The feasibility of mechanical thrombectomy versus medical management for acute stroke with a large ischemic territory

A breathless tweet from @JNIS_BMJ: BREAKTHROUGH in Stroke Treatment! Meta-analysis: Mechanical Thrombectomy >> Medical Management for large infarct stroke! ++ functional recovery & quality-adjusted life-years PLUS more cost-effective over life.

You can decide how breakthrough it is; I don't see full 100% recovery for all!

 The feasibility of mechanical thrombectomy versus medical management for acute stroke with a large ischemic territory

1. http://orcid.org/0000-0001-8797-0808Assala Aslan1,
2. Saad Abuzahra1,
3. Nimer Adeeb2,
4. http://orcid.org/0009-0000-4910-6090Basel Musmar2,
5. http://orcid.org/0000-0002-5208-8425Hamza A Salim2,
6. Sandeep Kandregula3,
7. http://orcid.org/0000-0003-0131-5699Adam A Dmytriw4,5,
8. Christoph J Griessenauer6,
9. Luis De Alba1,
10. Octavio Arevalo1,
11. Jan Karl Burkhardt3,
12. Vitor M Pereira5,
13. http://orcid.org/0000-0002-1544-4910Pascal Jabbour7,
14. http://orcid.org/0000-0001-6668-6656Bharat Guthikonda2,
15. Hugo H Cuellar1,3

1. Correspondence to Dr Hugo H Cuellar, Department of Radiology and Interventional radiology, Ochsner-Louisiana State University, Shreveport, LA 71104, USA; hugo.cuellarsaenz@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.

Data availability statement

Data are available upon reasonable request.

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

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