Endovascular Treatment In Patients Research Articles

The safety and clinical outcomes of endovascular treatment versus microsurgical clipping of ruptured anterior communicating artery aneurysms: a 2-year follow-up, multicenter, observational study

Background and objectiveCurrent data on the optimal treatment modality for ruptured anterior communicating artery (AComA) aneurysms are limited. We conducted this multicenter retrospective study to evaluate the safety and clinical outcomes of endovascular treatment (EVT) and microsurgical clipping (MC) for the treatment of ruptured AComA patients.MethodsPatients with ruptured AComA aneurysms were screened from the Chinese Multicenter Cerebral Aneurysm Database. Propensity score matching (PSM) was used to adjust for baseline characteristic imbalances between the EVT and MC groups. The safety outcomes included total procedural complications, procedure-related morbidity/death and remedial procedure for complication. The primary clinical outcome was 2-year functional independence measured by the modified Rankin scale (mRS) score.ResultsThe analysis included 893 patients with ruptured AComA aneurysms (EVT: 549; MC: 346). PSM yielded 275 pairs of patients in the EVT and MC cohorts for comparison. Decompressive craniectomy being more prevalent in the MC group (19.3% vs. 1.5%, p < 0.001). Safety data revealed a lower rate of total procedural complications (odds ratio [OR] = 0.62, 95% CI 0.39–0.99; p = 0.044) in the EVT group and similar rates of procedure-related morbidity/death (OR = 0.91, 95% CI 0.48–1.73; p = 0.880) and remedial procedure for complication (OR = 1.35, 95% CI 0.51–3.69, p = 0.657) between the groups. Compared with that of MC patients, EVT patients had a greater likelihood of functional independence (mRS score 0–2) at discharge (OR = 1.68, 95% CI 1.14–2.50; p = 0.008) and at 2 years (OR = 1.89, 95% CI 1.20–3.00; p = 0.005), a lower incidence of 2-year all-cause mortality (OR = 0.54, 95% CI 0.31–0.93; p = 0.023) and a similar rate of retreatment (OR = 1.00, 95% CI 0.23–4.40; p = 1.000).ConclusionClinical outcomes after treatment for ruptured AComA aneurysms appear to be superior to those after treatment with MC, with fewer overall procedure-related complications and no increase in the retreatment rate. Additional studies in other countries are needed to verify these findings.

European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) Guideline on Acute Management of Basilar Artery Occlusion.

The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs. Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).

Blood glucose to predict symptomatic intracranial hemorrhage after endovascular treatment of acute ischemic stroke with large infarct core: a prospective observational study.

Symptomatic intracranial hemorrhage (sICH) is a serious complication of acute ischemic stroke (AIS) after endovascular treatment (EVT). Limited data exist regarding predictors and clinical implications of sICH after EVT, underscoring the significance of identifying risk factors to enhance prevention strategies. Therefore, the main objective of this study was to evaluate the incidence of sICH and identify its predictors after EVT in patients with large infarct core-AIS in the pre-circulation stage. Using data from the EVT for the Pre-circulation Large Infarct Core-AIS Study, we enrolled patients who were treated with EVT from the Prospective Multicenter Cohort Study of Early Treatment in Acute Stroke (MAGIC) registry. Baseline demographics, medical history, vascular risk factors, blood pressure, stroke severity, radiographic features, and EVT details were collected. The patients were classified into three groups: without intracranial hemorrhage (ICH), with asymptomatic intracranial hemorrhage (aICH), and sICH, based upon the occurrence of sICH. The main outcomes were the occurrence of sICH according to the Heidelberg Bleeding Classification and functional condition at 90 days. Multivariate logistic regression analysis and receiver operating characteristic (ROC) curves were used to identify independent predictors of sICH after EVT. The study recruited a total of 490 patients, of whom 13.3% (n = 65) developed sICH. Patients with sICH had less favorable outcomes than those without intracranial hemorrhage (ICH) and those with aICH (13.8% vs. 43.5% vs. 32.2%, respectively; p < 0.001). The overall mortality was 41.8% (n = 205) at 90 days post-EVT. The univariate analysis revealed significant differences among the three groups in terms of blood glucose levels at admission, probability of favorable outcomes, incidence of brain herniation, and 90-day mortality. The multifactorial logistic regression analysis revealed that the blood glucose level at admission [odds ratio (OR) 1.169, p < 0.001, confidence interval (CI) 1.076-1.269] was an independent predictor of sICH. A blood glucose level of 6.95 mmol/L at admission was the best predictor of sICH, with an area under the ROC curve (AUC) of 0.685 (95% CI: 0.616-0.754). The study findings demonstrated that the probability of sICH after EVT was 13.3% in patients with pre-circulation large infarct core-AIS, and sICH increased the risk of an unfavorable prognosis. Higher blood glucose levels at admission were associated with sICH after EVT in patients with pre-circulation large infarct core AIS. These findings underscore the importance of early management strategies to mitigate this risk.

Safety and efficacy of tirofiban treatment in the endovascular treatment of patients with acute ischaemic stroke - a meta-analysis

Safety and efficacy of tirofiban treatment in the endovascular treatment of patients with acute ischaemic stroke - a meta-analysis

Outcomes and risk factors for infection after endovascular treatment in patients with acute ischemic stroke.

Infection is a common complication following acute ischemic stroke (AIS) and significantly contributes to poor functional outcomes after stroke. This study aimed to investigate the effects of infection after endovascular treatment (post-EVT infection) on clinical outcomes and risk factors in patients with AIS. We retrospectively analyzed AIS patients treated with endovascular treatment (EVT) between January 2016 and December 2022. A post-EVT infection was defined as any infection diagnosed within 7 days after EVT. The primary outcome was functional independence, defined as a modified Rankin scale (mRS) score of 0-2 at 90 days. A multivariable logistic regression analysis was conducted to determine independent predictors of post-EVT infection and the associations between post-EVT infection and clinical outcomes. A total of 675 patients were included in the analysis; 306 (45.3%) of them had post-EVT infections. Patients with post-EVT infection had a lower rate of functional independence than patients without infection (31% vs 65%, p = 0.006). In addition, patients with post-EVT infection achieved less early neurological improvement (ENI) after EVT (25.8% vs 47.4%, p < 0.001). For safety outcomes, the infection group had a higher incidence of any intracranial hemorrhage (23.9% vs 15.7%, p = 0.01) and symptomatic intracranial hemorrhage (10.1% vs 5.1%, p = 0.01). Unsuccessful recanalization (aOR 1.87, 95% CI 1.11-3.13; p = 0.02) and general anesthesia (aOR 2.22, 95% CI 1.25-3.95; p = 0.01) were identified as independent predictors for post-EVT infection in logistic regression analysis. AIS patients who develop post-EVT infections are more likely to experience poor clinical outcomes. Unsuccessful recanalization and general anesthesia were independent risk factors for the development of post-EVT infection.

Advances in non-invasive treatment of aortic diseases

The current clinical treatment methods for aortic diseases including aortic aneurysm, aortic dissection,etc.,are open surgery and endovascular surgery. Compared to traditional open surgery, endovascular surgery has the advantages of minimal trauma, fast recovery, fewer complications, and better prognosis, which gradually becomes the main trend in the treatment of aortic diseases. However, with the further development and long-term follow-up of endovascular treatment for aortic diseases, increasing evidence shows that in many cases, there are difficulties in the diagnosis of causes, decision-making of treatment timing, and lack of effective evaluation of treatment prognosis in endovascular treatments. Therefore, it is necessary to conduct in-depth research on non-invasive treatment including prevention, diagnosis, treatment, and prediction of aortic diseases. The non-invasive treatment of aortic disease is mainly applied to high-risk populations with aortic dissection, regulating key targets and mechanisms, and adopting drug intervention in advance to achieve the goal of controlling aortic dilation and preventing the occurrence of dissection. Conducting precise multi omics analysis to determine the optimal intervention timing and treatment strategy and targeting complications related to aortic disease or endovascular treatment for patients with a positive family history of aortic dilation or those who have developed aortic dissection. Precise regulation can be achieved to control the progression of aortic aneurysm and aortic dissection, delay or achieve long-term stable coexistence with aortic disease, and even reverse disease progression and achieve benign aortic remodelingthrough new intervention vectors. Ultimately achieving the ideal state of complete thrombosis and mechanized healing of the aortic aneurysm or aortic dissection false lumen.

Total cerebral small vessel disease burden and stroke outcomes in large vessel occlusion stroke receiving endovascular treatment: A systematic review and meta-analysis

BackgroundCerebral small vessel disease (CSVD) is prevalent in the population, especially among the elderly. Various types of CSVD markers commonly coexist, and the neurological function outcome is affected by their combined effect. Studies investigating the association between total CSVD burden and stroke outcomes in large vessel occlusion (LVO) stroke receiving endovascular treatment (EVT) are expanding but have not been systematically assessed. MethodsWe systematically searched the PubMed, Embase, and Cochrane databases for relevant clinical studies. The total CSVD burden score summarized the markers of CSVD, including lacunes, white matter hyperintensities (WMHs), cerebral microbleeds (CMBs), and enlarged perivascular spaces (EPVSs), which was a comprehensive index of overall CSVD burden. The pooled odds ratios (ORs) were used to calculate the association between high total CSVD burden score and outcomes of EVT in patients with LVO stroke. The primary outcome was poor functional outcome, which was defined as a modified Rankin Scale score (mRS) ≥ 3 at 90 days after EVT. The secondary outcomes were symptomatic intracranial hemorrhage (sICH) and poor collateral flow. ResultsOverall, 6 eligible studies with 1,774 patients with LVO stroke undergoing EVT were pooled in meta-analysis. High overall CSVD burden score was significantly associated with increased risks of poor functional outcome at 90 days (pooled OR 2.86, 95 % CI 1.31–6.25, p = 0.008). Besides, high overall CSVD burden score was associated with sICH (pooled OR 2.07, 95 % CI 0.38–5.17; p = 0.118) and poor collateral flow (pooled OR 1.57, 95 % CI 0.75–3.27; p = 0.232), but were not statistically significant. ConclusionsHigh overall CSVD burden was associated with increased risks of unfavorable outcomes in patients with LVO stroke undergoing EVT.

Acute management of cerebral venous thrombosis: Indications, technique, and outcome of endovascular treatment in two high-volume centers.

After several uncontrolled studies and one randomized clinical trial, there is still uncertainty regarding the role of endovascular treatment (EVT) in cerebral venous thrombosis (CVT). This study aims to describe and assess different acute management strategies in the treatment of CVT. We performed a retrospective analysis of an international two-center registry of CVT patients admitted since 2019. Good outcome was defined as a return to baseline modified Rankin scale at three months. We described and compared EVT versus no-EVT patients. We included 61 patients. Only one did not receive systemic anticoagulation. EVT was performed in 13/61 (20%) of the cases, with a median time from diagnosis to puncture of 4.5 h (1.25-28.5). EVT patients had a higher median baseline NIHSS [6 (IQR 2-17) vs 0 (0-2.7), p = 0.002)] and a higher incidence of intracerebral hemorrhage (53.8% vs 20.3%, p = 0.03). Recanalization was achieved in 10/13 (77%) patients. Thrombectomy was performed in every case with angioplasty in 7 out of 12 patients and stenting in 3 cases. No postprocedural complication was reported. An improvement of the median NIHSS from baseline to discharge [6 (2-17) vs 1(0-3.75); p < 0.001] was observed in EVT group. A total of 31/60 patients (50.8%) had good outcomes. Adjusting to NIHSS and ICH, EVT had a non-significant increase in the odds of a good outcome [aOR 1.42 (95%CI 0.73-2.8, p = 0.307)]. EVT in combination with anticoagulation was safe in acute treatment of CVT as suggested by NIHSS improvement. Selected patients may benefit from this treatment.

Damage Control Interventional Radiology in Liver Trauma: A Comprehensive Review.

The liver is the second most common solid organ injured in blunt and penetrating abdominal trauma. Non-operative management (NOM) has become the standard of care for liver injuries in stable patients, where transarterial embolization (TAE) represents the main treatment, increasing success rates and avoiding invasive surgical procedures. In hemodynamically (HD) unstable patients, operative management (OM) is the standard of care. To date, there are no consensus guidelines about the endovascular treatment of patients with HD instability or in ones that responded to initial infusion therapy. A review of the literature was performed for published papers addressing the outcome of using TAE as the primary treatment for HD unstable/transient responder trauma liver patients with hemorrhagic vascular lesions, both as a single treatment and in combination with surgical treatment, focusing additionally on the different definitions used in the literature of unstable and transient responder patients. Our review demonstrated a good outcome in HD unstable/transient responder liver trauma patients treated with TAE but there still remains much debate about the definition of unstable and transient responder patients.

Double stent-retriever technique for mechanical thrombectomy: a systematic review and meta-analysis.

Mechanical thrombectomy using a double stent-retriever technique has recently been described for the treatment of acute ischemic stroke, but its efficacy and safety are not well established. The aim of this systematic review and meta-analysis was to evaluate reports of the use of double stent-retriever during the endovascular treatment of patients with ischemic stroke. The PubMed, Embase, Web of Science and Scopus databases were searched to identify all studies (clinical trials, cohorts series and case reports) investigating the utility of double stent-retriever for the treatment of stroke. The study is reported in accordance with PRISMA 2020 guidelines and was prospectively registered in PROSPERO (BLINDED FOR PEER REVIEW). 17 studies involving a total of 128 patients with large vessel occlusions predominantly in the anterior circulation (93.0%) were identified. Outcomes of interest were the prevalence of successful recanalization (mTICI ≥2b) and a first-pass effect following double stent-retriever, as well as complications such as iatrogenic dissections and subarachnoid hemorrhage. Data were pooled using a random-effects model. Double stent-retriever was used as a rescue strategy in occlusions refractory to conventional endovascular treatment in 68.7% (88/128) of patients and as a first-line strategy in 31.3% (40/128) patients. Double stent-retriever achieved an overall final mTICI ≥2b in 92.6% cases with a first-pass effect of 76.6%. The complication rate remained low, with 0.37% dissection and 1.56% subarachnoid hemorrhage. Limitations of the study include (1) a large number of case reports or small series, (2) a meta-analysis of proportions with no statistical comparison to a control group, and (3) the lack of access to patient-level data. Our findings suggest that double stent-retriever thrombectomy may be safe and associated with good recanalization outcomes, but prospective comparative studies are needed to determine which patients may benefit from this endovascular procedure. AICH = asymptomatic intracranial hemorrhage; AIS = acute ischemic stroke; DSR = double stent-retriever; FPE = first pass effect; ICH = intracranial hemorrhage; LVO = large vessel occlusion; MT = mechanical thrombectomy; SAH = subarachnoid hemorrhage; SICH = symptomatic intracranial hemorrhage; SSR = single stent-retriever.

Endovascular vs surgical treatment of sigmoid sinus diverticulum causing pulsatile tinnitus: A systematic review.

Sigmoid sinus diverticulum (SSD) has been increasingly reported as a cause of pulsatile tinnitus (PT). While both endovascular and surgical treatments have been used, there is a lack of consensus on the treatment modality to treat SSD. We conducted a systematic review of the available literature to compare the clinical outcomes and safety of endovascular versus surgical approaches for treating SSD. A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify studies encompassing the management of SSD. Studies reporting the clinical outcomes and safety of endovascular or surgical treatments for SSD between January 2000 and January 2023 were included. Results were characterized using descriptive statistics. Endovascular treatment (EVT) was reported by 17 articles, yielding 26 patients with 27 diverticula. Surgical treatment was reported by 20 articles, yielding 105 patients with 107 diverticula. EVT led to complete or near-complete resolution in all patients with SSD and PT. Complications occurred in 3.7% (1/27) with a return to baseline after 2 months. There were no permanent complications from EVT. Surgical treatment resulted in complete resolution in 77.6% (83/107) of cases, incomplete resolution in 11.2% (12/107), and no resolution in 11.2% (12/107). Significant complications occurred in 9.3% (10/107) of the surgical-treated patients. EVT in patients with PT and venous diverticulum appears more effective and safer than surgical treatment, but large studies are lacking. Studies directly comparing endovascular and surgical treatment are needed.

Influencing factors of futile recanalization after endovascular intervention in patients with acute basilar artery occlusion.

To explore the influence factors for futile recanalization following endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO). Clinical data of patients with acute BAO, who underwent endovascular treatment within 24 h of onset from January 2017 to November 2022, were retrospectively analyzed. The futile recanalization was defined as modified thrombolysis in cerebral infarction (mTICI) grade ≥2b or 3 after successful reperfusion, but the modified Rankin Scale score >2 at 3 months after EVT. Binary logistic regression model was used to analyze the influencing factors of futile recanalization. A total of 471 patients with a median age of 68 (57, 74) years were included and 68.9% were males, among whom 298 (63.27%) experienced futile recanalization. Multivariate analysis revealed that concomitant atrial fibrillation (OR=0.456, 95%CI: 0.282-0.737, P<0.01), bridging thrombolysis (OR=0.640, 95%CI: 0.416-0.985, P<0.05), achieving mTICI grade 3 (OR=0.554, 95%CI: 0.334-0.918, P<0.05), arterial occlusive lesion (AOL) grade 3 (OR=0.521, 95%CI: 0.326-0.834, P<0.01), and early postoperative statin therapy (OR=0.509, 95%CI: 0.273-0.948, P<0.05) were protective factors for futile recanalization after EVT in acute BAO patients. High baseline National Institutes of Health Stroke Scale (NIHSS) score (OR=1.068, 95%CI: 1.049-1.087, P<0.01), coexisting hypertension (OR=1.571, 95%CI: 1.017-2.427, P<0.05), multiple retrieval attempts (OR=1.237, 95%CI: 1.029-1.488, P<0.05) and postoperative hemorrhagic transformation (OR=8.497, 95%CI: 2.879-25.076, P<0.01) were risk factors. For trial of ORG 10172 in acute stroke treatment (TOAST) classification, cardiogenic embolism (OR=0.321, 95%CI: 0.193-0.534, P<0.01) and other types (OR=0.499, 95%CI: 0.260-0.961, P<0.05) were related to lower incidence of futile recanalization. The incidence of futile recanalization after EVT in patients with acute BAO is high. Bridging venous thrombolysis before operation and an early postoperative statin therapy may reduce the incidence of futile recanalization.

Safety and efficacy of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis

Objective: To investigate the efficacy and safety of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis. Methods: A retrospective analysis was carried out on 46 patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis who received endovascular treatment at the Strategic Support Force Medical Center from January 2015 to August 2022. Twenty-seven patients underwent balloon angioplasty alone and 19 patients underwent acute stent implantation. The baseline characteristics, modified thrombolysis in cerebral infarction (mTICI) score of the responsible vessels, modified Rankin scale (mRS) score 90 days after operation, incidence of symptomatic intracranial hemorrhage and mortality of the two groups were evaluated. Results: The proportion of effective recanalization of the offending vessels (mTICI≥2b) in the acute stenting group was slightly higher than that in the balloon angioplasty group (16/19 vs. 81.5%), but the difference was not statistically significant (P>0.05). Besides, there was no significant difference in the median of mRS between the acute stenting group [3.0(0, 4.0)] and the balloon angioplasty group [4.0(1.0, 5.0)] 90 days after operation (P>0.05). In terms of safety, the incidence of symptomatic intracranial hemorrhage and mortality were comparable between the two groups (P>0.05). Conclusions: The effect of acute stent implantation during endovascular treatment for patients with emergent large vessel occlusion due to intracranial atherosclerotic stenosis is not inferior to that of balloon angioplasty, and it does not increase the risk of intracranial bleeding complications.

Management of intervenable factors to reduce vascular complications in patients with internal carotid artery occlusion treated by non-emergency endovascular treatment.

This study aims to identify risk factors for vascular complications during non-emergency endovascular treatment in patients with internal carotid artery occlusion (ICAO) and to propose potential interventions. A retrospective analysis of 92 patients with ICAO who received non-emergency endovascular treatment in our center from 1 January 2018 to 31 June 2023, was conducted. The correlation between intraoperative vascular complications and potential risk factors was studied, and interaction analysis was performed. Our findings revealed that the use of non-neurology guide wires to open vessels (adjusted OR: 4.1, 95%CI: 1.3-12.8; p = 0.014) and glycosylated hemoglobin (HbA1c) ≥ 6.5 mmol/L (adjusted OR: 3.2, 95%CI: 1.2-8.9; p = 0.023) was significantly associated with vascular complications in non-emergency endovascular treatment of ICAO patients. The restricted cubic spline (RCS) showed that the higher the HbA1c level, the higher the risk of vascular complications. The use of non-neurology guide wires for vessel opening during non-emergency endovascular treatment in patients with ICAO increases the risk of vascular complications. Preoperative assessment and management of HbA1c levels can reduce the incidence of intraoperative vascular complications.

Retraction: clinical characteristics and endovascular treatment in patients with intracranial giant serpentine aneurysms.

[This retracts the article DOI: 10.21037/qims-20-698.].

Surgery Versus Endovascular Treatment for Proximal Anterior Cerebral Artery Aneurysms: A Meta-Analysis

Background: Proximal anterior cerebral artery (PACA) aneurysms account for less than 1% of all intracranial aneurysms. These aneurysms possess a challenge to surgeons due to their small size, wide base, fragile wall, and accompanying vascular anomalies. Surgery and endovascular treatment are both effective treatment options for PACA aneurysms but there is currently no consensus on which is the method of choice. Objective: A systematic review and meta-analysis was conducted to investigate treatment strategies for aneurysms at proximal anterior cerebral artery. Material and Methods: The Cochrane Library, EMBASE, PubMed, and Web of Science databases were systematically searched for studies published between January 01, 2000 and December 01, 2020 that investigated surgery and/or endovascular treatment for patients with PACA. Results and Conclusions: Nineteen retrospective studies involving 358 patients met the inclusion criteria. Among these patients, 150 were treated surgically and 208 were treated using an endovascular technique. Preoperative morbidity was significantly greater in the surgical patients compared with the endovascular treated patients but there was no difference between groups in procedural related morbidity. The rates of favorable clinical outcome at time of discharge and at follow-up were statistically significantly greater in the endovascular group compared with the surgical group. Procedural related mortality was 8.7% for the surgical group and 1% in the endovascular group. In summary, our meta-analysis emphasized the safety and efficiency of endovascular treatment, and concluded that it was superior to surgery in acquiring favorable clinical outcome and reducing the perioperative complications. However, surgery was still the preferred treatment strategy for ruptured PACA aneurysms. Preoperative evaluation seems to be of great vital.

Abstract TMP47: Identifying and Categorizing Delays to Endovascular Treatment in Patients With Large Vessel Occlusions

Introduction: Early endovascular treatment (EVT) in patients with large vessel occlusions (LVO) is associated with better outcomes. Identifying and categorizing delays to EVT may reveal areas for improvement. Methods: We prospectively identified all patients who underwent EVT at our hospital between May 2022 - 2023. We determined eight steps in acute care: arrival, imaging, IR activation, ED release, arrival to IR, groin puncture, first pass, and recanalization. We classified patients as delayed if any interval exceeded their rolling six-month median. We created 12 categories and 36 subcategories of delays. We used t-test and odds ratios to compare intervals and outcomes between delayed and non-delayed patients. We analyzed subgroups based on causes of delay and location of presentation. Results: Out of 183 LVO patients who underwent EVT, 111 (61%) were delayed. There were no significant differences in age, gender, last known normal to arrival, NIHSS, thrombolytic use, or TICI scale. The delayed group had higher door to groin (99 min), door to device (126 min), and door to recanalization (159 min) compared to the non-delayed group (40, 65, 81 min; p &lt; 0.001). The most common causes of delay were: general case complexity (20%), which was associated with higher door to imaging (59 min, p &lt; 0.001) and imaging to IR activation (37 min, p = 0.03); after hours presentation (19%), which was associated with higher door to imaging (53 min, p = 0.02) and imaging to IR activation (36 min, p = 0.01); and procedural complexity (18%) which was associated with higher groin to device (34 min, p &lt; 0.001) and device to recanalization (53 min, p &lt; 0.001) when compared to other causes of delay. Between the delayed and non-delayed group, there was no significant difference in the length of stay, change in NIHSS at discharge, in-hospital mortality, disposition, or 90-day mRS. Subgroup analysis showed a trend towards higher mortality in delayed patients who presented after hours (OR 3.60 (CI) 0.92-14.10) or in-hospital (OR 2.41 (CI) 0.57-10.19). Conclusions: We determined seven intervals where delays can occur between arrival and recanalization of LVO patients. We created a system for categorizing delays that showed areas for improvement including after hours and in-hospital stroke evaluation.

Abstract TP321: Real World Outcomes in Patients With a Posterior Cerebral Artery Occlusion With a Low NIHSS

Introduction: Observational studies have reported improved outcomes following endovascular treatment (EVT) for posterior cerebral artery (PCA) occlusions. Whether there is a benefit of EVT in patients with NIHSS &lt;6 is less well understood. Methods: The National Inpatient Sample (2015-2020) was retrospectively queried for patients with a primary PCA occlusion with a NIHSS &lt;6 and age&gt;17 without a concomitant basilar artery occlusion (BAO). A secondary analysis including patients with a BAO was also performed. Treatment with best medical management (BMM) versus endovascular therapy (EVT) was compared using propensity score matching. Results: In this time frame, 31,175 patients presented with a PCA occlusion as the primary diagnosis and had a NIHSS&lt;6. Of these patients, 8.8% of patients were treated with EVT. 31,050 patients did not have a concomitant BAO. In a propensity matched cohort of primary PCA and patients without a concomitant BAO, 2720 were treated with EVT and 2720 were treated with BMM. Patients treated with EVT had greater odds of routine discharge (adjusted OR 1.34, 95% CI 1.02 to 1.77, p=0.036) with no difference in length of hospital stay (adjusted β -0.35, 95% -0.83 to 0.13, p=0.15) or in-hospital death (adjusted OR 0.77, 95% CI 0.15 to 3.99, p=0.76) as compared to patients treated with BMM. Patterns were also similar when patients with a concomitant BAO were present (routine discharge adjusted OR: 1.67, 95% CI: 1.28-2.19, p&lt;0.001). Conclusions: Our findings suggest potential real-world benefit for EVT in patients with a PCA occlusion with a low NIHSS, irrespective of concomitant BAO.

Abstract WP188: Differences in Outcomes Due to Anesthesia Management During Endovascular Treatment of Patients With Acute Ischemic Stroke Due to Tandem Lesions

Background: Endovascular therapy (EVT) has been reported to be safe and effective for acute ischemic stroke (AIS) patients with tandem lesions (TLs). However, the optimal anesthetic management during EVT for TL patients is unknown. We aimed to assess the impact of anesthesia modality on clinical outcomes in AIS patients with TLs. Methods: Patient level data were pooled from 16 centers for anterior circulation TLs from 2015-2020. Patients were divided into general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression was used to assess the association of outcomes including modified Rankin Score (mRS) 0-2, ordinal shift is mRS, symptomatic intracranial hemorrhage (sICH), successful reperfusion (mTICI score ≥2b), excellent reperfusion (mTICI 3), first pass effect (FPE), early neurological recovery (ENI), door to skin puncture and reperfusion, and 90-day mortality. Results: Among 691 patients, 595 (GA:230 [38.7%] and PS:365 [61.3%]) were included in the final analysis. Patients treated with GA had lower odds of mRS 0-2 (36.6% vs. 52.5%, aOR: 0.56, 95% CI: 0.38-0.84, p =0.005) and favorable shift in 90 days mRS (aOR: 0.71, 95% CI: 0.51-0.99, p =0.041) when compared to PS. No differences were noted for sICH (3.9% vs. 4.7%, aOR: 0.66, 95% CI: 0.26-1.66, p =0.38), successful reperfusion (89.1% vs 86.5%, aOR: 1.59, CI: 0.87-2.89, p=0.13), excellent reperfusion (48.5% vs 50.3%, aOR: 0.85, CI: 0.56-1.30, p=0.462), FPE (53.6% vs 63.4%, aOR: 0.67, CI 0.45-1.0, p=0.05), ENI (38.9% vs 38.8%, aOR: 0.70, CI: 0.44-1.12, p=0.138), mortality at 90 days (20.3% vs 16.3%, aOR: 0.74, CI: 0.29-1.87, p=0.525), door to skin puncture (80 [46-117.5] mins vs 54 [21-100], p=0.607) and skin puncture to reperfusion (59 [39.5-85.5] mins vs 54 [38-81], p=0.836). Conclusions: In patients with AIS with TLs treated with EVT, GA was associated with lower odds of functional independence without a significant increased risk of sICH, mortality, or treatment delays.

Abstract WMP43: Disparities in Large Vessel Occlusion Stroke Imaging and Endovascular Treatment Metrics, and Procedural Exclusions in the Global Registry of Stroke Care Quality (Res-Q)

Introduction: Global access to mechanical thrombectomy for large vessel occlusion (LVO) stroke is low and disparate between regions. Comparative global data on time metrics for imaging and endovascular treatment (EVT) performance, as well as the reasons for excluding EVT, are lacking. Methods: This is a cross-sectional study using quality metrics from the Res-Q registry on patients presenting directly to the hospital with acute ischemic stroke from January 1, 2022, to December 31, 2022, in countries with 200 or more cases. We used descriptive statistical methods to study the time metrics of interest including door to imaging and door to puncture. Additionally, reasons for not performing thrombectomy in patients with LVO were collected (Table 1). Results: Among the 153,181 patients from 912 hospitals across 67 countries enrolled in the Res-Q registry, 125,390 had an acute ischemic stroke. After excluding secondary transfers (n=26,648), patients with missing or erroneous data (n=42,232), and countries with less than 200 cases (n=1,626), data from a total of 54,884 patients from 631 hospitals across 30 countries were analyzed. CT angiography (CTA) was performed in 24,215 (44.1%) patients and EVT was done in 3,649 (6.6%) patients. For patients who had simultaneous CT+CTA, the median door-to-CTA time was 27.5 min (IQR 22.5-33.9) and the median door-to-puncture time was 98.5 (IQR 79.8-129.3) minutes. The most prevalent specific reason for excluding EVT in patients with LVO on CTA/MRA was the presentation in the late time window (42.0%). Only 11 (36.7%) countries achieved a median door-to-puncture time within 90 minutes (Table 1). Conclusions: The performance of acute imaging for LVO detection and time metrics for EVT appear to be disparate between countries and warrant further study. Additional data from global stroke care quality registries are needed to set benchmarks, compare regional stroke systems of care, and identify gaps to mobilize resources appropriately.