Bringing stroke patients straight to the angiography suite of a hospital capable of endovascular therapy reduced hospital delays and improved care for people with suspected large vessel occlusions (LVOs) who were admitted within 6 hours of symptom onset, a randomized trial indicated.
Following the mantra “time is brain,” the strategy of skipping the emergency department and usual CT scanner brought down time from door to arterial puncture to a median 18 minutes from 42 minutes with standard management (P<0.001); similarly, time from door to reperfusion fell to 57 minutes from 84 minutes (P<0.001).
Additionally, all of the roughly 85% of people with confirmed LVOs received endovascular therapy after direct transfer to the angiography suite versus 88% with usual care in the ANGIOCAT trial, reported Manuel Requena, MD, PhD, of Vall d’Hebron University Hospital in Barcelona, Spain, during a late-breaking scientific session at the American Stroke Association International Stroke Conference.
Ultimately, going straight to the angiography suite significantly improved outcomes for stroke patients as shown by the improved distribution of modified Rankin Scale scores at 90 days (adjusted common OR 2.2, 95% CI 1.2-4.1). Rates of mortality by then also numerically favored this strategy (20.2% vs 32.9%, P=0.07).
Thus, the trial is likely to change practice given its “impressive” results, according to Pooja Khatri, MD, of the University of Cincinnati, who was not involved with ANGIOCAT. “While not feasible everywhere, such as low population density or low-resourced areas, it will raise the bar for what we consider fast endovascular treatment overall.”
“Already, we know that sites need well-coordinated systems of care that do prehospital notification and transfer potential [endovascular therapy] candidates quickly. This strategy would also require that neurointerventionalists and other stroke clinicians be readily available onsite to receive the patient. The impact on clinical outcomes suggest that this is a worthy goal,” she said.
“It will require significant collaborative efforts from the first responders, teleneurology, emergency services, stroke physicians, and interventionalists to successfully implement the strategy on a wider scale. Furthermore, we still need to learn some more details on how often this was feasible. The feasibility of the DTAS approach over the weekend and off hours is vital for a wide implementation and consistent workflow,” commented Amrou Sarraj, MD, of UTHealth and McGovern Medical School in Houston.
ANGIOCAT participants were 174 stroke patients at Requena’s institution beginning in October 2018. Eligibility criteria included a prehospital RACE score over 4, NIH Stroke Scale (NIHSS) score above 10, and admission within 6 hours of symptom onset.
Participants were randomized to direct transfer to angiography suite or standard management. The two groups shared similar baseline characteristics, with a mean age of 73, and with men accounting for over half of participants. Median NIHSS score was roughly 18.
Complications from endovascular treatment reached 8.1% and 2.7% of direct transfer and standard management groups, respectively, with no statistical difference between arms.
The results are impressive but not every stroke patient needs an angiogram, and it might not be cost effective even in the enriched population of people likely to have LVOs in this trial, cautioned Lee Schwamm, MD, of Mass General Hospital and Harvard Medical School.
It remains to be seen if some groups, and not others, saw gains from going straight to the angiography suite, he said, pointing out that two-thirds of patients in ANGIOCAT were transfers from another hospital who could have had LVO already confirmed on imaging, and the rest of the people who showed up at the front door.
An analysis of whether both groups benefited from skipping the CT scanner would be important, Schwamm said in an interview.
Requena noted that the study’s results may not be applicable to centers with less angiography expertise.
Many stroke transfers in the U.S. also result in patients arriving beyond 6 hours, so an important question is whether those transfers should be taken directly to the angio suite or if imaging should be repeated to assess stroke evolution during transfer, according to Sarraj.
“A potential risk of this approach was that patients with ischemic stroke mimics could have received suboptimal initial management in the angio suite, such as intracerebral hemorrhage reversal agents, treatment of status epilepticus, or even possibly slow administration of alteplase,” Khatri said.
This appeared to not be the case in the small trial, she said, or at least the clinical impact of faster endovascular therapy washed out any of these risks.
“Our study is the first clinical trial that shows the superiority of direct transfer to an angiography suite,” Requena said in a press release. “Our findings were close to what we expected, and we were surprised that they occurred so early in the study. We trust that they will be confirmed in ongoing, multicenter, international trials.”
Further validation of direct transfer to the angiography suite may come from the ongoing WE-TRUST trial being conducted in Europe, North America, and South America.
The study was funded by the Vall d’Hebron Research Institute.
Requena disclosed no relevant relationships with industry. Co-authors disclosed relevant relationships with Anaconda Biomed, Methinks AI, Medtronic, Stryker, Johnson & Johnson, AptaTargets, Sanofi, Philips, Balt, and Perflow.
Sarraj disclosed relevant relationships with, and/or support from, Stryker Neurovascular and Stryker.