Researchers examined data on 1,140 patients with large vessel occlusion who underwent endovascular thrombectomy after transfer, including 327 (28.7%) who went directly to angiography and 813 (71.3%) who first underwent computed tomography (CT) with or without CT angiography or CT perfusion.
Compared with the group that underwent repeated imaging, the direct to angiography group had a shorter median time from arrival to groin puncture (34 vs 60 minutes) overall, as well as during regular and on-call hours, researchers report in JAMA Neurology.
At three months, going directly to angiography was associated with a greater likelihood of functional independence (52.6% vs 37.0%) overall, as well as among patients who arrived during regular and on-call hours. Each 10-minute increase in the interval from arrival to initiation of endovascular thrombectomy was associated with a 5% reduction in the odds of achieving functional independence.
"Our findings suggest that patients transferred for thrombectomy with shorter transfer times - less than 3 hours from outside hospital imaging to arrival (at) thrombectomy centers - and relatively stable neurological deficits may not require repeat imaging prior to thrombectomy and could benefit from the approximately 30-minute time saved by going directly to the angiography suite," said lead study author Dr. Amrou Sarraj, an associate professor of neurology at the University of Texas McGovern Medical School in Houston.
"So, if these circumstances were met in terms of time elapsed since imaging and neurological stability and the interventionalist team is available to proceed, then taking these patients directly to angiography suites may result in faster treatment and improved outcomes," Dr. Sarraj said by email.
At three months, mortality was also lower in the direct to angiography group than in the repeated imaging group (17% vs 24.4%, respectively).
Limitations of the study include the potential for unmeasured confounders to influence the results, the authors note. The researchers were also unable to compare outcomes for patients who received repeated imaging and either were excluded or then received endovascular thrombectomy.
The study team also points out that patients in the study were transferred from hospitals with varying triage protocols based on vessel imaging or stroke severity, and baseline images were not acquired for some of these patients prior to transfer.
Even so, the results underscore that clinicians at transfer hospitals should think critically about whether repeat imaging might alter the decision to proceed with endovascular thrombectomy, said Dr. Bruce Campbell, a neurologist at Royal Melbourne Hospital in Australia who wrote an editorial accompanying the study.
In most cases, repeating a CT scan when the patient has had one at another hospital does not change the approach to thrombectomy, Dr. Campbell said by email.
"Some groups are trialing a direct to angiography approach for patients who present directly to a thrombectomy-capable hospital with no CT scan at all," Dr. Campbell added. "However, the angiography suite is a limited resource so occupying it with patients who do not have a large blocked vessel to treat with thrombectomy may not be justified."
SOURCE: https://bit.ly/35tufY8 and https://bit.ly/3vvdoip JAMA Neurology, online June 14, 2021.
By Lisa Rapaport
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