IA Therapy Research Articles

Effect of Protein A-Immunoadsorption Therapy on Serum Cytokines in AAV Patients

Protein A-immunoadsorption (IA) is an extracorporeal apheresis technique used in patients with autoimmune diseases which aims to remove pathogenic autoantibodies. Apart from the adsorption of immunoglobulins (IgG), IA may influence cellular and humoral immunity. The aim of this study was to observe the effect of protein A-IA on cytokine networks in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients. A total of 12 newly diagnosed AAV patients received IA therapy on days 1, 3, and 5. Serum levels of inflammatory cytokines were measured before and after treatment including members of the interleukin family, PDGF-BB, TNF-α and IFN-γ. IL-1β, IL-9, IL-17A, PDGF-BB, IFN-γ, and TNF-α were elevated in AAV patients compared to healthy individuals. There were no changes in the levels of any cytokines after the first IA session but after 3 sessions, IL-9, PDGF-BB, and TNF-α dramatically decreased. Moreover, reductions in IL-9 levels were positively correlated with the changes of myeloperoxidase-ANCA (MPO-ANCA). Our observations suggest that protein A-IA therapy does not directly adsorb cytokines, but removes autoantibodies (MPO-ANCA) which indirectly leads to changes in cytokine networks linked to cellular or humoral immunity.

Time-resolved assessment of cortical venous drainage on multiphase CT angiography in patients with acute ischemic stroke.

Cortical vein opacification is not routinely assessed in patients presenting with acute ischemic stroke (AIS), and the value of temporal assessment of venous outflow is not known. We evaluated the utility of assessing cortical venous drainage over time using multiphase CT angiography (mCTA). Cortical venous drainage was assessed in patients from the Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy prospective multicenter cohort study of patients with symptoms of AIS with ICA and/or middle cerebral artery occlusion on baseline mCTA. Opacification of vein of Labbe, sphenoparietal sinus, superficial middle cerebral vein, and vein of Trolard of the affected hemisphere was graded as no (0), partial (1), or full (2) opacification in each mCTA phase. The venous opacification scores for each phase were added to generate a total venous score (TVS) (range 0-24). Primary outcome was 90-day modified Rankin score. Repeated measures analysis was used to assess the effect of phase timing on venous score on outcome. Of 432 patients, 284 (65.7%) had proximal arterial occlusions. Median venous opacification score per phase (range 0-8) was 3 (IQR 1-6) in the first phase and increased in the second and third phases [median (IQR): 6 (5-8) and 8 (6-8), respectively] of the mCTA. In a multivariable analysis adjusting for age, baseline National Institutes of Health Stroke Scale, and Albertastrokeprogram early CT score, a significant association between TVS and 90-day mRS was noted ([adjusted cOR for TVS 6-11: 0.16 (95% CI 0.05-0.51); TVS 12-17: 0.18 (95% CI 0.06-0.57); TVS 18-24: 0.20 (0.06-0.63)]. Repeated measures analysis of venous scores from all three phases showed a significant effect of time/phase on TVS (p < 0.001). This study concludes that venous opacification over time on multiphase CTA is associated with 90-day clinical outcome. There was however no added benefit of venous scoring vis-a-vis arterial collateral assessment in predicting outcome.

Inhaled antibiotics for treatment of adults with non-cystic fibrosis bronchiectasis: A systematic review and meta-analysis

BackgroundInhaled antibiotics (IA) in non-cystic fibrosis bronchiectasis (NCFB) are recommended by some clinical practice guidelines for prevention or treatment of NCFB exacerbations. MethodsWe performed a systematic review and meta-analysis to evaluate the efficacy and safety of IA use for treatment of adults with NCFB and Pseudomonas aeruginosa chronic bronchial infection. The search was performed in the Cochrane Library, PubMed, and Web of Science databases from 2000 to 2019. Studies of IA for treatment of stable or exacerbated NCFB adults (≥18 years) with P. aeruginosa infection were considered eligible. PROSPERO Registration number: CRD42019136154. ResultsTwelve trials (2476 participants) were included. IA therapy increased P. aeruginosa eradication from sputum in patients with exacerbations (OR: 3.19, 95%CI: 1.70–5.99) with similar effects on stable patients (OR: 7.22, 95%CI: 2.81–18.59), and a trend to reduced emergence of new respiratory pathogens (OR: 0.58, 95%CI: 0.28–1.18). IA achieved significant reduced exacerbation rates (RR: 0.90; 95%CI: 0.82–0.98) in stable patients, with a number needed to treat (NNT) of 59, but no significant changes in FEV1, mortality, hospitalizations or quality of life were identified. In stable patients, IA use increased antimicrobial resistance (RR: 2.10, 95%CI: 1.35–3.27) at the end of therapy, with a number needed to treat of 6. ConclusionsIA therapy achieved a statistically significant eradication of P. aeruginosa from sputum, with a 10% reduction of exacerbations in stable patients. This effect has to be balanced with significant increases in antimicrobial resistance. Our meta-analysis failed to show a significant benefit in terms of patient-centered outcomes.

Clinical Course of Acute Ischemic Stroke Due to Medium Vessel Occlusion With and Without Intravenous Alteplase Treatment.

Available data on the clinical course of patients with acute ischemic stroke due to medium vessel occlusion (MeVO) are mostly limited to those with M2 segment occlusions. Outcomes are generally better compared with more proximal occlusions, but many patients will still suffer from severe morbidity. We aimed to determine the clinical course of acute ischemic stroke due to MeVO with and without intravenous alteplase treatment. Patients with MeVO (M2/M3/A2/A3/P2/P3 occlusion) from the INTERRSeCT (The Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRoveIT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy) studies were included. Baseline characteristics and clinical outcomes were summarized using descriptive statistics. The primary outcome was a modified Rankin Scale score of 0 to 1 at 90 days, describing excellent functional outcome. Secondary outcomes were the common odds ratio for a 1-point shift across the modified Rankin Scale and functional independence, defined as modified Rankin Scale score of 0 to 2. We compared outcomes between patients with versus without intravenous alteplase treatment and between patients who did and did not show recanalization on follow-up computed tomography angiography. Logistic regression was used to provide adjusted effect-size estimates. Among 258 patients with MeVO, the median baseline National Institutes of Health Stroke Scale score was 7 (interquartile range: 5-12). A total of 72.1% (186/258) patients were treated with intravenous alteplase and in 41.8% (84/201), recanalization of the occlusion (revised arterial occlusive lesion score 2b/3) was seen on follow-up computed tomography angiography. Excellent functional outcome was achieved by 50.0% (129/258), and 67.4% (174/258) patients gained functional independence, while 8.9% (23/258) patients died within 90 days. Recanalization was observed in 21.4% (9/42) patients who were not treated with alteplase and 47.2% (75/159) patients treated with alteplase (P=0.003). Early recanalization (adjusted odds ratio, 2.29 [95% CI, 1.23-4.28]) was significantly associated with excellent functional outcome, while intravenous alteplase was not (adjusted odds ratio, 1.70 [95% CI, 0.88-3.25]). One of every 2 patients with MeVO did not achieve excellent clinical outcome at 90 days with best medical management. Early recanalization was strongly associated with excellent outcome but occurred in <50% of patients despite intravenous alteplase treatment.

Prevalence and Outcomes of Medium Vessel Occlusions With Discrepant Infarct Patterns.

The prognosis of medium vessel occlusions (MeVOs), that is, M2/3 middle cerebral artery, A2/3 anterior cerebral artery, and P2/3 posterior cerebral artery occlusions, is generally better compared with large vessel occlusions, since brain ischemia is less extensive. However, in some MeVO patients, infarcts are seen outside the territory of the occluded vessel (MeVO with discrepant infarcts). This study aims to determine the prevalence and clinical impact of discrepant infarct patterns in acute ischemic stroke due to MeVO. We pooled data of MeVO patients from INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRove-IT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy)-2 prospective cohort studies of patients with acute ischemic stroke. The combination of occlusion location on baseline computed tomography angiography and infarct location on follow-up computed tomography/magnetic resonance imaging was used to identify MeVOs with discrepant infarct patterns. Two definitions for discrepant infarcts were applied; one was more restrictive and purely based on infarct patterns of the basal ganglia, whereas the second one took cortical infarct patterns into account. Clinical outcomes of patients with versus without discrepant infarcts were summarized using descriptive statistics. Logistic regression was performed to obtain adjusted effect size estimates for the association of discrepant infarcts and good outcome, defined as a modified Rankin Scale score of 0 to 2, and excellent outcome (modified Rankin Scale score 0-1). Two hundred sixty-two patients with MeVO were included in the analysis. The prevalence of discrepant infarcts was 39.7% (definition 1) and 21.0% (definition 2). Patients with discrepant infarcts were less likely to achieve good outcome (definition 1: adjusted odds ratio, 0.48 [95% CI, 0.25-0.91]; definition 2: adjusted odds ratio, 0.47 [95% CI, 0.22-0.99]). When definition 1 was applied, patients with discrepant infarcts were also less likely to achieve excellent outcome (definition 1: adjusted odds ratio, 0.55 [95% CI, 0.31-0.99]; definition 2: adjusted odds ratio, 0.62 [95% CI, 0.31-1.25]). MeVO patients with discrepant infarcts are common, and they are associated with more severe deficits and poor outcomes.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Efficacy of Repeat Immunoadsorption.

(1) Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a complex neuroimmunological disease. There is evidence for an autoimmune mechanism for ME/CFS with an infection-triggered onset and dysfunction of ß2-adrenoreceptor antibodies (ß2AR-AB). In a first proof-of-concept study, we could show that IA was effective to reduce ß2AR-AB and led to improvement of various symptoms. (2) Five of the ME/CFS patients who had clinical improvement following treatment with a five-day IA were retreated in the current study about two years later with a modified IA protocol. The severity of symptoms was assessed by disease specific scores during a follow-up period of 12 months. The antibodies were determined by ELISA. (3) The modified IA treatment protocol resulted in a remarkable similar clinical response. The treatment was well tolerated and 80–90% decline of total IgG and ß2AR-AB was achieved. Four patients showed a rapid improvement in several clinical symptoms during IA therapy, lasting for six to 12 months. One patient had no improvement. (4) We could provide further evidence that IA has clinical efficacy in patients with ME/CFS. Data from our pilot trial warrant further controlled studies in ME/CFS.

Abstract WP202: Decompressive Hemicraniectomy After Malignant Middle Cerebral Artery Ischemic Stroke in a Developing Country is Associated With Poor Long Term Functional Outcome and High Mortality

Background: Decompressive hemicraniectomy (DH) is a level IA therapy for malignant middle cerebral artery (MCA) infarction. However, randomized trials were performed in high income countries with better access to post-stroke care and rehabilitation services. We aimed to assess long term functional outcome and the associated prognostic factors of patients undergoing DH in Brazil. Methods: From January 2013 and July 2018, all patients undergoing DH for malignant MCA infarction in a single comprehensive stroke center were retrospectively identified. Outcomes were the modified Rankin Scale (mRS) (dichotomized as ≤ 4 vs. &gt; 4) and mortality at follow-up. The mRS at follow-up was collected prospectively by telephone using a validated structured interview. Logistic regression analysis was performed to assess independent predictors of outcome. Results: Eighty patients who underwent DH for malignant MCA infarction were identified. Age ranged from 16 to 78 years (median 48 years, IQR 42 - 54,7 years), 46 (57.6%) were males and median time from stroke onset to hemicraniectomy was 30.75 hours (IQR 17.8-46.0). Hospital discharge mRS ≤ 3 and ≤ 4 was observed in 5 (6.2%) and 74 (92,5%) patients respectively. Follow-up information was available for 65 (81.2%) patients. At follow-up (raging from 1.1 to 5.6 years), mRS ≤ 4 was observed in 23 (35.3%) patients. In binary logistic regression analysis, age (OR 1.09, 95% CI 1.02 - 1.17, p=0.01), and right MCA infarction (OR 16.70, 95% CI 1.8-152.30, p=0.01) were independently associated with a worse functional outcome at follow-up. Admission NIHSS (OR 1.0 ,95% CI 0.8-1.3, p=0.45), IV rt-PA (OR 0.5, 95% CI 0.08-3.00, p=0.46) or time of hemicraniectomy (OR 1.00, 95% CI 1.00 - 1.00, p=0.94) were not associated with functional outcome at follow-up. Mortality was 26% (N=21) at hospital discharge and 46% (N=30) at follow-up. Conclusion: The large effect size of DH for malignant MCA infarction is significantly diminished in the population of patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country. Poor access to post-stroke care and rehabilitation services might be possible reasons for the results observed.

Abstract TP228: Circadian Rhythm and the Severity of Ischemic Stroke

Background: The circadian variation of stroke onset has been recognized for decades, and the temporal pattern of stroke onset time, stroke subtypes, first-ever and recurrent stroke has been extensively investigated all over the world. However, little information is available regarding the circadian rhythm of stroke severity. In the present study, we investigated the relationship between stroke onset time and severity on admission in patients with acute ischemic stroke. Method: 305 patients admitted with acute ischemic stroke were consecutively recruited in accordance with IRB approval. Stroke onset time was determined by a neurologist, by questioning patients and/or relatives who observed the onset and who were aware of the last time seen well. Stroke severity was determined by NIH stroke scale (NIHSS) on admission. Result: 100 patients (32.79%) developed ischemic stroke at night (8pm~8am), and 205 (67.21%) had strokes during the day (8am~8pm), which is consistent with previous reports that more patients suffer ischemic strokes while awake than while asleep. Daytime strokes were also more severe than those that occurred at night (Figure 1A and 1B). Patients who developed strokes in the afternoon demonstrated the worst functional status (Figure 1C). Conclusion: Our results explore the circadian variation of the severity of ischemic stroke, which has important therapeutic implications in light of new advances in IA therapy. Further study is ongoing to adjust for confounders such as treatment variation, co-morbidities, social factors, and stroke subtypes.

Risk Factors for Intraarticular Heterotopic Bone Formation in the Temporomandibular Joint in Juvenile Idiopathic Arthritis.

Intraarticular corticosteroid (IAC) injections are often used to treat temporomandibular joint (TMJ) arthritis associated with juvenile idiopathic arthritis (JIA). One potential complication of IA therapy is heterotopic bone formation (HBF). The purpose of our study was to evaluate risk factors for HBF development in children with JIA who received IA therapy for TMJ arthritis. This was a retrospective study of children with JIA who had received ≥ 1 IAC injection into the TMJ. Survival regression analysis was performed to identify risk factors for the development of HBF. There were 238 children included, of whom 33 (14%) developed HBF. No cases of HBF were diagnosed prior to the initial injection. Univariate analysis revealed that the risk factors for development of HBF were the total number of injections received into the TMJ and age at diagnosis of JIA, while the length of time from diagnosis of JIA to the first injection was inversely associated with the risk of HBF formation. The total number of injections was no longer significant following adjusted survival models. Children with HBF had increased physical examination evidence of acute or chronic changes, namely decreased maximal incisal opening and increased likelihood of jaw deviation. HBF within the TMJ is relatively common in patients with JIA receiving IAC injections for TMJ arthritis. Future prospective studies are required to delineate the risks posed by the injections themselves as opposed to the underlying disease activity, as well as to evaluate alternative forms of local therapy to the TMJ.

Abstract WMP90: Comparison of Acute Ischemic Stroke Care Between Comprehensive Stroke Centers and Primary Stroke Centers Participating in Get With the Guidelines-Stroke

Background: To improve stroke care, the Brain Attack Coalition recommended establishing primary stroke center (PSC) and comprehensive stroke center (CSC) certification. Achieving CSC designation requires the ability to provide more complex services. However, it remains unknown whether CSCs have better performance than PSCs for ischemic stroke care. This study compared ischemic stroke care between CSCs and PSCs. Methods: The study included consecutive patients who were admitted to the 134 CSCs and 1047 PSCs participating in Get With The Guidelines (GWTG)-Stroke between January 1, 2013 and December 31, 2015 with a final diagnosis of acute ischemic stroke. Multivariable logistic regression models were generated to examine the association between stroke center certification (CSC vs PSC) and performance measures and outcomes, after adjusting for potential confounders including patient and hospital characteristics. Results: Of the 605,136 patients who were admitted directly from the emergency department, 110,624 were admitted to CSCs and 494,512 to PSCs. CSCs were larger than PSCs (median number of beds 481 vs 263). Performance differences between CSCs vs. PSCs are shown in the table. CSCs and PSCs had comparable overall conformity to the seven performance measures represented by the summary defect-free care measure. CSCs outperformed PSCs in several key measures, especially the use of intravenous tissue plasminogen activator (IV tPA) and intra-arterial thrombectomy (IA-therapy). Compared with patients at PSCs, patients at CSCs were more likely to receive IV tPA in both unadjusted and adjusted models. The door to IV tPA time was shorter at CSCs. Patients at CSCs were more likely to receive IA therapy, with shorter door to IA therapy times. Mortality was higher at CSCs. Conclusions: Stroke care at CSCs exceeded PSCs for many but not all quality measures, particularly timely acute reperfusion therapy. Risk adjusted in-hospital mortality was modestly higher at CSCs.

Abstract WMP21: Texture Analysis of Intracranial Thrombus Using CT and CTA Predicts Early Recanalization With Intravenous Alteplase

Objective: In acute ischemic stroke (AIS), thrombus lysis and early restoration of blood flow to ischemic brain is the goal of reperfusion therapy. We hypothesize that image texture analysis of thrombus using non-contrast CT (NCCT) and CTA can predict early recanalization with IV alteplase in AIS patients with ICA/M1 MCA thrombi. Methods: We used a case control design for the study using the whole cohort of the clinical trial of Identifying New approaches to optimize Thrombus characterization for predicting Early Recanalization and Reperfusion with iv tPA using Serial CT angiography (INTERRSeCT). Cases were 31 patients with ICA/M1 MCA thrombi treated with IV alteplase, who achieved early recanalization (as assessed on first angio run in patients undergoing additional IA therapy or on repeat CTA at 4 hrs). Cases were matched with controls (37 patients with ICA/M1 MCA thrombi treated with IV alteplase who did not achieve recanalization). All patients had thin slice NCCT (slice thickness &lt; 2.5 mm) and CTA (≤ 0.625mm). Thrombi in ICA/M1 MCA region were manually contoured from NCCT guided by co-registered CTA. We extracted 378 features (including thrombus length and volume, first order statistics, and image texture features) from each thrombus in both NCCT and CTA images. This was followed by feature selection using linear discriminative analysis. The top 5 features from NCCT and CTA images along with the clot texture difference between NCCT and CTA were used to train a linear support vector machine classifier. Five times 6-fold cross validation was used to evaluate the trained classifier. Results: Receiver operator curves show that thrombus texture from NCCT and CTA are predictive of early recanalization with IV alteplase. Combined NCCT &amp; CTA features and texture difference is the best predictor (AUC: 0.82). Conclusions: Thrombus texture features from NCCT and CTA are strongly predictive of early recanalization with IV alteplase in AIS patients with proximal occlusions.

Interfacility Transfer Directly to the Neuroangiography Suite in Acute Ischemic Stroke Patients Undergoing Thrombectomy.

In patients identified at referring facilities with acute ischemic stroke caused by a large vessel occlusion, bypassing the emergency department (ED) with direct transport to the neuroangiography suite may safely shorten reperfusion times. We conducted a single-center retrospective review of consecutive patients transferred to our facility for consideration of endovascular therapy. Patients were identified as admitted directly to the neuroangiography suite (DAN), transferred to the ED before intra-arterial therapy (ED-IA), and transferred to the ED but did not receive IA therapy (ED-IV). A retrospective review of a prospectively maintained database of transfer patients between January 2013 and October 2016 with large vessel occlusions identified 108 ED-IV patients and 261 patients who underwent mechanical thrombectomy (DAN=111 patients and ED-IA=150 patients). There were no differences in baseline characteristics among the 3 groups. The median computed tomography ASPECTS (Alberta Stroke Program Early CT Score) was lower in the ED-IV group versus the ED-IA and DAN groups (8 versus 9; P=0.001). In the DAN versus ED-IA cohort, there were comparable rates of TICI2b/3 recanalization and access to recanalization time. There was significantly faster hospital arrival to groin access time in the DAN cohort (81 minutes versus 22 minutes; P=0.001). Functional independence at 90 days was comparable in the DAN versus ED-IA cohorts but worse in the ED-IV group (43% versus 44% versus 22%; P=0.001). DAN is safe, feasible, and associated with faster times of hospital arrival to recanalization. The clinical benefit of this approach should be assessed in a prospective randomized trial.

Abstract WP273: Evolution of a U.S. County System for Acute Comprehensive Stroke Care

Introduction: In an effort to maximize provision of acute stroke therapies, the Emergency Medical Services (EMS) in Orange County, CA (6 th most populous U.S. county) established a system of care whereby patients with suspected acute stroke are taken to hub sites with endovascular treatment (EVT) capability or to spoke hospitals. Patients at spokes with acute ischemic stroke (AIS) and suspected large vessel occlusion (LVO) are transferred by EMS to hubs. Here we examined the relationship between stroke features, hospital transfers, and mortality; and their change over time. Methods: All patients during 2013-2015 were included for whom 911 was called within 7 hours of onset, and EMS personnel declared “acute stroke" at end of initial evaluation. Results: A total of 6,188 patients (mean age 72) had suspected stroke, of which 54.9% were AIS and 19.4% hemorrhagic stroke. Across all patients, transfer rates into hub sites increased over time (OR 1.12 per 3-months, p&lt;0.0001) and differed by diagnosis (p&lt;0.0001), with transfer in 12.0% of hemorrhages (n=122) but only 3.5% of AIS (n=101). Among patients with AIS only, transfer rates into a hub site increased over time (OR 1.08, p&lt;0.0001), spiking mid-2015. Acute reperfusion therapy was given to 28.3% (20.9% IV tPA only, 3.6% IA therapy only, 3.8% IV tPA+IA), but its usage was unrelated to transfer status, and only 11% of all transferred AIS patients received EVT. Across all patients, mortality during acute hospitalization was 8.2% and did not differ by transfer status, but did differ by diagnosis (p&lt;0.0001): 23.6% of hemorrhages vs. 5.4% of AIS. Over time, mortality decreased only among patients with AIS (OR 0.95, p=0.03). Conclusions: There were several favorable features of this acute stroke care system, including that 28.3% of AIS patients received reperfusion therapy and that mortality decreased over time. However, while transfer to EVT-ready sites increased, rates of IA therapy were low. Continued efforts to optimize acute stroke systems of care should be tailored toward increasing EVT by early recognition of LVO and timely triage to hub facilities.

Abstract TP40: Prediction of a Small DWI Lesion Using Single Phase Collateral Score and Noncontrast CT ASPECT Score

Introduction and Hypothesis: Small initial DWI lesion volume (≤70 mL) is a strong predictor of favorable outcome post i IA thrombectomy and has been used for patient selection in multiple clinical trials. We sought to investigate if collateral and/or CT ASPECT scores could predict a small DWI lesion volume. Methods: We included 130 consecutive patients with CTA showing ICA and/or proximal MCA occlusions who underwent DWI within 8 hours of stroke onset. DWI lesion volumes were dichotomized to small (≤70mL) and large (&gt;70ml). Collateral vessels were categorized to 5 groups: 0=none, 1=minimal, 2=less than 50%, 3=more than 50%, 4=equal and 5=more than the contralateral side. Logistic regression, ROC curve analyses and weighted Kappa test were performed. Results: In 130 patients, 62 female (48%), the average values (mean±SD) were: age 70±17 years, NIHSS 16±6, DWI volume 59±65 mL, time after stroke onset 4.4±1.8 hours, CT ASPECT score 6±2 and collateral score 3±1. Time, age, gender, or occlusion site (ICA vs MCA) were not independent predictors of a small DWI volume with p values all &gt;0.05. Collateral score (OR 6.32, P&lt;0.0001), CT ASPECT score (OR 2.37, P&lt;0.0001), and NIHSS (OR 0.87, P&lt;0.0003) significantly contributed to prediction of a small DWI volume. ROC curve analysis with both ASPECT and collateral scores contributing to predicted probabilities showed an AUC of 0.93. The AUC was 0.88 and 0.85 for collateral and ASPECT scores alone respectively. Collateral score ≥3 with ASPECT ≥9 yields specificity of 97.4% and sensitivity of 48.9% while collateral score ≥4 alone provides specificity of 97.4% and sensitivity of 38.9%, missing approximately 16% and 43% of potential candidates for IA therapy based on a DWI lesion volume &lt; 70 mL respectively. Inter-rater agreements between two neuroradiologists were k=0.53 (41.5% agreement) for collateral and k=0.53 (32.3% agreement) for ASPECT scores. Conclusion: Collateral score alone or combined with ASPECTS can predict a small DWI lesion volume with high specificity. However, sensitivity is relatively low and inter-rater agreement is fair. These findings should be considered when DWI is not available to select patients for IA therapy.

Elevated mean platelet volume is associated with poor outcome after mechanical thrombectomy

BackgroundElevated mean platelet volume (MPV), indicating higher platelet activity, could be a predictor of prognosis in patients with acute ischemic stroke receiving medical therapy.ObjectiveTo investigate the relationship between MPV and...

Intra-arterial versus intravenous abciximab therapy for thromboembolic complications of neuroendovascular procedures: case review and meta-analysis

BackgroundAbciximab is used to treat thromboembolic complications of neuroendovascular procedures, but outcomes of treatment are not well defined.ObjectiveTo examine the angiographic and clinical outcomes based on route of abciximab administration...

Novel approaches to delivery of IA therapy in OA

Novel approaches to delivery of IA therapy in OA

Abstract TP1: Stent Retrievers in Transferred Patients: What Percentage Are Eligible for Treatment and Are They Effective?

Background: New generation IA devices are highly effective; however, it is unclear if transfer patients derive similar benefit given the treatment delay intrinsic to this approach. Our aim was to determine the potential eligibility and efficacy of CT perfusion (CTP) guided IA therapy in transferred patients. Methods: All transferred and stent retriever treated ischemic stroke patients selected using CTP between 5/12 -1/15 were included. Baseline demographics including age, NIHSS, IV tPA use, and time points pertinent to CTP imaging and IA procedures were collected. Primary outcome was 90d mRS. Secondary endpoints included successful reperfusion and mortality. Primary safety endpoint was symptomatic ICH (sICH) rate. Results: Overall 401 transferred patients were potentially eligible and 22% were treated (n=90). Median age was 70 and median NIHSS 14.5 (SD 6.8). Average remote site distance was 90 (range 1- 356) miles. 73% received IV tPA. Median time of onset to reperfusion was 530 min. Median onset to CTP time was 323 min. Median CTP to groin puncture 138 min and median CTP time to reperfusion 197 min. TICI 2B or 3 reperfusion was achieved in 80%. 84 patients had 90d outcome data. Favorable outcome (mRS of 0-2) was achieved in 64%. sICH rate was 4.4%. 90d mortality was 11%. Conclusions: Outcomes in transferred CTP guided IA stroke therapy patients were similar to clinical trials despite onset to treatment times at least 80% longer than in recently reported studies, strongly supporting this approach. A substantial proportion of transfer patients can receive successful IA therapy using modern imaging techniques and treatments.

Abstract TP299: The Feasibility of the Aldrete-FAST Screening Tool to Detect Stroke in the Post Cardiac Catheterization Setting: FAST-PC Study

Introduction: Peri-procedural cardiac catheterization related stroke (CRS) remains a feared complication. Risk estimates reach 7% but vary widely by institution and operator experience. Given the volume (&gt;2 million/yr in US), the impact of CRS is substantial. Evidence-based data on diagnosis/treatment are lacking for these patients despite being ideal targets for acute stroke treatment. Many CRS go undetected due to a lack of a standardized assessment tool. Hypothesis: A novel screening tool will be feasible to perform and effective in standardizing rapid diagnosis of CRS. Methods: Two validated tools form the basis of this screen 1) Aldrete score: 10-pt scale used in anesthesia cases to assess activity, respiration, circulation, consciousness and color 2)FAST screen designed to reliably diagnose stroke in &lt; 1 min: Facial droop, Arm weakness, Speech changes, Time. Patients are assessed pre/post procedure and catheterization sheath left in place until protocol completion to allow for CRS IA therapy. Feasibility criteria: Excellent if ≥80%; moderate if ≥50% had successful completion. Uni/multivariable logistic regression analysis assessed interaction with age, sedation &amp; sheath location. Results: 906 patients were enrolled over 7 months. Mean age was 64.9±13.6; 65% male. 727 cases completed 100% of Aldrete-FAST (80.2%, 95% CI: 77.5% - 82.8%). High dose Midazolam (&gt;2mg) was associated with completion of Aldrete-FAST (P&lt;0.001, OR 3.14 CI:1.79-5.52) while Fentanyl (100-200mcg) was a deterrent (P 0.027, OR 0.45 CI: 0.22-0.91). Fentanyl &gt;200mcg had no association (30 patients). 748 maintained the sheath (88.0%, 95%CI: 85.6%-90.1%). There was no association between age, sex or access site location (femoral, radial or both) on outcomes. Conclusions: This single-center prospective study demonstrates that the Aldrete-FAST score is a simple, safe screening tool with excellent feasibility to evaluate for CRS. No association between age, sex or access site implies generalizability. We found an interaction with sedation as midazolam and fentanyl had an inverse relationship regarding successful completion of the score. Further study is warranted to determine the optimal anesthesia for high risk patients undergoing cardiac catheterization.

Clinical outcomes of patients with acute minor stroke receiving rescue IA therapy following early neurological deterioration

BackgroundPatients presenting with minor ischemic stroke frequently have early neurological deterioration (END) and poor final outcome. The optimal management of patients with END has not been determined.ObjectiveTo investigate rescue IA...