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Abstract
Endovascular thrombectomy was shown to improve clinical outcomes in patients with large ischemic strokes(LIS) due to anterior circulation large vessel occlusions in 3 randomized controlled trials(RESCUE Japan, SELECT2 & ANGEL ASPECT) recently. We aimed to quantify the additional burden on the current EVT infrastructure in the US by estimating the potential increase in EVT procedures based on trial eligibility criteria.
Methods Using Nationwide inpatient sample and prior validated ICD-10 CM diagnostic and procedure codes, we obtained number of inpatient admissions with diagnosis of Ischemic stroke due to anterior circulation LVOs (carotid and/or middle cerebral artery) between 2016 to 2019. Estimates of proportion of patients presenting with LIS based on two separate definitions (ischemic core on MR DWI ≥70ml, MR DWI ASPECTS <6) were determined from prior reported prevalence from prospective stroke registries, whereas a third definition (CT ASPECTS <6) was used to identify eligible patients from prospective registry from 2 comprehensive stroke centers.% of patients(estimated) with very large core (ASPECTS 0-2) that would be excluded from thrombectomy considerations based on trials’ eligibility criteria were obtained by reviewing previously published statistics and screening data from SELECT2 trial. Expected increase in the number of thrombectomy cases with their 95% confidence intervals were calculated.
Results EVT procedures performed in patients with a documented carotid or middle cerebral artery occlusion increased from 13185(2016) to 29640(2019)[figure 1]. Inoue et al(2014) reported 75/210 patients having DWI ASPECTS <6(proportion: 35.71%, 95% CI: 29.54%-42.40%). Tisserand et al (2016) reported 54/267 patients with DWI lesion volume ≥70ml (proportion: 20.22%, 95% CI: 15.83%-25.47%). In the SELECT2 trial, 39/329(11.85%) with ASPECTS <6 and who met trial eligibility criteria otherwise had ASPECTS 0-2. Applying these criteria to the 2019 EVT cases for anterior circulation LVOs, 9330 (95% CI: 7718-11078) additional EVTs would be performed for MR DWI ASPECTS <6 (excluding patients with ASPECTS 0-2), whereas based on DWI core ≥70ml criteria, 5283 (95% CI: 4136-6654) additional EVTs would be performed (excluding patients with ASPECTS 0-2). Analyses based on CT ASPECTS <6 criteria are ongoing and will be available for presentation at SNIS 2023 meeting.
Conclusion Our preliminary analyses demonstrate that expansion of eligibility criteria for LIS would result in an increase in EVT cases from lower end 4136(14%increase) to 11078(37%increase) on higher end. These estimates and further analyses into how these increased number of cases would affect current systems of care and would help guide the long-term planning and policy decisions.
Disclosures O. Mir: None. D. Pujara: None.