HHE Neurology supplement 2018 - Page 17

Solitaire FR device, but anecdotally much lower with latest versions). The key strategy to minimise complications is for thrombectomy to be only performed in high-volume centres by trained physicians competent in intracranial endovascular procedures. In the event of a complication, there should be immediate availability of neurocritical care and neurosurgical support, which are essential and prove life-saving. Social benefit and cost effectiveness The only data on cost effectiveness of mechanical thrombectomy were published by the National Institute for Health and Care Excellence (NICE) in March 2016. 5 The data showed that patients undergoing mechanical thrombectomy had good clinical outcomes, with 50% of patients alive and independent with no significant disability (mRS<2). It also showed mortality rates of 17 compared with 50% 1-year mortality previously for such a subset of patients. 5 The median hospital stay for patients undergoing MT in the study was 14 days, less than a sixth of the previous figure of 60–90 days. More than 90% of patients were discharged home, compared with the previous situation in which >70% would go to a nursing home because of significant impairment, and 23% of patients undergoing MT were discharged home within one week. 6 Patients with severe strokes have a prolonged hospital stay of 60–90 days, which costs £31,500 per patient. 5 The community cost for disabled stroke patient ranges between £28,600/year to £68,000/year. 5 NICE data showed that offering the procedure could achieve savings of £2.4 million a year as a result of reduced time in hospital and savings from ongoing social care costs. 5 An estimated £440 million annual savings could be generated to the NHS and social care once full national implementation of mechanical thrombectomy takes place. 5 Following the adoption of this procedure by the Department of Health, it has now been fully-funded through specialised commissioning by NHS England and the agreed funding level is £12,500 per patient, which includes the hyperacute costs of the intervention. This will help References 1 World Health Organization. The top 10 causes of death. www. who.int/mediacentre/factsheets/ fs310/en/ (accessed April 2018). 2 Feigin VL et al. Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet 2013;383(9913):245–54. 3 Townsend N et al. Coronary heart disease statistics; 2012 edition. London: British Heart Foundation:57. 4 Bhatia R et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke 2010;41:2254–8. 5 National Institute for Health and Clinical Excellence. Mechanical thrombectomy for large vessel occlusion stroke: improving clinical outcomes and reducing cost. Quality and productivity case study. March 2016. www.nice.org.uk/savings andproductivityandlocalpracti ceresource?id=2599 (accessed April 2018). 6 Goyal M et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. www. mrclean-trial.org/docs/Goyal_ HERMESmetaanalyse_2016 Lancet.pdf (accessed April 2018). 7 Evans M et al. Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Pract Neurol 2017;17(4):252–65. 8 Nayak S et al. Mechanical thrombectomy in acute ischaemic stroke: a review of the different techniques. Clin Radiol 2018;73(5):428–38. 9 Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). London: Royal College of Physicians; 2008. 10 Dorn F et al. Endovascular treatment of acute intracerebral artery occlusions with Mechanical thrombectomy is one of the most effective treatment innovations of this decade all the UK Tertiary Neurosciences centres to build an infrastructure to develop and safely deliver this service. This intervention has the potential to save millions of pounds to the NHS if fully implemented on a large UK scale. Further developments and new guidelines In the new American Acute Ischemic Stroke Guidelines, the time window for mechanical thrombectomy has been increased to 24 hours if patients meet DAWN or DEFUSE-3 criteria, where advanced imaging plays a major role. 22 The DAWN trial used clinical imaging mismatch (a combination of NIHSS score and imaging findings on CTP or DW-MRI) as eligibility criteria to select patients with large anterior circulation vessel occlusion for treatment with mechanical thrombectomy between 6 and 24 hours from last known normal. 23 This trial demonstrated an overall benefit in function outcome at 90 days in the treatment group (mRS score 0–2, 49% versus 13%; adjusted difference, 33%; 95% CI 21–44; posterior probability of superiority >0.999). 22,23 The DEFUSE 3 trial used perfusion-core mismatch and maximum core size as imaging criteria to select patients with large anterior circulation occlusion 6–16 hours from last seen well for MT. 24 This trial showed a benefit in functional outcome at 90 days in the treated group (mRS score 0–2, 44.6% versus 16.7%; RR, 2.67; 95% CI 1.60–4.48; p<0.0001). 22,24 Conclusions Mechanical thrombectomy with modern stentriever devices achieves superior c linical outcome in acute stroke patients compared with medical therapy alone. This has revolutionised acute stroke care and is considered as one of the top innovations of the decade. However, its development is still in the early phases and for full-fledged implementation, there is a requirement of further investment to help develop care pathways, workforce, technological investment for diagnostic and therapeutic execution and improved infrastructure for patient transfer services including ambulance services and in-hospital pathways. the solitaire stent: single- centre experience with 108 recanalization procedures. Cerebrovasc Dis 2012;34(1):70–7. 11 Zaidat OO et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013;44(9):2650–63. 12 Eesa M et al. Manual aspiration thrombectomy through balloon-tipped guide catheter for rapid clot burden reduction in endovascular therapy for ICA L/T occlusion. Neuroradiology 2012;54(11):1261–5. 13 Campbell BC et al Safety and efficacy of Solitaire stent thrombectomy: individual patient data meta-analysis of randomized trials. Stroke 2016;47:798–806. 14 Gascou G et al. Stent retrievers in acute ischemic stroke: complications and failures during the perioperative period AJNR Am J Neuroradiol 17 HHE 2018 | hospitalhealthcare.com 2014;35:734–40. 15 Leishangthem L, Satti SR. Vessel perforation during withdrawal of Trevo ProVue stent retriever during mechanical thrombectomy for acute ischemic stroke J Neurosurg 2014;121:995–8. 16 Mokin M et al. Vessel perforation during stent retriever thrombectomy for acute ischemic stroke: technical details and clinical outcomes. J Neurointerv Surg 2016:neurintsurg-2016-012707. 17 Schneider DJ. Anti-platelet therapy: glycoprotein IIb-IIIa antagonists. Br J Clin Pharmacol 2011;72(4):672–82. 18 Arai D et al. Histological examination of vascular damage caused by stent retriever thrombectomy devices. J Neurointerv Surg 2016;8(10):992–5. 19 Ahmad N et al. Mechanical thrombectomy for ischaemic stroke: the first UK case series. PLoS One 2013;8(12):e82218. 20 Akpinar S, Yilmaz G. Spontaneous Solitaire™ AB thrombectomy stent detachment during stroke treatment. Cardiovasc Intervent Radiol 2015;38:475–8. 21 Kim ST et al. Unexpected detachment of Solitaire stents during mechanical thrombectomy. J Korean Neurosurg Soc 2014;56:463–8. 22 Powers WJ et al. Guidelines for the early management of patients with acute ischemic stroke. A guideline for healthcare professionals 2018. http://stroke. ahajournals.org/content/49/3/ e46 (accessed April 2018). 23 Nogueira RG et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018;378(1):11–21. 24 Albers GW et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018;378(8):708–18.