Effectiveness Of Endovascular Therapy Research Articles

Trevo 3 Mm and/or AXS Catalyst5 for the Treatment of Medium Distal Vessel Occlusion Stroke-results from the ASSIST Registry.

The effect of endovascular therapy (EVT) on the outcome of stroke patients with amedium distal vessel occlusion (MDVO) is unclear. We report the results of MDVO patients treated with the 3 mm Trevo stent retriever (SR) and/or the AXS Catalyst5 distal access catheter. Data was derived from aprospective, multicenter global registry (ASSIST registry) which enrolled patients treated with operator preferred EVT technique at 71sites from January 2019 to January 2022. Three techniques were assessed: SR classic, direct aspiration, and acombined approach. Additional inclusion criteria were (a)EVT performed with the 3 mm Trevo SR and/or AXS Catalyst5 distal access catheter on the first pass and (b)an occlusion of the M2segment or M3segment of the middle cerebral artery or the A1, A2 or A3segment of the anterior cerebral artery. The primary outcome was achieving an expanded Thrombolysis in Cerebral Infarction (eTICI) score of 2c or 3 on the first pass, with the primary technique as adjudicated by core lab. The primary clinical outcome measure was a90-day modified Rankin Scale (mRS) score of 0-2. Atotal of 155 patients (10.4% of the ASSIST population) were included. Most patients had an M2 occlusion (93.5%). First pass eTICI reperfusion was achieved in 43.1% of the patients. No modifying effect of the frontline technique was found. The rate of mRS 0-2 (overall 65.0%) did not significantly differ between groups. The data suggests that the Trevo 3 mm SR and/or the AXS Catalyst5 may be an option to treat medium distal vessel occlusion, but more data is needed to demonstrate safety and efficacy in this patient cohort. Further improvements are needed regarding materials and techniques to improve reperfusion results in this patient cohort in the future.

Effect of Endovascular Thrombectomy for Acute Ischemic Stroke on Cognitive Outcomes: A Secondary Analysis of the ESCAPE Trial.

The effect of endovascular therapy (EVT) for large vessel occlusion stroke on cognitive outcomes is not well understood. We evaluated the effect of EVT on cognitive function in the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial. Patient data from the ESCAPE randomized trial were analyzed. Cognitive assessments completed at 90 days after stroke were the Montreal Cognitive Assessment (MoCA), the Sunnybrook Neglect Assessment Procedure (SNAP), the Boston Naming Test (BNT), Trail-making test A (Trails A), and Trail-making test B (Trails B). We used logistic regression to evaluate the association between EVT and favorable cognitive outcome on the 5 separate tests, adjusting for demographic and clinical factors. We used generalized estimating equations and ordinal regression to determine the odds of favorable outcome with EVT on global cognition incorporating the 5 tests. We added final infarct volume (FIV) to the models to assess the relationship of FIV with cognitive outcome. The ESCAPE trial included 315 patients, 165 randomized to EVT and 150 randomized to control. There was higher odds of favorable outcome with EVT for MoCA (adjusted odds ratio [aOR] 2.32, 95% CI 1.30-4.16), SNAP (aOR 3.85, 95% CI 2.00-7.45), BNT (aOR 2.33, 95% CI 1.30-4.17), trails A (aOR 3.50, 95% CI 1.93-6.36), and trails B (aOR 2.56, 95% CI 1.46-4.48). There was higher odds of favorable outcome with EVT on global binary (aOR 2.57, 95% CI 1.67-3.94) and ordinal analyses (aOR 2.83, 95% CI 1.68-4.76) of cognitive function. After adding FIV to the models, both FIV and EVT were significantly associated with cognitive outcome. There was a significant correlation between global cognitive performance and mRS at day 90 (r = -0.78, p < 0.001), with the largest reductions in favorable cognitive outcome from mRS score 4 to 5 and from mRS 2 to 3. In this secondary analysis of the ESCAPE trial, EVT was associated with favorable outcome on 5 separate cognitive tests and in global analyses of cognitive benefit. These results provide novel evidence for the effect of EVT on cognition and support the global benefit of treatment with EVT. This study provides Class II evidence that in patients with acute ischemic stroke due to intracranial internal carotid artery (ICA) or M1 segment MCA occlusion, including tandem extracranial ICA occlusions, EVT compared with best medical therapy increased odds of favorable cognitive outcome.

Abstract 157: Endovascular Treatment of Acute Ischemic Stroke Patients With Tandem Lesions Presenting With Low Alberta Stroke Program Early Computed Tomography Score

Background and objective: The effect of endovascular therapy (EVT) in tandem lesion (TL) patients with baseline large core infarct is unclear. We investigated the safety and efficacy of EVT in TL patients with low ASPECTS (0-5). We also compared the safety of acute carotid stenting (CAS) in TLs with low ASPECTS. Methods: This prospective multicenter study from 16 centers included patients with anterior circulation TL from 2015-2020. Inclusion criteria were age ≥18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions with &gt;70% stenosis. Patients were divided into ASPECTS 0-5 and 6-10 groups. Inverse Probability of Treatment Weighting (IPTW) was used to assess the association of outcomes. Results: Of the 691 patients, 44 had an ASPECTS 0-5 and 505 had ASPECTS 6-10. After matching, there were decreased odds of favorable shift in mRS at 90 days (30.7% vs 48%, OR: 0.52, CI:0.29-0.97; p=0.002), higher rates of sICH (11.4% vs 3.6%, OR: 3.18, CI: 1.07-9.49; p=0.038), 90-day mortality (35.9% vs 16.3%; OR: 2.35, CI: 1.16-4.74; p=0.017) and comparable rates of successful reperfusion (79.5% vs 88.7%; OR: 0.73, CI: 0.33-1.63, p=0.45), excellent reperfusion (50% vs 49.1%; OR: 1.35, CI: 0.72-2.53; p=0.35) excellent reperfusion (50% vs 49.1%; OR: 1.35, CI: 0.72-2.53; p=0.35) in the ASPECTS 0-5 compared with 6-10. Among patients with ASPECTS 0-5, no significant differences were noted for sICH (OR: 0.31, CI: 0.03-3.05; p=0.32), PH2 (OR: 1.14, CI: 0.26-5.02; p=0.86), petechial hemorrhages (OR: 0.79, CI: 0.10-6.05; p=0.82), and 90-day mortality (OR: 0.68, CI: 0.14-3.45; p=0.6) in patients with stenting (18/44) versus no-stenting (25/44). Conclusion: This multicenter cohort study of AIS patients with TLs demonstrated poor outcomes for functional independence at 90 days and higher rates of sICH and mortality in patients with low ASPECTS (0-5). Among patients with ASPECTS 0-5, rates of sICH and mortality were similar in stenting and non-stenting groups.

Endovascular Therapy for Basilar Artery Occlusion in Sudden Onset to Maximal Deficit Ischemic Events.

The presence of sudden onset to maximal deficit (SOTMD) in patients with acute basilar artery occlusion often results in more severe outcomes. However, the effect of endovascular therapy on SOTMD and whether the outcome is affected by onset-to-puncture time remain unclear. This retrospective analysis was conducted using data from the prospective BASILAR (Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry). Consecutive patients with basilar artery occlusion receiving endovascular therapy were dichotomized into SOTMD and non-SOTMD cohorts. The primary outcomes included a favorable outcome (modified Rankin scale 0-3), recanalization, and mortality at 90 days. The outcomes of patients with SOTMD were analyzed using multivariable logistic regression. In the multivariate analysis, a favorable outcome was similar between the two cohorts (odds ratio [OR], 0.88 [95% CI, 0.58-1.34]; P=0.5), although the mortality of patients with SOTMD was higher than that of patients with non-SOTMD (OR, 1.67 [95% CI, 1.14-2.44]; P=0.008). The probability of mortality increased from 40.0% at 1 hour to 70.0% at 6 hours in the SOTMD cohort, and favorable outcomes of patients with non-SOTMD declined from 38.0% at 1 hour to 18.0% at 8 hours. No significant difference was observed in favorable outcomes between the SOTMD and non-SOTMD groups, although mortality was higher in the SOTMD cohort. The patients with SOTMD had a stronger time dependence for endovascular therapy in terms of mortality, while the time dependency regarding favorable outcome in the NSOTMD group was even higher. URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1800014759.

Association of Renal Impairment with Clinical Outcomes Following Endovascular Therapy in Acute Basilar Artery Occlusion.

Renal impairment (RI) is associated with unfavourable outcome after acute ischaemic stroke with anterior circulation large vessel occlusion. We assessed the association of RI with clinical outcomes in patients with acute basilar artery occlusion (ABAO), and the impact of RI on the effects of endovascular therapy (EVT) versus standard medical treatment (SMT). We used data from the BASILAR registry, an observational, prospective, nationwide study of patients with ABAO in routine clinical practice in China. Baseline estimated glomerular filtration rate (eGFR) was recorded at admission. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included favourable outcome (mRS score 0-3), mortality, and symptomatic intracranial haemorrhage (sICH). Multivariate logistic regression was used to assess the association of RI with mortality and functional improvement at 90 days. Among 829 patients enrolled, 747 patients were analysed. The median baseline eGFR was 89 mL/min/1.73m2 (IQR, 71-100), and 350 (46.8%), 297 (39.8%), and 100 (13.4%) patients had baseline eGFR values of ≥90, 60-89, and <60 mL/min/1.73m2, respectively. RI was associated with increased mortality (adjusted odds ratio [aOR], 1.97; 95% CI, 1.15-3.67) at 90 days and decreased survival probability (aOR 1.74; 95% CI, 1.30-2.33) within 1 year. EVT was associated with better functional improvement (common aOR, 2.50; 95% CI, 1.43-4.35), favourable outcome (aOR 5.42; 95% CI, 1.92-15.29) and lower mortality (aOR 0.47; 95% CI, 0.25-0.88) in ABAO patients with eGFR ≥90 mL/min/1.73m2. However, RI was not modified the relationship of EVT with functional improvement (common aOR, 3.03; 95% CI, 0.81-11.11), favourable outcome (aOR 2.10; 95% CI, 0.45-9.79), and mortality (aOR 0.56; 95% CI, 0.15-2.06) by eGFR categories. RI is associated with reduced efficacy of EVT and worse functional outcome and higher mortality at 3 months and lower survival probability at 1 year in patients with ABAO.

Clinical and Safety Outcomes of Endovascular Therapy 6 to 24 Hours After Large Vessel Occlusion Ischemic Stroke With Tandem Lesions.

Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6-24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6-24 hours. This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (<6 hours), and late window (6-24 hours). Primary clinical and safety outcomes were 90-day functional independence measured by the modified Rankin Scale (mRS: 0-2) and symptomatic intracranial hemorrhage (sICH). Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), first-pass effect, early neurological improvement, ordinal mRS, and in-hospital and 90-day mortality. Of 579 patients (median age 68, 32.1% females), 268 (46.3%) were treated in the late window and 311 (53.7%) in the early window. Late window group had lower median National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early Computed Tomography Score, rates of intravenous thrombolysis, and higher rates for perfusion imaging. After adjusting for confounders, the odds of 90-day mRS 0-2 (47.7% vs. 45.0%, adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.49-1.02), favorable shift in mRS (aOR 0.88, 95% CI 0.44-1.76), and sICH (3.7% vs. 5.2%, aOR 0.56, 95% CI 0.20-1.56) were similar in both groups. There was no difference in secondary outcomes. Increased time from LKW to puncture did not predicted the probability of 90-day mRS 0-2 (aOR 0.99, 95% CI 0.96-1.01, for each hour delay) among patients presenting <24 hours. EVT for acute TL-LVO treated within 6-24 hours after LKW was associated with similar rates of clinical and safety outcomes, compared to patients treated within 6 hours.

Effect of endovascular therapy in large anterior circulation ischaemic strokes: A systematic review and meta-analysis of randomised controlled trials.

The benefit of endovascular treatment in large anterior circulation ischaemic strokes with low ASPECTS score (<6) is uncertain. Recent randomised studies have demonstrated the benefit of endovascular treatment (EVT) in large ischaemic strokes. The present meta-analysis aims to assess the combined effect of these studies on efficacy and safety of endovascular treatment in this group of patients. We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases MEDLINE, PubMed, EMBASE, SCOPUS, Google Scholar, Tripdatabase were searched for randomised controlled trials with at least 50 participants from inception until February 16, 2023. The primary efficacy outcome analysed was the relative risk of functional independence defined as mRS - 0-2 at 90 days. Secondary efficacy outcomes included early neurological improvement, death due to any cause at 90 days and proportion of patients requiring decompressive hemicraniectomy. The primary safety outcome was the risk of developing symptomatic intracerebral haemorrhage (sICH). A total of three studies (RESCUE Japan-LIMIT, SELECT 2 and ANGEL ASPECTS) involving 1011 patients; 510 in the EVT arm and 501 in the medical management (MM) arm met the defined criteria (ASPECTS-3-5). The combined RR for the primary outcome of mRS 0-2 was 2.53 [1.84-3.47] (p = <0.0001) favouring EVT over MM. The primary safety outcome of sICH was not significant in the EVT arm with a combined RR of 1.84 [0.94-3.60] (p = 0.5157). Mortality rates were similar in both arms (26.67% in EVT arm vs 27.94% in MM arm) with a combined RR of 0.95 [0.78; 1.16] (p = 1.000). In patients with Large vessel occlusion (LVO) and low ASPECTS (3-5), EVT was associated with higher likelihood of achieving functional independence and early neurologic improvement but did not provide any mortality benefit.

The Effect of Endovascular Therapy on Surgical Bypass in a Limb Preservation Practice

The Effect of Endovascular Therapy on Surgical Bypass in a Limb Preservation Practice

Endovascular Therapy for Acute Stroke with a Large Ischemic Region

BackgroundEndovascular therapy for acute ischemic stroke is generally avoided when the infarction is large, but the effect of endovascular therapy with medical care as compared with medical care alone for large strokes has not been well studied.MethodsWe conducted a multicenter, open-label, randomized clinical trial in Japan involving patients with occlusion of large cerebral vessels and sizable strokes on imaging, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) value of 3 to 5 (on a scale from 0 to 10, with lower values indicating larger infarction). Patients were randomly assigned in a 1:1 ratio to receive endovascular therapy with medical care or medical care alone within 6 hours after they were last known to be well or within 24 hours if there was no early change on fluid-attenuated inversion recovery images. Alteplase (0.6 mg per kilogram of body weight) was used when appropriate in both groups. The primary outcome was a modified Rankin scale score of 0 to 3 (on a scale from 0 to 6, with higher scores indicating greater disability) at 90 days. Secondary outcomes included a shift across the range of modified Rankin scale scores toward a better outcome at 90 days and an improvement of at least 8 points in the National Institutes of Health Stroke Scale (NIHSS) score (range, 0 to 42, with higher scores indicating greater deficit) at 48 hours.ResultsA total of 203 patients underwent randomization; 101 patients were assigned to the endovascular-therapy group and 102 to the medical-care group. Approximately 27% of patients in each group received alteplase. The percentage of patients with a modified Rankin scale score of 0 to 3 at 90 days was 31.0% in the endovascular-therapy group and 12.7% in the medical-care group (relative risk, 2.43; 95% confidence interval [CI], 1.35 to 4.37; P=0.002). The ordinal shift across the range of modified Rankin scale scores generally favored endovascular therapy. An improvement of at least 8 points on the NIHSS score at 48 hours was observed in 31.0% of the patients in the endovascular-therapy group and 8.8% of those in the medical-care group (relative risk, 3.51; 95% CI, 1.76 to 7.00), and any intracranial hemorrhage occurred in 58.0% and 31.4%, respectively (P<0.001).ConclusionsIn a trial conducted in Japan, patients with large cerebral infarctions had better functional outcomes with endovascular therapy than with medical care alone but had more intracranial hemorrhages. (Funded by Mihara Cerebrovascular Disorder Research Promotion Fund and the Japanese Society for Neuroendovascular Therapy; RESCUE-Japan LIMIT ClinicalTrials.gov number, NCT03702413.)

Endovascular therapy for posterior communicating artery-infundibular dilatation aneurysms

Objective: The purpose of this study was to explore the effect of endovascular therapy on posterior communicating artery-infundibular dilatation aneurysms. Methods: A total of 15 patients with ruptured aneurysms caused by posterior communicating artery-infundibular dilatation who were treated in our neurosurgical center from January 2015 to December 2018were included in this study. They were performed with bilateral internal carotid angiography and vertebral angiography and treated with endovascular method. The modified Rankin Scale (mRS) was used for clinical follow-up for 18 months. Results: There were 10 patients in the posterior communicating artery-infundibular dilatation aneurysms with non-fetal posterior cerebral artery. Among them, 8 patients were treated with coil-alone embolization. Immediate imaging showed infundibular dilation residual in 6 cases and no contrast filling in either infundibular dilation or aneurysm in 2 case. Another 2 were treated with stent-assisted coiling embolization, and immediate imaging showed no contrast filling. Of the 5 patients in posterior communicating artery-infundibular dilatation aneurysms with fetal posterior cerebral artery, 4 were only coiled in the aneurysm sack with contrast filling in infundibular cones, and 2 were treated with stent assisted coiling. Among the 10 patients with non-fetal posterior cerebral artery, 3 showed recurrence, 4 showed stable images, 2 were also stable with no contrast filling in infundibular dilation or aneurysm and 1 was lost to follow-up. Among the 5 patients with fetal posterior cerebral artery, 1 showed stable images, 3 showed recurrence and 1 was lost to follow-up. Conclusions: For posterior communicating artery-infundibular dilatation aneurysms with non-fetal posterior cerebral artery, stent-assisted coiling of aneurysm embolization combined with occlusion of cones is effective to prevent or reduce recurrence.

Abstract P494: Automatically Predicting Modified Treatment in Cerebral Ischemia Scores From Patient Digital Subtraction Angiography Using Deep Learning

Introduction: We propose a new method for quantifying the effect of endovascular therapy for acute ischemic stroke. Currently, an mTICI (modified treatment in cerebral ischemia) score is assigned manually to document the success of endovascular revascularization therapy. The mTICI score based on Digital Subtraction Angiography (DSA), due to visual assignment, has limitations in settings where standardization is pertinent. Methods: We hypothesize that mTICI scores can be classified successfully by deep learning and thus be used as a standardized imaging biomarker. We aim to develop a regression framework using classification models that can assign continuous score to patients depending on the success of therapy, resulting in a score that is more granular than the mTICI. We use deep learning and 3D Convolutional Neural Networks (CNN) to classify frontal post-intervention DSA 2D time series into the mTICI score categories of 0, 1, 2a, 2b, and 3. An mTICI score of 0 represents no perfusion and a score of 3 represents full perfusion. The DSA series serve as features where the time dimension is the third dimension for the CNN. For our preliminary research we have condensed our groupings into binary {0,1} (0 refers to mTICI of 0, 1, 2a while 1 refers to mTICI of 2b, 3) of frontal DSA to see if Deep Learning models can categorize between the different mTICI classes. Results: We reduced our original data size of 181 patients to 93 patients in binary group 0 and 88 patients in group 1. Using a train/test split of 0.2, we have achieved a test classification accuracy of 73%, and F1-Score of 72.2% on the binary dataset. This is a good statistical indication that neural networks are able to classify between DSA. Conclusion: Neural network models show promise as a method of distinguishing between DSA to be used as an automatic standardized scoring method for acute ischemic stroke procedures. We aim to expand this research to frontal and lateral DSA images to get more vascular information to improve model accuracies. We propose using the softmax score of the classifier as a new score which will be a standardized measurement for endovascular therapy success.

Endovascular Therapy of Acute Ischemic Stroke in Patients with Large-Vessel Occlusion Associated with Active Malignancy

PurposeThere is limited data on the effectiveness of endovascular therapy (EVT) in stroke patients with active malignancy. In this study, we investigated the outcome of EVT for acute ischemic stroke for patients with active malignancy compared to those without malignancy. MethodsWe selected patients who underwent EVT for acute ischemic stroke between January 2015 and July 2019. Patients were divided into two groups, those with active malignancy (oncology group - OG) and those without (non-oncology group, NOG). Results300 patients were included in this study. There were 19 EVT procedures (18 patients) in the OG and 285 procedures (282 patients) in the NOG. There was no difference in recanalization success rate (mTICI 2b & 3) between the groups: 94.7% versus 80.9% in OG and NOG respectively (p = 0.13). Success rate using the direct aspiration (ADAPT) technique of EVT was not different between compared groups (42.9% versus 67.7%; p = 0.18). However, when using smaller-caliber aspiration devices, ADAPT was less successful in OG (0.0% versus 64.7%, p < 0.05). There was no difference in recanalization success rate of EVT when using a stent-retriever or combined technique. Patients in the OG had a less favorable functional outcome than in the NOG group (mRS 0-2 at 90-days post event: 22.2% versus 48.2%, p < 0.05) ConclusionThe technical success rate of EVT in patients with active malignancy is similar to the general population of stroke patients. Interestingly, the success rate of EVT using the ADAPT technique was lower in the OG when using smaller caliber aspiration devices.

Expansion of the dimensions in the current management of acute ischemic stroke.

Stroke is the fifth leading cause of death in the United States with a huge burden on health care. Acute ischemic stroke (AIS) accounts for 87% of all stroke. The use of thrombolytic agents in AIS treatment is well known since 1950 but no FDA approval until 1996, due to lack of strong evidence showing benefits outweigh the risk of intracranial hemorrhage. The NINDS trial led to the approval of intravenous tissue plasminogen activator treatment (IV recombinant tPA) within 3h of stroke. Due to this limitation of 3-4.5h. window, evolution began in the development of effective endovascular therapy (EVT). Multiple trials were unsuccessful in establishing the strong evidence for effectiveness of EVT. In 2015, MR CLEAN trial made progress and showed improved outcomes with EVT in AIS patients with large vessel occlusion (LVO), with 6-h window period. In 2018, two major trials-DAWN and DEFUSE 3-along with few other trials had shown improved outcomes with EVT and stretched window period from 6 to 24h. AHA Stroke Council is constantly working to provide focused guidelines and recommendations in AIS management since 2013. SVIN had started the initiative "Mission Thrombectomy-2020" to increase global EVT utilization rate 202,000 procedures by 2020. Physicians are using safer and easier approach like brachial and radial approach for EVT. TeleNeurology and artificial intelligence also played a significant role in increasing the availability of IV recombinant tPA in AIS treatment in remote hospitals and also in screening, triaging and identifying LVO patients for EVT. In this review article, we aim to describe the history of stroke management along with the new technological advancements in AIS treatment.

Abstract 5: Improved Quality of Life With Endovascular Therapy in the DEFUSE 3 Trial

Background: Little is known about the effect of endovascular therapy on patients’ quality of life. Using data from the randomized DEFUSE 3 trial, we aimed to assess if thrombectomy performed in the late (6-16 hour) time window leads to improved quality of life. Methods: Neuro-QoL is a measurement tool designed to assess quality of life (QoL) outcomes in adults with neurologic disorders. In DEFUSE 3, Neuro-QoL short forms were administered at day 90 to assess quality of life in four domains: mobility, ability to participate in social roles and activities, cognitive function, and depression. Raw scores were transformed to T-scores, which calibrates the scores to the distribution in the US general adult population with a mean score of 50 and SD of 10. For consistency among domains, the distribution of depression T-scores was inverted across the mean such that higher scores reflect better outcomes. Quality of life scores were compared between groups using the Wilcoxon rank-sum test (unadjusted) and linear regression (adjusted). Results: In DEFUSE 3, 146 patients were alive at day 90. Of these, 128 completed all four QoL forms, 10 did not complete any of the forms, and 8 completed a subset of the forms. Endovascular therapy compared to medical alone was associated with superior quality of life outcomes in all domains: mobility (p&lt;0.001), social participation (p&lt;0.001), cognition (p=0.013), and depression (p=0.003) (figure). Higher NIHSS at baseline was associated with worse outcomes in mobility, social participation and cognition, older age with worse mobility and depression, and female gender with worse mobility, cognition and depression (multivariable p&lt;0.05). The benefit of endovascular therapy in each quality of life domain remained significant after adjusting for these variables. Conclusion: In addition to improved functional outcomes, endovascular therapy 6 to 16 hours after onset preserves mental health and social capabilities critical to patients’ quality of life.

Abstract 177: Thrombectomy Results in Reduced Hospital Stay, More Time at Home, and More Favorable Living Situations for Patients in the DEFUSE 3 Trial

Background: The high burden of disease associated with stroke results in a tremendous cost to the healthcare system and a reduced quality of life for patients. The DEFUSE 3 trial found that endovascular thrombectomy in the 6-16 hour time-window results in a significant improvement in functional outcomes as measured by the modified Rankin Scale. The aim of this study was to determine the effect of this intervention on length of hospital stay, time spent at home during the first 3 months after stroke, and living situation after stroke. Methods: In DEFUSE 3, 182 patients were randomized to medical or endovascular therapy. Duration of hospital stay and time at home in the first 90 days following stroke onset was analyzed between the two groups using a Wilcoxon rank-sum test. Patient living situation was assessed at time of discharge, 30 days, and 90 days and categorized on an ordinal 4-point scale: as home, acute rehab unit, skilled nursing facility, or hospice / death. Differences between groups were analyzed using a Cochran-Armitage trend test. Results: Median length of hospital stay was 9 (IQR, 6 - 15) days in the medical group vs. 7 (IQR, 4 - 9) days in the endovascular group (p &lt; 0.001). Median time spent at home during the first 90 days following stroke was 0 (IQR, 0 - 54) days in the medical group vs. 55 (IQR, 0 - 83) days in the endovascular group (p &lt; 0.001). The endovascular group had more favorable living locations at time of discharge (p &lt; 0.001), 30 days (p &lt; 0.001), and 90 days (p &lt; 0.001) after stroke onset (see figure). Discussion: Endovascular thrombectomy resulted in shorter length of hospital stay, longer time spent at home in the first 90 days, and more desirable living situations at the time of discharge, 30 days, and 90 days after stroke. These results provide additional evidence for the effectiveness of endovascular therapy in the delayed time-window as these factors are associated with improved quality of life for stroke patients and reduced costs to the healthcare system.

Stent retriever thrombectomy for acute ischemic stroke: A systematic review and meta-analysis of randomized controlled trials, including THRACE

Background and purposeEndovascular thrombectomy has become the reference therapy for patients with large vessel occlusion (LVO). However, no meta-analysis including the THRACE Trial has yet been reported. Thus, the present review assessed the outcomes of stent retriever thrombectomy added to medical care compared with medical care alone in LVO patients. Materials and methodsA systematic review was conducted of all randomized controlled trials (RCTs) examining stent retrievers added to medical care vs medical care alone in the MEDLINE, Embase and Web of Science databases. Meta-analyses of 90-day functional outcomes and mortality, and the occurrence of symptomatic intracranial hemorrhage (sICH), with thrombectomy plus medical care vs medical care alone were performed. ResultsSix multicenter RCTs involving 1673 patients were included. Successful recanalization (modified thrombolysis in cerebral ischemia grades 2b–3) was seen in 71% of patients (95% CI: 62–79%) after thrombectomy. These patients also had significantly higher rates of 90-day functional independence (mRS scores 0–2) compared with those receiving medical care only (OR: 2.14, 95% CI: 1.72–2.67; P<0.00001), as well as excellent outcomes (mRS scores 0–1, OR: 2.05, 95% CI: 1.58–2.67; P<0.00001). Also, the rate of functional independence was higher (OR: 2.39, 95% CI: 1.88–3.04; P<0.00001) in the subgroup analysis without the THRACE Trial. The effect of endovascular therapy on 90-day mortality was inconclusive (OR: 0.82, 95% CI: 0.62–1.07; P=0.15), and there was no increased occurrence of sICH (OR: 1.11, 95% CI: 0.66–1.88; P=0.70). ConclusionStent retriever thrombectomy added to medical care improved 90-day functional outcomes compared with medical care alone with no impact on mortality and risk of sICH in LVO patients.

Abstract TP355: The Threshold of Baseline National Institutes of Health Stroke Scale Score to Predict Favorable Outcome After Medical Therapy in Patients With Acute M2 Occlusion

Objective: Although endovascular therapy is effective in acute ischemic stroke (AIS) patients with occlusion of the internal carotid artery or proximal middle cerebral artery (M1), the benefit are uncertain in those with the occlusion of distal middle cerebral artery (M2). To select the patient with potentially beneficial effects of endovascular therapy, we aimed to establish the threshold of NIHSS score as a predictive factor for favorable outcome in the patient with M2 occlusion treated with medical therapy alone. Methods: Among 2180 AIS patients admitted to our stroke center between October 2011 and February 2015 (ClinicalTrials.gov Identifier: NCT02251665), 72 patients met the following criteria; 1) arrived within 6 hours from the onset, 2) isolated M2 occlusion on MRA, and 3) ASPECTS of ≥ 6 on DWI. Three patients who received endovascular therapy were excluded. We evaluated predictive factors for favorable outcome, defined as a modified Rankin Scale (mRS) &lt;3 or equal to the premorbid mRS at 90 days after the onset. Results: A total of 69 patients (26 women, 79.9±8.6 years old) was analyzed, and favorable outcome was achieved in 38 patients (55%). The favorable outcome group had a younger age (median 78 vs 82, p=0.03) and a lower baseline NIHSS score (9.5 vs 15, p=0.07) than the poor outcome group. Using receiver operating characteristic curves analysis, the optimal cutoff value of NIHSS score to predict favorable outcome was 9 (AUC 0.626). After adjusting for age, sex, onset to door time, and intravenous thrombolysis, NIHSS&lt;9 was an independent predictor of favorable outcome (OR 3.95; 95% CI 1.04-18.22). Conclusion: In AIS patient with M2 occlusion who treated with medical therapy, the baseline NIHSS score &lt;9 was related to favorable outcome.

Effect of endovascular reperfusion in relation to site of arterial occlusion

To assess whether the association between reperfusion and improved clinical outcomes after stroke differs depending on the site of the arterial occlusive lesion (AOL). We pooled data from Solitaire With the Intention for Thrombectomy (SWIFT), Solitaire FR Thrombectomy for Acute Revascularisation (STAR), Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution Study 2 (DEFUSE 2), and Interventional Management of Stroke Trial (IMS III) to compare the strength of the associations between reperfusion and clinical outcomes in patients with internal carotid artery (ICA), proximal middle cerebral artery (MCA) (M1), and distal MCA (M2/3/4) occlusions. Among 710 included patients, the site of the AOL was the ICA in 161, the proximal MCA in 389, and the distal MCA in 160 patients (M2 = 131, M3 = 23, and M4 = 6). Reperfusion was associated with an increase in the rate of good functional outcome (modified Rankin Scale [mRS] score 0-2) in patients with ICA (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.7-7.2) and proximal MCA occlusions (OR 6.2, 95% CI 3.8-10.2), but not in patients with distal MCA occlusions (OR 1.4, 95% CI 0.8-2.6). Among patients with M2 occlusions, a subset of the distal MCA cohort, reperfusion was associated with excellent functional outcome (mRS 0-1; OR 2.2, 95% CI 1.0-4.7). The association between endovascular reperfusion and better clinical outcomes is more profound in patients with ICA and proximal MCA occlusions compared to patients with distal MCA occlusions. Because there are limited data from randomized controlled trials on the effect of endovascular therapy in patients with distal MCA occlusions, these results underscore the need for inclusion of this subgroup in future endovascular therapy trials.

TCT-761 Effectiveness of Endovascular therapy for Acute Ischemic Stroke-Evidence from a Meta-analysis of Randomized Trials

TCT-761 Effectiveness of Endovascular therapy for Acute Ischemic Stroke-Evidence from a Meta-analysis of Randomized Trials

Abstract 129: Endovascular Therapy Demonstrates Benefit over IV-tPA based on 90-day NIHSS: A Longitudinal, Secondary Analysis of the IMS III Trial

Introduction: The IMS III trial was a randomized controlled trial designed to compare the add-on effect of endovascular therapy after IV-tPA. The primary outcome was mRS at 90 days. Secondary outcomes included NIHSS, which was evaluated repeatedly through 90 days. Objective: To evaluate the treatment effect of endovascular therapy over time on NIHSS. Methods: 656 subjects were enrolled in the IMS III trial, including 434 subjects randomized to endovascular therapy and 222 to IV-tPA only. NIHSS evaluated at 40 min, 24 hours, Day 5 and Day 90 were included in the analysis. A mixed effects model was used to investigate the treatment effect on NIHSS over time, adjusting for relevant covariates including baseline stroke severity (NIHSS ≤19 vs ≥20). Model assumptions were held. Result: After adjusting for age, time from symptom onset to initiation of IV tPA, and baseline stroke severity, a significant time by treatment interaction effect (p = 0.0137) was observed. Only NIHSS at Day 90 showed a significant treatment effect (p = 0.0473), with subjects in the endovascular arm having lower NIHSS compared to the IV- tPA arm (mean 7 vs 8). Conclusion: The IMS III trial demonstrated an endovascular treatment effect based on the secondary outcome of NIHSS. However, the magnitude of this treatment effect varied by time of assessment. It was only at Day 90 that the endovascular arm had a significantly lower NIHSS compared to those in the IV- tPA arm.