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Is concurrent intravenous alteplase in patients undergoing endovascular treatment for large vessel occlusion stroke cost-effective even if the cost of alteplase is only US$1?
  1. Johanna Maria Ospel1,2,
  2. Rosalie McDonough2,3,
  3. Wolfgang G Kunz4,
  4. Mayank Goyal2,5
  1. 1 Radiology, Universitatsspital Basel, Basel, Switzerland
  2. 2 Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  3. 3 Diagnostic and Interventional Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
  4. 4 Ludwig Maximilians University Munich, Munich, Germany
  5. 5 Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Mayank Goyal, Diagnostic Imaging, University of Calgary, Calgary, AB T2N 1N4, Canada; mgoyal2412{at}


Background The added value of intravenous (IV) alteplase in large vessel occlusion (LVO) stroke over and beyond endovascular treatment (EVT) is controversial. We compared the long-term costs and cost-effectiveness of a direct-to-EVT paradigm in LVO stroke patients presenting directly to the mothership hospital to concurrent EVT and IV alteplase.

Methods We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes. Outcome data were from the DIRECT-MT trial (NCT03469206). Incremental cost-effectiveness ratios and net monetary benefits were calculated and probabilistic sensitivity analysis was performed. Analysis was performed from a healthcare perspective and a societal perspective using both a minimal assumed alteplase cost of US$1 and true alteplase cost.

Results When assuming a minimal cost of alteplase of $1, EVT with concurrent IV alteplase resulted in incremental lifetime cost of $5664 (healthcare perspective)/$4804 (societal perspective) and a decrement of 0.25 quality-adjusted life years (QALYs) compared with EVT only, indicating dominance of the EVT only approach. Net monetary benefits were consistently higher for EVT only compared with EVT with concurrent alteplase. Probabilistic sensitivity analysis showed increased costs without an increase in QALYs for EVT and concurrent IV alteplase compared with EVT only. Results were even more in favor of EVT when the true cost of alteplase was used for analysis.

Conclusion EVT without concurrent alteplase is the preferred strategy from a health economic standpoint.

  • stroke
  • thrombectomy
  • thrombolysis
  • economics

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • JMO and RM contributed equally.

  • WGK and MG contributed equally.

  • Contributors All authors: conceptualization, drafting, and critical revision of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests Mayank Goyal is a consultant for Medtronic, Stryker, Microvention, GE Healthcare, and Mentice. The remaining authors have nothing to disclose.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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