Time to Angiographic Reperfusion in Acute Ischemic Stroke: Decision Analysis

Study Questions:

What would be the optimal re-perfusion strategy for acute ischemic stroke?


The authors used decision analytic modeling to compare treatment strategy of intravenous recombinant tissue-type plasminogen activator (r-tPA) alone versus combined intravenous r-tPA/endovascular therapy in a subgroup of patients with large vessel (internal carotid artery terminus, M1, and M2) occlusion, based on varying times to angiographic reperfusion and varying rates of reperfusion. The decision model was developed using Interventional Management of Stroke (IMS) III trial data and comprehensive literature review. Probabilistic sensitivity analyses were performed to address uncertainty in total time to reperfusion for the endovascular approach.


In the base case, the endovascular approach yielded a higher expected utility (6.38 quality-adjusted life-years) than the intravenous-only arm (5.42 quality-adjusted life-years). One-way sensitivity analyses demonstrated superiority of endovascular treatment to the intravenous-only arm unless time to reperfusion exceeded 347 minutes. Two-way sensitivity analysis demonstrated that endovascular treatment was preferred when probability of reperfusion was high and time to reperfusion was small. Probabilistic sensitivity results demonstrated an average gain for endovascular therapy of 0.76 quality-adjusted life-years (standard deviation 0.82) compared with the intravenous-only approach.


In this decision analysis model, endovascular therapy after intravenous r-tPA was the preferred treatment as compared with intravenous r-tPA alone. In patients where time to reperfusion exceeds 347 minutes, intravenous r-tPA alone was the recommended strategy.


The IMS-3 trial did not show a benefit of endovascular therapy after intravenous t-PA over intravenous t-PA alone (Broderick JP, et al., N Engl J Med 2013;368:893-903), and the authors suggest that the benefit would be restricted to patients treated early after symptom onset. While the decision analysis is interesting, it would be premature to translate this into clinical practice, and these results should be best used to guide future clinical trials.

Clinical Topics: Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Lipid Metabolism

Keywords: Reperfusion, Stroke, Decision Support Techniques, Tissue Plasminogen Activator, Carotid Artery, Internal, Quality-Adjusted Life Years

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