Direct to angiography transfer improves outcomes in large vessel occlusion stroke
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Patients with large vessel occlusion stroke undergoing endovascular thrombectomy who were transferred directly to the angiography suite at admission had faster treatment and better functional outcomes during all hours and treatment windows.
“The direct to angiography approach is known to hasten the time to procedure, but this approach's efficacy and safety in the late treatment window (beyond 6 hours from last known time since being well), as well as its applicability during on-call hours and with prolonged transfer times, was not explored before,” Amrou Sarraj, MD, associate professor of vascular neurology in the department of neurology at the University of Texas McGovern Medical School, told Healio Neurology. “With this study, we aimed to explore whether this approach is associated with better clinical outcomes and whether it can be safely extended to patients presenting beyond 6 hours from their stroke ictus/last known time since being well and outside of regular work hours. We also aimed to assess the transfer duration for which the benefits of the approach are maintained.”
According to the researchers, it is possible to maximize endovascular thrombectomy (EVT) benefit by reducing the time from arrival to the EVT center into the angiography suite. Sarraj and colleagues conducted the current pooled retrospective cohort study, which was published in JAMA Neurology, at six comprehensive stroke centers in the U.S. and Europe among 1,140 adults aged 18 years or older (median age, 69 years; 53.4% men) with anterior circulation large vessel occlusion who were transferred for EVT within 24 hours of their last-known time since being well between January 2014 and February 2020. A total of 327 individuals (28.7%) composed the DTA group and 813 individuals (71.3%) composed the repeated imaging group.
Repeated imaging before EVT compared with DTA served as the exposure. Functional independence according to a score of zero to two on the 90-day modified Rankin Scale served as the primary outcome. The researchers also compared rates of symptomatic intracerebral hemorrhage, mortality and time metrics between the DTA and repeated imaging groups.
Results showed greater use of IV alteplase among patients who underwent DTA (P = .002); otherwise, groups had similar results. Those in the DTA group had faster median time from EVT center arrival to groin puncture overall (34 minutes vs. 60 minutes; P < .001), as well as in regular and on-call hours. This group also exhibited higher 3-month functional independence overall (164 of 312 [52.6%] vs. 282 of 763 [37%]; adjusted OR [aOR], 1.85; 95% CI, 1.33-2.57) and during regular (77 of 143 [53.8%] vs. 118 of 292 [40.4%]; P = .008) and on-call hours (87 of 169 [51.5%] vs. 164 of 471 [34.8%]; P < .001), with results not affected by time window, as well as lower 3-month mortality (53 of 312 [17%] vs. 186 of 763 [24.4%]; P = .008).
The researchers reported an association between a 10-minute increase in EVT-center arrival to groin puncture in the repeated imaging group and a 5% reduction in the likelihood of functional independence (aOR, 0.95 [95% CI, 0.91-0.99]). Interfacility transfer times of greater than 3 hours in the DTA group, but not in the repeated imaging group, correlated with a decrease in the rates of modified Ranking Scale scores of zero to two.
“These results suggest potential for wider applicability of the direct to angiography approach and may guide the patient triage algorithms until results from ongoing randomized trials become available,” Sarraj said.
In a related editorial, Bruce C. V. Campbell, MBBS(Hons), BMedSc, PhD, of the department of neurology at the Royal Melbourne Hospital’s Melbourne Brain Center in Australia, noted the decreasing need for obtaining a repeated CT scan among this patient population.
“The suspicion that reperfusion may have obviated the need for EVT could be assessed using a standard diagnostic angiogram or, if that were believed to be unjustifiably invasive, an intravenous digital subtraction angiography,” Campbell wrote. “There are also increasingly sophisticated flat-panel perfusion imaging solutions. The reasons to obtain a repeated CT scan after transfer for EVT are therefore diminishing.”