and coordinating the delivery of complex health services such as EVT.