Direct Transfer to Angio-Suite to Reduce Workflow Times and Increase Favorable Clinical Outcome

Background and Purpose- Time to reperfusion is fundamental in reducing morbidity and mortality in acute stroke. We aimed to demonstrate that direct transfer to angio-suite (DTAS) of patients with suspected large vessel occlusion stroke improves workflow times and outcomes. Methods- A case-control matched study of the first 79 DTAS patients with confirmed large vessel occlusion (cases) and 145 no-DTAS patients (controls). DTAS protocol included a cone beam computed tomography in the angio-suite to rule out intracerebral hemorrhage for those patients with no prior neuroimaging in a referring center. Cases and controls were matched by location of vessel occlusion, age, baseline National Institutes of Health Stroke Scale (NIHSS) score and time from symptoms onset to Comprehensive Stroke Center arrival. Dramatic clinical improvement was defined as a decrease in NIHSS score of >10 points or final NIHSS score of ≤2. Favorable outcome was defined as modified Rankin Scale score of ≤2 at 90 days. Results- During an 18 months period a total of 97 patients were directly transferred to the angio-suite after admission: 11 (11.6%) showed an intracerebral hemorrhage on cone beam computed tomography, 7 (7.2%) did not have a large vessel occlusion on initial angiogram, and 79 (76.3%) had a large vessel occlusion and received endovascular treatment (cases). There were no differences in age, baseline NIHSS score, level of occlusion and time from onset-to-door between cases and controls. The median door-to-groin time (16 [12-20] versus 70 [45-105] minutes; P<0.01) and onset-to-groin times (222 [152-282] versus 259 [190-345] minutes; P<0.01) were shorter in the DTAS group. At 24 hours, DTAS patients presented lower NIHSS score (7 [4-16] versus 14 [4-20]; P=0.01), higher rate of dramatic improvement (50.6% Vs. 31.7%; P=0.04), and higher rate of favorable clinical outcome at 90 days (41% versus 28%; P=0.05). A logistic regression model adjusting for all matching variables showed that DTAS protocol was independently associated with 3 months favorable outcome (odds ratio, 2.5; 95% CI, 1.2-5.3; P=0.01). Conclusions- DTAS is an effective strategy to reduce workflow time which may significantly increase the odds of achieving a favorable outcome.