Cost-effectiveness of Endovascular Therapy for Acute Ischemic Stroke:                    A Systematic Review of the Impact of Patient Age

OBJECTIVEAs the cost of health care continues to increase, there is a growing emphasis on evaluating the relative economic value of treatment options to guide resource allocation. The objective of this systematic review was to evaluate the current evidence regarding the cost-effectiveness of cranial neurosurgery procedures.METHODSThe authors performed a systematic review of the literature using PubMed, EMBASE, and the Cochrane Library, focusing on themes of economic evaluation and cranial neurosurgery following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Included studies were publications of cost-effectiveness analysis or cost-utility analysis between 1995 and 2017 in which health utility outcomes in life years (LYs), quality-adjusted life years (QALYs), or disability-adjusted life years (DALYs) were used. Three independent reviewers conducted the study appraisal, data abstraction, and quality assessment, with differences resolved by consensus discussion.RESULTSIn total, 3485 citations were reviewed, with 53 studies meeting the inclusion criteria. Of those, 34 studies were published in the last 5 years. The most common subspecialty focus was cerebrovascular (32%), followed by neurooncology (26%) and functional neurosurgery (24%). Twenty-eight (53%) studies, using a willingness to pay threshold of US$50,000 per QALY or LY, found a specific surgical treatment to be cost-effective. In addition, there were 11 (21%) studies that found a specific surgical option to be economically dominant (both cost saving and having superior outcome), including endovascular thrombectomy for acute ischemic stroke, epilepsy surgery for drug-refractory epilepsy, and endoscopic pituitary tumor resection.CONCLUSIONSThere is an increasing number of cost-effectiveness studies in cranial neurosurgery, especially within the last 5 years. Although there are numerous procedures, such as endovascular thrombectomy for acute ischemic stroke, that have been conclusively proven to be cost-effective, there remain promising interventions in current practice that have yet to meet cost-effectiveness thresholds.

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Abstract TP26: Endovascular Therapy and Outcomes in a Large Biracial Cohort of Patients with Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.tp26 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Leticia C Rebello ◽

Aaron Anderson ◽

Diogo C Haussen ◽

Samir R Belagaje ◽

Jonathan A Grossberg ◽

...

Keyword(s):

African American ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Ethnic Disparities ◽

Stroke Outcomes ◽

Good Outcome ◽

Caucasian Patients ◽

Baseline Characteristics ◽

The Impact

Background: The ethnic disparities in stroke outcomes have been well described. Stroke is twice more common and leads to higher mortality rates among blacks as compared to whites. We compared the outcomes of patients undergoing endovascular stroke therapy (ET) in a high-volume center according to their racial profile after age adjustment. Methods: Retrospective analysis of a prospectively collected ET database between September/2010-September/2015. The baseline characteristics of African-American vs. Caucasian patients were compared. Given the impact of age on stroke outcomes additional analyses were performed dichotomizing patients using the median age of the overall cohort. Primary and secondary efficacy outcomes included the rates of good outcome (90-day mRS 0-2) and successful reperfusion (mTICI 2b-3), respectively. Safety outcome was accessed by rates of any parenchymal hematoma (PH-1 and PH-2) and 90-day mortality. Results: 781 patients fit the inclusion criteria and were included in the analysis; 440 were included in the Caucasian group (56% overall cohort) and 341 in the African-American group (44%). Caucasian patients were significantly older (69±13 vs. 60±14 years-old, p<0.01) but the remaining baseline characteristics were otherwise well-balanced. This included similar baseline CT perfusion core volumes (rCBF<30%, 17.6 ± 20.8 vs. 17.9 ± 32.8; p=0.93). There were no differences in the rates successful reperfusion (mTICI 2b-3: 83% vs. 85%, p=0.37), any PH (8% vs. 5%, p=0.26), or final infarct volume (32 IQR 12-89 vs. 25 IQR 9-67; p=0.12) across the two groups. In the overall cohort, there was a lower proportion of 90-day good outcome (39% vs. 49%; p<0.01) and higher 90-day mortality (32% vs. 16%; p<0.01) among Caucasians presumably due to their older age. Subgroup analysis of patients 65 years-old or younger showed similar rates of 90-day good outcomes (59% vs. 53%; p=0.33) and mortality (17% vs. 12%; p=0.22) across Caucasian and African-American patients. Conclusion: Aggressive treatment of acute ischemic stroke with endovascular therapy leads to similar outcomes across African-American and Caucasian patients. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.

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EXPRESS: Impact of renal impairment on short-term outcomes following endovascular thrombectomy for acute ischemic stroke: A systematic review and meta-analysis

International Journal of Stroke ◽

10.1177/17474930211047337 ◽

2021 ◽

pp. 174749302110473

Author(s):

Jin Pyeong Jeon ◽

Chih-Hao Chen ◽

Fon-Yih Tsuang ◽

Jianming Liu ◽

Michael D Hill ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Renal Impairment ◽

Acute Ischemic Stroke ◽

Meta Analysis ◽

Functional Independence ◽

Continuous Variable ◽

Endovascular Thrombectomy ◽

Symptomatic Intracerebral Hemorrhage ◽

The Impact

Background. The impact of renal impairment (RI) on the outcomes of patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) was relatively limited and contradictory. We performed a systematic review and meta-analysis to investigate this. Aims. We registered a protocol on September 2020 and searched MEDLINE, EMBASE, and Google Scholar accordingly. RI was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. Predefined outcomes included functional independence (defined as a modified Rankin Scale of 0, 1, or 2) at 3 months, successful reperfusion, mortality, and symptomatic intracerebral hemorrhage (sICH). Summary of review. Eleven studies involving 3453 patients were included. For the unadjusted outcomes, RI was associated with fewer functional independence (odds ratio (OR), 0.49; 95% confidence interval (CI), 0.39â0.62) and higher mortality (OR, 2.55; 95% CI, 2.03â3.21). RI was not associated with successful reperfusion (OR, 0.80; 95% CI 0.63â1.00) and sICH (OR, 1.41; 95% CI, 0.95â2.10). For the adjusted outcomes, results derived from a multivariate meta-analysis were consistent with the respective unadjusted outcomes: functional independence (OR, 0.59; 95% CI, 0.45â0.77), mortality (OR, 2.23, 95% CI, 1.45â3.43), and sICH (OR, 1.34; 95% CI, 0.85â2.10). Conclusions. We presented the first systematic review to demonstrate that RI is associated with fewer functional independence and higher mortality. Future EVT studies should publish complete renal eGFR data to facilitate prognostic studies and permit eGFR to be analyzed in a continuous variable. Systematic Review Registration: PROSPERO CRD42020191309

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Impact of Blood Pressure After Successful Endovascular Therapy for Anterior Acute Ischemic Stroke: A Systematic Review

Frontiers in Neurology ◽

10.3389/fneur.2020.573382 ◽

2020 ◽

Vol 11 ◽

Author(s):

Benjamin Maïer ◽

François Delvoye ◽

Julien Labreuche ◽

Simon Escalard ◽

Jean-Philippe Desilles ◽

...

Keyword(s):

Systematic Review ◽

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy

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Quality of life and cost consequence of delays in endovascular treatment for acute ischemic stroke in China

Health Economics Review ◽

10.1186/s13561-021-00352-w ◽

2022 ◽

Vol 12 (1) ◽

Author(s):

Weiyi Ni ◽

Wolfgang G. Kunz ◽

Mayank Goyal ◽

Lijin Chen ◽

Yawen Jiang

Keyword(s):

Ischemic Stroke ◽

Cost Effectiveness ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Healthcare Costs ◽

Time Window ◽

Time Windows ◽

Sensitivity Analyses ◽

Health State ◽

The Impact

Abstract Background Although endovascular therapy (EVT) improves clinical outcomes in patients with acute ischemic stroke, the time of EVT initiation significantly influences clinical outcomes and healthcare costs. This study evaluated the impact of EVT treatment delay on cost-effectiveness in China. Methods A model combining a short-term decision tree and long-term Markov health state transition matrix was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes and healthcare costs. Clinical outcomes and cost data were derived from clinical trials and literature. Incremental cost-effectiveness ratio and incremental net monetary benefits were simulated. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of the model. The willingness-to-pay threshold per quality-adjusted life-year (QALY) was set to ¥71,000 ($10,281). Results EVT performed between 61 and 120 min after the stroke onset was most cost-effective comparing to other time windows to perform EVT among AIS patients in China, with an ICER of ¥16,409/QALY ($2376) for performing EVT at 61–120 min versus the time window of 301–360 min. Each hour delay in EVT resulted in an average loss of 0.45 QALYs and 165.02 healthy days, with an average net monetary loss of ¥15,105 ($2187). Conclusions Earlier treatment of acute ischemic stroke patients with EVT in China increases lifetime QALYs and the economic value of care without any net increase in lifetime costs. Thus, healthcare policies should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration in China.

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Brain Atrophy and the Risk of Futile Endovascular Reperfusion in Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.028511 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1514-1521 ◽

Cited By ~ 3

Author(s):

María I. Pedraza ◽

Mercedes de Lera ◽

Daniel Bos ◽

Ana I. Calleja ◽

Elisa Cortijo ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Brain Atrophy ◽

Regression Models ◽

Infarct Volume ◽

Cortical Atrophy ◽

Anterior Circulation ◽

Evans Index ◽

The Impact

Background and Purpose— We aimed to evaluate the impact of brain atrophy on long-term clinical outcome in patients with acute ischemic stroke treated with endovascular therapy, and more specifically, to test whether there are interactions between the degree of atrophy and infarct volume, and between atrophy and age, in determining the risk of futile reperfusion. Methods— We studied consecutive patients with acute ischemic stroke with proximal anterior circulation intracranial arterial occlusions treated with endovascular therapy achieving successful arterial recanalization. Brain atrophy was evaluated on baseline computed tomography with the global cortical atrophy scale, and Evans index was calculated to assess subcortical atrophy. Infarct volume was assessed on control computed tomography at 24 hours using the formula for irregular volumes (A×B×C/2). Main outcome variable was futile recanalization, defined by functional dependence (modified Rankin Scale score >2) at 3 months. The predefined interactions of atrophy with age and infarct volume were studied in regression models. Results— From 361 consecutive patients with anterior circulation acute ischemic stroke treated with endovascular therapy, 295 met all inclusion criteria. Futile reperfusion was observed in 144 out of 295 (48.8%) patients. Cortical atrophy affecting parieto-occipital and temporal regions was associated with futile recanalization. Total global cortical atrophy score and Evans index were independently associated with futile recanalization in an adjusted logistic regression. Multivariable adjusted regression models disclosed significant interactions between global cortical atrophy score and infarct volume (odds ratio, 1.003 [95%CI, 1.002–1.004], P <0.001) and between global cortical atrophy score and age (odds ratio, 1.001 [95% CI, 1.001–1.002], P <0.001) in determining the risk of futile reperfusion. Conclusions— A higher degree of cortical and subcortical brain atrophy is associated with futile endovascular reperfusion in anterior circulation acute ischemic stroke. The impact of brain atrophy on insufficient clinical recovery after endovascular reperfusion appears to be independently amplified by age and by infarct volume.

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C-reactive Protein, Infection, and Outcome After Acute Ischemic Stroke: A Registry and Systematic Review

Current Neurovascular Research ◽

10.2174/1567202616666191026122011 ◽

2020 ◽

Vol 16 (5) ◽

pp. 405-415 ◽

Cited By ~ 2

Author(s):

Lu Wang ◽

Yuxiao Li ◽

Changyi Wang ◽

Wen Guo ◽

Ming Liu

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Meta Analysis ◽

Reactive Protein ◽

Poor Outcome ◽

Pubmed Database ◽

Scale Scores ◽

The Impact

Background: A number of studies have explored the prognostic role of CRP in patients with acute ischemic stroke, however, the results have been inconclusive. The aim of our study was to investigate the impact of infection on the association between CRP and 3-month functional outcome by performing a registry study and systematic review. Methods: Patients admitted within 24 hours of acute ischemic stroke onset and had CRP measured within 24 hours after admission were included. Patients admitted between June 2016 and December 2018 in Chengdu Stoke Registry were enrolled. The PubMed database was searched up to July 2019 to identify eligible studies. Poor outcome was defined as modified Rankin Scale scores at 3-month more than 3. Results: Totally, 368 patients in the registry and 18 studies involving 15238 patients in the systematic review were included. A statistically significant association between CRP values on admission and 3-month poor outcome in patients without infection was found, both in our registry (CRP per 1-mg/L increment, OR 1.04, 95% CI 1.01 to 1.07, p=0.008) and meta-analysis (CRP per 1-mg/dL increment, OR 1.66 [95% CI 1.37 to 2.01, p<0.001]). In patients with infection, CRP was not associated with a 3-month poor outcome according to registry data (OR 1.00, 95% CI 0.99 to 1.01, p=0.663) and meta-analysis (OR 1.01, 95% CI 0.99 to 1.01, p=0.128). Conclusion: High CRP value was independently associated with a 3-month poor outcome after stroke in patients without infection. Further studies are required to examine the value of infection on CRP measures and long-term functional outcomes.

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