Endovascular Therapy Treatment Research Articles

Endovascular Therapy and Outcomes Among Patients With Very Large Ischemic Core Stroke

The association of endovascular therapy (EVT) with outcomes is unclear for patients with very low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) within 24 hours of stroke onset. To explore the association of EVT with functional and safety outcomes among patients with ASPECTS of 0 to 2 scored with noncontrast computed tomography. This cohort study used data from an ongoing, prospective, observational, nationwide registry including all patients treated at 38 stroke centers in China with an occlusion in the internal carotid artery or M1 or M2 segment of the middle cerebral artery within 24 hours of witnessed symptom onset. Patients with ASPECTS of 0 to 2 between November 1, 2021, and February 8, 2023, were included in analysis. Data were analyzed October to November 2023. EVT vs standard medical treatment (SMT). The primary outcome was favorable functional outcome, defined as modified Rankin Scale score (mRS) of 0 to 3, at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage (sICH) within 48 hours and mortality at 90 days. A total of 245 patients (median [IQR] age, 71 [63-78] years; 118 [48%] women) with ASPECTS of 0 to 2 were included, of whom 111 patients (45.1%) received SMT and 135 patients (54.9%) received EVT. The EVT group had significantly greater odds of favorable functional outcome at 90 days than the SMT group (30 patients [22.2%] vs 11 patients [9.9%]; P = .01; adjusted odds ratio [aOR], 3.07 [95% CI, 1.29-7.31]; P = .01). Patients in the EVT group, compared with the SMT group, had significantly greater odds of any ICH (56 patients [41.5%] vs 16 patients [11.4%]; P < .001; aOR, 4.27 [95% CI, 2.19-8.35]; P < .001) and sICH (24 patients [17.8%] vs 1 patient [0.9%]; P < .001; aOR, 23.07 [95% CI, 2.99-177.79]; P = .003) within 48 hours. There were no differences between groups for 90-day mortality (80 patients [59.3%] vs 59 patients [53.2%]; P = .34; aOR, 1.38 [95% CI, 0.77-2.47]; P = .28). The results remained robust in the propensity score-matched analysis. In this cohort study of patients with very low ASPECTS based on NCCT within 24 hours of stroke onset, those treated with EVT had higher odds of a favorable functional outcome compared with those who received SMT. Randomized clinical trials are needed to assess these findings.

Abstract 84: Efficacy of Endovascular Therapy in Acute Ischemic Stroke by Alberta Stroke Program Early Computed Tomography Score and National Institutes of Health Stroke Scale-A Secondary Analysis of a Randomized Controlled Trial

Introduction and Aims: The ANGEL-ASPECT trial demonstrated the effectiveness of endovascular therapy (EVT) in acute ischemic stroke (AIS) patients with large infarct. We did a secondary analysis to explore the efficacy of EVT according to Alberta Stroke Program Early Computed Tomography Score (ASPECT) and National Institutes of Health Stroke Scale (NIHSS). Methods: ANGEL-ASPECT trial was a randomized clinical trial involving patients with acute anterior-circulation large-vessel occlusion and an ASPECT score of 3-5 or an infarct-core volume of 70-100ml. Patients were randomly assigned to EVT or standard medical treatment (SMT) alone. We categorized patients based on the combination of ASPECT (≤3 or 4-5) and NIHSS (&lt;20 or ≥20) into four groups: low ASPECT &amp; low NIHSS; low ASPECT &amp; high NIHSS; high ASPECT &amp; low NIHSS and high ASPECT &amp; high NIHSS. We assessed the efficacy of EVT using ordinal shift analysis of 90-day modified Rankin Scale (mRS). Results: Among 455 patients, the prevalence of the four groups were 190 (41.8%), 70 (15.4%), 157 (34.5%) and 38 (8.4%), respectively. A significant shift in the distribution of 90-days mRS toward better outcomes in favor of EVT was observed in patients with low ASPECT &amp; low NIHSS (common OR [cOR], 2.25; 95% CI, 1.34-3.76; P=0.002), and high ASPECT &amp; low NIHSS (cOR, 2.30; 95% CI, 1.31-4.05; P=0.004), but not in other two groups with high NIHSS (all P &gt;0.05). Conclusions: EVT was associated with better outcomes in AIS patients with large infarct and mild-to-moderate stroke severity (NIHSS &lt;20), but not in those with severe stroke severity (NIHSS ≥20). Stroke severity should be considered when planning EVT for AIS patients with large infarcts.

Abstract TP216: Sex-Based Differences in Endovascular Thrombectomy Outcomes for Large Ischemic Stroke: A SELECT2 Subanalysis

Introduction: Multiple randomized controlled trials demonstrated better functional outcomes with endovascular therapy (EVT). Potential heterogeneity in EVT treatment effect by sex is an important question as several social and biological factors are shown to differentially affect stroke outcomes between men and women. We aimed to evaluate if clinical outcomes and thrombectomy treatment effect differed by sex among patients with large ischemic stroke. Methods: In the SELECT2 RCT, baseline characteristics and outcomes were compared between men and women. The primary outcome was a shift in modified Rankin Scale score, with functional independence (mRS 0-2), independent ambulation (mRS 0-3) and symptomatic ICH as secondary outcomes. Effect modification was examined using multiplicative sex-by-treatment interaction term. Additionally, repeated measure mixed effect models were used to evaluate if recovery in functional status differed by sex at discharge/ 5 to7-day, 30-day, and 90-day follow-up. Results: Of 352 enrolled patients, 71/145 (49%) of women and 109/207 (53%) of men underwent EVT. EVT was uniformly associated with better functional outcomes without evidence of treatment effect modification [Men - aGenOR: 1.66(1.24-2.23) vs women - aGenOR: 1.73(1.22-2.45), p-int: 0.94], functional independence [men - aRR: 1.99(0.99-4.02) vs women - aRR: 5.04(1.59-16.02), p-int: 0.20] and independent ambulation [men - aRR: 1.98(1.29-3.03) vs women - aRR: 2.44(1.40-4.24), p-int: 0.67]. There were no significant differences between the two cohorts’ recovery at discharge/5 to 7-day, 30-day, and 90-day follow-up (figure). Conclusions: EVT was associated with higher rates of functional independence and independent ambulation in both men and women, without significant heterogeneity in treatment effect or recovery arc between discharge and 90-day follow-up. Trial Registration: NCT03876457

Predictors for large vessel recanalization before stroke thrombectomy: the HALT score

BackgroundLarge vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke...

Abstract Number ‐ 277: Mobile Stroke Unit Direct to Angiosuite Process Metrics and Clinical Outcomes

Introduction Mobile Stroke Units (MSUs) speed treatment with tPA, but did not affect time from alert to puncture time for endovascular therapy (EVT) in the Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU), a prospective multicenter controlled trial comparing MSU with standard EMS management. The lack of improvement in EVT treatment time could be because the CTA to identify large vessel occlusions (LVOs), and alerting of the EVT team, were delayed in most MSU patients until after Emergency Department (ED) arrival. The impact of identifying LVOs by imaging on the MSU enabling a direct (from MSU) to angiosuite (DTAS) protocol has yet to be studied. Methods We conducted a pre‐specified substudy of tPA‐eligible stroke patients with LVOs on computed tomography (CT) and/or CT angiography (CTA) who were enrolled into the MSU arm of the BEST‐MSU study. We compared alert to puncture time and other process metrics, mean utility‐weighted modified Rankin Scale (uw‐mRS) and functional independence (mRS 0–2) at 90 days, and rate of early neurologic recovery (30% improvement in NIHSS score) at 24 hours in patients who were managed by DTAS vs post‐ED arrival diagnosis and alerting. Results A total of 169 MSU patients with LVOs were identified; 22 in the DTAS group and 111 in the non DTAS group. Data were not available for 36 LVO patients. Baseline characteristics including age, sex, ethnicity, prestroke mRS, and initial NIHSS were comparable between the groups. 100.0% of patients in the DTAS group vs 90.1% in the non DTAS received tPA (p = 0.264). EVT was performed on 85.0% of patients in the DTAS group vs 77.1% in the non DTAS group (p = 0.634). DTAS group had a faster alert to puncture time (108.00 min [94.75,124.75.] vs 150.50 min [121.25, 179.00], p&lt; 0.001) and door to puncture time (37.00 min [25.50,62.75 vs 86.50 min [62.50,116.00], p&lt; 0.001). The mean score on the uw‐mRS at 90 days was 0.626 ±0.367 in the DTAS group and 0.660 ±0.382 in the non DTAS group and after adjustment for age, baseline NIHSS, premorbid functional status, prior stroke/TIA and site, no significant difference was observed; (p = 0.54). In an unadjusted analysis, early neurologic recovery (72.7% vs 67.6%, (OR = 0.634, 95% CI [0.46,3.82]) and functional independence (50.0% vs 51.4%, p = 1.000) were comparable between DTAS and non DTAS patients. Patients in the DTAS group were less likely to receive general anesthesia (36.4% vs 71.2%, p = 0.004). Rates of recanalization (77.3% vs73,4%, p = 0.947) and post procedural PH‐2 hemorrhage (4.5% vs 0.9%, p = 0.746) were similar in the DTAS and non DTAS group respectively. Conclusions In tPA‐eligible LVO stroke patients, DTAS management resulted in shorter alert to puncture (42 minutes) and door to puncture times (50 minutes) with similar safety and clinical outcomes compared with non DTAS management. MSU DTAS represents an optimized pathway for LVO patients triaged and treated in the field.

Abstract WP151: DISPARI-TICI: Determining If Stroke Patients Assessed For Revascularization Show Ethnic Disparities In TICI Scores Or Complications

Introduction: There is limited data on ethnic disparities in endovascular therapy (EVT) Thrombolysis In Cerebral Infarction (TICI) revascularization scores and EVT complications. The goal of this study was to compare disparities in TICI scores and complications in Hispanic versus Non-Hispanic ethnicities. Methods: We retrospectively examined prospectively collected data from an IRB-approved stroke registry at two academic Comprehensive Stroke Centers (CSC). We included acute ischemic stroke (AIS) patients with large vessel occlusion within 24 hours of last known well that underwent EVT between 1/1/2013-6/30/2022. Favorable outcome was defined as TICI 2b-3. Complications of symptomatic intracranial hemorrhage (sICH), life-threatening or serious systemic hemorrhage, or other serious complication were collected within 36 hours of EVT and compared between Hispanic or Non-Hispanic subjects. Data was analyzed using Chi-squared and was adjusted for baseline NIHSS, blood glucose, and age. A p-value of &lt;0.05 was significant. Results: A total of 411 patients who met study criteria were identified. In Hispanics versus Non-Hispanics, the mean age was 69 vs 70 years, 44.6% vs 48.3% patients were female, and median initial NIHSS was 17 vs 16. The rate of Hispanics in this sample was 29.4% (n=121). There were no differences in baseline characteristics or in patients receiving IV rt-PA prior to EVT between Hispanic and Non-Hispanics (72.6% vs 65.5%; p=0.17). The overall rate of favorable TICI outcome was 93.7% (n=385/411). There was no difference in favorable TICI scores in Hispanic versus Non-Hispanics (96.7% vs 92.4%; p=0.12). Complication rates were also not significantly different in Hispanics versus Non-Hispanics for: sICH (5.8% vs 2.4%; p=0.09), other serious complications (1.7% vs 2.1%; p=0.78), and life-threatening systemic hemorrhage (0.8% vs 0.7%; p=0.88). Conclusion: There were no differences in TICI outcome or complication rates in Hispanic versus Non-Hispanic patients in these 2 academic CSCs. The use of consistent protocols and pathways at a CSC likely contribute to consistent EVT treatment between ethnicities. Further studies must examine EVT outcomes within various ethnicities and races in multiple stroke centers around the country.

Endovascular treatment for acute M2 occlusion stroke within 6 hours-a retrospective real-world evidence.

We compared the efficacy and safety of endovascular therapy (EVT), intravenous (IV) thrombolysis and conservative treatment in M2 segment occlusion stroke based on a real-world database. We retrospectively analyzed the database of admitted patients with M2 segment occlusion between January 2018 and December 2020. The patients who were eligible for reperfusion treatment were assigned to EVT, IV thrombolysis or conservative treatment according to the exact management proceeding. The primary outcome was a score of 0 and 1 on the modified Rankin scale (mRS) at 90 days. The odds ratio (OR) for the primary outcome was adjusted for age, baseline National Institute of Health Stroke Scale score, and door-to-treatment time. The secondary outcomes were based on a mRS score from 0 to 2 at 90 days and the safety outcomes including symptomatic intracranial hemorrhage, and all-cause mortality. The data were analyzed by the logistical regression model, including baseline adjustments. A total of 109 patients were included. Among them, 42 (38.5%) patients received EVT, 45 (42.5%) received IV thrombolysis and 22 (20.8%) received conservative treatment. The primary outcome based on a mRS score of 0 and 1, occurred in 66.7% of patients in the EVT group and 40% in the IV thrombolysis group (adjusted OR, 1.79; 95% confidence interval [CI], 1.19-2.68; P = 0.01). Symptomatic intracranial hemorrhage occurred in 1 patient (2.3%) in the EVT group and in 2 patients (4.4%) in the IV thrombolysis group (adjusted OR = 0.71, 95% CI: 0.13-4.07). EVT showed better functional outcomes than IV thrombolysis and conservative treatment in moderate to severe acute stoke patients with M2 occlusion. There was no significant difference in the three groups concerning the incidence of symptomatic intracranial hemorrhage.

Sex Differences in Endovascular Therapy for Ischemic Stroke: Results From the Get With The Guidelines-Stroke Registry.

In 2015, endovascular therapy (EVT) for large vessel occlusions became standard of care for acute ischemic stroke. Lower utilization of IV alteplase has been reported in women, but whether sex differences in EVT use in the United States exists has not been established. We identified all acute ischemic stroke discharges from Get With The Guidelines-Stroke hospitals between 2012 and 2019 who were potentially eligible for EVT, based on National Institutes of Health Stroke Scale score ≥6 and arrival <6 hours, according to 2018 American Heart Association/ASA guidelines. Multivariable regression analyses were used to determine the association between sex and EVT utilization, and outcomes (including mortality, discharge home, functional status) after EVT. Separate analyses were conducted for the 2 time periods: 2012 to 2014, and 2015 to 2019. Of 302 965 patients potentially eligible for EVT, 42 422 (14%) received EVT. Before 2015, EVT treatment rates were 5.3% in women and 6.6% in men. From 2015 to 2019, treatment rates increased in both sexes to 16.7% in women and 18.5% in men. The adjusted odds ratio for EVT in women compared with men was 0.93 (95% CI, 0.87-0.99) before 2015, and 0.98 (95% CI, 0.96-1.01) after 2015. There were no significant sex differences in outcomes except that after 2015, women were less able to ambulate at discharge (adjusted odds ratio, 0.95 [95% CI, 0.95-0.99]) and had lower in-hospital mortality (adjusted odds ratio, 0.93 [95% CI, 0.88-0.99]). EVT utilization has increased dramatically in both women and men since EVT approval in 2015. Following statistical adjustment, women were less likely to receive EVT initially, but after 2015, women were as likely as men to receive EVT. After EVT, women were more likely to be disabled at discharge but less likely to experience in-hospital death compared with men.

Clinical outcome of patients with mild pre-stroke morbidity following endovascular treatment: a HERMES substudy

BackgroundAnalyses of the effect of pre-stroke functional levels on the outcome of endovascular therapy (EVT) have focused on the course of patients with moderate to substantial pre-stroke disability. The effect...

Quality of life and cost consequence of delays in endovascular treatment for acute ischemic stroke in China

BackgroundAlthough endovascular therapy (EVT) improves clinical outcomes in patients with acute ischemic stroke, the time of EVT initiation significantly influences clinical outcomes and healthcare costs. This study evaluated the impact of EVT treatment delay on cost-effectiveness in China.MethodsA model combining a short-term decision tree and long-term Markov health state transition matrix was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes and healthcare costs. Clinical outcomes and cost data were derived from clinical trials and literature. Incremental cost-effectiveness ratio and incremental net monetary benefits were simulated. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of the model. The willingness-to-pay threshold per quality-adjusted life-year (QALY) was set to ¥71,000 ($10,281).ResultsEVT performed between 61 and 120 min after the stroke onset was most cost-effective comparing to other time windows to perform EVT among AIS patients in China, with an ICER of ¥16,409/QALY ($2376) for performing EVT at 61–120 min versus the time window of 301–360 min. Each hour delay in EVT resulted in an average loss of 0.45 QALYs and 165.02 healthy days, with an average net monetary loss of ¥15,105 ($2187).ConclusionsEarlier treatment of acute ischemic stroke patients with EVT in China increases lifetime QALYs and the economic value of care without any net increase in lifetime costs. Thus, healthcare policies should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration in China.

Outcomes of Endovascular Therapy in Acute Basilar Artery Occlusion With Severe Symptoms

Endovascular therapy (EVT) has been reported to be safe and effective in improving clinical outcomes among patients with acute basilar artery occlusion (ABAO). The benefits associated with EVT remain uncertain for patients with ABAO with severe symptoms (ie, National Institutes of Health Stroke Scale [NIHSS] score ≥ 21). To assess the outcomes associated with EVT and identify factors associated with outcomes among patients with ABAO and severe symptoms. This prospective, nationwide cohort study was conducted using data from January 2014 to May 2019 in China from the Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry (BASILAR). Included patients had ABAO and underwent EVT or standard medical treatment (SMT) alone in routine clinical practice. Patients were dichotomized into severe symptoms (ie, NIHSS score ≥ 21) and minor to moderate symptoms (NIHSS score < 21) groups. Patients were followed up for 90 days. Data were analyzed from December 2020 through June 2021. EVT with SMT vs SMT alone. The primary outcome was improvement in modified Rankin Scale (mRS) score at 90 days, defined as a decrease by 1 grade in mRS score. Secondary outcomes included favorable functional outcome (ie, mRS score, 0-3) and mortality. Among 542 patients with ABAO and severe symptoms (median [IQR] age, 65 [57-74] years; 147 [27.1%] women), 431 patients (79.5%) received EVT and 111 patients (20.5%) received SMT. Compared with SMT, EVT was associated with increased odds of improved mRS score (adjusted common odds ratio [OR], 3.44 [95% CI, 2.05-5.78]; P < .001), with increased odds of a favorable functional outcome (ie, mRS score, 0-3; adjusted OR, 4.52 [95% CI, 1.64-12.43]; P = .004) and decreased odds of mortality (adjusted OR, 0.27 [95% CI, 0.15-0.50]; P < .001). Among patients receiving EVT, baseline NIHSS score was associated with decreased odds of a favorable functional outcome (adjusted OR per 1-point increase in score, 0.90 [95% CI, 0.85-0.95]; P < .001) and increased odds of mortality (adjusted OR per 1-point increase in score, 1.13 [95% CI, 1.07-1.19]; P < .001), while posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) was associated with increased odds of a favorable functional outcome (adjusted OR per 1-point increase in score, 1.71 [95% CI, 1.41-2.07]; P < .001) and decreased odds of mortality (adjusted OR per 1-point increase in score, 0.74 [95% CI, 0.64-0.85]; P < .001). Different occlusion sites, compared with distal basilar artery, were associated with decreased odds of favorable functional outcome (eg, middle basilar artery: adjusted OR vs distal basilar artery, 0.36 [95% CI, 0.17-0.80]; P = .01). This study found that EVT was associated with increased odds of functional favorable outcomes among patients with ABAO and severe symptoms. Baseline NIHSS score, pc-ASPECTS, and occlusion site were independent factors associated with clinical outcomes.

Abstract P651: Should I Stay or Go: Seeking Stroke Care During Covid-19

Introduction: On March 16, 2020 San Diego County implemented a stay at home order in response to COVID-19 pandemic; followed by the state of California instituting a shelter in place order. Locally, San Diego County’s stroke receiving centers (SRC) determined a 30% drop in stroke code activations between March-April 2020 compared to the same time in 2019 indicating a possible delay in seeking care. Utilizing discharge data, we sought to understand the impact of the stay at home order on the timeliness of seeking care. Hypothesis: We hypothesized an increase in last known normal (LKN) to hospital arrival time and a decrease in alteplase (tPA) and endovascular therapy (EVT) treatment rates between March 16-June 30 2020 compared to March 16-June 30 2019. Methods: AIS patients presenting to one of 16 SRC in San Diego County between March 16-June 30 in 2019 and 2020, discharged from the hospital or treated in the ED and transferred to another facility were included. Patients arriving as transfers from another facility were excluded. Results: In 2019, of 1,342 AIS cases LKN time was recorded for 85.6% of cases; of 1,092 cases in 2020 86.4% of cases had a LKN. Average LKN to arrival was 20.5 hours in 2019 and 32.4 hours in 2020 (p = .001, 95% CI [4.79, 18.93]). In 2019, 209 (15.6%) received tPA and 91 (6.8%) had EVT. In 2020, 144 (13.2%) received tPA and 75 (6.9%) had EVT. Odds that a case in 2019 received tPA was 1.21 times that of cases in 2020 (p=.09). Odds that a case in 2019 had EVT was .99 times that of cases in 2020 (p=.93). Conclusion: Ischemic stroke patients arriving between March 16-June 30, 2020 had a longer LKN to arrival time compared to the same time frame in 2019. The longer time to arrival may have been due to patients waiting longer to seek care, as anecdotal information from patients eluded to. The odds of receiving tPA or EVT treatment in 2020 compared to 2019 were not statistically significant. This may be due to patients experiencing acute symptoms accessing healthcare at the same rate in 2020 as 2019. Analysis of percent of patients arriving within 4 hours of LKN and average NIHSS are important next steps to determine this. Regardless, during a time of community crisis, it is important to broadcast community messaging focusing on the importance of seeking emergency care for stroke-like symptoms.

Abstract P284: Coordinating Options for Acute Stroke Therapy (COAST): Demonstrating Patient Autonomy by Examining Preferences for Acute Stroke Treatment From a Stroke Advance Directive

Introduction: Respect for patient autonomy is critical, and patients/surrogates may have various preferences about acute stroke treatment that are not fully appreciated during a stroke code. COAST (Coordinating Options for Acute Stroke Therapy) is a stroke advance directive formalizing advanced consent for thrombolysis (tPA) and endovascular therapy (EVT). We examine the distribution of patient preferences to improve understanding and respect for patient autonomy in acute stroke. Methods: In our IRB-approved study, we collected COAST forms at UC San Diego from 12/1/2014-2/29/2020. Patients chose one of five tPA preferences: not under any circumstance (tPA 1); up to 3 hours only, based on FDA approval (tPA 2); up to 4.5 hours only, based on current guidelines (tPA 3); anytime per provider discretion (tPA 4); or other answer (tPA treatment under specific conditions written by the patient/surrogate) (tPA 5). Patients also chose one of five EVT preferences: not under any circumstance (EVT 1); up to 6 hours only (EVT 2); up to 12 hours only (EVT 3); up to 24 hours only (this option replaced "up to 12 hours only" on 3/1/2018 when the 6-24 hour window became standard of care) (EVT 4); anytime at provider discretion (EVT 5); or other answer (EVT treatment under specific conditions written by the patient/surrogate) (EVT 6). Frequency of preferences was calculated for each option. Results: In total, 342 COASTs were completed. Frequency of tPA preferences were: 3.2% for tPA 1 (11/342), 1.5% for tPA 2 (5/342), 25.7% for tPA 3 (88/342), 55.6% for tPA 4 (190/342), 14.0% for tPA 5 (48/342). Frequency of EVT preferences were: 1.8% for EVT 1 (6/342), 9.6% for EVT 2 (33/342), 3.2% for EVT 3 (11/342), 10.8% for EVT 4 (37/342), 62.3% for EVT 5 (213/342), 12.3% for EVT 6 (42/342). When the 6-24 hour window became standard of care, 0% (0/342) chose EVT 2. Total 81.6% (n=279) of COASTs had the same tPA and EVT preferences, and 18.4% (n=63) had tPA preferences that were different from EVT preferences. Conclusion: Preferences vary regarding tPA and EVT treatment. Most patients defer to provider discretion, though some patients have preferences that are different from current provider expectations and/or stroke guidelines. COAST is pivotal to inform respect for patient autonomy for acute stroke codes.

Effect of age and baseline ASPECTS on outcomes in large-vessel occlusion stroke: results from the HERMES collaboration

BackgroundPatient age and baseline Alberta Stroke Program Early CT score (ASPECTS) are both independent predictors of outcome in acute ischemic stroke patients treated with endovascular therapy (EVT). We assessed the...

Assessment of Cerebral Collateral Flow With Single-Phase Computed Tomography Angiography-Based Multimodal Scales in Patients With Acute Ischemic Stroke.

Assessing collateral status is important in acute ischemic stroke (AIS). The purpose of this study was to establish an easy and rapid method for evaluating collateral flow. A total of 60 patients with AIS were enrolled. The patients were aged 18 to 85 years with endovascular therapy treatment within 10 hours after the appearance of stroke symptoms, prestroke modified Rankin Scale ≤1, Alberta Stroke Program Early CT Score ≥6, and the occlusion of large vessels in anterior circulation. We reformed imaging strategies by conducting a small-dose group-injection test before normal computed tomography angiography (CTA) scanning and selected the visual collateral score and the regional leptomeningeal score scales as the single-phase CTA collateral flow assessment scales with the replacement of the parasagittal anterior cerebral artery territory by anterior cerebral artery regions adjacent to the longitudinal fissure and then verified, respectively, the consistencies between the 2 single-phase CTA-based collateral scales and the digital subtraction angiography (DSA)-based American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale and compared the prognosis of endovascular therapy between the AIS patients in the poor-collateral-flow group and the other patients' group assessed by 2 single-phase CTA-based collateral scales. There was a high consistency between the 2 single-phase CTA-based collateral flow scales with DSA-based American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale. The assessment by using CTA-based collateral flow assessment methods generated consistent results. The single-phase CTA-based visual collateral score scale and regional leptomeningeal score scale can be used as the imaging evidence for the evaluation of collateral flow in AIS patients in the majority of grassroots hospitals where DSA is difficult to carry out.

Abstract TP165: Mortality After Large Artery Occlusion Acute Ischemic Stroke

Introduction: Despite randomized trials demonstrating the benefit of endovascular therapy (EVT), large artery occlusion (LAO) acute ischemic stroke (AIS) remains associated with high mortality. Identifying factors associated with mortality for patients presenting with LAO AIS can assist in therapeutic decision-making and prognostication. Hypothesis: Among patients with LAO AIS, factors associated with 90-day mortality include older age, higher presenting NIHSS score, and lower final Thrombolysis in Cerebral Infarction (TICI) score. Methods: From November 2016 to April 2019, we conducted a retrospective analysis from a large healthcare system’s stroke network registry of patients presenting with ICA and/or MCA occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality. Results: Among 796 patients with 800 encounters, mean age was 68 years, 52% were women, mean presenting NIHSS was 14, and 97% presented within 24 hours of last known well time. Fifty-one percent were treated with EVT. Mortality rate for the entire cohort was 25%. In a univariate analysis, there were significant differences in age, gender, race, blood glucose, presenting NIHSS, hypertension, atrial fibrillation, CTP core volume, CTP delayed perfusion volume, EVT treatment, number of passes for EVT, final TICI score, and discharge mRS, between patients with and without 90-day mortality. In the multivariable model, increasing age (per 10 years, OR 1.54, 95% CI 1.20, 1.97) and higher discharge mRS (per 1 point, OR 4.47, 95% CI 3.05, 6.55) were associated with 90-day mortality. Female gender (OR 0.57, 95% CI 0.27, 1.18) and final TICI score of 2B or better (OR 0.42, 95% CI 0.18, 1.01) were protective against 90-day mortality. Conclusions: Increasing age and worse discharge functional outcome are associated with 90-day mortality after LAO AIS. Female gender and better revascularization after EVT are associated with lower mortality. Additional studies are required to refine mortality outcome prediction models for patients presenting with LAO AIS.

Outcomes of Endovascular Therapy versus Microsurgical Treatment for Aneurysmal Subarachnoid Hemorrhage in Patients ≥70 Years of Age.

This retrospective research aimed to compare the efficacy of endovascular therapy (EVT) versus microsurgical treatment (MST) for elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). Elderly (>70 years) patients with aSAH who underwent aneurysm obliteration during 2007-2017 were selected from our hospital database and enrolled in this retrospective study. We reviewed each patient's background, the severity of the aSAH, and aneurysmal characteristics that compelled EVT or microsurgery treatment and then compared the two treatment groups. A favorable primary outcome was defined by a modified Rankin scale (mRS) score of 0-3 at hospital discharge. The 78 patients formed two cohorts (39 patients each) based on their propensity scores for EVT or MST. We estimated the adjusted odds ratio, followed by a sensitivity analysis of the original 201 patients (118 with EVT and 83 with MST). In the propensity score-matched cohorts, favorable outcomes were observed in 33.3% and 7.7% of patients in the EVT and MST groups, respectively (p = 0.01). Results of the sensitivity analysis were similar to the main results. The clinical outcomes for the elderly aSAH patients were better in the EVT group than in MST group.

Endovascular therapy for middle cerebral artery M2 segment occlusion: subanalyses of RESCUE-Japan Registry 2

ObjectiveTo compare the efficacy of endovascular therapy (EVT) with that of medical treatment in ’real-world ’patients with M2 occlusion.MethodsThis was a post hoc analysis of the Recovery by Endovascular Salvage...

Abstract TP391: The Smoking Paradox - Does it Exist in Acute Ischemic Stroke Patients Receiving Endovascular Therapy?

Introduction: A “smoking paradox” has been observed in GWTG data whereby patients with an active smoking history paradoxically have lower post stroke mortality and better outcomes after IV thrombolysis than non-smokers. We sought to determine if this effect was present in acute ischemic stroke (AIS) patients who underwent endovascular therapy (EVT). Methods: Using local GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 13,420 consecutive stroke admissions from 01/2006 - 04/2018 and included all patients with EVT stratified by smoking status. We compared good clinical outcome (discharge to home versus other) and in-hospital mortality using Chi-square for categorial data, T-Test for parametric continuous and Wilcoxon for non-parametric continuous variables. We used multiple regression analysis to identify associations. Results: We identified 772 patients who underwent EVT. Of those, 128 (16%) were smokers. Smokers were younger, more frequently male and presented with fewer stroke risk factors such as CAD/MI and atrial fibrillation. Overall NIHSS was similar, but smokers had a higher frequency of weakness at presentation. (Table). IV tPA use and in-hospital complications (pneumonia and deep vein thrombosis) were similar across the groups. Smoking was associated with good outcome in univariate analysis (OR 1.90; 95% CI 1.25, 2.89, p&lt;0.001) but in multivariable analysis, only age was independently associated with good outcome (OR 0.97; 95% CI 0.96, 0.99, p&lt;0/001) or in-hospital mortality (OR 1.03; 95% CI 1.02, 1.05, p&lt;0.001). Conclusion: Unlike after IV tPA alone, smoking was not associated with a good outcome after multivariable adjustment in AIS patients receiving EVT. This may be due to differences in patient selection, stroke subtype or the effect size of EVT treatment. Replication in independent data sets is needed to confirm this observation.

Components and Trends in Door to Treatment Times for Endovascular Therapy in Get With The Guidelines-Stroke Hospitals.

Endovascular therapy (EVT) is standard of care in patients with acute disabling ischemic stroke attributable to large-vessel occlusion and is more effective when delivered quickly. It is currently unclear whether time targets achieved in clinical trials can be achieved in clinical practice. We describe interval times from patient arrival in the emergency department (door) to first pass (treatment initiation) in patients receiving EVT within Get With The Guidelines-Stroke hospitals and analyze patient- and hospital-level variables associated with these times. Data are from sites participating fully as Comprehensive Stroke Centers within Get With The Guidelines-Stroke hospitals from October 2014 to September 2016. Workflow times analyzed include door to imaging, imaging to arterial access, arterial access to first pass, and the composite door to first pass time. Data are described overall and by calendar-year quarters. Multivariable modeling was used to identify patient- and hospital-level variables associated with workflow times. Among 2929 patients with EVT from 195 hospitals (median age, 71 years [interquartile range {IQR}, 60-81]; 50.7% female; median baseline National Institute of Health Stroke Score, 17 [IQR, 12-22]; median annual EVT administration number, 16 [IQR, 10-27]), median door to first pass time was 130 minutes (IQR, 101-170 minutes), door to imaging time was 12 minutes (IQR, 7-20 minutes), imaging to arterial puncture time was 93 minutes (IQR, 68-126 minutes), and arterial puncture to first pass time was 18 minutes (IQR, 4-31 minutes). Overall, 3% patients achieved a door to first pass time ≤60 minutes. A statistically significant linear time trend was noted for door to first pass time (quarter 4 year 2014 median time, 134.5 minutes to quarter 3 year 2016 median time, 128 minutes, P=0.002). In multivariable analysis, older age, arrival during nonregular hours, and history of diabetes mellitus were associated with longer door to first pass time. Hospitals achieving shorter door to intravenous alteplase administration (door to needle) times were more likely to achieve faster door to first pass time ( P<0.001). Each 5 cases/y increase in EVT case volume was associated with a 3% shorter door to first pass time, up to a case volume of 40 per year ( P<0.001). Although EVT treatment times are modestly improving, additional efforts are needed to streamline workflow so that the true potential of this treatment is realized. These data may inform benchmark goals for EVT workflow times.