Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation

Background: Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion. Methods: Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (? "Costs) and quality-adjusted life years (? "QALY) per 1000 patients for 1000 model iterations as outcomes. Results: Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV=110 mL) or core-penumbra mismatch ratio (MMR=1.4) thresholds resulted in losses of health (median ? "QALYs for ICV=110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR=1.4: 0.0 (IQR: -1.3 to 0.0)) with median ? "Costs for ICV=110 mL of -€348 966 (IQR: -€712 406 to -€51 158) and for MMR=1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged =80 years Conclusion: In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients.