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Ischemic stroke
Original research
Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes
  1. Ansaar T Rai1,
  2. SoHyun Boo1,
  3. Chelsea Buseman2,
  4. Amelia K Adcock3,
  5. Abdul R Tarabishy4,
  6. Maurice M Miller4,
  7. Thomas D Roberts4,
  8. Jennifer R Domico1,
  9. Jeffrey S Carpenter1
  1. 1Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA
  2. 2Financial Analytics, West Virginia University, Morgantown, West Virginia, USA
  3. 3Neurology, West Virginia University, Morgantown, West Virginia, USA
  4. 4Neuroradiology, West Virginia University, Morgantown, West Virginia, USA
  1. Correspondence to Dr Ansaar T Rai, Interventional Neuroradiology, West Virginia University, Room 2278, HSCS, PO Box 9235, Morgantown, WV 26506, USA; ansaar.rai{at}gmail.com

Abstract

Background Limited efficacy of IV recombinant tissue plasminogen activator (rt-PA) for large vessel occlusions (LVO) raises doubts about its utility prior to endovascular therapy.

Purpose To 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)).

Methods A single-center retrospective analysis was performed. Clinical and demographic data were collected prospectively and relevant cost data were obtained for each patient in the study.

Results 90 consecutive patients were divided into EV-Only (n=52) and IV+EV (n=38) groups. There was no difference in demographics, stroke severity, or clot distribution. The mean (SD) time to presentation was 5:19 (4:30) hours in the EV-Only group and 1:46 (0:52) hours in the IV+EV group (p<0.0001). Recanalization: EV-Only 35 (67%) versus IV+EV 31 (81.6%) (p=0.12). Favorable outcome: EV-Only 26 (50%) versus IV+EV 22 (58%) (p=0.45). For patients presenting within 4.5 hours (n=64): Recanalization: EV-Only 21/26 (81%) versus IV+EV 31/38 (81.6%) (p=0.93). Favorable outcome: EV-Only 14/26 (54%) versus IV+EV 22/38 (58%) (p=0.75). There was no significant difference in rates of hemorrhage, mortality, home discharge, or length of stay. A stent retriever was used in 67 cases (74.4%), with similar recanalization, outcomes, and number of passes in the EV-Only and IV+EV groups. The mean (SD) total hospital cost was $33 810 (13 505) for the EV-Only group and $40 743 (17 177) for the IV+EV group (p=0.02). The direct cost was $23 034 (8786) for the EV-Only group and $28 711 (11 406) for the IV+EV group (p=0.007). These significantly higher costs persisted for the subgroup presenting in <4.5 hours and the stent retriever subgroup. IV rt-PA administration independently predicted higher hospital costs.

Conclusions IV rt-PA did not improve recanalization, thrombectomy efficacy, functional outcomes, or length of stay. Combined therapy was associated with significantly higher total and direct hospital costs than endovascular therapy alone.

  • Stroke
  • Economics
  • Thrombectomy
  • Intervention

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/neurintsurg-2016-012830

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    Footnotes

    • Contributors ATR: Study design, data analysis, manuscript preparation. AKA: Manuscript preparation. SHB, CB, ART, MMM, TDR, JRD: Data collection. JSC: Data collection, manuscript preparation.

    • Competing interests ATR has a consulting agreement with Stryker Neurovascular who make the Trevo ProVue device which is used for mechanical thrombectomy in acute ischemic stroke.

    • Ethics approval Ethics approval was obtained from the IRB.

    • Provenance and peer review Not commissioned; externally peer reviewed.