Patient with suspected large-vessel occlusion stroke who were taken directly to the angiography suite, bypassing the emergency department, received endovascular treatment faster and had better 90-day functional outcomes in a new study.
Results of the ANGIO-CAT trial were presented at the International Stroke Conference (ISC) 2021 on March 17.
The study involved patients suspected of having a large-vessel occlusion, as assessed in the prehospital setting by paramedics using the Rapid Arterial Occlusion Evaluation (RACE) score.
In his presentation, Manuel Requena, PhD, a neurologist and neurointerventionalist fellow at Vall d'Hebron Hospital, Barcelona, Spain, explained that if patients were within 6 hours of symptom onset with a RACE scale score >4, paramedics called ahead to a stroke neurologist, who met the patient directly at the hospital.
If on clinical examination the National Institutes of Health Stroke Scale (NIHSS) score was >10, patients could be enrolled into the study. Upon enrollment, they were randomly assigned either to be taken directly to the angiography suite or to receive standard care.
Requena noted that at his center, patients who receive standard care are transferred to the CT imaging suite, where they are evaluated with noncontrast CT and CT angiography. CT perfusion is also performed if the treating physician deems it necessary.
If a large-vessel occlusion is confirmed, parients are then transferred to the angiography suite for endovascular treatment. He added that in many centers, patients are evaluated in the emergency department before undergoing CT scanning.
Patients in the direct angiography group received a "flat panel" noncontrast CT in the angiography suite to rule out intracranial hemorrhage or a large, established infarct. The large-vessel occlusion would be confirmed by arteriography before the endovascular procedure was performed.
After CT scanning, patients received thrombolysis as recommended in the guidelines.
The current interim analysis includes the 174 patients who have been enrolled so far in the study. The median RACE score for these patients was 7, and the median NIHSS score was 17. Large-vessel occlusion was confirmed in 84% of patients, and 8% had an intracerebral hemorrhage.
Results showed that of the 147 patients who received endovascular therapy, puncture time was shorter for those who were taken directly to angiography (median, 18 min vs 42 min), as was time to reperfusion (median, 57 min vs 84 min).
The primary outcome was a shift analysis of the Modified Rankin Scale (mRS) functional outcome scale at 90 days (odds of 1-point improvement or more). In the direct angiography group, the adjusted odds ratio for an improved functional outcome was 2.2 (95% CI, 1.2 – 4.1).
There were no significant differences in safety endpoints. There was a trend toward more procedural complications in those receiving endovascular therapy in the direct angiography group (8.1% vs 2.7%; P = .6), but there was also a trend toward lower 90-day mortality in this group (20.2% vs 32.9%; P = .07)
Requena reported no significant difference in safety outcomes among those with a hemorrhagic stroke.
"Our study is the first clinical trial that shows the superiority of direct transfer to an angiography suite," said Requena. "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, multicenter, international trials."
Stroke patients who were transferred directly to an angiography suite were also less likely to be dependent on assistance with daily activities than were those who received the current standard of care, Requena said. "More frequent and more rapid treatment can help improve outcomes for our stroke patients," he noted.
A limitation of this study is that the hospital had extensive experience with immediate angiography, so findings may differ at hospitals or care centers with less angiography expertise or experience, Requena said.
He added that retrospective studies conducted in hospitals in the United States, Germany, and Switzerland show that this kind of protocol can be developed in any high-volume stroke center, although multicenter international trials are needed.
Commenting on the ANGIO-CAT study for Medscape Medical News, Michael Hill, MD, University of Calgary, Calgary, Canada, said the 27-minute improvement in door-to-reperfusion time achieved in the study was meaningful and correlates with the degree of improved outcomes observed. "So, the improvement in speed of treatment resulting in better outcomes makes sense," he said.
He cautioned that this strategy would only be feasible in certain centers with selected patients and that cost will be a fundamental issue.
"If you identify patients at angiography, you risk having some patients with no target large-vessel occlusion," Hill added. "The real question is, how many of these patients without a large-vessel occlusion can the system tolerate before it becomes uneconomical and not fruitful or harmful, given that groin puncture is not totally harmless?"
The moderator of the ISC news conference on the study, Mitchel Elkind, MD, professor of neurology at Columbia University, New York City, who is also president of the American Stroke Association, said the study reflects the growing recognition of the importance of speed when treating stroke. "If we can shorten time to treatment using rapid evaluation and imaging protocols, this will help save brain," he said.
Also commenting on the study, Lisa McCullough, MD, 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. "Speed is really of the essence. Whenever we can reduce delays, that will make a big difference to patients," she commented.
Referring to this study on improving hospital systems, as well as a second study that was presented at the meeting that showed benefits from delivery of prehospital thrombolysis via a mobile stroke unit, McCullough added: "We need to set up models so we can get the best of both these worlds. These studies are really leading the way on how we can change the stroke systems of care."
The study was funded by Vall d’Hebron Research Institute. Requena has disclosed no relevant financial relationships.
International Stroke Conference (ISC) 2021: Late-breaking abstract 1. Presented March 17, 2021.
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Cite this: Direct Transfer to Angio Improves Outcome in Large-Vessel Stroke - Medscape - Mar 17, 2021.