Endovascular treatment for acute ischemic stroke On the road to nationwide implementation

Acute ischemic stroke (AIS) is a leading cause of death and disability worldwide. In approximately one third of patients AIS is caused by a large vessel occlusion (LVO). Since 2015, endovascular treatment (EVT) has been proven clinical effective for AIS caused by LVO, with a number-needed-to-treat of less than three for improved clinical outcome. The focus of this thesis is to provide information on the long-term clinical follow-up, cost-effectiveness, and optimization of implementation of EVT for AIS patients. In our two-year clinical follow-up study in patients of the Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands trial (MR CLEAN) we found that patients randomized to EVT had a higher probability to achieve good clinical outcome (functional independence) compared to control. Additionally, we executed an economic evaluation, which showed that EVT dominated standard treatment with €76,937 saved per additional quality adjusted life year. Moreover, introduction of EVT in the Netherlands resulted in estimated net annual savings on the health care budget of €2.9 million in 2015 to €58 million in 2021.
Furthermore, in a post-hoc analysis of MR CLEAN we looked at the effect of anaesthetic management during EVT and observed that there was only a significant treatment effect of EVT in patients treated without general anesthesia. Lastly, we studied innovations that were made to the local EVT workflow protocol in the Greater Amsterdam Area. Results showed that these innovations led to shorter times from hospital presentation to start of EVT and improved clinical outcomes.