London, United Kingdom 2013 7 Management and economics 17:30 - 17:40 Cost-effectiveness of surgical decompression for space-occupying hemispheric infarction: economic evaluation of the randomised trial HAMLET J. Hofmeijer1, H.B. van der Worp2, L.J. Kappelle3, S. Eshuis4, A. Algra5, J.P. Greving6 on behalf of the HAMLET investigators Rijnstate Hospital and University of Twente, Arnhem, THE NETHERLANDS1,University Medical Centre Utrecht, Utrecht, THE NETHERLANDS2, University Medical Centre Utrecht, Utrecht, THE NETHERLANDS3, University Medical Centre Utrecht, Utrecht, THE NETH-ERLANDS4, University Medical Centre Utrecht, Utrecht, THE NETHERLANDS5, University Medical Centre Utrecht, Utrecht, THE NETHERLANDS6 Background In a pooled analysis of three small randomised trials on space-occupying hemi-spheric infarction, surgical decompression within 48 hours of stroke onset reduced case fatal-ity as compared to best medical treatment and increased the chance of a favourable functional outcome at 12 months (modified Rankin Scale score (mRS) ≤ 3). However, surgical decom-pression also increased the probability of survival with severe disability. We assessed the costs and cost-effectiveness of surgical decompression compared with best medical treatment, based on data derived from the randomised Hemicraniectomy After Middle cerebral artery infarction with Life-threatening Edema Trial (HAMLET). Methods We collected data on the resources used (including length of stay in intensive care unit, stroke unit, tertiary referral centre, gen-eral hospital, rehabilitation centre, and nursing home, outpatient visits to hospital, and visits to general practitioner) with data from hospital records for the first three years after the stroke onset. Long-term outcomes in terms of costs, life-years, and incremental costs per life-year gained were estimated. Results 39 patients with space-occupying hemispheric infarction, aged 60 years or younger, were randomly allocated to surgical decompression (n=21) or best medical treatment (n=18) within 48 hours of stroke onset. Surgical decompression reduced case fatali-ty (19% vs 79% died within 1 week). However, mean total costs were substantially higher for surgical decompression than for best medical treatment (€142,824 vs. €16,837, MD -125,987, 95% CI -178,805 to -71,168). Surgically treated patients experienced more health benefits (2.4 vs. 0.7 life-years) at three years after stroke onset. Incremental costs per life-year gained were about € 75,000 for the first three years. Conclusion The costs of surgical decompression per life-year gained are very high if analyses are limited to the first three years after stroke onset. Cerebrovasc Dis 2013; 35 (suppl 3)1-854 65 6 Vascular surgery and neurosurgery 17:20 - 17:30 Risk of brain infarctions during carotid endarterectomy and stenting. A prospective ran-domized study. M. Kuliha1, D. Školoudík2, E. Hurtíková3, M. Roubec4, A. Goldírová5, R. Herzig6, V. Procház-ka7, T. Jonszta8, J. Krajča9, D. Czerný10, T. Hrbáč11, D. Otáhal12, K. Langová13 Department of Neurology, University Hospital Ostrava, Czech Republic, Ostrava, CZECH REPUBLIC1,Comprehensive Stroke Center, Department of Neurology, Facul-ty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olo-mouc, CZECH REPUBLIC2, Department of Neurology, University Hospital Ostrava, Ostra-va, CZECH REPUBLIC3, Department of Neurology, University Hospital Ostrava, Ostrava, CZECH REPUBLIC4, Department of Neurology, University Hospital Ostrava, Ostrava, CZECH REPUBLIC5, Comprehensive Stroke Center, Department of Neurology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, CZECH REPUBLIC6, Department of Radiology, University Hospital Ostrava, Ostrava, CZECH REPUBLIC7, Department of Radiology, University Hospital Ostrava, Ostrava, CZECH RE-PUBLIC8, Department of Radiology, University Hospital Ostrava, Ostrava, CZECH REPUB-LIC9, Department of Radiology, University Hospital Ostrava, Ostrava, CZECH REPUBLIC10, De-partment of Neurosurgery, University Hospital Ostrava, Ostrava, CZECH REPUBLIC11, De-partment of Neurosurgery, University Hospital Ostrava, Ostrava, CZECH REPUBLIC12, De-partment of Biophysics, Palacký University Olomouc, Ostrava, CZECH REPUBLIC13 Background: Silent brain infarctions can be detected in up to 30% of patients after carotid end-arterectomy (CEA) and in up to 54% of patients after carotid stenting (CAS). The aim was to compare the risk of new brain infarctions in patients with internal carotid artery (ICA) stenosis >70% undergoing CEA or CAS. Methods: All consecutive patients 1/ with ICA stenosis >70%, 2/ indicated to carotid inter-vention, 3/ without contraindications to CEA or CAS, 4/ with signed informed consent, were enrolled to the study during 26 months. Patients were indicated to CEA or CAS according to the European Stroke Organisation guidelines. Only patients eligible for both methods were en-rolled to the study and randomly allocated to CEA or CAS. Neurological examination and brain magnetic resonance imaging (MRI) were performed before and 24 h after intervention in all patients. Occurrence of new brain infarctions and 30-day mortality and morbidity were statisti-cally evaluated using T-test. Results: Totally 142 patients were included in the study. 69 patients (44 males, mean age 63.8 ± 7.3 years) underwent CEA and 73 patients (53 males, mean age 67.2 ± 7.5 years) underwent CAS. New brain infarctions on control MRI were found in 16 (23.2%) patients in CEA group (only in the territory of the intervened artery) and in 37 (50.7%) patients in CAS group (in 15 cases in both hemispheres) (P<0.001). Brain infarction was symptomatic in only 1 patient in both groups (P>0.05). Conclusion: Study results confirm higher risk of the occurrence of silent brain infarctions on MRI during CAS in comparison with CEA. Supported by IGA MH CR grants NT/11046-6/2010, NT/11386-5/2010, NT/13498-4/2012.
Karger_ESC London_2013
To see the actual publication please follow the link above