National Trends in Utilization of Endovascular Treatment in Acute Ischemic Stroke Patients in Post-Stent Retriever Approval and Post-Clinical Trials Completion Era in United States

Introduction— Several recent trials have demonstrated the superiority of endovascular treatment in the treatment
of acute ischemic stroke. However, the pattern of utilization and associated outcomes in real world practice have not
been studied.
Methods— We obtained data for patients admitted with a primary diagnosis of ischemic stroke in the United States
from 2010 to 2017 using the Nationwide Inpatient Sample (NIS). We determined the rate and pattern of utilization and
associated in-hospital outcomes in identified patients. Outcomes were classified as either none to minimal disability,
moderate to severe disability, and death, and were compared between three time periods: 2010 to 2011, 2013 to 2014
and 2016 to 2017. These time periods represent the pre-stent retriever approval era, the post-stent retriever approval
era, and the years immediately following the publication of major clinical trials in United States, respectively.
Results— Of the 3,792,252 patients admitted with ischemic stroke, 45,692 (1.2%) underwent endovascular treat
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ment during the three time periods. There was an almost fourfold increase in patients who underwent endovascular
treatment in the span of 8 years (0.75% in 2010 vs. 2.89% in 2017, trend p<0.001). The rate of none to minimal dis
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ability consistently improved between the three study intervals (2010-2011 versus 2013-2014: odds ratio (OR) 1.51,
95% confidence interval (CI) 1.18-1.91, p=0.0009) and (2013-2014 versus 2016-2017: OR 1.87, 95% CI 1.49-2.35,
p= <0.0001)), respectively. There was significant decrease in inpatient mortality for patients treated during 2013-
2014 (OR 0.68, 95% CI 0.55-0.85, p=0.0006) and 2016-2017 (OR 0.52, 95% CI 0.43-0.63, p<0.0001).
Conclusions— There has been a significant increase in the proportion of acute ischemic stroke patients who re
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ceive endovascular treatment with improvement of outcomes in real world practice.