Single Comprehensive Stroke Center Research Articles

Effect of teleneurology on door-to-needle times for tenecteplase in acute ischemic stroke

IntroductionIntravenous thrombolysis remains the primary treatment for acute ischemic stroke (AIS); however, administration is time sensitive. Teleneurology services have increased in popularity in recent years due to their ability to aid in triaging patients with neurological conditions. Teleneurology services were implemented at this comprehensive stroke center, in August 2023 to aid in streamlining the administration of tenecteplase in AIS patients. Currently, there are no studies assessing whether the implementation of teleneurology services at a comprehensive stroke center influences tenecteplase door-to-needle time. The purpose of this study is to evaluate the difference in door-to-needle times when tenecteplase is administered with versus without a teleneurology consult. MethodsThis was an institutional review board approved, retrospective cohort study conducted at a single comprehensive stroke center. Adult patients who presented to the emergency department between January 1st, 2022 and April 1st, 2023 were included if they received tenecteplase for the treatment of AIS. The primary outcome was door-to-needle time, defined as the moment the patient first enters the door of the emergency department to the moment the IV bolus of fibrinolytic is administered. Secondary outcomes included the proportion of patients with door-to-needle time within 45 min, neurological improvement at 24 h and discharge, and rate of hemorrhagic conversion. ResultsA total of 93 patients were included with 43 patients in the pre-teleneurology group and 50 patients in the post-teleneurology group. Baseline characteristics were comparable between both treatment groups. The median door-to-needle time was significantly reduced in the post-teleneurology group (49 minutes [IQR, 40.0–70.0] preintervention vs. 34.5 minutes [IQR, 23.8–43.0] postintervention, p < 0.01). For secondary outcomes, the post-teleneurology group had more patients with a door-to-needle time within 45 minutes (44.2% vs. 80.0%, p < 0.01). There was no significant difference in early neurological improvement (58.1% vs. 54.0%), neurological improvement at discharge (60.5% vs. 62.0%), or hemorrhagic conversion (7.0% vs. 12.0%). ConclusionAmong patients who received tenecteplase for the treatment of AIS, there was a significant reduction in door-to-needle time with the use of teleneurology services. There was no difference in neurological improvement or rate of hemorrhagic conversion.

ROTEM and von Willebrand Factor in COVID patients presenting with acute ischemic stroke: A case series: ROTEM and von Willebrand Factor in COVID-19 Related Stroke

ObjectivesSARS-CoV-2 (COVID) induces systemic thrombotic complications including acute ischemic stroke. In this case series, we report markers of inflammation, coagulation factors including von Willebrand factor antigen, and rotational thromboelastometry (ROTEM) data. Materials and methodsRetrospective case series of COVID patients seen at a single comprehensive stroke center between 2020–2022. For patients undergoing mechanical thrombectomy (MT), ROTEM data was collected during the procedure and analyzed on ROTEM delta system. ResultsFifteen patients (33.3% female) median age 65-years-old presented with COVID and acute ischemic stroke. Thirteen had LVO. The mean NIHSS was 15 (range 0–35) on admission and 18 (0–42) at discharge. Most were cryptogenic (N=7, 46.7%), followed by cardioembolic (N=6, 40%) and large artery-to-artery embolization (N=2, 13.3%). mRS was < 3 in 8 (53%) patients at discharge. None of the patients were on anticoagulation, and five were on antiplatelet therapy pre-hospitalization. Seven received thrombolytics with alteplase (tPA), and 10 had MT.Baseline platelet count was 102 K/uL (range 102–291 K/uL). vWF was measured in 12 patients, all elevated, with seven having levels >400 (180%). ROTEM data was collected in six patients. Three who received tPA had abnormal EXTEM and FIBTEM data (CT extem > 85secs, A10 EXTEM < 45mm, and A10 FIBTEM < 10mm). Notably, INTEM (CT INTEM >208secs) was abnormal in five of the six patients, two of whom did not receive tPA. ConclusionsElevated vWF antigen levels with abnormal ROTEM data suggests that COVID induces changes in the clotting cascade. More robust research is needed to investigate these findings. Thrombolytics, MT, and antiplatelet agents should be utilized to treat COVID-related ischemic stroke based on current clinical guidelines.

Reliability assessment of distal occlusion eTICI scoring.

The eThrombolysis in Cerebral Infarction (eTICI) score has been validated in proximal large artery occlusion (pLAOs). Despite the growing number of distal medium vessel occlusions (DMVOs) mechanical thrombectomies (MT) and the widespread utilization of the eTICI scoring system, its reliability and standardization for more distal occlusions have not been validated. We aim to evaluate the interrater reliability of eTICI scores in primary DMVOs. This was a retrospective analysis of a prospectively maintained database for consecutive patients with pLAO and DMVO MT at a single comprehensive stroke center from 2015 to 2022. Two fellowship-trained neurointerventionalists blindly/independently assessed digital subtraction angiograms for final eTICI, followed by consensus reads for discrepancies. 59 DMVO of 2248 thrombectomies [M3:29(50%)/M4:1(2%)/A1:3(5%)/A2:12(22%)/A3: 5(9%)/P1:7(12%)/P2:1(2%)] and 124 pLAOs of 308 thrombectomies [i-ICA:13(11%)/MCA-M1: 111(90%)] were included. The distribution of final eTICI scores was comparable between pLAO vs DMVOs (p = 0.82). The pLAO final eTICI score assessment between two readers demonstrated moderate reliability with a kappa0.77 (95%CI: 0.67-0.88), while the DMVO eTICI score assessment exhibited almost-perfect agreement with kappa 0.94 (95%CI: 0.90-0.99). The agreement between the consensus read and the original report in DMVOs was 0.86 (95% CI: 0.71-1.00) while for pLAO it was 0.83(95% CI: 0.76-0.90). The performance of eTICI was comparable amongst different DMVO territories as well as for distal vs. very distal occlusions. eTICI score exhibited comparable performance for DMVO as compared to pLAO strokes. Further studies investigating DMVO eTICI grading and clinical outcomes are warranted.

Outcome in acute ischemic stroke patients with large-vessel occlusion and initial mild deficits

BackgroundThe management of patients with initially mild acute ischemic stroke (AIS), defined by the National Institutes of Health Stroke Scale (NIHSS) scores 0–5, remains ambiguous despite advances in stroke treatment. The early identification of patients likely to deteriorate is critical in preventing lasting disability.AimsWe investigated the frequency and early predictors of poor functional outcomes in AIS patients with large-vessel occlusion (LVO) and initial mild deficits.MethodsWe performed a retrospective observational study of consecutive AIS patients admitted to a single comprehensive stroke center between 2018 and 2021. The inclusion criteria were a diagnosis of AIS, an arrival NIHSS score of 0–5, imaging-confirmed LVO, and arrival within 24 h of the last-known-well time. The primary outcome was the change in the discharge-modified Rankin Score (ΔmRS) from baseline, categorized as 0–1 (stable outcome) or &amp;gt;1 (poor outcome). Early neurological deterioration was defined as a mean NIHSS score increase of &amp;gt;1 in the first 24-h period. Univariate and multivariable regression analyses were performed. The mean daily NIHSS scores were compared between groups using an analysis of variance (ANOVA).ResultsOf 4,410 stroke admissions, 120 patients met the study inclusion criteria, with 71 (59.2%) patients having a ΔmRS of 0–1 and 49 (40.8%) patients having a ΔmRS of &amp;gt; 1. The mean arrival NIHSS score was similar between groups. However, the mean first-24-h NIHSS score was significantly higher in the poor outcome group vs. the stable outcome group (2.13 vs. 0.95, p &amp;lt; 0.001). A demographic-adjusted multivariable logistic regression revealed that a higher mean first-24-h NIHSS score was the sole early predictor of poor outcome (odds ratio [OR] of 1.65 and a 95% confidence interval [CI] of [1.18, 2.48]). The only association with early neurological deterioration was vertebral artery occlusion, with an OR of 0.35 and a 95% CI of [0.14, 0.81]. The trending mean daily NIHSS scores revealed that patients with poor outcomes deteriorate within 24 h, a significant difference from the stable group (p &amp;lt; 0.001).ConclusionPoor outcomes occurred in a significant proportion of LVO patients with initial mild deficits. The only association was early neurological deterioration. To prevent poor outcomes, rapid identification of any clinical deterioration should prompt consideration of thrombectomy.

Role of the Critical Care Resuscitation Unit in a Comprehensive Stroke Center: Operations for Mechanical Thrombectomy During the Pandemic.

Standard of care for patients with acute ischemic stroke from large vessel occlusion (AIS-LVO) includes prompt evaluation for urgent mechanical thrombectomy (MT) at a comprehensive stroke center (CSC). During the start of the coronavirus 2019 pandemic (COVID-19), there were reports about disruption to emergency department (ED) operations and delays in management of patients with AIS-LVO. In this study we investigate the outcome and operations for patients who were transferred from different EDs to an academic CSC's critical care resuscitation unit (CCRU), which specializes in expeditious transfer of time-sensitive disease. This was a pre-post retrospective study using prospectively collected clinical data from our CSC's stroke registry. Adult patients who were transferred from any ED to the CCRU and underwent MT were eligible. We compared time intervals in the pre-pandemic (PP) period between January 2018- February 2020, such as ED in-out and CCRU arrival-angiography, to those during the pandemic (DP) between March 2020-May 31, 2021. We used classification and regression tree (CART) analysis to identify which time intervals, besides clinical factors, were associated with good neurological outcome (90-day modified Rankin scale 0-2). We analyzed 203 patients: 135 (66.5%) in the PP group and 68 (33.5%) in the DP group. Time from ED triage to computed tomography (difference 7 minutes, 95% confidence interval [CI] -12 to -1, P < 0.01) for the DP group was statistically longer, but ED in-out was similar for both groups. Time from CCRU arrival to angiography (difference 9 minutes, 95% CI 4-13, P < 0.01) for the DP group was shorter. Forty-nine percent of the DP group achieved mRS ≤ 2 vs 32% for the PP group (difference -17%, 95% CI -0.32 to -0.03, P < 0.01). The CART identified initial National Institutes of Health Stroke Scale, age, ED in-and-out time, and CCRU arrival-to-angiography time as important predictors of good outcome. Overall, the care process in EDs and at this single CSC for patients requiring MT were not heavily affected by the pandemic, as certain time metrics during the pandemic were statistically shorter than pre-pandemic intervals. Time intervals such as ED in-and-out and CCRU arrival-to-angiography were important factors in achieving good neurologic outcomes. Further study is necessary to confirm our observation and improve operational efficiency in the future.

Does Small Aneurysm Size (

Long-term safety and efficacy outcomes of Surpass Evolve flow diverter (SEFD) in treatment of intracranial aneurysms are lacking. Factors predicting complete aneurysm occlusion are elusive in literature. A retrospective review of all consecutive aneurysms treated with SEFD from February 2020 to July 2022, at a single comprehensive stroke center. Fifty-one patients with 80 aneurysms were included. Mean target aneurysm size was 5.6 mm and mean neck-width 3.42 mm. Small aneurysms (<10 mm) were 75% (n=60), while 25% were >10 mm. Unruptured were 71 (88.7%), previously ruptured were 8 (10%), and partially thrombosed 2.3% (n=1). Mean SEFDs used per patient were 1.07 and 40% (n=22) procedures were performed transradially. Mean procedure time was 59.1 minutes. The technical success rate for device deployment was 100%. Raymond Roy (RR) class I occlusion at 6 month (n=73) was seen among 56.2% (n=41), at 1 year (n=35) among 85.7% (n=30) and at 2 year (n=18) among 88.8% (n=16) aneurysms. Aneurysm size <10 mm significantly predicted RR-I occlusion outcome (odds ratio [OR]: 2.16; confidence interval [CI]: 0.02-4.29) at 6 months. Age, gender, smoking status, hypertension, location of aneurysm, and rupture status did not predict RR-I occlusion outcome. No mortality or permanent neurological morbidity was observed in the cohort. Major complications seen in 7.2% (n=4) patients were stent thrombosis (n=1, 1.8%), carotid-cavernous fistula (n=1, 1.8%) and transient ischemia in 2 (3.6%). Non-flow limiting stenosis was observed in 3 (5.4%) patients. SEFD gives good aneurysm occlusion rates with favorable long-term safety profile and low rate of thromboembolic complications. Small aneurysm size (<10 mm) was associated with complete aneurysm occlusion at 6-month angiographic follow-up. As Surpass Evolve is a newer generation Flow diverter of the Stryker Surpass FDs, with its improved design and applicability in intracranial aneurysms, we believe that more physicians will be encouraged to use this device worldwide.

Postprocedural delirium following mechanical thrombectomy for acute ischemic stroke: a retrospective study

IntroductionNational representative estimates on in-hospital delirium after acute ischemic stroke are not well established and there is limited data on the impact of delirium on clinical outcomes following mechanical thrombectomy. We evaluated risk factors for delirium and the impact on outcomes following mechanical thrombectomy for acute ischemic stroke.MethodsThis is a retrospective study of patients who underwent mechanical thrombectomy for acute ischemic stroke at a single tertiary comprehensive stroke center between April 2011 and December 2019. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit. Patient characteristics, comorbidities, laboratory data, elapsed times, tissue plasminogen activator use, duration of the procedure, type of anesthesia, National Institute of Health stroke scores (NIHSS), sedation scores, reperfusion grades, complications, length of hospital stay, discharge disposition, and 90-day mortality were evaluated.ResultsFive hundred and two patients were evaluated, and post-procedural delirium was identified in 24/467 (5.1%) patients. Thirty-five patients could not be assessed for delirium due to excessive sedation. The incidence of delirium in white vs. non-white patients &amp;lt;65 years was 5/137 (3.6%) compared to 0/91 (0%), and 7/176 (4.0%) compared to 12/63 (19%) in patients ≥65 years, P = 0.006. Bias reduction multi-variable analysis identified low postprocedural hemoglobin level odds ratio of 0.76 (95% CI 0.61–0.92, P = 0.006), greater age (odds ratio 1.04, 95% CI 1.01–1.009, P = 0.024), and non-white race odds ratio of 2.52 (95% CI 1.06–6.38, P = 0.030) as factors associated with delirium [Brier score = 0.045, C-index = 0.800, and Akaike Information Criterion (AIC) = 174]. General anesthesia was not associated with an increased delirium risk. NIHSS at 24 and 48 h and discharge, length of stay, and 90-day mortality were not different between delirium and no-delirium groups. Delirium patients had a reduced odds ratio of 0.13 (05% CI 0.01–1.00, P = 0.02) for home discharge.DiscussionDelirium following mechanical thrombectomy for acute ischemic stroke primarily affected older patients and was associated with reduced odds of home discharge following hospitalization. Changes in NIHSS during hospitalization and 90-day mortality were not adversely affected by the presence of delirium. General anesthesia was not associated with an increased delirium risk following mechanical thrombectomy.

Abstract TP211: TICI Scoring Reliability in Proximal vs Distal Vessel Thrombectomy: A Comparative Analysis

Introduction: The extended Thrombolysis in Cerebral Infarction (eTICI) scale has been demonstrated to correlate strongly with clinical outcomes. Thrombectomy has evolved into the pursuit of not only proximal but distal vessel occlusions, however the reliability of eTICI grading for distal occlusions has not been well studied. We aim to study the interrater agreement of proximal as compared to distal occlusions. Methods: A fellowship trained Neurointerventionalist retrospectively scored the Digital Subtraction Angiography(DSA) images of consecutive patients with only isolated proximal (MCA-M1 or ICA-T) or distal occlusions (MCA-M3, ACA, or PCA) that underwent MT at a single comprehensive stroke center (2022 for proximal occlusions and 2015-2022 for distals). We assessed the agreement between the Neurointerventionalist and original report for the ordinal eTICI scale using Fleiss-Cohen’s Weighted Kappa with quadratic weights. TICI distributions were compared using Wilcoxon’s rank sum test. Results: 187 patients were included in the analysis (124 Proximal and 60 patients distal: 32-M3, 20 -ACA, 8-PCA). The distribution of eTICI 0, 2a, 2b50, 2b67, 2c and 3 were comparable between proximal(MCA-M1 or ICA-T) vs distal occlusions (MCA-M3, ACA, or PCA). The Fleiss-Cohen weighted kappa coefficients were assessed. The proximal eTICI score assessment demonstrated moderate reliability with a kappa value of 0.77 (95%CI: 0.67-0.88)(Table 1A), while the distal eTICI score assessment exhibited almost perfect agreement with kappa value of 0.87 (95%CI: 0.71-1.00)(Table 1B). Conclusion: This study underscores comparable reliability of eTICI scores in assessing reperfusion post MT for distal as compared to proximal occlusions.

Abstract TP10: Artificial Intelligence Algorithm as a Diagnostic Tool for Aneurysms

Viz Aneurysm is an artificial intelligence engine created to detect aneurysms from CT-Angiography (CTA) scans. As with any new technology, it should be measured against the current standard of care. Here, we compared Viz.ai ‘flagging’ of an aneurysm against interpretation reports by faculty radiologists in order to understand accuracy and precision of the technology as a diagnostic tool. In this study, CTA scans were analyzed by Viz Aneurysm from October 2022 to June 2023 at a single Comprehensive Stroke Center. Information regarding each subject was collected through Epic, and the presence of an aneurysm was verified by a radiologist. Although Viz.ai states that the algorithm is limited to detecting aneurysms that are 4 mm in diameter or greater, we have included all aneurysms discovered by radiologists. These ranged in diameter from 0.8 to 22 mm. A total of 963 scans were analyzed, with 70 aneurysms detected total. Approximately 51.10% scans were performed on male patients, and our population ranged in age from 23 to 94 years. The algorithm performed well in flagging scans containing definite aneurysms, with a specificity of 96.78% (95% CI 0.95-0.98) and a negative predictive value of 97.23% (95% CI 0.96-0.98). It was less accurate in excluding scans without aneurysms, showing a sensitivity of 63.64% (95% CI 0.51-0.75) and a positive predictive value of 60.00% (95% CI 0.50-0.69). When aneurysms smaller than 4 mm were excluded, the sensitivity and specificity increased to 81.25% (95% CI 0.64-0.93) and 96.90% (95% CI 0.96-0.98), respectively. The algorithm was successful in identifying all cases (n = 5) of ruptured aneurysms. In several cases (n = 27), radiologists were unable to definitively diagnose an aneurysm, frequently citing the possibility of an infundibulum. It should be noted that there was one case where the algorithm detected an aneurysm, but the patient was diagnosed with a 23-mm pituitary macroadenoma. This suggests that the algorithm may be susceptible to neuroanatomical mimics. We have shown that Viz Aneurysm is a highly specific diagnostic tool that may help medical professionals to identify definite aneurysms. More studies of this nature should be conducted in a variety of populations to confirm these results.

Challenges in adapting a stroke unit in a middle-income country: warning about costs and underfunding to achieve the Brazilian Ministry of Health's benchmark.

Since the implementation of the stroke care line in Brazil, the relationship (adequacy) of costs spent during hospitalization with the Brazilian Ministry of Health indicators for a stroke unit have not yet been analyzed. This study aimed to assess the adequacy of a comprehensive stroke center for key performance indicators and analyze the costs involved in hospitalization. We verified the association between stroke severity at admission and care costs during hospitalization. A retrospective medical chart review of 451 patients was performed using semiautomatic electronic data from a single comprehensive stroke center in Brazil between July 2018 and January 2020. Clinical and resource utilization data were collected, and the mean acute treatment cost per person was calculated. The Kruskal-Wallis test with Dunn's post-test was used to compare the total costs between stroke types and reperfusion therapies. A robust linear regression test was used to verify the association between stroke severity at hospital admission and the total hospitalization costs. Good adequacy rates were observed for several indicators. Data from 451 patients were analyzed. The stroke unit had good adaptation to key performance indicators, but some critical points needed revision and improvement to adapt to the requirements of the Ministry of Health. The average total cost of the patient's stay was the USD 2,637.3, with the daily hospitalization, procedure, operating room, and materials/medication costs equating to USD 2,011.1, USD 220.7, USD 234.1, and USD 98.8, respectively. There was a positive association between the total cost and length of hospital stay (p < 0.001). The stroke unit complied with most of the main performance indicators proposed by the Brazilian Ministry of Health. Underfunding of the costs involved in the hospitalization of patients was verified, and high costs were associated with the length of stay, stroke severity, and mechanical thrombectomy.

Abstract WP22: “Chopperlysis:” Improved Functional Outcomes Associated With Helicopter Transport in Large Vessel Occlusion Stroke Patients Treated With Tenecteplase

Introduction: Tenecteplase (TNK) is increasingly being utilized for IV thrombolysis in acute ischemic stroke, including for patients with large vessel occlusion (LVO) prior to transfer to an endovascular thrombectomy (EVT) capable center (TCC). However, there is limited data regarding factors that influence functional outcome between the time of TNK administration and TCC arrival. The purpose of this analysis is to characterize the effect of the arrival method on the effectiveness of TNK to improve patient outcomes. Methods: A retrospective registry of stroke patients between 2019-2023 at a single comprehensive stroke center was queried. Patients with LVO stroke who had complete data for method of arrival (i.e. ground transportation versus helicopter), TNK treatment, and available 90-day modified Rankin score (mRS) were included. The primary outcome was a favorable 90-day mRS of 0-2. Categorical variables were reported as frequencies, and associations across variables were analyzed using Chi-square test or Fisher's exact test. Odds ratios were calculated with univariate logistic regressions. Results: Of 2675 patients meeting inclusion criteria, 14.4% arrived by helicopter and 85.6% arrived by ground transportation. 174 (6.5%) were treated with TNK, including 5.1% of ground transported patients and 14.1% of air transported patients. Irrespective of EVT, patients arriving by ground did not differ in likelihood of achieving the primary outcome whether they did or did not receive TNK (53.9% TNK vs. 48.4% no TNK, p=0.35). However, patients arriving by helicopter had a significantly higher likelihood of achieving the primary outcome with TNK, regardless of EVT (60% TNK vs. 41.2% no TNK, p=0.04), and in patients transported by helicopter who did not undergo EVT, there was an even higher likelihood of good functional outcome associated with TNK treatment (69.2% TNK vs. 40.1% no TNK, p=0.049). Conclusion: In our cohort, treatment with TNK was associated with improved functional outcomes in helicopter transported patients but not in those transported by ground, and this benefit was found to be even more robust in patients who did not undergo EVT. Future studies are needed to validate these findings and investigate the underlying pathophysiological mechanism.

Abstract TP66: Decreased Order to Administration Times Following Transition to Tenecteplase for Acute Ischemic Stroke

Introduction: Alteplase was the first approved tissue plasminogen activator and standard of care for acute ischemic stroke (AIS). The utilization of Tenecteplase as a thrombolytic agent in AIS has offered many organizations several advantages over Alteplase, including ease of preparation and administration. Both thrombolytic agents require a Physician's order and reconstitution by a certified Pharmacist or Registered Nurse prior to administration. Our academic comprehensive stroke center transitioned from Alteplase to Tenecteplase as standard thrombolysis for acute ischemic stroke in November 2022. Treatment times were monitored to explore the benefits of a single bolus administration. Methods: A retrospective chart review was conducted at a single academic comprehensive stroke center. Patients were included if they received thrombolytic therapy in the Emergency Department for a diagnosis of AIS. Patients prior to November 2022 received Alteplase, and those after November 2022 received Tenecteplase. We evaluated the time frame for the medication bolus order for Alteplase and Tenecteplase to the administration time. Results: Of 140 patients screened, 108 were included in the study, with 51 in the alteplase group and 57 in the Tenecteplase group. Mean order to administration times were 10.9 minutes in the alteplase group and 7.37 minutes in the Tenecteplase group, with statistical significance (P=0.0052). There was no significant difference in mean door-to-needle time (59.27 Alteplase vs 53.09 Tenecteplase, P= 0.1803). Conclusions: In a single CSC, the transition from Alteplase to Tenecteplase reduced the order to administration time by 3.53 minutes. The decreased administration time highlights one of Tenecteplase’s potential advantages. Further review is necessary to evaluate additional stroke metrics and clinical outcomes.

Abstract WP153: Factors Affecting Length of ICU Stay After Endovascular Thrombectomy for Acute Large Vessel Ischemic Stroke

Introduction: The advent of endovascular thrombectomy (EVT) for acute large vessel occlusion (LVO) ischemic stroke has reduced the overall ICU length of stay (LoS), especially for patients undergoing successful reperfusion. Prolonged ICU LoS is reported to be associated with worse clinical outcomes, but factors associated with prolonged LoS after MT are not established. Methods: A retrospective analysis of 499 patients undergoing EVT at a single large comprehensive stroke center from January 2015 to May 2020 was performed. Demographics, procedure variables, ICU LoS, ICU complications, and modified Rankin scale at discharge were collected. Multiple regression was used to identify independent variables affecting the ICU LoS. Additional analysis using t-test assuming unequal variances was performed for select variables. Results: The median age was 72 [61-82], 254 (51%) male &amp; median NIHSS was 16 [10-20]. The average door-to-puncture time was 104 ±28 mins and the average procedure time 43.9 ±28.7. General anesthesia (GA) was administered in 257 (51%) patients. Successful reperfusion (TICI 2c-3) was achieved in 334 (67%) patients. Median ICU LoS was 3 days [1-5]. Patients with mRS 0-2 at discharge (33%) had shorter ICU LoS (2.8 vs 5.7, P&lt;0.001). ASPECTS &lt; 7 (6.9 vs 4.6, P=0.03), use of GA (6.2 vs 3.3 days, P&lt;0.001) and ICU complications such as pulmonary embolism (PE) and pneumonia (10 vs 4 days; p &lt;0.001) significantly increased the ICU LoS. Successful reperfusion significantly reduced ICU LoS (4.2 vs 5.8 days, p=0.015). After adjusting for age, sex, baseline NIHSS and ASPECTS, both the procedure time (b= 0.03, P=0.02) and final TICI score (b= -0.76, P=0.001) were independently associated with prolonged ICU LoS (R2=0.1, F=4, P&lt;0.001). Conclusion: Pre-procedural factors such as poor ASPECTS (&lt; 7), procedural factors such as the use of GA, prolonged procedure time, and TICI 0-2b reperfusion, and ICU complications such as pneumonia and PE are associated with prolonged ICU LoS.

Radially adjustable stent retriever for mechanical thrombectomy in acute ischemic stroke: Improved first-pass effect with rapid-inflation deflation technique.

Evidence for improved first-pass effect with the novel radially adjustable radio-opaque stent retriever Tigertriever is lacking. To compare improvement in first pass success with Tigertriever using two different techniques-rapid inflation deflation (RID) and suction thrombectomy (ST). Retrospective analysis of patients with acute ischemic stroke who underwent mechanical thrombectomy with Tigertriever at a single comprehensive stroke center. Thirty patients were included. Mean age was 72.8 years. Twelve patients (48%) experienced successful first passes with Tigertriever. Successful revascularization (modified thrombolysis in cerebral infarction (mTICI) 2b/3) was achieved in all (100%) patients who received RID or ST technique for thrombectomy. Good clinical outcome (modified Rankin score = 0-2) was noted in 40% (n = 10). Total mortality in the cohort was 8% (n = 2). RID and ST groups comprised of 10 and 15 patients, respectively. Five patients underwent MT with Tigertriever as a rescue device. No difference was noted in mean age (p = 0.27), gender (p = 0.29), location of occlusion (p = 0.46), and device used for first pass (p = 0.57). A 70% first-pass success rate in RID group and 37.5% in ST group was noticed (p = 0.06). Mean time from groin puncture to reperfusion (TICI 2b//3) was statistically similar (p = 0.29, RID: 19.9 min vs ST: 25 min). Both groups noted a 100% complete recanalization rate. The rate of mortality between the two groups were not statistically different (p = 0.46). The preliminary first-pass success rates of RID technique with Tigertriever compared to ST technique, are encouraging. Longitudinal studies with longer follow up are needed to elucidate the smaller learning curve with this device.

Abstract 211: Comparing Early and Late Window 3mm Trevo Stent Retriever Performance in Medium Vessel Occlusion Thrombectomy

Introduction Endovascular thrombectomy has been shown to be beneficial for select patients with medium vessel occlusion ischemic strokes. Newer mechanical thrombectomy devices have designs to facilitate navigation of the medium and distal cerebrovasculature. In this single‐center study, we aim to compare the performance of 3mm Trevo NXT stent retrievers (Stryker, Kalamazoo, MI) for medium vessel occlusion mechanical thrombectomy for patients treated within either the early (&lt;6 hour) or late (&gt;6 hour) treatment window. Methods A retrospective review was conducted of acute ischemic stroke patients with medium vessel occlusions (i.e., M2‐M4, ACA, and PCA) who underwent thrombectomy over 5 years (2018‐2022) at a single comprehensive stroke center. Classification into early or late window was defined as time from last known well to groin puncture less than 6 hours or greater than 6 hours, respectively. Primary efficacy outcome included successful recanalization (modified thrombolysis in cerebral infarction [mTICI]&gt;=2B) using 3mm Trevo NXT on either first pass or rescue pass (i.e., after initial pass failure with another device). Primary safety outcome is rate of complications associated with the stent retriever. Primary clinical outcome was National Institutes of Health Stroke Scale (NIHSS) shift between admission and discharge. Results Of 81 patients with medium vessel occlusion ischemic strokes, 38 patients (44.7% female, median age of 73.5 years [IQR 66‐82], median initial NIHSS 13 [IQR 8‐23]) underwent thrombectomy with 3mm Trevo NXT. Stent retriever‐assisted aspiration (versus stent retriever only) was performed in 31/38 (81.6%) patients. Successful recanalization with stent retriever was achieved in 28/38 (73.7%) of patients. There was no significant difference in rate of recanalization between early and late window thrombectomy (16/22 [72.7%] early window vs. 12/16 [75%] late window, p=0.8752). The lack of significant difference in recanalization rate was consistent with stent retriever use during first pass (11/14 [78.6%] early window vs. 9/10 [90%] late window, p=0.6146) and as rescue (5/8 [62.5%] early window vs. 3/6 [50%] late window, p=0.6400). There was no significant difference in the rate of stent retriever complications between early and late windows (1/16 [6.3%] early vs. 0/22 [0%] late, p=0.4211). There was no significant difference in median NIHSS shift from admission to discharge ( ‐6 [IQR ‐16 ‐ 9] early window vs. ‐3 [IQR ‐5 ‐ 4] late window, p=0.3666). Conclusion In both early and late window medium vessel occlusion thrombectomy, the 3mm Trevo NXT as first line and rescue intervention performs comparably and adequately. Future multicenter studies will further characterize novel stent retriever performance in medium vessel occlusion thrombectomies.

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

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

Sex differences in acute ischemic stroke presentation are a matter of infarct location

IntroductionRecognition of stroke by Emergency Medical Services (EMS) is critical to initiate rapid emergency department treatment. Most prehospital stroke screening tools rely heavily on presentation with the classic symptoms of facial droop, speech changes, unilateral weakness. However, women may be less likely to present with classic symptoms and may also have different distributions of stroke by anatomical location. This study seeks to determine the association between biological sex, presentation with classic symptoms, and the location of the infarcted tissue. MethodsThis is a retrospective cohort study. Data from electronic health records were extracted for patients with acute ischemic stroke who presented via EMS to a single Comprehensive Stroke Center between January 1, 2018 and December 31, 2020. We used descriptive statistics characterize the cohort. Multivariable logistic regression identified factors associated with classic symptom presentation (facial droop, speech changes, and/or unilateral weakness). Biological sex, location of the infarct, stroke etiology, age and the interaction between sex and infarct location were assessed as covariates. ResultsThere were 364 (58.6%) males and 257 (41.1%) females with an acute ischemic stroke included in this study. EMS documented one or more classic symptoms in 125 (72.3%) males and 161 (67.9%) females. There were no baseline differences in infarct location or presentation with classic symptoms as documented by EMS comparing males and females. Multivariate logistic regression found no association between biological sex and presentation with classic symptoms (Odds Ratio 1.08; 95% CI 0.58 to 1.55) after controlling for age, stroke location, etiology of stroke or the interaction between sex and infarct location. Presence of an anterior circulation infarct compared to posterior circulation infarct was positively associated with a classic presentation to EMS (Odds Ratio 3.41; 95% CI 2.15 to 5.41). ConclusionsThis study found no difference in the frequency of patient presentation with classic stroke symptoms based on biological sex alone, nor a significant different in distribution of infarcts between males and females. Infarct location (i.e., involving the anterior circulation) was associated with a classic presentation. This suggests that the likelihood of presenting with classic stroke symptoms is not influenced by sex, but rather the location of the infarct.

Comparative analysis of stenting for carotid web and atherosclerotic disease.

Carotid Web (CaW) is an increasingly recognized etiology of ischemic stroke, and has been shown to be amenable to endovascular stenting. The technical complexity of stenting for CaW may be lower than for carotid atherosclerotic disease (CAD). We aimed to assess procedural characteristics of stenting for CaW as compared to CAD. We retrospectively analyzed a cohort of consecutive patients at a single comprehensive stroke center from 2014 to 2021, who had undergone elective endovascular stent placement for symptomatic CAD or CaW. In total, 118 patients underwent elective stent placement following ischemic stroke/transient ischemic attack; 88 patients had CAD and 30 patients had CaW. CAD patients were older (63.2 vs 51.2 years, p < 0.001), less likely to be female (28.4% vs 73.3%, p < 0.001), and more likely to have pre-existing vascular risk factors. Procedure time (73.0 vs 57.5 min, p = 0.007), radiation exposure (1482 vs 1125 milliGray, p = 0.03), filter time (24 vs 14 min, p = 0.04), and use of pre-stent (68.2% vs 0%, p < 0.001) and post-stent (34.1% vs 3.3%, p < 0.001) balloon angioplasty were higher in CAD cases. There was no significant difference between groups in the rate of periprocedural complications such as hypotension, use of vasopressors, or bradycardia. Recurrent stroke/TIA was reported in five CAD patients and 0 CaW patients by the end of the follow-up period (8.3% vs 0%, p = 0.12). In-stent restenosis was detected in seven CAD patients and 0 CaW patients (10.1% vs 0%, p = 0.09) at a median follow-up of 4 vs 16 months (p = 0.01), respectively. Periprocedural intracranial hemorrhage was not observed in either group. Stenting for CaW was found to be technically simpler than CAD and not to confer increased risk of baroreceptor dysregulation. Intimal hyperplasia was uncommon in CaW cases.

Impact of Insurance on Acute Stroke Care Cost: A mediation analysis (P1-5.022)

<h3>Objective:</h3> We hypothesized that LOS mediates the association between insurance status and hospital costs for acute stroke patients. <h3>Background:</h3> Length of stay (LOS) is a key quality indicator for stroke hospitalization, impacting costs, resource allocation, and transitions of care. Insurance status often affects stroke LOS through delayed authorization for rehabilitation services. <h3>Design/Methods:</h3> We queried data from a single comprehensive stroke center for all hospital admissions of adults (≥ 18 years) with any stroke (ICD10 I60–I69) from 2017 to 2021. We performed a mediation analysis using linear regression models to understand how much LOS carries the effect of various insurance plans on total acute stroke care cost using Medicare as the referent with age and race/ethnicity as covariates. We calculated non-parametric mediation metrics and bias-corrected-accelerated 95% confidence intervals from 10,000 bootstraps (p &lt;0.05). <h3>Results:</h3> The cohort included 3,604 hospitalized stroke patients: 52.16% men, median (IQR) age 68 (57 – 77) years. Median (IQR) LOS was 3 (1 – 7) days with a median (IQR) total admission cost of $67,426.10 ($37,610 – $132,077). Per patient estimated hospital costs compared to Medicare were lower for Medicaid (−$7,538.14; 95%CI [−$18,303, $3,226.72]; p 0.17) and self-pay (−$22,026.75; 95%CI [− $37,628.14, −$6,425.36]; p &lt;0.01), but higher for commercial plans ($11,139.60; 95%CI [$2,878.89, $19,400.30]; p &lt;0.01). LOS mediated 100% of the effect of Medicaid on hospital costs (p &lt; 0.01), but did not mediate costs for self-pay (p = 0.95) and commercial insurance (p = 0.32). <h3>Conclusions:</h3> In this single center analysis, length of stay fully mediated the effect of Medicaid on acute stroke hospital costs. Hospitals could possibly reduce stroke costs by improving Medicaid authorization and processing times. Further research is warranted to understand higher costs with commercial carriers compared to Medicare. <b>Disclosure:</b> Chad Aldridge has nothing to disclose. Mr. Victoria has nothing to disclose. Dr. Gusler has nothing to disclose. Miss Batton has received personal compensation for serving as an employee of University of Virginia. Dr. De Havenon has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Integra. Dr. De Havenon has stock in Certus. The institution of Dr. De Havenon has received research support from NIH/NINDS. The institution of Dr. De Havenon has received research support from Regeneron Pharmaceuticals. The institution of Dr. De Havenon has received research support from AMAG Pharmaceuticals. The institution of Dr. De Havenon has received research support from AMGEN. Dr. De Havenon has received publishing royalties from a publication relating to health care. Dr. Southerland has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Plaintiffs and Defense Cases related to Stroke and Vascular Neurology.. The institution of Dr. Southerland has received research support from Diffusion Pharmaceuticals. The institution of Dr. Southerland has received research support from American Heart Association. The institution of Dr. Southerland has received research support from National Science Foundation. The institution of Dr. Southerland has received research support from NIH. The institution of Dr. Southerland has received research support from Abbvie Pharmaceuticals, Inc.. Dr. Southerland has received intellectual property interests from a discovery or technology relating to health care. Dr. Southerland has received intellectual property interests from a discovery or technology relating to health care.

An Experience of a Single Comprehensive Stroke Center after Implementation of Routine Tenecteplase Administration for Acute Ischemic Stroke Treatment. (P7-5.023)

<h3>Objective:</h3> The objectives of this study were to determine if there is a significant difference between Alteplase and Tenecteplase in improvement of NIHSS, door to needle time (DTNT), disability at discharge determined by modified Rankin scale (mRS), and rate of intracranial hemorrhage (ICH). <h3>Background:</h3> There is growing interest in using Tenecteplase for acute ischemic stroke (AIS) treatment. Currently there is no clear consensus on its indication and dosage. We transitioned to Tenecteplase administration for AIS treatment in March 2021, at a dosage of 0.25 mg/kg. <h3>Design/Methods:</h3> A retrospective comparison analysis on the outcomes of AIS patients who were treated with Alteplase between April 2020 – March 2021 or Tenecteplase between April 2021 – March 2022. <h3>Results:</h3> Of 216 patients, 45.8% (n = 99) were given Alteplase and 54.1% (n = 117) were given Tenecteplase. There was no significant difference in baseline characteristics except hyperlipidemia, substance use, and history of smoking. No mean difference in mRS was measured at admission or discharge between Alteplase (1.42+/− 1.77) and Tenecteplase (1.32 +/− 1.56, p-value 0.703) and delta NIHSS between Alteplase and Tenecteplase (p-value 0.926). There was no difference in DTNT between both groups (p-value 0.172). Successful recanalization ratio was not significantly different. Symptomatic ICH was of no significant difference between the two groups: occurring in 5.05% patients receiving Alteplase and 5.13% patients receiving Tenecteplase (p-value 0.682). Rate of mortality was 13.13% (n = 13) in Alteplase and 11.11% (n = 13) in Tenecteplase, also of no significant difference (p-value 0.683). <h3>Conclusions:</h3> The results suggest that Tenecteplase has a similar efficacy and safety profile to Alteplase in real world practice. These findings are similar to results of previous randomized trials. At the dose of 0.25 mg/kg, Tenecteplase appears to be a reasonable alternative to Alteplase for use with acute ischemic strokes within 4.5 hours of onset. <b>Disclosure:</b> Dr. Cawley has nothing to disclose. Dr. Simon has nothing to disclose. Dr. Radomski has nothing to disclose. Dr. Kuns has nothing to disclose. Dr. Bejleri has nothing to disclose. Dr. Seol has nothing to disclose. Dr. Razak has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Janssen Pharmaceuticals.