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Socioeconomics
Original research
The feasibility of mechanical thrombectomy versus medical management for acute stroke with a large ischemic territory
  1. Assala Aslan1,
  2. Saad Abuzahra1,
  3. Nimer Adeeb2,
  4. Basel Musmar2,
  5. Hamza A Salim2,
  6. Sandeep Kandregula3,
  7. Adam A Dmytriw4,5,
  8. Christoph J Griessenauer6,
  9. Luis De Alba1,
  10. Octavio Arevalo1,
  11. Jan Karl Burkhardt3,
  12. Vitor M Pereira5,
  13. Pascal Jabbour7,
  14. Bharat Guthikonda2,
  15. Hugo H Cuellar1,3
  1. 1Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
  2. 2Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
  3. 3Department of Neurosurgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
  4. 4Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Boston, Massachusetts, USA
  5. 5Divisions of Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
  6. 6Department of Neurosurgery, Christian Doppler University Hospital & Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
  7. 7Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Hugo H Cuellar, Department of Radiology and Interventional radiology, Ochsner-Louisiana State University, Shreveport, LA 71104, USA; hugo.cuellarsaenz{at}lsuhs.edu

Abstract

Background Mechanical thrombectomy (MT) for acute ischemic stroke is generally avoided when the expected infarction is large (defined as an Alberta Stroke Program Early CT Score of <6).

Objective To perform a meta-analysis of recent trials comparing MT with best medical management (BMM) for treatment of acute ischemic stroke with large infarction territory, and then to determine the cost-effectiveness associated with those treatments.

Methods A meta-analysis of the RESCUE-Japan, SELECT2, and ANGEL-ASPECT trials was conducted using R Studio. Statistical analysis employed the weighted average normal method for calculating mean differences from medians in continuous variables and the risk ratio for categorical variables. TreeAge software was used to construct a cost-effectiveness analysis model comparing MT with BMM in the treatment of ischemic stroke with large infarction territory.

Results The meta-analysis showed significantly better functional outcomes, with higher rates of patients achieving a modified Rankin Scale score of 0–3 at 90 days with MT as compared with BMM. In the base-case analysis using a lifetime horizon, MT led to a greater gain in quality-adjusted life-years (QALYs) of 3.46 at a lower cost of US$339 202 in comparison with BMM, which led to the gain of 2.41 QALYs at a cost of US$361 896. The incremental cost-effectiveness ratio was US$−21 660, indicating that MT was the dominant treatment at a willingness-to-pay of US$70 000.

Conclusions This study shows that, besides having a better functional outcome at 90-days' follow-up, MT was more cost-effective than BMM, when accounting for healthcare cost associated with treatment outcome.

  • Stroke

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/jnis-2023-021368

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • Twitter @hamza_isleem, @AdamDmytriw, @cgriessenauer, @VitorMendesPer1, @PascalJabbourMD

    • Contributors The authors confirm contribution to the paper as follows: study conception and design: AA, SA, NA, SK, AAD, HHC; data collection: AA, SA, BM, HAS; analysis and interpretation of results: AA, SA, BM, HAS; draft manuscript preparation: AA, CJG, LDA, OA; data review and editing: JKB, VMP, PJ, BG, HHC;

      author responsible for the overall content: AA. All authors reviewed the results and approved the final version 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 None declared.

    • 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.