Time Is Brain: The Direct-to-Angiosuite Strategy

The Direct-to-Angiosuite (DTAS) approach is a workflow designed to reduce reperfusion times in stroke patients and ultimately improve neurological outcomes. A growing body of evidence has demonstrated the benefits of this modality in terms of improved functional outcomes. Unlike traditional protocols and guidelines, which typically require multiple imaging studies to diagnose stroke, assess cerebral perfusion, and determine the location of the occlusion, DTAS relies on direct endovascular therapy. This approach reduces the time from symptom onset to reperfusion. Delayed onset of reperfusion is associated with a higher likelihood of functional disability. In this context, “time is brain” can be translated as “imaging is brain.” To illustrate this approach, we present the case of a 68-year-old man who presented with left-sided weakness, expressive aphasia, and right-sided gaze palsy-symptoms suggestive of ischemic stroke. The patient arrived at the emergency department (ED) via Emergency Medical Services (EMS) with a stroke code for immediate evaluation. On initial assessment, the patient had a National Institutes of Health Stroke Scale (NIHSS) score of 14 and underwent a rapid neurological examination. He was then transferred to the angiosuite for urgent endovascular revascularization of a right MCA/M1 occlusion. The procedure was a combination of mechanical thrombectomy and aspiration. The door-to-puncture time was 20 min, and the door-to-reperfusion time was 65 min. Successful reperfusion, with a Thrombolysis in Cerebral Infarction (TICI) score of 2C, resulted in a good recovery with no neurological deficits. This case illustrates the potential benefits of a DTAS approach. A large, randomized, multicenter study is underway to determine its impact on patient outcomes.