Rapid thrombectomy initiation is critical for improving outcomes in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Direct transport to an angiography suite (DTAS), bypassing standard Emergency Department CT imaging, Direct to ED CT (DTCT), reduces door-to-puncture times. This study compares standard DTCT and expedited DTAS workflows using a hybrid multidetector CT (MDCT)-angiography suite.
Materials and methods
This single-center, prospective, blinded analysis study simulated AIS care using a medical mannequin. Twelve simulations were conducted (six per protocol): (a) Standard DTCT and (b) Direct DTAS. Simulations included ED arrival, triage, clinical assessment, imaging, and groin puncture. All mock patients had LVO and were thrombectomy candidates (S-LAMS ≥ 4) with contraindications to lysis. Time metrics were measured and compared.
Results
Mean door-to-puncture time was significantly shorter in the DTAS group (DTCT: 39.83 [4.36] min vs DTAS: 22.17 [2.4] min (P < .0001). Door-to-CT start times were similar (DTCT: 19.5 [7.15] vs DTAS: 15.0 [2.97]; P = .1848). CT-to-puncture time was shorter with DTAS (DTCT: 20.33 [5.01] vs DTAS: 7.17 [1.47]; P = .0009). CT-complete to puncture time favored DTAS (DTCT: 12.33 [3.93] vs DTAS: 2.33 [1.03]; P = .0011). Mean time from CT completion to Angio suite arrival in DTCT was 6.67 min.
Conclusion
A direct-to-CT-Angio (DTAS) workflow using MDCT technology significantly reduces door-to-puncture times compared to standard DTCT, improving hospital workflow for LVO stroke patients. Further clinical studies are needed.
JauchECSaverJLAdamsHP, et al.Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2013; 44: 870–947.
2.
BerkhemerOAFransenPSBeumerD, et al.A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J MedJan 1 2015; 372: 11–20.
3.
JovinTGChamorroACoboE, et al.Thrombectomy within 8 h after symptom onset in ischemic stroke. N Engl J Med2015; 372: 2296–2306.
4.
GoyalMDemchukAMMenonBK, et al.Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med2015; 372: 1019–1030.
5.
SaverJLGoyalMvan der LugtA, et al.Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA2016; 316: 1279–1288.
6.
CampbellBCMitchellPJKleinigTJ, et al.Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med2015; 372: 1009–1018.
7.
MoccoJSiddiquiAHFiorellaD, et al.POSITIVE: perfusion imaging selection of ischemic stroke patients for endovascular therapy. J Neurointerv Surg2022; 14: 126–132.
8.
SaverJL. Time is brain–quantified. Stroke2006; 37: 263–266.
9.
MazighiMChaudhrySARiboM, et al.Impact of onset-to-reperfusion time on stroke mortality: a collaborative pooled analysis. Circulation2013; 127: 1980–1985.
10.
BourcierRGoyalMLiebeskindDS, et al.Association of time from stroke onset to groin puncture with quality of reperfusion after mechanical thrombectomy: a meta-analysis of individual patient data from 7 randomized clinical trials. JAMA Neurol2019; 76: 405–411.
11.
DesaiSMPsychogiosMKhatriP, et al.Direct transfer to the neuroangiography suite for patients with stroke. Stroke2023; 54: 1674–1684.
12.
MehtaBPLeslie-MazwiTMChandraRV, et al.Reducing door-to-puncture times for intra-arterial stroke therapy: a pilot quality improvement project. J Am Heart Assoc2014; 3: e000963.
13.
GoyalMJadhavAPBonafeA, et al.Analysis of workflow and time to treatment and the effects on outcome in endovascular treatment of acute ischemic stroke: results from the SWIFT PRIME randomized controlled trial. Radiology2016; 279: 888–897.
14.
PsychogiosMNBehmeDSchregelK, et al.One-Stop management of acute stroke patients: minimizing door-to-reperfusion times. Stroke2017; 48: 3152–3155.
15.
RiboMBonedSRubieraM, et al.Direct transfer to angiosuite to reduce door-to-puncture time in thrombectomy for acute stroke. J Neurointerv Surg.2018; 10: 221–224.
16.
PsychogiosMNMaierILTsogkasI, et al.One-Stop management of 230 consecutive acute stroke patients: report of procedural times and clinical outcome. J Clin Med2019; 8: 2185. doi:10.3390/jcm8122185
17.
PfaffJARSchonenbergerSHerwehC, et al.Direct Transfer to Angio-Suite Versus Computed Tomography-Transit in Patients Receiving Mechanical Thrombectomy: A Randomized Trial. Stroke2020; 51: 2630–2638.
18.
RequenaMOlive-GadeaMMuchadaM, et al.Direct to angiography suite without stopping for computed tomography imaging for patients with acute stroke: a randomized clinical trial. JAMA Neurol2021; 78: 1099–1107.
19.
BrehmATsogkasIOspelJM, et al.Direct to angiography suite approaches for the triage of suspected acute stroke patients: a systematic review and meta-analysis. Ther Adv Neurol Disord2022; 15: 17562864221078177.
20.
MohammadenMHDoheimMFElfilM, et al.Direct to angiosuite versus conventional imaging in suspected large vessel occlusion: a systemic review and meta-analysis. Stroke2022; 53: 2478–2487.
21.
Galecio-CastilloMVivanco-SuarezJZevallosCB, et al.Direct to angiosuite strategy versus standard workflow triage for endovascular therapy: systematic review and meta-analysis. J Neurointerv Surg2023; 15: e17–e25.
22.
MendezBRequenaMAiresA, et al.Direct transfer to angio-suite to reduce workflow times and increase favorable clinical outcome. Stroke2018; 49: 2723–2727.
23.
PfaffJSchonenbergerSHerwehC, et al.Influence of a combined CT/C-arm system on periprocedural workflow and procedure times in mechanical thrombectomy. Eur Radiol2017; 27: 3966–3972.
24.
StruffertTDeuerling-ZhengYKloskaS, et al.Dynamic angiography and perfusion imaging using flat detector CT in the angiography suite: a pilot study in patients with acute middle cerebral artery occlusions. AJNR Am J Neuroradiol2015; 36: 1964–1970.
25.
RequenaMOliveMGarcia-TornelA, et al.Time matters: adjusted analysis of the influence of direct transfer to angiography-suite protocol in functional outcome. Stroke2020; 51: 1766–1771.
26.
JadhavAPKenmuirCLAghaebrahimA, et al.Interfacility transfer directly to the neuroangiography suite in acute ischemic stroke patients undergoing thrombectomy. Stroke2017; 48: 1884–1889.
27.
RegenhardtRWRosenthalJADmytriwAA, et al.Direct to angio-suite large vessel occlusion transfers achieve faster arrival-to-puncture times and improved outcomes. Stroke Vasc Interv Neurol2022; 2: e000327.
28.
RequenaMVanden BaviereHVermaS, et al.Cost-utility of direct transfer to angiography suite (DTAS) Bypassing conventional imaging for patients with acute ischemic stroke in Spain: results from the ANGIOCAT trial. J Neurointerv Surg2024; 16: 138–142.
29.
StruffertTDeuerling-ZhengYKloskaS, et al.Flat detector CT in the evaluation of brain parenchyma, intracranial vasculature, and cerebral blood volume: a pilot study in patients with acute symptoms of cerebral ischemia. AJNR Am J Neuroradiol2010; 31: 1462–1469.
30.
GemmeteJJChaudharyNPandeyAS, et al.Initial experience with a combined multidetector CT and biplane digital subtraction angiography suite with a single interactive table for the diagnosis and treatment of neurovascular disease. J Neurointerv Surg2013; 5: 73–80.
31.
DoerflerAGolitzPEngelhornT, et al.Flat-Panel computed tomography (DYNA-CT) in neuroradiology. From high-resolution imaging of implants to one-stop-shopping for acute stroke. Clin Neuroradiol2015; 25: 291–297.
32.
YangPNiuKWuY, et al.Time-Resolved C-arm computed tomographic angiography derived from computed tomographic perfusion acquisition: new capability for one-stop-shop acute ischemic stroke treatment in the angiosuite. Stroke2015; 46: 3383–3389.
33.
LeyheJRTsogkasIHesseAC, et al.Latest generation of flat detector CT as a peri-interventional diagnostic tool: a comparative study with multidetector CT. J Neurointerv Surg2017; 9: 1253–1257.
34.
EckertMGolitzPLuckingH, et al.Optimized flat-detector CT in stroke imaging: ready for first-line use?Cerebrovasc Dis2017; 43: 9–16.
35.
MaierILLeyheJRTsogkasI, et al.Diagnosing early ischemic changes with the latest-generation flat detector CT: a comparative study with multidetector CT. AJNR Am J Neuroradiol2018; 39: 881–886.
36.
HoelterPGoelitzPLangS, et al.Visualization of large vessel occlusion, clot extent, and collateral supply using volume perfusion flat detector computed tomography in acute stroke patients. Acta Radiol2019; 60: 1504–1511.
37.
MuellerAWagnerMHattingenE, et al.Flat panel computed tomography pooled blood volume and infarct prediction in endovascular stroke treatment. Stroke2019; 50: 3274–3276.
38.
TaijiRLinEYLinYM, et al.Combined angio-CT systems: a roadmap tool for precision therapy in interventional oncology. Radiol Imaging Cancer2021; 3: e210039.
39.
NicholsonPCancelliereNMBrackenJ, et al.Novel flat-panel cone-beam CT compared to multi-detector CT for assessment of acute ischemic stroke: a prospective study. Eur J Radiol2021; 138: 109645.
40.
BouslamaMHaussenDCGrossbergJA, et al.Flat-panel detector CT assessment in stroke to reduce times to intra-arterial treatment: a study of multiphase computed tomography angiography in the angiography suite to bypass conventional imaging. Int J Stroke2021; 16: 63–72.
41.
PsychogiosMNBahrMLimanJ, et al.One stop management in acute stroke: first mothership patient transported directly to the angiography suite. Clin Neuroradiol2017; 27: 389–391.
42.
SarrajAGoyalNChenM, et al.Direct to angiography vs repeated imaging approaches in transferred patients undergoing endovascular thrombectomy. JAMA Neurol2021; 78: 916–926.
