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Endovascular treatment (EVT) has become the standard treatment for acute ischemic stroke caused by large vessel occlusion (LVO), and multiple trials have verified its efficacy
.
The time from onset to reperfusion is a powerful indicator of clinical prognosis, and it is also the most relevant changeable factor for the final reperfusion status
Although most of the time consumed by the work process corresponds to the time consumed before the hospital, it is still necessary to constantly re-evaluate the process after admission to minimize the time from arrival at the hospital to recanalization
.
The time from admission to arterial puncture (door-to-puncture [door-to-puncture, DTP]) in the emergency room is a widely used performance indicator to evaluate the effectiveness of the workflow in the hospital, and it has been shown to be related to clinical outcomes
Although people are working to shorten the DTP time, published registration and clinical trials have shown that it is difficult to reduce the DTP time to less than 60 minutes (a goal agreed upon by experts)
.
In order to optimize the workflow, a new paradigm has been proposed for the acute treatment of severe stroke patients: direct transfer to angiography suite (DTAS)
.
Several centers mimic ST-segment elevation myocardial infarctions and devise strategies to bypass the emergency room and traditional imaging examinations
Regardless of the program details, DTAS has always been proven to be effective in reducing DTP time to 16 minutes without security issues
.
In non-randomized controlled trials, the effects of DTAS on long-term functional outcomes are different, and the long-term efficacy is unclear
In September 2021, Marc Ribo from Spain and others announced the results of the ANGIOCAT trial on JAMA Neurology, aiming to explore the efficacy of DTAS on LVO patients
.
The study is a single-center, evaluator-blinded randomized clinical trial initiated by the investigator
.
Among the 466 acute stroke patients who were continuously screened, 174 patients with suspected LVO within 6 hours of onset and with an acute stroke of NIHSS>10 were included in this study
The included patients were randomly assigned (1:1) to the DTAS group (89 patients) or the routine workflow group (85 patients were directly transferred to the CT room, undergoing routine imaging examinations and judging the indications of EVT) to evaluate the EVT Indications
.
The patients were stratified according to the transfer and direct admission of patients from the primary center
For patients in the DTAS group, FPCT was performed to rule out ICH or large-area ischemic lesions (which may be a contraindication to EVT)
.
Then perform diagnostic angiography to confirm the presence of LVO
For the routine workflow group (send the patient directly to the CT room), follow the routine neuroimaging protocol, including CT and CTA
.
In addition, if the treating physician deems it necessary, CTP can be performed
The main outcome was a shift analysis that assessed the distribution of mRS scores for 7 items (from 0 [asymptomatic] to 6 [death]) in patients with LVO over 90 days
.
A total of 174 patients were enrolled, with a mean (SD) age of 73.
4 (12.
6) years (range 19-95 years), and 78 patients (44.
8%) were women
.
The average onset time was 228.
0 (117.
9) minutes, and the median admission NIHSS score was 18 (IQR, 14-21)
.
In the modified ITT population, all 74 patients in the DTAS group and 64 patients (87.
7%) in the traditional workflow group received EVT treatment (P=0.
002)
.
The DTAS protocol shortened the portal-to-artery puncture time (median 18 minutes [IQR, 15-24 minutes] vs 42 minutes [IQR, 35-51 minutes]; P<0.
001) and door-to-reperfusion time (57 minutes [IQR] , 43-77 minutes] vs 84 minutes [IQR, 63-117 minutes]; P<0.
001)
.
DTAS reduced the severity of disability (mRS) (adjusted total cor, 2.
2; 95% CI, 1.
2-4.
1; P=0.
009)
.
The safety indicators between the two groups were comparable
.
In the end, the author believes that for LVO patients admitted to the hospital within 6 hours of onset, compared with the traditional workflow (directly sent to the CT room), DTAS increases the patient's chance of receiving EVT, shortens the hospital workflow time, and improves clinical outcomes
.
Original source:
Original source:Manuel Requena, et al.
Direct to Angiography Suite Without Stopping for Computed Tomography Imaging for Patients With Acute Stroke: A Randomized Clinical Trial .
JAMA Neurol.
2021 Sep 1; 78(9): 1099-1107.
doi: 10.
1001/jamaneurol.
2021.
2385 .
