Background: Time is brain! This paradigm is forcing the development of strategies with potential to shorten the time from symptom onset to recanalization. One of these strategies is to transport select patients with acute ischaemic stroke directly to an angio-suite equipped with flat-detector computed tomography (FD-CT) to exclude intracranial haemorrhage, followed directly by invasive angiography and mechanical thrombectomy if large-vessel occlusion (LVO) is confirmed. Aim: To present existing published data about the direct transfer (DT) of stroke patients to angio-suites and to describe our initial experience with this stroke pathway. Methods: We performed a systematic PubMed search of trials that described DT of stroke patients to angio-suites and summarized the results of these trials. In January 2020, we implemented a new algorithm for acute ischaemic stroke care in our stroke centre. Select patients suitable for DT (National Institute of Health Stroke Scale score ≥10, time from symptom onset to door <4.5 h) were referred by neurologists directly to an angio-suite equipped with FD-CT. Patients treated using this algorithm were analysed and compared with patients treated using the standard protocol including CT and CT angiography in our centre. Results: We identified seven trials comparing the DT protocol with the standard protocol in stroke patients. Among the 628 patients treated using the DT protocol, 104 (16.5%) did not have LVO and did not undergo endovascular treatment (EVT). All the trials demonstrated a significant reduction in door-to-groin time with DT, compared with the standard protocol. This reduction ranged from 22 min (DT protocol: 33 min; standard protocol: 55 min) to 59 min (DT protocol: 22 min; standard protocol: 81 min). In three of five trials comparing the 90-day modified Rankin scale scores between the DT and standard imaging groups, this reduction in ischaemic time translated into better clinical outcomes, whereas the two other trials reported no such difference in scores. Between January 2020 and October 2021, 116 patients underwent EVT for acute ischaemic stroke in our centre. Among these patients, 65 (56%) met the criteria for DT (National Institutes of Health Stroke Scale score >10, symptom onset-to-door time <4.5 h), but only 7 (10.8%) were transported directly to the angio-suite. The reasons that many patients who met the criteria were not transported directly to the angio-suite were lack of personnel trained in FD-CT acquisition outside of working hours, ongoing procedures in the angio-suite, contraindication to the DT protocol due to atypical clinical presentation, and neurologist's decision for obtain complete neurological imaging. All seven patients who were transported directly to the angio-suite had LVOs. The median time from door-to-groin-puncture was significantly lower with the DT protocol compared with the standard protocol {29 min [interquartile range (IQR): 25-31 min] vs. 71 min [IQR: 55-94 min]; P < 0.001}. None of the patients had symptomatic intracranial haemorrhage in the DT protocol group, compared with 7 (6.4%) patients in the standard protocol group. Direct transfer of acute ischaemic stroke patients to the angio-suite equipped with FD-CT seems to reduce the time from patient arrival in the hospital to groin puncture. This reduction in the ischaemic time translates into better clinical outcomes. However, more data are needed to confirm these results.

Department of Cardiology 3rd Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady Srobarova 1150 50 10034 Prague Czech Republic

Department of Neurology 3rd Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady Srobarova 1150 50 10034 Prague Czech Republic

Partner of INTERCARDIS Project Medtronic Czechia Prosecka 852 66 19000 Prague Czech Republic

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Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJH, van Walderveen MAA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PLM, van Rooij WJJ, van den Berg JSP, van Hasselt BAAM, Aerden LAM, Dallinga RJ, Visser MC, Bot JCJ, Vroomen PC, Eshghi O, Schreuder THCML, Heijboer RJJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers MES, Jenniskens SFM, Beenen LFM, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YBWEM, van der Lugt A, van Oostenbrugge RJ, Majoie CBLM, Dippel DWJ; MR CLEAN Investigators. A randomized trial of intra-arterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11–20. PubMed

Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM.. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;372:1009–1018. PubMed

Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo J-H, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn S-I, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD.. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372:1019–1030. PubMed

Saver JL, Goyal M, Bonafe A, Diener H-C, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, Du Mesnil de Rochemont R, Singer OC, Jahan R.. Stentretriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015;372:2285–2295. PubMed

Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Román L, Serena J, Abilleira S, Ribó M, Millán M, Urra X, Cardona P, López-Cancio E, Tomasello A, Castaño C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Pérez M, Goyal M, Demchuk AM, von Kummer R, Gallofré M, Dávalos A; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015;372:2296–2306. PubMed

Bush CK, Kurimella D, Cross LJS, Conner KR, Martin-Schild S, He J, Li C, Chen J, Kelly T.. Endovascular treatment with stent-retriever devices for acute ischemic stroke: a meta-analysis of randomized controlled trials. PLoS One 2016;11:e0147287. PubMed PMC

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL.. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019;50:e344–e418. PubMed

Turc G, Bhogal P, Fischer U, Khatri P, Lobotesis K, Mazighi M, Schellinger PD, Toni D, de Vries J, White P, Fiehler J.. European Stroke Organisation (ESO)–European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg 2019;11:535–538. PubMed

Jahan R, Saver JL, Schwamm LH, Fonarow GC, Liang L, Matsouaka RA, Xian Y, Holmes DN, Peterson ED, Yavagal D, Smith EE.. Association between time to treatment with endovascular reperfusion therapy and outcomes in patients with acute ischemic stroke treated in clinical practice. JAMA 2019;322:252–263. PubMed PMC

Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CBLM, Dippel DW, Campbell BC, Nogueira RG, Demchuk AM, Tomasello A, Cardona P, Devlin TG, Frei DF, Du Mesnil de Rochemont R, Berkhemer OA, Jovin TG, Siddiqui AH, van Zwam WH, Davis SM, Castaño C, Sapkota BL, Fransen PS, Molina C, van Oostenbrugge RJ, Chamorro Á, Lingsma H, Silver FL, Donnan GA, Shuaib A, Brown S, Stouch B, Mitchell PJ, Davalos A, Roos YBWEM, Hill MD; HERMES Collaborators. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 2016;316:1279–1288. PubMed

Struffert T, Deuerling-Zheng Y, Kloska S, Engelhorn T, Strother CM, Kalender WA, Köhrmann M, Schwab S, Doerfler A.. 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 Neuroradiol 2010;31:1462–1469. PubMed PMC

Struffert T, Richter G, Engelhorn T, Doelken M, Goelitz P, Kalender WA, Ganslandt O, Doerfler A.. Visualization of intracerebral hemorrhage with flat-detector CT compared to multislice CT: results in 44 cases. Eur Radiol 2009;19:619–625. PubMed

Leyhe JR, Tsogkas I, Hesse AC, Behme D, Schregel K, Papageorgiou I, Liman J, Knauth M, Psychogios M-N.. Latest generation of flat detector CT as a peri-interventional diagnostic tool: a comparative study with multidetector CT. J Neurointerv Surg 2017;9:1253–1257. PubMed PMC

Psychogios M-N, Behme D, Schregel K, Tsogkas I, Maier IL, Leyhe JR, Zapf A, Tran J, Bähr M, Liman J, Knauth M.. One-stop management of acute stroke patients: minimizing door-to-reperfusion times. Stroke 2017;48:3152–3155. PubMed

Jadhav AP, Kenmuir CL, Aghaebrahim A, Limaye K, Wechsler LR, Hammer MD, Starr MT, Molyneaux BJ, Rocha M, Guyette FX, Martin-Gill C, Ducruet AF, Gross BA, Jankowitz BT, Jovin TG.. Interfacility transfer directly to the neuroangiography suite in acute ischemic stroke patients undergoing thrombectomy. Stroke 2017;48:1884–1889. PubMed

Ribo M, Boned S, Rubiera M, Tomasello A, Coscojuela P, Hernández D, Pagola J, Juega J, Rodriguez N, Muchada M, Rodriguez-Luna D, Molina CA.. Direct transfer to angiosuite to reduce door-to-puncture time in thrombectomy for acute stroke. J Neurointerv Surg 2018;10:221–224. PubMed

Mendez B, Requena M, Aires A, Martins N, Boned S, Rubiera M, Tomasello A, Coscojuela P, Muchada M, Rodríguez-Luna D, Rodríguez-Villatoro N, Juega J, Pagola J, Molina CA, Ribó M.. Direct transfer to angio-suite to reduce workflow times and increase favorable clinical outcome. Stroke 2018;49:2723–2727. PubMed

Psychogios M-N, Maier IL, Tsogkas I, Hesse AC, Brehm A, Behme D, Schnieder M, Schregel K, Papageorgiou I, Liebeskind DS, Goyal M, Bähr M, Knauth M, Liman J.. One-stop management of 230 consecutive acute stroke patients: report of procedural times and clinical outcome. J Clin Med 2019;8:2185. PubMed PMC

Bouslama M, Haussen DC, Grossberg JA, Barreira CM, van der Bom IMJ, van Nijnatten F, Grünhagen T, Moyer L, Frankel MR, Nogueira RG.. 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 Stroke 2021;16:63–72. PubMed

Requena M, Olivé-Gadea M, Muchada M, Hernández D, Rubiera M, Boned S, Piñana C, Deck M, García-Tornel Á, Díaz-Silva H, Rodriguez-Villatoro N, Juega J, Rodriguez-Luna D, Pagola J, Molina C, Tomasello A, Ribo M.. Direct to angiography suite without stopping for computed tomography imaging for patients with acute stroke: a randomized clinical trial. JAMA Neurol 2021;78:1099–1107. PubMed PMC

Saver JL. Time is brain-quantified. Stroke 2006;37:263–266. PubMed

Ribo M, Molina CA, Cobo E, Cerdà N, Tomasello A, Quesada H, De Miquel MA, Millan M, Castaño C, Urra X, Sanroman L, Dàvalos A, Jovin T; REVASCAT Trial Investigators. Association between time to reperfusion and outcome is primarily driven by the time from imaging to reperfusion. Stroke 2016;47:999–1004. PubMed

Desilles JP, Consoli A, Redjem H, Coskun O, Ciccio G, Smajda S, Labreuche J, Preda C, Ruiz Guerrero C, Decroix JP, Rodesch G, Mazighi M, Blanc R, Piotin M, Lapergue B.; ETIS (Endovascular Treatment in Ischemic Stroke) Research Investigators. Successful reperfusion with mechanical thrombectomy is associated with reduced disability and mortality in patients with pretreatment diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score <6. Stroke 2017;48:963–969. PubMed

Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Mendes Pereira V, Gralla J, Fischer U.. Mechanical thrombectomy in ischemic stroke patients with Alberta Stroke Program Early Computed Tomography Score 0-5. Stroke 2019;50:880–888. PubMed PMC