Symptomatic ICH Research Articles

Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in Early and Late Time Windows.

This study aimed to compare outcomes of low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) patients with stroke who underwent mechanical thrombectomy (MT) within 6 hours or 6 to 24 hours after stroke onset. A retrospective cohort study was conducted using data from a large multicenter international registry from 2013 to 2023. Patients with low ASPECTS (2-5) who underwent MT for anterior circulation intracranial large vessel occlusion were included. A propensity matching analysis was conducted for patients presented in the early (<6 hours) vs late (6-24 hours) time window after symptom onset or last known normal. Among the 10 229 patients who underwent MT, 274 met the inclusion criteria. 122 (44.5%) patients were treated in the late window. Early window patients were older (median age, 74 years [IQR, 63-80] vs 66.5 years [IQR, 54-77]; P < .001), had lower proportion of female patients (40.1% vs 54.1%; P = .029), higher median admission National Institutes of Health Stroke Scale score (20 [IQR, 16-24] vs 19 [IQR, 14-22]; P = .004), and a higher prevalence of atrial fibrillation (46.1% vs 27.3; P = .002). Propensity matching yielded a well-matched cohort of 84 patients in each group. Comparing the matched cohorts showed there was no significant difference in acceptable outcomes at 90 days between the 2 groups (odds ratio = 0.90 [95% CI = 0.47-1.71]; P = .70). However, the rate of symptomatic ICH was significantly higher in the early window group compared with the late window group (odds ratio = 2.44 [95% CI = 1.06-6.02]; P = .04). Among patients with anterior circulation large vessel occlusion and low ASPECTS, MT seems to provide a similar benefit to functional outcome for patients presenting <6 hours or 6 to 24 hours after onset.

Endovascular treatment for proximal middle cerebral artery occlusion due to underlying intracranial atherosclerotic disease: A retrospective single-center case series

ObjectiveTo compare treatment outcomes between patients who received a front-line stent-retriever thrombectomy (SRT) or first stenting without retrieval (FRESH) for treating proximal M1 occlusion due to underlying intracranial atherosclerotic disease (ICAD). MethodsWe retrospectively reviewed consecutive acute ischemic stroke (AIS) patients with intracranial large vessel occlusion (LVO) in the anterior circulation who underwent endovascular treatment (EVT) between January 2017 and August 2021 at Yeungnam University Medical Center. LVO in the anterior circulation was classified according to etiology as follows: Embolic group and ICAD group. Occlusion of the proximal M1 due to ICAD were enrolled in this study. The ICAD group was divided into SRT and FRESH groups according to the treatment method. ResultsAmong the 72 patients in the ICAD group, 55 patients had occlusion of the M1, and 27 had occlusion of the proximal M1 (27/55, 49.1 %). Among the 27 patients, 11 (40.7 %) underwent SRT and 16 (59.3 %) underwent FRESH. The puncture-to-recanalization time was significantly shorter in the FRESH group (28 min vs. 52 min, p = 0.023). Symptomatic ICH tended to occur more frequently in the SRT group than in the FRESH group (27.3 % vs. 0.0 %, p=0.056). There was a nonsignificant trend towards a good functional outcome in the FRESH group compared to the SRT group (81.3 % vs. 45.5 %, p=0.097). ConclusionIn the FRESH group, the puncture-to-recanalization time was significantly shorter, symptomatic ICH tended to occur less frequently, and good functional outcomes were more common.

IV Thrombolysis for Acute Ischemic Stroke with Unknown Onset in Patients on Oral Anticoagulation

Introduction: IV thrombolysis (IVT) is established in the unknown or extended time window based on multimodal imaging. Further, increasing evidence exists regarding IVT in patients on oral anticoagulation including direct oral anticoagulants (DOACs). However, data on IVT in ischemic stroke patients on oral anticoagulation with unknown time of stroke onset are sparse. Methods: This study bases on the longitudinal cohort study Stroke Research Consortium in Northern Bavaria (STAMINA; ClinicalTrials.gov Identifier: NCT04357899). Acute ischemic stroke patients treated with IVT in the unknown or extended time window from January 2015 to December 2019 were included. Patient selection was based on multimodal CT or MRI. Patients on oral anticoagulation (vitamin-K antagonist [VKA] or DOAC within 48 h) were eligible for IVT based on INR measurement (VKA) or plasma levels (DOAC) according to an institutional protocol. Primary outcomes were the incidence of any and symptomatic intracranial hemorrhage. Results: Of 170 ischemic stroke patients treated with IVT in the unknown or extended time window, 151 had no oral anticoagulation at stroke onset and 19 were on oral anticoagulation (6 on VKA and 13 on DOAC). The risk of symptomatic ICH according to ECASS II criteria was similar between the patients with and without oral anticoagulation (1 [5.3%] vs. 4 [2.7%], p = 0.453). After adjustment for confounding factors, pre-medication with oral anticoagulation was not associated with symptomatic ICH (aOR 1.02 [0.09–11.02], p = 0.988). Conclusion: IVT for ischemic stroke with unknown onset appeared safe in selected patients on oral anticoagulation with both DOAC and VKA.

Safety and Efficacy of Mechanical Thrombectomy in Stroke Patients beyond 6 Hours

Abstract Background Stroke is one of the primary causes of death in Egypt. With advances in the stroke imaging and medical care we could extend the window of mechanical thrombectomy beyond 6 hours according to many studies. Objective To evaluate the safety and efficacy of endovascular treatment (EVT) of acute large vessel occlusion beyond 6 hours from the onset of the stroke. Patients and Methods A retrospective cohort study was conducted that include records for all patients diagnosed with acute ischemic stroke and treated after 6 hours of symptoms onset at Ain shams university hospitals from January 2019 to December 2021 (at least 20 cases) to evaluate the safety and efficacy of endovascular treatment of acute large vessel occlusion beyond 6 hours from the onset of the stroke. Results Twenty cases are included in our study with a mean age of 53.7±17, 65% were female, and the median NIHSS score at presentation was 13. Successful recanalization (mTICI 2b to 3) was obtained in 85% of patients and symptomatic ICH rate was 50% mostly in patients who didn’t undergo MRI prior to MT. overall 30% of the patients had good outcome (mRS ≤ 2) at 90 days post thrombectomy. Conclusion Mechanical thrombectomy beyond 6 hours is safe and effective with good selection of patients according to MRI and CT perfusion.

Intravenous thrombolysis in patients with recent intake of direct oral anticoagulants: A target trial analysis after the liberalization of institutional guidelines.

This study aimed to report the safety and efficacy of off-label intravenous thrombolysis (IVT) with alteplase after sequentially liberalizing our institutional guidelines allowing IVT for patients under direct oral anticoagulants (DOACs) regardless of plasma levels, time of last intake, and without prior anticoagulation reversal therapy. We utilized the target-trial methodology to emulate hypothetical criteria of a randomized controlled trial in our prospective stroke registry. Consecutive DOAC patients (06/2021-11/2023) otherwise qualifying for IVT were included. Safety and efficacy outcomes (symptomatic intracranial hemorrhage [ICH], any radiological ICH, major bleeding, 90-day mortality, 90-day good functional outcome [mRS 0-2 or return to baseline]) were assessed using inverse-probability-weighted regression-adjustment comparing patients with versus without IVT. Ninety eight patients fulfilled the target-trial criteria. IVT was given in 49/98 (50%) patients at a median of 178 (interquartile range 134-285) min after symptom onset with median DOAC plasma level of 77 ng/ml (15 patients had plasma levels > 100 ng/ml; 25/49 [51%] were treated within 12 h after last DOAC ingestion). Endovascular therapy was more frequent in patients without IVT (73% vs 33%). Symptomatic ICH occurred in 0/49 patients receiving IVT and 2/49 patients without IVT (adjusted difference -2.5%; 95% CI -5.9 to 0.8). The rates of any radiological ICH were comparable. Patients receiving IVT were more likely to have good functional outcomes. After liberalizing our approach for IVT regardless of recent DOAC intake, we did not experience any safety concerns. The association of IVT with better functional outcomes warrants prospective randomized controlled trials.

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Objective: Evaluate the characteristics of cerebral microbleeds and factors related to hemorrhagic transformation in patients with acute cerebral infarction undergoing revascularization treatment at University Medical Center, Ho Chi Minh City. Subjects and methods: Cross-sectional descriptive study combined with medical record monitoring on 79 patients diagnosed with acute cerebral infarction who were admitted and treated at the Department of Neurology, University Medical Center, Ho Chi Minh City. Results: Patients with microhemorrhage (VXH) accounted for 37.97%. The number of 1-4 VXH accounted for the highest rate of 31.65%, only 01 case had more than 10 VXH, accounting for 1.27% %. The location of social lesions is mainly in the deep brain area, accounting for 21.52%. There is an association between VXH and dyslipidemia with p = 0.16 (OR 4.12, CL 1.14-18.47), white matter pathology according to Fazekas classification with p = 0.041. The main complications of hemorrhagic transformation after revascularization are HI, accounting for 26.58%, followed by PH, accounting for 6.33%, and ICH+, accounting for 3.8%. There is an association between Glasgow scale (OR = 1.66, CI 0.79 - 3.51) with symptomatic ICH and PH with p &lt; 0.05. Found an association between NIHSS Scale and ICH with p = 0.037 (OR = 5.46 CI 1.10 – 19.00). There is not enough evidence to conclude about the relationship between the number and location of microbleeds and complications of hemorrhagic transformation after revascularization. Conclusion: VXH is not a factor to delay recanalization interventions in acute myocardial infarction patients with indications for intervention. Patients at high risk of multiple VHs should have an MRI scan before intervention.

315 A Propensity Score-matched Comparative Study of Balloon Guide Catheters Versus Conventional Guide Catheters for Mechanical Thrombectomy With Stenting in Tandem Strokes: Comparison of 1st-pass Effect, Symptomatic ICH, and 90-day Functional Outcomes

INTRODUCTION: Extensive clot burden in tandem strokes accounts for poor mechanical thrombectomy (MT) outcomes. Several studies have shown benefit of balloon guide catheters (BGC) in MT and carotid artery stenting. METHODS: Tandem stroke patients identified from our endovascular database were dichotomized into groups treated with BGCs versus conventional guide catheters. One-to-one PSM adjustment for baseline demographics and treatment selection bias using nearest-neighbor matching was performed. Patient demographics, presentation characteristics, and procedural details were recorded. Outcomes assessed were final modified thrombolysis in cerebral infarction (mTICI) grade, periprocedural symptomatic intracranial hemorrhage (sICH) rate, in-hospital mortality, and 90-day modified Rankin Scale (mRS) score. Mann-Whitney U-test and multivariate logistic regression were performed to compare procedural parameters and clinical outcomes. RESULTS: Concurrent carotid revascularization (stenting with/without angioplasty) and MT was performed in 125 cases (BGC: 85; no BGC: 40). After PSM (40 patients/group), BGC group had a significantly shorter procedure duration (77.9 vs. 61.5 min; odds ratio [OR] = 0.996; p = 0.006), lower discharge National Institutes of Health Stroke Scale score (8.0 vs. 11.0; OR = 0.987; p = 0.042), and higher odds of 90-day mRS 0-2 score (52.3% vs. 27.5%; OR = 0.34; p = 0.040). On multivariate regression, BGC group had a significantly higher first-pass effect rate (mTICI: 2B-3) (OR = 1.115, 95% confidence interval [CI] = 1.015-1.432; p = 0.013) and lower periprocedural sICH rate (OR = 0.615; 95% CI = 0.406-0.932; p = 0.025). No difference in in-hospital mortality was observed (OR = 1.591; 95% CI = 0.976-2.593; p = 0.067). CONCLUSIONS: BGCs used for concurrent MT–carotid revascularization with flow arrest were safe and resulted in superior clinical and angiographic outcomes in tandem stroke patients.

Assessment of the safety and efficacy of the Zoom 45 and 55 reperfusion catheters for medium and distal mechanical thrombectomies: A multi-institutional study

IntroductionThe Zoom aspiration catheters harbor novel dimensions and construction to enhance trackability and deliverability. In addition, a beveled tip may improve thrombus interaction and aspiration force for a set inner diameter. This study evaluates their utility in medium and distal vessel occlusions. ObjectiveTo evaluate the safety and efficacy of Zoom 45 and 55 aspiration catheters in medium and distal vessel thrombectomy. MethodsPatients treated for distal vessel occlusions via mechanical thrombectomy utilizing either the Zoom 45/55 catheter or a historical control catheter between 2021–2022 at two institutions were included in this study. Medium and distal occlusions were defined as any anterior or posterior cerebral artery branch as well as the M2-4 segment of the middle cerebral artery (MCA). Preprocedural, procedural, and postprocedural variables were obtained. ResultsThirty-eight patients underwent thrombectomy with Zoom 45 or 55 catheters; four had multiple occluded vessels. Occlusion location included the M2 in 32 cases, M3-4 in 7 cases, A2 in 2 cases and P2 in 1 case. The mean number of passes per occlusion was 1.6 and overall successful reperfusion (TICI 2b or greater) was achieved in 84 % of cases. There were no symptomatic procedure-related complications such as perforation or post-procedural symptomatic ICH. Modified Rankin scores rates of 0–2, 3–5, and 6 at three months post-procedure were 35.7 %, 21.4 %, and 42.9 %, respectively. ConclusionsThe Zoom beveled tip aspiration catheters are safe and effective for more challenging medium and distal vessel occlusions.

RapidpulseTM cyclic aspiration system for acute ischemic stroke due to large vessel occlusions.

The best strategy to achieve optimal reperfusion outcomes during mechanical thrombectomy remains to be defined. The RapidPulseTM Cyclic Aspiration System is a novel technology, delivering high-frequency pulsed vacuum forces to increase the efficiency of aspiration thrombectomy. Prospective, multicenter, open-label, core lab-adjudicated, two-arm study comparing safety and efficacy of a feasibility version of the RapidPulseTM system compared with contemporary controls. Primary endpoint was the rate of mTICI ≥ 2c after first-pass effect (FPE). Additional efficacy endpoints were the rates of mTICI 2b after first pass (modified FPE (mFPE)), last pass with study device defined as frontline technical success, and after all passes including rescue therapy. The primary safety endpoints included symptomatic ICH (sICH) within 24 h post-procedure. Between February 2022 to December 2022, 80 subjects were consented and enrolled in the study (n = 40 treatment arm, n = 40 control arm). In the intent to treat (ITT) population, mean age was 67.8 ± 11.5 years; 19 (47.5%) were male. Median NIHSS score was 16 (IQR: 13-22). Median ASPECTS score was 9 (IQR: 8-10). The rate of mTICI ≥ 2c after first pass was 53.9% in ITT population (60.0% in per-protocol population) versus 38.5% in the corresponding control population. Functional independence (mRS 0-2) at 90 days was achieved in 61.1% (22/36) in the RapidPulseTM arm and 52.8% (19/36) in the control arm. In the RapidPulseTM arm, no sICH within 24 h and no device-related morbidity or mortality occurred. Preliminary data suggests RapidPulseTM Aspiration System is highly effective and safe for recanalization of large vessel occlusions.

Asymptomatic Intracerebral Hemorrhage Following Endovascular Stroke Therapy Is Not Benign: A Systematic Review and Meta-Analysis.

Asymptomatic intracerebral hemorrhage (aICH) occurs in approximately 35% of patients with acute ischemic stroke after endovascular thrombectomy. Unlike symptomatic ICH, studies evaluating the effect of aICH on outcomes have been inconclusive. We performed a systematic review and meta-analysis to evaluate the long-term effects of postendovascular thrombectomy aICH. The meta-analysis protocol was submitted to the International Prospective Register of Systematic Reviews a priori. PubMed, Scopus, and Web of Science were searched from inception through September 2023, yielding 312 studies. Two authors independently reviewed all abstracts. Included studies contained adult patients with ischemic stroke undergoing endovascular thrombectomy with follow-up imaging assessment of ICH reporting comparative outcomes according to aICH versus no ICH. After screening, 60 papers were fully reviewed, and 10 studies fulfilled inclusion criteria (n=5723 patients total, 1932 with aICH). Meta-analysis was performed using Cochrane RevMan v5.4. Effects were estimated by a random-effects model to estimate summary odds ratio (OR) of the effect of aICH versus no ICH on primary outcomes of 90-day modified Rankin Scale 3 to 6 and mortality. The presence of aICH was associated with a higher odds of 90-day mRS 3 to 6 (OR, 2.17 [95% CI, 1.81-2.60], P<0.0001, I2 46% Q 19.15) and mortality (OR, 1.72 [95% CI, 1.17-2.53], P:0.005, I2 79% Q 27.59) compared with no ICH. This difference was maintained following subgroup analysis according to hemorrhage classification and recanalization status. The presence of aICH is associated with worse 90-day functional outcomes and higher mortality. Further studies to evaluate the factors predicting aICH and treatments aimed at reducing its occurrence are warranted.

Abstract WP208: Infarction Size Affects Clinical Outcomes in Emergent Carotid Artery Stenting With Mechanical Thrombectomy

Background: Management of large vessel occlusion with extensive ipsilateral internal carotid artery (ICA) occlusion is unknown. We evaluated patients who underwent emergent carotid artery stenting (CAS) of the ICA with mechanical thrombectomy (MT). Methods: We retrospectively collected baseline demographic, clinical, and radiographic data on 27 patients who presented as a stroke alert within 24 hours of symptoms and had extensive (from bifurcation to distal ICA) occlusion by computerized tomography angiography from 2019-2023 at our institution. All patients underwent CAS with MT and received dual antiplatelet therapy. We measured outcomes by: (1) development of symptomatic ICH at 24 hours, (2) mortality, (3) Modified Rankin Scale (mRS) at 90 days, and (4) change in NIHSS at 24 hours. Baseline characteristics were reported by descriptive statistics. Statistical analyses were completed using Fisher’s exact test, Wilcoxon rank sum test, and logistic regression. Differences were statistically significant at p &lt; 0.05. Results: The mean age for our cohort was 64.5 ± 10.62 and nine patients were females (33.3%). Sixteen had M1 (59.3%) while 10 had M2 occlusion (37%), 14 patients received IV tPA (51.9%), and mean NIHSS at presentation was 15.6 ± 5.99. All patients achieved TICI 2b or TICI 3 recanalization. In our cohort, patients with lower ASPECT score 7.4 ± 1.8 compared to those with higher ASPECT score 9.0 ± 1.0 were more likely to have symptomatic ICH ( p = 0.032), and higher odds of mortality OR = 0.496, 95% CI (0.261-0.945). The development of symptomatic ICH at 24 hours following procedure was associated with severe disability (mRS 4-6) at 90 days ( p = 0.032). Administration of intravenous tPA was significantly associated with improvement of 4 or more points on NIHSS at 24 hours ( p = 0.032), but not with symptomatic ICH ( p = 0.419). Age, NIHSS at presentation, systolic blood pressure, and diabetes mellitus were not associated with mortality or symptomatic ICH. Conclusion: The area of infarction at the time of presentation (ASPECT score) is an essential factor in stratifying patient selection for emergent CAS during MT in extensive internal carotid artery occlusion. Further studies are needed to evaluate infarction size for safe interventions.

Abstract TP196: Ischemic Stroke With Large Vessel Occlusion and Systemic Acidosis: Associations With Functional Outcomes and Mortality

Introduction: Systemic acidosis is common in critical conditions, including severe myocardial infarction, renal and liver injuries, and traumatic brain injury. However, the potential connection between ischemic stroke involving large vessel occlusion (LVO) and acidosis has not been extensively explored. With this study we aimed to assess the prevalence of respiratory and metabolic acidosis in ischemic stroke with LVO and their potential links to functional outcomes and mortality. Methods: Retrospective single center cohort of patients with ischemic stroke and LVO status post endovascular thrombectomy. Univariate logistic regression was used to examine the relationship between acidosis on admission and (1) hospital mortality and (2) 90-day modified Rankin Scale (mRS) dichotomized as unfavorable (&gt;3) vs favorable (≤3). In addition, we investigated association with acidosis and symptomatic ICH. Metabolic acidosis was defined by the presence of one of the following: Serum bicarbonate &lt;22 mEq/L, lactic acid &gt;2 mmol/L or pH &lt;7.35. Respiratory acidosis was defined by pCO2 &gt;45 mmHg. Results: There was a total of 346 patients, average age was 68.5 (±15) years, 169 (49%) were females. 168 (49%) patients were acidotic on admission, 4 (1%) had respiratory acidosis, 7 (2%) had mixed acidosis and the remaining 157 (45%) had metabolic acidosis. There was no statistically significant association between systemic acidosis with either hospital mortality (p=0.31]) or 90-day favorable functional outcome (p=0.23]). There was no association between acidosis with symptomatic ICH (p=0.47). Conclusion: In our retrospective cohort study, we observed that approximately half of the patients with stroke and LVO had systemic acidosis. Unlike other critical neurological conditions like traumatic brain injury, we did not identify a substantial correlation between systemic acidosis and either mortality or the functional outcome at the 90-day mark. Given the high prevalence of acidosis in patients with LVO, larger multi-center studies are needed to further investigate its association with the outcomes and mortality.

Abstract WP179: Clinical Outcomes in Acute Stroke in Patients Undergoing Emergency Intracranial Stenting Receiving IV Thrombolysis

Background: Stent-retriever thrombectomy is the first-line therapy for acute stroke with intracranial large vessel occlusion. In cases of stent-retriever thrombectomy failure, rescue stent angioplasty might be the sole option for achieving permanent recanalization. This study aims to evaluate the safety of combined intracranial vessel stent placement and thrombolysis. Methods: We conducted a retrospective analysis of patients with large vessel occlusion who underwent rescue stent angioplasty after stent-retriever thrombectomy between 2012 and 2023 in 8 neurovascular centers. We defined two binary outcomes: (1) functional clinical outcome (modified Rankin Scale 0-2) and (2) early symptomatic intracerebral hemorrhage (sICH). Clinical outcomes were assessed using uni- and multivariable logistic regression models. Results: A total of 216 patients were included, with target vessels located within the anterior circulation (133; 63.4%) and posterior circulation (79; 36.6%). Among patients who underwent emergency intracranial stenting, 66 (30.6%) received intravenous thrombolytic treatment. In multivariate logistic regression analysis, adjusted for age, gender, baseline NIHSS, target vessel, time to recanalization, number of passes including, and type of antiplatelet therapy, intravenous thrombolytic therapy was not associated with symptomatic ICH (odds ratio (OR) 1.05, 95% confidence interval (CI) 0.27-4.14, p=0.9502), but it was associated with a functional clinical outcome at 90 days (OR 3.39, 95% CI 1.11-10.43, p=0.0325). Conclusions: The use of rescue stent angioplasty can be considered after unsuccessful stent-retriever thrombectomy, along with intravenous thrombolytic therapy. Patients receiving intravenous thrombolytic therapy before the procedure exhibited higher rates of good functional outcomes.

Abstract TMP85: Endovascular Thrombectomy for Large Ischemic Strokes With Tandem Lesions: A SELECT2 Subanalysis

Introduction: Trials evaluating thrombectomy (EVT) efficacy and safety in large vessel occlusion (LVO) excluded patients with cervical tandem lesions (TL). We aimed to evaluate EVT efficacy and safety in large stroke patients with TL from the SELECT2 trial. Methods: SELECT2 was a randomized controlled trial evaluating EVT vs. medical management (MM) in patients with LVO ischemic strokes (ASPECTS 3-5 on computed tomography (CT) or ischemic core ≥50 ml on CT Perfusion/MR diffusion-perfusion). TL were defined as internal carotid artery occlusion with a concomitant LVO as determined by the core lab. Functional, safety, and imaging outcomes were compared between patients in EVT vs. MM. Results: Of 352 enrolled, 100 (28%) had tandem occlusions, with 56 receiving EVT. ASPECTS (EVT: 4 [3-5] vs. MM: 4 [4-5]), ischemic core estimates (EVT: 86 [58-133] ml vs. MM: 81 [61-121] ml) and critically hypoperfused tissue volume (EVT: 185 [131-266] ml vs. MM: 192 [142-252] ml) were similar between groups. TL Patients receiving EVT demonstrated significantly better functional outcomes (mRS at 90d: EVT 4[3-6] vs MM 5[4-6]; aGenOR: 2.22; 95%CI, 1.47-3.34; p&lt;0.001), similar to those without TL (aGenOR: 1.59, 95% CI: 1.23-2.05, p&lt;0.001; P-int-0.29) and a higher proportion of patients achieving functional independence (EVT: 20% vs. MM: 2%; aRR: 9.53; 95%CI, 1.71-53.21; p=0.010) and independent ambulation (EVT: 38% vs MM: 11%; aRR: 3.60; 95%CI, 1.68-7.67; p=0.001), with significantly reduced complete dependence or death (mRS 5-6) (aRR: 0.66 (0.48-0.90), p=0.009). There was no difference in symptomatic ICH (EVT: 2% vs MM: 0%) or parenchymal hemorrhage (EVT: 2% vs MM: 0%). Complications occurred in 10 (18%) patients receiving EVT. In the EVT group, successful reperfusion (mTICI 2b-3) was associated with better functional outcome (aGenOR: 2.30; 95%CI, 1.14-4.65; p=0.021). Conclusion: In patients with tandem lesions, EVT and successful reperfusion were associated with better functional outcomes. Frequency of vascular complications was similar to those without tandem lesions and no patients receiving immediate stenting demonstrated parenchymal hemorrhage. Our findings support consideration of EVT in patients with tandem lesions with large ischemic strokes. NCT03876457

Abstract TP183: Endovascular Thrombectomy in Patients With Pre-Existing Disability Presenting With Large Vessel Occlusion Stroke

Introduction: Despite representing a substantial proportion of patients who present with large vessel occlusion (LVO) acute ischemic stroke (AIS), patients with baseline disability are often excluded from endovascular thrombectomy (EVT) clinical trials. We present our institutional experience with EVT in this patient population. Methods: Prospectively maintained database from our comprehensive stroke center was retrospectively reviewed for consecutive cases from December 2014 to July 2023. Patients who underwent EVT were included. Two groups of patients were created; patients without existing disability (modified Rankin Score [mRS] 0-1) and those with existing disability (mRS≥2). Demographics and comorbidities were compared. Difference in 90 day mRS and baseline mRS (delta mRS) was calculated as primary outcome measure. Wilcoxon rank test and generalized linear regression were used for analysis. Results: Total of 1441 patients were identified, 347 patients (24.1%) had pre-existing disability.This group had higher average age (82 vs 68, p&lt;0.01), a higher proportion of female patients (66.57% vs 41.13%, p&lt;0.001), and elevated rates of comorbidities such as atrial fibrillation, diabetes, and hypertension. Additionally, they presented with a slightly higher median NIHSS of 18 (vs 15, p&lt;0.001).There was no difference in the rate of successful reperfusion (TICI 2b-3:90.49% vs 87.53%, p=0.16), or symptomatic ICH (1.44% vs 1.83%, p=0.75) between the two groups. Higher rate of delta mRS=0 (return to baseline) was observed in patients with pre-existing disability (17.58% vs 8.98%, p&lt;0.001). Similarly, delta mRS ≤ 1 was higher in this group (33.43% vs 22.36%, p&lt;0.001). In multivariable analysis, after adjusting for initial stroke severity and ASPECTS, patients with pre-existing disabilities had higher rate of return to baseline functional status and similar rate of ICH. Pre-existing deficit predicted an increase in delta mRS ≤ 1 (β=1.04, p&lt;0.001). Conclusion: EVT appears to be safe and effective in patients with baseline disability, often returning patients to their pre-morbid functional status by 90 days follow up. Although further studies are needed, it is reasonable to offer EVT for patients with baseline disability presenting with LVO stroke.

Abstract WP25: Eptifibatide in Acute Ischemic Strokes Without Large Vessel Occlusions

Background: Platelet glycoprotein IIb/IIIa inhibitors are currently being researched for patients with acute ischemic stroke (AIS), however there is no consensus on which inhibitor or dose is both safe and effective. Tirofiban has recently been studied, however it was associated with an increased risk of intracranial bleeding. In this study we share our experience using eptifibatide given it has shown to be as effective as tirofiban with a better safety profile. Methods: In this multi-center retrospective analysis, we screened 102 patients who received an eptifibatide bolus of 135 mcg/kg followed by 0.5 mcg/kg/min infusion and 332 patients treated with usual stroke care between December 2022 and May 2023. Patients were excluded if the NIHSS on presentation but within 24 hours of last known well was less than 3 or if the patient had a large vessel occlusion (LVO). There were 7 and 31 patients included in the eptifibatide and usual care group respectively. Our primary endpoint was change in NIHSS from admission to discharge. Our safety endpoints were symptomatic ICH and any ICH. Results: No patients included in the study experienced a symptomatic ICH. The median time of eptifibatide infusion was 24 hours with some patients receiving the infusion for multiple days. Conclusion: While larger studies are needed to confirm our findings, eptifibatide may be safe and effective in the treatment of AIS without LVO.

Abstract TP216: Sex-Based Differences in Endovascular Thrombectomy Outcomes for Large Ischemic Stroke: A SELECT2 Subanalysis

Introduction: Multiple randomized controlled trials demonstrated better functional outcomes with endovascular therapy (EVT). Potential heterogeneity in EVT treatment effect by sex is an important question as several social and biological factors are shown to differentially affect stroke outcomes between men and women. We aimed to evaluate if clinical outcomes and thrombectomy treatment effect differed by sex among patients with large ischemic stroke. Methods: In the SELECT2 RCT, baseline characteristics and outcomes were compared between men and women. The primary outcome was a shift in modified Rankin Scale score, with functional independence (mRS 0-2), independent ambulation (mRS 0-3) and symptomatic ICH as secondary outcomes. Effect modification was examined using multiplicative sex-by-treatment interaction term. Additionally, repeated measure mixed effect models were used to evaluate if recovery in functional status differed by sex at discharge/ 5 to7-day, 30-day, and 90-day follow-up. Results: Of 352 enrolled patients, 71/145 (49%) of women and 109/207 (53%) of men underwent EVT. EVT was uniformly associated with better functional outcomes without evidence of treatment effect modification [Men - aGenOR: 1.66(1.24-2.23) vs women - aGenOR: 1.73(1.22-2.45), p-int: 0.94], functional independence [men - aRR: 1.99(0.99-4.02) vs women - aRR: 5.04(1.59-16.02), p-int: 0.20] and independent ambulation [men - aRR: 1.98(1.29-3.03) vs women - aRR: 2.44(1.40-4.24), p-int: 0.67]. There were no significant differences between the two cohorts’ recovery at discharge/5 to 7-day, 30-day, and 90-day follow-up (figure). Conclusions: EVT was associated with higher rates of functional independence and independent ambulation in both men and women, without significant heterogeneity in treatment effect or recovery arc between discharge and 90-day follow-up. Trial Registration: NCT03876457

Abstract WMP30: Real World Experience With Tenecteplase on a Mobile Stroke Unit

Background: Tenecteplase (TNK) administered on a mobile stroke unit (MSU) has demonstrated superior rates of early reperfusion compared to alteplase. Current guidelines include TNK as a second-tier option for large vessel occlusions as TNK has many benefits, including rapid IV administration and ease of dosing. The objective of this study was to describe real world utilization of TNK on a MSU. Methods: This was a retrospective observational study of patients receiving TNK as compared to alteplase between February 2021 and April 2023 at a large academic comprehensive stroke center. Baseline demographics, GCS, NIHSS, as well as time of initial imaging were collected. Primary endpoint was time from MSU door to thrombolytic administration. Secondary endpoints included: MSU door to imaging interpretation, dispatch to thrombolytic administration, and provider decision time to thrombolytic administration. Safety endpoints included symptomatic ICH within 24 hours. Results: During the studied time period 40 patients received alteplase and 32 patients received TNK on the MSU. The median age was 65.7 years and median NIHSS score was 9. There was no difference in time from MSU door to thrombolytic administration (15 vs 17.5, p=0.30). There was also no difference in time from MSU door to imaging interpretation, dispatch to thrombolytic administration, or provider decision time to thrombolytic administration. No hemorrhagic conversion occurred. Conclusion: This is the largest series to date describing real-world utilization of TNK administration in a MSU. There were no significant differences in time to therapy in any of the time points evaluated. This data is promising for the treatment of ischemic stroke in which time to administration of thrombolytic therapy is paramount and TNK is administered as a rapid IV injection as compared to alteplase infusion.

Abstract WP183: Intracranial Atherosclerotic Disease in Acute Basilar Artery Occlusion

Background: Intracranial Atherosclerotic Disease (ICAD) large vessel occlusion (LVO) is responsible for up to 30% of anterior circulation LVOs and is less amenable to mechanical thrombectomy. In this study we aim to determine the prevalence of ICAD acute basilar occlusion and the likelihood of favorable functional outcomes (mRS 0-3) compared to embolic basilar occlusion. Methods: This is an analysis of PC-SEARCH Thrombectomy Registry in which consecutive patients with acute basilar artery occlusions from 8 high-volume comprehensive stroke centers were included from January 2015 to December 2021. Patients were dichotomized into two cohorts: with or without underlying ICAD. Descriptive statistics for each group and multivariate logistic analysis was performed on the primary outcome. Results: Three-hundred-ninety-nine patients were included in this analysis. There were 143 (36%) and 256 (64%) patients with and without ICAD; respectively. Baseline demographics were equivalent between the two groups except for gender (male 67% vs 47%; p &lt; 0.001), history of stroke (24% vs 14%; p = 0.01), and atrial fibrillation (18% vs 30%; p = 0.01). Presenting NIHSS was similar between groups (15 vs 16; p = 0.85), however, pc-ASPECTS was higher in the ICAD group (9 vs 8; p = 0.02). At 90 days, patients with ICAD were less likely to achieve favorable functional outcomes (OR 0.33 95% CI 0.18 - 0.59; p &lt; 0.001) after adjusting for potential confounding factors. Additionally, ICAD patients were less likely to achieve TICI ≥2b (38% vs 49%; p &lt; 0.001). There were equivalent rates of symptomatic ICH between groups (OR 0.8 95% CI 0.29 - 2.22; p = 0.66). Conclusion: Acute basilar artery occlusions with underlying ICAD have higher likelihood of morbidity and mortality. Lower rates of successful recanalization in the ICAD cohort support this finding; however, rates of sICH were similar between the two cohorts.

Safety and efficacy of endovascular thrombectomy for primary and secondary MeVO

BackgroundMedium-vessel occlusions (MeVO) are emerging as a new target for endovascular treatment (EVT). Primary MeVO occur de novo, while secondary MeVO arise from large vessel occlusion (LVO) through clot migration or fragmentation - spontaneously, following intravenous thrombolysis or EVT. We aimed to evaluate efficacy and safety of EVT in primary and EVT-induced secondary MeVO. MethodsRetrospective single-center study on consecutive EVT-treated acute ischemic stroke, from 2019-to-2021. We considered: (1) exclusive-LVO, patients with LVO and – in case of residual distal occlusion – no rescue endovascular procedure; (2) primary MeVO: initial A2, A3, M2 non-dominant, M3, P2, P3 occlusions; (3) EVT-induced secondary MeVO, presenting LVO with subsequent (treated) EVT-induced MeVO. We compared (univariable/multivariable logistic regression) EVT efficacy (eTICI≥2b, 3-month modified Rankin Scale [mRS] 0-2) and safety (EVT-complications [vessel dissection, perforation, persistent-SAH], symptomatic ICH) in all MeVO versus exclusive-LVO, primary MeVO versus exclusive-LVO, EVT-induced secondary MeVO versus exclusive-LVO and EVT-induced secondary MeVO versus primary MeVO. ResultsWe included 335 patients: 221 (66.0 %) exclusive-LVO and 114 (34.0 %) MeVO (55 [48.2 %] primary, 59 [51.8 %] secondary). Compared to exclusive-LVO, primary MeVO had higher rates of EVT complications (aOR 3.77 [95%CI 1.58-9.00],p=0.003), lower rates of eTICI≥2b (aOR 0.32 [95%CI 0.12-0.88],p=0.027) and mRS 0-2 (aOR 0.28 [95%CI 0.13-0.63],p=0.002). EVT-induced secondary MeVO had no major differences in efficacy and safety outcomes compared to exclusive-LVO, but a better mRS 0-2 (aOR 8.00 [95%CI 2.12-30.17],p=0.002) compared to primary MeVO. ConclusionsPrimary and EVT-induced secondary MeVO showed different safety/efficacy EVT-related profiles. Dedicated randomized data are needed to identify the best acute reperfusion strategy in the two categories.