Direct to Angiography Suite Improves Functional Outcomes in LVO Stroke Shortly After Symptom Onset

The direct transfer to angiography suite (DTAS) compared with direct transfer to computed tomography (DTCT) protocol is safe and leads to improved clinical outcomes in patients with acute ischemic stroke caused by large vessel occlusion (LVO) hospitalized within 6 hours of symptom onset, according to study results published in JAMA Neurology.

Endovascular treatment is the standard care among patients with acute ischemic stroke due to LVO. The time between symptom onset and reperfusion is critical in clinical outcomes in patients with LVO stroke. Therefore, strategies to decrease in-hospital workflow times are important in improving outcomes of functional independence.

Researchers conducted a prospective, randomized clinical trial (ANGIOCAT; ClinicalTrials.gov Identifier: NCT04001738) to investigate whether patients with clinically suspected LVO on hospital admission (National Institutes of Health [NIH] Stroke Scale [NIHSS] score >10) after a DTAS workflow have better long-term clinical outcomes vs patients who have a conventional neuroimaging in-hospital workflow.

The modified Rankin Scale (mRS) score at 90 days for patients with confirmed LVO (modified intention-to-treat [mITT] population) was the primary study outcome. Secondary efficacy outcomes included time from hospital admission to arterial puncture, rate of dramatic early recovery, rate of mRS score of 2 or lower at 90 days, and endovascular treatment rate of patients with LVO. Safety outcomes included rates of neurologic deterioration and complications, as well as 90-day mortality.

A total of 174 patients (mean age, 73.4±12.6 years; 44.8% women) were enrolled in the study (safety analysis population: 89 [51.1%] in the DTAS group; 85 [48.9%] in the DTCT group). Among the cohort, 147 patients (84.5%) presented with LVO (mITT population: 74 [50.3%] in the DTAS group; mean age, 71.8±13.1 years; 51.4% men; 73 [49.7%] in the DTCT group; mean age, 75.6±12.3 years; 56.2% women).

Participants had a mean onset-to-door time of 228.0±117.9 minutes and a median NIHSS score of 18 (interquartile range [IQR], 14-21) at admission.

The primary outcome analysis yielded an adjusted common odds ratio (OR) of a 1-point improvement in mRS score of 2.2 (95% CI, 1.2-4.1) in favor of the participants who received DTAS (P =.009). In the mITT cohort, the rate of endovascular treatment was significantly higher in the DTAS group compared with the DTCT group (74 [100%] vs 64 [87.7%], respectively; P =.002).

Regarding in-hospital treatment delays, patients who received DTAS vs DTCT had a significantly shorter median time from admission to arterial puncture (18 minutes [IQR, 15-24 minutes] vs 42 minutes [IQR, 35-51 minutes], respectively; P <.001), as well as a shorter median door-to-reperfusion time (57 minutes [IQR, 43-77 minutes] vs 84 minutes [IQR, 63-117 minutes], respectively; P <.001).

No significant differences were observed between the DTAS and the DTCT group regarding rates of clinical deterioration (10.1% and 17.6%, respectively; P =.15), rates of symptomatic hemorrhagic transformation (1.2% and 3.8%, respectively; P =.40), or rates of severe procedural complications (8.1% and 2.7%, respectively; P =.60).

The study had several limitations. The ANGIOCAT trial was conducted at a single center that typically performed DTAS protocols, and external data monitoring was not conducted except by the data safety monitoring board. In addition, early termination of the trial made it unpowered to detect differences between groups regarding safety variables, and an interim analysis may have overestimated the real treatment effect.

“The DTAS protocol decreased in-hospital delays, achieving shorter times from hospital admission to treatment onset and to reperfusion, which were associated with a significant shift toward better outcomes across the spectrum of disability,” the researchers concluded.

Disclosure: Some of the study authors declared affiliations with pharmaceutical companies. Please see the original reference for a full list of authors’ disclosures.

Reference

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