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Background and PurposeThe best approach to select patients for reperfusion therapy in acute ischemic stroke remains to be established. Different methodologies have been proposed using different clinical, vascular, and parenchymal imaging parameters. Our aim is to compare Perfusion-imaging Mismatch (PIM) and Clinical-Core Mismatch (CCM) patient selection and assess their ability to predict outcomes.MethodsWe reviewed our prospectively collected endovascular database at a tertiary care academic institution for patients with acute anterior circulation strokes, adequate CT perfusion imaging maps and a National Institute of health Stroke Scale (NIHSS)≥10 from September 2010 to March 2015. Patients were categorized according to the PIM and CCM definitions. The ability of PIM and CCM to predict good outcomes (modified Rankin scale 0–2) was evaluated using the area under the receiver operating characteristic curves (AUC), Akaike information criterion (AIC) and Bayesian information criterion (BIC).ResultsA total of 368 patients qualified for the study. PIM had a lower number of qualifying patients compared to CCM (n=231, 62.8% vs n=303, 82.3%). The two groups were statistically different (p<0.001) with the following disagreement: 12 PIM+/CCM– and 84 PIM–/CCM+. There were no differences in good outcomes between PIM+ and PIM- patients (52% vs 48%, p=0.5). CCM+ patients had higher rates of good outcomes than CCM- (53% vs. 35%, p=0.015). There were no differences between PIM and CCM in predicting good outcomes as assessed by the AUC, AIC and BIC (0.82, 323.64 and 330.61 vs 0.82, 323.56 and 330.53 respectively)ConclusionWe were unable to demonstrate a difference between the PIM and CCM selection modalities in the prediction of clinical outcomes. However, PIM seems to unjustifiably disqualify a significant proportion of patients that still benefit from reperfusion. In contrast with CCM, the existence of PIM does not seem to be a good discriminator of good outcomes. Future prospective studies are warranted.DisclosuresJ. Grossberg:None. M. Bouslama:None. D. Haussen:None. L. Rebello:None. M. Frankel:None. R. Nogueira:None.

IntroductionEndovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes (LVOS). Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied.MethodsWe retrospectively reviewed a prospectively collected endovascular database (September 2010-December 2015, n=898) for all patients with distal intracranial occlusions treated with endovascular therapy. Distal occlusions were defined as any occlusion of the anterior cerebral artery (ACA), any occlusion of the posterior cerebral artery (PCA), or any occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment.ResultsDistal occlusions were treated in 70 patients. The mean age was 66+/-14% and 57% of the patients were male. Thirty-one (44%) of the patients received IV-tPA. The median pre-procedure NIHSS was 19 (IQR, 13–23). The distal occlusion was the primary treatment location in 54 patients and in 16 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal LVOS. The locations of the primary cases were MCA-M3 (n=21), ACA with a concomitant MCA-M1 or MCA-M2 (n=16), ACA alone (n=9), PCA (n=6), and ACA with a concomitant MCA-M3 (n=2). The locations of the rescue cases were MCA-M3 (n=8), ACA (n=7), and both MCA-M3 and ACA (n=1). The most common treatment modalities employed were intra-arterial tPA (n=37, 52%), small (3 mm) stent-retrievers (n=24, 33%), and thromboaspiration (n=30, 42%). Near or complete reperfusion (mTICI 2b-3) was achieved in 56 cases (80%). Overall, there were 5 (7%) cases of any parenchymal hematoma (PH). However, two of the PHs were in patients with both a MCA-M1 and an ACA occlusion, and both of these hemorrhages were in the MCA territory. Thus only 3 PHs (4.3%) occurred in the territory of the treated distal occlusion with two of these patients also receiving IV tPA. At 90 days, 24 patients (40%) had a mRS of 0–2 and 13 (21%) had died.ConclusionsDistal intracranial occlusions can be treated safely and successfully with endovascular therapy. Although promising our results need to be corroborated by larger prospective controlled studies.DisclosuresJ. Grossberg:None. L. Rebello:None. M. Bouslama:None. D. Haussen:None. M. Frankel:None. R. Nogueira:None.

BackgroundThe minimal stroke severity justifying endovascular intervention remains elusive; however, a significant proportion of patients presenting with large vessel occlusions and mild symptoms subsequently decline and have poor outcomes. We aimed to evaluate clinical outcomes of patients presenting with mild symptoms (NIHSS≤8) undergoing endovascular therapy.MethodsRetrospective analysis of a prospectively collected ET database between September/2010-March/2016. Patients with mild symptoms (baseline NIHSS ≤8) were included in the analysis. Primary and secondary efficacy outcome included the rates of good outcome (90 day mRS 0–2) and successful reperfusion (mTICI 2b-3), respectively. Safety outcome was accessed by rates of any parenchymal hematoma (PH-1 and PH-2) and 90 day mortality.Results72 patients with baseline NIHSS ≤8 we included in the analysis. Mean age in the overall cohort was 63.3 years (range, 56–69) and 39 patients were men (54%). The mean baseline NIHSS, CTP core volumes, and ASPECTS were 6.3±1.5, 7.5±16.1 cc, and 8.5±1.3 respectively. A total of 28 patients (38%) received intravenous tPA. The occlusions were located as follows: proximal MCA-M1 in 29 (40%), MCA-M2 in 20 (27%), ICA terminus in 6 (8%) and vertebrobasilar in 9 patients (12%). Tandem occlusion was documented in 7 patients (9%). Successful reperfusion (TICI 2b-3) was achieved in 67 patients (93%) and 90 day good outcome (mRS 0–2) in 52 (72%). The mean final infarct volume was 32.2±59.9 cc. Any parenchymal hematoma occurred in 4 patients (5%). The 90 day mortality was 9% (n=7). Logistic regression showed that only successful reperfusion (OR 27.7; 95% CI [1.1–655.5]; p=0.04) was an independent predictor of good outcomes.ConclusionOur findings demonstrate a good safety profile for endovascular therapy in patients presenting with low NIHSS and proximal arterial occlusions. Future prospective controlled studies are warranted.DisclosuresJ. Grossberg:None. L. Rebello:None. M. Bouslama:None. D. Haussen:None. M. Frankel:None. R. Nogueira:None.

Background and PurposeDifferent imaging paradigms have been used to select patients for endovascular therapy (ET) in large vessel occlusion stroke (LVOS). We sought to determine whether CT perfusion (CTP) selection improves ET outcomes as compared to non-contrast CT (NCCT) alone.MethodsReview of a prospective single-center interventional database of consecutive patients between September 2010 and March 2016. Patients with anterior circulation strokes undergoing stent-retriever thrombectomy were categorized according to imaging selection: (1) CTP and (2) NCCT alone. Two separate analyses were performed to assess the impact of CTP selection on outcomes: (1) Uni- and Multivariate analysis of the overall cohort and (2) Matched case-control analysis based on age, baseline NIHSS, and glucose levels.ResultsThe overall cohort included 602 patients. CTP-selected patients (n=365; 61%) were younger (mean age 63.9 v±15.2 vs. 67.8±14.5, p=0.02) and had less comorbidities. On univariate analysis, CTP-selection was associated with higher rates of full reperfusion (mTICI-3: 54.8% vs. 40.1%, p<0.001), increased rates of good outcomes (90 day mRS 0–2: 52.9% vs. 40.4%, p=0.005), smaller final infarct volumes (24.7 cc [9.8–63.1] vs. 34.6 cc [13.1–88], p=0.017), lower mortality rate (16.6% vs. 26.8%, p=0.005), and a favorable shift in the overall distribution of 90 day mRS (p<0.001) as compared with NCCT alone. The rates of any parenchymal hematoma were comparable between groups (9% vs. 10.1%, p=0.671). Multivariate logistic regression showed that CTP was independently associated with full reperfusion (OR=1.79 95% CI [1.27–2.53], p=0.001) and good outcomes (aOR=1.72 95% CI [1.10–2.67], p=0.017). In the matched case-control analysis (n=424 patients), CTP-selection was associated with a favorable shift in the distribution of 90 day mRS (p=0.016), lower 90 day mortality (15.7% vs. 23.6%, p=0.02), higher rates of TICI 3 reperfusion (54.8% vs. 40.1%, p<0.001), and a trend towards higher rates of 90 day independence (53 .% vs. 40%, p=0.06). There was an advantage in the ability of CTP to determine functional outcomes in patients presenting later than 6 hour (Akaike information criterion (AIC) 199.35 vs. 287.49 and Bayesian information criterion (BIC) 196.71 vs 283.27) and with an ASPECTS≤7 (AIC 216.69 vs 334.96 and BIC 213.6 vs 329.94).ConclusionCTP-based selection is associated with a favorable shift in functional outcomes in patients undergoing stent-retriever thrombectomy. Future prospective studies are warranted.DisclosuresJ. Grossberg:None. M. Bouslama:None. D. Haussen:None. L. Rebello:None. M. Frankel:None. R. Nogueira:None.

IntroductionThe smoking-thrombolysis paradox has been well described in myocardial infarction. However, its existence in the stroke population remains elusive. In the past decade, several studies have investigated the phenomenon with mixed results. We sought to determine whether clinical outcomes differ between smokers and non-smokers with acute ischemic stroke undergoing endovascular therapy.MethodsWe reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients who underwent endovascular therapy for large vessel occlusion acute ischemic stroke were categorized into current smokers and non-smokers. Baseline characteristics, procedural radiological as well as outcome parameters where compared.ResultsA total of 968 patients qualified for the study of which 189 (19.5%) were current smokers. Smokers were younger (60.78±11.95 vs. 66.41±15.05 years, p<0.001), had higher rates of dyslipidemia (49.7% vs 31.7%, p<0.001) and posterior circulation strokes (13.2% vs 7.8%, p=0.02,) and lower rates of atrial fibrillation (21.1% vs 37.9%, p<0.001). There were no statistically significant differences between groups in terms of stroke severity (as assessed by NIHSS), baseline CT perfusion core and hypoperfusion volumes, CT angiogram collateral scores, as well as procedural variables. On univariate analysis, smokers had higher rates of good outcomes at 90 days (modified Rankin scale, mRS 0–2: 53.8% vs 42.8%, p=0.01) and similar rates of successful reperfusion (mTICI 2b-3) (92.1% vs 87.7%, p=0.09), parenchymal hematomas (4.2% vs 4%, p=0.84) and mortality at 90 days (20.2% vs 25.7%, p=0.14). Multivariate analysis showed that smoking was not independently associated with good outcomes. Stratifying for (1) stroke etiology and (2) anterior vs. posterior circulation topology yielded similar results.ConclusionIn stroke patients treated with mechanical thrombectomy, smoking does not seem to be associated with outcomes regardless of stroke subtype or location.DisclosuresJ. Grossberg:None. M. Bouslama:None. L. Rebello:None. D. Haussen:None. M. Frankel:None. R. Nogueira:None.