JAMA Neurology publishes Sarraj research on ischemic stroke

By Roman Petrowski, Office of Communications

Dr. Amrou Sarraj Ischemic Strokes Study
Amrou Sarraj, MD

International research from a multicenter study, led by McGovern Medical School neurologists, is providing more guidance on stroke treatment.

The study, led by Amrou Sarraj, MD, associate professor in the Department of Neurology and published in JAMA Neurology focuses on patients suffering from large vessel occlusions, ischemic strokes, resulting from a blockage in one of the major arteries of the brain including the carotid terminus and middle cerebral artery which cut off blood flow to large areas of the brain.

These patients receive endovascular treatment — microcatheters inserted into the blood clot to safely remove them through thrombectomy.

The purpose of the study was to determine if repeated imaging (computed tomography with or without computed tomographic angiography or computed tomography perfusion) is necessary, or if a direct to angiography treatment would be safe and improve outcomes in stroke patients with large vessel occlusions who were transferred to tertiary centers for endovascular treatment.

The study also evaluated if the direct-to-angiography suite approach can be applicable to patients presenting in the late time treatment window (six hours or more from stroke/last known well time) and patients presenting outside of regular work hours, as well as the transfer duration for which the approach maintained the superiority over repeat imaging.

“A direct to angiography treatment paradigm without repeated imaging for transferred patients with large vessel occlusion may reduce time to endovascular thrombectomy,” Sarraj said. “Whether the direct-to-angiography suite approach is safe and associated with better outcomes in the late (more than six hours) window is unknown. The applicability of the approach in patients presenting outside of regular hours has not been studied before.”

For their research, Sarraj’s group studied data on more than 1,100 patients with ischemic strokes presenting at six comprehensive stroke centers in the United States and Europe, who received endovascular thrombectomy.

Patients that were treated with direct-to-angiography suite approach received endovascular thrombectomy 26 minutes earlier compared to patients treated with the repeated imaging strategy (median 34 vs 60 minutes). Furthermore, these patients demonstrated higher rates of 90-day functional independence (52.6% vs. 37.0%) as well as lower mortality (17.0% vs. 24.4%) in the study.

Better functional and safety outcomes were maintained in patients presenting during after-hours and weekends. Longer transfer times were associated with less improvement, and the benefit of direct to angiography suite became non-significant in patients with inter-facility transfer times of 3 hours or longer.

“Our study findings suggest that the direct to angiography approach may be associated with faster treatment and better functional outcomes during all hours and treatment windows. Repeating the imaging may be reasonable in patients with prolonged transfer times,” the authors said. “Workflow optimization and judicious selection of patients for direct to angiography approach has the potential to significantly improve outcomes with endovascular thrombectomy. Our study findings may guide the treatment decision making by the physicians until the results of randomized controlled trials on the subject become available.”