Higher Aspects Research Articles

External validation of clinical risk prediction score for elderly treated with endovascular thrombectomy

Background and aimThe thrombectomy in the elderly prediction score (TERPS) for functional outcome after anterior circulation endovascular therapy (EVT) in patients ≥ 80 years was recently developed. The aim of this study was to assess predictors of functional outcome in the elderly and validate the prediction model.MethodsConsecutive patients treated with EVT from the Oslo Acute Reperfusion Stroke Study were evaluated for inclusion. Clinical and radiological parameters were used to calculate the TERPS, and functional outcome were assessed at 3-month follow-up.ResultsOut of 1028 patients who underwent EVT for acute ischemic stroke from January 2017 to July 2022, 218 (21.2%) patients ≥ 80 years with anterior ischemic stroke were included. Fair outcome, defined as modified Rankin scale ≤ 3 (mRS), was achieved in 117 (53.7%). In bivariate analyses, male sex (p 0.035), age (p 0.025), baseline National Institute of Health Stroke Scale (NIHSS, p < 0.001), pre-stroke mRS (p 0.002) and Alberta Stroke Program Early Computed Tomography score (ASPECTS, p 0.001) were associated with fair outcome. Significant predictors for fair outcome in regression analyses were lower pre-stroke mRS, adjusted odd ratio, (aOR) 0.67 (95% CI 0.50–0.91, p 0.01), NIHSS, aOR 0.92 (95% CI 0.87–0.97, p 0.002), and higher ASPECTS, aOR 1.22 (95% CI 1.03–1.44, p 0.023). The area under the curve (AUC) using TERPS was 0.74 (95% CI 0.67–0.80).ConclusionsThe risk prediction score TERPS showed moderate performance in this external validation. Other variables may still be included to improve the model and validation using other cohorts is recommended.Trial registrationNCT06220981.

Efficacy of endovascular therapy for stroke in developing country: A single-centre retrospective observational study in Indonesia from 2017 to 2021

BackgroundIndonesia as a developing nation faces a plethora of challenges in applying endovascular therapy (EVT), mostly due to the lack of physicians specialized in neuro-intervention, high operational cost, and time limitation. The efficacy of EVT in improving functional outcomes of stroke in developing countries has not been previously studied. MethodsThis retrospective cohort study was conducted at Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) from January 2017 to December 2021. Large vessel occlusion (LVO) diagnosis was established based on a combination of clinical and imaging characteristics. We assessed patients’ functional independence on day-90 based on modified Rankin Scale (mRS) between the endovascular treatment group and the conservative group (those receiving intravascular thrombolysis or medical treatment only). Functional independence was defined as mRS ≤2. ResultsAmong 111 stroke patients with LVO, we included 32 patients in the EVT group and 50 patients in the conservative group for this study. Patients with younger age (p = 0.004), lower hypertension rate (p < 0.001), higher intubation rate (p = 0.014), and earlier onset of stroke were observed in the EVT group. The proportion of mRS ≤2 at day-90 in the EVT group was higher than the conservative group (28.1 % vs. 18.0 %; p = 0.280). Patients within mRS ≤2 group had earlier onset-to-puncture time (p = 0.198), onset-to-recanalization time (p = 0.341), lower NIHSS (p = 0.026) and higher ASPECTS (p = 0.001) on admission. In multivariate analysis, ASPECTS (aOR 2.43; 95%CI 1.26–4.70; p = 0.008) defined functional independence in the EVT group. ConclusionThe endovascular therapy group had a higher proportion of mRS ≤2 at day-90 than the conservative group despite its statistical insignificance.

Abstract 223: Pre‐Thrombectomy Diagnosis of Large Vessel Occlusion with Underlying Intracranial Atherosclerotic Disease

Introduction Intracranial atherosclerotic disease (ICAD) is one of the leading causes of ischemic stroke. We sought to identify variables associated with ICAD underlying large vessel occlusion strokes (LVOS) to facilitate pre‐procedural diagnosis. Methods Retrospective analysis of a prospectively collected thrombectomy single comprehensive stroke center database. Inclusion criteria: anterior circulation occlusion involving the intracranial ICA, MCA‐M1/M2/M3 or ACA(A1‐A2‐A3). ICAD cases were matched for age and sex in a 1:1 ratio to non‐ICAD controls. Results A total of 348 patients were included in the analysis. Patients with ICAD more frequently presented with vascular risk factors. ICAD LVOS showed less frequent atrial fibrillation(AF)(4%vs31%,P=0.001), and lower baseline NIHSS(14vs17,P=0.002) compared to the non‐ICAD group. The ICAD group less frequently showed hyperdense vessel sign and territorial cortical infarcts, but presented more frequently borderzone, deep subcortical and bilateral infarcts on CT compared to the non‐ICAD group. ICAD strokes had higher ASPECTS, and more frequently had calcifications at the carotid siphon as well as multifocal intracranial stenosis on CTA. CTA collaterals scores were comparable between groups. The ICAD group had lower median infarct core volume (1vs12 ml;P&gt;0.001), Tmax&gt;4s (249vs276 ml;P&gt;0.003), and Tmax&gt;6s (97vs140 ml;P&lt;0.003) and higher Tmax&gt;4:6 s ratio (2vs1;P=0.007) on CTP compared to non‐ICAD group. On multivariable analysis, absence of AF, absence of cortical infarcts, presence calcium at ipsilateral carotid siphon, cerebrovascular stroke risk factors burden (DM‐HTN‐Hyperlipidemia‐smoking), borderzone infarcts either (superficial cortical or Internal deep border zone), and multifocal intracranial stenosis were independent factors associated with ICAD. The model (table 1) by AUC for the whole model had sensitivity of 88% [P=&lt;0.001,95%CI(0.84‐0.91)]. Conclusion In patients with anterior circulation LVO strokes, our study suggests that presence of CVS risk factors burden, calcium at carotid siphon, borderzone infract pattern, absence of territorial cortical infarct pattern, multifocal intracranial stenosis, and absence of AF were predictors for ICAD. Additional validation is warranted

Predictors of congruency between clinical and radiographic Oxfordshire Community Stroke Project Classification subtypes

BackgroundThe Oxfordshire Community Stroke Project (OCSP) classification has been widely used to assess ischemic stroke patients based on clinical characteristics alone. However, the correlation between the clinical presentation evaluated using OCSP and imaging findings is yet to be determined. Our study aimed to describe the baseline characteristics of the OCSP subtypes of patients admitted with ischemic stroke and evaluate the predictors of the relationship between clinical and neuroimaging findings. MethodsPatients with a confirmed diagnosis of ischemic stroke admitted to a comprehensive stroke center in Brazil between February 2015 and October 2017 were eligible for the study. All participants underwent computed tomography (CT) at admission and follow-up neuroimaging within seven days, per the institutional protocol. Trained staff classified patients according to the OCSP at hospital admission. The radiographic OCSP classification was retrospectively assessed based on the last follow-up neuroimaging by investigators unaware of the clinical classification. ResultsThe overall agreement rates ranged from 65.5% to 88.7%. Lower NIHSS scores, absent hyperdense MCA sign, higher ASPECTS, and absent brainstem symptoms were related to a higher risk of misclassification. Treatment with intravenous tPA was associated with reclassification in patients with total anterior circulation syndrome. For predicting radiographic posterior circulation involvement, vertigo (OR 2.9, 95% CI 1.7–5.1, p < 0.001) and brainstem symptoms (OR 35, 95% CI 20.5–60.2, p < 0.001) were directly associated with correct classification, but motor and higher cerebral function were not correlated. ConclusionThe clinical OCSP classification presented good congruency rates with the neuroimaging findings. However, patients with lacunar syndromes are often misclassified when radiological criteria are considered.

Predictors of Mechanical Thrombectomy for Anterior Circulation Emergent Large-Vessel Occlusion in the Older Adults.

Few studies have reported the clinical outcomes of older adult patients with acute anterior circulation large-vessel occlusion (LVO) who underwent mechanical thrombectomy (MT). Therefore, we investigated the safety, functional outcomes, and predictors of MT for anterior circulation LVO in older adults. We enrolled patients with acute anterior circulation LVO from May 2018 to October 2021 in this retrospective study. Patients were divided into older (≥80 years) and young (<80 years) groups. Multivariable logistic regression analyses determined the safety, functional outcomes, and predictors of MT for anterior circulation LVO. We divided 1182 patients with acute ischemic stroke into young (18-79 years; 1028 patients) and older (≥80 years; 154 patients) groups. Compared with the young group, the older group had more unfavorable functional outcomes and increased mortality (P = .003). In the older adult patients, lower initial NIHSS score and higher ASPECTS were correlated with good outcomes. On the contrary, higher initial NIHSS score and lower ASPECTS were related to increased mortality. No difference was detected in symptomatic intracranial hemorrhage within 48 h between two groups. Increasing age was associated with lower rates of favorable functional outcomes and higher mortality rates. The lower initial NIHSS score combined with the higher ASPECTS may predict functional outcomes post-thrombectomy in older adults.

A Portrait of Korean Won-Buddhist’s Mind Practice Experiences: Focusing on Higher Aspects from the Ways of Evolving to Inner Maturity

This paper presents a portrait of a Korean woman Wonmahn (pseudonym) who engaged in Won Buddhist religious life including Mind Practice. Mind Practice allows the participant to reflect on one’s own state of mind and observe how it triggers other emotions, feelings, or effects in human relationships and in relation to facing troubles in everyday life. We try to understand how her Mind Practice affected her inner states of mind, feelings, attitudes etc. more deeply based on the “Participant as Ally - Essentialist Portraiture” approach. The in-depth interviews were conducted 6 times between the fall of 2011 and 2013. We tried to find out significant passages of transcripts and then articulate them on her ways of evolving to inner maturity through Mind Practice activities. This portrait illustrates her nature and impression with some alive passages and a timeline for grasping unity or oneness of the whole person. Also she repeatedly tried to be aware of her own mind states whenever she encounter troublesome situations in order to become a better person revealing higher aspects. In this portrait, we explore that such “higher aspects” are related with her values, commitments or inner changes as a whole person. Further we try to understand that her higher aspects are manifested as a “subtle and pervasive inner consciousness” in a person.

Side matters: differences in functional outcome and quality of life after thrombectomy in left and right hemispheric stroke

BackgroundPatients with a left (LHS) or right hemispheric stroke (RHS) differ in terms of clinical symptoms due to lateralization of specific cortical functions. Studies on functional outcome after stroke and endovascular thrombectomy (EVT) comparing both hemispheres showed conflicting results so far. The impact of stroke laterality on patient-reported health-related quality of life (HRQoL) after EVT has not yet been adequately addressed and still remains unclear.MethodsConsecutive stroke thrombectomy patients, derived from a multi-center, prospective registry (German Stroke Registry) between June 2015 and December 2019, were included in this study. At 90 days, outcome after EVT was assessed by the modified Rankin scale (mRS) and HRQoL using the European QoL-five dimensions questionnaire utility-index (EQ-5D-I; higher values indicate better HRQoL) in patients with LHS and RHS. Adjusted regression analysis was applied to evaluate the influence of stroke laterality on outcome after EVT.ResultsIn total, 5683 patients were analyzed. Of these, 2953 patients (52.8%) had LHS and 2637 (47.2%) RHS. LHS patients had a higher baseline NIHSS (16 vs. 13, p < 0.001) and a higher ASPECTS (9 vs. 8, p < 0.001) compared to RHS patients. Among survivors, patients with LHS less frequently had a self-reported affected mobility (p = 0.037), suffered less often from pain (p = 0.04) and anxiety/depression (p = 0.032) three months after EVT. After adjusting for confounders (age, sex, baseline NIHSS), LHS was associated with a better HRQoL (ß coefficient 0.04, CI 95% 0.017–0.063; p = 0.001), and better functional outcome assessed by lower values on the mRS (ß coefficient − 0.109, CI 95% − 0.217–0.000; p = 0.049).ConclusionsNinety days after EVT, LHS patients have a better functional outcome and HRQoL. Patients with RHS should be actively assessed and treated for pain, anxiety and depression to improve their HRQoL after EVT.

Benefit of Intravenous Alteplase before Thrombectomy Depends on ASPECTS.

Baseline variables could be used to guide the administration of additional intravenous alteplase (IVT) before mechanical thrombectomy (MT). The aim of this study was to determine how baseline imaging and demographic parameters modify the effect of IVT on clinical outcomes in patients with ischemic stroke due to large vessel occlusion. Multicenter retrospective cohort study of ischemic stroke patients triaged by multimodal-CT undergoing MT treatment after direct admission to an MT-eligible center. Inverse-probability weighting analysis (IPW) was used to assess the treatment effect of IVT adjusted for baseline variables. Multivariable logistic regression analysis with IPW-weighting and interaction terms for IVT was performed to predict functional independence (mRS 0-2 at 90-days). 720 patients were included, of which 366 (51%) received IVT. In IPW, the treatment effect of IVT on outcome (mRS 0-2) distinctively varied according to the ASPECTS subgroup (ASPECTS 9-10:+15%, ASPECTS 6-8:+7%, ASPECTS <6: -11%). In multivariable logistic regression analysis, IVT was independently associated with functional independence (aOR: 1.57, 95% CI: 1.16-2.14, p=0.003) and the interaction term was significant for ASPECTS and IVT revealing that IVT was only significantly associated with better outcomes in patients with higher ASPECTS. No other significant baseline variable interaction terms were identified. ASPECTS was the only baseline variable that showed a significant interaction with IVT for outcome prediction. Use of IVT prior to MT in patients with an ASPECTS of <6 was not associated with a treatment benefit and should be considered carefully. ANN NEUROL 2022;92:588-595.

Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: A real-world multicenter experience.

Endovascular thrombectomy (EVT) is the standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO). Young patients with AIS-LVO have distinctly different underlying stroke mechanisms and etiologies. Much is unknown about the safety and efficacy of EVT in this population of young AIS-LVO patients. All consecutive AIS-LVO patients aged 50years and below were included in this multicenter cohort study. The primary outcome measured was functional recovery at 90days, with modified Rankin Scale of 0-2 deemed as good functional outcome. A total of 275 AIS-LVO patients that underwent EVT from 10 tertiary centers in Germany, Sweden, Singapore, and Taiwan were included. Successful reperfusion was achieved in 85.1% (234/275). Good functional outcomes were achieved in 66.0% (182/275). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%). National Institutes of Health Stroke Scale (NIHSS) score at presentation was inversely related to good functional outcomes (aOR: 0.92, 95% CI: 0.88-0.96 per point increase, p<0.001). Successful reperfusion (aOR: 3.22, 95% CI: 1.44-7.21, p=0.005), higher ASPECTS (aOR: 1.21, 95% CI: 1.01-1.44, p=0.036), and bridging intravenous thrombolysis (aOR: 2.37, 95% CI: 1.29-4.34, p=0.005) independently predicted good functional outcomes. Successful reperfusion was inversely associated with in-hospital mortality (aOR: 0.14, 95% CI: 0.03-0.57, p=0.006). History of hypertension strongly predicted in-hospital mortality (aOR: 4.59, 95% CI: 1.10-19.13, p=0.036). While differences in functional outcomes exist across varying stroke aetiologies, high rates of successful reperfusion and good outcomes are generally achieved in young AIS-LVO patients undergoing EVT.

Hypoperfusion intensity ratio for refinement of elderly patient selection for endovascular thrombectomy

BackgroundPatients ≥80-year-old presenting with large-vessel occlusion treated with endovascular thrombectomy (EVT) have worst outcomes than younger individuals. Improved patient selection in this age range is warranted. We investigated the hypoperfusion-intensity-ratio...

Abstract P493: Outcomes in Young Adults With Acute Ischemic Stroke Undergoing Endovascular Thrombectomy: A Multi-Centre Experience

Introduction: Endovascular thrombectomy(EVT) is considered standard of care for anterior circulation acute ischemic stroke(AIS) with large vessel occlusion(LVO). Young AIS-LVO patients have distinctly different underlying stroke mechanisms and etiologies. Methods: In this multicenter cohort study conducted from August 2014 to January 2020, we investigated the safety and effectiveness of EVT in young AIS-LVO patients aged≤50 years and evaluated associations between demographics, stroke etiology, neuroimaging factors and clinical outcomes, including functional outcomes, in-hospital mortality and symptomatic intracranial haemorrhage(sICH) in univariable and multivariable regression models. Results: 275 AIS-LVO patients from 10 tertiary centers in Germany, Sweden, Singapore and Taiwan were included. The more common TOAST subtypes included cardioembolism (82/275, 29.8%) and stroke of undetermined etiology (85/275, 30.9%). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%) and had the highest rate of good functional outcomes (29/42, 69.0%). Successful reperfusion was achieved in 85.1% (234/275). Excellent and good functional outcomes were achieved in 48.0% (132/275) and 66.0% (182/275) respectively. sICH occurred in 6.5% (18/275). National Institute of Health Stroke Scale (NIHSS) at presentation was inversely related with good functional outcomes (aOR0.92, 95% CI 0.88- 0.96 per point increase, p&lt;0.001). Successful reperfusion (aOR3.22, 95% CI 1.44-7.21, p=0.005), higher ASPECTS (aOR1.21, 95% CI 1.01-1.44, p=0.036) and bridging intravenous thrombolysis (aOR2.37, 95% CI 1.29-4.34, p=0.005) independently predicted good functional outcomes. Higher initial NIHSS (aOR1.08, 95% 1.02-1.14, p=0.007) and lower ASPECTS (aOR0.73, 95% 0.58-0.93, p=0.012) were associated with sICH. Successful reperfusion was inversely associated with in-hospital mortality (aOR0.14, 95% CI 0.03-0.57, p=0.006). Hypertension strongly predicted in-hospital mortality (aOR4.59, 95% CI 1.10-19.13, p=0.036). Conclusion: While differences in functional outcomes exist across varying stroke aetiologies, high rates of successful reperfusion and good outcomes are generally achieved in young AIS-LVO patients undergoing EVT.

Inter-hospital transfer for mechanical thrombectomy within the supraregional stroke network NEVAS

BackgroundTelemedicine stroke networks are mandatory to provide inter-hospital transfer for mechanical thrombectomy (MT). However, studies on patient selection in daily practice are sparse.MethodsHere, we analyzed consecutive patients from 01/2014 to 12/2018 within the supraregional stroke network “Neurovascular Network of Southwest Bavaria” (NEVAS) in terms of diagnoses after consultation, inter-hospital transfer and predictors for performing MT. Degree of disability was rated by the modified Rankin Scale (mRS), good outcome was defined as mRS ≤ 2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction (mTICI) was 2b-3.ResultsOf 5722 telemedicine consultations, in 14.1% inter-hospital transfer was performed, mostly because of large vessel occlusion (LVO) stroke. A total of n = 350 patients with LVO were shipped via NEVAS to our center for MT. While n = 52 recanalized spontaneously, MT-treatment was performed in n = 178 patients. MT-treated patients had more severe strokes according to the median National institute of health stroke scale (NIHSS) (16 vs. 13, p < 0.001), were more often treated with intravenous thrombolysis (64.5% vs. 51.7%, p = 0.026) and arrived significantly earlier in our center (184.5 versus 228.0 min, p < 0.001). Good outcome (27.5% vs. 30.8%, p = 0.35) and mortality (32.6% versus 23.5%, p = 0.79) were comparable in MT-treated versus no-MT-treated patients. In patients with middle cerebral artery occlusion in the M1 segment or carotid artery occlusion good outcome was twice as often in the MT-group (21.8% vs. 12.8%, p = 0.184). Independent predictors for performing MT were higher NIHSS (OR 1.096), higher ASPECTS (OR 1.28), and earlier time window (OR 0.99).ConclusionWithin a telemedicine network stroke care can successfully be organized as only a minority of patients has to be transferred. Our data provide clinical evidence that all MT-eligible patients should be shipped with the fastest transportation modality as possible.

Abstract WP502: Predictors Of First Pass Reperfusion In Anterior Circulation Large Vessel Occlusion Stroke

Introduction: The speed and completeness of endovascular reperfusion strongly correlate with functional outcomes. First-Pass Reperfusion (FPR) has been recently established as a critical procedural performance metric for mechanical thrombectomy (MT). We aimed to study the predictors of FPR and its effect on the outcome Methods: Review of a prospectively collected database of MT patients with large vessel occlusion strokes (LVOS) from 05/2012-11/2018. Patients were included in the analysis if they had an anterior circulation LVOS that was successfully reperfused (mTICI 2b-3). FPR was defined as the achievement of mTICI 2c-3 after a single pass with any thrombectomy device. Uni- and multivariate analyses were performed to identify the independent predictors of FPR. Results: A total of 563 patients qualified for the analysis (mean age, 64.4±12.3 years, baseline NIHSS 16.2). FPR was achieved in 202 (35.9%) patients. On univariate analysis, FPR was significantly associated with higher ASPECTS (8.1 vs. 7.8, p=0.008), higher usage of balloon guide catheters (BGC) (88.1% vs. 75.3%, p&lt;0.001), lower use of general anesthesia (9.5% vs. 18.2%, p= 0.006), and shorter procedure duration (mean, 45.5 vs. 79.9 min, p &lt;0.001 and 90.5%). Both BGC (OR, 2.26; 95%CI [1.32-3.87], p=0.003) and ASPECTS (OR, 1.15; 95% CI [1.03-1.28], p= 0.01) were independent predictors of FPE on multivariate regression analysis. Conclusion: Higher baseline ASPECTS score and the use of BGC are strong predictors of First-Pass Reperfusion in mechanical thrombectomy.

Abstract WP21: “Stunned Brain”– Early versus Delayed Clinical Recovery After Neurothrombectomy

Introduction: Heterogeneity in early neurological improvement after neurothrombectomy for large vessel occlusion (LVO) stroke is well documented. Delayed clinical recovery is observed in a subset of patients who do not experience early improvement. Understanding the temporality of clinical recovery after thrombectomy is essential in guiding prognostication and targeting rehabilitation. In this study, we aim to describe the characteristics and incidence of early and delayed clinical recovery and identify their predictors after LVO stroke thrombectomy. Methods: A retrospective analysis of prospectively-collected data on patients undergoing anterior circulation LVO stroke thrombectomy. Demographic characteristics, clinical and radiological data, treatment and procedural information were extracted and analyzed. Characteristics and predictors of early clinical recovery (ECR-1-NIHSS &lt;6 at 24 hours and ECR-2-mRS 0-2 at discharge) and delayed clinical recovery (DCR-1 and 2- mRS 0-2 at 90 days) were analyzed. Statistical analyses were performed on SPSS 23 (IBM, Armonk, NY). Results: Three hundred and fifty-five patients met study criteria. 55% (195) were females and mean age was 71±15 years. Mean NIHSS score and median ASPECTS were 17±6 and 9 (8-10), respectively. ECR-1 and ECR-2 were observed in 31% (115) and 21% (73) patients, respectively. Among non-ECR patients, delayed recovery was observed in 27-30% of patients. Lower NIHSS [OR-0.83 (0.75-0.91), p=&lt;0.01] and higher ASPECTS [OR-2.14, (1.29-3.54), p=0.003] scores were independent predictors of ECR-1 and younger age [OR-0.96 (0.94-0.99), p=0.01] and absence on parenchymal hemorrhage (PH) [OR-3.1 (1.3-7.1), p=0.007] were independent predictors of DCR-1. Among non-early improvers, patients &lt;80 years and without PH have a 40% chance of DCR compared to no patients over 80 years with parenchymal hemorrhage experiencing DCR. Conclusion: About one-third of patients experience early clinical recovery (ECR-1-31%) and approximately one-third (DCR-1-30%) of non-early improvers experience delayed clinical recovery. Lower NIHSS score and higher ASPECTS predict ECR while younger age and absence of parenchymal hemorrhage predict DCR.

Abstract TP14: Endovascular Thrombectomy May Improve Outcomes in Patients with Acute Ischemic Stroke and Pre-Morbid Stroke Disability

Background: Whether Endovascular Thrombectomy (EVT) may improve clinical outcomes in patientswith Pre-Stroke disability as compared to medical management only (MM) is unknown. Methods: A retrospective analyses of anterior circulation LVOs (ICA, MCA M1/M2) with mRS 2-4presenting 0-24 hrs from last-known-well to a single comprehensive stroke center was performed.Patients were stratified based on the treatment received into EVT and MM. The primary outcome was90-day mRS. Safety (sICH and mortality) was a secondary outcome. Ordinal analysis compared the twogroup for a shift towards less severe disability with EVT and identified variables independentlycorrelated with better and worse outcomes in both EVT and MM. Results: From Jan 2012 - Aug 2019, 101 patients were identified (EVT=42, MM=59). Baselinecharacteristics were similar in the two groups. EVT resulted in higher rates of mRS 2 and 3 (15% vs 4%,P=0.064) and a shift towards better outcomes (adj cOR 1.142; 95% CI1.050-1.369, p=0.039) as comparedto MM only (Figure 1). There was no significant difference in the composite outcome of sICH andmortality (aOR=0.47, 95% CI 0.307 - 1.810, p=0.167). Higher ASPECTS was associated with betteroutcomes in EVT (adj cOR 1.312 for each point, 95%CI 1.021 - 3.859, p-0.027) while higher NIHSS (adjcOR 0.886 for each point increment in NIHSS, 95%CI 0.793-0.951, p-0.034), left hemispheric strokes (adjcOR 1.615; CI 1.24 - 4.5; p = 0.04) independently correlated with worse outcomes in MM. Conclusions: EVT may result in better outcomes and avoid worsening disability in patients with Prestrokeimpairment without increasing safety concerns. Those with more severe and left hemisphericstrokes were more likely to have devastating outcomes if not treated with EVT.

Abstract WP80: Thrombus Imaging Characteristics and Association With Functional Outcomes in Patients Undergoing Endovascular Treatment

Background: Intracranial thrombus characteristics on computed tomography angiography (CTA) in patients undergoing endovascular therapy (ET) for anterior circulation large vessel occlusion (LVO) acute ischemic stroke (AIS) has been shown to be useful in prognosticating functional outcomes. We establish if thrombus characteristics on non-contrast computed tomography (CT) scans and CTA were associated with clinical outcomes. Methods: We included 257 patients with anterior circulation LVO AIS from our Hyper-Acute Stroke Thrombolysis and Endovascular (HASTEN) registry treated at our tertiary academic institution from 2014-2018. We evaluated associations of patient’s characteristics and thrombus imaging characteristics with patients’ functional outcomes, scored with the modified Rankin Scale (MRS) at 3 months. Imaging characteristics were assessed on CT and CTA. Patient characteristics included age, presence of co-morbidities, initial NIHSS and ASPECTS. Thrombus characteristics included presence of hyperdense middle cerebral artery (MCA) sign, CT dense MCA length, CTA location and length of thrombus, CTA clot burden score (CBS) and recanalization status (mTICI). A good functional outcome was defined as patients who achieved an MRS of 0-2 at 3 months. Results: Patient characteristics associated with good functional outcomes were younger age, absence of diabetes mellitus, lower NIHSS, higher ASPECTS and successful recanalization measured by a mTICI 2b/3 (Table 1). Thrombus characteristics associated with good functional outcomes were a shorter CT dense MCA length and a higher CTA CBS (Table 1). Of note, presence of a hyperdense MCA sign on CT and CTA thrombus length were not significantly associated with good functional outcomes. Conclusions: In patients with anterior circulation LVO AIS, a shorter CT dense MCA length and a higher CTA CBS were associated with good functional outcomes, and may aid in improving patient selection.

Abstract 4: RESILIENT Collaterals and 24-Hour Infarct Growth: Revascularization is Essential

Background: The RESILIENT randomized trial of endovascular therapy for anterior circulation stroke within 8 hours of symptom onset excluded subjects with poor collaterals. We analyzed the relationship of CTA collateral grade with respect to subsequent infarct growth over 24 hours, with and without revascularization. Methods: The independent RESILIENT imaging and angiography core lab scored baseline CTA Tan collateral grade (0-3) and CT ASPECTS scores at baseline and 24 hours in both arms. ASITN collateral grade (0-4) was adjudicated prior to revascularization in the interventional arm. Descriptive statistics, univariate, multivariate and ANOVA related CTA collateral grade with 24-hour infarct growth. Results: 210/221 (95%) subjects (median age 67 (53-76) years; 48% women) in RESILIENT had baseline single-phase CTA available to the core lab evaluation. CTA collateral grade was complete (grade 3) in 106 (50.5%), grade 2 (50-99%) in 68 (32.4%), grade 1 (1-49%) in 36 (17.1%), with no collaterals in 0. The extent of collaterals was more robust in the medical arm (55.0% grade 3, 31.4% grade 2, 13.3% grade 1) compared to the interventional arm (45.7% grade 3, 33.3% grade 2, 21.0% grade 1), although this finding was not statistically significant (p=0.11). In the interventional arm, the extent of CTA collaterals had a strong correlation with ASITN grade (ρ=0.59, p&lt;0.001). Overall, the median baseline ASPECTS (n=210) was 8 (range 6-10) with CTA grade 3 collaterals, 8 (5-9) with grade 2 and 7 (2-10) with grade 1. For 24-hour ASPECTS (n=202) the median was 6 (range 0-10) with CTA grade 3 collaterals, 4 (0-8) with grade 2 and 3 (0-7) with grade 1. 24-hour infarct growth (n=200) was greater in those with worse collateral grade, p&lt;0.001. 24-hour infarct growth was more pronounced in the medical arm compared with subjects treated with revascularization in the interventional arm, p&lt;0.01. Multivariate analysis showed that 24-hour infarct growth was worse in the medical arm, despite more extensive collaterals at baseline p=0.001. Conclusions: In RESILIENT, CTA collateral grade was linked with higher ASPECTS and less infarct growth over 24 hours. Despite more robust collaterals in the medical arm, greater infarct growth occurred without revascularization or endovascular therapy.

Abstract TP2: Impact of Neglect on Outcomes After Right Hemisphere Stroke Thrombectomy

Introduction: Right Hemisphere Strokes (RHS) are characterized by severe motor and sensory deficits and signs of neglect including extinction and inattention. National Institutes of Health Stroke Scale (NIHSS) score provides an objective measurement of presence or absence of neglect. Data regarding the impact of neglect on outcomes after RHS thrombectomy are lacking. We hypothesize that the presence of neglect in RHS is associated with worse outcomes after thrombectomy in RHS. Methods: Retrospective analysis of prospectively collected database of right sided anterior circulation large vessel occlusion [internal carotid and/or middle cerebral artery M1] strokes at a comprehensive stroke center. Patients with successful recanalization (TICI≥ 2B) and complete follow-up data were included in the study. Two group of RHS were identified- with and without neglect by itemized NIHSS. Baseline characteristics and outcomes were compared. Results: A total of 172 patients were included in the study. Median NIHSS score was 15 (11-18) and median ASPECTS was 9 (8-10). Signs of neglect were observed in 63% (108) of patients. In multivariate analyses, younger age [0.9 (0.8-0.95) p=&lt;0.01] and higher ASPECTS [1.8 (1.1-3.1) p=0.015] were independent predictors of mRS 0-2 at 90 days. Absence of neglect [0.39 (0.13-1.1) p=0.07] may predict good outcome. Independent predictors of mortality on multivariate analyses included older age [1.1 (1.03-1.15) p =0.001], presence of atrial fibrillation [0.3 (0.1-1) p=0.05] and diabetes mellitus [0.16 (0.05-0.53) p=0.003]. Presence of neglect [2.5 (0.9-6.6) p=0.06] and lower ASPECTS [0.7 (0.4-1) p=0.06] may predict mortality. Conclusion: Signs of neglect were observed in approximately 63% of right hemisphere LVO strokes. Presence of neglect may predict poor functional outcome and mortality at 90 days after thrombectomy for right hemisphere strokes. Further studies are required to evaluate the impact of thrombectomy on recovery of neglect.

Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients

Introduction: Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO). Methods: Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome. Results: Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO &lt;=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO &gt;120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital. Conclusion: Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.

Influence of vessel morphology and variations on technical and clinical success in mechanical thrombectomy: -In vivo and in vitro analyses-

PurposeTo determine the impact of vessel variation and anatomical features on technical and clinical success. Materials and methodsIn vitro blood clots (n=100) were introduced into a silicon carotid-T flow model of 2, 3 or 4mm. The ICA/M1angle varied at 45°, 90°, 135° and 180°. Peripheral embolism was measured. In vivo 50 pat. (73.5 yrs.,±15) with MCA occlusion were examined for siphon variation, ICA morphology, vessel diameter and angles. The patients were divided according to the clinical success (mRS): group A: mRS≤2 after 90 day and group B: mRS≥3. Furthermore the technical success (TICI) and number of retrieval (n) were analysed. ResultsIn vitro with larger vessel diameter the migrated thrombus load decreased (P=.001). The steeper the M1/ICA angles, the higher thrombus weighs (180°: 2.94mg; 135°: 6.32mg; 90°: 8.65mg, 45°: 10.69mg; P<.001). In vivo patients with mRS≤2 had significantly lower NIHSS (16.5 vs 20, P=.009) and higher ASPECTS (9 vs 6, P<.05). TICI≥2b was more often achieved (86.6 vs 40% P=.002). The procedure time was lower (45 vs. 80min, P<.05) with smaller number of retrieval (1.5 vs 4, P<05). Proximal ICA stenosis offers a trend to unfavourable outcome (P=.073). Siphon variation “D” is associated with less retrieval manoeuvre. ConclusionWhile in vitro there is a close correlation between embolism and vascular anatomy, in vivo carotid artery stenosis and siphon variation influence clinical and technical success.