title: Time to angiographic reperfusion in acute ischemic stroke: decision analysis.
abstract: OBJECTIVE
  Our objective was to use decision analytic modeling to compare 2 treatment strategies 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.
  
  
  METHODS
  We developed a decision model using Interventional Management of Stroke (IMS) III trial data and comprehensive literature review. We performed 1-way sensitivity analyses for time to reperfusion and 2-way sensitivity for time to reperfusion and rate of reperfusion success. We also performed probabilistic sensitivity analyses to address uncertainty in total time to reperfusion for the endovascular approach.
  
  
  RESULTS
  In the base case, 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 intravenous-only arm unless time to reperfusion exceeded 347 minutes. Two-way sensitivity analysis demonstrated that endovascular treatment was preferred when probability of reperfusion is high and time to reperfusion is small. Probabilistic sensitivity results demonstrated an average gain for endovascular therapy of 0.76 quality-adjusted life years (SD 0.82) compared with the intravenous-only approach.
  
  
  CONCLUSIONS
  In our post hoc model with its underlying limitations, endovascular therapy after intravenous r-tPA is the preferred treatment as compared with intravenous r-tPA alone. However, if time to reperfusion exceeds 347 minutes, intravenous r-tPA alone is the recommended strategy. This warrants validation in a randomized, prospective trial among patients with large vessel occlusions.
authors.affiliation: From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.). Achala.Vagal@uchealth.com.
authors.forename: Achala S
authors.initials: AS
authors.lastname: Vagal
authors.affiliation: From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.).
authors.forename: Pooja
authors.initials: P
authors.lastname: Khatri
authors.affiliation: From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.).
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Broderick
authors.affiliation: From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.).
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Tomsick
authors.affiliation: From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.).
authors.forename: Sharon D
authors.initials: SD
authors.lastname: Yeatts
authors.affiliation: From the Department of Radiology (A.S.V., T.A.T.), Department of Neurology (P.K., J.P.B.), and Department of Internal Medicine (M.H.E.), University of Cincinnati Medical Center, OH; and Department of Public Health Sciences, Medical University of South Carolina, Charleston (S.D.Y.).
authors.forename: Mark H
authors.initials: MH
authors.lastname: Eckman
mesh_terms: D002533:Cerebral Angiography; D017326:Clinical Trials, Phase III as Topic; D003661:Decision Support Techniques; D057510:Endovascular Procedures / Q000379:methods; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D061185:Mechanical Thrombolysis / Q000379:methods*; D020521:Stroke / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: reperfusion; stroke