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Originally Published 20 May 2022
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Direct to Angiosuite Versus Conventional Imaging in Suspected Large Vessel Occlusion: A Systemic Review and Meta-Analysis

Mahmoud H. Mohammaden, MD, MSc https://orcid.org/0000-0002-7393-9989, Mohamed Fahmy Doheim, MD https://orcid.org/0000-0001-8279-5078, Mohamed Elfil, MD https://orcid.org/0000-0002-1125-2946, Alhamza R. Al-Bayati, MD https://orcid.org/0000-0001-8103-1930, Agostinho Pinheiro, MD https://orcid.org/0000-0002-2496-9479, Thanh N. Nguyen, MD https://orcid.org/0000-0002-2810-1685, Nirav R. Bhatt, MD https://orcid.org/0000-0001-9838-6180, Diogo C. Haussen, MD https://orcid.org/0000-0003-1884-2196, and Raul G. Nogueira, MD https://orcid.org/0000-0003-4532-153X [email protected]Author Info & Affiliations
Stroke
Volume 53, Number 8
https://doi.org/10.1161/STROKEAHA.121.038221
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Abstract

Background:

There is growing evidence to suggest that the direct transfer to angiography suite (DTAS) approach for patients with suspected large vessel occlusion stroke potentially requiring mechanical thrombectomy shortens treatment times and improves outcomes compared with the direct transfer to conventional imaging (DTCI) model. Therefore, we conducted this meta-analysis to compare both approaches to build more concrete evidence to support this innovative treatment concept.

Methods:

All potentially relevant studies published in 4 electronic databases/search engines (PubMed, Web of Science, Cochrane Library, and Scopus) from inception to November 2021 were reviewed. Eligible studies were included if they enrolled ≥10 patients in both groups, were published in English, and reported baseline and procedural characteristics and outcomes. Relevant data were then extracted and analyzed.

Results:

Among 4514 searched studies, 7 qualified for the analysis with 1971 patients (DTAS=675, DTCI=1296). Times from door to puncture (mean difference, −30.76 minutes [95% CI, −43.70 to −17.82]; P<0.001) as well as door-to-reperfusion (mean difference=−33.24 minutes [95% CI, −51.82 to −14.66]; P<0.001) were significantly shorter and the rates of functional independence (modified Rankin Scale score, 0–2: risk ratio [RR], 1.25 [95% CI, 1.02–1.53]; P=0.03) at 90 days were higher in the DTAS versus the DTCI approach. There was no difference across the DTAS and DTCI groups in terms of the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2B–3: RR, 1.03 [95% CI, 0.95–1.12]; P=0.42), near-complete/full reperfusion (modified Thrombolysis in Cerebral Infarction 2C–3: RR, 0.89 [95% CI, 0.74–1.08]; P=0.23), symptomatic intracranial hemorrhage (RR, 0.81 [95% CI, 0.56–1.17]; P=0.26), or fair outcomes (modified Rankin Scale score, 0–3: RR, 1.14 [95% CI, 0.88–1.47]; P=0.32) or mortality (RR, 0.98 [95% CI, 0.67–1.44]; P=0.93) at 90 days. Subgroup analysis showed no significant difference in 90-day functional independence across approaches in transfer patients (RR, 1.20 [95% CI, 0.96–1.51]; P=0.11).

Conclusions:

Our meta-analysis showed that the DTAS approach seems to be associated with improved time metrics and functional outcomes with comparable safety to the DTCI approach. Ongoing multicenter randomized clinical trials will hopefully provide more definite data about this promising approach.

Graphical Abstract

Endovascular treatment (EVT) has become the standard of care for patients with large vessel occlusion stroke meeting the eligibility criteria.1 Time to reperfusion has been identified as one of the strongest predictor of clinical outcomes.2,3 There are different workflow optimization strategies that have been evaluated and proposed to minimize time to treatment at both the prehospital and intrahospital levels. For instance, improving large vessel occlusion stroke recognition and triage in the field4,5 as well as identifying the best treatment logistics (ie, mothership, drip and ship, and trip and treat models) have facilitated prehospital access to EVT.6–9 Time from hospital arrival to arterial puncture (door-to-puncture [DTP] time) has been widely accepted as a key performance metric to evaluate intrahospital workflow.10 It has been reported that every 10-minute increase in the DTP time is associated with a 5% reduction in the likelihood of achieving functional independence at 90 days.11
Multiple strategies have been adopted to minimize DTP times including streamlining the workflow by rapid and concurrent clinical and imaging evaluations, neuroendovascular team notifications for all suspected interventional cases, and immediate transfer to the angiography suite even before the arrival of the neuroendovascular team.12,13 Moreover, it has been demonstrated that the image to angiosuite arrival time represents both the longest and the most variable time interval in the intrahospital workflow.14 Therefore, many recent studies have evaluated whether bypassing the direct transfer to conventional imaging (DTCI) approach by implementing a direct transfer to angiosuite (DTAS) pathway would result in reduction of DTP times and improvement of functional outcomes in patients presenting with moderate or severe clinical deficits in the early time window.15,16
The goal of the current study was to compile the published literature in a meta-analysis of comparative studies reporting on the safety and efficacy outcomes of the DTAS versus DTCI approaches to build more concrete evidence to support the novel DTAS treatment concept.

Methods

The data that support the findings of the study are available from the corresponding author on reasonable request.

Search Strategy

We performed a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.17 We reviewed published studies using 4 electronic databases/search engines (PubMed, Web of Science, Cochrane Library, and Scopus) from inception to November 2021. The following strategies were used: (“direct to angiosuite” OR “door to reperfusion” OR “door to puncture” OR “transfer” OR “one stop management” OR “flat panel CT”) and (“stroke” OR “thrombectomy”). Then, we exported references using Endnote X8 software (Thompson Reuter, CA) into a local library. Furthermore, we reviewed the bibliography of key studies to identify additional relevant articles.

Selection Criteria and Data Extraction

Studies were included if they enrolled ≥10 patients in each DTAS and DTCI group, were published in English, and reported baseline and procedural characteristics and 90-day outcomes.
Three reviewers (M.F.D., M.H.M., and M.E.) independently screened the studies. The data extraction sheet template was initially built through a pilot trial from the most relevant studies. Then, the reviewers independently extracted the data into the template. The extracted data included the following: first author’s name, year of publication, study design, number of patients in each group, mean/median age, number of female patients, mean/median baseline National Institutes of Health Stroke Scale score, preprocedural administration of IV tPA (intravenous tissue-type plasminogen activator), Alberta Stroke Program Early CT Score, workflow time metrics including DTP, door-to-reperfusion. Discrepancies were resolved via consensus.

Outcome

The primary outcome was functional independence defined as modified Rankin Scale (mRS) score of 0 to 2 at 90 days. Secondary outcomes included fair clinical outcome defined as mRS score of 0 to 3 at 90 days, successful reperfusion defined as modified Thrombolysis in Cerebral Infarction score of 2B to 3 and near-complete/full reperfusion defined as modified Thrombolysis in Cerebral Infarction score of 2C to 3. Safety measures included symptomatic intracerebral hemorrhage (sICH) and 90-day mortality. Additionally, we performed a sensitivity analysis for studies that only included patients in the early time window (0–6 hours of symptom onset).

Subgroup Analysis

We performed a subgroup analysis to determine whether the outcome measures were different based on the prehospital workflow (transfer versus mothership models) or study design (observational versus randomized clinical trials [RCTs]).

Risk of Bias Assessment

Two independent reviewers assessed the quality of the included observational studies using the Newcastle-Ottawa Scale.18 The scale contains 3 domains (selection, comparability, and ascertainment of outcome) with a maximum of 4, 2, and 3 points given to each domain, respectively, if satisfied. Therefore, a study could be maximally awarded 9 points. Lower score indicates higher risk of bias. For instance, if less than 7 points were awarded, the study was considered poor quality. Additionally, we used the Cochrane risk of bias assessment tool to assess the quality of the included RCTs.19 This tool assesses selection bias, performance bias, detection bias, attrition bias, reporting bias, and other potential sources of bias. Each bias domain was assigned low, high, or unclear.

Statistical Analysis

The pooled outcomes were meta-analyzed using a random-effects model. To estimate mean or SD for studies reporting median and interquartile range, the Wan method was used.20 To pool the data between the 2 study arms, we estimated mean difference and 95% CI for continuous data and risk ratios (RRs) and 95% CI for dichotomous data. P<0.05 was considered statistically significant. To determine heterogeneity, the χ2 and I-square (I2) tests were applied. When the χ2 P value was <0.1 or the I2 was >50%, heterogeneity was considered. Analysis was performed using Review Manager 5.4.1 (The Cochrane Collaboration, Oxford, United Kingdom).

Results

Selection and Characteristics of the Included Studies

After removal of duplicates by the EndNote software, the literature search yielded 4417 reports. Of these articles, title and abstract screening excluded 4386. Then, full-text screening excluded 24 articles based on our inclusion and exclusion criteria, yielding 7 articles, 2 RCTs16,21 and 5 observational studies,11,15,22–24 eligible for analysis including 1971 patients (DTAS=675, DTCI=1296; Figure 1). Notably, we excluded 5 studies for potential duplicate inclusion of patients secondary to overlap in study period25–29 with the included studies.11,23 Also among the eligible studies, there was a recently published article included from the journal website.24
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart.
Patients’ characteristics of the included studies are summarized in the Table. The observational studies scored more than 7 points using Newcastle-Ottawa Scale, which was considered satisfactory. The overall assessed risk of bias was moderate to high in the assessment of included RCTs as evaluated by the Cochrane risk of bias assessment tool (Figure S1).
Table. Baseline Characteristics of the Included Studies
Author; yearCountryStudy designStudy periodNo. of patientsAge, yFemaleLKN- hospital arrival, minBaseline NIHSS scoreIV tPAASPECTS
DTASDTCIDTAS; N=675DTCI; N=1296DTASDTCIDTASDTCIDTASDTCIDTASDTCIDTASDTCIDTASDTCI
Jadhav et al22; 2017United StatesSingle-center retrospectiveJanuary 2013 to October 20161111507469.5……303*304*18.51738; 34%97; 65%99
Psychogios et al23; 2019GermanySingle-center retrospectiveJune 2016 to November 20184343777726; 61%26; 61%160129161730; 70%36; 84%98
Pfaff et al21; 2020GermanySingle-center RCTDecember 2017 to February 2019263476*74*13; 50%21; 61.8%192219161815; 57.7%14; 41.2%6–10=22; <6=1; not assessable=36–10=32; <6=2
Bouslama et al15; 2020United StatesSingle-center retrospectiveMay 2016 to December 2017494965.7*65.7*27 55.1%23; 46.9%2603651817.919; 38.8%20; 40%……
Sarraj et al11; 20216 CSC in United States and EuropeMulticenter retrospectiveJanuary 2014 to February 20203278136869152; 46.6%377; 46.4%3203511717200; 61.2%412; 51%98
Requena et al16; 2021SpainSingle-center RCTSeptember 2018 to February 2021747371.9*74.8*36; 48.6%41; 56.2%233.6*240.2*171837; (50%)39; (53%)1010
Mendez et al24; 2021United StatesSingle-center retrospectiveJanuary 2015 to August 201945134†/24169732411422219518†17†3016798
ASPECTS indicates Alberta Stroke Program Early CT Score; CSC, comprehensive stroke centers; DTAS, direct to angiography suite; DTCI, direct transfer to conventional imaging; IV tPA, intravenous tissue-type plasminogen activator; LKN, last known normal; NIHSS, National Institutes of Health Stroke Scale; and RCT, randomized controlled trial.
*
Mean.
†
For 134 patients who underwent mechanical thrombectomy.
All eligible studies measured DTP times; however, only 6 studies reported door-to-reperfusion times.15,16,21–24 Three studies reported number of nontransfer patients (ie, mothership [DTAS=262]) in whom 188 (71.8%) patients underwent EVT, and 74 (28.2%) were non-LVO (small vessel stroke [11%], ICH [13%], or stroke mimics [4.2%]).16,21,23
Regarding the 90-day mRS score, 6 studies reported functional independence (mRS score of 0–2),11,15,16,22–24 whereas fair outcome (90-day mRS score of 0–3) was reported in 3 studies.11,16,21 Six studies reported rates of successful reperfusion15,16,21–24 with 3 of these studies describing rates of near-complete/full reperfusion at the end of the procedure.15,16,21 For safety measures, rates of sICH and 90-day mortality were reported in 6 studies.11,15,16,22–24

Time Metrics (DTP and Door-to-Reperfusion)

The overall effect from 7 studies favored the DTAS group over the DTCI group in reducing DTP time (mean difference, −30.76 minutes [95% CI, −43.70 to −17.82]; P<0.001), with significant heterogeneity of the results (P<0.0001; I2=98%). Similarly, the overall effect favored DTAS group over DTCI group regarding door-to-reperfusion time (mean difference, −33.24 minutes [95% CI, −51.82 to −14.66]; P<0.001). However, these results were also heterogeneous (P<0.0001; I2=91%; Figure 2).
Figure 2. Time metrics. A, Door to puncture. B, Door-to-reperfusion. DTAS indicates direct to angiography suite; and DTCI, direct transfer to conventional imaging.

Primary Outcome

The pooled analysis demonstrated significantly higher functional independence (90-day mRS score of 0–2) in the DTAS compared with DTCI approach (overall effect; RR, 1.25 [95% CI, 1.02–1.53]; P=0.03). These results were associated with moderate level of heterogeneity (P=0.06; I2=53%). Similarly, the overall effect in early time window favored DTAS approach (RR, 1.27 [95% CI, 1.01–1.61]; P=0.04) with moderate level of heterogeneity (P=0.05, I2=58%; Figure 3).
Figure 3. Functional independence (modified Rankin Scale [mRS] score of 0
–2 at 90 d). A, Overall time window. B, Early time window. DTAS indicates direct to angiography suite; and DTCI, direct transfer to conventional imaging.

Secondary Outcomes

The pooled analysis showed no difference between groups regarding fair clinical outcome (mRS score of 0–3 at 90 days) either in the overall time window (RR, 1.14 [95% CI, 0.88–1.47]; P=0.32) or early time window (RR, 1.14 [95% CI, 0.87–1.49]; P=0.34). These results were associated with moderate level of heterogeneity (P=0.05, I2=67%; Figure 4).
Figure 4. Fair clinical outcome (modified Rankin Scale [mRS] score of 0
–3 at 90 d). A, Overall time window, B, Early time window. DTAS indicates direct to angiography suite; and DTCI, direct transfer to conventional imaging.
In terms of procedural outcomes, there was no difference between DTAS and DTCI groups in achieving successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2B–3), overall effect (RR, 1.03 [95% CI, 0.95–1.13]; P=0.42). This was associated with heterogeneity (P<0.01; I2=70%). Similarly, there was no difference in near-complete/full reperfusion (modified Thrombolysis in Cerebral Infarction score of 2C–3), overall effect (RR, 0.89 [95% CI, 0.74–1.08]; P=0.23). This was associated with low heterogeneity (P=0.28; I2=22%; Figure S2).

Safety Measures

There was no significant difference between both groups in rates of sICH either in the overall time window (RR, 0.81 [95% CI, 0.56–1.17]; P=0.26) or early time window (RR, 0.75 [95% CI, 0.47–1.20]; P=0.24). The results were homogenous (P=0.89; I2=0%). Likewise, there was no significant difference in 90-day mortality among the DTAS and DTCI groups both in the overall and early time windows (RR, 0.98 [95% CI, 0.67–1.44]; P=0.93 and RR, 0.102 [95% CI, 0.65–1.60]; P=0.43, respectively). The results were associated with a moderate level of heterogeneity (P=0.003; I2=72% and P=0.003; I2=75%, respectively; Figure 5).
Figure 5. Safety measures: symptomatic intracerebral hemorrhage (sICH). A, Overall time window. B, Early time window. Mortality at 90 d (C) overall time window (D) early time window. DTAS indicates direct to angiography suite; and DTCI, direct transfer to conventional imaging.

Subgroup Analysis

Mothership Versus Transfer Models

Five studies11,15,16,22,24 were included in the transfer model compared with 2 studies in the mothership model.16,21 The study of Psychogios et al23 was excluded from this analysis because of the mixed patient population. The rates of sICH, mRS score of 0 to 2, and mortality at 90 days in the mothership model were reported only in 1 study (RCT).16 Consequently, we could not perform pooled analysis of these variables in the mothership model. However, there was no significant difference in the rates of 90-day functional independence across both approaches in mothership patients in the above study (RR, 1.11 [95% CI, 0.43–2.85]; P=0.84).16
There was no significant difference in rates of functional independence between DTAS compared with DTCI approach in transfer patients (RR, 1.20 [95% CI, 0.96–1.51]; P=0.11). The results were associated with a moderate level of heterogeneity (P=0.05, I2=58%; Figure S3). Additionally, the pooled analysis showed no significant difference between DTAS and DTCI approach in terms of secondary outcomes and safety measures in either transfer or mothership patients (Figures S4 through S8).

Observational Versus Randomized Study Design

A second subgroup analysis was performed to explore potential differences in outcomes across 5 observational studies11,15,22–24 versus 2 RCTs.16,21 Once again, the rates of sICH, functional independence, and mortality at 90 days were reported only in one RCT,16 which precluded data pooling. Pooled analysis of the 5 observational studies showed comparable rates of functional independence across the DTAS and DTCI approaches (RR, 1.21 [95% CI, 0.96–1.52]; P=0.11). The results were associated with a moderate level of heterogeneity (P=0.04, I2=59%).
There was no significant difference in rates of fair outcome, reperfusion, sICH, and 90-day mortality between the DTAS and DTCI approaches in either observational studies or RCTs (Figures S9 through S14).

Discussion

Our meta-analysis, including 1971 patients derived from 7 different studies, demonstrated the estimates of the effect of the DTAS approach on the time metrics, efficacy outcomes, and procedural safety compared with DTCI approach as follows: (1) DTAS approach resulted in significantly shorter DTP and door-to-reperfusion times. (2) DTAS approach was associated with higher rates of functional independence (90-day mRS score of 0–2) both in the overall and early time windows. However, there was no significant difference between the 2 approaches after dividing the overall study population according to transfer versus mothership models or according to observational versus RCT study design. (3) No significant differences existed between the DTAS and DTCI approach in terms of successful or near full/complete reperfusion, fair clinical outcome (90-day mRS score of 0–3), sICH, and 90-day mortality.
Our meta-analysis showed that the DTAS approach resulted in reduction of time to reperfusion of ≈33 minutes. It has been reported that the chances of good outcomes decrease on average by 10% to 15% for every 30-minute delay in reperfusion.2,3 Congruently, the observed reduction in time to treatment with the DTAS in our study translated into higher rates of functional independence (RR, 1.25 [95% CI, 1.02–1.53]; P=0.03) as compared with the DTCI approach. Current guidelines discourage the utilization of advanced imaging to confirm EVT eligibility in the early time window (within 6 hours of symptom onset).1 Moreover, a recent study by Nguyen et al30 showed that there were no significant differences in the clinical outcomes of patients undergoing EVT for large vessel occlusion stroke in the extended time window selected with noncontrast computed tomography compared with those selected with advanced imaging (ie, computed tomography perfusion or magnetic resonance imaging).
Despite the concern of overwhelming the neurointerventional team by false activation, the present analysis showed that 28.2% of patients were not eligible for EVT in the DTAS approach (ie, no large vessel occlusion stroke, stroke mimics, or ICH). This finding is comparable with what has been reported in the cardiology literature where false-positive catheterization laboratory activation has been documented in as many as 23.5% of patients undergoing percutaneous coronary intervention for suspected ST-segment–elevation myocardial infarction.31 Furthermore, we need to consider the possibility that excessive imaging evaluation may not only delay treatment but may also lead to over-selection by only including those patients with the highest chances of favorable outcomes at the cost of excluding many more patients who could still benefit from intervention, even if to a more modest degree.32 Although perfusion imaging may identify the patients who are more likely to achieve favorable EVT outcomes on the basis of infarct volume and mismatch profiles,33,34 many studies (including a recent small RCT) have now described improved outcomes after EVT as compared with medical management alone even in the presence of large infarct burden.35–39 Multicenter clinical trials are ongoing to provide more concrete evidence on the EVT of large infarcts. Notably, our results reported no significant difference in rates of sICH and mortality at 90 days among both approaches suggesting that detailed knowledge about infarct size may not be a critical factor to ensure EVT safety in the early time window.
It has been previously suggested that the benefits of DTAS may decrease over time, with the highest treatment effect being observed in those patients treated within 3 hours from symptom onset (odds ratio [OR], 2.6 [95% CI, 1.31–5.28]; P<0.01) followed by a more modest (if any) effect in the 3 to 6 hours window (OR, 1.37 [95% CI, 0.72–2.60]; P=0.2). This could be explained by the nonlinear progression of infarct growth overtime at a population level, with higher overall lesion growth rates during the very early time window. Therefore, the reduction of hospital-workflow times will more significantly reduce infarct growth and improve functional outcomes in the more hyperacute phases.28,40 However, a recent multicenter study showed benefit of DTAS across different subgroup analysis including early (57.1% versus 40.7%; adjusted OR, 1.63 [95% CI, 1.07–2.48]; P=0.02) and late time windows (45.5% versus 33.1%; adjusted OR, 2.18 [95% CI, 1.28–3.37]; P=0.004) compared with DTCI approach.11 Moreover, it has been demonstrated that the impact of DTAS on decreasing workflow times and improving outcomes was maintained both during regular work hours as well as on-call hours.11 The present pooled analysis showed that the overall effect favored DTAS in achieving functional independence in the early time window with this benefit remaining significant even when considering studies that also included patients treated beyond 6 hours of symptom onset. However, subgroup analysis showed no significant difference between DTAS and DTCI approaches in transfer patients. Likewise, there was no significant difference in observational studies with mixed patient populations. These findings could be explained by the fact that patients who are transferred to EVT-capable centers tend to be those with more favorable imaging (eg, slow progressors). It has been reported that the time from stroke onset to reperfusion was not associated with outcome in slow progressors compared with fast progressors.41,42 Although, the current evidence in mothership patients indicates similar results, it was only derived from one single-center RCT including small sample sizes in subgroup analyses (mRS score of 0–2; DTAS=6/19 [31.6%] versus DTCI=6/21 [28.8%]; P=0.88).16
Our study has limitations. First, there is a relatively small number of available studies. Therefore, we could not perform an assessment of publication bias or meta-regression analysis. Second, there were only 2 RCTs among the 7 included studies, both of which were single-center in design. Third, we reported significant heterogeneity for some outcomes that could not be solved by sensitivity analysis. However, we performed a random effect model to overcome heterogeneity. Fourth, we did not consider evaluating outcomes of DTAS according to stroke severity (ie, baseline National Institutes of Health Stroke Scale score or Alberta Stroke Program Early CT Score) since only one study reported the outcomes in different National Institutes of Health Stroke Scale score categories (≤15 and >15) while other studies identified the outcome only in the overall population. Finally, we excluded studies that potentially included duplicate patients from the analysis but, by doing so, we may have also potentially excluded nonduplicate patients.

Conclusions

Our meta-analysis showed that the DTAS paradigm seems to be associated with significant improvement in workflow time metrics and functional outcomes with a comparable safety profile to the DTCI approach in the overall study population. However, in subgroup analysis, DTAS was not associated with improved functional independence neither in transfer patients nor in observational studies. Multicenter RCTs are ongoing to better evaluate this paradigm and hopefully establish a new approach for EVT in the early window: “Select Faster, Select Less and Treat More.”

Article Information

Supplemental Material

PRISMA 2020 Checklist
Figures S1–S14

Acknowledgments

Dr Mohammaden participated in study conception, design of the work, review of the literature, interpretation of data, and drafting of the article. Dr Doheim contributed to statistical analysis, review of the literature, critical revision of the article. Dr Elfil contributed to review of the literature, and critical revision of the article. Dr Nogueira contributed to study conception, design of the work, interpretation of data, and critical review of the article. Other coauthors participated in critical revision of article. All authors gave final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Footnote

Nonstandard Abbreviations and Acronyms

DTAS
direct transfer to angiosuite
DTCI
direct transfer to conventional imaging
DTP
door-to-puncture
EVT
endovascular treatment
IV tPA
intravenous tissue-type plasminogen activator
mTICI
modified Thrombolysis in Cerebral Infarction
RR
risk ratio
sICH
symptomatic intracerebral hemorrhage

Supplemental Material

File (str_stroke-2021-038221_supp1.pdf)
File (str_stroke-2021-038221_supp2.pdf)

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Published In

Go to Stroke
Stroke
Volume 53 • Number 8 • August 2022
Pages: 2478 - 2487
PubMed: 35593152

Copyright

© 2022 American Heart Association, Inc.

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History

Received: 30 November 2021
Revision received: 24 February 2022
Accepted: 1 April 2022
Published online: 20 May 2022
Published in print: August 2022

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Keywords

  1. angiography
  2. cerebral infarction
  3. hemorrhage
  4. reperfusion
  5. thrombectomy

Subjects

  1. Angiography
  2. Ischemic Stroke

Authors

Affiliations

Mahmoud H. Mohammaden, MD, MSc https://orcid.org/0000-0002-7393-9989
Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
Grady Memorial Hospital, Atlanta, GA (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
View all articles by this author
Mohamed Fahmy Doheim, MD https://orcid.org/0000-0001-8279-5078
Alexandria Faculty of Medicine, Alexandria University, Egypt (M.F.D.).
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Mohamed Elfil, MD https://orcid.org/0000-0002-1125-2946
Department of Neurological Sciences, University of Nebraska Medical Center, Omaha (M.E.).
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Alhamza R. Al-Bayati, MD https://orcid.org/0000-0001-8103-1930
Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
Grady Memorial Hospital, Atlanta, GA (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
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Agostinho Pinheiro, MD https://orcid.org/0000-0002-2496-9479
Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
Grady Memorial Hospital, Atlanta, GA (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
View all articles by this author
Thanh N. Nguyen, MD https://orcid.org/0000-0002-2810-1685
Department of Neurology, Boston University School of Medicine, MA (T.N.N.).
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Nirav R. Bhatt, MD https://orcid.org/0000-0001-9838-6180
Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
Grady Memorial Hospital, Atlanta, GA (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
View all articles by this author
Diogo C. Haussen, MD https://orcid.org/0000-0003-1884-2196
Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
Grady Memorial Hospital, Atlanta, GA (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
View all articles by this author
Raul G. Nogueira, MD https://orcid.org/0000-0003-4532-153X [email protected]
Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
Grady Memorial Hospital, Atlanta, GA (M.H.M., A.R.A.-B., A.P., N.R.B., D.C.H., R.G.N.).
View all articles by this author

Notes

This manuscript was sent to Steven M. Greenberg, Guest Editor, for review by expert referees, editorial decision, and final disposition.
Supplemental Material is available at Supplemental Material.
For Sources of Funding and Disclosures, see page 2485.
The podcast and transcript are available at https://www.ahajournals.org/str/podcast.
Correspondence to: Raul G. Nogueira, MD, UPMC Stroke Institute, C-400 PUH, 200 Lothrop Street, Pittsburgh, PA 15213. Email [email protected]

Disclosures

Disclosures Dr Nogueira reports consulting fees for advisory roles with Stryker Neurovascular, Cerenovus, Medtronic, Phenox, Anaconda, Genentech, Biogen, Prolong Pharmaceuticals, Imperative Care and stock options for advisory roles with Brainomix, Viz-AI, Corindus Vascular Robotics, Vesalio, Ceretrieve, Astrocyte, and Cerebrotech. Dr Haussen is a consultant for Stryker and Vesalio and holds stock options at Viz.AI. Dr Al-Bayati is a consultant for Stryker Neurovascular. Dr Nguyen reports research support from Medtronic, SVIN. The other authors report no conflicts.

Sources of Funding

None.

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Direct to Angiosuite Versus Conventional Imaging in Suspected Large Vessel Occlusion: A Systemic Review and Meta-Analysis
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