Speeding stroke care with direct angio improves functional outcome

Getting patients with suspected large-vessel occlusion (LVO) stroke to undergo immediate angiography instead of the standard CT scan speeds up time stroke treatment and improves 90-day functional outcomes, according to the ANGIOCAT study presented at the ISC 2021 Meeting.

“[These findings] reflect the growing recognition of the importance of speed in the care of stroke patients. As we all like to say, time is brain,” said AHA President Dr Mitchell Elkind of New York-Presbyterian Hospital, New York, New York, US.

“If we can shorten time to treatment using rapid evaluation and imaging protocols, this will help save brain,” he added.

At 90 days post-stroke, patients who received immediate angiography were more likely to achieve at least a 1-point improvement on the Modified Rankin Scale (mRS) functional outcome scale (adjusted odds ratio [OR], 2.2, 95 percent confidence interval [CI], 1.2–4.1). [ISC 2021, abstract LB1]

“Stroke patients transferred directly to an angiography suite were less likely to be dependent for assistance with daily activities compared to the stroke patients who received the current standard of care [of] CT scan,” said presenting author Dr Manuel Requena of Vall d'Hebron Hospital, Barcelona, Spain. “More frequent and more rapid treatment can help improve outcomes for our stroke patients.”

Importantly, direct transfer to angiography suite (DTAS) improved the rate of endovascular therapy (EVT) without significant differences in safety outcomes. Although procedural complications were numerically higher among EVT-treated patients in the DTAS arm vs the CT scan arm (8.1 percent vs 2.7 percent; p=0.6), 90-day mortality also trended lower in the DTAS arm (20.2 percent vs 32.9 percent; p=0.07).

There was also no significant difference in the rates of symptomatic haemorrhage between the two arms (1.4 percent vs 4.1 percent; p=0.28).

“Our study is the first clinical trial that shows the superiority of direct transfer to an angiography suite,” Requena stated. “Our findings were close to what we expected, and we were surprised that they occurred so early in the study. We trust that they will be confirmed in ongoing, multicentre, international trials.”

The ANGIOCAT study enrolled 174 patients with suspected LVO stroke (with a prehospital RACE* score of >4) who were admitted in <6 hours of symptom onset. Eligible patients also had to meet the criteria of having NIHSS** score of >10 and premorbid mRS of ≤2. They were randomized 1:1 to either DTAS or standard care of undergoing CT imaging before heading to angiography suite if LVO is confirmed.

Transferring patients directly to angiography suite significantly shortened in-hospital delays in terms of door-to-puncture time (median, 18 vs 42 minutes; p<0.001) and door-to-reperfusion time (median, 57 to 84 minutes; p<0.001).

“Speed is really of the essence. Whenever we can reduce delays, that will make a big difference to patients,” commented ISC meeting chair Dr Lisa McCullough from the University of Texas Health Science Center at Houston, Texas, US.

Also commenting on the study, Lisa McCullough, chief of neurology at Memorial Hermann Hospital–Texas Medical Center, Houston, Texas, who is the ISC meeting chair, said she thought the study would be relevant to the United States.

“This protocol improved clinical outcome, with a significant shift towards better outcomes across the spectrum of disability,” reported Requena.

Dr Manuel Requena (Photo credit: AHA)

*RACE: Rapid Arterial Occlusion Evaluation Scale

**NIHSS: National Institutes of Health Stroke Scale