Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes

Key points:

    • To assess if there is a significant difference in hospital costs for patients receiving endovascular stroke therapy following IV thrombolysis compared with endovascular therapy alone.

    • To assess the benefit of IV rt-PA prior to endovascular therapy.

Nowadays there are a number of trials that have shown improved outcomes following endovascular therapy for LVO strokes compared with standard therapies alone, but only a little number of patients is treated without prior IV recombinant tissue plasminogen activator (rt-PA). For this reason the question of whether previous IV rt-PA really help the endovascular treatment remains unanswered. In this paper, published online January 6, 2017, in the Journal of NeuroInterventional Surgery, Authors compare outcomes and hospital costs for anterior circulation LVOs (middle cerebral artery, internal carotid artery terminus [ICA-T]) treated with either primary endovascular therapy alone (EV-Only) or bridging therapy (IV+EV).

Rai AT, Boo SH, Buseman C, et al. performed a review of their patients database treated with endovascular therapy (with or without prior IV rt-PA) for anterior circulation LVO over a 3-year period, assessing direct costs, pocedural outcome (TICI score) and clinical outcome (mRs).

Baseline characteristics

EV-Only (n=52) IV+EV (n=38)
ICA-T/MCA 8/44 4/34
CT ASPECT 7.5 8
NIHSS median 16 18
Mean procedure duration 1:16 1:18
Mean time from symptom onset 5:19 1:46

Interestingly in this paper, Authors have found that IV rt-PA did not improve recanalization or favorable outcomes, despite the significantly longer time to presentation for the EV-Only group (see Baseline characteristics), neither in cases with good revascularization rate nor in cases with poor revascularization rate. They also conducted a separate analysis of patients presenting within 4.5 hours to remove time effects, without any difference in term of results.

Clinical outcomes

Entire cohort (n=90)

EV-Only (n=52) IV+EV (n=38)
TICI 2b/3 35 31
Favorable outcome 26 22
Mortality 13 4
Home discharge 19 11
Symptoms onset ≤4.5h

EV-Only (n=26) IV+EV (n=31)
TICI 2b/3 21 31
Favorable outcome 14 22
Mortality 5 4
Home discharge 11 11

Then, Authors analyzed hospital costs, showing significantly higher total and direct hospital costs for patients who received IV rt-PA before endovascular therapy.

Hospital costs
EV-Only (n=52) IV+EV (n=38)
Total cost ($) 33 810 40 743
Direct cost ($) 23 034 28 711
Indirect cost ($) 10 777 12 032

Authors used stent retriever technique like first approach in some cases, thromboaspiration in others. As reported by Turk A.S., Turner R., Spiotta A., et al., ADAPT technique may incur lower direct costs than stent retrievers.

In conclusion, probably we really need a clinical trial!

Reference

  • Rai AT, Boo S, Buseman C, Adcock AK, Tarabishy AR, Miller MM, Roberts TD, Domico JR, Carpenter JS. Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes. J Neurointerv Surg. 2017 Jan 6. pii:neurintsurg-2016-012830. doi:10.1136/neurintsurg-2016-012830. [Epub ahead of print].

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