90-day mRS Research Articles

Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions (S24.003)

Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions (S24.003)

Examining Predictors of Favorable 90-day Outcome in Stroke Patients with Active Cancer Undergoing Endovascular Therapy (P8-5.022)

<h3>Objective:</h3> To determine covariates associated with long-term outcomes for patients with acute ischemic stroke (AIS) who had active cancer and underwent endovascular therapy. <h3>Background:</h3> Intraarterial therapy (IAT) is the standard of care for all AIS patients, even those with active cancer. Many studies show poor outcomes for patients with active malignancy compared to those without who undergo IAT. Few studies, however, have identified other characteristics that may contribute to 90-day modified Rankin scale (mRS) scores for patients with active cancer undergoing IAT. <h3>Design/Methods:</h3> This retrospective study included patients (age ≥ 18) admitted from 07/18–10/20 with AIS, treated by IAT, and had active cancer. The primary outcome was 90-day mRS; secondary outcomes were complications. The receiver operating characteristic area under the curve (AUC) was used to determine optimal admission national institutes of health scores (NIHSS) to obtain a 90-day mRS of 0–2. Alpha=0.05. <h3>Results:</h3> There were 53 patients; 42% had a 90-day mRS of 0–2 and 58% had 3–6. The median (interquartile range) age was 71 years (64–81), 58% were male, and the median admission NIHSS was 12 (6–17). Compared to patients who had a 90-day mRS of 3–6, patients with a 0–2 had a significantly lower median admission NIHSS (6.5 (3–15) vs. 15 (9–22), p=0.006), more had IV-tPA (41% vs. 13%, p=0.02), and significantly less experienced a thromboembolic event during their hospital course (17% vs. 57%, p=0.004). No patients with an mRS of 0–2 had a symptomatic intracranial hemorrhage, respectively (0% vs. 10%, p=0.13). The NIHSS cut-off for predicting a favorable 90-day mRS was 8.2 and indicated a moderate fit. <h3>Conclusions:</h3> This data suggests that both admission NIHSS and thromboembolic events were strong predictors of 90-day outcomes. Using an NIHSS cut-off of 8.2 for patients with active cancer in determining who should receive IAT may increase the probability of a favorable 90-day outcome. <b>Disclosure:</b> Dr. Pirahanchi has nothing to disclose. Constance McGraw has nothing to disclose. Dr. Bartt has nothing to disclose. David Bar-Or has received personal compensation in the range of $10,000-$49,999 for serving as an officer or member of the Board of Directors for Ampio Pharmaceuticals. David Bar-Or has stock in Ampio Pharmaceuticals.

Endovascular Thrombectomy Beyond 24 Hours from Stroke Onset: A Systematic Review and Meta-Analysis (S24.001)

<h3>Objective:</h3> To assess the safety and efficacy of endovascular thrombectomy (EVT) &gt;24-h and compare clinical outcomes with patients treated &lt;24-h. <h3>Background:</h3> Trials have demonstrated the benefit of EVT up to 24-hours after acute ischemic stroke (AIS) onset. Recently, real-world observational studies reported that EVT was effective and safe beyond 24-h from AIS onset with comparable outcomes to EVT within 24-h. <h3>Design/Methods:</h3> A systematic search was performed in MEDLINE and EMBASE for studies published from inception to July 2022. Studies including patients with AIS who received EVT beyond 24-h from stroke onset were selected. We also included patients treated with EVT (&gt;24-h and &lt;24-h) from our institutional retrospective data. Outcomes of interest included functional independence (90-day mRS 0–2), successful recanalization (mTICI 2b-3), symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days. First, a single-arm meta-analysis (MA) of proportions was conducted for studies with EVT &gt;24-h. Then, we performed a comparative MA between the &lt;24-h and &gt;24-h groups to calculate pooled odds ratios (OR) for each outcome. Statistical heterogeneity across studies was assessed with I² statistics. <h3>Results:</h3> Five studies with 298 patients treated &gt;24-h were included. Functional independence rate was 39% (95%CI 27–54%; I²=68%) and successful recanalization rate was 79% (95%CI 75–83%; I²=0%). Mortality and sICH rates were 25% (95%CI 20–30%; I²=0%) and 6% (95%CI 4–9%; I²=0%), respectively. We included 3272 patients (&gt;24-h = 179; &lt;24-h = 3093) in the comparative analysis. There was no significant difference in functional independence (OR 0.76; 95%CI 0.41–1.32), successful recanalization (OR 0.6; 95%CI 0.44–1.0), and mortality (OR 1.18; 95%CI 0.7–1.9) rates between patients who underwent EVT &lt;24-h versus &gt;24-h. <h3>Conclusions:</h3> Our findings prove that EVT beyond 24-h is safe and effective. Also, this MA did not demonstrate a significant difference between EVT beyond and within 24-h from stroke onset regarding functional independence, successful recanalization, and mortality. <b>Disclosure:</b> Dr. Rodriguez-Calienes has nothing to disclose. Mr. Vivanco-Suarez has nothing to disclose. Dr. Galecio-Castillo has nothing to disclose. Cynthia Zevallos has nothing to disclose. Mr. Malaga has nothing to disclose. Dr. Farooqui has nothing to disclose. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for stryker. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for medtronic. Dr. Ortega Gutierrez has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for microvention. Dr. Ortega Gutierrez has received personal compensation in the range of $0-$499 for serving as an officer or member of the Board of Directors for SVIN. The institution of Dr. Ortega Gutierrez has received research support from stryker. The institution of Dr. Ortega Gutierrez has received research support from Siemens. The institution of Dr. Ortega Gutierrez has received research support from IschemiaView. The institution of Dr. Ortega Gutierrez has received research support from Medtronic.

Predictive validity of the prognosis on admission aneurysmal subarachnoid haemorrhage scale for the outcome of patients with aneurysmal subarachnoid haemorrhage

This multicentre prospective cohort study aimed to compare the accuracy of the PAASH, WFNS, and Hunt and Hess (H&H) scales in predicting the outcomes of adult patients with aneurysmal SAH presented to three central hospitals in Hanoi, Vietnam, from August 2019 to June 2021. Of 415 eligible patients, 32.0% had a 90-day poor outcome, defined as an mRS score of 4 (moderately severe disability) to 6 (death). The PAASH, WFNS and H&H scales all have good discriminatory abilities for predicting the 90-day poor outcome. There were significant differences in the 90-day mean mRS scores between grades I and II (p = 0.001) and grades II and III (p = 0.001) of the PAASH scale, between grades IV and V (p = 0.026) of the WFNS scale, and between grades IV and V (p < 0.001) of the H&H scale. In contrast to a WFNS grade of IV–V and an H&H grade of IV–V, a PAASH grade of III–V was an independent predictor of the 90-day poor outcome. Because of the more clearly significant difference between the outcomes of the adjacent grades and the more strong effect size for predicting poor outcomes, the PAASH scale was preferable to the WFNS and H&H scales.

Lack of Better Functional Outcomes in Young Border Hispanic Patients with Acute Ischemic Stroke after Endovascular Thrombectomy Compared to Older Patients: A Retrospective Chart Review (P8-5.001)

<h3>Objective:</h3> To study the interaction between age and Hispanic status to assess functional outcomes after endovascular thrombectomy in young versus older patients in a predominantly Hispanic population with a high prevalence of diabetes mellitus and obesity. <h3>Background:</h3> Previous data indicates that young acute ischemic stroke patients have better prognosis after endovascular thrombectomy. However, data has also shown that Hispanic patients are associated with poorer outcomes following thrombectomy, yet the combination of these factors is not well characterized. <h3>Design/Methods:</h3> A retrospective chart review of patients with an anterior circulation large vessel occlusion between August 2012 to January 2022 was performed, comparing the data of young patients (18–49 years) and older patients (≥ 50 years). Baseline characteristics and outcomes including Modified Rankin Scale (mRS), Symptomatic Intracerebral Hemorrhage (sICH), Expanded Treatment in Cerebral Infarction score (eTICI), and mortality were studied, adjusting for confounders. <h3>Results:</h3> A total of 811 patients, with 66 (8%) being 18 to 49 years old (33% female) revealed younger patients had lower presenting median National Institute of Health Stroke Scale (NIHSS) scores (9.5 versus 17, P &lt;0.001), and lower presence of co-morbidities. Both groups had a Hispanic predominance (73 versus 74%, P = 0.97). Subset analysis indicated that 90-day mRS score 0–2, sICH, eTICI, and mortality rates did not differ significantly. <h3>Conclusions:</h3> Our Hispanic population demonstrates no differences in sICH, mortality, and functional independence between young and older acute ischemic stroke patients after endovascular thrombectomy, deviating from previous data. The Texas Rio Grande Valley region has uniquely high rates of diabetes and obesity in young patients compared to elsewhere. Our findings demonstrate that Hispanic status and high diabetes rates in young patients may predominate over age-related outcome differences in prior data. Further investigation is needed to elucidate the unique intersection between Hispanic status, diabetes mellitus, obesity, and age in ischemic stroke patients after endovascular thrombectomy. <b>Disclosure:</b> Ms. Ravi has nothing to disclose. Mr. Desai has nothing to disclose. Mr. Ghozy has nothing to disclose. Dr. Tekle has nothing to disclose. Dr. Hassan has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Medtronic. Dr. Hassan has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Stryker. Dr. Hassan has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Penumbra. Dr. Hassan has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Cerenovus. Dr. Hassan has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Viz.ai. Dr. Hassan has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Genentech. Dr. Hassan has received research support from GE Healthcare.

A Weighted Cortical ASPECTS Compared Against Total ASPECTS in Outcome Prediction of Anterior Large Vessel Occlusion Thrombectomy (S24.007)

<h3>Objective:</h3> Compare outcome prediction using Cortical Alberta Stroke Program Early Computed Tomography Score(ASPECTS) against total ASPECTS, in large vessel occlusion strokes undergoing Thrombectomy. <h3>Background:</h3> The 10-point ASPECTS accounts for subcortical structures that may be more likely to infarct and differentially associated with long-term outcomes when compared to injured cortical regions. More specific, cortically-weighted 7-point ASPECTS score could more accurately predict long-term functional outcomes following successful recanalization. <h3>Design/Methods:</h3> Registry data from 2 Comprehensive Stroke Centers(site 1:2016–2021; site 2:2019–2021) including patients with M1 or internal carotid artery(ICA) occlusions who underwent thrombectomy were consolidated for analysis. The primary outcome was a shift in 90-day modified Rankin(mRS), which was adjusted a priori for age, pre-stroke mRS, baseline National Institutes of Health Stroke Scale, M1 versus internal carotid artery (ICA) occlusion, and successful recanalization(TICI 2b/3). The training model of 10-point ASPECTS(tASPECTS) vs. 7-point cortical-weighted ASPECTS(cASPECTS) was generated in site 1 and validated in site 2, with models compared using receiver operator characteristics(ROC) and corrected Akaike’s Information Criterion(AICc). <h3>Results:</h3> Of 328 included patients (site 1/training cohort=181; site 2/validation=147), median age was 71y(IQR 61.25–82), of whom 119(36.28%) had ICA occlusion, with a median tASPECTS of 9(IQR 8–10) and median cASPECTS of 6(IQR 5–7). In derivation cohort for the cASPECTS, multi-class adjusted ROC curves were generated, with areas under the curve (AUC) for predicting mRS shift ranging from 0.8546–0.9110(AICc=690.078, r^2=0.5936). In validation cohort, the misclassification rate was 71.6%, however, when expanded for flexibility(+/−1 mRS unit), model classifies validation site data correctly 55.8% of time. In training cohort for the tASPECTS, the AUC for predicted mRS classes ranged from 0.8812–0.9250(AICc=693.646, r^2=0.6165), with no difference in model performance against cASPECTS (p=0.14). In validation cohort, the misclassification rate was 73.47%, and improved to 50.3% correct when expanded for flexibility(+/−1 mRS unit). <h3>Conclusions:</h3> The cASPECTS and tASPECTS were similarly predictive of 90-day mRS scores following successful recanalization. <b>Disclosure:</b> Dr. Patel has nothing to disclose. Ms. Koneru has nothing to disclose. Ms. Penckofer has nothing to disclose. Dr. Nguyen has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Vesalio. Dr. Nguyen has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for NIH. Dr. Nguyen has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Avania. Dr. Nguyen has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for AHA. The institution of Dr. Nguyen has received research support from Boston Medical Center. The institution of Dr. Nguyen has received research support from Society of Vascular and Interventional Neurology. Dr. Khalife has nothing to disclose. Dr. Oliveira has nothing to disclose. Mohamad Abdalkader has nothing to disclose. Mr. Klein has nothing to disclose. Mr. Vigilante has nothing to disclose. Scott Kamen has nothing to disclose. Dr. Thomas has received personal compensation for serving as an employee of Cooper Univeristy Health Care. Dr. Thomas has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Stryker. Dr. Thomas has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Medtronic. Dr. Thomas has received personal compensation in the range of $500-$4,999 for serving as a Consultant for CereVasc. Dr. Siegler has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Ceribell. Dr. Siegler has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for AstraZeneca.

The BAND score: a simple upfront predictive model for futile recanalization to guide patient selection for endovascular thrombectomy during acute ischemic stroke triage (P8-5.004)

<h3>Objective:</h3> To develop a clinical scoring system for upfront prediction of poor post-endovascular thrombectomy (EVT) outcomes during the acute stroke triage process. <h3>Background:</h3> Futile recanalization (FR) is an unfavorable outcome following successful EVT for acute ischemic stroke patients. There is currently no clinical scoring system that can accurately predict FR. <h3>Design/Methods:</h3> Consecutive EVT patients for anterior circulation large vessel occlusion strokes were identified from 2016 to 2021 at a Comprehensive Stroke Center, and clinical information was recorded. FR was defined as a 90-day modified Rankin Scale (mRS) of 4 or greater despite achieving modified thrombolysis in cerebral infarction (mTICI) score 2b or greater. Multivariable regression analyses were used to identify independent risk factors for FR, and a scoring system was constructed. <h3>Results:</h3> 619 patients were identified, and 483 patients with successful recanalization and available 90-day follow-up data were analyzed. Overall, FR was observed in 46.5% of patients. From a randomly selected training cohort (n=357), individual risk factors for FR were identified and used to construct the 10-point BAND score: baseline disability (1 point: baseline mRS ≥ 2), age (1 point: 60–69 years, 2 points: 70–79 years, 3 points: 80–84 years, 4 points: 85 years or older), NIHSS (2 points: 13–17, 3 points: 18–22, and 4 points: 23 or higher), and delay from last known normal (1 point: ≥6 hours). The BAND score achieved good predictability of FR with an area under the receiver-operating characteristic curve of 0.80 in our training cohort and 0.78 in our validation cohort. 88.2% of the total and 90.2% of patients 80 years or older with BAND ≥7 had a 90-day mRS of 4 or greater despite successful EVT recanalization. <h3>Conclusions:</h3> The BAND score is a simple clinical scoring system for prediction of FR, and it has potential to serve as a valuable triage tool for physicians in a real-world setting. <b>Disclosure:</b> Mr. Chen has received research support from National Institues of Health. Dr. Colasurdo has nothing to disclose. Dr. Phipps has nothing to disclose. The institution of Dr. Miller has received research support from Medtronic. The institution of Dr. Miller has received research support from Cerenovus, DePuy Synthes Products, Inc.. The institution of Dr. Miller has received research support from InSightec. The institution of Dr. Miller has received research support from Microvention. The institution of Dr. Miller has received research support from Microvention. The institution of Dr. Miller has received research support from InSightec. The institution of Dr. Miller has received research support from MicroVention. The institution of Dr. Miller has received research support from InSightec. The institution of Dr. Miller has received research support from Vesalio. Jacob Cherian has nothing to disclose. Dr. Marino Granados has nothing to disclose. Dr. Cronin has nothing to disclose. Dr. Wozniak has nothing to disclose. Dheeraj Gandhi has nothing to disclose. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Astra Zeneca. Dr. Chaturvedi has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for University of Calgary. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Ramar &amp; Paradiso. Dr. Chaturvedi has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Cole, Scott, Kissane. The institution of Dr. Chaturvedi has received research support from NINDS. Gaurav Jindal has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Penumbra.

A propensity score-matched comparative study of balloon guide catheters versus conventional guide catheters for concurrent mechanical thrombectomy with carotid stenting in tandem strokes: comparison of first pass effect, symptomatic intracranial hemorrhage, and 90-day functional outcomes

BackgroundExtensive clot burden in tandem strokes accounts for poor mechanical thrombectomy (MT) outcomes. Several studies have shown the benefit of balloon guide catheters (BGCs) in MT and carotid artery stenting.ObjectiveIn...

Current status of endovascular treatment for older adults with acute large vessel occlusion stroke in China: subgroup analysis of ANGEL act registry.

Although endovascular treatment (EVT) has become the standard treatment for acute large vessel occlusion (LVO), its safety and efficacy in older adults have not been fully determined. The present study aimed to compare the safety and efficacy of EVT for acute LVO between younger (<80 years old) and older adults (≥80 years old) in the Chinese population. The subjects were selected from the ANGEL-ACT registry (endovascular treatment key technique and emergency workflow improvement of acute ischemic stroke). The 90-day modified Rankin score (mRS), successful recanalization, procedure duration, number of passes, intracranial hemorrhage (ICH), and mortality within 90 days were compared after adjusting for confounders. A total of 1,691 patients, 1,543 classified as young and 148 classified as older, were included. We observed that young and older adults had a similar 90-day mRS distribution, successful recanalization, procedure duration, number of passes, ICH, and mortality within 90 days (all p > 0.05). The rate of 90-day mRS 0-3 was found to be higher in young patients than in older adults (39.9% vs. 56.5%, odds ratio = 0.64, 95% confidence interval = 0.44-0.94, p = 0.022). We found that patients less than or greater than 80 years of age share similar clinical outcomes, without increasing the risk of ICH and mortality.

480 Cerebrospinal Fluid Volume Assessed From Clinical T1w-MRI Predicts Functional Outcomes Post-Thrombectomy

INTRODUCTION: Endovascular treatment (EVT) is recognized as the standard of care for patients with acute ischemic stroke caused by large vessel occlusion (LVO). However, many patients do not achieve functional independence after successful EVT, which may be due to the pre-existing brain atrophy and higher total cerebrospinal fluid volume (CSFV). Prediction of patients who will highly benefit from EVT may be possible using baseline total CSFV as a marker of brain health and reserve. METHODS: We performed a retrospective analysis of Wake Forest Baptist Health’s Stroke Thrombectomy and Aneurysm Registry (n = 602), collected between 2015 - 2021. We selected 213 patients (mean age 67.5 ± 14.6, 49.3% female) who had adequate MRI within 14 days of EVT and a record of the modified Rankin scale (mRS) at 90 days post EVT. Clinical T1w images were transformed into high-resolution images using the convolutional neural network SynthSR. Then, FreeSurfer was used to estimate total cranial CSFV including the ventricles and choroid plexus. To correct for head size, total CSFV was adjusted to the estimated total intracranial volume. RESULTS: Baseline total CSFV significantly predicted 90-day mRS in an ordinal regression model adjusted for baseline mRS (p &lt; 0.001). After further adjustment for age, sex, smoking history, prior stroke, hypertension, congestive heart failure, hemoglobin A1c, atrial fibrillation, ASPECT score, and other confounders, total CSFV remained an independent predictor of 90-day mRS (p = 0.007). CONCLUSIONS: This study elucidates the clinical implications of pre-existing brain health and reserve in the setting of acute ischemic strokes to aid clinicians in treatment decisions impacting prognosis. Increased total CSFV correlates with increased brain frailty and poorer functional outcomes after mechanical thrombectomy, which may ultimately attenuate its benefit.

Elevated Serum NOX2 Levels Contribute to Delayed Cerebral Ischemia and a Poor Prognosis After Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study.

NADPH oxidase 2 (NOX2) is highly expressed in injured brain tissues. We determined serum NOX2 levels of aneurysmal subarachnoid hemorrhage (aSAH) patients and further investigated correlation of serum NOX2 levels with disease severity, delayed cerebral ischemia (DCI) plus prognosis after aSAH. Serum NOX2 levels were measured in 123 aSAH patients and 123 healthy controls. World Federation of Neurological Surgeons scale (WFNS) score and modified Fisher (mFisher) score were utilized to assess disease severity. Modified Rankin scale (mRS) score was used to evaluate the clinical prognosis at 90 days after aSAH. Relations of serum NOX2 levels to DCI and 90-day poor prognosis (mRS score of 3-6) were analyzed using multivariate analysis. Receiver operating characteristic curve (ROC) was built to evaluate the prognostic predictive capability. Serum NOX2 levels in aSAH patients, compared with healthy controls, were significantly increased, and were independently correlated with WFNS score, mFisher score and post-stroke 90-day mRS score. Patients with poor prognosis or DCI had significantly higher serum NOX2 levels than other remainders, and serum NOX2 levels independently predicted 90-day poor prognosis and DCI. Serum NOX2 had high prognosis and DCI predictive abilities, and their areas under ROC curve were similar to those of WFNS score and mFisher score. Serum NOX2 levels are significantly associated with hemorrhage severity, poor 90-day prognosis and DCI in aSAH patients. Hence, complement NOX2 may serve as a potential prognostic biomarker after aSAH.

Endovascular treatment of acute basilar artery occlusion caused by vertebral artery stump syndrome: A clinical analysis of 37 cases

IntroductionAcute basilar artery occlusion (ABAO) caused by vertebral artery stump syndrome (VASS) has a low incidence and is always underestimated. Due to the occlusion of the origin of the vertebral artery (VA), it is often combined with basilar artery (BA) endovascular diseases or non-dominant contralateral vertebral artery, making the endovascular treatment (EVT) challenging to implement. ObjectiveThis article focuses on whether EVT and two interventional route options could bring clinical benefits to this group of patients: basilar artery thrombectomy through the occluded lateral vertebral artery and implementing revascularization of the occluded vertebral artery (dirty-road-path); thrombectomy through the non-occluded lateral vertebral artery (clean-road-path). MethodsWe collected six cases of acute embolic basilar artery occlusion (ABAO) due to VASS from January 2020 to December 2021 at our hospital and retrospectively analyzed 31 patients previously reported in the literature and applied statistical analysis to investigate the treatment options and clinical prognosis of these patients. ResultsThe clean-road-path surgical protocol was applied in 4 of 37 patients, the dirty-road-path protocol was applied in 29 patients, and 4 patients did not recanalized the basilar artery. By statistical analysis we found that successful recanalization of the basilar artery was clinically significant in reducing the modified Rankin Scale (mRS) scores in these patients, the statistical difference in the benefit of the two surgical protocols was negative. There was a significant positive correlation between preoperative National Institute of Health Stroke Scale (NIHSS) and postoperative 90-day mRS scores. ConclusionEndovascular treatment can benefit patients with ABAO due to VASS, and patients with higher preoperative NIHSS scores are more vulnerable to getting a poor prognosis. Comparison between the two endovascular options did not yield statistically significant results, but the dirty-road-path option may be superior to using the clean-road-path.

Editors' Note: Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.

Dr. Siegler and colleagues evaluated outcomes of mechanical thrombectomy (MT) vs medical management in a multinational cohort of 554 patients with a prestroke modified Rankin Scale (mRS) score of 2–4 and anterior circulation large vessel occlusion, treated 6–24 hours from the time last seen well. They found that MT was associated with higher odds of return to prestroke mRS by 90 days. In response, Drs. Bruno and Nichols noted that there is no clear guidance for scoring a baseline or prestroke mRS (indeed, the mRS was originally intended for evaluating poststroke outcomes). They also contend that scoring a 90-day mRS in patients with prestroke disability is not clearly defined. Responding to these comments, the authors agree that the prestroke mRS has important limitations, but point to the fact that this measure has been used in various studies, including in the selection of patients for interventional stroke trials. They correctly note that current guidelines to score the poststroke mRS are intended simply to score how the patient is functioning at the time in question, rather than making judgments about how they are doing in relation to their prestroke status. Overall, this exchange demonstrates important nuances in the assessment of prestroke status and poststroke outcomes in patients with prestroke disability—a population that has been poorly represented in acute stroke trials. Dr. Siegler and colleagues evaluated outcomes of mechanical thrombectomy (MT) vs medical management in a multinational cohort of 554 patients with a prestroke modified Rankin Scale (mRS) score of 2–4 and anterior circulation large vessel occlusion, treated 6–24 hours from the time last seen well. They found that MT was associated with higher odds of return to prestroke mRS by 90 days. In response, Drs. Bruno and Nichols noted that there is no clear guidance for scoring a baseline or prestroke mRS (indeed, the mRS was originally intended for evaluating poststroke outcomes). They also contend that scoring a 90-day mRS in patients with prestroke disability is not clearly defined. Responding to these comments, the authors agree that the prestroke mRS has important limitations, but point to the fact that this measure has been used in various studies, including in the selection of patients for interventional stroke trials. They correctly note that current guidelines to score the poststroke mRS are intended simply to score how the patient is functioning at the time in question, rather than making judgments about how they are doing in relation to their prestroke status. Overall, this exchange demonstrates important nuances in the assessment of prestroke status and poststroke outcomes in patients with prestroke disability—a population that has been poorly represented in acute stroke trials.

Computed tomography derived cervical fat-free muscle fraction as an imaging-based outcome marker in patients with acute ischemic stroke: a pilot study

BackgroundOutcome assessment in stroke patients is essential for evidence-based stroke care planning. Computed tomography (CT) is the mainstay of diagnosis in acute stroke. This study aimed to investigate whether CT-derived cervical fat-free muscle fraction (FFMF) as a biomarker of muscle quality is associated with outcome parameters after acute ischemic stroke.MethodsIn this retrospective study, 66 patients (mean age: 76 ± 13 years, 30 female) with acute ischemic stroke in the anterior circulation who underwent CT, including CT-angiography, and endovascular mechanical thrombectomy of the middle cerebral artery between August 2016 and January 2020 were identified. Based on densitometric thresholds, cervical paraspinal muscles covered on CT-angiography were separated into areas of fatty and lean muscle and FFMF was calculated. The study cohort was binarized based on median FFMF (cutoff value: < 71.6%) to compare clinical variables and outcome data between two groups. Unpaired t test and Mann-Whitney U test were used for statistical analysis.ResultsNational Institute of Health Stroke Scale (NIHSS) (12.2 ± 4.4 vs. 13.6 ± 4.5, P = 0.297) and modified Rankin scale (mRS) (4.3 ± 0.9 vs. 4.4 ± 0.9, P = 0.475) at admission, and pre-stroke mRS (1 ± 1.3 vs. 0.9 ± 1.4, P = 0.489) were similar between groups with high and low FFMF. NIHSS and mRS at discharge were significantly better in patients with high FFMF compared to patients with low FFMF (NIHSS: 4.5 ± 4.4 vs. 9.5 ± 6.7; P = 0.004 and mRS: 2.9 ± 2.1 vs.3.9 ± 1.8; P = 0.049). 90-day mRS was significantly better in patients with high FFMF compared to patients with low FFMF (3.3 ± 2.2 vs. 4.3 ± 1.9, P = 0.045).ConclusionCervical FFMF obtained from routine clinical CT might be a new imaging-based muscle quality biomarker for outcome prediction in stroke patients.

Derivation and validation of a composite scoring system (SAVED2) for prediction of unfavorable modified Rankin scale score following intracerebral hemorrhage.

To develop a composite score for predicting functional outcome post-intracerebral hemorrhage (ICeH) using proxy measures that can be assessed retrospectively. Data from the observational ERICH study were used to derive a composite score (SAVED2) to predict an unfavorable 90-day modified Rankin scale (mRS) score. Independent predictors of unfavorable mRS were identified via multivariable logistic regression and assigned score weights based on effect size. Area under the curve (AUC) was used to measure the score's discriminative ability. External validation was performed in the randomized ATACH-2 trial. There were 2,449 patients from ERICH with valid mRS data who survived to hospital discharge. Predictors associated with unfavorable 90-day mRS score and their corresponding point values were: age ≥70 years (odds ratio [OR], 3.8; 1-point); prior stroke (OR, 2.8; 1-point); need for ventilation (OR, 2.7; 1-point); extended hospital stay (OR, 2.7; 1-point); and non-home discharge location (OR, 5.3; 2-points). Incidence of unfavorable 90-day mRS increased with higher SAVED2 scores (P < 0.001); AUC in ERICH was 0.82 (95% CI, 0.80-0.84). External validation in ATACH-2 (n = 904) found an AUC of 0.74 (95% CI, 0.70-0.77). Using data collected at hospital discharge, the SAVED2 score predicted unfavorable mRS in patients with ICeH.

Too bad to treat? Predicting clinical outcome after mechanical thrombectomy in octogenarians

ObjectivesWe aimed to reveal the effect of the totaled health risk in vascular events (THRIVE) score and the radiological parameters of the Alberta stroke program early computed tomography score (ASPECTS), the Van Swieten Scale (VSS) score, and the Evans Index on clinical outcomes in patients over 80 years of age who underwent endovascular thrombectomy (EVT). Materials and MethodsWe retrospectively analyzed anterior ischemic stroke (AIS) patients over 80 years of age who underwent EVT between May 2017 and April 2022. Good functional outcome was accepted as a 90-day modified Rankin Scale (mRS) score of 0–2. We constructed three models to compare to the mRS (model 1: THRIVE, CTA-ASPECT; model 2: THRIVE, CTA-ASPECT, Evans Index; model 3: THRIVE, CTA-ASPECT, Evans Index, VSS). ResultsA total of 39 octogenarian patients with thrombolysis in cerebral infarction (TICI) 2c-3 recanalization were selected, and their 90-day mRS scores were compared. Of these, 19 patients (48%) showed good outcomes. In multivariable receiver operating characteristic (ROC) analyses, the AUC of model 1 was 0.797 (95% confidence interval [CI], 0.638–0.909), the AUC of model 2 was 0.862 (95% CI, 0.714–0.951), and the AUC of model 3 was 0.905 (95% CI, 0.768–0.975). ConclusionsEvaluation of the THRIVE score, which measures vascular disease burden and stroke severity, together with the radiological parameters of ASPECTS score, VSS score, and the Evans Index, provides useful guidance in predicting the clinical outcomes of elderly AIS patients after EVT.

Selection of patients with acute vertebrobasilar artery occlusion for endovascular treatment by magnetic resonance imaging.

The best method for selecting patients with acute vertebrobasilar artery occlusion (VBAO) who would benefit from endovascular treatment (EVT) is still the key question. This study aimed to assess the efficacy of magnetic resonance imaging (MRI) for selecting patients with acute VBAO for EVT. A total of 14 patients with suspected acute VBAO on MR angiography (MRA) in the EVT database (from April 2016 to August 2019) were enrolled. Acute Stroke Prognosis Early Computed Tomography Score (ASPECTS) and pons-midbrain index were assessed on diffusion-weighted imaging (DWI). EVT included a stent retriever and a rescue treatment (angioplasty and/or stenting). The proportion of successful reperfusion and favorable functional outcomes (modified Rankin Scale ≤ 3) at 90 days was documented. A total of 11 patients were included in the final analysis. The median DWI-ASPECTS and pons-midbrain index were 7 and 2, respectively. Underlying stenosis was detected in 10 of 11 (90.9%) patients. Balloon angioplasty and/or stenting were used as rescue therapy for five patients and two patients, respectively. A total of nine patients (81.8%) achieved successful reperfusion (mTICI, 2b, or 3). The 90-day mRS score of 0-3 was achieved in six (54.5%) patients. The mortality rate within 90 days was 18.2% (two of 11 patients). DWI plus MRA could help select the patients with acute VBAO for EVT by assessing ASPECTS and the pons-midbrain index. Patients could achieve good reperfusion and favorable functional outcomes.

General anesthesia vs. non-general anesthesia for vertebrobasilar stroke endovascular therapy.

The optimal type of anesthesia for acute vertebrobasilar artery occlusion (VBAO) remains controversial. We aimed to assess the influence of anesthetic management on the outcomes in VBAO patients received endovascular treatment (EVT). Patients underwent EVT for acute VBAO at 21 stroke centers in China were retrospectively enrolled and compared between the general anesthesia (GA) group and non-GA group. The primary outcome was the favorable outcome, defined as a modified Rankin Scale (mRS) score 0-3 at 90 days. Secondary outcomes included functional independence (90-day mRS score 0-2), and the rate of successful reperfusion. The safety outcomes included all-cause mortality at 90 days, the occurrence of any procedural complication, and the rate of symptomatic intracranial hemorrhage (sICH). In addition, we performed analyses of the outcomes in subgroups that were defined by Glasgow Coma Scale (GCS) score (≤8 or >8). In the propensity score matched cohort, there were no difference in the primary outcome, secondary outcomes and safety outcomes between the two groups. Among patients with a GCS score of 8 or less, the proportion of successful reperfusion was significantly higher in the GA group than the non-GA group (aOR, 3.57, 95% CI 1.06-12.50, p = 0.04). In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar results were found. Patients placed under GA during EVT for VBAO appear to be as effective and safe as non-GA. Furthermore, GA might yield better successful reperfusion for worse presenting GCS score (≤8). URL: http://www.chictr.org.cn/; Unique identifier: ChiCTR2000033211.

Abstract TP14: Does Atrial Fibrillation (Afib) Impact The Rate Of 90 Days Modified Rankin Scale (mRS) In Patients Who Received Intravenous Thrombolytic (IVT) Before Endovascular Treatment (EVT)?results From A Large Health System In Six Western States Of The United States

Introduction: Previous studies indicate patients with acute ischemic stroke (AIS) due to Afib may not respond well to intravenous thrombolysis (IVT) compared to those without Afib. We assessed the association between a history of atrial Afib, good 90-day mRS (≤2), and the rate of symptomatic intracerebral hemorrhage (sICH) in patients treated with IVT and/or EVT. Methods: Data from a multi-state health system’s stroke registry for patients who received acute stroke treatment and were discharged between 2018 and 2022 were used. Patients were stratified into groups 1:EVT only with or without Afib; 2: IVT plus EVT with or without Afib; 3:IVT only with or without Afib.Multivariable mixed-effect logistic regression was performed and adjusted for baseline NIHSS, age, sex, race, and ethnicity, NIHSS on admission, blood glucose on admission, SBP at admission, and history of diabetes, CAD/prior MI, carotid stenosis, smoking, dyslipidemia, heart failure, being overweight, or renal insufficiency Results: Overall, 2558 patients who underwent AIS treatment had a 90-day mRS, of whom 30% had a history of AFib, 48% had a 90-day mRS 0-2; with the median age at arrival 72 years,73% white, median NIHSS was 9, 27% diabetes, 21% CAD, 4% carotid stenosis, 13% smoker, 60% dyslipidemia, 13% HF, 62% overweight, 11% chronic renal insufficiency, median SBP 153 mmHg, median glucose 124.Among group 1(n=978): 39.4% had Afib, 36.1% had a 90-day mRS 0-2 and 5% had sICH .In group 2 (n=402): 28.1% had Afib, 44.3% had a 90-day mRS 0-2 and 5.9% had sICH. In group 3(n=1178): 16.1% had Afib, 59.9% had a 90-day mRS of 0-2, and 2.6% had sICH.After adjustment, there was no association between Afib and 90-day mRS in any group. Also, the rate of sICH did not significantly differ between Afib and non-Afib patients. Conclusions: History of Afib did not significantly impact favorable functional outcomes or the rate of sICH in patients who underwent EVT with or without intravenous thrombolytics.

Abstract TMP85: Initial CT Perfusion Imaging Is Not A Significant Predictor Of Functional Outcome In Patients Undergoing Thrombectomy

Background: In patients with acute ischemic stroke involving the anterior circulation who undergo mechanical thrombectomy (MT), it is not known which, if any, measure of ischemic core volume (ASPECTS, CBF &lt;30% volume, or Tmax &gt;10 seconds volume) is best at predicting functional outcome as defined by 90-day mRS. This retrospective study investigated the relationship between measures of ischemic core volumes and functional outcomes and compared these to known outcome predictors including baseline NIHSS and thrombectomy reperfusion success (TICI) scores. Methods: We included 100 consecutive patients with ischemic stroke due to internal carotid artery or middle cerebral artery occlusion who underwent CT perfusion and were treated with MT. CBF &lt;30% volumes and Tmax &gt;10 s volumes were automatically estimated using RAPID software. ASPECTS were automatically scored using e-ASPECTS software. TICI scores were graded by the case interventionalist and neurologist. Pearson correlation coefficients (r) were calculated to evaluate relationships between each predictor variable (initial NIHSS, TICI score, ASPECTS, CBF &lt;30% volume, and Tmax &gt;10 s volume) and the dependent variable (90-day mRS). Results: As expected, there was a significant relationship between both baseline NIHSS and TICI score and 90-day mRS (NIHSS-mRS r=0.25, R 2 =0.063, p=0.01; TICI-mRS r=-0.28, R 2 =0.077, p=0.005). In contrast, all measures of ischemic core volume had very low, non-significant correlations with 90-day mRS (ASPECTS-mRS r=-0.057, R 2 =0.0032, p=0.6; CBF &lt;30% volume-mRS r=0.0042, R 2 =0, p=0.9; Tmax &gt;10 s volume-mRS r=-0.020, R 2 = 0.0004, p=0.9). Conclusions: Initial stroke severity and MT success remain the best predictors of functional outcomes in patients undergoing MT. None of the assessed markers of ischemic core volume predicted functional outcomes. These results only apply to thrombectomy patients and not to cases excluded by larger cores.