90-day Modified Rankin Scale Research Articles

Intravenous thrombolysis outcome in posterior vs anterior circulation stroke in a tertiary stroke center in Egypt

BackgroundIntravenous thrombolysis (IVT) with alteplase is the first-line therapy for acute ischemic anterior and posterior circulation strokes (ACS and PCS).Knowledge about safety and efficacy of IVT in posterior circulation stroke is deficient as most of the Egyptian studies either assessed IVT outcome in comparison to conservative therapy or its outcome in anterior circulation stroke only.Therefore, our aim was to compare the relative frequency and outcome after intravenous thrombolysis in anterior versus posterior circulation stroke patients presenting to stroke centers of Ain Shams University hospitals (ASUH).ResultsA total of 238 anterior circulation stroke and 61 posterior circulation strokes were enrolled, onset-to-door and door-to-needle time were statistically insignificant.NIHSS showed comparable difference at all time points despite higher scores along anterior circulation stroke; 90-day modified Rankin Scale (mRS) showed significant improvement in both groups from mRS >2 to ≤2 with a better percentage along posterior circulation stroke patients.There was insignificant difference for either incidence of death or intracranial hemorrhage (ICH) between the two groups.ConclusionIVT significantly reduced NIHSS for both anterior and posterior circulation stroke along different studied time points. Meanwhile, a higher percentage of patients with posterior circulation stroke had a better mRS outcome at 90 days.

Neuroprotective effects of intraoperative dexmedetomidine versus saline infusion combined with goal-directed haemodynamic therapy for patients undergoing cranial surgery: A randomised controlled trial.

By inhibiting neuroinflammation dexmedetomidine may be neuroprotective in patients undergoing cranial surgery, but it reduces cardiac output and cerebral blood flow. To investigate whether intra-operative dexmedetomidine combined with goal-directed haemodynamic therapy (GDHT) has neuroprotective effects in cranial surgery. A double-blind, single-institution, randomised controlled trial. A single university hospital, from April 2017 to April 2020. A total of 160 adults undergoing elective cranial surgery. Infusion of dexmedetomidine (0.5 μg kg-1 h-1) or saline combined with GDHT to optimise stroke volume during surgery. The proportion who developed postoperative neurological complications was compared. Postoperative disability was assessed using the Barthel Index at time points between admission and discharge, and also the 30-day modified Rankin Scale (mRS). Postoperative delirium was assessed. The concentration of a peri-operative serum neuroinflammatory mediator, high-mobility group box 1 protein (HMGB1), was compared. Fewer patients in the dexmedetomidine group developed new postoperative neurological complications (26.3% vs. 43.8%; P = 0.031), but the number of patients developing severe neurological complications was comparable between the two groups (11.3% vs. 20.0%; P = 0.191). In the dexmedetomidine group the Barthel Index reduction [0 (-10 to 0)] was less than that in the control group [-5 (-15 to 0)]; P = 0.023, and there was a more favourable 30-day mRS (P = 0.013) with more patients without postoperative delirium (84.6% vs. 64.2%; P = 0.012). Furthermore, dexmedetomidine induced a significant reduction in peri-operative serum HMGB1 level from the baseline (222.5 ± 408.3 pg ml-1) to the first postoperative day (152.2 ± 280.0 pg ml-1) P = 0.0033. There was no significant change in the control group. The dexmedetomidine group had a lower cardiac index than did the control group (3.0 ± 0.8 vs. 3.4 ± 1.8 l min-1 m-2; P = 0.0482) without lactate accumulation. Dexmedetomidine infusion combined with GDHT may mitigate neuroinflammation without undesirable haemodynamic effects during cranial surgery and therefore be neuroprotective. Clinicaltrials.gov Identifier: NCT02878707.

Impact of Direct Admission Versus Interfacility Transfer on Endovascular Treatment Outcomes for Acute Ischemic Stroke: Systematic Review and Meta-Analysis

Mechanical thrombectomy is a proven treatment for large-vessel ischemic stroke with improved functional outcomes compared with intravenous thrombolytics. Access to thrombectomy-capable sites varies greatly by geography, often necessitating interhospital transfer of patients who first present to hospitals unable to provide thrombectomy. The purpose of this meta-analysis was to examine the impact of interhospital transportation on patient outcomes to better inform recommendations for prehospital protocols. A meta-analysis was performed following systematic literature searches. Outcomes of interest included successful reperfusion, symptomatic intracranial hemorrhage, 90-day modified Rankin Scale score 0-2, 90-day mortality, onset-to-puncture times, and door-to-puncture times. Pooled analysis comprised >27,000 patients. Door-to-puncture time was 35.6 minutes shorter among transferred patients; however, symptom onset-to-puncture time was 91.6 minutes longer. Rate of reperfusion or symptomatic intracranial hemorrhage as well as 90-day mortality did not differ significantly between transferred and directly admitted patients. While the proportion of patients achieving good functional outcome at 90 days with modified Rankin Scale score 0-2 did not differ by admission type, when modified Rankin Scale score was narrowed to 0-1, direct transport showed 20% greater probability of achieving excellent functional outcome (P < 0.001). This meta-analysis represents the largest pooled population examined to date to assess how interfacility transportation to thrombectomy-capable sites affects patient outcomes. Our results indicate that direct admission is a significant predictor of excellent functional outcome. The findings presented here can be used to better inform quality improvement projects to streamline access to facilities providing endovascular mechanical thrombectomy capabilities.

Predicting 90-day modified Rankin Scale score with discharge information in acute ischaemic stroke patients following treatment

ObjectivesTo understand variability in modified Rankin Scale scores from discharge to 90 days in acute ischaemic stroke patients following treatment, and examine prediction of 90-day modified Rankin Scale score by...

Characteristics and Outcomes of Left Ventricular-Assist Device-Associated Cerebrovascular Events in Setting of Infectious Intracranial Aneurysms.

Background and purpose: The study aims to identify the characteristics and neurological outcomes of the left ventricular-assist device (LVAD)-associated cerebrovascular events (CVE) and infections, particularly in the setting of infectious intracranial aneurysms (IIA).Methods: A single-center retrospective review of patients having undergone LVAD implantation between 2011 and 2017 was conducted using institutional registries and screened for CVE. Patients with CVE were assessed for concurrent bacteremia; neurovascular imaging was then used to isolate patients with IIA. A review of comorbidities, imaging characteristics, and management were performed to determine predictors of neurological outcomes, as defined by the 90-day modified Rankin scale (mRS) scores.Results: Of the 383 HeartMate II LVAD implantations performed, 43 all-cause stroke events were identified across 35 (9%) patients. The majority of the events were hemorrhagic CVE (n=28) with 21 events complicated by bacteremia. Of patients with hemorrhagic CVE and bacteremia, Staphylococcus aureus (n=10) and Pseudomonas aeruginosa (n= 8) infection were the most frequently associated organisms. Severe disability or death (90-day mRS > 4) was observed in 15 patients (63%). Seven patients had confirmed findings of IIA on diagnostic cerebral angiogram and were associated with distal middle cerebral artery (MCA) territory involvement (n=6; 86%) with concurrent Staphylococcus (n=5, 71%) and/or Pseudomonas (n=4, 57%) infections. Overall, a higher incidence of acute and chronic bacteremia was observed in the hemorrhagic CVE subgroup compared to the ischemic CVE subgroup (74% vs 36% & 71% vs 29%, respectively; p <0.05). Despite endovascular and/or surgical intervention in patients with IIA, four patients failed management and elected for comfort measures.Conclusion: Our results indicate that P. aeruginosa and S. aureus bacteremia are associated with a greater incidence of intracranial hemorrhage and worse neurological outcomes. Future management considerations may include pre-implantation cerebrovascular imaging to assess vascular pathology including prior aneurysms and intracranial atherosclerotic disease burden as a screen for higher-risk patients, as well as more aggressive antibiotic therapy at bacteremia onset.

Effectiveness and safety of endovascular thrombectomy for large versus medium vessel occlusions: a single-center experience

BackgroundThe effectiveness and safety of endovascular thrombectomy (EVT) for medium vessel occlusions (MeVO) in the anterior intracranial circulation for patients with acute ischemic stroke (AIS) has yet to be definitively...

Editors' Note: Association of Initial Imaging Modality and Futile Recanalization After Thrombectomy

In “Association of Initial Imaging Modality and Futile Recanalization After Thrombectomy,” Meinel et al. reported that the rate of futile recanalization (defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization) among patients enrolled in the BEYOND-SWIFT multicenter, retrospective observational registry was significantly higher in patients selected for thrombectomy based on a CT scan as compared with patients selected for thrombectomy based on an MRI. Siegler and Thon cautioned that these findings should not dissuade against (1) use of a CT scan to determine eligibility for thrombectomy because this could lead to unnecessary delays in care or (2) performance of thrombectomy after CT scans because the imaging modality itself does not directly affect outcome and 40% of patients selected for thrombectomy based on a CT scan had a good 90-day mRS score (which represents a 22%–27% absolute increase compared with patients treated with medical management in the DAWN and DEFUSE-3 trials). Meinel et al agreed that it is imperative to avoid delays before thrombectomy and reinforced that their findings should not influence the selection of imaging modality for potential thrombectomy candidates. They also pointed out that implementation of high-speed MRI protocols should be considered to obtain more detailed information than a CT scan can provide while avoiding lengthy delays between imaging and groin puncture. In “Association of Initial Imaging Modality and Futile Recanalization After Thrombectomy,” Meinel et al. reported that the rate of futile recanalization (defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization) among patients enrolled in the BEYOND-SWIFT multicenter, retrospective observational registry was significantly higher in patients selected for thrombectomy based on a CT scan as compared with patients selected for thrombectomy based on an MRI. Siegler and Thon cautioned that these findings should not dissuade against (1) use of a CT scan to determine eligibility for thrombectomy because this could lead to unnecessary delays in care or (2) performance of thrombectomy after CT scans because the imaging modality itself does not directly affect outcome and 40% of patients selected for thrombectomy based on a CT scan had a good 90-day mRS score (which represents a 22%–27% absolute increase compared with patients treated with medical management in the DAWN and DEFUSE-3 trials). Meinel et al agreed that it is imperative to avoid delays before thrombectomy and reinforced that their findings should not influence the selection of imaging modality for potential thrombectomy candidates. They also pointed out that implementation of high-speed MRI protocols should be considered to obtain more detailed information than a CT scan can provide while avoiding lengthy delays between imaging and groin puncture.

Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes: Insight from the STAR Collaboration

Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions. This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 and December 2018. The study cohort was divided into 2 groups based on the location of occlusion (proximal vs. distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery, or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale score 0-2. A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared with the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; P= 0.03) and a lower rate of successful reperfusion (78% vs. 84%; P= 0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality, or procedure-related complications between the 2 groups. Successful reperfusion, age, and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group. Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.

Off-hour effect on time metrics and clinical outcomes in endovascular treatment for large vessel occlusion: A systematic review and meta-analysis

There is an ongoing debate on the off-hour effect on endovascular treatment (EVT) for acute large vessel occlusion (LVO). This meta-analysis aimed to compare time metrics and clinical outcomes of acute LVO patients who presented/were treated during off-hour with those during working hours. Structured searches on the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted through 23 February 2021. The primary outcomes were onset to door (OTD), door to imaging, door to puncture (DTP), puncture to recanalization, procedural time, successful recanalization, symptomatic intracranial hemorrhage (SICH), mortality in hospital, good prognosis (90-day modified Rankin Scale (mRS) score 0-2), and 90-day mortality. The secondary outcomes were imaging to puncture (ITP), onset to puncture (OTP), onset to recanalization (OTR), door to recanalization (DTR) time, mRS 0-2 at discharge, and consecutive 90-day mRS score. The odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) of the outcomes were calculated using random-effect models. Heterogenicity and publication bias were analyzed. Subgroup and sensitivity analyses were conducted as appropriate. Nineteen studies published between 2014 and 2021 with a total of 14,185 patients were eligible for quantitative synthesis. Patients in the off-hour group were significantly younger than those in the on-hour group and with comparable stroke severity and intravenous thrombolysis rate. The off-hour group had longer OTD (WMD [95% CI], 12.83 [1.84-23.82] min), DTP (WMD [95% CI], 11.45 [5.93-16.97] min), ITP (WMD [95% CI], 10.39 [4.61-16.17] min), OTP (WMD [95% CI], 25.30 [13.11-37.50] min), OTR (WMD [95% CI], 25.16 [10.28-40.04] min), and DTR (WMD [95% CI], 18.02 [10.01-26.03] min) time. Significantly lower successful recanalization rate (OR [95% CI], 0.85 [0.76-0.95]; p = 0.004; I2 = 0%) was detected in the off-hour group. No significant difference was noted regarding SICH and prognosis. But a trend toward lower OR of good prognosis was witnessed in the off-hour group (OR [95% CI], 0.92 [0.84-1.01]; p = 0.084; I2 = 0%). Patients who presented/were treated during off-hour were associated with excessive delays before the initiation of EVT, lower successful reperfusion rate, and a trend toward worse prognosis when compared with working hours. Optimizing the workflows of EVT during off-hour is needed.

CT perfusion based ASPECTS improves the diagnostic performance of early ischemic changes in large vessel occlusion

BackgroundASPECTS scoring method varies, but which one is most suitable for predicting the prognosis still unclear. We aimed to evaluate the diagnostic performance of Automated (Auto)-, noncontrast CT (NCCT)- and CT perfusion (CTP) -ASPECTS for early ischemic changes (EICs) in acute ischemic stroke patients with large vessel occlusion (LVO) and to explore which scoring method is most suitable for predicting the clinical outcome.MethodsEighty-one patients with anterior circulation LVO were retrospectively enrolled and grouped as having a good (0–2) or poor (3–6) clinical outcome using a 90-day modified Rankin Scale score. Clinical characteristics and perfusion parameters were compared between the patients with good and poor outcomes. Differences in scores obtained with the three scoring methods were assessed. Diagnosis performance and receiver operating characteristic (ROC) curves were used to evaluate the value of the three ordinal or dichotomized ASPECTS methods for predicting the clinical outcome.ResultsSixty-three patients were finally included, with 36 (57.1%) patients having good clinical outcome. Significant differences were observed in the ordinal or dichotomized Auto-, NCCT- and CTP-ASPECTS between the patients with good and poor clinical outcomes (all p < 0.01). The areas under the curves (AUCs) of the ordinal and dichotomized CTP-ASPECTS were higher than that of the other two methods (all p < 0.01), but the AUCs of the Auto-ASPECTS was similar to that of the NCCT-ASPECTS (p > 0.05).ConclusionsThe CTP-ASPECTS is superior to the Auto- and NCCT-ASPECTS in detecting EICs in LVO. CTP-ASPECTS with a cutoff value of 6 is a good predictor of the clinical outcome at 90-day follow-up.

Non-contrast head CT-based thrombolysis for wake-up/unknown onset stroke is safe: A single-center study and meta-analysis.

Recent studies have shown that tPA can be safely administered past the standard 4.5 h window with good outcomes when selected with multi-model imaging, which is often lacking outside of comprehensive stroke centers. We aim to analyze the safety and outcomes of wake up/unknown onset (WUS/UNK) patients treated based on non-contrast head CT (NCCT) at our institution and in the literature. Suspected stroke patients from January 2015 to December 2018 receiving tPA within 4.5 h (standard window-SW) and with WUS/UNK based on NCCT and clinical-imaging mismatch were identified. We compared baseline characteristics, tPA metrics, and outcome data, with primary outcome as symptomatic intracerebral hemorrhage (sICH). A meta-analysis was performed evaluating NCCT-based treatment of WUS/UNK patients. Of 1827 patients treated at our hub or through telestroke, 93 underwent WUS/UNK-based treatment. There was no statistical difference in sICH between WUS/UNK and SW: 1% vs. 4% (OR 0.3; 95% confidence interval 0.0-1.9). 90-day modified Rankin scale outcomes were similar between SW and WUS/UNK-treated patients. Seven studies encompassing 485 WUS/UNK patients were included in a pooled analysis with a 2.1% incidence of sICH. In our meta-analysis, three studies compared NCCT-based treated WUS/UNK patients with SW patients with no difference in rate of hemorrhage: 2.1% vs 3.4% (OR 1.01; 95% confidence interval 0.45-2.28). Our single-center analysis and meta-analysis suggest that tPA can be safely administered based on NCCT with comparable rates of sICH for select WUS/UNK stroke patients.

Intravenous Tirofiban Infusion After Angioplasty and Stenting in Intracranial Atherosclerotic Stenosis-Related Stroke.

This study aimed to investigate the effectiveness and safety of intravenous infusion of tirofiban after emergent angioplasty with or without stenting in patients with intracranial atherosclerotic stenosis-related large-vessel occlusion stroke. We performed a retrospective case series study of 98 patients who underwent thrombectomy followed by angioplasty with or without stenting to treat intracranial atherosclerotic stenosis-related large-vessel occlusion. Patients were divided into 2 groups: those who received continuous intravenous infusion of tirofiban for 12 hours after procedure (intravenous tirofiban group, n=30) and those who did not receive postprocedural intravenous tirofiban (control group, n=68). The following treatment outcomes in the 2 groups were compared: early reocclusion of treated arteries on computed tomography angiography, parenchymal hematoma, symptomatic hemorrhage, and 90-day functional outcome. Early reocclusion occurred in 18 patients (18.4%). The rate of early reocclusion was significantly lower in the intravenous tirofiban group than in the control group (3.3% versus 25%, P<0.001). The rates of parenchymal hematoma, symptomatic hemorrhage, 90-day good outcome, and mortality were not significantly different between the 2 groups. In multivariate logistic analysis, the only independent predictor of early reocclusion was no use of intravenous tirofiban (odds ratio, 9.212 [95% CI, 1.155-73.495], P=0.036). A good outcome (90-day modified Rankin Scale score of 0-2) was significantly less frequent in patients with early reocclusion than in those without it (16.7% versus 72.5%, P<0.001). The use of intravenous tirofiban for 12 hours was associated with decreased risk of early reocclusion of treated arteries, with no increased risk of hemorrhage after emergent angioplasty, with or without stenting, in patients with intracranial atherosclerotic stenosis-related large-vessel occlusion stroke. Early reocclusion was associated with a poor outcome in such cases.

Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes

BackgroundPatients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have...

Thrombectomy Versus Combined Thrombolysis and Thrombectomy in Patients With Acute Stroke: A Matched-Control Study.

A recent randomized controlled trial DIRECT-MT (Direct Intra-Arterial Thrombectomy to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals) compared the safety and efficacy of mechanical thrombectomy (MT) versus combined intravenous thrombolysis (IVT) and MT for acute large vessel occlusion. The current study utilized a prospective, nationwide registry to validate the results of the DIRECT-MT trial in a real-world practice setting. Subjects were selected from a prospective cohort of acute large vessel occlusion patients undergoing endovascular treatment at 111 hospitals from 26 provinces in China (ANGEL-ACT registry [Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke]) between November 2017 and March 2019. All patients eligible for IVT and receiving MT were reviewed and then grouped according to whether prior IVT or not (MT and combined IVT+MT). After a 1:1 propensity score matching, the outcome measures including the 90-day modified Rankin Scale, successful recanalization, door-to-puncture time, symptomatic intracranial hemorrhage, and intraprocedural embolization were compared. A total of 1026 patients, 600 in the MT group and 426 in the combined group, were included. Among 788 patients identified after matching, there were no significant differences in the 90-day modified Rankin Scale (median, 3 versus 3 points; P=0.82) and successful recanalization (86.6% versus 89.3%; P=0.23) between the two groups; however, patients of the MT group had a shorter door-to-puncture time (median, 112 versus 136 minutes; β=−45.02 [95% CI, −68.31 to −21.74]), lower rates of symptomatic intracranial hemorrhage (5.5% versus 10.1%; odds ratio, 0.52 [95% CI, 0.30–0.91]), and embolization (4.6% versus 8.1%; odds ratio, 0.54 [95% CI, 0.30–0.98]) than those of the combined group. This matched-control study largely confirmed the findings of the DIRECT-MT trial in a real-world practice setting, suggesting that MT may carry similar effectiveness to combined IVT+MT for acute large vessel occlusion patients, despite MT alone seems to be associated with a shorter in-hospital delay until procedure, lower risks of symptomatic intracranial hemorrhage, and embolization. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03370939

Abstract P524: Impact of Intra-Procedural Workflow and Time Metrics of Establishing Fast Reperfusion on Clinical Outcomes in the ESCAPE-NA1 Trial

Background: Time from imaging to establishing reperfusion is a major influencer of clinical outcomes and over the years thrombectomy techniques have evolved rapidly. This has led to improvements in achieving fast and complete reperfusion. We analyzed the impact of various intra-procedural techniques and tools on the speed of reperfusion and correlated procedural duration with probability of achieving good clinical outcomes. Methods: We analyzed intra-procedural time metrics and examined factors leading to delays during EVT. The relationship between outcome (mRS Scale) and procedural time from arterial puncture to time of achieving mTICI 2b-3 First Reperfusion (FRE) was modeled using logistic regression. Results: The various procedural time metrics are summarized in Figure 1. Every 10-minute increase in FRE time reduced the probability of achieving functional independence(90-day modified Rankin Scale 0-2) by 6.7% (P=0.021, adjusted). The medianFRE timewas 25min (IQR 17-39) and was significantly longer in patients with tandem occlusions(median 34min, p 0.0005). General anesthesia vs procedural sedation vs no sedation use did not significantly alter the FRE time (p = 0.1453). The use of BGC (54.2%) was nominally longer FRE (median 26min “IQR 18-38” vs 23ming, “IQR 16-38”; p 0.095)while the use of contact aspiration (n=213) vs retrievable stents (n=676) as the first approach was associated with a shorter FRE time (21min “IQR 14-35” vs 26 min “IQR18-40”, p =0.001). Conclusions: Puncture to first reperfusion time is a significant predictor of clinical outcome in theESCAPE-NA1 trial. Various procedural and anatomical factors influence this timemetric. Figure: Intra-Procedural workflow time metrics expressed in medians and 90th percentiles. The cumulative times are calculated for each major milestone in the procedure for upto three attempts. First reperfusion duration where TICI 2b was achieved is shown in comparison to other procedural time metrics.

Abstract P528: Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy a Meta-Analysis

Introduction and hypothesis: In patients with acute ischemic stroke with large vessel occlusion (AIS-LVO), the role of intra-arterial adjunctive medications (IAM) like urokinase, tPA or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We hypothesize that AIS-LVO patients treated with both MT + IAM (rescue or concurrent) achieve better safety and efficacy outcomes than patients treated with MT alone and aim to determine the efficacy and safety of concomitant or rescue IAM for AIS-LVO patients undergoing MT. Methods: We searched Medline, Embase and Cochrane Stroke Group Trials Register databases from inception until 13th March 2020. We analysed all studies with patients diagnosed with AIS-LVO in the anterior or posterior circulation, that provided data for the two treatment arms: 1)MT+IAM and 2)MT-only, and also reported on at least one of the following outcomes: reperfusion, 90-days modified Rankin Scale (mRS), symptomatic intracranial hemorrhage (sICH) and 90-days mortality. Data were collated in accordance with the PRISMA guidelines. Results: Sixteen non-randomized observational studies with a total of 4581 patients were analysed. MT-only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT+IAM. As compared to patients treated with MT alone, patients treated with combination therapy (MT +IAM) had a higher likelihood of achieving good functional outcome (risk ratio=1.13, 95% CI 1.03-1.24) and a lower risk of 90-day mortality (risk ratio=0.82, 95% CI 0.72-0.94). There was no significant difference in successful reperfusion (risk ratio=1.02, 95% CI 0.99-1.06) and sICH between the two groups (risk ratio = 1.13, 95% CI 0.87-1.46) (Figure 1). Conclusions: In AIS-LVO, use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to confirm the safety and efficacy of IAM as adjunctive treatment of MT.

Abstract P392: Early Brain Injury and Soluble ST2 After Non-Traumatic Subarachnoid Hemorrhage

Intro: Early Brain Injury (EBI) after non-traumatic subarachnoid hemorrhage (SAH) is a significant mediator of neurological injury, but the injury pathways and markers are not well understood. We hypothesized that the inflammatory mediator soluble ST2 (sST2) is associated with markers of EBI. Methods: We studied two independent cohorts, including 190 SAH patients in a discovery cohort and 50 patients in a replication cohort. Clinical markers of EBI included early loss of consciousness, Glasgow Coma Scale (GCS) score at 24 hours, and neurological deterioration within the first 72 hours (defined as a decrease in GCS ≥ 2 points). Radiographic markers included bicaudate index, clinically significant hydrocephalus requiring external ventricular drainage (EVD), and global cerebral edema. Serial plasma sST2 level was measured at early (3.5 ± 1.2 days post-hemorrhage), intermediate (7.8 ± 1.3 days post-hemorrhage), and late (13 ± 2.3 days post-hemorrhage) time points in the discovery cohort and daily during post-hemorrhage days 1-9 in the replication cohort. In the discovery cohort, the relationship between EBI markers and poor functional outcome (90-day modified Rankin Scale; mRS ≥ 3) was assessed using multivariable logistic regression. The association between sST2 level and EBI markers was evaluated using repeated measures analysis. In the replication cohort, associations were examined using an analysis of response profiles. Results: Clinical and radiographic markers of EBI, except for global edema, were each associated with functional outcome in univariate analysis. Of these EBI markers, independent predictors of poor outcome included 24-hour GCS (OR=5.76, 95% CI 2.31-14.4, p&lt;0.001) and clinically significant hydrocephalus (OR=8.74, 95% CI 2.44-31.3, p=0.001). Elevated sST2 was associated with all markers of EBI except for global edema, and independently predicted poor outcome in a multivariate model that included EBI markers. These findings were further replicated in an independent cohort. Conc: Of the potential clinical and radiographic contributors to EBI, poor 24-hour GCS and clinically significant hydrocephalus remain independent predictors of poor outcome. Furthermore, soluble sST2 level is associated with EBI and poor outcome.

Abstract MP37: Race/Ethnicity Differences in Response to Intensive Blood Pressure Treatment After Intracerebral Hemorrhage: Analysis of the Atach-2 Trial

Background: The main analysis of the ATACH-2 (Antihypertensive Treatment in Intracerebral Hemorrhage-2) trial suggested no benefit from intensive blood pressure lowering (BPL) treatment after intracerebral hemorrhage (ICH). However, whether outcome and response to treatment differs according to race was not sufficiently studied. Methods: This is a post-hoc analysis of the ATACH-2 trial. The primary outcome was death or disability (90-day modified Rankin Scale [mRS] 4-6). Patients were divided according to race/ethnicity. Logistic regression was fit to assess the association between race and the primary outcome. In addition, we assessed the interaction between intensive BPL treatment and race. Results: A total of 939 patients (White=206, Asian=549, Black=111, Hispanic=73) were included. Death and disability occurred more frequently in White patients than other races (Figure). However, after adjusting for patient age, sex, baseline Glasgow Coma Scale, intracranial hemorrhage volume in mL, presence of intraventricular hemorrhage, deep vs. lobar, left vs. right hemisphere, intubation and ATACH treatment arm, Black patients had higher odds of the primary outcome (OR=1.98, P=0.02) compared to White patients. In contrast, Asian and Hispanic patients had non-statistically significant lower odds of the primary outcome (OR=0.68, P=0.09; OR= 0.97; P=0.95, respectively) compared to White patients. We did not observe treatment-by-race interaction. the p values for the interaction of intensive BPL treatment vs. standard BPL were 0.508 in Blacks, 0.336 in Hispanics and 0.190 in Asians, with Whites as the reference group. Conclusion: Black patients had higher odds of death or disability after non-traumatic supratentorial intracerebral hemorrhage compared to White patients.

Abstract P535: Quality of Reperfusion and Clinical Outcome in ESCAPE-NA1 Trial

Background: We evaluated clinical outcome in relation to the degree of reperfusion in ESCAPE-NA1 trial. Methods: ESCAPE-NA1 was a multicenter, international randomized trial assessing the efficacy of nerinetide in ischemic stroke patients who underwent EVT within 12h from onset. Independent clinical outcome [90-days modified Rankin Scale (mRS) 0-2], excellent clinical outcome (90-days mRS 0-1), isolated subarachnoid hemorrhage with no parenchymal hemorrhage (iSAH) or symptomatic hemorrhage (sICH) on follow-up imaging, and death were compared between a treatment group and control group with respect to the level of reperfusion defined as mTICI. Univariable and multivariable logistic regression analyses were performed. Results: Data from 1090 patients were assessed. The occlusion locations were terminal ICA (18.3%), M1 MCA (61.8%,) M2 MCA (15.1%), other - e.g. M3 (3.7%). Final mTICI 0-1 was achieved in 5.5% of patients, mTICI 2a in 7.5%, mTICI 2b in 40.8%, mTICI 2c in 26.6% and mTICI 3 in 19.5%. Isolated SAH was present in 1.7% and sICH in 3%. There was no significant difference between the nerinetide and control groups in the reperfusion grade, presence of iSAH or sICH, or in clinical outcome. Odds of independent outcomes (mRS 0-2) and odds of excellent outcome (mRS 0-1) were significantly increasing with each improved reperfusion grade, Table 1. Sixty percent of patients with final mTICI 2b, 70% with mTICI 2c and 69% with mTICI 3 achieved good clinical outcome in comparison to 30% of patients with mTICI 0-2a. The incidence of iSAH was significantly lower in the NA1 arm (OR 0.28, 95%CI: 0.09-0.86, p=.027) adjusting for reperfusion status. Conclusion: Degrees of better reperfusion are strongly associated with better outcomes and reduced mortality. mTICI 2c-3 reperfusion should be a standard goal of EVT.

Abstract P335: Post-Treatment Blood-Brain Barrier Disruption is Associated With Cerebral Edema and Extends Into Penumbral Tissue in Anterior Circulation Large Vessel Occlusion

Background: Blood Brain Barrier (BBB) disruption is central to vasogenic edema development after ischemia in preclinical studies. We investigated the relationship between BBB disruption and cerebral edema in patients receiving reperfusion therapies for anterior circulation large vessel occlusion. Methods: In a post-hoc pooled analysis of the Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) part 1 and 2 multicenter RCTs, the DWI lesion on 24h post-treatment MRI and peri-infarct salvaged penumbra derived from pre-treatment CT-Perfusion (CTP) were segmented and registered to 24h MR Perfusion. A validated permeability measure (percentage of measured cerebral blood volume lost due to T1 effect from gadolinium leakage across the BBB) was calculated for each ROI. The association between post-treatment BBB disruption in the infarct and cerebral edema assessed on a trichotomized ordinal scale of negligible (&lt;1mm midline shift), mild (≥1 to &lt;5mm) or severe (≥5mm) was analyzed using ordinal logistic regression. Results: Of 220 patients analyzed, median (IQR) BBB disruption was 2.36(1.4-4.1)% in the infarct, 1.61(1.0-2.6)% in salvaged penumbra and 0.98(0.7-1.5)% in normal brain (p&lt;0.001). There were 119 (54.1%) patients with negligible, 90 (40.8%) mild and 11 (5.0%) severe cerebral edema at 24h. In multivariable analysis, infarct BBB disruption was associated with increased cerebral edema (cOR=1.11 per%, 95%CI 1.02-1.21;p=0.012, adjusted for age, admission NIHSS and reperfusion (mTICI2b/3 or &gt;50% reperfusion on early CTP 2h post-lysis). Infarct BBB disruption correlated with follow-up infarct volume (rho=0.37;p&lt;0.001), and was associated with parenchymal hematoma (aOR=1.18, 95%CI 1.00-1.40;p=0.048) and worse outcome assessed on 90-day modified Rankin Scale (cOR=1.16 per%, 95%CI 1.08-1.26;p&lt;0.001, adjusted for age, admission NIHSS and reperfusion). Conclusions: BBB disruption after reperfusion treatment extends beyond the infarct lesion, and is associated with cerebral edema development, hemorrhagic transformation and poor outcome. Further studies to evaluate BBB integrity as an imaging biomarker and potential therapeutic target in malignant cerebral edema after ischemic stroke are needed.