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

Educational Objective
To evaluate the functional and safety outcomes of direct to angiography treatment paradigm vs repeated imaging in the different acute stroke treatment windows and on-call hours vs regular hours.
1 Credit CME
Key Points

Question  What is the association of direct to angiography (DTA) vs repeated imaging treatment paradigms with stroke management workflow and outcomes in patients transferred to endovascular thrombectomy centers?

Findings  In a multicenter cohort of 1140 patients with large vessel occlusion, DTA was associated with faster times from arrival to groin puncture (34 vs 60 minutes) and better functional and safety outcomes, overall and in both early and late windows. Furthermore, no meaningful difference in workflow parameters or functional and safety outcomes were found in patients arriving during regular vs on-call hours.

Meaning  These findings suggest that DTA may be associated with faster treatment and better functional outcomes during all hours and treatment windows; repeated imaging may be reasonable with prolonged transfer times.

Abstract

Importance  A 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 Participants  This pooled retrospective cohort study at 6 US and European comprehensive stroke centers enrolled adults (aged ≥18 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.

Results  A total of 1140 patients with LVO received EVT after transfer, including 327 (28.7%) in the DTA group and 813 (71.3%) in the repeated imaging group. The median age was 69 (interquartile range [IQR], 59-78) years; 529 were female (46.4%) and 609 (53.4%) were male. Patients undergoing DTA had greater use of intravenous alteplase (200 of 327 [61.2%] vs 412 of 808 [51.0%]; P = .002), but otherwise groups were similar. Median time from EVT center arrival to groin puncture was faster with DTA (34 [IQR, 20-62] vs 60 [IQR, 37-95] minutes; P < .001), overall and in both regular and on-call hours. Three-month functional independence was higher with DTA overall (164 of 312 [52.6%] vs 282 of 763 [37.0%]; adjusted odds ratio [aOR], 1.85 [95% CI, 1.33-2.57]; P < .001) and during regular (77 of 143 [53.8%] vs 118 of 292 [40.4%]; P = .008) and on-call (87 of 169 [51.5%] vs 164 of 471 [34.8%]; P < .001) hours. The results did not vary by time window (0-6 vs >6 to 24 hours; P = .88 for interaction). Three-month mortality was lower with DTA (53 of 312 [17.0%] vs 186 of 763 [24.4%]; P = .008). A 10-minute increase in EVT-center arrival to groin puncture in the repeated imaging group correlated with 5% reduction in the functional independence odds (aOR, 0.95 [95% CI, 0.91-0.99]; P = .01). The rates of modified Rankin Scale score of 0 to 2 decreased with interfacility transfer times of greater than 3 hours in the DTA group (96 of 161 [59.6%] vs 15 of 42 [35.7%]; P = .006), but not in the repeated imaging group (75 of 208 [36.1%] vs 71 of 192 [37.0%]; P = .85).

Conclusions and Relevance  The DTA approach may be associated with faster treatment and better functional outcomes during all hours and treatment windows, and repeated imaging may be reasonable with prolonged transfer times. Optimal EVT workflow in transfers may be associated with faster, safe reperfusion with improved outcomes.

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Article Information

Accepted for Publication: April 2, 2021.

Published Online: June 14, 2021. doi:10.1001/jamaneurol.2021.1707

Corresponding Author: Amrou Sarraj, MD, Department of Neurology, The University of Texas McGovern Medical School, 6431 Fannin St, Medical School Bldg 7.044, Houston, TX 77030 (amrou.sarraj@uth.tmc.edu).

Author Contributions: Dr Sarraj had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Sarraj, Kamal, Cai, Alenzi, Day.

Acquisition, analysis, or interpretation of data: Sarraj, Goyal, Chen, Grotta, Blackburn, Requena, Kamal, Abraham, Elijovich, Dannenbaum, Mir, Tekle, Pujara, Shaker, Maali, Radaideh, Reddy, Parsha, Alenzi, Abdulrazzak, Greco, Hoit, Martin-Schild, Song, Sitton, Tsivgoulis, Alexandrov, Arthur, Day, Hassan, Ribo.

Drafting of the manuscript: Sarraj, Blackburn, Kamal, Alenzi, Greco, Martin-Schild.

Critical revision of the manuscript for important intellectual content: Goyal, Chen, Grotta, Requena, Kamal, Abraham, Elijovich, Dannenbaum, Mir, Tekle, Pujara, Shaker, Cai, Maali, Radaideh, Reddy, Parsha, Alenzi, Abdulrazzak, Hoit, Martin-Schild, Song, Sitton, Tsivgoulis, Alexandrov, Arthur, Day, Hassan, Ribo. Statistical analysis: Pujara, Parsha, Alenzi.

Administrative, technical, or material support: Sarraj, Chen, Abraham, Mir, Tekle, Parsha, Arthur, Day.

Supervision: Sarraj, Blackburn, Elijovich, Dannenbaum, Cai, Reddy, Abdulrazzak, Greco, Hassan.

Conflict of Interest Disclosures: Dr Sarraj reported being the principal investigator for the SELECT and SELECT 2 trials, funded by The University of Texas McGovern Medical School through grants from Stryker and serving as a member of the speaker bureau and advisory board for Stryker. Dr Grotta reported consulting for Frazer, Ltd, outside of the submitted work. Dr Abraham reported consulting and lecturing for Stryker outside the submitted work. Dr Elijovich reported consulting for MicroVention, Inc, Balt, Cerenovus, Scientia Ltd, and Viz.ai, Inc, outside the submitted work. Dr Hoit reports personal fees from Medtronic, MicroVention, Inc, and Penumbra, Inc, and grants from Siemens AG outside the submitted work and stock ownership in Cerebrotech Medical Systems, Inc. Dr Arthur reported personal fees from Balt, Johnson & Johnson Services, Inc, Medtronic, MicroVention, Inc, Penumbra, Inc, Scientia Ltd, Siemens, and Stryker outside the submitted work. Dr Hassan reported consulting and speaker fees from Medtronic, Stryker, MicroVention, Inc, Cerenovus, Penumbra, Inc, Balt, Viz.ai, Inc, GE Healthcare, Genentech, Inc, Proximie Limited, and NovaSigna during the conduct of the study. Dr Ribo reported nonfinancial support from Philips NV as the co−principal investigator of the WeTRUST study during the conduct of the study; being cofounder of Anaconda BioMed; ownership in less than 1% of Methinks; consulting for Medtronic, Cerenovus, and Apta Targets; and lecturing for Stryker outside the submitted work. No other disclosures were reported.

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