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Background: We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020. Methods: We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am –8:59 pm ) and nighttime (9:00 pm –7:59 am ). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated. Results: We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR], 1.620 [95% CI, 1.020–2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680–1.163]; P interaction =0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548–1.072]; nighttime, acOR, 1.785 [95% CI, 1.024–3.112] ; P interaction P interaction >0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers. Conclusions: Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02795962.

Background: Acute ischemic stroke with large or medium-vessel occlusion associated with intracranial artery calcification (IAC) is an infrequent phenomenon presumably associated with intracranial atherosclerotic disease. We aimed to characterize IAC and its impact on endovascular treatment outcomes. Methods: We performed a retrospective cross-sectional study of consecutive patients with stroke treated with thrombectomy from January 2020 to July 2021 in our institution. We described IAC findings (length, density, and location pattern) on baseline noncontrast computed tomography. Patients were divided into 3 groups: IAC related to the occlusion location (symptomatic-IAC group), unrelated to the occlusion (asymptomatic-IAC group), and absence of any IAC (non-IAC group). We analyzed the association between the IAC profile and outcomes using logistic regression models. Intracranial angioplasty and stenting were considered rescue treatments. Results: Of the 393 patients included, 26 (6.6%) patients presented a symptomatic-IAC, 77 (19.6%) patients an asymptomatic-IAC, and in 290 (73.8%) patients no IAC was observed. The rate of failed recanalization (expanded Thrombolysis in Cerebral Infarction 0-2a) before rescue treatment was higher in symptomatic-IAC (65.4%) than in asymptomatic-IAC (15.6%; P P P P P P =0.004), and poor functional outcome (90-day modified Rankin Scale score ≥3; odds ratio, 3.51 [95% CI, 1.02–12.00]; P =0.046). Conclusions: The presence of IAC related to the occlusion location is associated with worse angiographic and functional outcomes. Therefore, identification of symptomatic-IAC on baseline imaging may guide optimal endovascular treatment strategy, predicting the need for intracranial stenting and angioplasty.

Background: We aim to compare the outcome of patients from urban areas, where the referral center is able to perform thrombectomy, with patients from nonurban areas enrolled in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion). Methods: Patients with suspected large vessel occlusion stroke, as evaluated by a Rapid Arterial Occlusion Evaluation score of ≥5, from urban catchment areas of thrombectomy-capable centers during RACECAT trial enrollment period were included in the Stroke Code Registry of Catalonia. Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with an ischemic stroke. Secondary outcomes included mortality at 90 days, rate of thrombolysis and thrombectomy, time from onset to thrombolysis, and thrombectomy initiation. Propensity score matching was used to assemble a cohort of patients with similar characteristics. Results: The analysis included 1369 patients from nonurban areas and 2502 patients from urban areas. We matched 920 patients with an ischemic stroke from urban areas and nonurban areas based on their propensity scores. Patients with ischemic stroke from nonurban areas had higher degrees of disability at 90 days (median [interquartle range] modified Rankin Scale score, 3 [2–5] versus 3 [1–5], common odds ratio, 1.25 [95% CI, 1.06–1.48]); the observed average effect was only significant in patients with large vessel stroke (common odds ratio, 1.36 [95% CI, 1.08–1.65]). Mortality rate was similar between groups(odds ratio, 1.02 [95% CI, 0.81–1.28]). Patients from nonurban areas had higher odds of receiving thrombolysis (odds ratio, 1.36 [95% CI, 1.16–1.67]), lower odds of receiving thrombectomy(odds ratio, 0.61 [95% CI, 0.51–0.75]), and longer time from stroke onset to thrombolysis (mean difference 38 minutes [95% CI, 25–52]) and thrombectomy(mean difference 66 minutes [95% CI, 37–95]). Conclusions: In Catalonia, Spain, patients with large vessel occlusion stroke triaged in nonurban areas had worse neurological outcomes than patients from urban areas, where the referral center was able to perform thrombectomy. Interventions aimed at improving organizational practices and the development of thrombectomy capabilities in centers located in remote areas should be pursued. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02795962.

Background and Purpose: The potential benefit of blood pressure (BP) lowering in intracerebral hemorrhage (ICH) patients is time-dependent and is an easy and modifiable treatment applicable to different hospital scenarios. However, previous clinical trials did not establish consensus about the best BP strategy to achieve a rapid and sustained BP control. We aimed to assess the impact of learning a staged implementation of rapid-intensive-sustained BP protocol on time targets and BP control rate over the first 24 hours of ICH. Methods: We conducted a retrospective analysis of data prospectively collected of consecutive patients with spontaneous ICH (150 mmHg under a rapid (antihypertensive IV bolus by a stroke nurse at CT scan), intensive (SBP target Results: A total of 207 patients were included in the study. Compared between the periods, the frequency of SBP target achievement during the first hour was increased steadily over different periods(33.3% vs. 54.5% vs. 69.2% vs 69.4% vs 75% and 59.7%; P=0.024 ); median time to SBP target achievement tended to be lower during the evolution of protocol assessment (120 [45-240] min; 49.5 [30-101] min; 53 [29-82] min; 47 [28-74] min; 48 [27-66] min; 50 [30-85] min; P=0.054 ) and SBP sustention rate below the target improve during the acute phase at different time frames, including 2h (26.3% vs. 71.9% vs 60% vs 73.9% vs. 57,7% vs 59.5%; P= 0.012 ), 4h (57.1% vs. 63.3% vs 87.5% vs 85% vs. 61.5% vs. 69.2%; P= 0.05 ), 6h (60.9% vs. 58.6%, vs 95.5% vs 84.4% vs 58.3% vs. 75%; P=0.009 ). Conclusions: Rapid-intensive-sustained BP protocol is a good intervention to both achieve a rapid BP target and reduce time delays,and improve the rates of BP control over the acute phase of ICH patients.

Background and Purpose: Different studies have pointed that CT perfusion (CTP) could overestimate ischemic core in early time window. We aim to evaluate the influence of time and collateral status on ischemic core overestimation. Methods: Retrospective single-center study including patients with anterior circulation large-vessel stroke that achieved reperfusion after endovascular treatment. Ischemic core and collateral status were automatically estimated on baseline CTP using commercially available software. CTP-derived core was considered as tissue with a relative reduction of cerebral blood flow 6 seconds with time to maximum of tissue residue function >10 seconds). Final infarct volume was measured on 24 to 48 hours noncontrast CT. Ischemic core overestimation was considered when CTP-derived core was larger than final infarct. Results: Four hundred and seven patients were included in the analysis. Median CTP-derived core and final infarct volume were 7 mL (interquartile range, 0–27) and 20 mL (interquartile range, 5–55), respectively. Median hypoperfusion intensity ratio was 0.46 (interquartile range, 0.23–0.59). Eighty-three patients (20%) presented ischemic core overestimation (median overestimation, 12 mL [interquartile range, 41–5]). Multivariable logistic regression analysis adjusted by CTP-derived core and confounding variables showed that poor collateral status (per 0.1 hypoperfusion intensity ratio increase; adjusted odds ratio, 1.41 [95% CI, 1.20–1.65]) and earlier onset to imaging time (per 60 minutes earlier; adjusted odds ratio, 1.14 [CI, 1.04–1.25]) were independently associated with core overestimation. No significant association was found with imaging to reperfusion time (per 30 minutes earlier; adjusted odds ratio, 1.17 [CI, 0.96–1.44]). Poor collateral status influence on core overestimation differed according to onset to imaging time, with a stronger size of effect on early imaging patients( P interaction Conclusions: In patients with large-vessel stroke that achieve reperfusion after endovascular therapy, poor collateral status might induce higher rates of ischemic core overestimation on CTP, especially in patients in earlier window time. CTP reflects a hemodynamic state rather than tissue fate; collateral status and onset to imaging time are important factors to consider when estimating core on CTP.

Background and Purpose— Despite recanalization, almost 50% of patients undergoing endovascular treatment (EVT) experience poor outcome. We aim to evaluate the value of computed tomography perfusion as immediate outcome predictor postendovascular treatment. Methods— Consecutive patients receiving endovascular treatment who achieved recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI] 2a-3) underwent computed tomography perfusion within 30 minutes from recanalization (CTPpost). Hypoperfusion was defined as the Tmax>6 second volume; hyperperfusion as visually increased cerebral blood flow/cerebral blood volume with reduced Tmax compared with unaffected hemisphere. Dramatic clinical recovery (DCR) was defined as 24-hour National Institutes of Health Stroke Scale score ≤2 or ≥8 points drop. Delayed recovery was defined as no-DCR with favorable outcome (modified Rankin Scale score 0–2) at 3 months. Results— We included 151 patients: median National Institutes of Health Stroke Scale score 16 (interquartile range, 10–21), median admission ASPECTS 9 (interquartile range, 8–10). Final recanalization was the following: mTICI2a 11 (7.3%), mTICI2b 46 (30.5%), and mTICI3 94 (62.3%). On CTPpost, 80 (52.9%) patients showed hypoperfusion (median Tmax>6 seconds: 4 cc [0–25]) and 32 (21.2%) hyperperfusion. There was an association between final TICI and CTPpost hypoperfusion(median Tmax>6: 91 [56–117], 15 [0–37.5], and 0 [0–7] cc, for mTICI 2a, 2b, and 3, respectively, P P P P P Conclusions— Hypoperfusion on CTPpost constitutes an immediate accurate surrogate marker of success after endovascular treatment and identifies those patients with delayed recovery and favorable outcome.

Background and Purpose— Substantial proportion of patients who achieve successful recanalization of acute ischemic stroke due to large vessel occlusion do not achieve good functional outcome. We aim to analyze the effect of number of thrombectomy device passes and degree of the recanalization (by modified Thrombolysis in Cerebral Infarction) on the clinical and functional outcome. Methods— Five hundred forty-two consecutive patients underwent mechanical thrombectomy for large vessel occlusion in the anterior circulation at a single tertiary stroke center. Baseline characteristics, number of passes, recanalization degree, clinical outcome at 24 hours (measured by National Institutes of Health Scale score), and functional outcome (measured by modified Rankin Scale at 90 days) were registered. Multivariate analysis was performed to determine the association of number of passes and degree of recanalization with dramatical clinical recovery (final National Institutes of Health Scale score ≤2 or decrease in 8 or more National Institutes of Health Scale score points in 24 hours) and good functional outcome (modified Rankin Scale score ≤2 at 90 days). Results— Four hundred fifty-nine patients (84%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction 2B–3), 213 (39%) of them after first device pass. In the multivariate analysis, first-pass recanalization and modified Thrombolysis in Cerebral Infarction 3 were independent predictors of good functional outcome (odds ratio, 2.5; 95% CI, 1.4–4.5; P =0.002 and odds ratio, 2.6 CI; 1.5–4.7; P =0.001, respectively) and dramatical clinical recovery (odds ratio, 1.8; 95% CI, 1.1–3; P =0.032 and odds ratio, 2.9; 95% CI, 1.7–5.1; P P P Conclusions— High number of device passes and less degree of recanalization are associated with worse outcome in patients with acute ischemic stroke secondary to large vessel occlusion. Future studies should investigate the optimal number of passes that should be attempted in patients without substantial recanalization.

Background and Purpose— Risk factor control and treatment compliance in the following months after stroke are poor. We aim to validate a digital platform for smartphones to raise awareness among patients about the need to adopt healthy lifestyle, improve communication with medical staff, and treatment compliance. Methods— Farmalarm is an application (app) for smartphones designed to increase stroke awareness by medication alerts and compliance control, chat communication with medical staff, didactic video files, exercise monitoring. Patients with stroke discharged home were screened for participation and divided into groups: to follow the FARMALARM program for 3 to 4 weeks or standard of care follow-up. We determined achievement of risk factor control goals at 90 days. Results— From August 2015 to December 2016, from the 457 patients discharged home, 159 (34.8%) were included: Farmalarm (n=107); age 57±12, Control (n=52), age 59±10; without significant differences in baseline characteristics between groups. At 90 days, knowledge of vascular risk factors was higher in FARMALARM group (86.0% versus 69.2%, P P P =0.03) under control and the rate of patients with 4 out of 4 risk factors under control was higher in FARMALARM group (50.4% versus 30.7%, P =0.02). A regression model showed that the use of Farmalarm was independently associated with all risk factors under control at 90 days (odds ratio, 2.3; 95% CI, 1.14–4.6; P =0.02). Conclusions— In patients with stroke discharged home, the use of mobile apps to monitor medication compliance and increase stroke awareness is feasible and seems to improve the control of vascular risk factors.

Background and Purpose— Direct transfer to angiography-suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The magnitude of the improvement of good outcome rates in function of time depends of several factors. We aim to analyze the benefit of DTAS according to time from symptom onset. Methods— Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to computed tomography (directly transferred to computed tomography) from February 2016 to June 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline National Institutes of Health Stroke Scale score (±2 points), and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (modified Rankin Scale score, 0–2) and safety variables stratified in less or more than 3 hours from onset to arrive. Results— There were no significant differences regarding age, sex, or baseline National Institutes of Health Stroke Scale score. Median door-to-groin time was shorter in the DTAS patients (16 [3–21] minutes versus 70 [41.5–98.5]; P P =0.01) and a lower rate of symptomatic hemorrhagic transformation (4.6% versus 10.9%, P P =0.01). Better outcome in DTAS was observed in patients admitted in the 0 to 3 hours form onset window (n=156, odds ratio 2.63 [95% CI, 1.31–5.28]; P P =0.2). Conclusions— DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.

Background and Purpose— First pass (FP) recanalization has been shown to be a predictor of favorable outcome in endovascular treatment of stroke. The reasons why FP recanalization leads to better outcome as compared with multiple passes (MP) are unknown. We aim to investigate the recanalization pattern and its relationship with outcome. Methods— Six hundred nine consecutive patients underwent endovascular treatment. Recanalization was defined as modified Thrombolysis in Cerebral Infarction score 2B-3. Favorable outcome was defined as modified Rankin Scale score of 0 to 2 at 90 days. Sudden recanalization (SR) was considered when modified Thrombolysis in Cerebral Infarction score varied from 0-1 to 2B-3 in a single pass. Progressive recanalization (PR) was considered if modified Thrombolysis in Cerebral Infarction score 2A was achieved at an interim pass before achieving recanalization. Patients were also categorized as recanalizers at FP, MP, or nonrecanalizers. Results— Five hundred nine (83.9%) patients achieved recanalization. SR was achieved in 378 (62.1%) patients; 280 (46%) were FP-SR, and 98 (16.1%) were MP-SR. MP-PR was achieved in 131 (21.5%) patients. Rates of favorable outcome were similar between patients with FP-SR (57.5%) and MP-SR (57.1%; odds ratio [OR], 0.9 [CI, 0.53–1.54]; P =0.7) but lower in MP-PR (29.8%; OR, 3.33 [CI, 1.71–5.63]; P P P P P P P =0.937). Conclusions— SR strongly predicts favorable outcome in patients undergoing endovascular treatment, even after previous unsuccessful attempts. PR may reflect clot fragmentation and embolization due to more friable composition, leading to worse outcomes. Prospective studies with independent assessment of recanalization pattern should validate these results.

Introduction: Perfusion imaging has emerged as an imaging tool to select patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) for endovascular treatment (EVT). We aim to compare an automated method to assess the infarct ischemic core (IC) in Non-Contrast Computed Tomography (NCCT) with Computed Tomography Perfusion (CTP) imaging and its ability to predict functional outcome and final infarct volume (FIV). Methods: 494 patients with anterior circulation stroke treated with EVT were included. Volumetric assessment of IC in NCCT (eA-IC) was calculated using eASPECTS™ (Brainomix, Oxford). CTP was processed using availaible software considering CTP-IC as volume of Cerebral Blood Flow (CBF) Results: Median eA-IC and CTP-IC were 16 (IQR 7-31) and 8 (IQR 0-28), respectively. 419 patients (85%) achieved complete recanalization, and their median FIV was 17.5cc (IQR 5-52). Good functional outcome was achieved in 230 patients (47%). EA-IC and CTP-IC had moderate correlation between them (r=0.52, p40cc, OR 1.5, IC1.3-1.8, p Conclusion: Automated volumetric assessment of infarct core in NCCT has similar performance predicting prognosis and final infarct volume than CTP. Prospective studies should evaluate a NCCT-core / vessel occlusion penumbra missmatch as an alternative method to select patients for EVT.

Introduction: Systemic blood pressure (BP) should be strictly monitored and adjusted during the initial stages of stroke. Due to the impairment of cerebral autoregulation, cerebral blood flow is directly affected by systemic BP and some degree of permissive hypertension might be beneficial prior to reperfusion treatments to ensure an adequate perfusion in the ischemic tissue. However, after generalization of endovascular treatment (EVT) the rate of successful recanalization has skyrocketed and it is not well established if, once achieved, BP control should be stricter given its potential risks. We aim to explore the relation between BP and outcome among patients who underwent EVT. Methods: This is a retrospective study of a prospectively acquired unicentric database that includes patients who underwent EVT with successful recanalization measured by a mTICI ≥2b. Hourly measuring of systolic and diastolic BP was conducted during the first 24 hours post-procedure. BP variation was measured using standard deviation (SD) and range. We explored the effects of BP on functional outcome at 3 months and safety variables. Results: The study included 351 subjects with a mean age of 72.7+/-13.1 and 51.6% were men. The 3-months mRS was ≤2 in 50.4% of patients, 66 subjects (19.2%) presented hemorrhagic transformation and 67 (19.1%) were dead in the 3-months follow-up period. Both systolic BP SD (15.6+/-9.9 vs. 12.9+/-4.3; p2). Subjects with hemorrhagic transformation presented higher range of DBP (35.7+/-12.4 vs. 32.0+/-11.9; p=0.03) and SBP (56.8+/-17.0 vs. 51.4+/-18.1; p=0.03) and higher diastolic DBP SD (9.3+/-4.1 vs. 8.2+/-2.7; p Conclusions: Major fluctuations in systolic and diastolic BP predict increased risk of hemorrhagic complications and poor functional outcome. Minimizing BP fluctuations may improve outcome of EVT patients after recanalization.

Background and Purpose: Extracranial internal carotid artery (ICA) lesion in the setting of tandem occlusions is a therapeutic challenge, and hemorrhagic transformation (HT) is one of the leading causes of poor clinical outcome. We aimed to determine determinants of HT for tandem occlusions undergoing emergent extracranial ICA stenting during endovascular treatment (EVT). Methods: We performed a prospective, observational cohort study of consecutive patients with non-cardioembolic ischemic stroke due to tandem occlusion who underwent EVT with extracranial ICA stent placement during the procedure from April 2013 to June 2019 in a single stroke center. We compared clinical (vascular risk factors, previous antiplatelet treatment, and IV rtPA), radiological (ASPECTS at admission and in-stent thrombosis at 24 hours) and serological (platelet count, fibrinogen, total cholesterol, HDL-cholesterol, and LDL-cholesterol) parameters according to the presence of HT in 24 hours CT-scan. Results: One-hundred and eight patients were included: 78.7% were men, mean age 68.5±14.3 years, median time from symptoms onset to treatment was 220 (150-337.5) minutes, median ASPECTS at admission was 9 (8-10). Eighty-six (79.6%) patients presented an extracranial ICA occlusion, and 22 (20.4%) a high-grade (>50%) stenosis. In 88 (81.5%) patients the etiology of extracranial ICA lesion was ateroma, and in 20 (18.5%) was a dissection. Intravenous rtPA was administered in 47 (43.5%) patients. Successful recanalization (mTICI ≥2b) was achieved in 83 (76.9%) patients, and extracranial ICA recanalization in 108 (100%) patients. Type 2 diabetes (OR 1.5, 95% CI 1.1-3.5), higher fibrinogen levels (OR 4.6, 95% CI 1.6-12.9), and ASPECTS Conclusions: Patients with a non-cardioembolic ischemic stroke due to tandem occlusion who present type 2 diabetes, higher fibrinogen levels, or ASPECTS

Introduction: First pass recanalization (FPR) is known to be a strong predictor of good outcome in endovascular treatment (EVT) of stroke. The reasons why FPR leads to better outcome than if achieved in multiple-passes (MP) are unknown. We aim to investigate the recanalization pattern and its relation with good outcome. Methods: 609 consecutive patients underwent EVT in the anterior circulation at a single stroke center. Demographic and imaging characteristics, number of passes and recanalization pattern were recorded. Complete recanalization was defined as mTICI2b-3 at the end of EVT. Good functional outcome was defined as modified Rankin scale (mRs) 0-2 at 90 days. Sudden recanalization(SR) was considered when mTICI score varied from 0-1 to 2B-3 in a single pass. Progressive recanalization (PR) was considered if mTICI 2a was achieved at an interim pass before achieving complete recanalization. Patients were categorized as recanalizers at first-pass (FP) and multiple-passes (MP) or non-recanalizers (NR). 70 (10.3%) patients in MP group were excluded due to missing procedural data. Results: 509 (83.9%) patients achieved complete recanalization. SR was achieved in 378 (62.1%) patients; 280 (46%) were FP-SR and 98 (16.1%) were MP-SR. MP-PR was achieved in 131 (21.5%) patients. Rates of good functional outcome depending on recanalization pattern were: FP-SR 57.5%, MP-SR 57.1% (FP-SR vs MP-SR, OR 0.9 CI 0.53-1.54, p=0.7), MP-PR 29.8% (MP-SR vs MP-PR, OR 3.06 CI 1.66-5.62, p Conclusions: Sudden recanalization is a strong predictor of good functional outcome in patients undergoing EVT, even after previous unsuccessful attempts. Progressive recanalization may reflect clot fragmentation and embolization due to more friable composition, leading to worse outcomes. Benefits of first pass effect are driven by sudden recanalization.

Direct transfer to angio suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The association of different time windows with prognosis in this population is influenced by several factors. We aim to analyze the influence of DTAS in clinical and functional outcome depending on time from symptom onset to treatment. Methods: Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to CT (DTCT) from February 2016 to April 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline NIHSS score (±2 points) and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (mRS 0-2) and safety variables stratified in less or more than 3 hours from onset to arrive. Results: There were no significant differences regarding age, gender or baseline NIHSS score (table 1). Median door-to-groin time was shorter in the DTAS patients (16 (13-21) minutes Vs 70 (41.5-98.5); p Conclusion: DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.

On CT perfusion (CTP), cerebral blood flow < 30% than the contralateral hemisphere (CBF Methods: Retrospective analysis of a prospective database of acute ischemic strokes who underwent CTP on admission and immediately after endovascular thrombectomy (EVT). CC was graded on CT angiography (CTA) by the modified Tan scale (good CC: 2-3 grades). Complete recanalization was defined by modified Thrombolysis in Cerebral Ischemia ≥ 2B. Final infarct volume (FIV) was semi-automatically measured on 48-72h CT; ghost core was defined as: admission CBF 10cc. Results: We included 494 patients; median time from onset to CT: 137 min (IQR 68-238). Median CBF10cc)). Even in recanalized patients, baseline CBF Conclusion: CBF

We aim to define a target population of stroke patients treated with EVT, in whom a potential neuroprotective (NP) drug has highest chances to show clinical and radiological positive effects. Methods: we studied stroke patients treated with EVT. CBF Results: We included 211 patients, mean FIV was 39(±58)cc and median dNIHSS 6(1-15). FIV strongly correlated to dNIHSS (rs=0.74; p Conclusion: One in 4 patients will develop minimal FIV, including these patients in NP trials may dilute a treatment effect and reduce odds of positive results. In large FIV patients, mild relative clinical impacts may become relevant due to substantial absolute FIV reductions. Admission CTP may help sorting patients according to expected drug effect profile.

Background and Purpose- Substantial proportion of patients who achieve successful recanalization of acute ischemic stroke due to large vessel occlusion do not achieve good functional outcome. We aim to analyze the effect of number of thrombectomy device passes and degree of the recanalization (by modified Thrombolysis in Cerebral Infarction) on the clinical and functional outcome. Methods- Five hundred forty-two consecutive patients underwent mechanical thrombectomy for large vessel occlusion in the anterior circulation at a single tertiary stroke center. Baseline characteristics, number of passes, recanalization degree, clinical outcome at 24 hours (measured by National Institutes of Health Scale score), and functional outcome (measured by modified Rankin Scale at 90 days) were registered. Multivariate analysis was performed to determine the association of number of passes and degree of recanalization with dramatical clinical recovery (final National Institutes of Health Scale score ≤2 or decrease in 8 or more National Institutes of Health Scale score points in 24 hours) and good functional outcome (modified Rankin Scale score ≤2 at 90 days). Results- Four hundred fifty-nine patients (84%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction 2B-3), 213 (39%) of them after first device pass. In the multivariate analysis, first-pass recanalization and modified Thrombolysis in Cerebral Infarction 3 were independent predictors of good functional outcome (odds ratio, 2.5; 95% CI, 1.4-4.5; P=0.002 and odds ratio, 2.6 CI; 1.5-4.7; P=0.001, respectively) and dramatical clinical recovery (odds ratio, 1.8; 95% CI, 1.1-3; P=0.032 and odds ratio, 2.9; 95% CI, 1.7-5.1; P0.001, respectively). Rate of recanalization declined after each pass 39% (213/542), 35% (113/310), 33% (63/190), and 24% (26/154) for passes 1 to 4, respectively and 28% (45/158) for every attempt above 4 passes ( P0.001). In patients who achieved recanalization, a linear association between number of passes and good functional outcome was observed: 1 pass (58.6%), 2 passes (50.5%), 3 passes (48.4%), 4 passes (38.5%), or 5 or more passes (25.6%; P0.001) as compared with patients who did not achieve recanalization (16.9%). Conclusions- High number of device passes and less degree of recanalization are associated with worse outcome in patients with acute ischemic stroke secondary to large vessel occlusion. Future studies should investigate the optimal number of passes that should be attempted in patients without substantial recanalization.

Background and Purpose- Risk factor control and treatment compliance in the following months after stroke are poor. We aim to validate a digital platform for smartphones to raise awareness among patients about the need to adopt healthy lifestyle, improve communication with medical staff, and treatment compliance. Methods- Farmalarm is an application (app) for smartphones designed to increase stroke awareness by medication alerts and compliance control, chat communication with medical staff, didactic video files, exercise monitoring. Patients with stroke discharged home were screened for participation and divided into groups: to follow the FARMALARM program for 3 to 4 weeks or standard of care follow-up. We determined achievement of risk factor control goals at 90 days. Results- From August 2015 to December 2016, from the 457 patients discharged home, 159 (34.8%) were included: Farmalarm (n=107); age 57±12, Control (n=52), age 59±10; without significant differences in baseline characteristics between groups. At 90 days, knowledge of vascular risk factors was higher in FARMALARM group (86.0% versus 69.2%, P0.01). The rate of patients with diabetes mellitus (83.2% versus 63.5%, P0.01) and hypercholesterolemia (80.3% versus 63.5%, P=0.03) under control and the rate of patients with 4 out of 4 risk factors under control was higher in FARMALARM group (50.4% versus 30.7%, P=0.02). A regression model showed that the use of Farmalarm was independently associated with all risk factors under control at 90 days (odds ratio, 2.3; 95% CI, 1.14-4.6; P=0.02). Conclusions- In patients with stroke discharged home, the use of mobile apps to monitor medication compliance and increase stroke awareness is feasible and seems to improve the control of vascular risk factors.

Introduction: Mechanical thrombectomy is the best treatment for large vessel occlusion in acute strokes, this technique can obtain clots for further analysis. Objective: To evaluate flow cytometry in thrombi obtained in the treatment of hyperacute stroke by mechanical thrombectomy, as a diagnostic tool in the etiological study of stroke Methods: Consecutively, intracranial clots were obtained in the hyperacute phase of stroke with solitaire device. Cell suspensions of thrombi were prepared that were labeled by direct immunofluorescence using conjugated monoclonal antibodies. The labeled samples were acquired in a Naviostm flow cytometer (Beckman-Coulter). The following leukocyte populations were studied: granulocytes, monocytes, total lymphocytes, T lymphocytes (CD3 +), helper T lymphocytes (CD3 +, CD4 +), suppressor-cytotoxic T lymphocytes (CD3 +, CD8 +), TNK lymphocytes (CD3 +, CD56 / 16 +) , NK lymphocytes (CD3-, CD56 / 16 +) and B lymphocytes (CD19 +). The results were expressed as percentages (%). The aetiology of stroke was categorized in secondary to: major structural heart disease, atrial fibrillation, stroke of atherosclerotic etiology (severe stenosis or complicated aortic atheromatosis ulceration) or infrequent causes. Results: 40 samples were analyzed. Clots of atherosclerotic etiology (n = 13) were associated with higher% of CD4 T lymphocytes (24.85% vs 15.83% p = 0.016), and higher% of NK (21.08% vs 17.04) % p = 0.07), also showed a tendency to a higher% LT (23.69% vs 16.46% p = 0.052). Strokes secondary to AF were associated with a higher percentage of CD8 T lymphocytes (20.24 vs 13.56 p = 0.048). Conclussion: Analysis by flow cytometry of clots obtained in the hyperacute phase of stroke showed significant differences in the different lymphocyte populations according to the etiology

Despite successful recanalization after endovascular treatment (EVT), a proportion of patients will not experience favorable outcome. We hypothesize that an early computed tomography perfusion (CTP-AFT) immediately after EVT may improve clinical outcome prediction. Methods: Consecutive patients with large vessel occlusion (LVO) who achieved partial (TICI 2a) or complete (TICI 2b/3) recanalization after EVT underwent CTP-AFT within 30 minutes. Different CTP parameters were measured with the Rapid software. Clinical data were recorded including dramatic recovery (DR: ≥8 points decrease from baseline NIHSS or NIHSS 0-2 at 24 hours) Results: Forty-six LVO were included, median baseline NIHSS was 18 (P25-75 13-22). Final recanalization grades were: TICI 2a, 5 patients (10.8%); TICI 2b, 19 (41.6%); and TICI 3, 22 (47.8%). Median 24h infarct volume was 7.5 cc (0-19). Median NIHSS decrease after 24h was 8 (1-16). Twenty-seven (58%) patients experienced DR. The volume with Tmax>6 seconds was the only CTP parameter that correlated with degree of recanalization: TICI 2a: 102cc (60-138); TICI 2b: 15cc (0-37); and TICI 3: 0cc (0-5), p6s volume was associated with lower 24h-infarct volume (p6s volume 6s volume Conclusion: CTP maps performed immediately after EVT correlated with degree of recanalization. However, a low Tmax>6s volume predicted clinical outcome better than post-procedural TICI scores.

Background: Endovascular therapies(EVT) have exponentially increased in the last few years. To maximize the benefits of EVT, complications related to the treatment need to be prevented or minimized with early detection and appropriate management. We implemented a specific registry to collect femoral post-puncture complications detected at different timepoints. Our aim was to identify factors associated with severe groin punction complications. Methods: Prospective study of consecutive patients treated with acute EVT or scheduled (angioplasty), admitted to our Stroke Unit from February2017-June2018. Post-catheterization femoral complications included: groin bleeding(GB), groin hematoma(GH), retroperitoneal hematoma(RH), femoral artery pseudoaneurysm(FAP), and artery dissection(AD). A specific registry was created for data collection at different timepoints: During or immediate post-EVT, at 24h post-compression and at discharge. Results: 384patients were treated with EVT(73%acute), mean age 71+/-13y.o, 69% men. Mynxgrip closure system was used in 346(91,8%). Compressive measures needed to be reinforced in 55 cases(14,5%)/changed in 15(4%). Early mobilization protocol(24-48h) was initiated in 335patients(92,3%). 9patients (2,8%) did not maintain the first 24h absolute rest. 57patients(15,1%) presented mild immediate complications(49GH,6GB). At 24h, 181(47,1%)patients presented GH(28,6%superficial, 18,2%internal) and 5GB(1,3%). At discharge, 29(8,1%)patients had presented clinically significant femoral complications: 16GH(13deep), 5FAP, 1AD, 4RH. 2 of those complications were fatal. Variables associated with severe complications at discharge were: age(p=0.037), non-use of mynxgrip(p=0.001), compressive replacement(p Conclusion: In our series, we found a yield of 8,1% of clinically significant groin complications associated with the EVT (0,5% fatal). We indentified age, closure device, requirement to replace compressive and lack of accomplishment of the early mobilization protocol as predictors of these complications.

Background and Purpose: Recent studies have highlighted the key influence of both time to achieve blood pressure (BP) control and the persistence of BP stable in the potential benefit of intensive BP reduction on attenuating intracerebral hemorrhage (ICH) expansion. We aimed to compare two different BP management protocols in acute ICH to determine the influence of stroke nursing practice in BP control over first 24h. Methods: Consecutive patients with spontaneous ICH 150 mmHg under an early (antihypertensive IV bolus by nursing attention at CT scan), intensive (SBP target Results: One hundred and three Early-Intensive-Maintained SBP patients were matched with 103 controls. Mean age was 71.7±13.3 years, 134 (65%) were men, and median SBP was 177 (162-197) mmHg. Median time to SBP target achievement was lower in Early-Intensive-Maintained SBP patients as compared with control group (45 [30-60] vs. 90 [27-167.50] min, P=0.045 ). Early-Intensive-Maintained SBP patients maintained the SBP below the target more frequently than control group at different time points, including 60 min (40.8% vs. 36.9%, P P P P Conclusions: The stroke nurse plays a key role in the management of BP in acute ICH patients. An early and continued nursing care allows a fast and maintained BP reduction in acute ICH patients under an intensive BP reduction protocol.