Independent Predictors Of Good Outcome Research Articles

Abstract WP37: Real-World Applicability of Thrombectomy in Anterior Circulation Large Vessel Occlusion Strokes Treated in the Extended Window: Analysis of the Prospective Trevo Registry

Background: Two recent trials showed a strong benefit of thrombectomy in the extended window. However, these studies were performed in selected centers and utilized strict inclusion criteria. We aim to evaluate the outcomes of thrombectomy in a large prospective cohort treated outside the rigid clinical trial setting. Methods: Trevo Registry patients with ICA, MCA-M1 or M2 occlusions and pre-morbid mRS0-2 were categorized according to time-from-last-seen-well (TLSW) to puncture as early (0-6hours) vs. late (6-24hours). Uni- and multivariate analyzes were performed to identify good outcome (90-day mRS0-2) predictors. Subgroup analyses were performed for the basic DAWN (age >=18, NIHSS >=10, ICA or M1 occlusion, pre-morbid mRS 0-1) and DEFUSE 3 (age 18-90, NIHSS >=6, ICA or MCA-M1 occlusion, mRS 0-2) trial criteria. Results: As compared to the late (n=430), early patients (n=1173) were older (70 vs 68, p=0.011) and had higher IV tPA use (69 vs 25%, p<0.001), lower smoking frequency (33 vs 40%, p=0.011), larger baseline infarcts (21.2 vs 15.6 cc, p=0.045), less frequent ICA occlusions (18 vs 24%, p=0.015), and a trend towards higher admission NIHSS (16 vs 15, p=0.09). Despite significantly longer TLSW to puncture (3.5 vs 9.6 h, p<0.001), late patients had similar rates of mTICI2b-3 (92 vs 94%, p=0.20), good outcomes (60 vs 56%, p=0.128), symptomatic ICH (1.5 vs.1.4%, p=0.84), and 90-day-mortality (10.9 vs.11.4%, p=0.79). Age (OR 0.96, 95%CI [0.96-0.97]), admission-NIHSS (0.91 [0.89-0.93]), baseline mRS (0.49 [0.40-0.60]), ASPECTS >= 6 (1.37 [1.07-1.75]), DM (0.58 [0.44-0.77]), and time to treatment (0.98 [0.97-1.00]) were independent predictors of good outcomes. Imaging modality did not predict outcomes. Similar findings were observed in the early versus late DAWN-like (n=709 vs 257) and DEFUSE 3-like (n=855 vs 273) cohorts. There was great similarity between the outcomes of the Trevo Registry subsets vs their analogous RCTs: early DAWN-like vs SWIFT Prime (90-day mRS 0-2: 57.5 vs 60%; 90-day mRS 6: 11.% vs 9%), Late DAWN-like vs DAWN (50.2 vs 48.6%; 10.6 vs 18%), and Late DEFUSE 3-like vs DEFUSE 3 (52 vs 45%; 10.3 vs 14%). Conclusions: Our study provides favorable data for the generalizability of the safety and efficacy of thrombectomy in the “real-world” setting.

Abstract 164: Early Infarct Growth Correlates With Both Collateral Status and Clinical Outcomes After Thrombecomy

Background: We assessed the correlation between early infarct growth rate (EIGR), collaterals and clinical outcomes following endovascular thrombectomy (EVT). Methods: In a prospective multicenter cohort study of imaging selection for EVT (SELECT), consecutive patients with large vessel occlusion (ICA, M1, M2) presenting up to 24 hr from last known well (LKW) were enrolled at 9 centers. CT perfusion was obtained prior to EVT. EIGR was defined as CTP ischemic core volume (rCBF<30%) divided by the time from LKW to baseline CTP. The optimal EIGR cutoff was identified by maximizing the sum of the sensitivity and specificity to predict favorable outcome (90 day mRS 0-2). Slow progressors were defined as having an EIGR below the cutoff. Good collaterals were defined on CTP as a hypoperfusion intensity ratio (HIR) <0.4 and on CTA as collateral score > 2. Results: Of 445 enrolled, 284 received EVT. The optimal EIGR was <10 ml/hr; 199 were slow and 85 fast progressors. Fast progressors had higher median NIHSS (19 vs. 15, P< 0.001), earlier median LKW to puncture 180 vs. 266 min, P< 0.001,. Slow progressors had better collaterals on both CTP and CTAs: HIR aOR 4.97 (2.3-10.7), p<0.001; CTA collaterals 3.02 (1.6-5.7), p=0.001. EIGR was an independent predictor of good outcome after adjusting for age NIHSS, LKW to puncture, mTICI and tPA aOR 0.73 (95% CI 0.61-0.89, p=0.001). Slow progressors were 3.5 times more likely to achieve mRS 0-2 after EVT aOR 3.51 (95% CI 1.8-6.7, p<0.001). Fast progressors had substantially worse clinical outcomes both in early and late time window (Table 1). The odds of good outcome decreased by 14% for each 5 ml/hour increase in EIGR, OR:0.87(0.80-0.94), p<0.001 and the probability of good outcome declined more rapidly in fast progressors (Figure 1). Conclusion: The early infarct growth strongly correlates with both collateral status and clinical outcomes after EVT. Fast progressors have a much more rapid decline in favorable outcomes at late treatment times.

Abstract WMP20: E-Aspects Derived Acute Ischemic Volumes on Non-Contrast Enhanced Computed Tomography Images Correlate With Diffusion Weighted Imaging Lesion Volumes and Predict Clinical Outcome in Acute Ischemic Stroke Patients

Background and Purpose: e-ASPECTS derived automated acute ischemic volume (AAIV) measurements on non-contrast computed tomography (NCCT) were correlated with clinical variables and diffusion weighted lesion volumes (DWI) in acute ischemic stroke patients. Methods: Data from three studies were reanalyzed with e-ASPECTS Version 7. The National Institute of Health Stroke Scale (NIHSS) determined stroke severity at baseline and clinical outcome was measured with the modified Rankin Scale (mRS) between 45 to 120 days. Spearman ranked correlation coefficients (R) of AAIV and e-ASPECTS scores with DWI lesion volumes, NIHSS and mRS were calculated. Multivariate regression analysis (odds ratio, OR with 95% confidence intervals, CI) and receiver operating characteristic (ROC) curve analysis (area under the curve, AUC with 95% CI) with regard to good outcome (mRS 0-2) were performed. Results: In total 388 patients were included. Median AAIV was 33.5+/-24.9 ml, (interquartile range) e-ASPECTS was 9 (8-10) and mean time to scan was 155+/-119 minutes. AAIV and e-ASPECTS correlated strongly (R=-0.78, p<0.001), and AAIV, respectively e-ASPECTS correlated with NIHSS (R=0.33, p<0.001; R=-0.35, p<0.001) and mRS (R=0.31, p<0.001; R=-0.31, p<0.001). AAIV correlated strongly with DWI lesion volume (n=37, R=0.69, p<0.001). AAIV (OR 0.98 per ml, 95% CI 0.97-0.99) was an independent predictor of good outcome, and 29.8 ml (AUC: 0.67, 0.61-0.71) was the optimal cut-off for good outcome. Conclusion: AAIV on NCCT is a new feature of the e-ASPECTS software, which significantly correlates with clinical severity and clinical outcome as well as DWI lesion volumes.

Clinical Outcome after Thrombectomy in Patients with Stroke with Premorbid Modified Rankin Scale Scores of 3 and 4: A Cohort Study with 136 Patients.

We aimed to analyze the clinical outcome after mechanical thrombectomy in patients with premorbid mRS 3 and 4 because there are currently no data on this patient group. Between January 2009 and November 2017, all patients with premorbid mRS 3 or 4 undergoing mechanical thrombectomy due to anterior circulation stroke were selected. Good outcome was defined as a clinical recovery to the status before stroke onset (ie, equal premorbid mRS and mRS at 90 days). In addition, mortality at discharge and at 90 days was analyzed. One hundred thirty-six patients were included, of whom 81.6% presented with premorbid mRS 3; and 18.4%, with premorbid mRS 4; 24.0% of patients with premorbid mRS 4 achieved clinical recovery compared with 20.7% of patients with premorbid mRS 3 (P = .788). However, the proportion of hospital mortality and mortality at 90 days was nonsignificant, but markedly higher in patients with premorbid mRS 4. Multivariate analysis identified low NIHSS scores (OR, 0.92; 95% CI, 0.85-0.99; P = .040), high ASPECTS (OR, 1.45; 95% CI, 1.02-2.16; P = .049), and TICI 2b-3 (OR, 7.11; 95% CI, 1.73-49.90; P = .017) as independent predictors of good outcome. Good outcome in patients with premorbid mRS 3 and 4 is less frequent compared with premorbid mRS 0-2. Nevertheless, about 20% of the patients return to their premorbid mRS, which may justify endovascular treatment. The most important predictor of good outcome is successful recanalization.

Impact of infarct location on functional outcome following endovascular therapy for stroke

ObjectivesThe relationship between stroke topography (ie, the regions damaged by the infarct) and functional outcome can aid clinicians in their decision-making at the acute and later stages. However, the side...

Impact of isolated basal ganglia infarction at pretreatment DWI on outcomes after endovascular thrombectomy in acute anterior circulation stroke.

Acute infarction confined to the basal ganglia (BG) is occasionally observed on baseline imaging before endovascular thrombectomy. This study aimed to investigate the impact of isolated BG infarction revealed on pretreatment DWI in a large cohort of patients with acute anterior circulation stroke who underwent thrombectomy. We retrospectively analyzed clinical and DWI data from 328 patients who underwent thrombectomy for emergent occlusions of the intracranial internal carotid artery or the middle cerebral artery. Characteristics and treatment outcomes were compared between patients with isolated BG infarction and those with non-isolated BG infarction. Binary logistic regression analyses were performed to identify independent predictors of good outcome (90-day mRS 0-2). Isolated BG infarction was found in 57 patients (17.4%). Patients with isolated BG infarction had a higher incidence of underlying severe intracranial atherosclerotic stenosis (21.1% vs. 10.7%, P = 0.032) than those with non-isolated BG infarction. Successful reperfusion occurred more frequently in patients with isolated BG infarction than those with non-isolated BG infarction (93% vs. 79%, odds ratio 3.529, 95% confidence interval 1.226-10.161, P = 0.014). On multivariate logistic regression analysis, independent predictors of good outcome were age, DWI-ASPECTS, and admission NIHSS score. There was no significant difference in the rate of good outcome between the two groups (54.4% vs. 42.8%, P = 0.110). Isolated BG infarction on pretreatment DWI may predict successful reperfusion after endovascular thrombectomy in patients with acute anterior circulation stroke. In addition, our study suggested a novel finding that isolated BG infarction was more frequently associated with underlying severe ICAS than non-isolated BG infarction.

Characteristics of the patients in an Infectious Diseases Intensive Care Unit

Background: Infectious Diseases Intensive Care Unit (IDICU) is different from a usual ICU due to the pathology and rate of mortality. The aim of our study was to characterize the most frequent admisssion causes in an IDICU and to identify prognostic factors for patients’ outcomes. Methods & Materials: We conducted a retrospective analysis of patients admitted between November 2014–August 2016 in IDICU of “Dr Victor Babes” Clinical Hospital of Infectious and Tropical Diseases from Bucharest. Results: 432 patients (254 male) were included. The main reasons for ICU admission were acute respiratory failure (requiring ventilatory support) in 212 patients, multisystem organ failure (MSOF) in 93 cases, neurologic disorders (coma with altered mental status or respiratory compromise) in 75 cases and acute congestive heart failure (respiratory failure and/or requiring hemodynamic support) in 28 cases. The main diagnosis was sepsis (29.6% of the cases), neurologic infections (16%), bacterial inferior respiratory infections (10.9%), influenza (10.2%), infectious endocarditis (8.1%), acute enterocolitis (7.2%), acute respiratory failure in chronically pulmonary diseases (4.4%) and HIV complications (3.5%). ANOVA test highlights a longer length of stay in ICU for neurologic infections and infective endocarditis (p < 0.037). The overall mortality rate was 40.7% (176 deaths). The mortality rate was significantly lower in patients with neurologic infections (27% vs. 56% in those with sepsis and 80% in those with HIV complications,p < 0.05). After performing a multinomial logistic analysis, independent predictors of good outcome were: main diagnosis of neurological infections and acute enterocolitis (p < 0.001), age (p = 0.026) and length of hospital stay (p = 0.010). Regarding main reason for ICU admission, patients with neurologic disorders are statistically significant (p < 0.001) a lower death outcome compared to MSOF patients. Conclusion: In an IDICU, acute respiratory failure, MSOF and neurologic disorders are the main reasons for admission, while sepsis, neurologic infections, respiratory infections, influenza and infectious endocarditis represent the main diagnosis. The overall mortality rate is higher than in a general ICU, with significant increases in patients with sepsis and HIV complications; patient age and the length of hospitalization are independent predictors of outcome.

Endovascular Treatment of Acute Basilar Artery Occlusion: Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) Study Group Experience

Acute basilar artery occlusion (BAO) is considered among the most severe medical emergencies, with very high morbidity and mortality. The aims of this study are to present 5 years experience of 12 centers in Lombardy region on BAO endovascular treatment and to evaluate prognostic factors that may improve clinical outcomes and recanalization rates. Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) registry is a retrospective multicentric collection of patients with acute BAO who underwent endovascular treatment between 2010 and 2015. A total of 102 patients (mean age 65 years) were included. Clinical, procedural, and neuroradiological data were collected. Angiographic results (Treatment in Cerebral Ischemia scale [TICI] score 2b-3) were assessed by each center's interventional neuroradiologist. Good clinical outcome was considered as a modified Rankin Scale score ranging between 0 and 2 in a 3-month follow-up. Thirty-nine percent of patients showed good clinical outcome at 3 months. Mortality rate was 30%. TICI 2b-3 was achieved in 62% of patients. Univariate analysis showed that age, National Institutes of Health Stroke Scale (NIHSS) at onset, time to recanalization, and TICI score were all statistically significant clinical outcome predictors (P < .05). Multivariate logistic regression showed that time to recanalization, age, and NIHSS at onset were significant independent predictors of good outcome. BAO treatment needs more efforts to assure patients better clinical outcomes. Mechanical thrombectomy is feasible and effective in patients with acute BAO. These results must be confirmed by further prospective studies within randomized controlled settings.

Endovascular treatment for emergent large vessel occlusion due to severe intracranial atherosclerotic stenosis.

The optimal treatment strategy for patients with emergent large vessel occlusion (ELVO) due to underlying severe intracranial atherosclerotic stenosis (ICAS) is unclear. The purpose of this study was to compare treatment outcomes from intracranial angioplasty with or without stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor in patients with ELVO due to severe ICAS, and to investigate predictors of outcome after endovascular therapy in such patients. A total of 140 consecutive patients with ELVO attributable to severe ICAS underwent endovascular therapy at two stroke centers (A and B). Intracranial angioplasty/stenting was primarily performed at center A and intraarterial infusion of glycoprotein IIb/IIIa inhibitor (tirofiban) at center B. Data from both centers were prospectively collected into a database and retrospectively analyzed. Overall, successful reperfusion was achieved in 95% (133/140) of patients and a good outcome in 60% (84/140). The mortality rate was 7.9%. Symptomatic hemorrhage occurred in 1 patient. There were no significant differences in the rates of successful reperfusion, symptomatic hemorrhage, 3-month modified Rankin scale score 0-2, and mortality between the two centers. Multivariate logistic regression analysis revealed the only independent predictor of good outcome was a history of previous stroke or transient ischemic attack (TIA) (odds ratio 0.254, 95% confidence interval 0.094-0.689, p = 0.007). Both intracranial angioplasty/stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor are effective and safe in the treatment of underlying severe ICAS in acute stroke patients with ELVO. In addition, a lack of a history of stroke/TIA was the only independent predictor of good outcome after endovascular therapy in such patients.

Ear, nose and throat involvement in granulomatosis with polyangiitis: how it presents and how it determines disease severity and long-term outcomes.

Ear, nose and throat (ENT) manifestations in granulomatosis with polyangiitis (GPA) represent the most frequent symptoms at disease onset. The aim of the study was to analyse ENT involvement at diagnosis, as well as how it could influence relapse rate, mortality and disease severity. A retrospective non-controlled cohort study was performed including all consecutive diagnosed GPA from 1996 to 2016 in two rheumatology centres of Northern Italy, focusing particularly on ENT presenting signs and symptoms at baseline. Eighty-nine patients (48.3% females) with new onset GPA were evaluated. They were mostly Caucasian (97.7%), middle aged (mean 54.5years) and more frequently anti-neutrophil cytoplasmic antibodies (ANCA) positive (78.6%) with PR3 specificity (81.4%). At diagnosis, ENT involvement was reported in 71.9% patients, second only to systemic symptoms. These patients were significantly younger at disease onset (0.013), with less frequent renal involvement (0.014) irrespectively to ANCA status, but with significantly higher Vasculitis Damage Index (VDI) (0.001). The most frequent ENT manifestation was sinonasal involvement (58.4%, 73% of which with nasal inflammation/chronic sinusitis and 48% with nasal crusting), while otologic involvement (mainly otitis media/otomastoiditis) was observed in 34.8%. ENT-GPA patients presented a higher survival rate at 5years (98.1 vs 77.7%, 0.049), and ENT involvement resulted to be an independent predictor of better outcome (OR 0.37, 95% CI 0.2-0.8, 0.019). Our data confirms that ENT involvement is not only one of the key clinical features of GPA, but also could point out a milder GPA subset with lower renal involvement and lower mortality rate, irrespectively to ANCA status.

Abstract TMP3: Age-Adjusted Infarct Volume Cut-off For Favorable Outcome After Large Vessel Occlusion Stroke Endovascular Therapy

Background: Optimal selection paradigms for large vessel occlusion acute stroke endovascular therapy are yet to be established. Previous studies have shown the benefit of adjusting infarct size to age. We sought to study the impact of age-adjusted final infarct volumes (FIV), a surrogate for pre-reperfusion infarct core, on functional outcomes and determine the ideal thresholds for good outcome discrimination (90-day mRS 0-2). Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between 9/2010- 8/2016. All patients that underwent endovascular therapy for large vessel occlusion anterior circulation acute ischemic stroke were stratified into five age groups: (G1) &lt;50 years, (G2) 50-69, (G3) 70-79 (G4) 80-89 and (G5) ≥90. Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. FIV was measure on follow-up MRI or CT within 5 days of treatment. : 966 patients were studied (G1:136, G2:408, G3:233, G4:160, G5:29). Overall, the mean FIV was 59.9±79.9mL and 46% had good outcome. Patients with poor outcome had larger FIV in each group (Mean/Median[IQR]) (G1:46.8/29.2[8.7-64.6] vs 145.3/91.5[51.9-223.5], G2:26.9/15.8[7.7-37.2] vs 93.6/68.1[22.2-146.8], G3:26.2/17.6[7.6-34.1] vs 96.1/61.9[25.5-130.9], G4:14.7/8.7[3.9-16.4] vs 60.2/29[13.6-85.2], G5:2.9/1.3[0.6-4.3] vs 58.3/36.6[18.2-91.1], p&lt;0.01 for all). The target FIV cut-off (mL) decreased with increased age: G1:52.4(SE 75%, SP 65%); G2:23.2(SE 75%,SP 64%); G3:24.6(SE 76%,SP 64%); G4:13.4(SE 75%,SP 70%); G5:12.8(SE 79%,SP 100%). In multivariate analysis, after adjusting for age, baseline NIHSS, glucose level, reperfusion status, parenchymal hematoma and FIV, achieving a final infarct volume less than the age-adjusted target was an independent predictor of good outcome (OR:1.94 95%CI [1.06-3.53], p=0.03). Conclusions: Age-adjusted infarct volume represents a strong outcome discriminator substitute and might help refine patient selection for stroke endovascular therapy

Abstract TP42: Equivalent Favorable Outcomes Possible After Thrombectomy for Posterior Circulation Large Vessel Occlusion Compared to Anterior Circulation: The MUSC Experience

Introduction: In acute ischemic stroke (AIS), posterior circulation large vessel occlusions (LVO) have been associated with poorer outcomes compared to anterior circulation LVO. Using a strategy for determining candidacy relying on CT perfusion rather than time parameters, the outcomes of anterior vs. posterior circulation thrombectomy for LVO were compared at a high volume center employing a direct aspiration first pass technique (ADAPT). Methods: We retrospectively studied a database of AIS cases that underwent ADAPT thrombectomy for large vessel occlusions. Cases were grouped by anatomical location of thrombectomy (posterior vs. anterior circulation), and analysis was performed on both entire sample size and on matched subsets within each group. Results: A total of 436 AIS patients (50.2% women, mean age 67.3 years) underwent ADAPT thrombectomy for LVO during the study period of which 13% of had posterior circulation thrombectomy. Patients with posterior circulation thrombectomy did not show a significant difference in pre-procedural variables including age, baseline NIHSS and onset to groin time compared to anterior circulation (p&gt;0.05). There were also no differences in procedural variables between the two groups. Patients in the posterior group were found to have a similar likelihood of good outcome (mRS 0—2) at 90 days compared to the anterior group (42.9% vs. 43.2% respectively) and a small but not significant increase in mortality at 90 days. Multivariate logistic regression analysis shows that the anatomical location (anterior vs. posterior) is not an independent predictor of good outcome or mortality after thrombectomy. Prominent predictors of outcome/mortality include age, female gender, procedure time, and baseline NIHSS. Conclusion: Our findings suggest that posterior circulation thrombectomy for LVO has a similar outcome and a similar rate of post-procedural complications compared to anterior circulation thrombectomy indicating comparable safety and efficacy profiles.

Clinical and Basic Evaluation of the Prognostic Value of Uric Acid in Traumatic Brain Injury

Background: As a major antioxidant in serum, uric acid (UA) was once considered only as the leading cause of gout; however, recent studies have validated its neuroprotective role in ischemic stroke. Because the potential protective effects of UA in traumatic brain injury (TBI) remain largely unknown, this study investigated the role of UA in TBI in both clinical patients and experimental animals.Methods: In TBI patients, serum UA concentrations were measured within 3 days after injury. Clinical outcomes at discharge were classified according to the Glasgow Outcome Scale: good outcome (4-5) and poor outcome (1-3). Risk factors for good outcome were identified via backward logistic regression analysis. For the animal study, a controlled cortical impact (CCI) injury model was established in mice. These mice were given UA at different doses intraperitoneally, and subsequent UA concentrations in mouse serum and brain tissue were determined. Neurological function, oxidative stress, inflammatory response, neuronal maintenance, cerebral blood flow, and lesion size were also assessed.Results: The serum UA level was significantly lower in TBI patients who had a good outcome (P<0.01), and low serum UA was an independent predictor of good outcome after TBI (P<0.01; odds ratio, 0.023; 95% confidence interval, 0.006-0.082). Consistently, decreased levels of serum UA were observed in both TBI patients and CCI animals (P<0.05), whereas the UA concentration was increased in CCI brain tissue (P<0.05). Administration of UA further increased the UA level in brain tissue as compared to that in control animals (P<0.05). Among the different doses administered, 16 mg/kg UA improved sensorimotor functional recovery, spatial learning, and memory in CCI mice (P<0.05). Moreover, oxidative stress and the inflammatory response were inhibited by UA treatment (P<0.05). UA treatment also improved neuronal maintenance and cortical blood flow (P<0.05) but not lesion size (P>0.05).Conclusions: UA acted to attenuate neuronal loss, cerebral perfusion impairment and neurological deficits in TBI mice through suppression of neuronal and vascular oxidative stress. Following TBI, active antioxidant defense in the brain may result in consumption of UA in the serum, and thus, a decreased serum UA level could be predictive of good clinical recovery.

Equivalent favorable outcomes possible after thrombectomy for posterior circulation large vessel occlusion compared with the anterior circulation: the MUSC experience

IntroductionIn acute ischemic stroke (AIS), posterior circulation large vessel occlusions (LVOs) have been associated with poorer outcomes compared with anterior circulation LVOs. The outcomes of anterior versus posterior circulation thrombectomy...

Alberta Stroke Program Early CT Score-Time Score Predicts Outcome after Endovascular Therapy in Patients with Acute Ischemic Stroke: A Retrospective Single-Center Study

Clinical outcomes after successful endovascular therapy in patients with acute ischemic stroke are associated with several factors including onset-to-reperfusion time (ORT), the National Institute of Health Stroke Scale (NIHSS) score, and the Alberta Stroke Program Early CT Score (ASPECTS). The NIHSS-time score, calculated as follows: [NIHSS score] × [onset-to-treatment time (h)] or [NIHSS score] × [ORT (h)], has been reported to predict clinical outcomes after intravenous recombinant tissue plasminogen activator therapy and endovascular therapy for acute stroke. The objective of the current study was to assess whether the combination of the ASPECTS and the ORT can predict the outcomes after endovascular therapy. The charts of 117 consecutive ischemic stroke patients with successful reperfusion after endovascular therapy were retrospectively reviewed. We analyzed the association of ORT, ASPECTS, and ASPECTS-time score with clinical outcome. ASPECTS-time score was calculated as follows: [11 - ASPECTS] × [ORT (h)]. Rates of good outcome for patients with ASPECTS-time scores of tertile values, scores 5.67 or less, scores greater than 5.67 to 10.40 or less, and scores greater than 10.40, were 66.7%, 56.4%, and 33.3%, respectively (P < .05). Ordinal logistic regression analysis showed that the ASPECTS-time score (per category increase) was an independent predictor for better outcome (common odds ratio: .374; 95% confidence interval: .150-0.930; P < .05). A lower ASPECTS-time score may predict better clinical outcomes after endovascular treatment.

Clinical and Imaging Outcomes of Endovascular Therapy in Patients with Acute Large Vessel Occlusion Stroke and Mild Clinical Symptoms

Background: The minimal stroke severity justifying endovascular intervention remains elusive. However, a significant proportion of patients presenting with large vessel occlusion stroke (LVOS) and mild symptoms go untreated and face poor outcomes. We aimed to evaluate the clinical outcomes of patients presenting with LVOS and low symptom scores (National Institutes of Health Stroke Scale [NIHSS] score ≤8) undergoing endovascular therapy (ET). Methods: We performed a retrospective analysis of a prospectively collected ET database between September 2010 and March 2016. Endovascularly treated patients with LVOS and a baseline NIHSS score ≤8 were included. Baseline patient characteristics, procedural details, and outcome parameters were collected. Efficacy outcomes were the rate of good outcome (90-day modified Rankin Scale score 0-2) and of successful reperfusion (modified Treatment in Cerebral Infarction [mTICI] score 2b-3). Safety was assessed by the rate of parenchymal hematoma (parenchymal hematoma type 1 [PH-1] and parenchymal hematoma type 2 [PH-2]) and 90-day mortality. Logistic regression was used to identify predictors of good clinical outcomes. Results: A total of 935 patients were considered; 72 patients with an NIHSS score ≤8 were included. Median [IQR] age was 61.5 years [56.2-73.0]; 39 patients (54%) were men. Mean (SD) baseline NIHSS score, computed tomography perfusion core volume, and ASPECTS were 6.3 (1.5), 7.5 mL (16.1), and 8.5 (1.3), respectively. Twenty-eight patients (39%) received intravenous tissue plasminogen activator. Occlusions locations were as follows: 29 (40%) proximal MCA-M1, 20 (28%) MCA-M2, 6 (8%) ICA terminus, and 9 (13%) vertebrobasilar. Tandem occlusion was documented in 7 patients (10%). Sixty-seven patients (93%) achieved successful reperfusion (mTICI score 2b-3); 52 (72%) had good 90-day outcomes. Mean final infarct volume was 32.2 ± 59.9 mL. Parenchymal hematoma occurred in 4 patients (6%). Ninety-day mortality was 10% (n = 7). Logistic regression showed that only successful reperfusion (OR 27.7, 95% CI 1.1-655.5, p = 0.04) was an independent predictor of good outcomes. Conclusion: Our findings demonstrate that ET is safe and feasible for LVOS patients presenting with mild clinical syndromes. Future controlled studies are warranted.

367 Functional Outcome in Patients with Refractory Cerebral Vasospasm Treated with Repeat Instant Endovascular Interventions

Abstract INTRODUCTION For patients suffering from cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular interventions often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the functional outcome of multiple repeated instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions. METHODS A single-center retrospective study of prospectively collected data on patients suffering from cerebral vasospasm refractory to therapies requiring at least 3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary endpoint was functional outcome at last follow-up (mRS &lt;3). The secondary endpoint was angiographic response to endovascular therapies and appearance of cerebral infarctions. RESULTS &gt;Over a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, &lt;3 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with 3 or more interventions compared to 31 (61%) of those with 1 or 2 interventions (P = 0.82). The initial Hunt and Hess score &lt;3 was a significant independent predictor of good outcome (OR 4.7, 95% CI, 1.2 18.5; P = 0.03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3 6; OR 13.5, 95% CI, 2.3 81.2; P = 0.004). CONCLUSION Repeated instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated.

Characteristics of Blood Pressure Profiles After Endovascular Coiling as Predictors of Clinical Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

Accurate identification of patients who will achieve a favorable outcome is almost impossible preoperatively or postoperatively in poor-grade (Hunt and Hess Grade IV and V) aneurysmal subarachnoid hemorrhage (SAH). Whether characteristics of blood pressure profiles during the first 24 hours after endovascular coiling could predict prognosis in poor grade patients was explored. Data were obtained retrospectively on all patients undergoing endovascular treatment with poor-grade SAH from November 2011 to June 2016. Blood pressure during the initial 24 hours was measured at 2-hour intervals after coil embolization. Studied features of mean systolic blood pressure (MSBP) and systolic blood pressure variability (SBPV) as well as demographics, medical history, clinical characteristics, and neurologic outcomes were documented. SBPV was determined as standard deviation and successive variation of systolic blood pressure. Logistic regression analysis was used to identify predictors of favorable outcome assessed on modified Rankin Scale score of 0 to2. The patients with favorable and unfavorable outcome were comparable with respect to systolic blood pressure on admission and MSBP after coiling. However, MSBP between 120 and 140 mm Hg was one of independent predictors of good outcomes at discharge (odds ratio 7.1; P= 0.002). SBPV-successive variation after embolization was associated with functional recovery (odds ratio 0.87; P= 0.011) in multivariate logistic analysis and mortality by Cox proportional hazard regression (hazard ratio, 1.10; P=0.001) at 6-month follow-up. Characteristics of blood pressure profiles after coiling appeared to be simple and convenient indexes for the prognosis of patients with poor-grade SAH.

The role of phenylephrine in patients with small deep subcortical infarct and progressive weakness

Background and purposeAlthough progression of small deep subcortical infarct (PSDI) comprises 12% to 36% of all small deep subcortical infarcts, the therapy for progression is not clear. This study investigated whether induced-hypertension therapy using phenylephrine is a useful therapy for PSDI. MethodsA group of 2427 consecutive patients, diagnosed with stroke at a tertiary hospital over a period of 4years was reviewed retrospectively. We analyzed patients with small deep subcortical infarct using clinical, laboratory, and pulse wave velocity (PWV). PSDI is defined as one or more increase in the motor score according to the NIHSS. Good outcome was designated as a modified Rankin scale of 0 to 2 at discharge. ResultsAmong all 662 patients who had a small deep subcortical infarct, 66 patients experienced motor progression (9.97%). The induced-hypertension therapy group (n=25) received phenylephrine, and the conventional group (n=41) received anticoagulation therapy such as heparin, volume expansion, or both. Although there were no significant differences in baseline clinical and laboratory findings, the PSDI group showed a significantly more frequent decrease in blood pressure at progression (P<0.0001) and higher PWV (P=0.001). The phenylephrine group (vs the conventional group) had a lower NIHSS score (P=0.036) and good outcome at discharge (P=0.004). In multiple regression analysis, PWV (OR, 1.004 per 1-cm/s increase; 95% CI, 1.001–1.008; P=0.018) was an independent predictor of good outcome in the phenylephrine group. A side effect of phenylephrine treatment was dysuria (n=1). ConclusionsThe present study suggests that vascular stiffness can be not only a predictor for PSDI but also a predictor of motor improvement after induced-hypertension therapy using phenylephrine in lacunar stroke.

Abstract WP4: Transfer Patients and Patients Presenting Directly to Endovascular Capable Centers Achieve Similar Good Outcome Rates with Endovascular Therapy

Background: While endovascular therapy (EVT) is effective for large vessel occlusions (LVO), most patients present to hospitals without EVT capability and are transferred for intervention, delaying treatment. Objective: We evaluated outcomes in LVO patients treated with thrombectomy who were transferred compared to those presenting directly to EVT facilities. Methods: In a large multicenter international prospective cohort study of LVO patients treated with stent retriever thrombectomy (TREVO Registry), patients were stratified by initial presentation into transferred (TNS) vs direct (DIR). 90 day mRS was the primary outcome (0-1 excellent, 0-2 good outcomes); sICH and reperfusion by mTICI were secondary outcomes. Outcomes were compared in the 2 groups (0-8 hrs onset to groin puncture (GP) then in time matched 3-8 hrs subgroups for validation). Logistic regression identified independent predictors of good outcome in TNS patients. Results: We identified 540 patients (230 TNS; 310 DIR) (Fig 1). TNS patients were younger and had longer onset to GP times (4.6 vs 3.1 hrs; p &lt;0.001) (Table 1). DIR achieved higher excellent outcomes (50.4 vs 38.7%; p &lt;0.001) (Table 2). There were no significant differences in good clinical outcomes (61 DIR vs 57.4% TNS, OR 0.90, 95% CI 0.63-1.27; p =0.4) (Fig 2) and no difference in the time matched 3-8 hrs subgroups (59.2% DIR vs 56.3% TNS, p =0.6). Fig 3 plots good outcome probabilities over time, showing similar confidence interval bands. Younger age (OR 0.95), lower NIHSS (OR 0.90), glucose level &lt; 170 mg/dL (OR 2.4), distal clot location (M2) (OR 1.7), excellent reperfusion (mTICI≥2b) (OR 2) and time to GP &lt;5 hrs (OR 1.6) were independent predictors of good outcome in TNS patients. Conclusion: While excellent outcomes were higher in directly-presenting patients, EVT-treated transfers may achieve similar good outcomes. The association between earlier EVT after transfer and better outcomes emphasizes the need to streamline the transfer process.