New era of stroke therapy and new challenges

Time to Endovascular Reperfusion and Outcome in Acute Ischemic Stroke : A Nationwide Prospective Registry in China

PURPOSE

The benefit of endovascular reperfusion therapy for acute ischemic stroke is highly time-dependent but the relation of delays in workflow with outcomes and the key determinants of delays remain uncertain. This study aimed to evaluate the association between faster endovascular therapy and outcomes in a Chinese population with acute ischemic stroke.

METHODS

Patients treated with endovascular therapy within 7 h due to anterior large vessel occlusion were enrolled in the ANGEL-ACT registry. Time intervals from hospital arrival to arterial puncture (door-to-puncture), hospital arrival to reperfusion (door-to-reperfusion) and puncture-to-reperfusion were recorded. The outcomes included modified Rankin Scale (mRS) scores 0-1, 0-2, mortality at 3 months, substantial reperfusion, and symptomatic intracranial hemorrhage (sICH).

RESULTS

Of 932 patients receiving endovascular therapy (mean age 65.1 years, 60.1% male), the median door-to-puncture, door-to-reperfusion, and puncture-to-perfusion times were 110min (interquartile range, IQR 72-155min), 200min (IQR, 149-260min), and 76min (IQR, 50-118min). Of the patients 87.4% achieved substantial reperfusion and 9.6% had sICH. The mRS 0-1, 0-2, and mortality at 3 months were 39.8%, 43.2%, and 16.4%. Faster door-to-reperfusion and puncture-to-reperfusion were associated with higher likelihood of mRS 0-1, mRS 0-2, and lower rate of sICH. There was a trend of improved mRS, lower mortality, and fewer ICH with shorter door-to-puncture time; however, most differences were not statistically significant.

CONCLUSION

Among patients with acute ischemic stroke in routine clinical practice, shorter time to reperfusion was associated with better outcome after endovascular therapy. Standardized workflows and training in endovascular treatment techniques should be promoted nationally to reduce in-hospital delays.

Cost-effectiveness of mechanical thrombectomy within 6 hours of acute ischaemic stroke in China

OBJECTIVES

Endovascular mechanical thrombectomy is an effective but expensive therapy for acute ischaemic stroke with proximal anterior circulation occlusion. This study aimed to determine the cost-effectiveness of mechanical thrombectomy in China, which is the largest developing country.

DESIGN

A combination of decision tree and Markov model was developed. Outcome and cost data were derived from the published literature and claims database. The efficacy data were derived from the meta-analyses of nine trials. One-way and probabilistic sensitivity analyses were performed in order to assess the uncertainty of the results.

SETTING

Hospitals in China.

PARTICIPANTS

The patients with acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours.

INTERVENTIONS

Mechanical thrombectomy within 6 hours with intravenous tissue plasminogen activator (tPA) treatment within 4.5 hours versus intravenous tPA treatment alone.

OUTCOME MEASURES

The benefit conferred by the treatment was assessed by estimating the cost per quality-adjusted life-year (QALY) gained in the long term (30 years).

RESULTS

The addition of mechanical thrombectomy to intravenous tPA treatment compared with standard treatment alone yielded a lifetime gain of 0.794 QALYs at an additional cost of CNY 50 000 (US$7700), resulting in a cost of CNY 63 010 (US$9690) per QALY gained. The probabilistic sensitivity analysis indicated that mechanical thrombectomy was cost-effective in 99.9% of the simulation runs at a willingness-to-pay threshold of CNY 125 700 (US$19 300) per QALY.

CONCLUSIONS

Mechanical thrombectomy for acute ischaemic stroke caused by proximal anterior circulation occlusion within 6 hours was cost-effective in China. The data may be used as a reference with regard to medical resources allocation for stroke treatment in low-income and middle-income countries as well as in the remote areas in the developed countries.

Future challenges of stroke treatment

Posterior circulation stroke accounts for approximately 20% of all ischaemic strokes. Acute basilar artery occlusion (BAO) is one of the most severe conditions, it is associated with death or major disability in more than three quarters of the cases, and its optimal management remains unestablished. Currently, the treatment is based primarily upon consensus, the clinical practice varies widely, and the actual benefit of mechanical thrombectomy has to be fully estimated. Although the recent years have profoundly revolutionized and improved the stroke care, many questions still remain unanswered and will represent the challenges of the next future.