Direct to angiography transfer improves outcomes in large vessel occlusion stroke

 Look at that tyranny of low expectations in full display: 'improves'. NOT RECOVERS! Hope they are OK with that shitworthy result when they are the 1 in 4 per WHO that has a stroke?

The only goal in stroke is always 100% recovery, pulling the clot out is only the first step, doing nothing after that is medical malpractice, allowing billions of neurons to die. I lost 5.4 billion neurons after I had tPA in 90 minutes. My doctors did nothing after that 90 minutes.

Direct to angiography transfer improves outcomes in large vessel occlusion stroke

Patients with large vessel occlusion stroke undergoing endovascular thrombectomy who were transferred directly to the angiography suite at admission had faster treatment and better functional outcomes during all hours and treatment windows.

“Many patients present initially to [non-endovascular thrombectomy (EVT)] centers and require transfer to EVT centers, resulting in significant delays during interfacility transfer,” Amrou Sarraj, MD, associate professor of vascular neurology in the department of neurology at the University of Texas McGovern Medical School, and colleagues wrote in JAMA Neurology. “Efforts to streamline arrivals of patients with [large vessel occlusion (LVT)] to EVT-capable centers continue to evolve, including prehospital triaging directly to EVT-capable centers and optimal methods for transporting patients to and from non-EVT to EVT centers. Meanwhile, delays may occur at EVT centers owing to processes and treatment protocols adopted by these hospitals.”

According to the researchers, it is possible to maximize EVT benefit by reducing the time from arrival to the EVT center into the angiography suite. In the current pooled retrospective cohort study, Sarraj and colleagues aimed to assess the functional and safety outcomes of a direct to angiography (DTA) treatment paradigm compared with repeated imaging in the various treatment windows and on-call hours compared with regular hours. They conducted the study at six comprehensive stroke centers in the U.S. and Europe among 1,140 adults aged 18 years or older (median age, 69 years; 53.4% men) with anterior circulation LVO who were transferred for EVT within 24 hours of their last-known time since being well between January 2014 and February 2020. A total of 327 individuals (28.7%) composed the DTA group and 813 individuals (71.3%) composed the repeated imaging group.

Repeated imaging before EVT compared with DTA served as the exposure. Functional independence according to a score of zero to two on the 90-day modified Rankin Scale served as the primary outcome. The researchers also compared rates of symptomatic intracerebral hemorrhage, mortality and time metrics between the DTA and repeated imaging groups.

Results showed greater use of IV alteplase among patients who underwent DTA (P = .002); otherwise, groups had similar results. Those in the DTA group had faster median time from EVT center arrival to groin puncture overall (34 minutes vs. 60 minutes; P < .001), as well as in regular and on-call hours. This group also exhibited higher 3-month functional independence overall (164 of 312 [52.6%] vs. 282 of 763 [37%]; adjusted OR [aOR], 1.85; 95% CI, 1.33-2.57) and during regular (77 of 143 [53.8%] vs. 118 of 292 [40.4%]; P = .008) and on-call hours (87 of 169 [51.5%] vs. 164 of 471 [34.8%]; P < .001), with results not affected by time window, as well as lower 3-month mortality (53 of 312 [17%] vs. 186 of 763 [24.4%]; P = .008).

The researchers reported an association between a 10-minute increase in EVT-center arrival to groin puncture in the repeated imaging group and a 5% reduction in the likelihood of functional independence (aOR, 0.95 [95% CI, 0.91-0.99]). Interfacility transfer times of greater than 3 hours in the DTA group, but not in the repeated imaging group, correlated with a decrease in the rates of modified Ranking Scale scores of zero to two.

“The potential efficacy and safety of the DTA approach decreased as transfer time increased,” Sarraj and colleagues wrote. “Therefore, repeated imaging may be reasonable in patients with prolonged transfer times. Optimizing EVT workflow in transferred patients may result in faster, safe reperfusion with higher chances of achieving functional independence.”

In a related editorial, Bruce C. V. Campbell, MBBS(Hons), BMedSc, PhD, of the department of neurology at the Royal Melbourne Hospital’s Melbourne Brain Center in Australia, noted the decreasing need for obtaining a repeated CT scan among this patient population.

“The suspicion that reperfusion may have obviated the need for EVT could be assessed using a standard diagnostic angiogram or, if that were believed to be unjustifiably invasive, an intravenous digital subtraction angiography,” Campbell wrote. “There are also increasingly sophisticated flat-panel perfusion imaging solutions. The reasons to obtain a repeated CT scan after transfer for EVT are therefore diminishing.”

Reference:

Campbell BCV. JAMA Neurology. 2021;doi:10.1001/jamaneurol.2021.1369.