Thrombectomy For Acute Ischemic Stroke Research Articles

PREDICTORS OF OUTCOMES IN ELDERLY ACUTE STROKE PATIENTS UNDERGOING ENDOVASCULAR THROMBECTOMY

Introduction: The aging population is one of the main reasons for the increase in stroke cases.The aim of this study was to evaluate the predictors of 3-month outcomes in patients aged ≥65 years who underwent mechanical thrombectomy for acute ischemic stroke and compare patients aged 65–79 years with those aged ≥80 years in terms of demographic characteristics, workflow, functional outcomes, and complication rates. Materials and Method: This retrospective cohort study included 169 consecutive patients aged ≥65 years who underwent mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion between April 2020 and May 2023. Results: Recanalization was successful for 148 (87.57%) patients.According to multivariable logistic regression analysis results, low (≤9) Alberta Stroke Program Early Computed Tomography score (odds ratio: 4.217, 95% confidence interval: 1.209–14.715, and p=0.024), high National Institutes of Health Stroke Scale score at 24th hour (odds ratio: 1.192, 95% confidence interval: 1.087–1.306, and p<0.001), high Acute Physiology and Chronic Health Evaluation score (odds ratio: 1.127, 95% confidence interval: 1.016–1.250, and p=0.023), and intubation need (odds ratio: 15.055, 95% confidence interval: 2.087–108.612, and p=0.007) were independent predictors of poor outcome. Conclusion: The lack of significant differences in workflow, functional outcomes, and complications among patients ˃80 years of age indicates that MT is effective in this age group. Considering the aging population, identifying the predictors of 3-month outcomes after mechanical thrombectomy will help predict outcomes, better identify elderly patients who may benefit from the procedure, and guide treatment decisions. Keywords: Aged; Ischemic Stroke; Endovascular Procedures; Thrombectomy.

Technique for Recanalization of Sheath Introducer Occlusion due to Captured Thrombus during Mechanical Thrombectomy for Acute Ischemic Stroke: A Technical Note.

Mechanical thrombectomy (MT) is the gold standard treatment for acute ischemic stroke. During these interventions, a thrombus frequently obstructs a guiding catheter. The obstructed guiding catheter should be withdrawn before distal embolism occurs; however, albeit infrequently, the thrombus occludes even a sheath introducer (SI). While conventionally new SI placement is required for continuation of treatment, we propose a viable alternative for recanalization of the occluded SI, termed vacuum-assisted delivery of thrombus (VADT), with a clinical report of our cases. The usefulness of this technique was also evaluated in simulation experiments. The VADT procedure is as follows: 1) insert a peel-away sheath, originally attached to a balloon-guiding catheter (BGC), into the SI to continuously open the hemostatic valve; 2) advance the BGC into the peel-away sheath while applying mechanical aspiration; and 3) remove the peel-away sheath/BGC assembly slowly. In a simulation environment using an artificial thrombus, we repeated the VADT procedure five times and reproducibly achieved SI reopening within only 10-20 seconds. From March 2013 to September 2022, 204 patients were treated with MT at our stroke center and SI occlusion occurred in three patients (1.5%). These events occurred exclusively in patients with extracranial internal carotid artery occlusion. All three patients with SI occlusion underwent successfully thrombus extraction in the SI using the VADT on the first try. The results of clinical experience and simulation experiments strongly support VADT as a reliable option for recanalization of an occluded SI.

Safety and efficacy of mechanical thrombectomy for acute ischemic stroke with volume over 50 mL and significant perfusion mismatch.

This study aims to address the safety and efficacy of mechanical thrombectomy (MT) in acute ischemic stroke with an established infarction equal to or >50 mL with a significant difference between penumbra and established infarction detected by perfusion cerebral computed tomography (CT) with the Rapid® system. This was a retrospective case-control study. Patients diagnosed with established and extensive ischemic stroke, defined by an ischemic volume equal to or >50 mL on CT or magnetic resonance imaging perfusion using the RAPID® system, were examined. The intervention group received endovascular interventional treatment with or without recombinant tissue plasminogen activator (rt-PA) in addition to standard therapy, and the control group received conservative treatment with or without rt-PA plus standard therapy. A total of 59 patients were enrolled, including 38 in the intervention group and 21 in the control group. Baseline characteristics were similar between groups. Patient National Institutes of Health Stroke Scale at discharge was significantly different between the control (median 30, interquartile range [IQR] 13) and intervention group (median 8, IQR 14) (P < 0.001). Modified Rankin scale (mRS) scores were significantly different at discharge between intervention (median mRS 2, IQR 3) and controls (median mRS 5, IQR 1) (P = 0.002). These mRS differences remained significant at 90 days, with median (IQR) values of 2 (2.75) and 5 (1), respectively (P < 0.001). MT is safe and effective for large-core ischemic strokes with significant perfusion mismatch, leading to better functional outcomes without significant complications compared to the best medical treatment.

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.

Hemorrhagic Complications of Mechanical Thrombectomy for Acute Ischemic Stroke: A Single-Center Study of Related Factors

Hemorrhagic Complications of Mechanical Thrombectomy for Acute Ischemic Stroke: A Single-Center Study of Related Factors

Making Neuroendovascular Therapy for Cerebrovascular Disease Using Distal/Trans-radial Artery Access Safer.

Neuroendovascular therapy using distal/trans-radial artery access (d/TRA) has attracted attention as a less invasive procedure. We have selected dTRA or TRA in all cases of carotid artery stenting (CAS). In recent years, TRA has been actively selected for mechanical thrombectomy for acute ischaemic stroke (MT for AIS) and Onyx embolisation for arteriovenous malformations. We compared the patient background, surgical strategy, perioperative complications, and outcome in 41 patients who underwent CAS in the first period (Apr 2017-Feb 2019) and 12 patients in the second period (Apr 2020-Feb 2022) avoiding trans-femoral artery access (TFA) as possible. We compared the patient background, surgical strategy, perioperative complications, and outcome in 46 patients who underwent MT for AIS via TFA from Apr 2022 to Dec 2022 as the first period and five patients who underwent MT for AIS via TRA from Jan 2023 to Sep 2023 as the second period. Concerning CAS, the second period included significantly more symptomatic cases, with a higher rate of edaravone use to prevent hyperperfusion and a significantly smaller sheath diameter. In the second period, CAS was performed in severe conditions; nevertheless, there was no significant difference between the two groups in terms of either the ratio of cases detected by postoperative diffusion-weighted imaging positive or the ratio of cases with puncture site-related complications (PSCs). Concerning MT for AIS, there were no significant differences between the two groups with the patient backgrounds. The percentage of effective reperfusion, time from puncture to recanalisation, and outcome in the second period were all non-inferior to those in the first period when conventional MT for AIS was performed. Even though we introduced d/TRA in patients with cognitive decline and inability to remain at rest during the perioperative period, we completely avoided PSCs via d/TRA. In particular, cerebral hyperperfusion syndrome after CAS and ischaemia-reperfusion injury or re-occlusion after MT were rare but critical perioperative complications, and near-infrared spectroscopy (NIRS) may be used to monitor these problems. We introduced intensive evaluation by NIRS if we had time to spare.

Quality of Life After Endovascular Thrombectomy for Acute Ischemic Stroke in Northern Finland

Quality of Life After Endovascular Thrombectomy for Acute Ischemic Stroke in Northern Finland

Could emergency admission plasma D-dimer level predict first pass effect of stent retriever thrombectomy in acute ischemic stroke?

Evidence on plasma biomarkers to identify first pass effect (FPE) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) treated with thrombectomy is limited. To evaluate whether plasma D-dimer could predict FPE. Consecutive patients with LVO who underwent first-line stent retriever thrombectomy at our center between January 2018 and August 2021 were enrolled. Patients were classified into the FPE (modified Thrombolysis in Cerebral Infarction [mTICI] ≥2c) group or non-FPE (mTICI 0-2b) group based on angiographic outcomes. Logistic regression analysis was performed to determine the predictors of FPE. The overall ability of D-dimer levels in predicting FPE was evaluated using receiver operating characteristic (ROC) curves. In total, 313 patients were included; 88 (28.1%) patients achieved FPE. Compared to those with non-FPE, patients with FPE had more diabetes mellitus history, lower D-dimer levels, higher clot burden score, a higher proportion of M1 middle cerebral artery, and a higher proportion of main stem occlusion pattern (P <0.05). After adjusting for potential variables, D-dimer levels (OR=0.81, 95% CI=0.52-0.96), clot burden score (OR=1.76, 95% CI=1.38-2.87), and main stem occlusion pattern (OR=1.85, 95% CI=1.19-2.62) remained independently associated with FPE. Based on the ROC analysis, the D-dimer as a predictor for predicting FPE presented with a specificity of 79%, a negative predictive value of 87%, and an area under the curve of 0.761. Low emergency admission plasma D-dimer level is an independent predictor of FPE in patients with AIS treated with stent retriever thrombectomy.

Atrial Fibrillation and Clinical Outcomes of Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-Analysis of Adjusted Effect Estimates.

The impact of atrial fibrillation (AF) on the clinical outcomes in patients with acute ischemic stroke (AIS) who received endovascular thrombectomy remains unclear. We aimed to perform a meta-analysis of adjusted effect estimates to examine the association between the presence of AF and the clinical outcomes in patients with AIS who received endovascular thrombectomy. We searched PubMed, Embase, and the Cochrane database between January 1, 2013 and July 10, 2023. Data were meta-analyzed to compare the outcomes among patients with AIS with and without AF who received endovascular thrombectomy. Our primary outcome was 90-day functional independence defined as a modified Rankin Scale score of 0 to 2. Secondary outcomes included excellent independence (90-day modified Rankin Scale score of 0-1), 90-day mortality, symptomatic intracranial hemorrhage, and any intracranial hemorrhage. Eighteen observational studies comprising 16 096 patients with AIS (mean age, 70.1 years; women, 48.2%; 6862 with AF versus 9234 without AF) were included. There were no statistically significant differences for modified Rankin Scale score of 0 to 2 (pooled odds ratio [OR], 1.14 [95% CI, 0.95-1.37]; [95% prediction interval [PI], 0.72-1.80]), mortality (OR, 0.92 [95% CI, 0.79-1.08]; [95% PI, 0.77-1.11]), symptomatic intracranial hemorrhage (OR, 0.97 [95% CI, 0.71-1.32]; [95% PI, 0.43-2.17]), and any intracranial hemorrhage (OR, 1.08 [95% CI, 0.91-1.28]; [95% PI, 0.74-1.58]) among patients with AIS with and without AF. This meta-analysis detected no significant differences in 90-day functional outcomes, mortality, and intracerebral hemorrhage risk after endovascular thrombectomy in patients with AIS with and without AF. URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD 42021293511.

Symptomatic intracranial hemorrhage mediates the association between eosinophils and 90-day outcomes after mechanical thrombectomy for acute ischemic stroke

BackgroundDecreased eosinophil level is associated with poor outcomes after mechanical thrombectomy in patients with acute ischemic stroke (AIS), but the underlying mechanism of this association is elusive. We aimed to assess the mediation effect of symptomatic intracranial hemorrhage (sICH) on the aforementioned association.MethodsA total of 328 consecutive AIS patients undergoing mechanical thrombectomy between May 2017 and March 2021 were analyzed. SICH was defined as any evidence of brain hemorrhage on CT scan with neurological deterioration. Regression analysis was used to assess the effect of eosinophils on sICH, and its effect on poor outcome. Mediation analysis was performed to assess the proportion of total effect by sICH on the association between eosinophils and poor outcome.ResultsMultivariate analysis revealed an independent association between eosinophil count and sICH after adjusting for potential confounders (odds ratio, 0.00; 95% CI, 0.00–0.01; P = 0.0141), which is consistent with the result of eosinophil count (dichotomous) as a categorical variable (odds ratio, 0.22; 95% CI, 0.11–0.46; P < 0.0001). Eosinophil count was negatively associated with poor outcome (odds ratio, 0.00; 95% CI, 0.00–0.02; P = 0.0021). Mediation analysis revealed that sICH partially mediated the negative relationship between eosinophil count and poor outcome (indirect effect=-0.1896; 95%CI: -0.3654 – -0.03, P < 0.001).ConclusionThis study showed an important effect of sICH on the association between eosinophils and poor outcome.

Adhesion of vessel wall to stentriever during combined technique for mechanical thrombectomy in acute ischemic stroke: A histomorphological study.

Detection of vessel wall tissue in thrombus material in patients with ischemic stroke is judged as vascular injury. So far, several studies investigated components of the free clots after mechanical thrombectomy. The aim of this retrospective study was to investigate the involvement and role of the stentriever in vessel wall injury by analysis of the composition of adherent tissue to the stentriever during combined aspiration thrombectomy with stentriever. Stentriever with adherent tissue and free clots in aspiration samples from patients undergoing mechanical thrombectomy (aspiration plus stentriever) were separately assessed for the occurrence of parts of vascular tissue together with clinical and interventional data as well as clinical outcome data. Specimens were analyzed histomorphologically and immunohistochemically. Findings, focused on parts of vessel wall were reported together with clinical data. Specimens from 21 identified patients were available. Parts of the vessel wall were detected in 7 out 21 (33%) samples. All specimens revealed fresh thrombus material without signs of organization or atheromatous tissue. In 90% of patients mTICI was greater than 2b without signs of secondary vessel injury. No vascular tissue was found in free clots of the aspiration samples. The examination of adherent tissue to the stentriever instead of the examination of free clots may affect the number of detected parts of vessel wall. Further studies in combination with vessel wall imaging may elucidate the origin of remnants of vessel wall.

Mechanical thrombectomy for AIS from large vessel occlusion – current trends and future perspectives

Stroke is found to be one of the global top causes of mortality and the major factor in years of life with a handicap (DALYs). Ischemic strokes contributed to nearly 70% of all strokes worldwide. For endovascular thrombectomy in acute ischemic stroke with large vessel obstruction (AIS-LVO), using stent retrievers and/or reperfusion catheters has become the gold standard of therapy. The methodology involved keyword-based search in databases like PubMed, Embase, and Google Scholar for recent publications on mechanical thrombectomy (MT), AIS, large vessel occlusion (Large Vessel Occlusion (LVO)), screening relevant articles, retrieving full texts, and synthesizing key findings on procedural advancements, patient selection, COVID-19 (coronavirus disease 2019) impact, delay effects, effectiveness, clinical outcomes, and future perspectives. Only people with substantial cerebral artery obstruction may do well from MT. This includes the distal carotid artery and the proximal middle cerebral artery (segment M1). The size of a blocked vessel and NIHSS (National Institute of Health Stroke Scale) score are directly connected. Both the 2018 and 2019 versions of the AHA/ASA (American Heart Association/American Stroke Association) Guidelines for the Early Management of Patients with Acute Ischemic Stroke contained the recommendations that cases with AIS-LVO get endovascular therapy when administered during the time frame of 0–6 h after onset (Grade IA evidence). It is questionable whether this group of patients can be managed without the need for intravenous tissue plasminogen activator at the onset. When functional independence [modified Rankin Scale (mRS) score 2] was present at long-term follow-up, the endovascular intervention was favored. Tenecteplase, which differs from alteplase in terms of genetic variation, has a greater half-life and a higher level of fibrin selectivity, enabling bolus infusion. Studies have also demonstrated its efficacy and safety, as well as its long-term cost-effectiveness.

Sexual dimorphism in peripheral blood cell characteristics relate to success of endovascular thrombectomy in acute ischemic stroke

Abstract Introduction The success of endovascular thrombectomy (EVT) in acute ischemic stroke is related to stroke etiology and clot composition. The latter two may differ between women and men. An improved understanding of sex differences in EVT success may contribute to more personalized treatment. We therefore tested the hypothesis that blood cell characteristics (BCCs) related to EVT success in acute ischemic stroke differ by sex. Methods We analyzed electronic health record (EHR) data of AIS patients undergoing EVT at a single intervention center. Of 311 patients, 71 pretreatment erythrocyte-, leukocyte-, and thrombocyte-related BCCs from the Sapphire hematology analyzer were extracted. BCCs were sex-stratified, clustered, and analyzed based on the first principal component of the clusters. To identify BCC clusters related to successful EVT (TICI 3), Partial Least Squares Discriminant Analysis (sPLS-DA) was performed, including cross-validation and stability selection to identify stable BCCs relative to EVT success in women and men. We also related the identified BCCs to stroke etiology (cardioembolism (CE), large-artery atherosclerosis (LAA), undetermined), and controlled for known cardiovascular risk factors. Results Successful EVT was achieved in 69 women (51%) and 87 men (49%). Women and men differed on 21 out of 71 BCCs (pFDR-corrected &amp;lt; 0.05). Analyzing sex-stratified data led to lower error rates for the female model for EVT success compared to the pooled (t(192.4) = 5.9, p &amp;lt; 0.001), and male model (t(182.6) = -15.6, p &amp;lt; 0.001). In women, a higher number of reticulocytes was associated with successful EVT and CE, whereas a higher mean corpuscular hemoglobin concentration was associated with unsuccessful EVT and LAA. In men, a higher coefficient of variance of lymphocyte complexity of the intracellular structure was associated unsuccessful EVT and LAA. Conclusions BCCs associated with EVT success differed by sex and were related to stroke subtype. This improved understanding may contribute to more personalized treatment of acute ischemic stroke.Model performance after sex-stratifyingSex-specific BCCs relate to EVT success

Association between blood pressure variability and outcomes after endovascular thrombectomy for acute ischemic stroke: An individual patient data meta-analysis.

Data on the association between blood pressure variability (BPV) after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) and outcomes are limited. We sought to identify whether BPV within the first 24 hours post EVT was associated with key stroke outcomes. We combined individual patient-data from five studies among AIS-patients who underwent EVT, that provided individual BP measurements after the end of the procedure. BPV was estimated as either systolic-BP (SBP) standard deviation (SD) or coefficient of variation (CV) over 24 h post-EVT. We used a logistic mixed-effects model to estimate the association [expressed as adjusted odds ratios (aOR)] between tertiles of BPV and outcomes of 90-day mortality, 90-day death or disability [modified Rankin Scale-score (mRS) > 2], 90-day functional impairment (⩾1-point increase across all mRS-scores), and symptomatic intracranial hemorrhage (sICH), adjusting for age, sex, stroke severity, co-morbidities, pretreatment with intravenous thrombolysis, successful recanalization, and mean SBP and diastolic-BP levels within the first 24 hours post EVT. There were 2640 AIS-patients included in the analysis. The highest tertile of SBP-SD was associated with higher 90-day mortality (aOR:1.44;95% CI:1.08-1.92), 90-day death or disability (aOR:1.49;95% CI:1.18-1.89), and 90-day functional impairment (adjusted common OR:1.42;95% CI:1.18-1.72), but not with sICH (aOR:1.22;95% CI:0.76-1.98). Similarly, the highest tertile of SBP-CV was associated with higher 90-day mortality (aOR:1.33;95% CI:1.01-1.74), 90-day death or disability (aOR:1.50;95% CI:1.19-1.89), and 90-day functional impairment (adjusted common OR:1.38;95% CI:1.15-1.65), but not with sICH (aOR:1.33;95% CI:0.83-2.14). BPV after EVT appears to be associated with higher mortality and disability, independently of mean BP levels within the first 24 h post EVT. BPV in the first 24 h may be a novel target to improve outcomes after EVT for AIS.

Association of Neighborhood Deprivation With Thrombolysis and Thrombectomy for Acute Stroke in a Health System With Universal Access.

The association between socioeconomic status and acute ischemic stroke treatments remain uncertain, particularly in countries with universal health care systems. This study aimed to investigate the association between neighborhood-level material deprivation and the odds of receiving IV thrombolysis or thrombectomy for acute ischemic stroke within a single-payer, government-funded health care system. We conducted a population-based cohort study using linked administrative data from Ontario, Canada. This study involved all community-dwelling adult Ontario residents hospitalized with acute ischemic stroke between 2017 and 2022. Neighborhood-level material deprivation, measured in quintiles from least to most deprived, was our main exposure. We considered the receipt of thrombolysis or thrombectomy as the primary outcome. We used multivariable logistic regression models adjusted for baseline differences to estimate the association between material deprivation and outcomes. We performed a sensitivity analysis by additionally adjusting for hospital type at initial assessment. Furthermore, we tested whether hospital type modified the associations between deprivation and outcomes. Among 57,704 patients, those in the most materially deprived group (quintile 5) were less likely to be treated with thrombolysis or thrombectomy compared with those in the least deprived group (quintile 1) (16.6% vs 19.6%, adjusted odds ratio [aOR] 0.76, 95% CI 0.63-0.93). The association was consistent when evaluating thrombolysis (13.0% vs 15.3%, aOR 0.78, 95% CI 0.64-0.96) and thrombectomy (6.4 vs 7.8%, aOR 0.73, 95% CI 0.59-0.90) separately. There were no statistically significant differences between the middle 3 quintiles and the least deprived group. These associations persisted after additional adjustment for hospital type, and there was no interaction between material deprivation and hospital type (p interaction >0.1). We observed disparities in the use of thrombolysis or thrombectomy for acute ischemic stroke by socioeconomic status despite access to universal health care. Targeted health care policies, public health messaging, and resource allocation are needed to ensure equitable access to acute stroke treatments for all patients.

Abstract 231: Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke:An Analysis of the SVIN Registry

Introduction Mechanical thrombectomy (MT) often fails to achieve successful reperfusion in up to 20% of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) [1, 2]. Rescue strategies options, including balloon angioplasty alone, rescue stenting (RS) alone, or stent with balloon angioplasty, have shown promise in observational studies and meta‐analyses [3, 4]. We aimed to evaluate the association between RS with functional outcomes compared to medical management (MM) in anterior circulation LVO‐AIS patients who underwent failed MT. Methods This retrospective cohort study utilized prospectively collected data from the Society of Vascular and Interventional Neurology (SVIN) Registry, including adult patients with AIS who experienced a failed MT at 14 comprehensive stroke centers. A failed MT was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score of 0 to 2a after multiple attempts to clot retrieval. The patients were divided into two groups: those who received RS and those who only received MM. The primary efficacy outcome was the shift in the degree of disability, as measured by the modified Rankin Scale (mRS), at 90 days. Additional outcomes included functional independence (defined as a 90‐day mRS score of 0‐2), symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. These outcomes were assessed using uni‐ and multivariable logistic regression models. Results A total of 642 patients were included in the analysis. The RS group consisted of 294 (45.8%) patients, while the MM group comprised 348 (54.2%) patients. A mTICI score of 2b‐3 was achieved in 242/293 (82.6%) patients in the RS group. Compared to the MM group, the RS showed a favorable shift in the overall 90‐day mRS distribution (adjusted common odds ratio [OR]=1.97, 95% CI 1.36–2.85, p=&lt;0.001), higher rates of functional independence (RS: 30.7% vs. MM: 12%, adjusted OR [aOR]=2.39, 95% CI 1.34‐4.26, p=0.003), lower rates of sICH (RS: 2.7% vs. MM: 9%, aOR=0.32, 95% CI 0.14‐0.71, p=0.005), and lower 90‐day mortality (RS: 29.5% vs. MM: 49.7%, aOR=0.49, 95% CI 0.33‐0.74, p=&lt;0.001). Conclusion RS showed promising functional outcomes compared to MM. RS was associated with improved functional independence, reduced sICH rates, and lower 90‐day mortality. The RS group exhibited a favorable shift in the 90‐day mRS distribution, indicating better overall functional outcomes. These findings support RS as a potential rescue strategy for AIS patients with failed MT, with implications for clinical decision‐making. However, further prospective studies are needed to validate these observations and optimize outcomes.

Abstract 215: A Sweet Indicator: HbA1C and Thrombectomy Outcomes in Hispanics

Introduction There is a higher prevalence of diabetes mellitus type 2 in Hispanics as compared to other ethnic groups in the United States. Diabetes is a risk factor for acute ischemic stroke and also a poor predictor of outcome for many interventional surgeries. We performed this retrospective cohort analysis to assess the impact of poorly controlled diabetes, defined as HbA1C of 9.0% or greater, on the functional and procedural outcomes of Hispanic patients with acute ischemic stroke undergoing mechanical thrombectomy. Methods We conducted a retrospective review of a prospectively maintained patient database at a large volume comprehensive stroke center. Patients included were of Hispanic origin presenting between 2012 and 2022 who underwent thrombectomy for acute ischemic stroke. Baseline patient demographics and clinical characteristics recorded include age, gender, HbA1C level, National Institutes of Health Stroke Scale (NIHSS) at admission, manual CT ASPECTS and stroke risk factors (hypertension, atrial fibrillation, coronary artery disease, congestive heart failure, LDL, smoking, history of stroke/TIAs). Patients were separated into two groups depending on the presence poorly controlled diabetes defined as an HbA1C of 9.0% or greater. Outcomes evaluated include modified Rankin scale at 3 months, symptomatic intracranial hemorrhage, mass effect, 90‐day mortality, and whether any stenting or angioplasty was required during mechanical thrombectomy. Results 495 patients met the inclusion criteria out of which 69 had HbA1c of 9% or greater. Patients with poorly controlled diabetes were significantly younger (median age 63 vs 72, p &lt;0.001), had a lower prevalence of atrial fibrillation (7.69% vs 29.8%, p &lt;0.001) and a higher median LDL level (95.5 vs 72, p&lt;0.001) compared to patients who did not have poorly controlled diabetes. Median NIHSS on admission was also lower in the poorly controlled diabetics group (13 vs 17, p = 0.02). There was a statistically significant lower rate of functional independence (mRS 0‐2) at 90 days in patients with poorly controlled diabetes (30.6% vs 45.3%, p=0.05) after adjusting for age, NIHSS, and atrial fibrillation. Patients with poorly controlled diabetes also were more likely to require angioplasty (31.3% vs. 20.5%; p = 0.048) and stenting (28.4% vs. 18.1%; p = 0.049) during mechanical thrombectomy. Conclusion High HbA1c levels upon admission may be used to predict poor functional outcomes of thrombectomy and may also be associated with a greater chance of patients requiring angioplasty and/or stenting during thrombectomy. This can assist the physician in deciding if thrombectomy should be done on a patient with poorly controlled diabetes.

Abstract 020: Undulating Flow Velocities as an Induced Test of Autoregulation After Thrombectomy for Acute Ischemic Stroke

Introduction Loss of autoregulation after endovascular therapy (EVT) for large‐artery acute ischemic stroke (AIS) is well documented. [1] This might result in worse outcomes, despite successful recanalization, from hyper‐ or hypoperfusion with a risk for hemorrhagic conversion or larger stroke volume, respectively. Transcranial doppler (TCD) was previously used to document this phenomenon using spontaneous fluctuations in reactivity. Herein, we present a patient with suspected obstructive sleep apnea (OSA) with undulating flow velocities on TCD, serving as a test for induced vasoreactivity with pre‐ and post‐EVT TCD. Methods A case‐report. Results A middle‐aged patient was admitted with acute left cerebellar stroke (figure 1A). An Embolic etiology was suspected and a 20‐minuteTCD was done for spontaneous emboli detection on bilateral middle cerebral arteries (MCA). The patient fell asleep during the study and it incidentally revealed a bilaterally symmetric undulating velocity, which is a pattern that was previously described with OSA as a result of vasomotor response to multiple apnea and hypopnea episodes occurring in succession (Figure 1D – Pre‐EVT). [2] This pattern indicates intact vasomotor reactivity to fluctuating O2 and CO2 levels during episodes of apnea. Six days later, the patient developed acute right MCA stroke (Figure 1B) and was treated with EVT with successful reperfusion (TICI 2B67) (Figure 1C). TCD was repeated after EVT, and the previously seen undulating pattern was lost with significantly reduced variability on the right MCA compared to the contralateral side (figure 1E – Post‐EVT). This indicates a significant reduction in vasomotor reactivity and autoregulatory capacity of the right MCA. Follow up imaging revealed hemorrhagic conversion in the bed of the stroke with intraparenchymal bleeding (PH1) (Figures 1F‐H). This case is unique since it provides an induced test of autoregulation and compares pre‐ and post‐EVT autoregulatory function. Prior reports did not use any stressors to test for autoregulation. While in this case, apnea served as a natural test for autoregulation allowing for easier detection. This can serve as a future marker that can be easily quantified and might guide post‐EVT care. Using breath holding maneuvers or medication (e.g., Acetazolamide) might be considered in the future to quantify the autoregulatory response. Further studies are required to investigate the utility of induced, instead of spontaneous, autoregulation assessment post‐EVT to guide blood pressure goals and the duration of strict blood pressure control after endovascular intervention. Conclusion Induced tests for autoregulation using TCD might be feasible and should be considered in the future as an easy method for quantifying autoregulation post‐EVT. Further studies are required to clarify the utility of this biomarker in guiding post‐EVT care.

Abstract 204: On Old Dogs and New Tricks: Connecticut Perfusion Predicts Hemorrhagic Transformation After Thrombectomy

Introduction Hemorrhagic transformation is a major complication of large vessel occlusion (LVO) recanalization after mechanical thrombectomy in acute ischemic stroke. We investigated whether computed tomography perfusion (CTP) derived hypoperfusion index ratio correlates with the rate of hemorrhagic transformation. Methods We conducted a retrospective cohort analysis of a prospectively maintained patient database. Included patients underwent mechanical thrombectomy for large vessel ischemic stroke from January 2019 to December 2022. Patients were separated into 2 groups depending on whether or not hemorrhagic transformation developed. Hypoperfusion index ratio on admission CTP was determined using VizAI software. Data were analyzed using Chi‐square and Mann‐Whitney U tests. Results Among the 289 patients included (median age, 72.5; 41.5% female), 55 (19%) had hemorrhagic transformation. Patients with hemorrhagic transformation had a significantly higher hypoperfusion index ratio (median, 0 vs 0.2; P= 0.004) compared with those with no hemorrhagic transformation. Multivariable analysis showed that for every 0.1 increase in the hypoperfusion index ratio, there was a significant 4.64‐fold increase in hemorrhagic transformation (OR 4.64; 95% CI 1.40 to 15.18; p=0.011). Conclusion In patients with LVO who underwent mechanical thrombectomy, a higher hypoperfusion index ratio on admission CTP was associated with an increased rate of hemorrhagic transformation. This suggests that the hypoperfusion index ratio could be used as a predictor for hemorrhagic transformation after mechanical thrombectomy.

Evaluation of effectiveness and safety of the multizone NeVaTM stent retriever for mechanical thrombectomy in ischemic stroke

PurposeThis study aimed to evaluate the effectiveness and safety of the NeVaTM stent retriever as first- and second-line device for mechanical thrombectomy in acute ischemic stroke.MethodsIn this retrospective single-center study, all consecutive patients that underwent mechanical thrombectomy with NeVaTM stent retriever as first- or second-line device due to intracranial vessel occlusion with acute ischemic stroke between March and November 2022 were included.ResultsThirty-nine patients (m=18, f=21) with a mean age of 69.9 ± 13.3 years were treated with the NeVaTM stent retriever. NeVaTM stent retriever was used as first-line device in 24 (61.5%) of patients and in 15 (38.5%) as second-line device. First-pass rate (≥mTICI 2c) of NeVaTM stent retriever was both 66.7% when used as first- or second-line device. Final recanalization rate including rescue strategies was 92.3% for ≥mTICI2c and 94.9% for ≥mTICI2b. No device-related minor or major adverse events were observed. A hemorrhage was detected in 33.3% of patients at 24h post-thrombectomy dual-energy CT, of which none was classified as symptomatic intracerebral hemorrhage. NIHSS and mRS improved significantly at discharge compared to admission (p<0.05).ConclusionThe NeVaTM stent retriever has a high effectivity and good safety profile as first- and second-line device for mechanical thrombectomy in acute ischemic stroke.