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Introduction Ischemic stroke secondary to acute extracranial internal carotid artery (EC-ICA) occlusion accounts for approximately 20% of all stroke cases. Pure EC-ICA lesions account for only a minority of cases as a larger subgroup of people who experience these occlusions, concomitantly develop an intracranial anterior circulation large vessel occlusion (ACLVO), i.e. a tandem lesions. Endovascular management includes acute carotid artery stenting (CAS) with or without balloon angioplasty for pure EC-ICA occlusions and concurrent mechanical thrombectomy (MT) for tandem lesions. In lieu of the scarcity of randomized data and abundance of observational studies, we intend to perform a systematic review and pooled analysis of the data over the past decade to evaluate clinical outcomes, safety and feasibility of endovascular management of acute EC-ICA strokes. Methods Systematic search of the Pubmed, MEDLINE, and EMBASE databases was conducted based on Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. We performed a systematic review of all acute EC-ICA stroke papers (including tandem lesions) published between January 2010 and December 2020. A pooled analysis of the extracted data was performed. Results Data from 1153 patients from 22 studies were pooled and analyzed. Mean age after pooling was 66.9 years, mean NIHSS at admission was 15.9,% IV tPA use before endovascular intervention was seen 56.1% of studies. 82.8% of subjects had a tandem lesion involving both Extracranial and intracranial part of ICA and only 17.2% had a pure and isolated EC-ICA lesion. Angioplasty + stenting (both) was done in 77.6% of cases. Pooling was also done for any and all approaches taken in case of a tandem lesion i.e. anterograde or retrograde. Anterograde approach was taken in 61.7% of cases whereby CAS was performed first followed by MT. Outcome measures were reported as successful recanalization (TICI ≥ 2B) in 80.0% of cases, with good outcome (90-day mRS Conclusion Our systematic review for endovascular treatment of EC-ICA strokes found a high rate of good outcomes and an impressive rate for recanalization, with low mortality rates. Since these results are from observational, retrospective studies, more rigorous randomized trials are required to establish the best approach. Disclosures A. Baig: None. M. Waqas: None. S. Khan: None. A. Monteiro: None. H. Rai: None. R. Dossani: None. J. Cappuzzo: None. F. Almayman: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University at Buffalo. K. Snyder: 2; C; Canon Medical Systems Corporation, Penumbra Inc., Medtronic, and Jacobs Institute. E. Levy: 2; C; Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed;. 4; C; NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical;. A. Siddiqui: 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc., Cerebrotech Medical Systems Inc., Cerenovus, Corindus Inc., Endostream Medical Ltd., Imperative Care, Inc. Integra LifeSciences C. 4; C; Adona Medical, Inc, Amnis Therapeutics, (Purchased by Boston Scientific October 2017), Blink TBI Inc., Buffalo Technology Partners Inc., Cerebrotech Medical Systems, Inc., Cognition Medical, Endostrea.

Introduction Middle meningeal artery (MMA) embolization for the treatment of subacute/chronic subdural hematoma (cSDH) is an emerging therapy for minimally invasive treatment of subdural blood products. Trans radial access (TRA) may offer certain benefits to this patient population who are often on blood thinners with multiple comorbid medical issues. Methods 46 consecutive patients between 2018 and January of 2020 undergoing trans radial access for MMA embolization with Onyx were analyzed from a single center prospectively maintained database. Patient demographics, comorbidities, ambulatory times, subdural resorption status, and guide catheter type were recorded. We specifically looked at conversion to femoral access and complication rates from access for this series. Multivariate analysis with SPSS version 25 was utilized. Results 46 patients were included in this study. The average age was 71.7± 14 years. TRA was successful for MMA embolization in 44 patients (95%). There were no access site complications. The mean cSDH size was 14 ±5 mm. 5 patients had recurrent cSDH prior to undergoing MMA embolization (10.8%). 4 patients (8.7%) had adjuvant MMA embolization performed within 24 hrs of burr hole evacuation. Symptomatic improvement was seen in 88.6% of patients (39/44). Mean length of stay was 4 ±3 days, all patients previously ambulatory were ambulated immediately post procedure. 3 patients were appropriate for same day discharge. Mean followup was 8 weeks ± 4. 86.4% of patients had either resolution or partial resolution of the cSDH at mean follow-up. Univariate analysis revealed use of antiplatelet agents was associated with failed resorption of cSDH (83.3% vs 23%, P=0.009). Charlson comorbidity index, gender, age, and treatment approach (adjuvant vs primary) were not associated with failed resorption status. 48% of patients had a Charlson Comorbidity index >5. 91% of TRA embolizations were performed with a 6F 071 guide catheter. Conclusion MMA embolization with Onyx for cSDH appears to result in symptomatic and radiographic relief in the majority of patients. Trans radial access via 6F 071 guide catheter in this population with numerous comorbidities offers a safe and effective strategy for early ambulation and procedural success. Disclosures G. Rajah: None. M. Waqas: None. R. Dossani: None. A. Gong: None. K. Rho: None. S. Housley: None. H. Rai: None. F. Chin: None. M. Tso: None. E. Levy: None. A. Siddiqui: None. K. Snyder: None. J. Davies: None.

Background Diagnostic cerebral angiography (DSA) and neurointerventions have traditionally been performed via transfemoral access (TFA). The perception of a steep learning curve associated with transradial access (TRA) has limited adoption in neurointervention. This study compares the learning curves of transradial vs. transfemoral DSA in a cohort of neurointerventional fellows. Methods The first 150 consecutive radial and femoral DSA were identified for each fellow from a prospective neurointerventional registry from July 2017 to March 2020. Total fluoroscopy time and number of intracranial arteries injected were recorded. Mean fluoroscopy time per intracranial artery injected (termed angiographic efficiency) was calculated and was used as a surrogate measure of technical proficiency. Mean angiographic efficiencies were compared across partitions of 25 consecutive DSAs (e.g. 1–25, 26–50, 51–75, etc.). Results There were 607 radial DSA and 635 femoral DSA identified among 5 fellows. The overall angiographic efficiencies were not significantly different based on access site (radial mean 3.2 min, femoral mean 3.7 min, p>0.05). For 3 fellows without prior endovascular experience, technical proficiency was obtained between 25–50 femoral DSA procedures. Among these same fellows, one fellow achieved technical proficiency after 25–50 radial DSA procedures, while the other 2 fellows had flattened learning curves. There were 2 fellows that had no significant learning curve for either access type, but both had extensive experience with endovascular procedures prior to starting fellowship. Two patients (2/1342 = 0.1%) experienced transient neurologic symptoms post-procedure. Among 635 femoral DSA, there were 22 (3.5%) minor adverse events (14 small groin hematomas not requiring transfusion, 1 pseudoaneurysm, 7 non-flow-limiting dissections). Among 607 radial DSA, there were 3 (0.5%) minor adverse events (2 small forearm hematomas, 1 intraluminal wire removed with radial cut-down), which was significantly less than femoral DSA minor adverse events (p=0.0001). Radial to femoral conversion rate was 1.2% (7/607, 2 radial spasm, 2 unsuccessful radial artery access, 3 aberrant right subclavian artery). Femoral to radial conversion rate was 0.3% (2/635). From March 2019 to February 2020, the proportion of DSA performed via transradial access increased from 36% to 78% at our institution. Conclusion This study demonstrates the learning curves for both TRA and TFA diagnostic cerebral angiograms. Proficiency improves significantly with either type of access, typically requiring between 25–50 procedures. TRA DSA have significantly less access site complications than TFA DSA. Disclosures M. Tso: None. G. Rajah: None. R. Dossani: None. M. Meyer: None. M. McPheeters: None. K. Vakharia: None. M. Waqas: None. K. Snyder: None. E. Levy: None. A. Siddiqui: None. J. Davies: None.

Introduction The NAPA study was a prospective, multicenter, single-arm IDE trial of the PulseRider device as an adjunctive treatment in conjunction with coil embolization of unruptured wide-neck bifurcation aneurysms which was electively discontinued for reasons not related to the safety or performance of the device. We report on the available enrollments in NAPA and their available follow up. Methods The PulseRider device was implanted in 18/21 enrollments. Available core-lab adjudicated data from the first 18 implants is presented. Of those, 5 have one year follow up data available. Of the 3 device implantation failures, the locations included basilar (1), carotid terminus (1), and ACOMM (1). Results For the 18 patients with PulseRider implanted as a coil-adjunct device, the mean age was 60.7± 8.9 yrs and 16 were female. The mean aneurysm diameter was 6.6± 2.2 mm, height 5.3±1.7 mm and neck 4.8 ±1.5 mm. Locations included the basilar apex (11), MCA bifurcation (4) and ACOMM (3). Thirteen of 18 were de novo aneurysms while the remainder (5) were treated in the setting of aneurysmal recurrence. The most common PulseRider placement was extra-aneurysmal (12/18), followed by intra-aneurysmal (4/18) and hybrid (2/18). Immediate angiographic occlusions were 66.6% RR-I, 16.7% RR-II, 16.7% RR-III. There were no device related adverse events. There were 3 (16.7%) procedure-related adverse events which did not result in neurological changes. Seven enrollments have 6 month follow up and all are RRI-II. Only 1 has one year angiographic follow up (RRI) adjudicated by the core lab, and 4 have clinical follow up (4/4 mRS 0–2). None of the target aneurysms have required retreatment. Conclusions The results of the discontinued NAPA provide high quality data on the occlusion rates and safety profile for the PulseRider device. Further one year angiographic and clinical follow up will be reported when available. Disclosures A. Spiotta: 1; C; Microvention. 2; C; Minnetronix, Penumbra, Cerenovus. 6; C; Cerenovus, Penumbra, Pulsar Vascular, Stryker, Microvention. K. Ebersole: None. J. Lena: None. R. Starke: 2; C; Medtronic Neurovascular, Penumbra, Cerenovus, Abbott. R. De Leacy: 6; C; Penumbra, Cerenovus, Siemens. A. Puri: 1; C; Stryker Neurovascular, Medtronic Neurovascular. 2; C; Stryker Neurovascular, Medtronic Neurovascular. D. Yavagal: 2; C; Medtronic Neurovascular, Rapid Medical, Steering Committee, Neuralanalytics. 6; C; Medtronic, Cerenovus/Johnson & Johnson, Rapid Medical, Neuralanalytics. B. Bohnstedt: 2; C; Penumbra, Stryker, Medtronic. L. Rangel-Castilla: None. A. Cheema: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University of Buffalo. 2; C; Medtronic, Neurotrauma Science, LLC. 4; C; RIST Neurovascular. K. de Macedo Rodrigues: None. J. Grossberg: None. B. Howard: None. C. Kellner: 1; C; Penumbra, Siemens Corp. G. Lanzino: None. S. Tateshima: 2; C; Cerenovus, Medtronic, Neurovasc, Stryker. 4; C; Neurovasc.

Introduction/Purpose Computed tomography perfusion (CTP) is a common imaging modality utilized to assess acute ischemic stroke (AIS) patient eligibility for mechanical thrombectomy. This assessment is done using an ischemic tissue ratio (penumbra to infarct) which is required to be greater than 1 for patients to be eligible for thrombectomy. Since various CTP software utilize different perfusion parameters and thresholds, there are known to be discrepancies in the amount of ischemic tissue quantified for each and therefore conflicting decisions regarding thrombectomy eligibility across software. This study aimed to assess the volumetric agreement of infarct between CTP and 24-hour follow-up fluid-attenuation inversion recovery (FLAIR) magnetic resonance imaging (MRI) along with the number of patients who would be misdiagnosed as ineligible for thrombectomy based on penumbra to infarct ratios by each CTP software. Materials and Methods Eighty-one emergent large vessel occlusion AIS patients who underwent successful reperfusion (thrombolysis in cerebral infarction 2b/2c/3) were included in this study. Predicted infarct and penumbra volumes were quantified within RAPID, Sphere, and Vitrea CTP software and compared with infarct measurements from FLAIR MRI. The following CTP parameters and thresholds were used to quantify ischemic tissue through comparison with contralateral hemispheres: RAPID: infarct=30% reduction of cerebral blood flow (CBF), penumbra=6 second increase in time to reach maximal residue function; Sphere: infarct=25% reduction of CBF (and 5 second increase of time-to-peak (TTP)), penumbra=5 second increase in TTP; Vitrea: infarct=38% reduction in cerebral blood volume (and 5.3 second increase in TTP or 55% reduction in mean-transit-time), penumbra=5.3 second increase in TTP or 5.8 second increase in delay time or 58% reduction in CBF. Penumbra to infarct ratios were calculated utilizing each software. Results Mean infarct differences, represented as 95% confidence intervals, between each software and FLAIR MRI are as follows: RAPID=6.96±4.93 mL, Sphere=-0.07±6.11 mL, Vitrea=4.13±4.73 mL. Mean absolute errors for each CTP software compared with FLAIR MRI are: RAPID=14.48 mL, Sphere=15.43 mL, Vitrea=11.44 mL. Mean penumbra to infarct ratios for each CTP software are: RAPID=70.93; Sphere=32.72; Vitrea=12.33. Total number of patients misdiagnosed as ineligible for thrombectomy (penumbra to infarct ratio less than 1 but successful reperfusion was conducted) for each software: RAPID=1.23% (1/81), Sphere=6.17% (5/81), Vitrea=25.93% (21/81). Conclusions Sphere provided the most accurate results regarding the closest predicted CTP infarct volume to the true FLAIR MRI infarct volume, although with slightly higher error in its measurements compared to RAPID and Vitrea. Penumbra to infarct ratio analysis indicated RAPID and Sphere to provide the most accurate assessment regarding patient eligibility for thrombectomy. However, it appears sacrificing ischemic tissue measurement precision is required for more accurate inclusion of patients as thrombectomy eligible. This is seen by the significantly high mean penumbra to infarct ratio for RAPID which may suggest a caution overestimation of penumbra to label as many patients as possible as thrombectomy eligible for the purpose of regaining lost neurological function. Disclosures R. Rava: None. M. Mokin: 1; C; NIH grant support R21NS109575. 2; C; Canon Medical Systems Corporation, Cerebrotech, Imperative care. M. Waqas: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413. 3; C; Penumbra. 4; C; RIST Neurovascular. E. Levy: 2; C; Claret Medical, GLG Consulting, Guidepoint Global, Imperative Care, Medtronic, Rebound, StimMed. 4; C; NeXtGen Biologics, RAPID Medical, Claret Medical, Cognition Medical, Imperative Care (formerly the Stroke Project), Rebound Therapeutics, StimMed, Three Rivers Medical. Y. Hoi: 5; C; Canon Medical Systems Inc. A. Siddiqui: 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc, Cerebrotech Medical Systems Inc, Cerenovus, Corindus Inc, Endostream Medical Ltd, Guidepoint Global Consulting, Imperative Care, Integra LifeSciences Corp, Medtronic, MicroVention, Northwest University–DSMB Chair for HEAT Trial, Penumbra, Q’Apel Medical Inc, Rapid Medical, Rebound Therapeutics Corp, Serenity Medical Inc, Silk Road Medical, StimMed, Stryker, Three Rivers Medical, Inc., VasSol, W.L. Gore & Associates. 4; C; Amnis Therapeutics, Apama Medical, Blink TBI Inc, Buffalo Technology Partners Inc, Cardinal Consultants, Cerebrotech Medical Systems, Inc, Cognition Medical, Endostream Medical Ltd, Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics Inc, Q’Apel Medical Inc, Rebound Therapeutics Corp, Rist Neurovascular Inc, Serenity Medical Inc, Silk Road Medical, StimMed, Synchron, Three Rivers Medical Inc, Viseon Spine Inc. C. Ionita: 1; C; Equipment grant from Canon Medical Systems, Cummings Foundation support. K. Snyder: 2; C; Canon Medical Systems Corporation, Penumbra Inc, Medtronic, Jacobs Institute.