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BackgroundThe increasing utilization of balloon guide catheters (BGCs) in thrombectomy therapy for ischemic stroke has led to concerns about large-bore sheaths causing vascular groin complications.Objective To retrospectively assess the impact of large large-bore sheaths and vascular closure devices on groin complication rates at a comprehensive stroke center over a 10-year period.MethodsRadiological and clinical records of patients with acute ischemic stroke who underwent mechanical endovascular therapy with an 8Fr or larger sheaths were reviewed. A groin complication was defined as the formation of a groin hematoma, retroperitoneal hematoma, femoral artery pseudoaneurysm, or the need for surgical repair. Information collected included size of sheath, type of hemostatic device, and anticoagulation status of the patient. Blood bank records were also analyzed to identify patients who may have had an undocumented blood transfusion for a groin hematoma.ResultsA total of 472 patients with acute ischemic stroke who underwent mechanical thrombectomy with a sheath and BGC sized 8Fr or larger were identified. 260 patients (55.1%) had tissue Plasminogen Activator (tPA) administered as part of stroke treatment. Vascular closure devices were used in 97.9% of cases (n=462). Two patients were identified who had definite groin complications and a further two were included as having possible complications. There was a very low rate of clinically significant groin complications (0.4–0.8%) associated with the use of large-bore sheaths.ConclusionsThese findings suggest that concerns for groin complications should not preclude the use of BGCs and large-bore sheaths in mechanical thrombectomy for acute ischemic stroke.

Introduction/purpose Posterior circulation strokes with basilar occlusions have the worse clinical outcomes of all strokes. The outcome data utilizing new generation stent retrievers is sparse as most of the clinical trials evaluating stent retrievers exclude posterior circulation strokes. This retrospective review was undertaken to report our experience with stent retrievers in acute basilar occlusions. Materials/methods From March 2012 to March 2016, we performed thrombus retrieval in 337 patients. Retrospective review revealed 23 patients (7%) with basilar occlusions were treated with stent retrieval and adjuvant therapy. • Patient demographic: ○ 23 patients: 16 males, 7 females ○ Age ranged from 29–87 years (mean: 60.4, median: 63) • Presentation time from symptom onset: ○ 0–3 hours: 4 patients ○ 3–8 hours: 6 patients ○ Time unknown: 13 patients. 9/13 patients: wake up strokes ○ Intravenous TPA was administered in 4/23 patients (17%) ○ Initial non contrast CT scan findings: ○ Negative: 17 patients ○ Positive for patchy strokes: 6 patients ○ Dense basilar artery on CT: 9 patients • Thrombectomy device utilized: ○ Solitaire 4x20mm in 7, 4x40mm in 4, 6x30mm in 9, 6x20mm in 1 patient ○ In one patient solitaire could not be deployed ○ In one patient: Trevo was utilized ○ Balloon guide catheters were used in 10 patients with balloon dilated in the Subclavian artery. In 9 patients, local suction with stent retrievers was applied.o 6/23 patients required stent placement for underlying stenosis Results • NIHSS ○ NIHSS at presentation range from 2–38 (mean: 24, median: 22.5) ○ NIHSS 24 hour post intervention range from 0–38 (mean: 17, median: 13.5) • Number of passes: ○ Pass attempts range from 1–5. Successful 1 st pass achieved in 10 patients (mean number of passes: 2/patient) • TICI scores: ○ Initial TICI pre procedure: TICI 0: 19 patients, TICI 1/2a: 4 patients ○ Final TICI score post procedure: TICI 3: 11, TICI 2c: 2, TICI 2b: 5, TICI 1: 2, and TICI 0: 3 patients. Successful reperfusion (TICI 2b or higher) was achieved in 18/23 patients (78.3%). • Outcome: ○ Modified Rankin Score (MRS) at discharge/90 days: Death (6): 10 patients MRS 0–2 (good clinical outcome group): 7/23 (30%) MRS 3–5: 5 patients 1 patient declined follow up Good clinical outcome group 5/7 patients presented within 6 hours of symptom onset while 2/7 patients presented as wake up strokes. Initial CT findings were negative in all 7 patients. Conclusion Although the successful recanalization rate (TICI 2 b or higher) in basilar occlusions is high (18/23 (78.3%)), the mortality (10/23 (43%)) and morbidity with MRS ≥ 3 (5/23 (22%)) remains disappointingly high. In our study, good clinical outcome (MRS 0–2) was achieved in 30% (7/23) of patients, better than the natural course in basilar occlusions, which is encouraging. This group highlights the value of early presentation and a negative CT as strong predictors of a good outcome. The prognosis in patients with basilar occlusions with positive CT findings and unknown time of onset remain guarded. Disclosures I. Akhtar: None. J. Halpin: None. W. Holloway: None. C. Martin: None. N. Akhtar: None.

Introduction/purpose Stents for the intracranial circulation are approved for stent assisted coiling of brain aneurysms, flow diversion of brain aneurysms and atherosclerotic occlusive disease. These stents are deliverable and approved for intracranial placement of cerebral arteries ranging in size from 2.5 to 4.5 mm. The relatively small stents are unsuitable for skull based internal carotid artery for dissection and venous sinus deployment due to the large diameter of these vessels. Self-expandable cobalt chromium carotid stents are properly sized to these circulations but do not track the curvatures of the intracranial arterial and venous circulations. These self-expanding cobalt chromium carotid stents are available in 6 and 8 mm diameter sizes and, due to the braided design, these implants will track curves when partially deployed. We report a technique of partially deploying a cobalt chromium stent within a 072 intracranial support catheter which has already been positioned distal to the target. This allows the stent to be advanced around curves and unsheathed directly from the catheter thus allowing intracranial stenting of larger vessels. Materials and methods This is a retrospective review of 11 cases in which cobalt chromium stents were placed in the intracranial circulation at our facility over a two year period. These stents were placed with an 072 intracranial support catheter positioned distal to the target. Three stents were placed in distal cervical ICA transitioning into the horizontal petrous ICA. Eight stents were placed in the venous circulation (1 straight sinus to transverse sinus, 5 transverse sinus, 1 transverse-sigmoid junction, 1 sigmoid-jugular junction). In two venous cases, the stents were used to support coil masses. Results All cases in which the cobalt chromium stents were deployed were successful. No neurological sequelae were observed post procedure. Conclusion This technique allows for a wider range of stent sizes to access the tortuous intracranial circulation and provides an additional tool to the neurointerventional surgeon. Disclosures C. Martin: None. I. Akhtar: None. J. Halpin: None. W. Holloway: None. N. Akhtar: None.

Introduction/purpose Endovascular treatment using stent retrievers are now the standard of care in patients with acute ischemic stroke due to proximal middle cerebral artery occlusion. Recent randomized clinical trials have shown stent retriever recanalization rates (TICI 2 b or higher) surpassing 80%. The Solitaire stent retriever is available in different diameters and lengths. More recently, in August 2014, a 4 × 40 device was made available for thrombus retrieval in the US. While there have been many studies comparing the Solitaire to the other mechanical thrombectomy devices, at present, there have been little to no human data comparing the relatively new 4 × 40 Solitaire device with the older 4 × 20 and 4 × 15 devices. In our presentation we will be looking at the cases in which the 4 × 40 device was deployed and compare the recanalization rates to those achieved with cases treated with the 4 × 20 and 4 × 15 in patients with acute stroke. Materials and methods Materials used were the Solitaire Revascularization device in the sizes 4 × 40 mm, 4 × 20 mm, and 4 × 15 mm. All devices are identical in diameter but differ in the working length. Methods This is a retrospective study of 247 stroke patients who underwent clot retrieval using a 4 mm diameter Solitaire device as the first device deployed in a case at Saint Luke’s Hospital of Kansas City from 2012 till January 2016. Of the 247 total patients, 34 had undergone initial endovascular treatment with the Solitaire 4 × 40 device. The remainder were either treated with the 4 × 20 or the 4 × 15 Solitaire devices. Successful recanalization was determined as having a final TICI score of 2b or higher (>50% recanalization). Almost every case was performed with a balloon guide catheter inflated in the neck vasculature with aspiration on the guide catheter during Solitaire retrieval. Results The following Table 1 shows the recanalization rate with the different Solitaire devices. Conclusions The Solitaire 4 × 40 device showed a statistical trend for achieving better recanalization compared to the shorter devices. However due to our small sample size of patients undergoing treatment with the 4 × 40, further investigation is warranted to determine whether this result is maintained in larger sample size such as the STRATUS registry. Disclosures W. Holloway: None. I. Akhtar: None. J. Halpin: None. C. Martin: None. N. Akhtar: None.

Introduction The relationship between the two angiographic parameters, recanalization and reperfusion, as they relate to clinical outcome of acute stroke patients undergoing endovascular intervention is not well defined. We sought to determine the relationship of recanalization of the primary arterial occlusive lesion (AOL) and global reperfusion of the distal vascular bed in patients treated with endovascular stroke rescue at our institution. Hypothesis We assessed the hypothesis that recanalization and reperfusion scores would comparably predict outcome. Methods 96 angiograms were reanalyzed using recanalization and reperfusion scores by neurointerventionalists blinded to clinical outcome. The AOL score was defined as follows: 0=no recanalization of the primary occlusion; I=incomplete or partial recanalization of the primary occlusion with no distal flow; II=incomplete or partial recanalization of the primary occlusion with distal flow; or III=complete recanalization of the primary occlusion with distal flow. The Thrombolysis in Cerebral Infarction (TICI) Score was defined as follows: 0=no perfusion; 1= penetration, but no distal branch filling; 2a= perfusion with incomplete ( 50%) distal branch filling; and 3=full perfusion with filling of all distal branches. We compared these methods of assessment to one another and with good clinical outcome (modified Rankin Score 0 to 2). Results AOL and TICI scores showed moderate to substantial agreement (κ=0.660, 95% CI (0.518 to 0.801). Good clinical outcome was seen in 60% of patients with AOL II/III scores (p=0.462) and in 71% with TICI 2/3 scores (p=0.854). The two methods did not significantly differ in predicting outcome (p=0.52). Conclusion In conclusion, TICI reperfusion scores and AOL recanalization scores comparably predicted clinical outcome in our patient population. However, further investigation should be performed, possibly with the aid of other imaging modalities, to further differentiate between these parameters and their relationship to clinical outcome.