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Original Investigation
August 2, 2021

Direct to Angiography Suite Without Stopping for Computed Tomography Imaging for Patients With Acute Stroke: A Randomized Clinical Trial

Author Affiliations
  • 1Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
  • 2Grup de Recerca en Ictus, Vall d’Hebron Insitut de Recerca, Barcelona, Spain
  • 3Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
JAMA Neurol. 2021;78(9):1099-1107. doi:10.1001/jamaneurol.2021.2385
Key Points

Question  Does direct transfer to angiography suite (DTAS) improve functional outcomes compared with usual imaging workflow for patients within 6 hours of onset of symptoms for large vessel occlusion ischemic stroke?

Findings  In this randomized clinical trial including 174 patients with suspected large vessel occlusion stroke on admission, large vessel occlusion was confirmed in 147. The use of a DTAS protocol improved in-hospital workflow times, increased the rate of endovascular treatment, and decreased the severity of disability across the range of modified Rankin Scale scores.

Meaning  For patients with acute ischemic stroke due to large vessel occlusion within 6 hours of symptom onset, compared with usual imaging, the use of DTAS led to safe patient triage for acute stroke endovascular treatment, decreased workflow times, and improved outcomes; ongoing international, multicenter clinical trials are exploring the generalizability of these results.

Abstract

Importance  Direct transfer to angiography suite (DTAS) for patients with suspected large vessel occlusion (LVO) stroke has been described as an effective and safe measure to reduce workflow time in endovascular treatment (EVT). However, it is unknown whether DTAS improves long-term functional outcomes.

Objective  To explore the effect of DTAS on clinical outcomes among patients with LVO stroke in a randomized clinical trial.

Design, Setting, and Participants  The study was an investigator-initiated, single-center, evaluator-blinded randomized clinical trial. Of 466 consecutive patients with acute stroke screened, 174 with suspected LVO acute stroke within 6 hours of symptom onset were included. Enrollment took place from September 2018 to November 2020 and was stopped after a preplanned interim analysis. Final follow-up was in February 2021.

Interventions  Patients were randomly assigned (1:1) to follow either DTAS (89 patients) or conventional workflow (85 patients received direct transfer to computed tomographic imaging, with usual imaging performed and EVT indication decided) to assess the indication of EVT. Patients were stratified according to their having been transferred from a primary center vs having a direct admission.

Main Outcomes and Measures  The primary outcome was a shift analysis assessing the distribution of the 90-day 7-category (from 0 [no symptoms] to 6 [death]) modified Rankin Scale (mRS) score among patients with LVO whether or not they received EVT (modified intention-to-treat population) assessed by blinded external evaluators. Secondary outcomes included rate of EVT and door-to-arterial puncture time. Safety outcomes included 90-day mortality and rates of symptomatic intracranial hemorrhage.

Results  In total, 174 patients were included, with a mean (SD) age of 73.4 (12.6) years (range, 19-95 years), and 78 patients (44.8%) were women. Their mean (SD) onset-to-door time was 228.0 (117.9) minutes, and their median admission National Institutes of Health Stroke Scale score was 18 (interquartile range [IQR], 14-21). In the modified intention-to-treat population, EVT was performed for all 74 patients in the DTAS group and for 64 patients (87.7%) in the conventional workflow group (P = .002). The DTAS protocol decreased the median door–to–arterial puncture time (18 minutes [IQR, 15-24 minutes] vs 42 minutes [IQR, 35-51 minutes]; P < .001) and door-to-reperfusion time (57 minutes [IQR, 43-77 minutes] vs 84 minutes [IQR, 63-117 minutes]; P < .001). The DTAS protocol decreased the severity of disability across the range of the mRS (adjusted common odds ratio, 2.2; 95% CI, 1.2-4.1; P = .009). Safety variables were comparable between groups.

Conclusions and Relevance  For patients with LVO admitted within 6 hours after symptom onset, this randomized clinical trial found that, compared with conventional workflow, the use of DTAS increased the odds of patients undergoing EVT, decreased hospital workflow time, and improved clinical outcome.

Trial Registration  ClinicalTrials.gov Identifier: NCT04001738

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