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Direct Transfer to Angiography Suite for LVO Acute Stroke Offers Benefit Over Conventional Workflow

The direct transfer protocol had greater decreases in the median door-to-arterial puncture time and door-to-reperfusion time in comparison to conventional workflow in acute ischemic stroke care.

For patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), direct transfer to angiography suite (DTAS) within 6 hours of symptom onset was safe and led to improved clinical outcomes compared with direct transfer to computed tomography (DTCT) suite.

ANGIOCAT, a prospective, open clinical trial (NCT04001738), included 174 patients who were randomized 1:1 to follow either DTAS (n = 89) or conventional workflow (n = 85) to assess the indication of endovascular treatment (EVT). Lead author Manuel Requena, MD, PhD, research fellow, Hospital Universitari Vall d’Hebron, and colleagues used a shift analysis evaluating the distribution of 90-day 7-category modified Rankin Scale (mRS) scores from patients as the primary outcome of the study.

At the end of the study period, findings showed an adjusted common OR of improvement of 1 point on the mRS scrore of 2.2 (95% CI, 1.2-4.1) favoring DTAS over DTCT (P = .009). Requena et al wrote, "the improvements in clinical outcomes shown in our study are substantial and are likely due to 2 major reasons: increasing the rate of EVT by avoiding overselection in treatment indication and reducing in-hospital workflow."

For the group using DTAS, flat-panel computed tomography (FPCT) was performed to exclude intracerebral hemorrhage or large established ischemic lesions that would contraindicate EVT. To confirm the presence of LVO, investigators obtained a diagnostic angiogram. Intravenous tissue plasminogen activator would be immediately initiated after FPCT if patients were indicated for LVO.

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Investigators also observed a significantly higher rate of EVT in the DTAS group (n = 74; 100%) compared with those in the DTCT group (n = 64; 87.7%)(all P = .002). On average, patients in the DTAS group experienced a median time from admission to arterial puncture of 18 minutes (interquartile range [IQR], 15-24 minutes) compared with 42 minutes (IQR, 35-51 minutes) in the DTCT group. Additionally, these patients also had a significantly shorter median door-to-reperfusion time (DTAS: 57 minutes [IQR, 43-77 minutes]; DTCT: 84 minutes [IQR, 63-117 minutes] P <.001).

Good clinical outcome, indicated by an mRS score of 2 or lower, was achieved in 43.6% of those in the DTAS group at 90 days compared with 27.8% of those in the DTCT group (P = .11). A pure intention-to-treat analysis including all patients showed an adjusted common OR of improvement of 1 point on mRS score of 1.98 (95% CI, 1.10-3.51) favoring DTAS (P = .02).

Between the DTAS group and DTCT control group, there were no significant differences in the rates of clinical deterioration (10.1% in the DTAS group vs 17.6% in the DTCT group; P = .15), rates of symptomatic hemorrhagic transformation (1.2% in the DTAS group vs 3.8% in the DTCT group; P = .40) or rates of severe procedural complications (8.1% in the DTAS group vs 2.7% in the DTCT group; P = .60).

Both groups had similar median time from arterial puncture to reperfusion (DTAS: 37 minutes [IQR, 23-60 minutes] vs DTCT: 39 minutes [IQR, 22-62 minutes]; P = .49). For directly admitted patients who received intravenous tissue plasminogen activator, the median door-to-needle time was similar between groups (DTAS: 20 minutes [IQR, 18-25 minutes] vs DTCT: 18 minutes [IQR, 16-38 minutes]; P = .80).

"To offer the clinical benefits of DTAS to the highest number of patients, the angiography suite and interventional team should be immediately available 24 hours a day, 7 days a week. Having a dedicated acute stroke angiography suite and a permanently available team would require organizational and staff efforts that would be justified in large-volume centers if our results are confirmed in a second randomized clinical trial," Requena et al concluded.

Requena M, Olive-Gadea M, Muchada, et al. Direct to angiography suite without stopping for computed tomography imaging for patients with acute ischemic stroke: a randomized clinical trial. JAMA Neurol. Published online August 2, 2021. doi: 10.1001/jamaneurol.2021.2385