Parenchymal Hemorrhage Type Research Articles

Streamlined workflow including nurse recognition of conjugate gaze deviation for reduced door-to-puncture time in endovascular thrombectomy: A retrospective study

BackgroundEndovascular thrombectomy is recognized as a pivotal treatment for acute ischemic stroke due to large vessel occlusion. Prolonged door-to-puncture time correlates with decreased patient independence after acute ischemic stroke. This study aimed to assess whether a streamlined workflow, including nurse recognition of conjugate gaze deviation, could reduce door-to-puncture time in endovascular thrombectomy. MethodsThis study retrospectively reviewed patients with acute ischemic stroke who underwent endovascular thrombectomy between March 2017 and March 2022 and compared a previous workflow with a streamlined workflow implemented in April 2019. In the streamlined workflow, nurses recognized conjugate gaze deviation to identify patients with large vessel occlusions and played a more active role in reducing the door-to-puncture time. We compared time metrics and outcomes, including recanalization status, parenchymal hemorrhage type 2, and favorable outcomes (modified Rankin Scale score 0–2) at three months between the previous and streamlined workflow groups. ResultsAfter the application of the streamlined workflow, the door-to-puncture time was reduced from 76 min to 68 min (p = 0.014), and the number of patients with a door-to-puncture time of less than 60 min increased (15% vs. 36%, p = 0.002). Outcomes including modified thrombolysis in cerebral infarction ≥ 2b (73% vs. 71%, p = 1.000), parenchymal hemorrhage type 2 (7% vs. 2%, p = 0.281), and favorable outcome (33% vs. 34%, p = 1.000) were comparable between the two groups. ConclusionNurse recognition of conjugate gaze deviation contributed to an 8-minute reduction in the door-to-puncture time, demonstrating the potential benefits of an organized workflow in acute ischemic stroke.

The Safety and Efficacy of Emergency Stenting during Bridging Therapy: A Single-Center Retrospective Study

Introduction: The objective of this study was to investigate the safety and efficacy of emergency stenting for patients with ischemic stroke treated with bridging therapy. Methods: Patients with onset of stroke who underwent bridging therapy were included in the two groups with emergency stenting (ESG) and without stenting (NSG). To avoid the bias due to confounding variables, subjects were further assigned in two groups using 1:1 propensity score matching (PSM). The safety outcomes include the incidence of intracranial hemorrhage (ICH), parenchymal hemorrhage type 2 (PH2), symptomatic intracranial hemorrhage (sICH), fatal hemorrhage, and mortality. The efficacy outcomes include successful recanalization, 3-month favorable outcome (modified Rankin Scale [mRS]: 0–2). Results: 175 patients treated with bridging therapy were included in this study, with 52 patients in the ES group and 123 patients in the groups without ES, and with 30 patients in each group after PSM. No significant differences in the incidences of ICH, PH2, sICH, fatal hemorrhage, and mortality were found between the two groups with ES and without ES before and after PSM (p > 0.05 for all groups). The analysis without PSM showed that the group with ES had a higher rate of successful recanalization (98.1 vs. 88.6%, p = 0.041) than the group without ES, but no significant difference was seen (96.6 vs. 93.3%, p = 0.554) between the two groups after PSM. There was no difference in favorable outcome between the two groups before and after matching as well (p > 0.05). Conclusions: It is safe and effective for patients with onset of ischemic stroke to receive emergency stenting during bridging therapy, without increasing the risk of hemorrhagic transformation and mortality.

Abstract Number ‐ 22: Hemorrhagic Outcomes in Patients Demonstrating Early Venous Filling After Mechanical Thrombectomy For Acute Ischemic Stroke

Introduction Endovascular thrombectomy (EVT) for acute ischemic infarcts with large vessel occlusion have been shown to improve functional outcomes. However, there is still the risk of hemorrhagic transformation (HT). Early identification of patients at risk of HT is paramount to enhance EVT outcomes. EVF can be an indicator of the hyperemia that occurs following an infarct. We evaluated if early venous filling (EVF) defined as contrast filling of any cerebral vein within the arterial phase on angiogram can predict individuals at a higher risk of HT after EVT. Methods From the SELECT cohort,EVT patients with evaluable digital subtraction angiography were included in the study. Baseline clinical and imaging characteristics as well as clinical and hemorrhagic outcomes were compared between patients demonstrating EVF and no EVF. Association between EVF with symptomatic ICH and parenchymal hemorrhage was examined using multivariable logistic regression models. Results 46/254 (18%) patients had EVF at the end of the procedure. Age and NIHSS were similar between the patients with and without EVF, although patients with EVF presented earlier (1.39 (0.88‐2.75) hours vs 2.62 (1.10‐4.28) hours, p = 0.024), and demonstrated lower CT ASPECTS (7 (6‐9) vs 8 (7‐9), p = 0.022). The presence of EVF was associated with significantly higher odds of sICH (EVF: 8.7% vs no EVF: 5.6%, aOR: 4.72, 95% CI: 1.05‐21.28, p = 0.043) and demonstrated a trend towards higher odds of parenchymal hemorrhage type 1 or 2 (EVF: 10.9% vs no EVF: 6.3%, aOR: 3.64, 95% CI: 0.96‐13.73, p = 0.057) and mortality (EVF: 17% vs no EVF: 12%, aOR: 3.22, 95% CI: 0.93‐11.13, p = 0.064). Functional outcomes did not differ at 90 days between the two groups Conclusions Early identification of EVF may help to identify patients with increased risk of hemorrhagic transformation after EVT. This finding was independent from time last known well. While EVF is suggestive of hyperemia it is also a biomarker of infarct volume and may help to implement early therapeutic measurements to reduce hemorrhagic transformation risk such as strict blood pressure control. Further studies to evaluate EVF as a potential marker for hemorrhagic transformation are required.

Abstract WP154: Low-field Portable Mri For Routine Post-thrombectomy Assessment Of Ongoing Brain Injury

Introduction: Conventional MRI (cMRI) is not routinely available post-mechanical thrombectomy (MT), which can preclude accurate infarction assessment. Our objective was to evaluate the use of low-field portable MRI (pMRI) for bedside evaluation post-MT, including its use as a post-procedural baseline monitor. Methods: Low-field pMRI was used to obtain bedside imaging in post-MT patients between December 2021 to August 2022 at Yale-New Haven Hospital. All pMRI exams were conducted in the standard ferromagnetic environment of the IR suite. Volumetric analyses were performed by a neuroradiologist using 3D Slicer software. If cMRI was not available for comparison, a CT was used. Patients’ charts were reviewed for pre-revascularization MAP and occurrences of MAP dropping by 10% and 20% from individual baselines between the time of pMRI and delayed imaging. Results: A total of 25 patients (64% females, median age 77 years-old [IQR 69.5-84.5]) underwent bedside pMRIs in the IR suite post-MT. The median time from last known normal to access was 6 hours [IQR 4-17]. The median pMRI examination time was 30 minutes [IQR 17-32]. Of the 24 patients with available delayed imaging, 7 (29.2%) had infarct progression compared to immediate post-MT pMRI, while 15 patients (62.5%) had stable/decreased stroke volume. Two patients (8.3%) had parenchymal hemorrhage type 2 and were excluded from further analysis. There was no statistically significant difference between the proportions of favorable TICI scores (85.7% in the infarct progression group vs. 92.3% in the stable/decreased infarct group, p=1.00). Patients with infarct progression had comparable pre-revascularization MAP compared to those with stable/decreased delayed infarct volume (mean of 100.3±4.6 vs. 101.9±15.9 respectively, p=0.727) but had more occurrences of MAP dropping by 10% and 20% of their baseline between the time of pMRI and delayed imaging (mean of 35.0±23.3 vs. 14.7±11.3 occurrences, p=0.011; and mean of 21.7±16.5 vs. 8.5±9.5 occurrences, p=0.026, respectively). Conclusions: The use of low-field MRI in the post-MT setting can facilitate benchmark brain monitoring and serial examinations to evaluate the impact of potential physiological perturbations that may impact ongoing brain injury.

Imaging Indicators for Parenchymal Hemorrhage After Mechanical Thrombectomy in Acute Stroke

Background In patients with acute ischemic stroke with large vessel occlusion, the presence of hyperintense lesions on fluid‐attenuated inversion recovery (FLAIR‐positive) before mechanical thrombectomy (MT) and that of hyperdense lesions on noncontrast computed tomography (CT‐positive) after MT are associated with parenchymal hemorrhage, but the significance of these findings is unclear. Methods Patients with acute stroke with large vessel occlusion underwent magnetic resonance imaging, including diffusion‐weighted imaging and FLAIR, before MT. Noncontrast CT was obtained within 60 minutes after MT. The occurrence of parenchymal hemorrhage type 2 (PH2) was assessed on CT within 7 days after MT. FLAIR and CT‐positive were defined as a case with hyperintense and hyperdense lesions immediately before and after MT, respectively. Clinical and imaging factors associated with PH2 were evaluated by multivariate regression analysis. Results Enrolled were 412 patients (median age, 76 years; men, 58.3%; median National Institutes of Health Stroke Scale score, 16). The site of occlusion was the internal carotid artery (n=122, 29.6%), M1 (n=180, 43.7%), and M2 (n=96, 23.3%). FLAIR‐positive, CT‐positive, and PH2 were found in 149 (36.2%), 223 (54.1%), and 34 patients (8.3%), respectively. PH2 was significantly more frequent in CT‐positive than CT‐negative patients (14.3% versus 1.1%; P <0.001), but not in FLAIR‐positive than FLAIR‐negative patients (10.7% versus 6.8%; P =0.193). Regardless of FLAIR status, PH2 was significantly more frequent in CT‐positive than CT‐negative patients (12.8% versus 0.8% [ P <0.001] for FLAIR‐negative, and 16.7% versus 1.7% [ P =0.003] for FLAIR‐positive). Multivariate regression analysis demonstrated that CT‐positive was the only independent factor associated with PH2 (odds ratio, 12.699 [95% CI, 2.964–54.416]; P <0.001). Sensitivity, specificity, positive predictive value, and negative predictive values of CT‐positive for predicting PH2 occurrence were 94.1%, 49.5%, 14.3%, and 98.9%, respectively. Conclusion In patients with acute ischemic stroke with large vessel occlusion, CT‐positive immediately after MT was strongly predictive of PH2, but no such relationship was found for FLAIR‐positive before MT.

Endovascular Therapy of Anterior Circulation Tandem Occlusions: Pooled Analysis From the TITAN and ETIS Registries.

Endovascular therapy for tandem occlusion strokes of the anterior circulation is an effective and safe treatment. The best treatment approach for the cervical internal carotid artery (ICA) lesion is still unknown. In this study, we aimed to compare the functional and safety outcomes between different treatment approaches for the cervical ICA lesion during endovascular therapy for acute ischemic strokes due to tandem occlusion in current clinical practice. Individual patients’ data were pooled from the French prospective multicenter observational ETIS (Endovascular Treatment in Ischemic Stroke) and the international TITAN (Thrombectomy in Tandem Lesions) registries. TITAN enrolled patients from January 2012 to September 2016, and ETIS from January 2013 to July 2019. Patients with acute ischemic stroke due to anterior circulation tandem occlusion who were treated with endovascular therapy were included. Patients were divided based on the cervical ICA lesion treatment into stent and no-stent groups. Outcomes were compared between the two treatment groups using propensity score methods. A total of 603 patients were included, of whom 341 were treated with acute cervical ICA stenting. In unadjusted analysis, the stent group had higher rate of favorable outcome (90-day modified Rankin Scale score, 0–2; 57% versus 45%) and excellent outcome (90-day modified Rankin Scale score, 0–1; 40% versus 27%) compared with the no-stent group. In inverse probability of treatment weighting propensity score–adjusted analyses, stent group had higher odds of favorable outcome (adjusted odds ratio, 1.09 [95% CI, 1.01–1.19]; P=0.036) and successful reperfusion (modified Thrombolysis in Cerebral Ischemia score, 2b-3; adjusted odds ratio, 1.19 [95% CI, 1.11–1.27]; P<0.001). However, stent group had higher odds of any intracerebral hemorrhage (adjusted odds ratio, 1.10 [95%, 1.02–1.19]; P=0.017) but not higher rate of symptomatic intracerebral hemorrhage or parenchymal hemorrhage type 2. Subgroup analysis demonstrated heterogeneity according to the lesion type (atherosclerosis versus dissection; P for heterogeneity, 0.01), and the benefit from acute carotid stenting was only observed for patients with atherosclerosis. Patients treated with acute cervical ICA stenting for tandem occlusion strokes had higher odds of 90-day favorable outcome, despite higher odds of intracerebral hemorrhage; however, most of the intracerebral hemorrhages were asymptomatic.

Blood-brain barrier leakage and hemorrhagic transformation: The Reperfusion Injury in Ischemic StroKe (RISK) study.

In patients with acute ischemic stroke treated with reperfusion therapy we aimed to evaluate whether pretreatment blood-brain barrier (BBB) leakage is associated with subsequent hemorrhagic transformation (HT). We prospectively screened patients with acute ischemic stroke treated with intravenous thrombolysis and/or endovascular treatment. Before treatment, each patient received computed tomography (CT), CT angiography, and CT perfusion. We assessed pretreatment BBB leakage within the ischemic area using the volume transfer constant (Ktrans ) value. Our primary outcome was relevant HT, defined as hemorrhagic infarction type 2 or parenchymal hemorrhage type 1 or 2. We evaluated independent associations between BBB leakage and HT using logistic regression, adjusting for age, sex, baseline stroke severity, Alberta Stroke Program Early CT Score (ASPECTS)≥6, treatment type, and onset-to-treatment time. We enrolled 171 patients with available assessment of BBB leakage. The patients' mean (±SD) age was 75.5 (±11.8) years, 86 (50%) were men, and the median (interquartile range) National Institutes of Health Stroke Scale score was 18 (12-23). A total of 32 patients (18%) received intravenous thrombolysis, 102 (60%) underwent direct endovascular treatment, and 37 (22%) underwent both. Patients with relevant HT (N=31;18%) had greater mean BBB leakage (Ktrans 0.77 vs. 0.60; p=0.027). After adjustment in the logistic regression model, we found that BBB leakage was associated both with a more than twofold risk of relevant HT (odds ratio [OR]2.50; 95% confidence interval [CI]1.03-6.03 per Ktrans point increase; OR2.34; 95% CI1.06-5.17 for Ktrans values>0.63 [mean BBB leakage value]) and with symptomatic intracerebral hemorrhage (OR4.30; 95% CI1.13-13.77 per Ktrans point increase). Pretreatment BBB leakage before reperfusion therapy was associated with HT, and may help to identify patients at risk of HT.

Direct versus Bridging Mechanical Thrombectomy in Elderly Patients with Acute Large Vessel Occlusion: A Multicenter Cohort Study.

PurposeElderly people represent a growing stroke population with different pathophysiological states than younger. Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is beneficial for elderly patients remains unclear. This study compared the efficacy and safety between elderly patients treated with MT alone and those treated with both IVT and MT.Patients and MethodsPatients aged ≥65 years who were eligible for IVT within 4.5 h from symptom onset were selected from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke) registry, a prospective registry program for patients with endovascular treatment from 111 Chinese stroke centers. The primary efficacy outcome was the 90-day modified Rankin Scale score. We compared efficacy and safety outcomes using ordinal or binary logistic regression or a generalized linear model.ResultsIn total, 482 elderly patients were included: 187 (38.8%) received IVT and MT (bridging MT) and 295 (61.2%) received MT alone (direct MT). There was no significant difference in the 90-day modified Rankin Scale score between the two groups (median: 4 vs 4 points, respectively; adjusted β=−0.048, P=0.822). The direct MT group had a shorter onset-to-puncture time (225 vs 255 min, respectively; adjusted β=−55.074, P=0.002) and a lower rate of parenchymal hemorrhage type 2 within 24 h (2.80% vs 6.63%, respectively; adjusted odds ratio [OR]=0.287, 95% confidence interval [CI]=0.096–0.856, P=0.025). In addition, the direct MT group showed a trend toward a lower incidence of sICH (5.67% vs 10.06%, adjusted OR=0.453, P=0.061), procedure-related complications (7.12% vs 12.30%, adjusted OR=0.499, P=0.052) and distal or new territorial embolization (4.07% vs 6.95%, adjusted OR=0.450, P=0.093).ConclusionDirect MT had similar efficacy to bridging MT in terms of the 90-day functional outcome in elderly patients, whereas bridging MT had a longer onset-to-puncture time and increased risk of hemorrhagic transformation and procedure-related complications.

The Relationship of the Type of Intracerebral Hemorrhage to Early Disease Evolution and Long-Term Prognosis After r-tPA Thrombolysis.

To investigate the relationship of different subtypes of intracerebral hemorrhage (ICH) to early disease evolution and long-term prognosis in patients with acute cerebral infarction after intravenous recombinant tissue plasminogen activator(r-tPA). Seventy ischemic stroke patients treated with intravenous r-tPA who underwent computed tomography (CT) within 24 hours after thrombolysis were divided into 4 types (hemorrhagic infarction type 1 [HI-1], HI-2, parenchymal hemorrhage type 1 [PH-1], or PH-2 which according to the size of the hematoma and the presence or absence of space-occupying effect). Early evolution of the disease was observed by the change in the National Institutes of Health Stroke Scale (NIHSS) score within 24 hours after thrombolysis. The long-term prognosis was assessed by the modified Rankin Scale (mRS) score at the third month. There were 17 (24.3%) patients with ICH. Compared with patients in the non-ICH group, HI did not affect early neurological function or clinical outcome at the third month. PH-1 did not increase the risk of early neurological deterioration; however, PH-1 has a tendency to increase the risk of death at the third month (50% vs 11.3%, P = 0.090). PH-2 was significantly related to early neurological deterioration (66.7% vs 3.8%, P < 0.001) and mortality at the third month (50.0% vs 11.3%, P = 0.040). Patients with different subtypes of ICH after thrombolysis have different clinical outcomes. PH-2 is significantly associated with early neurological deterioration and increases mortality at the third month.

Clinical Characteristics and Outcome of Patients With Hemorrhagic Transformation After Intravenous Thrombolysis in the WAKE-UP Trial.

Background: Hemorrhagic transformation (HT) is an important complication of intravenous thrombolysis with alteplase. HT can show a wide range from petechiae to parenchymal hematoma with mass effect with varying clinical impact. We studied clinical and imaging characteristics of patients with HT and evaluated whether different types of HT are associated with functional outcome.Methods: We performed a post-hoc analysis of WAKE-UP, a multicenter, randomized, placebo-controlled trial of MRI-guided intravenous alteplase in unknown onset stroke. HT was assessed on follow-up MRI or CT and diagnosed as hemorrhagic infarction type 1 and type 2 (HI1 and HI2, combined as HI), and parenchymal hemorrhage type 1 and type 2 (PH1 and PH2, combined as PH). Severity of stroke symptoms was assessed using the National Institutes of Health Stroke Scale (NIHSS) at baseline. Stroke lesion volume was measured on baseline diffusion weighted imaging (DWI). Primary endpoint was a favorable outcome defined as a modified Rankin Scale score 0–1 at 90 days.Results: Of 483 patients included in the analysis, 95 (19.7%) showed HI and 21 (4.4%) had PH. Multiple logistic regression analysis identified treatment with alteplase (OR, 2.08 [95% CI, 1.28–3.40]), baseline NIHSS score (OR, 1.11 [95% CI, 1.05–1.17]), DWI lesion volume (OR, 1.03 [95% CI, 1.01–1.05]), baseline glucose levels (OR, 1.01 [95% CI, 1.00–1.01]) and atrial fibrillation (OR, 3.02 [95% CI, 1.57–5.80]) as predictors of any HT. The same parameters predicted HI. Predictors of PH were baseline NIHSS score (OR, 1.11 [95% CI, 1.01–1.22]) and as a trend treatment with alteplase (OR, 2.40 [95% CI, 0.93–6.96]). PH was associated with lower odds of favorable outcome (OR 0.25, 95% [CI 0.05–0.86]), while HI was not.Conclusion: Our results indicate that HI is associated with stroke severity, cardiovascular risk factors and thrombolysis. PH is a rare complication, more frequent in severe stroke and with thrombolysis. In contrast to HI, PH is associated with worse functional outcome. The impact of HT after MRI-guided intravenous alteplase for unknown onset stroke on clinical outcome is similar as in the trials of stroke thrombolysis within a known early time-window.

The Safety and Efficiency of Tirofiban in Acute Ischemic Stroke Patients Treated with Mechanical Thrombectomy: A Multicenter Retrospective Cohort Study.

Introduction Limited comparative studies have reported the safety and efficacy of tirofiban in acute ischemic stroke (AIS) patients after mechanical thrombectomy (MT). Additionally, the available studies are inconsistent with each other, which makes application of tirofiban unclear in neuro-intervention. Here, we performed a comparative retrospective study to investigate whether tirofiban combined with MT improves short- and long-term prognosis in AIS patients and whether its use is associated with complications. Method Retrospective data were collected for AIS patients admitted between January 2013 and January 2019 at three stroke centers. According to whether tirofiban was used during the operation, patients were divided into tirofiban group and control group. Multivariate and COX regression analyses were performed to determine the association of tirofiban treatment with safety and efficiency in subjects treated with MT. Result A total of 174 patients were analyzed, of whom 89 (51.1%) were treated with tirofiban. There were no differences in the incidence of symptomatic intracerebral hemorrhage (10.2% vs. 10.6%, p=0.918), parenchymal hemorrhage type 2 (18.0% vs. 16.5%, p=0.793), and reocclusion at 24 h (3.4% vs. 10.6%, p=0.060) between the tirofiban group and control group. Multivariate regression showed that tirofiban was not associated with intracerebral hemorrhage, early neurological deterioration, neurological improvement at 7 days, functional independence at 3-month and 9-month follow-up, or death at 9-month follow-up (adjusted p > 0.05 for all). However, AIS patients treated with MT + tirofiban showed a trend towards acquiring faster functional independence, with a median time to acquire functional independence of 4.0 months compared with 6.5 months in the control group (risk ratio = 1.49, 95% confidence interval 0.98–2.27; long rank p=0.066). Conclusion Tirofiban may help AIS patients given MT to gain functional independence faster, without increasing the risk of complications.

Abstract WP4: Efficacy of EVT in Patients Presenting Very Late (&gt;16 Hours) From Last Known Well

Background: Recent endovascular treatment (EVT) trials suggest the presence of target mismatch profiles up until 24 hours after stroke symptom onset. We aim to a) demonstrate the presence of target mismatch in patients presenting beyond these recent time thresholds and b) potential benefit with EVT in these patients. Methods: Between 01/2012 and 12/2018, patients with AIS with ICA or MCA occlusion and baseline NIHSS score ≥6 arriving ≥16 hours from last known well were identified. CT or MR perfusion images at presentation were evaluated using RAPID software; ischemic core was defined as rCBF &lt;30% (CTP) or ADC &lt;620 (MRI). Clinical information and outcome events were collected prospectively. Results: Of 154 patients [55% male, mean age 70 ± 13 years, median baseline NIHSS 13 [IQR 8 - 18], 76 (49%) had unwitnessed onset. Median last known well to arrival in hospital time was 42.2 [22.8 - 76.9]. CTP or MR perfusion were obtained in 115 (75%). Median ischemic core volume i.e., 11.0 ml [iqr 0 - 40 ml], and penumbra volume (Tmax &gt;6 s) i.e., 57 ml [16 - 133 ml] and a median mismatch ratio 4.0 [iqr 0.9 - 18.0] were noted. When inclusion criteria of the following trials, namely, ESCAPE, DAWN and DEFUSE3 trial were applied, DAWN-eligible patients were n=45 (29%), DEFUSE3 n= 61 (40%) and ESCAPE n=59 (43%). Figure 1a shows trial eligibility by time from last known well. 24 (16%) patients had EVT. EVT was associated with better functional recovery at 3 months (Figure 1b) for 90-day mRS 0-2 (adjusted OR [95% CI], 8.11 [2.49 - 30.44]) and 90-day mRS shift (common adjusted OR 5.50 [2.33 - 13.29]). Treatment effect with EVT was seen from 16 to 240 hours since last known well (Figure 1c). Parenchymal Hemorrhage type 2 was seen in 13 % offered EVT vs. 3% (adjusted OR 4.11 [0.73 - 21.72]). Conclusions: Patients with anterior circulation LVO presenting very late, even days from last known well, may potentially benefit from EVT.

Abstract WP6: Safety of Acute Carotid Stenting Treatment in Acute Symptomatic Patients

Carotid stenting (CAS) has been shown to be equivalent to carotid endarterectomy in symptomatic patients; however its optimal timing remains unclear. In this study, we aim to evaluate the safety of CAS when performed within the first 48 hours of symptom onset. We performed a retrospective analysis of a prospectively collected database of consecutive CAS patients admitted to our comprehensive stroke center with TIA/stroke and ipsilateral symptomatic carotid stenosis &gt;50% from 2014 to 2019. Medical records were retrospectively reviewed for demographic, clinical and procedural data and outcomes. Acute and delayed treatment were defined as ≤48 and &gt;48 hours from last known well (LKW) respectively. The primary endpoint was procedure-related major complications (stroke with NIHSS increase of ≥4, myocardial infarction, parenchymal hemorrhage type 2 or death) ≤30 days after CAS. Secondary endpoints were procedure-related minor neurological (stroke with NIHSS increase of &lt;4 and reperfusion injury) and non-neurological (groin puncture hematoma, acute anemia and arrhythmia) complications. Functional outcome was assessed by discharge and 90 days mRS, dichotomized as good (0-2) and bad (3-6). A total of 72 patients were included in the analysis, 36 in each group. There was no difference in age, NIHSS at presentation, gender, incidence of TIA as presentation or percentage of TPA received. The acute group differed significantly from the delayed group in number of thrombectomies (36.1% vs. 5.6%, p=0.001) and median time from LKW to CAS (15.9 hours vs. 88.0 hours, p&lt;0.001). There were significantly more carotid occlusions in the acute group when compared to the delayed group (37.8% vs. 2.2, p&lt;0.0001). Overall, the acute group did not show significant difference from the delayed group in major (2.8% vs. 5.6%, p=1.0), minor neurological (13.9% vs. 2.8%, p=0.09) and minor non-neurological complication rates (13.9% vs. 8.3%, p=0.7). Rates of good outcomes were not significantly different between the two groups at discharge (52.8% vs. 50%) or 90 days (75% vs. 63%). CAS can be performed safely in acute symptomatic carotid stenosis patients within the first 48 hours from symptom onset.

A Direct Aspiration First Pass Technique in Japanese Real-World Clinical Setting.

It is debatable whether mechanical thrombectomy has benefits in a real-world setting outside the more rigid and selective clinical trial environment. To evaluate clinical outcomes, efficacy, and safety of mechanical thrombectomy in single-center retrospective cohort case series. We reviewed prospectively collected data from our large-vessel occlusion stroke database to identify patients undergoing mechanical thrombectomy using Penumbra catheters (Penumbra, Almeida, California) as first-line devices. The primary outcomes were the modified Rankin Scale score at 90 d and recanalization rate. The secondary outcomes included the rates of hemorrhagic complications and mortality. The entire study population included 298 patients. Thrombolysis in Cerebral Infarction Scale ≥2b was achieved in 86.6% of patients. Fifty-five patients (18.5%) were outside the 6 hr time window and 82 patients (27.5%) were over 80-yr old. The posterior circulation thrombectomy rate was 12.4%. At 90 d from onset, 49.3% of patients had favorable outcomes. The parenchymal hemorrhage type 2 (PH2) and subarachnoid hemorrhage rates were 2.3% and 11.7%, respectively. In multivariate analyses, cerebral blood flow/cerebral blood volume mismatch (odds ratio [OR]=9.418; 95% confidence interval [CI], 3.680-27.726; P<.0001), onset to recanalization time (OR=0.995; 95% CI, 0.991-0.998; P=.0003), and hemorrhagic complications including PH2 and subarachnoid hemorrhage (OR=0.186; 95% CI, 0.070-0.455; P=.0002) were associated with favorable outcomes. A direct aspiration first pass technique with an adjunctive device demonstrated high recanalization rates in old Japanese patients. Our patient cohort may reflect the application of endovascular techniques in acute ischemic stroke treatment in a real-world setting.

Blood pressure variability and hemorrhagic transformation in patients with successful recanalization after endovascular recanalization therapy: A retrospective observational study.

Although blood pressure (BP) variability has been regarded as a risk factor for hemorrhagic transformation (HTF) after intravenous thrombolysis, its effect on HTF after endovascular recanalization therapy (ERT) remains to be elucidated. We aimed to study the relationship between BP variability and symptomatic intracerebral hemorrhage (sICH) after successful recanalization with ERT. A total of 211 patients with acute ischemic stroke and successful recanalization (thrombolysis in cerebral infarction 2b or 3) after ERT were included between January 2013 and May 2017. The BP data following ERT was obtained over the first 24 hours using parameters including mean, maximum, minimum, difference between maximum and minimum, standard deviation, coefficient of variation, successive variations, and time rate (TR) of BP variation for systolic BP (SBP) and diastolic BP. sICH was defined as parenchymal hemorrhage type 2 with neurological deterioration of 4 points of more on the National Institute of Health Stroke Scale. Among the included patients, 20 (9.5%) developed sICH after successful ERT. The parameters linked with BP fluctuation over time were significantly related to sICH. After adjusting for confounders, the TR of SBP (per 0.1 mmHg/min increase) variation was independently associated with sICH (odds ratio = 1.71, 95% confidence interval = 1.013-2.886). Time-related BP variability in the first 24 hours following successful ERT was more correlated with sICH than other absolute BP levels. This suggests that maintaining a stable BP may be an important factor in preventing sICH after successful ERT. Ann Neurol 2019;85:574-581.

Intra-Arterial Tissue Plasminogen Activator Is a Safe Rescue Therapy with Mechanical Thrombectomy

Intra-arterial tissue plasminogen activator (IA-tPA) has been widely used in conjunction with mechanical thrombectomy (MT) or as rescue therapy. Data on the safety of IA-tPA as a rescue therapy are scarce. To report the safety outcome of IA-tPA during MT with respect to hemorrhage and functional outcome. We reviewed our prospectively maintained data and identified patients who received mechanical thrombectomy between November 1, 2014, and January 30, 2018. Collected variables included demographics, comorbidities, baseline National Institutes of Health Stroke Scale, procedural variables, and outcome variables, which were subjected to a matched and unmatched analysis. Hemorrhagic transformation was classified based on European Cooperative Acute Stroke Study criteria. Functional outcome was assessed based on modified Rankin Scale. A total of 486 patients were treated with MT during the study period, of whom 67 patients received IA tPA as a rescue therapy. IA tPA was used at the discretion of neuroendovascular surgeon if complete recanalization (modified Treatment in Cerebral Ischemia ≥2c) was not achieved with ADAPT (A Direct Aspiration First Pass Technique) or for distal occlusion that could not be reached with thrombectomy catheters. Both groups did not differ in baseline characteristics, comorbidities, or admission National Institutes of Health Stroke Scale. There was no significant difference in good outcome (modified Rankin Scale ≤2), death, any hemorrhage, or parenchymal hemorrhage type 2 between groups in matched and unmatched analyses. IA-tPA administration during MT was not associated with increased risk of hemorrhage in selected patients with incomplete recanalization after thrombectomy.

Active Reperfusion Hemorrhage during Thrombectomy: Angiographic Findings and Real-Time Correlation with the CT “Spot Sign”

Introduction: Symptomatic intracranial hemorrhage represents one of the most feared complications of endovascular reperfusion. We aim to describe a series of patients that experienced immediate reperfusion injury with active intraprocedural extravasation within the territory of the deep penetrating arteries and provide real-time correlation with CT “spot sign.” Methods: This was a retrospective analysis of patients that suffered reperfusion injury with active arterial extravasation during endovascular stroke treatment in two tertiary care centers. Results: Five patients were identified. Median age was 63 (58–71) years, 66% were male. Median NIHSS was 13.5 (9.5–23.0), platelet level 212,000 (142,000–235,000), baseline systolic blood pressure 152 (133–201) mm Hg, and non-contrast CT ASPECTS 7.0 (6.5–9.0). Two patients were taking aspirin and one had received intravenous thrombolysis. There were three middle cerebral artery M1, one internal carotid artery terminus, and one vertebrobasilar junction occlusion. Three patients had anterior circulation tandem occlusions. Stroke etiology was extracranial atherosclerosis (n = 2), intracranial atherosclerosis (n = 2), and cervical dissection (n = 1). The median time from onset to puncture was 5.5 (3.9–8.6) h. Intravenous heparin was administered in all patients (median dose of 4,750 [3,250–6,000] units) and intravenous abciximab in four. All tandem cases had the cervical lesion addressed first. Four lenticulostriates and one paramedian pontine artery were involved. Intraprocedural flat-panel CT was performed in four (80%) cases and provided real-time correlation between the active contrast extravasation and the “spot sign.” The bailout included use of protamine, blood pressure control, and balloon guide catheter or intracranial compliant balloon inflation plus coiling of targeted vessel. All patients had angiographic cessation of bleeding at the end of the procedure with parenchymal hemorrhage type 1 in one case and type 2 in four. Three patients had modified Rankin score of 4 and two were dead at 90 days. Conclusions: Active reperfusion hemorrhage involving perforator arteries was observed to correlate with the CT “spot sign” and to be associated with poor outcomes.

Abstract 138: Plasma Soluble ST2 Concentration Predicts Functional Outcome and Hemorrhagic Transformation After Acute Ischemic Stroke

Introduction: Soluble ST2 (sST2) is a member of the interleukin-1 receptor family that predicts mortality and outcome in cardiovascular disease. We aimed to determine whether baseline sST2 predicts functional outcome after stroke and examined its potential role in hemorrhagic transformation (HT). Methods: We measured plasma sST2 and matrix metalloproteinase-9 (MMP-9) in 646 patients who presented with acute ischemic stroke and were enrolled in the Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) network biomarker study. Soluble ST2 and total MMP-9 were measured by ELISA. Functional outcome was assessed at 3 months with the modified Rankin Scale (mRS), with good outcome defined as mRS 0-2, and poor outcome defined as mRS 3-6. HT was classified in 246 patients with available CT scans, using the ECASS III criteria. The relationships between sST2, outcome, and HT were evaluated using multivariate logistic regression. Results: Median admission sST2 level was 35.0 ng/mL [IQR 25.7—49.8] in 646 patients (mean age 69 years; 44% women). The plasma concentration of sST2 was independently associated with poor outcome (OR 3.06, 95% CI 1.15-8.31, P =0.02) and mortality (OR 8.94, 95% CI 2.13-39.55, P =0.003) after adjustment for age, sex, NIHSS, admission glucose, cardioembolic stroke subtype, and tPA treatment. Of the 246 patients with imaging data available, HT occurred in 37 (15%) patients: 18 (48%) with hemorrhagic infarction type 1 (HI1), 11 (30%) with hemorrhagic infarction type 2 (HI2), 4 (11%) with parenchymal hemorrhage type 1 (PH1) and 4 (11%) with parenchymal hemorrhage type 2 (PH2). Admission sST2 level was associated with the subsequent development of any HT ( P =0.03) and with hemorrhagic infarction type 2 or greater (HI2, PH1, or PH2; P =0.008). Elevated sST2 independently predicted HI2 or greater after adjustment for age, MMP-9, blood glucose level, and tPA treatment (OR 9.27, 95% CI, 1.05-86.76, P =0.045). Conclusion: Plasma sST2 levels predicted mortality, functional outcome, and risk of HT after ischemic stroke. Further study of the potential link between sST2 and the brain injury response after stroke is warranted.

Intravenous thrombolysis and three-year ischemic stroke mortality.

Intravenous thrombolysis (IVT) in ischemic stroke (IS) does not reduce three-month mortality; however, longer-term survival after IVT has not been clearly established. Thus, we aimed to compare three-year mortality after IS in IVT-treated vs non-treated patients and to indicate predictors of long-term mortality after IVT. We have evaluated data of 366 subjects with IS (196 treated with IVT and 170 non-treated with IVT, whose age, sex, and calendar time of IS occurrence matched the control group) collected via the Pomeranian Stroke Register. We estimated the three-year survival and its determinants in both groups. In univariate analysis, IVT was not associated with three-year mortality (OR 0.68; 95% CI 0.44-1.05). Independent predictors for unfavorable long-term outcome in a Cox regression model were older age, parenchymal hemorrhage type 2 (ph2), and modified Rankin scale >2points at discharge from the hospital. IVT was strongly associated with a lower risk of death in the period 0-36months from IS (HR 0.44, 95% CI 0.28-0.69, P<.001). Treatment of IS with intravenous recombinant tissue plasminogen activator was associated with increased survival during the three-year follow-up.

Abstract W P62: Symptomatic Intracerebral Hemorrhage after Thrombolysis in MRI Selected Patients is Rare and Unpredictable

Background: Symptomatic intracerebral hemorrhage (sICH) is the most feared complication following intravenous tissue plasminogen activator (IV-tPA) in ischemic stroke with a mortality rate of 50%. The strictest definition of a sICH is a parenchymal hemorrhage type 2 (defined as a hemorrhage of more than 30% of the infarct with a mass effect or hemorrhage in an unrelated area) and associated with an increase in NIHSS of 4 points or more. The incidence of sICH in a stroke cohort selected by CT was nearly 3% in a recent study. Objectives: We examined the incidence of sICH in acute MRI-evaluated stroke patients treated with IV-tPA in a Danish stroke center between 2004 and 2010. We also sought to identify clinical and imaging factors related to an increased risk of sICH. Methods: MRI is the preferred imaging modality for patients presenting with symptoms of acute stroke at our hospital. Treatment with IV tPA was guided by MRI findings and patients with DWI lesions &gt;1/3 of MCA was excluded from therapy. No higher or lower NIHSS cut off was applied and treatment was initiated within 4.5 hours from symptom onset. Results: Overall, 519 patients received IV tPA on the basis of an acute MRI scan. (Forty-six patients who received both IV tPA and intraarterial treatment were excluded.) Six patients (1.2%) had a sICH as defined above. Age, acute DWI lesion size, stroke severity and time to treatment did not differ significantly among patients with and without a sICH. The patients with sICH did not differ from the patients not suffering sICH regarding vascular risk factors (sex, hypertension, diabetes, hyperlipidemia, smokingor atrial fibrillation). However, five patients suffering an sICH (83%) were taking antiplatelet drugs prior to treatment, while only 33% of the “non-bleeders” were (p=0.03). Conclusion: MRI-based IV tPA, with exclusion of large infarct sizes from treatment, is associated with low rates of sICH. No pretreatment clinical or imaging characteristics, but antiplatelet drugs, could identify patients with an increased risk of sICH.