The cost-effectiveness of telestroke in the treatment of acute ischemic stroke.

OBJECTIVE: To conduct a cost-effectiveness analysis of telestroke--a 2-way, audiovisual technology that links stroke specialists to remote emergency department physicians and their stroke patients--compared to usual care (i.e., remote emergency departments without telestroke consultation or stroke experts). METHODS: A decision-analytic model was developed for both 90-day and lifetime horizons. Model inputs were taken from published literature where available and supplemented with western states' telestroke experiences. Costs were gathered using a societal perspective and converted to 2008 US dollars. Quality-adjusted life-years (QALYs) gained were combined with costs to generate incremental cost-effectiveness ratios (ICERs). In the lifetime horizon model, both costs and QALYs were discounted at 3% annually. Both one-way sensitivity analyses and Monte Carlo simulations were performed. RESULTS: In the base case analysis, compared to usual care, telestroke results in an ICER of $108,363/QALY in the 90-day horizon and $2,449/QALY in the lifetime horizon. For the 90-day and lifetime horizons, 37.5% and 99.7% of 10,000 Monte Carlo simulations yielded ICERs <$50,000/QALY, a ratio commonly considered acceptable in the United States. CONCLUSION: When a lifetime perspective is taken, telestroke appears cost-effective compared to usual care, since telestroke costs are upfront but benefits of improved stroke care are lifelong. If barriers to use such as low reimbursement rates and high equipment costs are reduced, telestroke has the potential to diminish the striking geographic disparities of acute stroke care in the United States.

Intrasinus catheter-directed heparin infusion in the treatment of dural venous sinus thrombosis.

BACKGROUND AND PURPOSE: In this small series, local intrasinus catheter-directed heparin infusion with or without balloon thrombectomy was safe in the treatment of dural venous sinus thrombosis (DVST). Although systemic anticoagulation (SAC) is the treatment of choice, there is a lack of consensus regarding the best treatment should SAC fail or be contraindicated. We present our institutional experience with 16 patients in whom failure of, or contraindication to, SAC occurred and who subsequently underwent intrasinus catheter-directed heparin infusion with or without balloon thrombectomy. MATERIALS AND METHODS: A retrospective review of 16 patients ranging in age from 14 days to 77 years who had intrasinus catheter-directed heparin infusion was undertaken with 9 male and 7 female patients identified. Of these 16 patients, 4 (25%) had a contraindication to SAC and SAC failed in 12 (75%). Technically successful intrasinus infusion catheter placement was achieved in all 16 patients (100%). Mean duration of infusion was 3.3 days (range, 1-6 days). Adjunctive balloon thrombectomy was performed in 9 (56.3%) of 16 patients. No procedure-related mortality occurred. RESULTS: Partial and complete sinus recanalization occurred in 10 (62.5%) of 16 patients and 1 (6.3%) of 16 patients, respectively. There were 3 deaths (18.8%) attributed to disease progression. At most recent clinical follow-up (mean, 9.3 months), 11 (84.6%) of 13 surviving patients were independent, with a modified Rankin Scale (mRS) score of 1 or less. CONCLUSIONS: Local intrasinus catheter-directed heparin infusion with or without adjunctive balloon thrombectomy seems to be a safe and effective treatment of DVST in patients in whom SAC failed or in whom there was a contraindication to SAC. In addition, the risk for symptomatic intracranial hemorrhage may be significantly lower than intrasinus infusion of thrombolytics.

Novel intra-arterial strategies in the treatment of acute ischaemic stroke.

Acute ischaemic stroke is among the leading causes of death and disability in developed societies. I.v. and intra-arterial thrombolysis, and mechanical thrombectomy carried out within the appropriate time window can result in superior clinical outcomes compared with traditional therapy consisting of anticoagulation and/or aspirin. In cases where thrombolysis and/or thrombectomy have not been proven effective or have failed to result in rapid clinical and/or angiographic improvement, novel intra-arterial strategies may be applied by experienced interventional neuroradiologists to achieve recanalization of recalcitrant vessel occlusions with good clinical outcomes.

Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.

OBJECTIVE: To determine whether spinal manipulative therapy (SMT) is an independent risk factor for cervical artery dissection. METHODS: Using a nested case-control design, the authors reviewed all patients under age 60 with cervical arterial dissection (n = 151) and ischemic stroke or TIA from between 1995 and 2000 at two academic stroke centers. Controls (n = 306) were selected to match cases by sex and within age strata. Cases and controls were solicited by mail, and respondents were interviewed using a structured questionnaire. The medical records of interviewed patients were reviewed by two blinded neurologists to confirm that the patient had stroke or TIA and to determine whether there was evidence of arterial dissection. RESULTS: After interview and blinded chart review, 51 patients with dissection (mean age 41 +/- 10 years; 59% female) and 100 control patients (44 +/- 9 years; 58% female) were studied. In univariate analysis, patients with dissection were more likely to have had SMT within 30 days (14% vs 3%, p = 0.032), to have had neck or head pain preceding stroke or TIA (76% vs 40%, p < 0.001), and to be current consumers of alcohol (76% vs 57%, p = 0.021). In multivariate analysis, vertebral artery dissections were independently associated with SMT within 30 days (OR 6.62, 95% CI 1.4 to 30) and pain before stroke/TIA (OR 3.76, 95% CI 1.3 to 11). CONCLUSIONS: This case-controlled study of the influence of SMT and cervical arterial dissection shows that SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain. Patients undergoing SMT should be consented for risk of stroke or vascular injury from the procedure. A significant increase in neck pain following spinal manipulative therapy warrants immediate medical evaluation.

Pallidotomy improves motor responses and widens the levodopa therapeutic window in Parkinson's disease.

Stereotactic posteroventral pallidotomy (PVP) as a treatment for Parkinson's disease (PD) symptoms has been increasingly used in moderate-advanced disease. We examined the pharmacodynamic responses of PD patients to single oral levodopa doses and intravenous levodopa infusions before and after PVP surgery. Nine subjects with advanced PD received a single oral dose and ramped intravenous levodopa infusions before and 3-5 weeks after unilateral PVP. Timed motor tasks, Unified Parkinson's Disease Rating Scale (UPDRS) evaluations, and ordinal dyskinesia rating were performed after oral levodopa and during i.v. levodopa infusions. Serum prolactin and dopa levels were measured during the levodopa infusions. Overall timed motor but not motor UPDRS scores were improved after PVP in both the worst ("off") and best ("on") states. Contralateral but not ipsilateral limb dyskinesias were substantially reduced at all serum (dopa) levels after PVP. Ipsilateral and contralateral timed motor performance at low serum (dopa) levels was improved by PVP. Walking speeds at all serum (dopa) levels were not changed by PVP. Serum prolactin was reduced equally by increasing (dopa) preoperatively and postoperatively. PVP significantly and favorably altered oral and intravenous levodopa pharmacodynamics by improving bilateral limb motor function and contralateral dyskinesia but did not alter walking speed. PVP appears to widen significantly the therapeutic window for levodopa in PD.