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Introduction: Balloon test occlusion (BTO) with adjunctive single-photon emission computed tomography (SPECT) has been utilized to predict clinical tolerance after permanent internal carotid artery (ICA) occlusion. Cerebrovascular anatomical characteristics might predict BTO outcomes and identify patients susceptible to test failure. Methods: We performed a single center retrospective study of patients who underwent catheter based cerebral angiogram and ICA BTO from July 2013 to June 2020. SPECT imaging was completed in all the patients who passed the clinical BTO; technetium 99m-ethyl cysteinate dimer was injected intravenously after 15-30 min of occlusion and induced hypotension. The diameter of each of the vessels of the Circle of Willis was measured angiographically. The severity of hypoperfusion on SPECT imaging was classified as none, mild, low intermediate, high intermediate, and severe. Results: A total of 57 patients underwent BTO; neoplasia was the most common indication (n=43, 75%). Twelve patients (21.1%) developed neurologic symptoms and clinically failed the BTO; 45 patients (78.9%) passed and proceeded to SPECT. Contralateral dominant vertebral artery (p=0.02), smaller ACom (p=0.002) and ipsilateral PCom (p=0.03) diameters were correlated with clinical BTO failure. Smaller ACom was most predictive with an AUC of 0.907. The Youden index identified an ACom diameter threshold of 1.1 mm, which demonstrated a sensitivity of 91.7% and specificity of 77.8% (OR 0.026, 95% CI 0.003 - 0.226, ROC=0.847) for the prediction of BTO failure. Patients with severe SPECT asymmetry had significantly smaller caliber ACom arteries (ACom median diameter 0.95 mm vs. rest of cohort median 1.4; p=0.0073). Conclusions: BTO outcomes may be predicted using angiographic findings. A small (

Introduction: Previous research reported higher prevalence of vascular risk factors and worse outcomes after stroke in non-white patients compared to whites. Whether similar results still apply in the post mechanical thrombectomy era remains unknown. Methods: The STAR registry combined the prospectively maintained databases of 11 thrombectomy-capable stroke centers in the US, Europe, and Asia. Consecutive patients who underwent MT were included in these analyses. Baseline features, risk factors, location of occlusion, time from symptom onset, tPA receipt, procedural complication rates, symptomatic hemorrhage, and long-term functional outcome were compared between white and non-white patients. Multivariate logistic regression analysis was performed to evaluate the impact of race on long-term outcome. Results: Total of 2,284 patients were included in this analysis. Of those, 1,436 (62.9%) were white. Baseline features and outcomes are summarized in table 1. Non-white patients were older ( 71 Vs 66, p= Conclusion: In this study, white race was independent predictor of good 90-day outcome. This finding could be due to higher prevalence of vascular risk factors in non-white patients.

Introduction: There is no definitive evidence currently to guide the choice between general anesthesia (GA) over conscious sedation (CS) for patients undergoing mechanical thrombectomy (MT). As MT outcomes are highly time-sensitive especially in the early time window, we aim to evaluate work-flow metrics and outcome differences between the two approaches in routine clinical practice at a Comprehensive Stroke Center (CSC). Methods: From 2/2015-9/2018, 329 consecutive MT patients were included from a large retrospective CSC database. In late 2017, we implemented a first-choice GA protocol at our CSC from a first choice CS for MT. Baseline characteristics, work-flow metrics and outcomes measures: mRS at discharge, mRS last follow-up (median, IQR 184 days, 37.25-202.5), radiological hemorrhagic conversion (rHT) and symptomatic intracranial hemorrhage (sICH) defined as rHT with post-MT (4-24 hours) NIHSS worsening ≥4, were examined. Multivariate logistic regression model was used to compare workflow and outcomes in GA vs. CS patients. Results: 82 (25.2%) patients received GA and 246 (74.8%) received CS. Baseline characteristics show significantly higher baseline HTN (p .043) and posterior circulation strokes (p .02) in GA patients. Compared to CS, patients undergoing GA had significantly longer procedure times 54±35 vs. 37±22min (OR .98, 95%CI .97-.996) but no difference in onset- or door-to-puncture times. Both had similar first pass success ~57% vs. 53% (p .59), number of attempts 1(1-2) vs. 1(1-2) (p .94) and rate of TICI 2b-3 ~87% vs. 84% (p .85). On multivariate regression, there was no significant difference in outcome measures between GA and CS: rHT (OR 1.1, 95%CI .64-1.9), sICH (OR 1.15, 95%CI .41-3.2), mRS at discharge (OR .75, 95%CI .176-3.22) and mRS at last follow-up (OR 1.05, 95%CI .53-2.08). Conclusion: In routine clinical practice, compared to CS, patients who underwent GA for MT had no difference in clinical outcomes, despite longer procedure times.

Background: Obesity is an established risk factor for acute ischemic stroke (AIS), but its impact on clinical outcomes and mortality after AIS remains controversial. In this study, we evaluate the association of body mass index (BMI) on outcomes after mechanical thrombectomy (MT) for large vessel occlusion acute ischemic stroke (LVOS). Methods: We reviewed our prospective MT database for LVOS between 2015 and 2018. BMI was analyzed as a continuous and categorical variable with underweight BMI 30. Multivariate analysis was used to determine predictors of outcome. Results: 335 patients underwent MT with 7 (2.1%) patients classified as underweight, 107 (31.9%) normal, 141 (42.1%) overweight, and 80 (23.9%) obese. Compared to normal weight (reference), obese patients had higher rates of hypertension and hyperlipidemia, while underweight patients had higher rates of previous stroke and presentation NIHSS. The time from symptom onset to puncture, procedural techniques, and reperfusion success (>TICI 2b) was not significantly different between BMI categories. There was a significant inverse linear correlation between BMI and symptomatic hemorrhagic. In patients with successful reperfusion (>TICI 2b), there was also a significant bell-shaped relationship between BMI and functional independence (mRS < 3) with both low and high BMIs associated with worse outcomes. In patients without post-procedural symptomatic hemorrhage, there was a significant linear correlation between BMI and inpatient mortality. Conclusion: In LVOS patients treated with MT, BMI is inversely related with post-procedural symptomatic hemorrhage. Yet in those whom reperfusion is achieved, both lower and higher than normal BMI were associated with worse functional outcomes. Thus, the obesity paradox does not appear to pertain to mechanical thrombectomy, although larger prospective studies are necessary.

Introduction: Endovascular thrombectomy (ET) for treating acute stroke in the real-world has expanded beyond the selection criteria used in major trials, and currently includes posterior circulation strokes. Posterior circulation stroke is believed to have worse outcomes than anterior circulation stroke, and its outcomes following ET are still being studied. We explored the major determinants of functional recovery after ET for posterior circulation stroke in a large cohort of patients from the Stroke Thrombectomy and Aneurysm Registry (STAR). Methods: STAR includes patients undergoing ET for acute ischemic stroke at 12 comprehensive stroke centers in the US and globally. Data on patient demographics, technical and clinical outcomes was reviewed retrospectively from patient charts and procedure notes. Primary outcomes was the modified Ranking Score (mRS) at 90 days dichotomized into favorable (mRS 0-2) and poor outcome (mRS 3-6). Results: A total of 3850 patients were reviewed, of which 345 patients (mean age 60±14) were treated for posterior circulation stroke with predominantly basilar artery occlusion (80%). Patients were treated using aspiration thrombectomy (ADAPT, 39%), stent retriever thrombectomy (31%), combined approach (19%) or intracranial stenting (7%). The overall rate of favorable outcome was 33%. Patients with diabetes, high NIHSS on admission, and proximal occlusions had significantly higher odds of poor functional outcomes on multivariate analysis (p Conclusions: Despite similar rates of functional recovery after ET for anterior circulation stroke between stent retriever and ADAPT, our analysis demonstrates that in posterior circulation stroke, ADAPT may lead to better functional outcomes compared to stent retriever without differences in safety profiles.

Background: Standard mechanical thrombectomy (MT) techniques utilized include aspiration thrombectomy (ADAPT), stent retriever (SR), and a combination of both (Solumbra). Many studies compare outcomes between ADAPT and SR; however, there has yet to be a large multicenter investigation comparing ADAPT and SR to Solumbra. Methods: All patients from the participating STAR collaboration who underwent MT from 2015-2019 were included. Patients were analyzed by first MT technique utilized (ADAPT, SR, or Solumbra). Univariable and multivariable linear regression was utilized to analyze the MT technique association to number of thrombectomy attempts and procedure time. Univariable and multivariable logistic regression was utilized to determine the association between MT technique and the following outcomes: recanalization, symptomatic hemorrhage, 90-day functional independence, or 90-day mortality. P value less than 0.5 was considered significant. Results: A total of 2515 MT for stroke were identified: 1155 (46%) ADAPT, 735 (29%) SR, 625 (25%) Solumbra. Patients who received Solumbra MT were older (p Conclusion: Compared to standard ADAPT and SR thrombectomy, the Solumbra technique for MT is a longer procedure that results in an increased likelihood of hemorrhage and 90-day mortality.

Introduction: Radiological hemorrhagic transformation (rHT) and symptomatic intracranial hemorrhage (sICH) remain a major complication of mechanical thrombectomy (MT) in acute stroke. Our aim is to identify independent predictors of rHT and sICH. Methods: A retrospective multicenter international study across the US and Europe included 2499 patients, 18 years or older, who underwent EVT for acute stroke from 2015-2019. rHT is defined as any intracranial hemorrhage post MT and subgrouped per ECASS II as petechial (HI), parenchymal hematoma without (PH1) and with mass effect (PH2) and subarachnoid hemorrhage (SAH). sICH was defined as presence of PH2 or SAH. Functional outcomes were described using the 90-day modified Rankin score (mRS) as “good” 0-2 or “poor” 3-6. Multivariable logistic regression model was used to identify predictors of rHT and sICH. Results: 600 (24%) had rHT and 145 (5.8%) had sICH. On multivariable regression model, independent predictors for both rHT and sICH were higher admission NIHSS (OR 1.03, p Conclusion: Compared to posterior circulation, anterior circulation strokes have higher rates of rHT and sICH. Baseline hyperlipidemia is protective for rHT or sICH post MT and this association needs further study. Clinical severity of stroke, poor ASPECTS on admission and higher thrombectomy attempts are associated with higher rates of rHT or sICH. Both rHT and sICH are independently associated with poor functional outcomes.

Background: The transradial approach (TRA) to endovascular procedures decreases access site morbidity and mortality when compared to the traditional transfemoral technique (TFA). Despite its improved safety profile, there remains concerns that performing mechanical thrombectomy (MT) via TRA may lead to longer revascularization times and thus worse outcomes. However, TRA may confer an added benefit in mechanical thrombectomy (MT) where navigation of challenging aortic arch and carotid anatomy is often facilitated by a right radial artery trajectory. In this study, we compare technical and clinical outcomes in patients who underwent MT via TRA versus TFA. Methods: We performed a retrospective review of our institutional database to identify 51 patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion between February 2015 and February 2017. Patient characteristics, procedural techniques, and outcomes were recorded and TFA and TRA cohorts were compared. Results: Of the 51 patients, 35% of patients (n=18) underwent MT via TRA. There were no significant differences between the cohorts in patient characteristics, clot location, or aortic arch type and presence of ICA tortuosity. There were no significant differences in technical or clinical outcomes between the 2 cohorts, including rates of single-pass recanalization (54.6% vs. 55.6%, p=0.949) and average number of passes (1.9 vs. 1.7, p=0.453). Mean time from vascular access to reperfusion (61.9 vs. 61.1 mins, p=0.920), rates of successful revascularization (>= TICI2b; 87.9% vs. 88.9%, p=1.0) and functional outcomes (mRS >=2, 39.4% vs. 33.3%, p=0.669) were also similar between the TFA and TRA cohorts, respectively. Conclusions: Our results demonstrate equivalence in efficacy and efficiency between transradial and transfemoral access for MT in acute large vessel occlusion in the anterior circulation in patients with challenging vascular anatomy. Given the established advantage in access-site morbidity, our data suggests that the transradial approach may be superior to the transfemoral approach in well-selected patients undergoing MT.

Introduction: For patients with large vessel occlusions (LVOs), current data focuses on strict blood pressure (BP) management 24 hours post-mechanical thrombectomy (MT). We assessed the longitudinal relationship between in-hospital BP following MT and outcomes. Methods: We reviewed our prospectively maintained database of consecutive patients with LVO treated with MT from 2016 to 2017. Daily maximum systolic (SBP) and diastolic blood pressures were recorded. Relationships between maximum BP values and mortality, hemorrhage, and functional outcome (FI=mRS≤2) at follow up were analyzed in a multivariable logistic regression analysis. Longitudinal BP trends with regards to outcome was analyzed with repeated measures ANOVA. Results: A total of 228 thrombectomies were performed. Incremental 10 mmHg increases in peak 24-hour SBP were independently predictive of a higher likelihood of hemorrhagic conversion (OR 1.2, p=0.017) and a trend towards decreased functional outcome (OR 0.86, p=0.06). Independent of hemorrhage and additional covariates, incremental 10 mmHg increases in day 3 peak SBP was strongly correlated with worse functional outcomes (OR, 0.66 p=.0001). Day 3 SBP>140 was independently predictive of a lower likelihood of favorable outcome (OR 0.35, p=0.006). Between 24 and 48 hours post-MT, all patients demonstrated a decrease in peak SBP. Patients with functional dependence on follow up (mRS>2) had a rebound in peak SBP 48-72 hours post-MT (mean SBP change: FI -3.5 mmHg, non-FI +3.9 mmHg; p=.005; figure 1). This trend more pronounced in patients without hemorrhage (mean SBP change: FI -3.1 mmHg, non-FI +5.9 mmHg; p=.003). Conclusion: High maximum SBP and a rebound SBP on the third day following MT is independently associated with worse functional recovery.

Mechanical thrombectomy (MT) has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) in well-selected patients. Although many devices and strategies exist, use of a balloon-tip guide catheter (BGC) in conjunction with stent-retriever (SR) may hold many advantages. We aim to assess the efficacy and identify predictors of technical success of this unique approach. We reviewed our prospectively maintained database to identify 93 consecutive cases in which a BGC was used for MT in anteriorcirculation LVO, between February 2015 and September 2016. Various preprocedural and intraprocedural variables were recorded in addition to technical and clinical outcome measures. Predictors of technical and clinical outcome were identified by univariate and multivariable logistic regression analysis. Successful recanalization of the LVO (mTICI=2b) was achieved in 86.9% (n=80) of cases, including a first-pass success rate of 52.7% (n=49) and complete revascularization of mTICI 3 in 56.5% (n=52) of cases. Average time from groin puncture to reperfusion was 67.9 minutes. The M1 segment was the most common location of the occlusive thrombus (64.5%, n=60). Preoperative IV-tPA was administered in 55.9% (n=52) of cases and 48.4% (n=45) were functionally independent (mRS=4; OR 1.76, p=0.008). BGC use in MT results in a high rate of technical success and excellent clinical outcome in anterior circulation LVOs. While the optimal strategy for performing thrombectomy is unclear, our data suggest BGC in combination with SR may be most effective in removing MCA clots.