Rate Of Symptomatic Hemorrhage Research Articles

Safety and efficacy comparison of Tenecteplase and Alteplase for clinically suspected large vessel occlusion strokes without thrombectomy.

Tenecteplase is a thrombolytic with higher fibrin affinity, and is potentially better in clot lysis. A higher spontaneous recanalization rate for large vessel occlusions strokes (LVO) had been shown in comparison studies with Alteplase. Results of the LVO studies reflect the composite effect of the thrombolytic and thrombectomy, as patients would be treated by thrombectomy had they not been recanalized by intravenous thrombolysis alone. Thrombectomy is not readily available in many parts of the world. Our study aimed to compare the outcomes of suspected LVO patients treated with Tenecteplase versus Alteplase only, without the confounding effect of thrombectomy. This is a retrospective review. Data of patients given Tenecteplase from May 2020 to August 2023, and those given Alteplase 0.9 mg/kg from January 2019 to August 2023 were retrieved. (Due to fluctuation in supply of Tenecteplase during the COVID pandemic, some large vessel occlusion patients were given Alteplase.) Patients with anterior circulation, clinically suspected large vessel occlusion strokes (defined as National Institutes Health Stroke Scale (NIHSS) score >= 6, plus cortical signs or hyperdense vessel sign), with thrombolysis given within 4.5 hours of stroke onset were analyzed. Patients with thrombectomy done were excluded. Safety and efficacy outcomes were compared. There were 245 Tenecteplase treated patients treated between 1st May 2020 and 31st August 2023, and 732 patients were treated with Alteplase between 1st January 2019 to 31st August 2023. Out of these, 148 Tenecteplase patients and 138 Alteplase 0.9 mg/kg patients fulfilled the study criteria. The symptomatic intracerebral haemorrhage rate was non-significantly lower in the Tenecteplase group (2.1% versus 5.8%, p=0.13). There were no significant differences in the rate of >=8 points NIHSS improvement (23.6% versus 23.7%, p=1) or the >= 4 points improvement (40.5% versus 40.7%, p=1) at 24 hours. At 3 months, 21.6% of Tenecteplase patients had good functional outcome (modified Rankin scale (mRS) 0-2), compared to 26.3% in the Alteplase group (p=0.40). In this pragmatic study of clinically suspected anterior circulation LVO patients without thrombectomy, outcome solely reflects the effects of Tenecteplase. Tenecteplase showed comparable safety and efficacy to Alteplase. But the result should be interpreted with caution in view of its small sample size and non-randomized study design.

Prevalence and Angiographic Outcomes of Rescue Intracranial Stenting in Large Vessel Occlusion Following Stroke Thrombectomy – STRATIS

BACKGROUND Large vessel occlusion secondary to underlying intracranial atherosclerotic disease (ICAD‐LVO) has an estimated prevalence of 7% to30%. There is a large variation in the use of intracranial rescue stenting in interventional practice. We aimed to characterize the frequency and characteristics of intracranial rescue stenting in a large cohort of endovascular therapy for stroke. METHODS The Systematic Evaluation of Patients Treated With Stroke Devices for Acute Ischemic Stroke (STRATIS) angiography core lab adjudicated the location of the occlusion, hyperdense vessel sign on initial imaging, the use of angioplasty and stenting, and imaging outcomes following endovascular therapy. Underlying cause of stroke was categorized into intracranial atherosclerosis, cardioembolic, and other subtypes. Statistical analyses examined the relationship between intracranial rescue stenting and imaging outcomes including intracranial hemorrhage, and arterial reperfusion using expanded Thrombolysis in Cerebral Infarction reperfusion score in patients with ICAD‐LVO. RESULTS Among 978 patients with LVO stroke undergoing endovascular therapy, 91 (9.3%) patients had ICAD‐LVO. Baseline hyperdense vessel sign was observed among 44 (62.7%) with ICAD versus 178 (68.2%) with cardioembolic LVO ( P = 0.4). Final successful reperfusion (expanded Thrombolysis in Cerebral Infarction 2b50 or more) was significantly lower among ICAD‐LVO as compared with cardioembolic‐LVO (74.2% versus 87.5%; P = 0.007). Intracranial rescue stenting was used among 14/665 (2.1%) of patients with LVO (5 ICA terminus, 7 M1 middle cerebral artery, 1 M2 middle cerebral artery, 1 proximal basilar artery). Among 14 intracranial rescue stenting cases, 5/70 (7.1%) belonged to the ICAD group, 3/261 (1.1%) cardioembolic group, and 6/334 (1.8%) in other or undetermined group. Successful reperfusion following rescue stenting was achieved in all cases with ICAD‐LVO. Among ICAD‐LVO, the rate of 24 hours symptomatic intracranial hemorrhage was 0% with acute intracranial stenting versus 7.7% in the nonstenting subgroup. CONCLUSION In STRATIS, nearly 1 of every 11 thrombectomies were performed in patients with underlying ICAD, among whom 7.1% underwent rescue intracranial stenting concomitant with thrombectomy. Acute intracranial stenting as rescue therapy in ICAD‐LVO was associated with favorable angiographic outcomes and low symptomatic hemorrhage rates.

Contemporary cohort of cerebral cavernous malformations: natural history and utility of follow-up MRI.

This study reports the natural history of cerebral cavernous malformations (CCMs) in a contemporary cohort with prospectively collected data from multiple sources, access to follow-up imaging, integrated electronic medical records, and detailed imaging review by study investigators. The authors aimed to define the first prospective symptomatic hemorrhage (SH) and severe SH rates, determine the risk of a second prospective SH, and identify risk factors for SH. From a prospectively maintained database of adult patients with radiologically defined CCM, those with radiation-induced CCM, those who underwent surgery within 3 months postdiagnosis, and those with < 1 year of follow-up were excluded. The patients' medical history and radiological features of the CCM were recorded at the time of diagnosis. Follow-up annual written surveys were completed for 5 years after the initial diagnosis and then semiannually thereafter in addition to medical record and follow-up imaging review. Outcomes of interest included SH and severe SH. Of 315 patients, 58.7% were female and 19.7% had familial CCMs. At diagnosis, 37.1% of patients had ruptured CCMs and 28.9% of the CCMs were located in the brainstem. The 5-year cumulative rates of prospective SH and severe SH in those with ruptured CCMs at diagnosis were 41.2% and 12.8%, respectively, compared with 6.1% and 2.5% in patients with unruptured CCMs at diagnosis (p < 0.0001). Risk factors for prospective SH included a ruptured CCM at diagnosis and persistent or new hyperintensity on T1-weighted MRI performed > 3 months after baseline MRI. For those with a ruptured CCM at diagnosis, the risk of developing a second prospective SH was similar to that of developing a first SH. In a contemporary cohort of adult patients with CCM, the authors report 5-year SH and severe SH rates, rates of second prospective hemorrhage, and predictors of SH. Persistent or new hyperintensity on T1-weighted MRI may be a useful marker of disease activity.

Comparison of the Efficacy and Safety Between Intravenous Thrombolysis, Direct Endovascular Therapy, and Bridging Therapy for Acute Basilar Artery Occlusion in Cerebral Infarction Patients

ObjectiveTo compare the efficacy and safety of intravenous thrombolysis (IVT), direct endovascular therapy (EVT), and bridging therapy (BT=IVT+EVT) for acute basilar artery occlusion cerebral infarction. MethodsOne hundred and fourteen patients with acute basilar artery occlusion cerebral infarctions admitted between January 2020 and August 2023 were selected. Differences in the reperfusion rate, prognosis, incidence of stroke-associated pneumonia, and mortality rate were compared among the three groups. ResultsThere was no statistically significant difference in the percentage of patients who achieved successful reperfusion (86.8% vs. 84.2%) or complete reperfusion (72.1% vs. 68.4%) between the direct EVT and BT groups (both P>0.05). There were no statistically significant differences in the rates of symptomatic intracranial haemorrhage (3.7% vs. 10.3% vs. 10.5%, P=0.763). There were statistically significant differences in the rates of good prognosis (mRS score 0-2) (59.3% vs. 30.9% vs. 26.3%, P=0.021), stroke-related pneumonia (29.6% vs. 66.2% vs. 36.8%, P=0.002), and mortality (14.8% vs. 48.5% vs. 42.1%, P=0.010) among the three treatment groups. According to the binary logistic regression analysis, a good prognosis was independently associated with a baseline National Institutes of Health Stroke Scale (NIHSS) score <=10 (odds ratio [OR], 3.714; 95% confidence interval [CI], 1.207-11.430; P =0.022) and the incidence of stroke-associated pneumonia (OR, 0.640; 95% CI, 0.484-0.845; P=0.002). ConclusionAlthough there were differences in prognosis, mortality, and incidence of complications among the three treatment groups, after adjusting for confounding factors, prognosis was independently correlated only with the baseline NIHSS score and stroke-associated pneumonia but not with treatment methods.

Safety of Concomitant Cortical and Thalamic Stereoencephalography Explorations in Patients With Drug-Resistant Epilepsies.

Intracranial electrophysiology of thalamic nuclei has demonstrated involvement of thalamic areas in the propagation of seizures in focal drug-resistant epilepsy. Recent studies have argued that thalamus stereoencephalography (sEEG) may aid in understanding the epileptogenic zone and treatment options. However, the study of thalamic sEEG-associated hemorrhage incidence has not been investigated in a cohort study design. In this article, we present the largest retrospective cohort study of sEEG patients and compare hemorrhage rates between those with and without thalamic sEEG monitoring. Retrospective chart review of clinical and epilepsy history, electrode implantation, rationale, and outcomes was performed for 76 patients (age 20-69 years) with drug-resistant epilepsy who underwent sEEG monitoring at our institution (2019-2022). A subset of 38% of patients (n = 30) underwent thalamic monitoring of the anterior thalamic nucleus (n = 14), pulvinar nucleus (n = 25), or both (n = 10). Planned perisylvian orthogonal sEEG trajectories were extended to 2- to 3-cm intraparenchymally access thalamic area(s).The decision to incorporate thalamic monitoring was made by the multidisciplinary epilepsy team. Statistical comparison of hemorrhage rate, type, and severity between patients with and without thalamic sEEG monitoring was made. Our approach for thalamic monitoring was not associated with local intraparenchymal hemorrhage of thalamic areas or found along extended cortical trajectories, and symptomatic hemorrhage rates were greater for patients with thalamic coverage (10% vs 0%, P = .056), although this was not found to be significant. Importantly, patients with perisylvian electrode trajectories, with or without thalamic coverage, did not experience a higher incidence of hemorrhage ( P = .34). sEEG of the thalamus is a safe and valuable tool that can be used to interrogate the efficacy of thalamic neuromodulation for drug-resistant epilepsy. While patients with thalamic sEEG did have higher incidence of hemorrhage at any monitoring site, this finding was apparently not related to the method of perisylvian implantation and did not involve any trajectories targeting the thalamus.

RE-OPEN: Randomised trial of biosimilar TNK versus TPA during endovascular therapy for acute ischaemic stroke due to large vessel occlusions

RationaleRapid and timely treatment with intravenous thrombolysis and endovascular treatment (EVT) in patients with acute ischaemic stroke (AIS) and large vessel occlusion (LVO) significantly improves patient outcomes. Bridging therapy is...

Abstract TP112: Clinical Consequences of Tenecteplase Substitution for Alteplase at a Large Hub-Spoke Care Model

Introduction: Tenecteplase (TNK) is becoming the preferred thrombolytic for acute brain ischemia. We report a system-wide transition using intentional change management of a hub-spoke delivery model annually providing about 300 intravenous thrombolytic administrations to 3000 stroke alerts from alteplase to TNK. Methods: By 2021, evidence supported transition to TNK from alteplase to treat acute ischemic stroke at 0.25mg/kg (maximum 25mg). We began by gathering opinions from key stakeholders regarding TNK’s clinical merit to gauge support. We subsequently educated constituents including nursing, pharmacy, technical and clinical staff. A six-month lead-in, six-month introductory, and one-year transition period began in April 2021 using an intentional change method. Median door-to-needle (DTN), door-to-puncture (DTP), thrombolytic utilization and symptomatic hemorrhage rates were recorded at five primary (P) and a comprehensive stroke center (C). Results: During lead-in to TNK, DTN were 60(P), 26(C) minutes with 10%(P), 19%(C) utilization. DTP was 73 minutes. Symptomatic hemorrhage occurred in 0.0%(P), 4.9%(C) of alteplase-treated patients. During TNK’s 6-month introductory period DTN were 60(P), 20(C) minutes with 10%(P), 19%(C) utilization. DTP was 71 minutes. Symptomatic hemorrhage occurred in 0.0%(P), 4.9%(C) of TNK patients. During the subsequent one-year transition period, DTN was 53(P) and 23(C) minutes with 8%(P),16%(C) utilization. DTP was 78 minutes. Symptomatic hemorrhage occurred in 1.5%(P) and 3.0%(C). Conclusions: Hub-spoke delivery systems can safely transition to TNK using intentional process change reducing DTN and hemorrhagic complications with stable utilization. Substitution may not reduce DTP if thrombolytic administration is not the rate-limiting step. Intentional process change provides smooth transition when stakeholder education precedes, and pathway adherence follows implementation.

A comparison of conscious sedation and local anesthesia for thrombectomy in acute ischemic stroke: a multicenter study.

Ischemic cerebrovascular disease (ICVD) is a serious health problem in which brain tissue suffers from hypoxic damage due to obstruction in cerebral vessels. Mechanical thrombectomy is a commonly used method in the treatment of these patients. However, the effects of local anesthesia (LA) and conscious sedation (CS) during thrombectomy are still unclear. We evaluated whether there was a relationship between the two anesthesia regimens in terms of 90-day modified Rankin Scale (mRS) scores. In this study, a retrospective observational study was conducted to evaluate the effects of LA and CS used during mechanical thrombectomy in four comprehensive stroke centers among ICVD patients. Patients were divided into the LA group and the CS group. Statistical analysis was performed before and after 1:1 matching under propensity score matching (PSM) analysis. The primary outcome measure was an mRS score of 0-2 at 90 days. Secondary outcomes were procedure times, recanalization rates, symptomatic and asymptomatic hemorrhage rates, and procedural complications. A total of 193 patients (118 patients with LA and 75 patients with CS) were included in the final analysis before PSM. After 1:1 PSM, 98 patients-49 patients from each group-were included in the study. There was no difference in clinical outcomes between the LA- and CS-applied groups (p = 0.543). When blood pressure (BP) values at follow-up after endovascular treatment (EVT) were compared, the lowest systolic and lowest diastolic BP were found to be lower in the CS group (p = 0.001 and p = 0.009). There was no significant difference between the two groups in terms of recanalization rates, symptomatic intracranial hemorrhage (sICH) rates, 90-day mRS, and procedure-related complication rates (p = 0.617, p = 0.274, p = 0.543, and p = 1.000). This study did not reveal the superiority of CS applied during EVT on 90-day mRS, sICH, recanalization rates, or procedural complications. However, the risk of developing hypotension during the CS application was found to be high.

Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial

Recent evidence suggests a beneficial effect of endovascular thrombectomy in acute ischaemic stroke with large infarct; however, previous trials have relied on multimodal brain imaging, whereas non-contrast CT is mostly used in clinical practice. In a prospective multicentre, open-label, randomised trial, patients with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and a large established infarct indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 were randomly assigned using a central, web-based system (using a 1:1 ratio) to receive either endovascular thrombectomy with medical treatment or medical treatment (ie, standard of care) alone up to 12 h from stroke onset. The study was conducted in 40 hospitals in Europe and one site in Canada. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days, assessed by investigators masked to treatment assignment. The primary analysis was done in the intention-to-treat population. Safety endpoints included mortality and rates of symptomatic intracranial haemorrhage and were analysed in the safety population, which included all patients based on the treatment they received. This trial is registered with ClinicalTrials.gov, NCT03094715. From July 17, 2018, to Feb 21, 2023, 253 patients were randomly assigned, with 125 patients assigned to endovascular thrombectomy and 128 to medical treatment alone. The trial was stopped early for efficacy after the first pre-planned interim analysis. At 90 days, endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better outcome (adjusted common OR 2·58 [95% CI 1·60-4·15]; p=0·0001) and with lower mortality (hazard ratio 0·67 [95% CI 0·46-0·98]; p=0·038). Symptomatic intracranial haemorrhage occurred in seven (6%) patients with thrombectomy and in six (5%) with medical treatment alone. Endovascular thrombectomy was associated with improved functional outcome and lower mortality in patients with acute ischaemic stroke from large vessel occlusion with established large infarct in a setting using non-contrast CT as the predominant imaging modality for patient selection. EU Horizon 2020.

Efficacy and Safety Outcomes for Acute Ischemic Stroke Patients Treated with Intravenous Infusion of Tirofiban After Emergent Carotid Artery Stenting

IntroductionEmergent stenting of the extracranial internal carotid artery (ICA) in stroke patients requires antiplatelet therapy to prevent in-stent thrombosis with a higher risk of intracranial haemorrhage.Aim of the StudyAssess the efficacy and safety of emergent carotid stenting with intravenous tirofiban in acute ischemic stroke patients.MethodsPrimary endpoint: symptomatic hemorrhage. Secondary endpoints: 90-day functional outcome and mortality.ResultsOf the 62 patients, 21 (34%) received tirofiban as a single antiplatelet, and 41 (66%) received combined therapy. Premedication with anticoagulants and antiplatelets was significantly more frequent in the tirofiban-only group. The rate of symptomatic haemorrhage was significantly lower in the tirofiban-only group than in the combined group (4.8% vs. 27%, p = 0.046). The patients with tirofiban alone had a significantly better functional outcome at day 90 than the combined group (52% vs. 24%, p = 0.028). Mortality was equal (24%) in both groups. Pre-interventional NIHSS score (p = 0.003), significant blood pressure fluctuations (p = 0.012), tandem occlusion (p = 0.023), and thrombolysis (p = 0.044) showed relevant influence on the rate of symptomatic hemorrhage in the entire patient cohort.ConclusionsA single antiplatelet therapy with tirofiban regardless of the premedication may improve the functional outcome in patients with stroke due to acute extracranial carotid lesion and emergent carotid stenting with lower rates of serious intracranial haemorrhage.For patients with high pre-interventional NIHSS score, tandem occlusion and after pre-interventional thrombolysis, caution is advised. Additionally, strict blood pressure monitoring should be conducted during the first 72 h after intervention.

Balloon‐Expandable Stenting as a Bridging Therapy in Patients With Acute Stroke and Tandem Occlusions

Background Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual‐antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear. Methods We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5‐year period receiving either conventional self‐expanding carotid stents (SX) or balloon‐expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow‐up and symptomatic intracranial hemorrhage. Results A total of 112 patients admitted from April 2016 to April 2021 were included. Dual‐antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) ( P &lt;0.001). Patients in the BX stent group (3/73 [4.1%]) developed a lower rate of symptomatic intracranial hemorrhage compared with patients in the SX stent group (7/39 [17.9%]) ( P =0.031). No differences in extracranial ICA high‐grade restenosis or reocclusion were found between groups at 24 hours after procedure (BX: 20/73 [27.4%]; SX: 9/39 [23.1%]; P =0.673). Conclusions In patients with acute ischemic stroke and tandem occlusions, a bridging therapy including BX stents with less‐aggressive antiplatelet therapy and subsequent definitive SX stenting to treat extracranial ICA lesions resulted in a lower rate of symptomatic hemorrhagic transformation and no differences in stent patency.

Mechanical thrombectomy in patients with heart failure: the Italian registry of Endovascular Treatment in Acute Stroke.

Heart failure (HF) is the second most important cardiac risk factor for stroke after atrial fibrillation (AF). Few data are available on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with HF. The source of data is the multicentre Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). All AIS patients ≥ 18years receiving MT were categorised in two groups: HF and no-HF. Baseline clinical and neuroradiological findings on admission were analysed. Of 8924 patients, 642 (7.2%) had HF. Compared to the no-HF group, HF patients had higher prevalence of cardiovascular risk factors. Rate of complete recanalisation (TICI 2b-3) was 76.9% in HF vs 78.1% in no-HF group (p = 0.481). Rate of symptomatic intracerebral haemorrhage at 24-h non-contrast computed tomography (NCCT) was 7.6% in HF vs 8.3% in no-HF patients (p = 0.520). At 3months, 36.4% of HF patients and 48.2% of no-HF patients (p < 0.001) had mRS 0-2, and mortality was, respectively, 30.7% and 18.5% (p < 0.001). In multivariate logistic regression, HF was independently associated with mortality at 3months (OR 1.53, 1.24-1.88 95% CI, p < 0.001). In multivariate ordinal regression, HF patients had a probability of transitioning to a higher mRS level of 1.23 (1.05-1.44 95% CI, p = 0.012). The propensity score analysis of two groups matched for age, sex, and NIHSS at admission yielded the same results. MT is safe and effective in HF patients with AIS. Patients with HF and AIS suffered from higher 3-month mortality and unfavourable outcome regardless of acute treatments.

Effect of Antiplatelet Therapy in Acute Ischemic Stroke with Tandem Lesions (P7-5.001)

Effect of Antiplatelet Therapy in Acute Ischemic Stroke with Tandem Lesions (P7-5.001)

Safety and Efficacy of MCA‐M2 Thrombectomy in Delayed Time Window: A Propensity Score Analysis From the STAR Registry

Background Mechanical thrombectomy of middle cerebral artery M2 segment occlusion of the middle cerebral artery has reported safety and efficacy in recent post‐hoc and observational studies. However, there is no known benefit of mechanical thrombectomy for patients with M2 segment occlusions in the delayed time window (&gt;6 hours). Methods The Stroke Thrombectomy and Aneurysm Registry (STAR) is a prospective, multicenter, nonrandomized observational study registry for acute ischemic stroke thrombectomy and aneurysm treatment. We analyzed all patients who underwent mechanical thrombectomy within the late time window (&gt;6 hours from symptom onset) involving isolated M2 occlusions. We used propensity score matching to select a comparison group of patients who underwent mechanical thrombectomy for M1 occlusion in the same time window. Results Of 1083 consecutive patients analyzed, propensity matching yielded 180 well matched M1 and M2 pairs. Baseline demographics were well balanced between the groups (M1 and M2). Alberta stroke program early CT score (7.6±1.7 versus 8.3±1.5; P &lt;0.001) was higher in the M2 group. There was a trend towards less complete recanalization (Thrombolysis in Cerebral Infarction 3) 46.1% versus 39.9% ( P =0.053) in the middle cerebral artery M2 segment cohort. However, successful recanalization (Thrombolysis in Cerebral Infarction 2b‐3) was better in middle cerebral artery M2 segment cohort (85% versus 90.5%; P =0.053). Postprocedural asymptomatic hemorrhage rates were similar (29.4% versus 27.8%; P =0.816), but symptomatic hemorrhage rates were higher in the M1 group (7.2% versus 2.2%; P =0.047). Rates of good clinical outcome (modified Rankin scale 0–2) were similar at final follow‐up (43.9% versus 46.7%; P =0.672). The overall mortality was also similar between the cohorts (12.8% versus 13.9%; P =0.877). Conclusion In our analysis of the Stroke Thrombectomy and Aneurysm Registry, M2 occlusions not only achieved similar rates of recanalization and good functional outcome compared with M1 occlusions in a delayed time window (6–24 hours from last normal) but also had less symptomatic intracranial hemorrhage.

Abstract Number ‐ 157: Effect of Antiplatelet Therapy in Acute Ischemic Stroke with Tandem Lesions

Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs. Methods Patient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (EVT) procedure into four groups including; 1) no antiplatelets, 2) single oral antiplatelet, 3) dual antiplatelets, and 4) intravenous antiplatelets (in combination of single or dual antiplatelets). Multivariable logistic regression models with multiple imputations were built to assess the association of primary outcome; symptomatic intracranial hemorrhage (sICH), and secondary outcomes including; modified Rankin Score (mRS) 0–2 at 90 days, and successful reperfusion (mTICI score ≥ 2b). Results A total of 682 patients were included. Of these, 138 (20.2%) did not receive any antiplatelet therapy, while 143 (20.97%) were treated with single oral, 207 (30.35%) with dual oral, and 194 (28.5%) with intravenous combined with single or dual antiplatelets. The rate of favorable outcome was non‐significantly higher in the dual (53%) and IV‐combination (54.4%) antiplatelets, as compared with single (38.9%) and without antiplatelet (38.6%) medications. In the multivariable model, after adjusting, there was no significant differences in the sICH (single: aOR: 1.07, CI: 0.62‐1.84, p = 0.8, dual: aOR: 1.18, CI: 0.70‐1.99, p = 0.55, IV‐combination: aOR: 1.01, CI: 0.57‐1.78, p = 0.98) and functional outcome at 90 days (single: aOR: 1.15, CI: 0.63‐2.12, p = 0.64, dual: aOR: 1.03, CI: 0.55‐1.9, p = 0.9, IV‐combination: aOR: 0.83, CI: 0.42‐1.64, p = 0.59) among the study groups. Interestingly, successful reperfusion (mTICI score ≥ 2b) was significantly higher in dual oral and IV‐combination antiplatelets (single: aOR: 1.14, CI: 0.61‐2.14, p = 0.69, dual: aOR: 4.82, CI: 2.23‐10.42, p = &lt; 0.001, IV‐combination: aOR: 3.65, CI: 1.71‐7.79, p = 0.001). Conclusions Administration of antiplatelet medications during EVT was associated with successful reperfusion without increasing the rate of symptomatic hemorrhage in patients with anterior circulation LVO with TLs. Further large‐scale randomized studies are warranted to validate the optimal antiplatelet regimens during acute carotid artery stenting in patients with TLs.

Comparison of Safety and Efficacy after Emergency Stenting in Patients Exhibiting Intracranial Atherosclerotic Stenosis Associated with Large-vessel Occlusion with and without Intravenous Infusion of Tirofiban

PurposeIntracranial rescue stent angioplasty is a bailout strategy for acute stroke patients in cases of unsuccessful endovascular thrombectomy due to underlying atherosclerotic stenosis. However, there is no consensus on a preprocedural and intraprocedural antiplatelet regimen. The aim of this single-centre study was to compare the safety and efficacy of emergency stenting in patients exhibiting intracranial atherosclerotic stenosis-related acute large-vessel occlusion with or without peri-interventional intravenous infusion of tirofiban.Materials and MethodsWe performed a retrospective analysis of 78 patients who were treated with rescuestent angioplasty between 2010 and 2019 due to acute ischaemic stroke. The patients were divided into 2 groups: those who received peri-interventional intravenous tirofiban and those who did not receive tirofiban. We compared clinical safety and functional outcomes in both treatment groups with symptomatic haemorrhage as the primary endpoint. Bivariate and multivariable logistic regression was performed to investigate the association between tirofiban and outcome measures.ResultsThirty-seven patients were treated with intravenous tirofiban (47.4%), and 41 patients did not receive intravenous tirofiban (52.6%). Statistical analysis revealed no significant difference between the two groups in the rate of symptomatic haemorrhage (16.2% in the tirofiban group versus 14.6% in the control group, p = 0.847). The 3-month mortality (21.6% in the tirofiban group versus 17.1% in the control group, p = 0.611) and good functional outcomes according to the modified Rankin scale (45.9% versus 34.1%, p = 0.289) were comparable.ConclusionThe results of our study suggest that the application of tirofiban for rescue stenting after failed mechanical thrombectomy is safe.

Endovascular Thrombectomy with or without Intravenous Thrombolysis for Anterior Circulation Large Vessel Occlusion in the Imperial College London Thrombectomy Registry.

Background and purpose. Mechanical thrombectomy (MT) is the standard of care for eligible patients with a large vessel occlusion (LVO) acute ischemic stroke. Among patients undergoing MT there has been uncertainty regarding the role of intravenous thrombolysis (IVT) and previous trials have yielded conflicting results regarding clinical outcomes. We aim to investigate clinical, reperfusion outcomes and safety of MT with or without IVT for ischemic stroke due to anterior circulation LVO. Materials and Methods. This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. The primary outcomes were the rate of in-hospital mortality, symptomatic intracranial haemorrhage and functional independence (mRS 0-2 at 90 days). Results. We enrolled a total of 577 consecutive patients: 161 (27.9%) were treated with MT alone while 416 (72.1%) underwent IVT and MT. Patients with MT who were treated with IVT had lower rates of in-hospital mortality (p = 0.037), higher TICI reperfusion grades (p = 0.007), similar rates of symptomatic intracranial haemorrhage (p = 0.317) and a higher percentage of functional independence mRS (0-2) at 90 days (p = 0.022). Bridging IVT with MT compared to MT alone was independently associated with a favorable post-intervention TICI score (>2b) (OR, 1.716; 95% CI, 1.076-2.735, p = 0.023). Conclusions. Our findings suggest that combined treatment with MT and IVT is safe and results in increased reperfusion rates as compared to MT alone.

Abstract WP14: A Patient-level Data Euclidean-matched Analysis Of Reperfusion Therapies In Acute Ischemic Stroke From The Latin American Stroke Registry (lase)

Introduction: As acute stroke therapies expand to less well-resourced regions, it is imperative to study real-world data to assess outcomes and the quality of stroke care. The present study analyzes clinical, and imaging outcomes after acute IV thrombolysis (IV-tPA) compared to mechanical thrombectomy (MT) or combined therapy in the LASE. Methods: A retrospective analysis of consecutive acute ischemic stroke cases in 17 centers from 9 Latin American (LA) countries since 2012 was performed using weighted Euclidean matching of nearest neighbors in 3-D space of baseline NIHSS, age, and glucose. Results: 950 patients receiving only IV-tPA were matched to 127 treated with MT+IV-tPA. Matching resulted in 97 pairs well balanced for age (69.1 vs. 69.3), baseline NIHSS (17 vs. 17), and glucose (124.3 vs. 124.5), all p&gt;0.2. 3-month mRS 0-1 (38.3% vs 29.8%, p=0.23) and mRS 0-2 (46.8% vs 41.5%, p=0.54) were non-significantly higher in the MT+IV-tPA group, with higher hemorrhage (26.6% vs 15.5%, p=0.05) and trends for higher death (15.1% vs 9.5%, p=0.40) and symptomatic hemorrhage (7.4% vs 6.2%, p=1.0). One hundred one patients receiving only MT were matched to 127 patients with MT+IV-tPA, resulting in 61 pairs; MT+IV-tPA showed trends for higher rates of 3-month mRS 0-1 (45.0% vs 35.6%, p=0.31), mRS 0-2 (48.3% vs 42.4%, p=0.54); with trends for lower rates of death (16.9% vs 20.0%, p=1.0) and symptomatic hemorrhage (8.3% vs 11.1%, p=0.75). Conclusions: In this real-world LA sample, trends for better functional outcomes were demonstrated with MT+IV-tPA compared to either treatment alone, as in non-LA populations. A trend for higher adverse events in the combined group requires further investigation.

Abstract 121: Prospective Symptomatic Hemorrhage Rates And Functional Outcomes In Trial Eligible Cavernous Angiomas With Symptomatic Hemorrhage

Background: Cerebral cavernous angiomas with symptomatic hemorrhage (CASH) carry highest rebleed rates and are targeted for novel interventions. A multisite clinical trial readiness project (clinicaltrials.gov NCT03652181) aims to identify clinical and functional changes over time in trial eligible CASH patients. Methods: Adult patients from 5 high volume centers with a CASH in the prior year and no planned surgical intervention were enrolled. In addition to demographic, clinical, and imaging review, patients underwent baseline, 1 year and 2 year NIH-stroke scale (NIHSS), modified Rankin scale (mRS), Euro-QOL 5D-3L (EQ-5D-3L) and EQ VAS (visual analog score), and PROMIS 29 assessments. Recurrent symptomatic hemorrhages (SH) were verified. We assessed the hemorrhage rate, change in scores/scales over time, and determined which scales/scores were most affected in patients with SH. Results: 123 patients completed baseline assessments and were prospectively followed (60.9% female; mean age 44.1 years; 39.1% familial; 41.5% brainstem location). As of reporting date, 89 of 104 (86%) and 58 of 76 (76%) cases have completed assessments. There were 16 SHs during 147 patient-years of follow up (10.9% per patient year). At baseline, 111 (90.2%) of patients had NIHSS 0-2 and 77 (62.6%) patients had mRS baseline 0-1 which improved to 40 (95.2 %) and 43 (75.4%) at 2 years. At baseline, 54 (43.9%) of patients had at least one moderate to severely abnormal PROMIS-29 domain compared to 13 (26.5%) at 2 years. EQ-5D-3L baseline demonstrated a moderate proportion of patients reporting some difficulty with pain (48.8%), anxiety (41.5%), and activity (41.5%) which improved to 28%, 30%, and 34% respectively at 2 years. Patients with a prospective SH were more likely than those without recurrent SH at 2 years to display mild functional decline (0.5 SD) of most PROMIS-29 domains, a mRS of 2 or higher and an abnormal EQ- self-care (P&lt;0.05). Other scales/scores were not significantly different between the groups. Conclusion: We report SH rate and functional outcome at baseline and rates of changes during 2 years in trial eligible CASH patients. The PROMIS-29, mRS, and EQ-self-care domains were most discriminative in patients with recurrent SH. No test was 100% specific.

Neurointerventional Advances in 2022

Neurointerventional Advances in 2022