title: Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes.
abstract: BACKGROUND
  Limited efficacy of IV recombinant tissue plasminogen activator (rt-PA) for large vessel occlusions (LVO) raises doubts about its utility prior to endovascular therapy.
  
  
  OBJECTIVE
  To compare outcomes and hospital costs for anterior circulation LVOs (middle cerebral artery, internal carotid artery terminus (ICA-T)) treated with either primary endovascular therapy alone (EV-Only) or bridging therapy (IV+EV)).
  
  
  METHODS
  A single-center retrospective analysis was performed. Clinical and demographic data were collected prospectively and relevant cost data were obtained for each patient in the study.
  
  
  RESULTS
  90 consecutive patients were divided into EV-Only (n=52) and IV+EV (n=38) groups. There was no difference in demographics, stroke severity, or clot distribution. The mean (SD) time to presentation was 5:19 (4:30) hours in the EV-Only group and 1:46 (0:52) hours in the IV+EV group (p<0.0001). Recanalization: EV-Only 35 (67%) versus IV+EV 31 (81.6%) (p=0.12). Favorable outcome: EV-Only 26 (50%) versus IV+EV 22 (58%) (p=0.45). For patients presenting within 4.5 hours (n=64): Recanalization: EV-Only 21/26 (81%) versus IV+EV 31/38 (81.6%) (p=0.93). Favorable outcome: EV-Only 14/26 (54%) versus IV+EV 22/38 (58%) (p=0.75). There was no significant difference in rates of hemorrhage, mortality, home discharge, or length of stay. A stent retriever was used in 67 cases (74.4%), with similar recanalization, outcomes, and number of passes in the EV-Only and IV+EV groups. The mean (SD) total hospital cost was $33 810 (13 505) for the EV-Only group and $40 743 (17 177) for the IV+EV group (p=0.02). The direct cost was $23 034 (8786) for the EV-Only group and $28 711 (11 406) for the IV+EV group (p=0.007). These significantly higher costs persisted for the subgroup presenting in <4.5 hours and the stent retriever subgroup. IV rt-PA administration independently predicted higher hospital costs.
  
  
  CONCLUSIONS
  IV rt-PA did not improve recanalization, thrombectomy efficacy, functional outcomes, or length of stay. Combined therapy was associated with significantly higher total and direct hospital costs than endovascular therapy alone.
authors.affiliation: Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Ansaar T
authors.identifier: http://orcid.org/0000-0001-9864-4805
authors.initials: AT
authors.lastname: Rai
authors.affiliation: Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: SoHyun
authors.initials: S
authors.lastname: Boo
authors.affiliation: Financial Analytics, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Chelsea
authors.initials: C
authors.lastname: Buseman
authors.affiliation: Neurology, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Amelia K
authors.initials: AK
authors.lastname: Adcock
authors.affiliation: Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Abdul R
authors.initials: AR
authors.lastname: Tarabishy
authors.affiliation: Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Maurice M
authors.initials: MM
authors.lastname: Miller
authors.affiliation: Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Roberts
authors.affiliation: Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Domico
authors.affiliation: Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Carpenter
mesh_terms: D061605:Administration, Intravenous; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging; D057510:Endovascular Procedures / Q000191:economics* / Q000379:methods; D005260:Female; D017721:Hospital Costs / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging / Q000191:economics* / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000191:economics* / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000191:economics; D016896:Treatment Outcome
chemical_list: D010959:Tissue Plasminogen Activator
keywords: Economics; Intervention; Stroke; Thrombectomy