Direct to Angiography vs Repeated Imaging Approaches in Transferred Patients Undergoing Endovascular Thrombectomy

Abstract

IMPORTANCEA direct to angiography (DTA) treatment paradigm without repeated imaging for transferred patients with large vessel occlusion (LVO) may reduce time to endovascular thrombectomy (EVT). Whether DTA is safe and associated with better outcomes in the late (>6 hours) window is unknown. Also, DTA feasibility and effectiveness in reducing time to EVT during on-call vs regular-work hours and the association of interfacility transfer times with DTA outcomes have not been established. OBJECTIVE To evaluate the functional and safety outcomes of DTA vs repeated imaging in the different treatment windows and on-call hours vs regular hours. DESIGN, SETTING, AND PARTICIPANTSThis pooled retrospective cohort study at 6 US and European comprehensive stroke centers enrolled adults (aged Ն18 years) with anterior circulation LVO (internal cerebral artery or middle cerebral artery subdivisions M1/M2) and transferred for EVT within 24 hours of the last-known-well time from January 1, 2014, to February 29, 2020.EXPOSURES Repeated imaging (computed tomography with or without computed tomographic angiography or computed tomography perfusion) before EVT vs DTA.MAIN OUTCOMES AND MEASURES Functional independence (90-day modified Rankin Scale score, 0-2) was the primary outcome. Symptomatic intracerebral hemorrhage, mortality, and time metrics were also compared between the DTA and repeated imaging groups.

Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient‐Level Analysis from the EXTEND‐IA Trials, INSPIRE, and SELECT Studies

“…EVT has become the standard of care for selected patients with ICA/M1 occlusions presenting with moderate to severe strokes, 10,34 with efforts ongoing to optimize EVT outcomes with emphasis on utility of i.v. thrombolysis prior to EVT 35 and faster delivery of EVT using the direct‐to‐angio approach 36,37 . Other populations, including milder strokes 38 and distal occlusions, 8,9 are still considered without definitive evidence in favor of EVT.…”

Should Primary Stroke Centers Perform Advanced Imaging?

“…Finally, advances in flat-panel CT allows for the potential for a direct-to-neuro-angiosuite approach which has been and could be implemented more widely, if the costs of imaging patients with stroke presentations not due to LVO can be justified. 44 Using criteria from positive treatment trials, advanced imaging is not recommended for early time windows but is recommended for later time windows. 29,31,32,45,46 For now, we favor re-emphasizing 2 ideas: (1) simple brain and neurovascular imaging (non-contrast CT and CTA, or MR with MRA) is the minimum standard that has broad utility for all stroke types and; (2) reperfusion treatment for acute ischemic stroke is one of the most powerful treatments in all of medicine and it is highly time-dependent.…”

Evaluation of time-resolved whole brain flat panel detector perfusion imaging using RAPID ANGIO in patients with acute stroke: comparison with CT perfusion imaging

“…Our results also support the establishment and further evaluation of direct-to-angio approaches in everyday clinical practice, as FD-CT can produce FD-CTP as well as soft tissue brain imaging and multiphase FD-CT angiography, similar to conventional CT ‘stroke protocol’ sequences. This, in turn, can speed up in-hospital workflows and may ultimately increase the chances of good clinical outcome 6–11. Of paramount importance to the success of the direct-to-angio workflow is the familiarity of the technical and nursing staff as well as the diagnostic neuroradiologists with the practice.…”

“…In contrast to conventional CT perfusion (CTP), flat panel detector CT can be acquired directly in the angiosuite and can generate angiograms (FD-CTA) and perfusion maps (FD-CTP) directly on the intervention-table. This allows direct transport of patients to the angiosuite (‘direct to the angio’ workflow), reduces time to puncture, and increases the likelihood of clinical improvement 6–11. It is an essential precondition that FD-CTP provides comparable data to that obtained from validated conventional CTP.…”