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November 16, 2021; 97 (20 Supplement 2) Prehospital & Triage

Direct Transfer to Angiosuite in Acute Stroke

Why, When, and How?

View ORCID ProfileManuel Requena, View ORCID ProfileZeguang Ren, View ORCID ProfileMarc Ribo
First published November 16, 2021, DOI: https://doi.org/10.1212/WNL.0000000000012799
Manuel Requena
From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D’Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston.
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  • ORCID record for Manuel Requena
Zeguang Ren
From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D’Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston.
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Marc Ribo
From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D’Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston.
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Citation
Direct Transfer to Angiosuite in Acute Stroke
Why, When, and How?
Manuel Requena, Zeguang Ren, Marc Ribo
Neurology Nov 2021, 97 (20 Supplement 2) S34-S41; DOI: 10.1212/WNL.0000000000012799

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Abstract

Time to reperfusion is one of the strongest predictors of functional outcome in acute stroke due to a large vessel occlusion (LVO). Direct transfer to angiography suite (DTAS) protocols have shown encouraging results in reducing in-hospital delays. DTAS allows bypassing of conventional imaging in the emergency room by ruling out an intracranial hemorrhage or a large established infarct with imaging performed before transfer to the thrombectomy-capable center in the angiography suite using flat-panel CT (FP-CT). The rate of patients with stroke code primarily admitted to a comprehensive stroke center with a large ischemic established lesion is <10% within 6 hours from onset and remains <20% among patients with LVO or transferred from a primary stroke center. At the same time, stroke severity is an acceptable predictor of LVO. Therefore, ideal DTAS candidates are patients admitted in the early window with severe symptoms. The main difference between protocols adopted in different centers is the inclusion of FP-CT angiography to confirm an LVO before femoral puncture. While some centers advocate for FP-CT angiography, others favor additional time saving by directly assessing the presence of LVO with an angiogram. The latter, however, leads to unnecessary arterial punctures in patients with no LVO (3%–22% depending on selection criteria). Independently of these different imaging protocols, DTAS has been shown to be effective and safe in improving in-hospital workflow, achieving a reduction of door-to-puncture time as low as 16 minutes without safety concerns. The impact of DTAS on long-term functional outcomes varies between published studies, and randomized controlled trials are warranted to examine the benefit of DTAS.

Glossary

ANGIOCAT=
Evaluation of Direct Transfer to Angiography Suite vs. Computed Tomography Suite in Endovascular Treatment: Randomized Clinical Trial;
ASPECTS=
Alberta Stroke Program Early CT Score;
CI=
confidence interval;
CTA=
CT angiography;
CTP=
CT perfusion;
DIRECT-MT=
Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals;
DTAS=
direct transfer to angiography suite;
DTP=
door arrival to femoral puncture;
EVT=
endovascular treatment;
FP-CT=
flat-panel CT;
HERMES=
Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke;
LVO=
large vessel occlusion;
MR CLEAN=
Multicenter Randomized Clinical Trial of Endovascular Treatment for AIS in the Netherlands;
mRS=
modified Rankin Scale;
MT=
mechanical thrombectomy;
MVO=
medium vessel occlusion;
NIHSS=
NIH Stroke Scale;
OR=
odds ratio;
OTD=
onset to door arrival;
RCT=
randomized controlled trial;
THRACE=
Trial and Cost Effectiveness Evaluation of Intra-Arterial Thrombectomy in Acute Ischemic Stroke;
tPA=
tissue plasminogen activator

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • ↵* All authors contributed equally to this work.

  • Received February 12, 2021.
  • Accepted in final form May 5, 2021.
  • © 2021 American Academy of Neurology
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  • Article
    • Abstract
    • Glossary
    • Rationale for DTAS
    • Role of Advanced Imaging for Patient Selection for EVT
    • Imaging Protocols for DTAS
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    • Evidence Supporting DTAS
    • Will IV Thrombolysis Be Needed for Patients Receiving DTAS?
    • Randomized Clinical Trials for DTAS
    • Conclusion
    • Study Funding
    • Disclosure
    • Appendix Authors
    • Footnotes
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