Background A direct admission to angiosuite (DAA) strategy in transfer patients with large vessel occlusion (LVO) is considered to decrease stroke time metrics and benefit functional outcomes. However, feasibility and effectiveness of DAA have not been established in rural settings. Fast door‐to‐reperfusion times and high‐quality reperfusion are key predictors of outcome in patients with LVO. To reduce treatment times in transferred patients with suspected LVO, we initiated a DAA triage protocol in 2017. Methods We conducted a nested interventional cohort study of adult patients with anterior LVO from January 2015 to August 2019 transferred to our center from an outside hospital. Patients were divided into DAA for mechanical thrombectomy (MT) and patients directly admitted to the emergency department (DAED). DAED was subdivided into patients undergoing MT and patients who did not. Workflow times and clinical and radiographic outcomes were analyzed. Results Forty‐five DAA patients and 241 DAED patients (DAED patients undergoing MT=134 patients and DAED patients not undergoing MT=107 patients) were identified. DAA patients had significantly shorter median door‐to‐arterial‐puncture times (15 versus 71 minutes) and puncture‐to‐recanalization times (27 versus 42.5 minutes). At discharge, DAA patients had a significant decrease in median admission National Institutes of Health Stroke Scale (NIHSS) score (ΔNIHSS score 10 versus 4; P =0.02), and higher rate of dramatic clinical improvement (ΔNIHSS score >10; 48.9% versus 23.5%; P <0.001). Both groups had comparable rates of functional independence (modified Rankin Scale; mRS 0–2; 36.1% versus 29.2%; P =0.52), and mortality at 90 days ( P =0.63). When mortality was excluded, DAA patients showed a significant proportion of excellent functional outcome (mRS 0–1; 50% versus 26%) before ( P =0.04) and after ( P =0.02) adjusting for confounders. Conclusions DAA is feasible and can safely reduce reperfusion times in transferred patients with LVO to MT centers in a rural setting. Reducing workflow times may impact the functional recovery of patients undergoing MT.

BackgroundThere is limited evidence on the indication and role of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs). The aim of this systematic review and meta-analysis was to evaluate all the evidence available on the efficacy and safety of MT techniques (stent retriever, aspiration) in primary and secondary DMVOs.MethodsFive databases were searched from inception to January 2023 for studies of MT in primary and secondary DMVOs. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0–2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Prespecified subgroup meta-analyses according to the specific MT technique and to the vascular territory (distal M2-M5, A2-A5, P2-P5) were also performed.ResultsA total of 29 studies with 1262 patients were included. For primary DMVOs (n=971 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 84% (95% confidence interval (CI) 76 to 90%), 64% (95% CI 54 to 72%), 12% (95% CI 8 to 18%), and 6% (95% CI 4 to 10%), respectively. For secondary DMVOs (n=291 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 82% (95% CI 73 to 88%), 54% (95% CI 39 to 69%), 11% (95% CI 5 to 20%), and 3% (95% CI 1 to 9%), respectively. Subgroup analyses by MT technique and by vascular territory showed no differences in primary and secondary DMVOs.ConclusionOur findings suggest that MT using aspiration or stent retriever techniques appears to be effective and safe in primary and secondary DMVOs. However, given the level of evidence of our results, further confirmation in well-designed randomized controlled trials is needed.

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BackgroundReducing stroke workflow times when performing endovascular thrombectomy is associated with improvement in clinical outcomes. We compared outcomes among large vessel occlusion (LVO) stroke patients following the direct to angiosuite (DTAS) strategy versus standard workflow (SW) when undergoing endovascular therapy.MethodsWe conducted a systematic review and meta-analysis to compare rates of functional outcomes, reperfusion, symptomatic intracranial hemorrhage (sICH) and stroke workflow metrics. We included observational studies and clinical trials that compared the DTAS strategy versus SW, and at least one outcome of interest was assessed. Clinical, methodological and statistical heterogeneity were measured, and a random-effects model was used.Results12 studies were included in the systematic review and 8 in the meta-analysis (n=2890). The DTAS strategy was associated with significant higher odds of good functional outcome at 90 days (47.3% vs 34.9%; OR 1.58, 95% CI 1.16 to 2.14) and a significant average reduction of door-to-puncture (mean differences (MD) −35.09, 95% CI −49.76 to −20.41) and door-to-reperfusion times (MD –32.88, 95% CI –50.75 to –15.01). We found no differences in sICH (OR 0.80, 95% CI 0.53 to 1.20), mortality (OR 1.00, 95% CI 0.60 to 1.67) or successful reperfusion rates (OR 1.37, 95% CI 0.82 to 2.29). Moreover, the DTAS strategy was associated with greater odds of dramatic clinical improvement at 24 hours (OR 1.79, 95% CI 1.15 to 2.79).ConclusionPatients undergoing the DTAS strategy had a significant reduction in door-to-puncture and door-to-reperfusion times. This resulted in an increased rate of early neurological and 90-day functional recovery without compromising safety in LVO patients undergoing endovascular thrombectomy.

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