Thrombolysis In Cerebral Ischemia Scores Research Articles

Abstract TP195: Impact of Intracranial Atherosclerotic Disease on Thrombectomy Outcomes in Acute Cerebral Infarction With Large Vessel Occlusion

Introduction: In acute cerebral infarction with Large Vessel Occlusion (LVO), Intracranial Atherosclerotic Disease (ICAD) often causes vascular occlusion. Previous studies have noted that ICAD-related LVOs, compared to embolic occlusions, have longer procedural times and lower successful reperfusion rates. However, clinical outcomes remain similar. This study compares post-thrombectomy outcomes in both groups, matched by initial NIHSS scores. Method: From October 2017 to March 2023, we studied LVO cases undergoing thrombectomy for acute ischemic stroke. Our primary focus was on evaluating thrombectomy outcomes within two distinct groups— ICAD-related LVO group (ICAD group) and Embolic LVO group (Embolic group)—matched based on preoperative NIHSS scores. ICAD group was defined as persistent occlusion or residual stenosis at the initial occlusion site. Patient outcomes at 3 months were assessed using modified Rankin Scale (mRS) scores, defining devastating outcomes as mRS 5-6. Successful recanalization was defined as Thrombolysis in Cerebral Ischemia score ≥2b. Logistic regression identified factors independently associated with devastating outcomes. Result: Analyzing 2407 cases, we extracted matched pairs (33 each) adjusted by NIHSS. ICAD group had lower atrial fibrillation frequency, lower BNP levels, more M1 occlusions, and fewer M2 occlusions compared to the Embolic group. In treatment outcomes, ICAD group had lower successful recanalization (82% vs 43%, P =0.001), higher reocclusion rates (0% vs 21%, P =0.005), and longer puncture-to-reperfusion time (median 51 vs 88 minutes, P <0.001). Devastating outcomes were higher in ICAD group (15% vs 39%, P =0.027). Multivariate analysis showed ICAD's independent association with devastating outcomes (Odds ratio, 6.54; 95% CI, 1.56-27.4; P =0.010) along with age, NIHSS, and tPA absence. Conclusion: In thrombectomy-treated LVO patients, matching based on admission NIHSS scores revealed significantly higher devastating outcomes in the ICAD group when compared to the Embolic group.

Abstract TP193: Impact of Number of Passes on Outcomes of Mechanical Thrombectomy in Stroke Patients With Low ASPECTS

Introduction: Real-world data showed that less than half of the acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) presenting with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (2-5) achieved favorable outcomes at 90 days after mechanical thrombectomy (MT). In this study, we aim to investigate the relationship between the number of MT passes at which successful recanalization is obtained and outcomes in LVO-related AIS patients with low ASPECTS. Methods: This retrospective cohort study was performed on the data from 31 thrombectomy-capable centers between 2013 to 2022. Successful recanalization was defined as modified Thrombolysis in Cerebral Ischemia Score≥ 2b. The primary outcome was a 90-day modified Rankin Scale (mRS) of 0-3. Secondary outcomes were symptomatic intracranial hemorrhage and intracranial hemorrhage within 24 hours and mortality at 90 days. Outcomes were compared among patients with unsuccessful recanalization, and successful recanalization at first, second, third, and more than four passes. Results: A total of 297 patients with a median age of 70 [IQR 59-78] years were included and 140 (47.1%) were female. In 239 (80.4%) patients, successful recanalization was achieved: 88 patients (29.6 %) with 1 pass, 59 patients (19.9 %) with 2 passes, 35 patients(11.8%) with 3 passes, and 57 patients (19.2%) with more than 4 passes. Compared to unsuccessful recanalization, successful recanalization at first pass (adjusted OR 5.25, 95% CI 1.78 - 17.1), second passes (adjusted OR 5.20, 95% CI 1.68 - 17.6), and passes 4 (adjusted OR 4.90, 95% CI 1.68 - 17.6) was related to 90-day mRS 0-3. Recanalization status and MT attempt number were not related to secondary outcomes except for 90-day mortality. Compared to unsuccessful recanalization, successful recanalization at second and third passes were inversely related to 90-day mortality (adjusted OR 0.37, 95% CI 0.14 - 0.93; adjusted OR 0.33, 95% CI 0.11 - 0.95, respectively). Conclusion: The present results indicated that successful recanalization was related to 90-day good outcome regardless of the number of MT passes but the odds of achieving favorable outcome declines with each pass.

Abstract 221: EARLY EXPERIENCE OF EMBOGUARD BALLOON GUIDE CATHETER IN LARGE VESSEL OCCLUSION THROMBECTOMY

Introduction Endovascular thrombectomy (EVT) is the standard of care in acute ischemic stroke secondary to large vessel occlusion in selective patients within the first 24 hours. With the evolving technology and newer generation of catheters and devices, the interest in improving the technical and procedural factors that can help better the recanalization success, clinical outcomes, and efficiency is ever‐growing. Proximal flow arrest with balloon guide catheters (BGC) has been shown to optimize revascularization success and functional outcome in stroke EVT. We aim to evaluate the performance of the Emboguard BGC (Cerenovus, Irvine, CA, USA) in anterior circulation large vessel occlusion (LVO) acute ischemic strokes. Methods A prospectively maintained EVT database was reviewed for 12 months between May 2022 to May 2023 to identify all patients at our institution with intracranial vessel occlusion who underwent EVT using Emboguard BGC. Included patients were ≥18 years with large‐vessel occlusion who presented within 24 hours of time from last‐known‐well and had baseline National Institutes of Health Stroke Scale (NIHSS) score ≥ 6. Non‐dominant M2, M3, and A2 occlusions were excluded. We collected baseline demographic, clinical, and radiographic characteristics including age, sex, co‐morbidities, baseline NIHSS score, baseline modified Rankin Score (mRS), ASPECTS score, site of occlusion, imaging at our site, and use of intravenous and/or intra‐arterial thrombolytics. Outcomes included complications, NIHSS at discharge, final modified TICI (thrombolysis in cerebral ischemia) scores including the first‐pass effect (FPE, defined as mTICI 2c/3 after first pass), modified‐FPE (defined as, mTICI 2b‐3 after first pass), symptomatic intracranial hemorrhage (SITS‐MOST definition), and death at discharge. Data were analyzed using descriptive statistics, with frequency/percent for qualitative data and median/ interquartile range (IQR) for quantitative data. Results A total of 57 patients underwent EVT using Emboguard BGC. Among them, 54.4% were female and the median age was 72 years [IQR 66‐80]. Most of the patients had MCA occlusion (68.4% with 50.9% M1 and dominant/co‐dominant M2s 17.5%) with median ASPECTS 9 [IQR 8‐10]). About one‐third of our patients received intravenous thrombolytics. Following EVT, successful recanalization defined as modified TICI (thrombolysis in cerebral ischemia) scores of 2b/3 was achieved in 56 cases (98.2%) with 1 being the median number of passes (IQR 1‐2). The first pass effect (defined as one pass with mTICI of 2c/3) was achieved in 45.6% of cases. The median National Institutes of Health Stroke Scale (NIHSS) reduced significantly from 16 (IQR 12‐22) at baseline to 4 (IQR 1.5–12) at discharge (Table). Symptomatic intracranial hemorrhage was reported in 6 cases (10.5%), death at discharge was reported in 9 cases (15.8%), and access site complications were reported in 3 cases (5.3%). Conclusion Emboguard BGC showed promising results evident by a high rate of FPE, smaller number of EVT passes and improved recanalization rates with reasonable safety profile. Comparative prospective studies are needed to confirm these results.

First pass effect of mechanical thrombectomy for acute vertebrobasilar artery occlusion: data from the ANGEL-ACT registry

BackgroundTo explore the incidence, predictors, and association of first pass effect (FPE) on clinical outcomes of mechanical thrombectomy (MT) for acute vertebrobasilar artery occlusion (VBAO) in the Asian population.MethodsWe selected...

Stenting and Angioplasty in Neurothrombectomy: Matched Analysis of Rescue Intracranial Stenting Versus Failed Thrombectomy.

Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0-1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0-2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61-3.32]; P<0.001), higher rates of functional independence (35.1% versus 7%; adjusted odds ratio [aOR], 6.33 [95% CI, 3.14-12.76]; P<0.001), and lower mortality (28% versus 46.5%; aOR, 0.55 [95% CI, 0.31-0.96]; P=0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42-2.34]; P=0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16-6.57]; P<0.001), higher rates of functional independence (34.6% versus 6.5%; aOR, 10.91 [95% CI, 4.11-28.92]; P<0.001), and lower mortality (29.9% versus 43%; aOR, 0.49 [95% CI, 0.25-0.94]; P=0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31-2.42]; P=0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

BOBBY balloon guide catheter thrombectomy in large-vessel occlusion stroke: Initial experience.

Nonrandomized studies have found Balloon Guide Catheter (BGC) use to improve technical and functional outcomes in patients undergoing mechanical thrombectomy (MT). We performed a retrospective analysis on prospectively collected data of consecutive ischemic stroke patients undergoing MT at our institution (December 2020-October 2021). Interventions where BOBBY BGC (BBGC, MicroVentionTM, Aliso Viejo, CA) was used were identified. Baseline demographics and clinico-radiographic characteristics were retrospectively collected and analysed using descriptive statistics. A total of 43 patients received BBGC-MT (male: female = 26:17, median age 72 years [IQR 62-82]). The most common occlusion site was the middle cerebral artery (MCA) (60.4%). Over half (51.2%) received intravenous thrombolytics. The BBGC tracked well over tortuous aortic arches (type II 34.8%, type III 16.3%), with median arteriotomy-to-perfusion time of 29 min (IQR 20-46). Thromboaspiration was used as first-line MT technique in 69.7% cases, with 1 (IQR 1-2) median MT pass achieving modified TICI (thrombolysis in cerebral ischemia) scores of 3 and 2b/3 in 74.4% and 95.3% respectively. Our overall first pass effect (FPE, defined as mTICI 3 after firs-pass) and modified FPE (defined as, mTICI 2b/3 after first-pass) rates were 51.1% and 79.1% respectively, with rates of 92.3% and 100% respectively when stentretriever and thromboaspiration were combined. The median reduction in National Institutes of Health Stroke Scale (NIHSS) was 9 (IQR 4-15, p < 0.0001), with a median 90-day modified Rankin Score (mRS) of 1.5 (IQR 0-2). BOBBY BGC use resulted in a high first-pass effect rate and may contribute towards improved functional outcomes.

Accuracy of CT Perfusion-Based Core Estimation of Follow-up Infarction: Effects of Time Since Last Known Well.

To assess the accuracy of baseline CT perfusion (CTP) ischemic core estimates. From SELECT (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke), a prospective multicenter cohort study of imaging selection, patients undergoing endovascular thrombectomy who achieved complete reperfusion (modified Thrombolysis In Cerebral Ischemia score 3) and had follow-up diffusion-weighted imaging (DWI) available were evaluated. Follow-up DWI lesions were coregistered to baseline CTP. The difference between baseline CTP core (relative cerebral blood flow [rCBF] <30%) volume and follow-up infarct volume was classified as overestimation (core ≥10 mL larger than infarct), adequate, or underestimation (core ≥25 mL smaller than infarct) and spatial overlap was evaluated. Of 101 included patients, median time from last known well (LKW) to imaging acquisition was 138 (82-244) minutes. The median baseline ischemic core estimate was 9 (0-31.9) mL and median follow-up infarct volume was 18.4 (5.3-68.7) mL. All 6/101 (6%) patients with overestimation of the subsequent infarct volume were imaged within 90 minutes of LKW and achieved rapid reperfusion (within 120 minutes of CTP). Using rCBF <20% threshold to estimate ischemic core in patients presenting within 90 minutes eliminated overestimation. Volumetric correlation between the ischemic core estimate and follow-up imaging improved as LKW time to imaging acquisition increased: Spearman ρ <90 minutes 0.33 (p = 0.049), 90-270 minutes 0.63 (p < 0.0001), >270 minutes 0.86 (p < 0.0001). Assessment of the spatial overlap between baseline CTP ischemic core lesion and follow-up infarct demonstrated that a median of 3.2 (0.0-9.0) mL of estimated core fell outside the subsequent infarct. These regions were predominantly in white matter. Significant overestimation of irreversibly injured ischemic core volume was rare, was only observed in patients who presented within 90 minutes of LKW and achieved reperfusion within 120 minutes of CTP acquisition, and occurred primarily in white matter. Use of a more conservative (rCBF <20%) threshold for estimating ischemic core in patients presenting within 90 minutes eliminated all significant overestimation cases. ClinicalTrials.gov: NCT03876457.

Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in the Early and Extended Window

Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score. All patients underwent MT in one of the included centers. A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset). A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64). In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window.

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

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

Safety and Efficacy of Low-Dose Tirofiban Combined With Intravenous Thrombolysis and Mechanical Thrombectomy in Acute Ischemic Stroke: A Matched-Control Analysis From a Nationwide Registry.

Purpose: Tirofiban administration to acute ischemic stroke patients undergoing mechanical thrombectomy with preceding intravenous thrombolysis remains controversial. The aim of the current study was to evaluate the safety and efficacy of low-dose tirofiban during mechanical thrombectomy in patients with preceding intravenous thrombolysis.Methods: Patients with acute ischemic stroke undergoing mechanical thrombectomy and preceding intravenous thrombolysis were derived from “ANGEL-ACT,” a multicenter, prospective registry study. The patients were dichotomized into tirofiban and non-tirofiban groups based on whether tirofiban was administered. Propensity score matching was used to minimize case bias. The primary safety endpoint was symptomatic intracerebral hemorrhage (sICH), defined as an intracerebral hemorrhage (ICH) associated with clinical deterioration as determined by the Heidelberg Bleeding Classification. All ICHs and hemorrhage types were recorded. Clinical outcomes included successful recanalization, dramatic clinical improvement, functional independence, and mortality at the 3-month follow-up timepoint. Successful recanalization was defined as a modified Thrombolysis in Cerebral Ischemia score of 2b or 3. Dramatic clinical improvement at 24 h was defined as a reduction in NIH stroke score of ≥10 points compared with admission, or a score ≤1. Functional independence was defined as a Modified Rankin Scale (mRS) score of 0–2 at 3-months.Results: The study included 201 patients, 81 in the tirofiban group and 120 in the non-tirofiban group, and each group included 68 patients after propensity score matching. Of the 201 patients, 52 (25.9%) suffered ICH, 15 (7.5%) suffered sICH, and 18 (9.0%) died within 3-months. The median mRS was 3 (0–4), 99 (49.3%) achieved functional independence. There were no statistically significant differences in safety outcomes, efficacy outcomes on successful recanalization, dramatic clinical improvement, or 3-month mRS between the tirofiban and non-tirofiban groups (all p > 0.05). Similar results were obtained after propensity score matching.Conclusion: In acute ischemic stroke patients who underwent mechanical thrombectomy and preceding intravenous thrombolysis, low-dose tirofiban was not associated with increased risk of sICH or ICH. Further randomized clinical trials are needed to confirm the effects of tirofiban in patients undergoing bridging therapy.

Predictors of Outcome After Mechanical Thrombectomy in Stroke Patients Aged ≥85 Years

The effectiveness of mechanical thrombectomy (MT) in elderly stroke patients remains debated. We aimed to describe outcomes and their predictors in a cohort of patients aged ≥ 85 years treated with MT. Data from consecutive patients aged ≥ 85 years undergoing MT at two stroke centers between January 2016 and November 2019 were reviewed. Admission National Institutes of Health Stroke Scale (NIHSS), pre-stroke, and 3-month modified Rankin scale (mRS) were collected. Successful recanalization was defined as modified thrombolysis in cerebral ischemia score ≥ 2b. Good outcome was defined as mRS 0-3 or equal to pre-stroke mRS at 3 months. Of 151 included patients, successful recanalization was achieved in 74.2%. At 3 months, 44.7% of patients had a good outcome and 39% had died. Any intracranial hemorrhage (ICH) and symptomatic ICH occurred in 20.3% and 3.6%, respectively. Logistic regression analysis identified lower pre-stroke mRS score (adjusted odds ratio [aOR], 0.52; 95% CI, 0.36-0.76), lower admission NIHSS score (aOR, 0.90; 95% CI, 0.83-0.97), successful recanalization (aOR, 3.65; 95% CI, 1.32-10.09), and absence of ICH on follow-up imaging (aOR, 0.42; 95% CI, 0.08-0.75), to be independent predictors of good outcome. Patients with successful recanalization had a higher proportion of good outcome (45.3% vs 34.3%, p = 0.013) and lower mortality at 3 months (35.8% vs 48.6%, p = 0.006) compared to patients with unsuccessful recanalization. Among patients aged ≥ 85 years, successful recanalization with MT is relatively common and associated with better 3-month outcome and lower mortality than failed recanalization. Attempting to achieve recanalization in elderly patients using MT appears reasonable.

Mechanical Thrombectomy in Medium Vessel Occlusions

Mechanical thrombectomy techniques for intracranial medium vessel occlusions (MeVOs) have evolved in recent years, although the optimal approach is still unclear. The aim of this study was to investigate the effectiveness and safety of mechanical thrombectomy in MeVOs using mini (0.017 inches microcatheter compatible) stent retrievers combined with low-profile (0.035 inches distal inner diameter) distal aspiration catheters through the blind exchange/mini-pinning (BEMP) technique compared with mini stent retrievers alone. Retrospective review of a prospectively maintained database of patients treated with the BEMP technique or mini stent retriever alone for intracranial MeVOs from 2017 to 2020 in a comprehensive stroke center. Both groups were compared about baseline characteristics, occlusion site, clinical presentation, clot cause, procedural outcomes (MeVO first-pass and final expanded Thrombolysis in Cerebral Ischemia score, the mini stent retriever used, number of passes with the front-line approach, and need of rescue therapy), safety outcomes (emboli to unwanted territories and hemorrhagic complications), and clinical outcomes at 90 days. Multivariable logistic regression analysis was performed with potential predictors of vessel recanalization to find independent variables associated with MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization. We reviewed 102 patients/106 MeVOs treated with the BEMP technique (n=56) or mini stent retriever (n=50). There was a higher rate of MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization (57% versus 34%, P=0.017), lower need of rescue therapy (7.1% versus 22%, P=0.028), and lower rate of emboli to new territory (1.8% versus 12%, P=0.035) and symptomatic intracranial hemorrhage (1.9% versus 12.8%, P=0.038) with the BEMP technique. After multivariable analysis, the sole independent factor associated to MeVO first-pass expanded Thrombolysis in Cerebral Ischemia 2c/3 recanalization was the BEMP technique (odds ratio, 2.72 [95% CI, 1.19-6.22]; P=0.018). In the setting of MeVOs, the BEMP technique may lead to higher rates of the first-pass recanalization and a lower incidence of symptomatic intracranial hemorrhage than mini stent retrievers alone.

Early successful reperfusion after endovascular therapy reduces malignant middle cerebral artery infarction occurrence in young patients with large diffusion-weighted imaging lesions.

Malignant middle cerebral artery infarction (MMI) is a severe complication of acute ischaemic stroke (AIS). The aim of our study was to assess whether successful reperfusion after endovascular therapy (EVT) in AIS with clinical and imaging predictors of MMI decreased its occurrence. Data were collected between January 2014 and July 2018 in a monocentric prospective AIS registry of patients treated with EVT. Patients selected were <65years old with severe anterior circulation AIS with a National Institutes of Health Stroke Scale score >15, baseline Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score≤6 and baseline diffusion-weighted imaging lesion volume >82mL within 6h of symptom onset. Successful reperfusion was defined as a Thrombolysis in Cerebral Ischemia score≥2b. Occurrence of MMI was the primary endpoint. A total of 66 EVT-treated patients were included in our study. MMI occurred in 27 patients (41%). In unadjusted analysis, successful reperfusion was associated with fewer MMIs (31.8% vs. 65.0%; P=0.015) and with more favorable outcome at 3months (50% vs. 20%; P=0.023). In multivariate analysis, successful reperfusion was associated with an adjusted odds ratio (95% confidence intervals) of 0.35 (0.10-1.12) for MMI and 2.77 (0.84-10.43) for 3-month favorable outcome occurrence. Early successful reperfusion performed in patients with AIS with clinical and imaging predictors of MMI was associated with decreased MMI occurrence. Reperfusion status might be considered in evaluating the need for craniectomy in patients with early predictors of MMI.

Abstract 116: Predicting Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy: The TAG Score

Background: There is limited data on predictors of sICH in patients who underwent mechanical thrombectomy. In this study, we aim to determine those predictors with external validation. Methods: We evaluated mechanical thrombectomy in a derivation cohort of patients at a comprehensive stroke center over a 30-month period. sICH was defined using the European Cooperative Acute Stroke Study III. We compared clinical and radiographic characteristics between patients with and without sICH to identify independent predictors of sICH with p&lt;0.1. We then derived an sICH prediction score and validated it using the Blood Pressure After Endovascular Treatment (BEST) multicenter prospective registry. Results: We identified 578 patients with acute ischemic stroke who received thrombectomy, 19 had sICH (3.3%). Predictive factors of sICH were: Thrombolysis in cerebral ischemia score, Alberta stroke program early computed tomography score (ASPECTS), and Glucose level, and using these predictors, we derived the weighted TAG score which was associated with sICH in the derivation (OR per unit increase 1.98, 95% CI 1.48-2.66, AUC=0.79) and validation (OR per unit increase 1.48, 95% CI 1.22-1.79, AUC=0.69) cohorts. Conclusion: High TAG scores are associated with sICH in patients receiving mechanical thrombectomy. Larger studies are needed to validate this scoring system and test strategies to reduce sICH risk and make thrombectomy safer in patients with elevated TAG scores.

Feasibility of Distal Mechanical Thrombectomy in M3, A3 and P3 Segments via a 0.013-inch Delivery System: Preliminary Experience.

To assess the safety and efficacy of distal thrombectomy (DT) using a Catch View mini (CVm) device via a microcatheter with a 0.013-inch inner diameter. Nine of 246 acute ischemic stroke patients who underwent mechanical thrombectomy developed distal emboli and were included in the study. In all nine subjects (mean age, 64.5 ± 11.6; range, 39?77 years), a combination of CVm and a 0.013-inch microcatheter was used in distal mechanical thrombectomy. Modified Thrombolysis in Cerebral Ischemia scores of 2c and 3 were considered to indicate successful recanalization, and patients with a Modified Rankin Score of ? 2 on the 90th day were considered to have good clinical outcomes. Eleven DT maneuvers were performed using the same stent retriever and microcatheter. The mean National Institutes of Health Stroke Scale score was 13 ± 3.4. Thrombectomy was performed from M3 in six patients, A3 in four, and P3 in one. Successful recanalization was achieved in all of the procedures. The rate of good clinical outcome was 55.5%. Advances in technology in the endovascular field enable access to more distal vessels in acute ischemic stroke. As the profile of the instruments used during access decreases, the risk of complications may decrease. The CVm stent retriever could become a useful tool in DT based on its compatibility with a 0.013-inch lumen delivery system.

Stent Expansion and In-Stent Thrombus Sign in the Trevo Stent Retriever Predict Recanalization and Possible Etiology During Mechanical Thrombectomy: A Case Series of 50 Patients with Acute Middle Cerebral Artery Occlusion

Interaction between the stent retriever and clot is a key factor for recanalization during mechanical thrombectomy. The aim of this study was to evaluate the association between radiographically apparent features during thrombectomy and angiographic outcomes using the Trevo stent retriever with a fully radiopaque strut. We retrospectively reviewed 50 patients with acute middle cerebral artery occlusion who were treated with the Trevo. Patients were divided into groups that achieved (first-pass recanalization group, n= 21) or did not achieve (non-first-pass recanalization group, n= 29) a modified Thrombolysis in Cerebral Ischemia score of 2b or 3 with the first-pass procedure. Patients were also divided into a thromboembolic (n= 39) and atherosclerotic (n= 11) group by occlusion etiology. We evaluated radiographic findings of the Trevo's strut (e.g., degree of stent expansion and filling defect of the thrombus in the strut [in-stent thrombus sign]) during the first-pass procedure. Median stent expansion was significantly greater in the first-pass recanalization group than in the non-first-pass recanalization group (60% vs. 34%; P < 0.01) and in the thromboembolic group than in the atherosclerotic group (45% vs. 31%; P < 0.01). The receiver operator characteristic curve showed moderate capacity for prediction of recanalization and etiology, with an area under the curve of 0.83 and 0.73, respectively. In-stent thrombus sign was significantly more common in the thromboembolic group than in the atherosclerotic group (86% vs. 10%; P < 0.01). Greater stent expansion was associated with recanalization after thrombectomy. The in-stent thrombus sign may be useful for etiology prediction. These radiographic findings could provide useful real-time feedback during procedures, reflecting clot-stent interaction.

Off-hour admission and impact on neurological outcome in endovascular treatment for acute ischemic stroke.

In the new era of endovascular treatment for acute ischemic stroke, one of the main predictors of good neurological outcome is a short time interval from stroke onset to recanalization of the occluded vessel. In this study, we examined the effect of on-hour vs off-hour admittance on the time intervals from stroke onset to recanalization in patients with acute ischemic stroke (AIS) undergoing endovascular treatment (EVT). One-hundred-ninety-eight patients receiving EVT for anterior AIS between 2007 and 2016 were included. Time of day and weekday for stroke admittance were recorded as well as several time intervals. Age, sex, co-morbidities, admission National Institutes of Health Stroke Scale (NIHSS), intraprocedural blood pressure, blood glucose, modified Thrombolysis in Cerebral Ischemia score (mTICI) and neurological outcome at 3months, measured as modified Rankin Scale (mRS), were registered. On-hour was defined as 8am-4pm weekdays, and off-hour as weekdays outside these hours and weekends. The time interval from CT (computed tomography) to recanalization was longer during off-hours, while no difference was seen in the time interval from stroke onset to CT. No statistically significant difference was seen in neurological outcome between the on- and off-hour groups in a univariate analysis. Stroke admittance during off-hours is associated with longer time interval from CT examination to vessel recanalization. The study highlights the need of logistic improvement and probably more resources off-hour in order to deliver an effective stroke care around the clock.

Factors associated with early dramatic recovery following successful recanalization of occluded artery by endovascular treatment in anterior circulation stroke

Endovascular treatment (EVT) significantly increases the recanalization rate and improves functional outcomes in acute ischemic stroke. However, despite successful recanalization by EVT, some stroke patients demonstrate no early dramatic recovery (EDR). We assessed factors associated with EDR following recanalization by EVT. We included subjects with anterior circulation stroke treated with EVT who met the following criteria: Thrombolysis in Cerebral Ischemia scores (TICI) 2b-3 after EVT, lesion volume <70mL as seen on the pre-treatment diffusion-weighted imaging (DWI) scan and a baseline NIHSS score ≥6. EDR was defined as a ≥8-point reduction in the NIHSS score, or NIHSS score of 0 or 1 measured 24h following treatment. Multivariate regression analyses were performed to identify the predictors associated with EDR. Of the 102 patients (mean age, 64.3years; median National Institutes of Health Stroke Scale score, 14), EDR was achieved in 39 patients (38.2%). The median DWI lesion volume was 12mL (interquartile range, 5–25mL). Median onset-to-recanalization time in these patients was 320min (interquartile range, 270–415min). Logistic regression analysis identified a higher initial NIHSS score (OR 1.17, 95% CI 1.03–1.33, P=0.016) and shorter time from onset to recanalization (OR 0.99, 95% CI 0.986–0.997, P=0.003), to be independently associated with EDR. In the setting of pretreatment DWI lesion volume <70mL, a higher initial NIHSS score and faster time from onset to recanalization may be important predictors of EDR following successful EVT.

Two Paradigms for Endovascular Thrombectomy After Intravenous Thrombolysis for Acute Ischemic Stroke

Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) is recommended to treat acute ischemic stroke (AIS) with a large vessel occlusion (LVO). Most hospitals do not have on-site MT facilities, and most patients need to be transferred secondarily after IVT (drip and ship), which may have an effect on the neurologic outcome. To compare the functional independence at 3 months between patients treated under the drip-and-ship paradigm and those treated on site (mothership). This study used a prospectively gathered registry of patients with AIS to select patients admitted through the Saint-Antoine and Tenon (drip and ship) or the Fondation Rothschild (mothership) hospitals from January 1, 2013, through April 30, 2016. The study included patients older than 18 years treated with bridging therapy for AIS with LVO of the anterior circulation. Among the 159 patients who received MT at the mothership, 100 had been transferred after IVT from the drip-and-ship hospitals and 59 had received IVT on site. The main outcome was 3-month functional independence (modified Rankin scale score ≤2). Both groups were compared using a multivariate linear model, including variables that were significantly different in the 2 groups. During the study period, 497 patients were hospitalized at the drip-and-ship and mothership hospitals for an AIS eligible to reperfusion therapy; 11 patients had a basilar artery occlusion and were excluded, leaving 100 patients in the drip-and-ship group (mean age, 73 years; age range, 60-81 years; 57 men [57.0%]) and 59 in the mothership group (mean age, 70 years; age range, 58-82 years; 29 men [49.2%]). The proportion of patients with a favorable neurologic outcome at 3 months was similar in both groups (drip and ship, 61 [61.0%]; mothership, 30 [50.8%]; P = .26), even after adjusting the analysis for the baseline National Institutes of Health Stroke Scale score, diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, and general anesthesia (P = .82). Patients had less severe conditions in the drip-and-ship group (median baseline National Institutes of Health Stroke Scale score, 15 vs 17 [P = .03]; median diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, 7.5 vs 7 [P = .05]). Process times were longer in the drip-and-ship group (onset-to-needle time, 150 vs 135 minutes; onset-to-puncture time, 248 vs 189 minutes; and onset-to-recanalization time, 297 vs 240 minutes; P < .001). Both groups were similar in terms of substantial recanalization (Thrombolysis in Cerebral Ischemia scores 2B to 3; drip and ship, 84 [84.0%]; mothership, 47 [79.7%]; P = .49) and symptomatic hemorrhagic transformation (drip and ship, 2 [2.0%]; mothership, 2 [3.4%]; P = .63). This study found that patients treated under the drip-and-ship paradigm also benefit from bridging therapy, with no statistically significant difference compared with those treated directly in a comprehensive stroke center.

Drip, Ship, and On-Demand Endovascular Therapy for Acute Ischemic Stroke.

BackgroundThe “drip and ship” approach can facilitate an early initiation of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) at community hospitals. New endovascular treatment modalities, such as stent retrieval, have further improved the rate of safe and successful recanalization. We assessed the clinical outcomes of on-demand endovascular therapy in patients with AIS who were transported to a comprehensive stroke center under the “drip and ship” paradigm.MethodsThis retrospective study evaluated prospectively registered patients with acute large vessel occlusions in the anterior circulation who underwent endovascular recanalization after IVT at our regional comprehensive stroke center between January 2011 and April 2014. Clinical outcomes and neuroradiological findings were compared between patients who received IVT at the center (direct visit, DV) and at a community hospital (drip and ship, DS).ResultsBaseline characteristics such as age, initial National Institutes of Health Stroke Scale (NIHSS) score, and risk factors for stroke were similar, and most patients underwent endovascular therapy with a Solitaire stent (81.9% vs. 89.3% for DV and DS, respectively, P = 0.55). The average initial NIHSS score was 12.15±4.1 (12.06 vs. 12.39 for DV and DS, respectively, P = 0.719). The proportions of long-term favorable outcomes (modified Rankin Scale score ≤2 at 90 days) and successful recanalization (Thrombolysis in Cerebral Ischemia score ≥2b) were not significantly different (P = 0.828 and 0.158, respectively). The mortality rates and occurrences of symptomatic intracerebral hemorrhage were not significantly different (P = 0.999 and 0.267, respectively).ConclusionsThe “drip and ship” approach with subsequent endovascular therapy is a feasible treatment concept for patients with acute large vessel occlusion in the anterior circulation that could help improve clinical outcomes in patients with AIS.