Melissa Trotman-Lucas, PhD
The number of deaths due to stroke is 10 million per year globally, with a prevalence of 42 million. Large vessel occlusions (LVO) account for a third of all occlusive ischemic strokes and are the largest contributor to the morbidity and mortality associated with ischemic stroke. The evolution and use of endovascular thrombectomy (EVT) for these patients have transformed stroke treatment and care; clinical trials utilizing EVT demonstrated the benefits of this technique during post-stroke recovery, including reduced disability and improved outcome. In multiple countries, EVT has been adopted as the standard of care for LVO and is recommended for use where possible in other countries — limits come from availability of suitably trained staff and equipment.
Kunz et al. evaluated, in a recent article, the long-term financial and health benefits of improved EVT induced reperfusion following ischemic stroke in order to assess the benefits of further improvement of reperfusion for patients. The expanded thrombolysis in cerebral infarction (eTICI) reperfusion grades are used following EVT to record achieved reperfusion levels. eTICI grade 2c equates to 90-99% reperfusion, and grade 3 is the achievement of 100% reperfusion following intervention. The group reported, using U.S. data, that just a 10% increase in the achievement of eTICI 2c/3 reperfusion levels in EVT-treated patients could lead to an increase in quality adjusted life years and savings of millions of U.S. dollars for the healthcare system and society. Quality-adjusted life years (QALYs) are often used to measure a person’s ability to perform daily activities with freedom from pain and mental disturbance. One QALY is equal to one year of life with perfect health in an individual. Where 100% reperfusion is achieved, either with first pass or second phase intervention, within 6 hours of stroke onset, there was a significant cost savings and improvement of health longevity for the patient. This data suggests that a clinical push towards achieving eTICI grade 3 can be deemed an economically effective strategy, irrespective of additional procedural costs associated with achieving improved reperfusion. Furthermore, research suggests that achieving eTICI grade 3 following a first intervention, known as the “first pass effect,” is highly relevant to achieving improvements in patient outcome when faster and more complete reperfusion is achieved the first time. It is, however, important to note that patients who achieved eTICI grades 2c or 3 following a second intervention, if eTICI 2b (50-90%) grade was achieved at first pass, fared equally as well as those patients who achieved 2c/3 grades following a first pass intervention.
In the U.S., the annual financial burden of stroke is approximately $40 billion U.S. dollars, a figure that is projected to triple within 10 years. The data presented in this recent article by Kunz et al. supports the need to improve funding and investment geared towards achieving 100% reperfusion post ischemic stroke in many more patients. Improving the distribution of training, experience, facilities and devices has the potential to improve patient outcomes and the ever-increasing financial burden on the healthcare systems worldwide. Although the data used within this paper is exclusively from the U.S., where healthcare expenditures surpass other countries, it is clear to see that improved reperfusion rates can lead to improved health benefits and impactful financial savings within other countries. Investment to realize the full potential of EVT for patients and societies is shown here to be justified and cost effective.