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  • Temporal Trends in Use and Outcomes of Endovascular Intra-arterial Therapy for Acute Ischemic Stroke: National Inpatient Sample Analysis, 2004-2012

    Final Number:

    Srikanth Boddu MD; Xingwen Sun; Thomas W Link MD; Ning Lin MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Given progressive advances in devices and technique, we aimed to investigate nationwide, temporal trends in the use and outcomes of endovascular intra-arterial therapy (IAT) for stroke with respect to technological changes.

    Methods: Patients with hospital discharge diagnoses of acute ischemic stroke from 2004-2012 were identified from the Nationwide Inpatient Sample (NIS). The rates of endovascular IAT and in-hospital mortality over three time periods: 2004-2007 (post-MERCI), 2008-2011 (post-Penumbra), and 2012 (post-Solitaire), were evaluated stratified by hospital and patient characteristics.

    Results: Endovascular IAT has steadily increased from 2004 (0.05%) to 2012 (1.57%). The overall in-hospital mortality in patients treated with endovascular IAT decreased significantly from 2004 (31.8%) to 2012 (17.1%) despite increases in the mean age (p<0.001) and Charlson Comorbidity Index (CCI) of these patients (p<0.001). The mortality decrease was significant from post-MERCI (25.3%), to post-Penumbra (20.1%), to post-Solitaire period (17.1%). In subgroup analyses based on age, the mortality decrease from 3 periods of technological changes was significant for patients older than 65 (27.3% vs. 23.4% vs. 16.8%, p<0.001), and trending towards significance for those younger than 65 (24.0% vs. 17.2% vs. 17.4%, p=0.07).

    Conclusions: Endovascular IAT utilization for acute ischemic stroke has increased significantly from 2004 to 2012. Despite significant increase in mean patient age and comorbidities, mortality associated with endovascular IAT has decreased from post-MERCI (2004-2007), post-Penumbra (2008-2011), to post-Solitaire (2012) era, significantly in patients between 65 and 80 years of age.

    Patient Care: The data from this study support the use of acute stroke therapy for patients with advanced age as the outcomes in this subgroup have improved the most over the past decade with technological advancement.

    Learning Objectives: To understand the temporal trend of endovascular stroke therapy, and outcome improvement over the past decade, especially in age-specific subgroups.

    References: 1. Centers for disease control and prevention, national center for health statistics. Underlying cause of death 1999-2013 on cdc wonder online database, released 2015. Data are from the multiple cause of death files, 1999-2013, as compiled from data provided by the 57 vital statistics jurisdictions through the vital statistics cooperative program. Accessed at http://wonder.Cdc.Gov/ucd-icd10.Html on may 15, 2015 4:10:11 pm. 2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Despres JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER, 3rd, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB, American Heart Association Statistics C, Stroke Statistics S. Heart disease and stroke statistics--2015 update: A report from the american heart association. Circulation. 2015;131:e29-322 3. James ML, Grau-Sepulveda MV, Olson DM, Smith EE, Hernandez AF, Peterson ED, Schwamm LH, Bhatt DL, Fonarow GC. Insurance status and outcome after intracerebral hemorrhage: Findings from get with the guidelines-stroke. J Stroke Cerebrovasc Dis. 2014;23:283-292 4. Bhatia R, Hill MD, Shobha N, Menon B, Bal S, Kochar P, Watson T, Goyal M, Demchuk AM. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: Real-world experience and a call for action. Stroke. 2010;41:2254-2258 5. Gonzalez RG, Furie KL, Goldmacher GV, Smith WS, Kamalian S, Payabvash S, Harris GJ, Halpern EF, Koroshetz WJ, Camargo EC, Dillon WP, Lev MH. Good outcome rate of 35% in iv-tpa-treated patients with computed tomography angiography confirmed severe anterior circulation occlusive stroke. Stroke. 2013;44:3109-3113 6. de Los Rios la Rosa F, Khoury J, Kissela BM, Flaherty ML, Alwell K, Moomaw CJ, Khatri P, Adeoye O, Woo D, Ferioli S, Kleindorfer DO. Eligibility for intravenous recombinant tissue-type plasminogen activator within a population: The effect of the european cooperative acute stroke study (ecass) iii trial. Stroke. 2012;43:1591-1595 7. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2014 8. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD, Investigators ET. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-1030 9. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Devlin TG, Lopes DK, Reddy V, du Mesnil de Rochemont R, Jahan R, Investigators SP. Solitaire with the intention for thrombectomy as primary endovascular treatment for acute ischemic stroke (swift prime) trial: Protocol for a randomized, controlled, multicenter study comparing the solitaire revascularization device with iv tpa with iv tpa alone in acute ischemic stroke. Int J Stroke. 2015;10:439-448 10. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM, Investigators E-I. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-1018 11. Molina CA, Chamorro A, Rovira A, de Miquel A, Serena J, Roman LS, Jovin TG, Davalos A, Cobo E. Revascat: A randomized trial of revascularization with solitaire fr(r) device vs. Best medical therapy in the treatment of acute stroke due to anterior circulation large vessel occlusion presenting within eight-hours of symptom onset. Int J Stroke. 2015;10:619-626 12. Mocco j, khatri p, zaidat o. The therapy trial: The randomized, concurrent controlled trial to assess the penumbra system’s safety and effectiveness in the treatment of acute stroke. European stroke organization conference 2015. Glasgow, uk. 13. Bracard s, investigators t. The contribution of intra-arterial thrombectomy in acute ischemic stroke in patients treated with intravenous thrombolysis. European stroke organization conference 2015. Glasgow, uk. 14. Campbell BC, Donnan GA, Lees KR, Hacke W, Khatri P, Hill MD, Goyal M, Mitchell PJ, Saver JL, Diener HC, Davis SM. Endovascular stent thrombectomy: The new standard of care for large vessel ischaemic stroke. Lancet Neurol. 2015 15. Brinjikji W, Rabinstein AA, Kallmes DF, Cloft HJ. Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke: A study of the national inpatient sample: 2006 to 2008. Stroke. 2011;42:1648-1652 16. Qureshi AI, Chaudhry SA, Hassan AE, Zacharatos H, Rodriguez GJ, Suri MF, Lakshminarayan K, Ezzeddine MA. Thrombolytic treatment of patients with acute ischemic stroke related to underlying arterial dissection in the united states. Arch Neurol. 2011;68:1536-1542 17. Hassan AE, Chaudhry SA, Grigoryan M, Tekle WG, Qureshi AI. National trends in utilization and outcomes of endovascular treatment of acute ischemic stroke patients in the mechanical thrombectomy era. Stroke. 2012;43:3012-3017 18. Grigoryan M, Chaudhry SA, Hassan AE, Suri FK, Qureshi AI. Neurointerventional procedural volume per hospital in united states: Implications for comprehensive stroke center designation. Stroke. 2012;43:1309-1314 19. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with icd-9-cm administrative databases. J Clin Epidemiol. 1992;45:613-619 20. Villwock MR, Singla A, Padalino DJ, Deshaies EM. Acute ischaemic stroke outcomes following mechanical thrombectomy in the elderly versus their younger counterpart: A retrospective cohort study. BMJ Open. 2014;4:e004480 21. Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, Feng L, Meyer BC, Olson S, Schwamm LH, Yoo AJ, Marshall RS, Meyers PM, Yavagal DR, Wintermark M, Guzy J, Starkman S, Saver JL. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368:914-923 22. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO. Solitaire flow restoration device versus the merci retriever in patients with acute ischaemic stroke (swift): A randomised, parallel-group, non-inferiority trial. Lancet. 2012;380:1241-1249 23. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Roman L, Serena J, Abilleira S, Ribo M, Millan M, Urra X, Cardona P, Lopez-Cancio E, Tomasello A, Castano C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Perez M, Goyal M, Demchuk AM, von Kummer R, Gallofre M, Davalos A. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296-2306 24. Zaidat OO, Lazzaro M, McGinley E, Edgell RC, Nguyen T, Linfante I, Janjua N. Demand-supply of neurointerventionalists for endovascular ischemic stroke therapy. Neurology. 2012;79:S35-41 25. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, Jauch EC, Jovin TG, Yan B, Silver FL, von Kummer R, Molina CA, Demaerschalk BM, Budzik R, Clark WM, Zaidat OO, Malisch TW, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson C, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Martin RH, Foster LD, Tomsick TA. Endovascular therapy after intravenous t-pa versus t-pa alone for stroke. N Engl J Med. 2013;368:893-903 26. Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayberg MR, Starke RD, Todd HW, Viste KM, Girgus M, Shephard T, Emr M, Shwayder P, Walker MD. Recommendations for the establishment of primary stroke centers. Brain attack coalition. JAMA. 2000;283:3102-3109 27. Adamczyk P, Attenello F, Wen G, He S, Russin J, Sanossian N, Amar AP, Mack WJ. Mechanical thrombectomy in acute stroke: Utilization variances and impact of procedural volume on inpatient mortality. J Stroke Cerebrovasc Dis. 2013;22:1263-1269 28. Choi JC, Hsia RY, Kim AS. Regional availability of mechanical embolectomy for acute ischemic stroke in california, 2009 to 2010. Stroke. 2015;46:762-768 29. Commission J. Joint commission certified advanced comprehensive stroke centers. 2015 30. Mullen MT, Branas CC, Kasner SE, Wolff C, Williams JC, Albright KC, Carr BG. Optimization modeling to maximize population access to comprehensive stroke centers. Neurology. 2015;84:1196-1205 31. Fargen KM, Neal D, Blackburn SL, Hoh BL, Rahman M. Health disparities and stroke: The influence of insurance status on the prevalence of patient safety indicators and hospital-acquired conditions. J Neurosurg. 2015;122:870-875 32. Gezmu T, Gizzi MS, Kirmani JF, Schneider D, Moussavi M. Disparities in acute stroke severity, outcomes, and care relative to health insurance status. J Stroke Cerebrovasc Dis. 2014;23:e93-98 33. Brinjikji W, Rabinstein AA, McDonald JS, Cloft HJ. Socioeconomic disparities in the utilization of mechanical thrombectomy for acute ischemic stroke in us hospitals. AJNR Am J Neuroradiol. 2014;35:553-556 34. Brinjikji W, Rabinstein AA, Cloft HJ. Socioeconomic disparities in the utilization of mechanical thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis. 2014;23:979-984 35. Attenello FJ, Adamczyk P, Wen G, He S, Zhang K, Russin JJ, Sanossian N, Amar AP, Mack WJ. Racial and socioeconomic disparities in access to mechanical revascularization procedures for acute ischemic stroke. J Stroke Cerebrovasc Dis. 2014;23:327-334 36. Giacovelli JK, Egorova N, Nowygrod R, Gelijns A, Kent KC, Morrissey NJ. Insurance status predicts access to care and outcomes of vascular disease. J Vasc Surg. 2008;48:905-911 37. Langagergaard V, Palnum KH, Mehnert F, Ingeman A, Krogh BR, Bartels P, Johnsen SP. Socioeconomic differences in quality of care and clinical outcome after stroke: A nationwide population-based study. Stroke. 2011;42:2896-2902 38. Addo J, Ayerbe L, Mohan KM, Crichton S, Sheldenkar A, Chen R, Wolfe CD, McKevitt C. Socioeconomic status and stroke: An updated review. Stroke. 2012;43:1186-1191 39. Brinjikji W, El-Sayed AM, Rabinstein AA, McDonald JS, Cloft HJ. Disparities in imaging utilization for acute ischemic stroke based on patient insurance status. AJR Am J Roentgenol. 2014;203:372-376 40. Brown AF, Liang LJ, Vassar SD, Merkin SS, Longstreth WT, Jr., Ovbiagele B, Yan T, Escarce JJ. Neighborhood socioeconomic disadvantage and mortality after stroke. Neurology. 2013;80:520-527 41. Kapral MK, Fang J, Chan C, Alter DA, Bronskill SE, Hill MD, Manuel DG, Tu JV, Anderson GM. Neighborhood income and stroke care and outcomes. Neurology. 2012;79:1200-1207 42. Albright KC, Branas CC, Meyer BC, Matherne-Meyer DE, Zivin JA, Lyden PD, Carr BG. Access: Acute cerebrovascular care in emergency stroke systems. Arch Neurol. 2010;67:1210-1218 43. Brown TM, Parmar G, Durant RW, Halanych JH, Hovater M, Muntner P, Prineas RJ, Roth DL, Samdarshi TE, Safford MM. Health professional shortage areas, insurance status, and cardiovascular disease prevention in the reasons for geographic and racial differences in stroke (regards) study. J Health Care Poor Underserved. 2011;22:1179-1189 44. Kleindorfer D, Lindsell C, Alwell KA, Moomaw CJ, Woo D, Flaherty ML, Khatri P, Adeoye O, Ferioli S, Kissela BM. Patients living in impoverished areas have more severe ischemic strokes. Stroke. 2012;43:2055-2059 45. Qureshi AI, Harris-Lane P, Siddiqi F, Kirmani JF. International classification of diseases and current procedural terminology codes underestimated thrombolytic use for ischemic stroke. J Clin Epidemiol. 2006;59:856-858

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