RESUMEN
BACKGROUND: The MR CLEAN-LATE trial has shown that patient selection for endovascular treatment (EVT) in the late window (6-24 h after onset or last-seen-well) based on the presence of collateral flow on CT-angiography is safe and effective. We aimed to assess the cost-effectiveness of late-window collateral-based EVT-selection compared to best medical management (BMM) over a lifetime horizon (until 95 years of age). MATERIALS AND METHODS: A model-based economic evaluation was performed from a societal perspective in The Netherlands. A decision tree was combined with a state-transition (Markov) model. Health states were defined by the modified Rankin Scale (mRS). Initial probabilities at 3-months post-stroke were based on MR CLEAN-LATE data. Transition probabilities were derived from previous literature. Information on short- and long-term resource use and utilities was obtained from a study using MR CLEAN-LATE and cross-sectional data. All costs are expressed in 2022 euros. Costs and quality-adjusted life years (QALYs) were discounted at a rate of 4% and 1.5%, respectively. The effect of parameter uncertainty was assessed using probabilistic sensitivity analysis (PSA). RESULTS: On average, the EVT strategy cost 159,592 (95% CI: 140,830-180,154) and generated 3.46 QALYs (95% CI: 3.04-3.90) per patient, whereas the costs and QALYs associated with BMM were 149,935 (95% CI: 130,841-171,776) and 2.88 (95% CI: 2.48-3.29), respectively. The incremental cost-effectiveness ratio per QALY and the incremental net monetary benefit were 16,442 and 19,710, respectively. At a cost-effectiveness threshold of 50,000/QALY, EVT was cost-effective in 87% of replications. DISCUSSION AND CONCLUSION: Collateral-based selection for late-window EVT is likely cost-effective from a societal perspective in The Netherlands.
Asunto(s)
Angiografía por Tomografía Computarizada , Análisis Costo-Beneficio , Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico , Años de Vida Ajustados por Calidad de Vida , Humanos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/métodos , Accidente Cerebrovascular Isquémico/economía , Accidente Cerebrovascular Isquémico/terapia , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Angiografía por Tomografía Computarizada/economía , Anciano , Masculino , Femenino , Circulación Colateral/fisiología , Países Bajos , Persona de Mediana Edad , Anciano de 80 o más Años , Modelos EconómicosRESUMEN
OBJECTIVE: To determine the association between early post-endovascular treatment (EVT) contrast extravasation (CE) on dual-energy CT (DECT) and stroke outcomes. METHODS: EVT records in 2010-2019 were screened. Exclusion criteria included the occurrence of immediate post-procedural intracranial haemorrhage (ICH). Hyperdense areas on iodine overlay maps were scored according to the Alberta Stroke Programme Early CT Score (ASPECTS), thus forming a CE-ASPECTS. Maximum parenchymal iodine concentration and maximum iodine concentration relative to the torcula were recorded. Follow-up imaging was reviewed for ICH. The primary outcome measure was the modified Rankin Scale (mRS) at 90 days. RESULTS: Out of 651 records, 402 patients were included. CE was found in 318 patients (79%). Thirty-five patients developed ICH on follow-up imaging. Fourteen ICHs were symptomatic. Stroke progression occurred in 59 patients. Multivariable regression showed a significant association between decreasing CE-ASPECTS and the mRS at 90 days (adjusted (a)cOR: 1.10, 95% CI: 1.03-1.18), NIHSS at 24-48 h (aß: 0.57, 95% CI: 0.29-0.84), stroke progression (aOR: 1.14, 95% CI: 1.03-1.26) and ICH (aOR: 1.21, 95% CI: 1.06-1.39), but not symptomatic ICH (aOR 1.19, 95% CI: 0.95-1.38). Iodine concentration was significantly associated with the mRS (acOR: 1.18, 95% CI: 1.06-1.32), NIHSS (aß: 0.68, 95% CI: 0.30-1.06), ICH (aOR: 1.37, 95% CI: 1.04-1.81) and symptomatic ICH (aOR: 1.19, 95% CI: 1.02-1.38), but not stroke progression (aOR: 0.99, 95% CI: 0.86-1.15). Results of the analyses with relative iodine concentration were similar and did not improve prediction. CONCLUSIONS: CE-ASPECTS and iodine concentration are both associated with short- and long-term stroke outcomes. CE-ASPECTS is likely a better predictor for stroke progression.
Asunto(s)
Yodo , Accidente Cerebrovascular , Humanos , Accidente Cerebrovascular/diagnóstico por imagen , Hemorragia Cerebral/tratamiento farmacológico , Extravasación de Materiales Terapéuticos y Diagnósticos/diagnóstico por imagen , Tomografía Computarizada por Rayos X/efectos adversos , Yodo/efectos adversosRESUMEN
Background: Endovascular treatment (EVT) for acute ischemic stroke (AIS) is performed in intervention centers that provide the full range of neuro(endo)vascular care (level 1) and centers that only perform EVT for AIS (level 2). We compared outcomes between these center types and assessed whether differences in outcomes could be explained by center volume (CV). Patients and methods: We analyzed patients included in the MR CLEAN Registry (2014-2018), a registry of all EVT-treated patients in the Netherlands. Our primary outcome was the shift on the modified Rankin scale (mRS) after 90 days (ordinal regression). Secondary outcomes were the NIHSS 24-48 h post-EVT, door-to-groin time (DTGT), procedure time (linear regression), and recanalization (binary logistic regression). We compared outcomes between level 1 and 2 centers using multilevel regression models, with center as random intercept. We adjusted for relevant baseline factors, and in case of observed differences, we additionally adjusted for CV. Results: Of the 5144 patients 62% were treated in level 1 centers. We observed no significant differences between center types in mRS (adjusted(a)cOR: 0.79, 95% CI: 0.40 to 1.54), NIHSS (aß: 0.31, 95% CI: -0.52 to 1.14), procedure duration (aß: 0.88, 95% CI: -5.21 to 6.97), or DTGT (aß: 4.24, 95% CI: -7.09 to 15.57). The probability for recanalization was higher in level 1 centers compared to level 2 centers (aOR 1.60, 95% CI: 1.10 to 2.33), and this difference probably depended on CV. Conclusions: We found no significant differences, that were independent of CV, in the outcomes of EVT for AIS between level 1 and level 2 intervention centers.