Stroke is a leading cause of death and disability worldwide and treatment decisions must balance clinical benefit with healthcare costs. Treatment options in the acute phase (first hours) include intravenous thrombolysis (a medication given to dissolve the clot causing the stroke) and thrombectomy (a minimally invasive procedure to mechanically retrieve or aspirate the clot). Thrombectomy is highly effective for large-vessel occlusion stroke, but whether patients should also receive intravenous alteplase beforehand remains debated, especially given the potential time delays and rising healthcare costs.
The researchers analyzed data from 2,268 patients from six clinical trials (IRIS collaboration) and modeled outcomes across 16 countries over 15 years. They found that timing plays a crucial role. When intravenous alteplase was given within 170 minutes after symptom onset, the combined treatment (intravenous alteplase and thrombectomy) was cost-effective in all countries studied. However, the benefits decreased as treatment was delayed. Administration of intravenous alteplase beyond 200 minutes after onset was not cost-effective anymore.
The study also included real-world healthcare costs and differences in mortality rates between countries, making the results relevant for both high- and middle-income settings. The magnitude of cost-effectiveness varied substantially between countries, depending on willingness-to-pay thresholds, post-stroke healthcare costs, and the cost of intravenous thrombolysis.
This study was conducted as part of the CONTRAST research consortium (funded by the Dutch Heart Foundation and the Brain Foundation). It is the first study to show that the cost-effectiveness of intravenous alteplase before thrombectomy is not fixed, but depends on how quickly treatment is started and varies across countries. The findings support giving alteplase as early as possible when feasible, but suggest reconsidering its use if there are significant delays when patients are admitted directly to thrombectomy capable centers. By demonstrating that treatment value changes dramatically after 170–200 minutes, the study highlights that in stroke care, every minute counts, not only for the brain, but also for sustainable healthcare spending.
The CONTRAST consortium is a collaboration between various university medical centers, Dutch hospitals and partners from industry. It is funded by the Heart Foundation, the Brain Foundation and Health~Holland. The consortium is part of the Dutch CardioVascular Alliance; a partnership of currently 24 organizations that have expressed the joint ambition to reduce the cardiovascular burden of disease by a quarter by 2030.
