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BackgroundThere is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT).MethodsThis was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration.ResultsIn the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0–2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0).ConclusionsPrior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO.

BackgroundIn large vessel occlusionstroke, navigation of aspiration catheters (AC) can be impeded by vessel tortuosity and the ophthalmic artery origin. A novel tapered delivery catheter was designed to facilitate delivery without disturbing the embolus. We assessed AC deliverability in vitro and validated the observations in a first-in-human experience.MethodsIn a vascular model with three challenging craniocervical scenarios, two commercial AC were advanced from the carotid to the middle cerebral artery by four neurointerventionalists. Catheter deliverability with standard microwire and microcatheter (MC) combinations and the Tenzing 7 (T7) Delivery Catheter (Route 92 Medical, San Mateo, CA) were compared. Operators rated aspects of catheter deliverability on a 5-point scale. Results were compared with device delivery patterns at a neurovascular center before and after clinical introduction of T7.ResultsIn vitro, success rate and speed were higher with T7 (96%; mean 30±10 s) than with MC (65%; 72±47 s, pConclusionCompared with microcatheter and microwire combinations, T7 improves aspiration catheter delivery in vitro, minimizing the need to cross the occlusion. Initial clinical experience appears to validate the model’s observations.

BackgroundClot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion.MethodsClot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis.ResultsAmong all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034).ConclusionsClot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy.

BackgroundThrombectomy is an efficacious treatment for acute ischemic stroke (AIS). However, relatively few studies to date have specifically examined the impact and clinical implications of age on outcomes for thrombectomy in anterior AIS.ObjectiveTo provide a snapshot of patient metrics and outcomes with respect to age following thrombectomy for anterior AIS to supplement the current body of data for predictors of clinical outcomes in a real-world setting.MethodsData were collected for 20 consecutive patients with AIS treated with thrombectomy at 15 high-volume stroke centers across North America between 2015 and 2016. Patients with anterior occlusions were dichotomized based on whether they were older or younger than 80 years. Ordinal logistic regression analyzed how clinical variables impacted disability using 90-day modified Rankin Scale (mRS) scores.ResultsAdequate revascularization (TICI ≥2B) was achieved in 92.3% of patients aged ConclusionThis analysis affirms age is a significant determinant of 90-day mRS scores following thrombectomy for large vessel anterior AIS. Further investigation into risks faced by elderly patients during thrombectomy may provide actionable information to help refine patient selection and improve outcomes.

Over the past decade there has been a growing use of intracranial stents for the treatment of both ischemic and hemorrhagic cerebrovascular disease, including stents to assist in the remodeling of the neck of aneurysms as well as the use of flow diverting devices for aneurysm treatment. With this increase in stent usage has come a growing need for the neurointerventional (NI) community to understand the pharmacology of medications used for modifying platelet function, as well as the testing methodologies available. Platelet function testing in NI procedures remains controversial. While pre-procedural antiplatelet assays might lead to a reduced rate of thromboembolic complications, little evidence exists to support this as a standard of care practice. Despite the routine use of dual antiplatelet therapy (DAT) with aspirin and a P2Y12 receptor antagonist (such as clopidogrel, prasugrel, or ticagrelor) in most neuroembolization procedures necessitating intraluminal reconstruction devices, thromboembolic complications are still encountered.1–3 Moreover, DAT carries the risk of hemorrhagic complications, with intracerebral hemorrhage (ICH) being the most potentially devastating.4 ,5 Light transmission aggregometry (LTA) is the gold standard to test for platelet reactivity, but it is usually expensive and may not be easily obtainable at many centers. This has led to the development of point-of-care assays, such as the VerifyNow (Accumetrics, San Diego, California, USA), which correlates strongly with LTA and can reliably measure the degree of P2Y12 receptor inhibition.6–9 VerifyNow results are reported in P2Y12 reaction units (PRUs), with a lower PRU value corresponding to a higher level of P2Y12 receptor inhibition and, presumably, a lower probability of platelet aggregation, and a higher PRU value corresponding to a lower level of P2Y12 receptor inhibition and, hence, a higher chance of platelet activation and aggregation. While aspirin resistance is perhaps less common, clopidogrel resistance may be more challenging as …

Background Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates and better outcomes compared to previous devices. However, despite successful recanalization rates (Treatment in Cerebral Infarction, TICI, score ≥ 2b) between 70 and 90%, good clinical outcomes assessed by modified Rankin Scale (mRS ≥ 2 is present in 40–50% of patients. We aimed to evaluate predictors of poor outcomes (mRS ≥ 2) despite successful recanalization (TICI ≥ 2b) in the acute stroke patients treated with the Solitaire device of the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. Methods The NASA registry is a multicenter, non-sponsored, physician-conducted, post-marketing registry on the use of SOLITAIRE FR device in 354 acute, large vessels, ischemic stroke patients. Logistic regression was used to evaluate patient characteristics and treatment parameters for association with 90-day mRS score of 0–2 (good outcome) versus 3–6 (poor outcome) within patients who were recanalised successfully (Thrombolysis in Cerebral Infarction or TICI score 2b-3). Univariate tests were followed by development of a multivariable model based on stepwise selection with entry and retention criteria of p Results Out of 354 patients, 256 (72.3%) were successfully recanalised (TICI ≥ 2b). Based on 90-day mRS score for 234 of these patients, there were 116 (49.6%) with mRS ≥2. Univariate analysis identified increased risk of mRS ≥2 for each of the following: age ≥ 80 years (upper quartile of data), occlusion site other than M1/M2, NIH Stroke Scale (NIHSS) score ≥ 18 (median), history of diabetes mellitus (DM), TICI = 2b, use of rescue therapy, not using a balloon-guided catheter (BCG) or intravenous tissue plasminogen activator (IV t-PA), and time to recanalization > 30 min (all p ≤ 0.05). Three or more passes was marginally significant (p = 0.097). In multivariable analysis, age ≥80 years, site other than M1/M2, initial NIHSS ≥18, DM, absence of IVtPA, use of rescue therapy and three or more passes were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index = 0.80). Conclusions Age, occlusion site, high NIHSS, diabetes, not receiving IVtPA, use of rescue therapy and three or more passes, were associated with poor 90-day outcome despite successful recanalization. Disclosures I. Linfante: None. G. Dabus: None. A. Starosciak: None. A. Castonguay: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. T. Malisch: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. R. Novakovic: None. A. Yoo: None. O. Zaidat: None.

Background Advances in acute ischemic stroke mechanical thrombectomy devices have led to increased expectations of their safety and efficacy results. Objective To describe a new measure for the newer generation stroke thrombectomy devices, the First Pass Effect (FPE), defined as achieving thrombolysis in cerebral ischemia (TICI) score of 3 from the first pass, without the use of rescue therapy. In addition, a second objective was to assess if achieving TICI2b only with FP (FPE-TICI2b only) yielded similar results as FPE-TICI3 or non-FPE-TICI3 or non-FPE-TICI2b. The influence of FPE on clinical outcome, and its frequency and predictors was evaluated in the North American Solitaire Acute stroke (NASA) registry. Methods The FPE group was identified from the NASA multicenter registry database. Baseline features and clinical outcomeswere compared between the FPE group and the rest of the cohort. Subsequently, two multivariate analyzes were performed to identify if FPE is an independent predictor of clinical outcome and to identify the predictors of FPE. Furthermore, we assessed the difference between FPE and achieving other revascularization grades such as non-FPE-TICI3, FPE-TICI2b, and non-FPE-TICI2b scores. Clinical outcomes were mRS0–2 at 90 days, NIH stroke severity scale, mortality, and symptomatic intracranial hemorrhage (sICH). Results A total of 354 patients from 24 US centers were included in the NASA registry. The FPE was achieved in 89/354 (25.1%). Baseline demographics were comparable between FPE and the rest of the cohort, except that the FPE population had less octogenarians (34.6% vs. 65.4%), more woman (60.7% vs. 47.2%), and more Caucasians (83% vs. 71.2%). Baseline NIHSS and time from onset to groin puncture did not differ among the two groups. Angiographic features demonstrated more MCA occlusion (64% vs. 52.7%) and less ICA occlusion (10.1% vs. 27.7%) in the FPE group. Technical factors associated with FPE were limited to BGC use (64.8% vs. 36.8%), with no difference with use of IV-tPA, IA-tPA, or General Anesthesia. Multivariate analysis demonstrated use of BGC, no ICA occlusion, MCA occlusion, female gender, and white race as independent predictors of FPE. Clinical outcome measured with mRS 0–2 at 90 days was seen in 61.3%, 52.4%, 44.7%, and 39.1% with FPE-TICI3, FPE-TICI 2b, non-FPE-TICI3, and non-FPE-TICI2b, respectively. sICH was seen less frequently in FPE (5.6%,11.6%, 9.6%, and 12.9% in FPE-TICI3, FPE-TICI2b, non-FPE-TICI3,and non-FPE-TICI2b, respectively). Ninety days mortality was 16.3%, 31.0%, 27.7%, and 29.7% with FPE-TICI3, FPE-TICI2b, non-FPE-TICI3, and non-FPE-TICI2b, respectively. Conclusions The First Pass Effect was seen in 25.1% of NASA post-marketing registry patients and is the most powerful predictor of clinical outcome with best safety results. FPE is more commonly seen in white patients, MCA occlusion, and balloon guide catheter use; however, ICA terminus occlusion seems to be resistant to FPE. The FPE may also be related to gender, race, and age. Further research is needed to better understand the FPE and to guide future technical advances. Disclosures O. Zaidat: 1; C; Covidien, Stryker. 2; C; Covidien, Stryker. A. Castonguay: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. I. Linfante: None. G. Dabus: None. T. Malisch: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. R. Novakovic: None. A. Yoo: None. A. Abou-Chebl: None. P. Chen: None. G. Britz: None. R. Kaushal: None. A. Nanda: None. R. Nogueira: None.

Background Real life practice can differ significantly from criteria in randomized clinical trials (RCT), including patient population, treatment criteria, and broader treatment times. Distinguishing device performance in these two different scenarios is critical in applying RCT data to routine clinical practice. Objective The TREVO Stent-Retriever Acute Stroke (TRACK) Registry aimed to assess the real-world safety, angiographic, and clinical efficacy of the TREVO device in comparison to the results from the TREVO-2 clinical trial. Design/methods The TRACK Registry recruited clinical sites within the USA. Demographic, clinical, angiographic, and outcome data on patients treated with the TREVO device were collected. Symptomatic intracranial hemorrhage (sICH) was defined as any parenchymal hematoma, SAH, or IVH associated with a worsening of the NIHSS score by≥4 within 24 h. The primary outcome was achieving TICI≥2a revascularization. Secondary outcomes were mRS at 3 months, mortality, and sICH. Results 23 centers contributed data on 586 patients for the final analysis. Baseline demographics were: 48.6% female, 68.3% white, mean age 65.8 ± 14.9 years, median baseline NIHSS of 17 (IQR 13–22), M1 (54.2%)/ICA(17.1%)/VB(13.7%) occlusion, IV-tPA use 50.4%, general anesthesia 63.2%, balloon guide catheter use 47.0%, mean fluoroscopic time 26.2 ± 22.1 min, and a median revascularization time of 65.5 (IQR 37–105.75) minutes. The TICI ≥2a and TICI ≥2b revascularization rates were 92.4% (537/581) and 80.4% (467/581), compared to the operator reported TICI ≥ 2a rate of 85% and core laboratory adjudicated TICI ≥2b of 68% in TREVO-2. Good outcome (mRS≤2) was demonstrated in 48.3% (240/497), compared to 40% (TREVO-2). The rate of sICH was 7.5% (43/574), compared to 4% (TREVO-2). 90-day mortality was 20.1% (100/497) versus 29% in TREVO-2. Multivariate logistic regression analysis demonstrated that younger patients, lower baseline NIHSS, revascularization success (TICI ≥2B), and use of conscious sedation were independent predictors of good clinical outcome. Independent predicators of mortality included older patients, higher baseline NIHSS, vertebral-basilar occlusion, lack of IV-tPA use, failure to achieve revascularization, and sICH. Conclusion The investigator-initiated TRACK Registry demonstrates that the post-marketing TREVO stent-retriever performance in routine clinical practice is comparable to the TREVO-2 trial, with improved revascularization success, good outcome, and decreased mortality. Disclosures O. Zaidat: 1; C; Stryker, Covidien. 2; C; Stryker, Covidien. A. Castonguay: None. R. Nogueira: None. P. Ramakrishnan: None. D. Haussen: None. A. Lima: None. J. English: None. H. Farid: None. E. Veznedaroglu: None. M. Binning: None. A. Puri: None. S. Hou: None. V. Janardhan: None. N. Vora: None. R. Budzik: None. A. Alshekhlee: None. M. Abraham: None. R. Edgell: None. M. Taqi: None. E. Lin: None. R. Khoury: None. M. Mokin: None. A. Majjhoo: None. M. Kabbani: None. M. Froehler: None. I. Finch: None. S. Prabhakaran: None. R. Novakovic: None. T. Nguyen: None. J. Wesley: None.

Background The MR CLEAN multicenter randomized clinical trial demonstrated the safety and effectiveness of intra-arterial treatment within 6 h after stroke onset in patients with acute ischemic stroke (AIS) caused by proximal intracranial occlusion in the anterior circulation. Objective To present the clinical and angiographic outcomes of a MR CLEAN-like population within the real-world multicenter TREVO Stent-Retriever Acute Stroke (TRACK) Post-marketing Registry and assess its performance relative to the MR CLEAN population. Design/methods The investigator-initiated TRACK Registry recruited sites within North America to submit retrospective data on consecutive patients treated with the TREVO device. A TRACK sub-cohort matched to the MR CLEAN interventional population (based on the following criteria: anterior circulation occlusion, time of onset to groin puncture ≤6 hrs, NIHSS ≥2) was identified (TRACK-MRCL) and compared to the MR CLEAN interventional and control (MRC-I, MRI-C) group of 233 and 267 patients, respectively. The groups were evaluated for differences in the clinical (mRS at 3 months, mortality, and sICH) and angiographic outcomes (TICI revascularization grades). Results 409 patients underwent treatment using the TREVO device in 18 centers. Of those patients, 250 patients were included in the TRACK-MRCL group. Demographics of the TRACK-MRCL, MRC-I, and MRC-C groups (respectively): median age (IQR) 69 (55–78) versus 65.8 (54.5–76.0), and 65.7 (55.5–76.4); median NIHSS (IQR) 18 (14–22) versus 17 (14–21), and 18 (14–22); male 49.2% vs. 57.9%, and 58.8%, p = 0.12; ICA occlusion 20.4% vs. 25.3%, and 28.2%, p = 0.19; M1 occlusion 59.2% vs. 66.1%, and 62%, p = 0.13; IV-tPA use 67.2% vs. 87.1%, 90.6%, p = 0.0001; general anesthesia use 65.5% vs. 37.5%, p = 0.0001; median time of onset to groin puncture (min) (IQR) 215 (169.8–268.5) versus 260 (210–313). TICI ≥ 2a and TICI ≥ 2b revascularization rates were 92.8% vs. 80.6% (p = 0.0002) and 83.6% vs. 58.7% (p = 0.0001) in the TRACK-MRCL and MRC-I groups, respectively. sICH was noted in 8.5% of TRACK-MRCL patients compared to 7.7% and 6.4% in the MRC-I and MRC-C groups, respectively (p = 0.87). In TRACK-MRCL patients with available 90-day outcomes, 47.3% (113/239) had achieved a good clinical outcome (mRS 0–2) versus 32.6% (76/233) and 13.1% (35/267) in the MRC-I and MRC-C groups, respectively (p = 0.0014). Mortality was 14.2% (34/239) in the TRACK-MRCL cohort versus 9.0% (21/233) and 8.2% (22/267) in the MRC-I and MRC-C groups, respectively (p = 0.09). Conclusion Although not directly comparable, this sub-analysis of a real-world TREVO stent-retriever registry patient matched to MR CLEAN population demonstrated consistent higher rates of good clinical and revascularization outcomes than the MR CLEAN control group. Disclosures A. Castonguay: None. O. Zaidat: None. R. Nogueira: None. P. Ramakrishnan: None. D. Haussen: None. A. Lima: None. J. English: None. H. Farid: None. E. Veznedaroglu: None. M. Binning: None. A. Puri: None. S. Hou: None. V. Janardhan: None. N. Vora: None. R. Budzik: None. A. Alshekhlee: None. M. Abraham: None. R. Edgell: None. M. Taqi: None. E. Lin: None. R. Khoury: None. M. Mokin: None. A. Majjhoo: None. M. Kabbani: None. M. Froehler: None. I. Finch: None. S. Prabhakaran: None. R. Novakovic: None. T. Nguyen: None.

Background Randomized trials have recently shown that intra-arterial (IA) treatment of large vessel occlusion (LVO) acute ischemic stroke (AIS) with new generation devices is highly effective at restoring perfusion and significantly improving outcome. As these trials were performed at high-volume academic centers, it remains unclear whether these results can be replicated in the community setting outside of a clinical trial, or in a "drip and ship" referral model. Since May 2012, the California Pacific Medical Center (CPMC) in San Francisco has treated referral acute LVO AIS patients using CT, CT angiography and CT perfusion (CTP) combined with stent-retriever based IA therapy. Methods IA AIS cases performed at CPMC between May 2012 and October 2014 were reviewed. CTP scans were evaluated by the stroke neurologist and neurointerventionist to determine suitability for intervention (e.g., core infarct volume, perfusion mismatch). Automated software was not utilized. Baseline demographics including age, NIHSS, IV tPA treatment, and time points pertinent to CTP imaging and procedural times were collected. The primary safety endpoint was symptomatic ICH (sICH), and the primary outcome was mRS at 90 days; secondary endpoints included successful reperfusion and mortality. Results 108 patients were treated, 20 with Solitaire and 88 with Trevo. The majority of patients (88%) were transferred via the CPMC Northern California Telestroke Network. The median age was 66.1 and the median NIHSS was 15.2. 72% of patients were treated with IV tPA, most prior to transfer. Median onset of symptoms to imaging at CPMC was 296 min. All procedures were performed under general anesthesia. Median CT scan to groin puncture was 136 min. Median CT scan to reperfusion was 205 min. TICI 2B or 3 reperfusion was achieved in 77%, with a median of 2.3 passes. 90 day outcome data was available in 102 patients, with 62% achieving a favorable outcome (mRS of 0–2). sICH was noted in 5.5% of patients. 90 day mortality was 14%. Conclusions Endovascular treatment of LVO AIS based upon selection with CT perfusion imaging and modern stent retriever technology can be feasible, safe, and effective in the community setting. Times from imaging to groin puncture and reperfusion were longer compared to recent trials, however mRS at 90 days and sICH ratees were comparable. Good outcomes were noted despite long stroke onset to CTP times for many patients, emphasizing the potential role of CTP imaging in identifying patients with favorable perfusion and small core infarct who can benefit from IA therapy at extended time periods. These data suggest that a ‘drip and ship’ approach with a hub/spoke model commonly utilized by comprehensive stroke centers and in Telemedicine networks may provide benefit to this patient population, and can be achieved in a community setting. Disclosures B. Gao: None. N. Barazangi: None. D. Tong: None. C. Chen: None. C. Wong: None. A. Yee: None. M. Morrow: None. A. Bedenk: None. W. Kim: 2; C; Stryker Neurovascular, Silk Road Medical. J. English: 1; C; Stryker Neurovascular. 2; C; Stryker Neurovascular, Covidien, Silk Road Medical.

Background and purpose With the recent results of clinical trials showing the marked benefit of reperfusion with stent retrievers compared to medical therapy, the Trevo registry is a real world study to assess self-reported reperfusion rates and outcomes. The study was originally planned to enroll 300 patients but has been expanded to 1000 patients. Methods A total of 1000 patients at a maximum of 75 sites internationally will be enrolled and analyzed. The aim of the study is for to centers to enroll consecutive patients in whom the Trevo device (Trevo ProVue, XP 4 × 20 or XP 3 × 20) was used as the first device to remove a thrombus. Patients were eligible if the device was used in a patient suffering from an ischemic stroke and data was locally adjudicated and submitted to the sponsor for collation and analysis of the data. Data regarding key time points of the processes, reperfusion grade, adverse events and 90 day modified Rankin scores were collected. Results As of February 9, 2015 a total of 200 patients have been enrolled with a target enrollment of 300 by October 2015. Currently data has been completed on 150 patients with a plan to present data on 225 patients. The mean time from last known normal to arrival to the hospital was 3.7 ± 5.6 h and 64% of patients were treated under 6 h from last known normal and 13% beyond 12 h. The majority of patients were treated for proximal ICA or M1 MCA occlusions (66%) with the rest of the patients being treated for posterior circulation or M2 MCA occlusions. General anesthesia was employed in 69% of procedures and the vast majority of these were for the procedure itself. The mean procedure time was 62 ± 440 min with an average of 1.7 ± 1 pass with the device. The rate of TICI 2B or 3 was 88% and TICI 3 was achieved in 43% of patients. The median NIHSS was reduced from 17 at admission to 8 at 24 h. A total of 33% of patients were discharged to home and 32% to inpatient acute rehab with only 14% of patients being discharged to a nursing home or hospice. Conclusions The Trevo Retriever Registry represents the first look at the real world data with stent retriever use in the era of clinical trials showing the overwhelming benefit of stent retrievers to treat acute ischemic stroke. Future subgroup analysis of this large cohort will help to identify areas of future research to enhance outcomes further with this treatment modality. Disclosures R. Gupta: 1; C; Wellstar Foundation, Stryker Neurovascular, Penumbra, Covidien, Zoll. 2; C; Stryker Neurovascular, Covidien, Rapid Medical, Penumbra. R. Budzik: 2; C; Stryker Neurovascular. B. Xiang: 2; C; Stryker Neurovascular. J. English: 2; C; Stryker Neurovascular. B. Baxter: 2; C; Penumbra, Stryker Neurovascular. S. Ge: 5; C; Stryker Neurovascular. E. Veznedaroglu: 2; C; Stryker Neurovascular.

Background Wide-necked and large intracranial aneurysms are challenging to treat through endovascular approach. Adjunctive treatments like Balloon-assisted coil embolization (BACE) and Stent-assisted coil embolization (SACE) play a major role in the treatment of such aneurysms. The TransForm™ Occlusion Balloon Catheter (TOBC) registry is intended to evaluate safety and efficacy of BACE using the TOBC. It is the first prospective registry trial of BACE for intracranial aneurysms. Hypothesis BACE using TOBC is safe and effective. Design The TOBC registry is a prospective multicenter registry trial. 7 sites in the USA and 1 in Spain were selected to enroll; each site could enroll up to 20 patients. Final analysis of data collected for 81 patients enrolled from November 2013 through January 2015 was performed. Results Mean age was 54.78 yrs (SD±14.51). 30.86% were male and 69.14% were females. TOBC was used for BACE in 73.9%, test occlusion 5.7%, safety 9.1% and others (vasospasm and post flow diverter placement) 11.4%. Most common arteries where TOBC was used were internal carotid artery (35.9%), MCA (18.5%), ACA (13.0%) and BA (10.9%). Mean proximal vessel diameter was 3.29 mm (SD±1.19). Mean distal vessel diameter was 2.89 mm (SD±1.26). Most common contrast concentrations used were 70/30 (35.87%) and 50/50 (30.43%). Most common balloon type used were Compliant 4 x 10 mm (31.40%) and Super compliant 4 x 7 mm (17.44%). Most common guide wires used were Transend (54.9%) and Synchro14 (15.9%). Mean dome to neck ratio of the aneurysms treated was 1.31 (SD±0.69). 50% were at bifurcation, 45.8% of the aneurysms were sidewall and 4.17% were terminal aneurysms. Following were the means scores (1= Excellent, 2=Very good, 3=Good, 4= Fair, 5=poor); for visibility under fluoroscopy 1.78 (SD±0.84), ability to reach intended site 1.59 (SD±0.78), stability during first positioning 1.54 (SD±0.63), stability during inflation 1.56 (SD±0.68), stability during deflation 1.57 (SD±0.64), ability to temporarily stop flow 1.55 (SD±0.67), ability to assist in coil embolization 1.71 (SD±0.80). Mean time to inflate the balloon was 4.85 seconds (SD±3.17) and mean time to deflate was 5.64 seconds (SD±4.53). Complete obliteration of the aneurysm (Raymond class I) was achieved in 69.44%. Thrombus formation occurred in 4/81 (4.8%) cases. In all cases thrombus resolved with medications and no patient suffered infarction. In all cases an underlying hyper coagulable state from subarachnoid hemorrhage was considered a contributing factor. Vessel rupture/perforation occurred in 1/81 (1.2%) case but was unrelated to TOBC. Conclusions BACE using TOBC was safe and effective. The balloon catheter performed as intended in the treatment of cerebral aneurysms in our cohort of patients. All variables assessed for TOBC performance showed good to excellent results. No serious side effects occurred. The short inflation and deflation times and ability to use a 0.014 guidewire allowed improved performance of this balloon catheter in comparison to older balloon catheters available. Disclosures M. Taqi: None. S. Quadri: None. A. Puri: None. B. Fitzsimmons: None. A. Rai: None. C. Given: None. J. Masso: None. C. Powers: None. J. English: None. S. Zaidat: None.

Background and Purpose Prior studies have reported that stent-assisted coiling (SAC) may result in less aneurysm recanalization but more complications than coiling alone (CA). We evaluated outcomes of SAC in the prospective, multi-center MAPS Trial. Materials and Methods 361 MAPS patients with unruptured intracranial aneurysms (UIA) were treated per protocol by SAC or CA. Data were analyzed post hoc for all UIAs and for the wide neck (≥4 mm) aneurysm (WNA) subset. Baseline patient and aneurysm characteristics, procedural details, neurological outcomes, and safety data were compared. An independent core laboratory evaluated all angiographic outcomes. Groups were not randomized to SAC or CA and are dissimilar, especially within the large UIA group. Results Baseline characteristics. 137 of 361 patients received a Neuroform stent. SAC patients were more likely to be North American (88% vs 66%, p Aneurysm characteristics. Among UIAs, 62% of SAC vs 33% of CA were WNA, (p 10 mm (48% vs 31%, p=0.03), while SAC aneurysms had lower dome-to-neck ratios (1.5 vs 1.9, p Procedural characteristics. For UIAs, packing density trended higher with SAC (26.2% vs 24.2%, p=0.07). Among WNAs, SAC packing density was significantly higher than CA (26.4% vs 21.1% p=0.002). Periprocedural significant adverse events (SAEs) were not different between SAC and CA (6.6% vs 4.5%, p=0.39). Neurological outcomes and safety. At 1 year, SAEs, mortality, and worsening of modified Rankin scores (mRS) were not different between SAC and CA. Among UIAs, SAC had a higher 1-year ischemic stroke rate (8.8% vs 2.2% p=0.005). Of note, 42% of SAC ischemic strokes occurred at one enrolling site, exclusion of which brings the comparative stroke rates to 5.1% vs 2.2%, respectively (p=0.22). There was no significant difference in ischemic stroke rates between SAC and CA within the more similar WNA subset. Angiographic outcomes. Despite a trend toward a lower rate of initial aneurysm obliteration, SAC weakly trended toward a higher rate of obliteration at 1 year in UIAs (51.8% vs 44.4%, p=0.22). Complete obliteration rates for SAC were significantly higher than CA in the WNA subset (45.7% vs 27.1%, p=0.03). Angiographic worsening was significantly lower for SAC than CA in both the UIA (16.7% vs 33.3%, p=0.002) and WNA groups (21.4% vs 50.8%, p=0.0005). Core lab analysis revealed no instances of significant stent migration at 1 year. Conclusion SAC was safe and effective in treating unruptured intracranial aneurysms in MAPS. SAC correlated with higher coil packing densities and better angiographic outcomes at 1 year without significantly higher rates of SAEs, mortality, death or disability despite the stented aneurysms having more difficult morphology than coiled aneurysms. Ongoing clinical evaluation over the next 4 years will help assess the overall utility of the SAC approach. Competing interests S Hetts: NIH-NIBIB, Stryker Neurovascular. Silk Road Medical. University of California. A Turk: Stryker Neurovascular. J English: Stryker Neurovascular. Silk Road Medical. J Mocco: None. C Prestigiacomo: None. G Nesbit: None. S Ge: Stryker Neurovascular. J Jin: Stryker Neurovascular. Y Murayama: Stryker Neurovascular, Asahi Intec. Inventor: Matrix Coil, Trainer: eV3, Concentric. A Gholkar: None. S Barnwell: None. D Lopes: Stryker Neurovascular. Proctor: Stryker Neurovascular. Y Gobin: None. S Johnston: Boston Scientific / Stryker Neurovascular. C McDougall: None.

Purpose To characterize clinical, radiological, treatment, and outcome data in patients diagnosed with acute ischemic stroke or transient ischemic attack who underwent emergent endovascular intervention at a single tertiary care institution. Methods Patients undergoing endovascular intervention for acute ischemic stroke or transient ischemic attack were identified from a neurointerventional database and their medical records retrospectively analyzed. Univariate statistical analysis and logistic regression were performed using custom Matlab scripts. Results Baseline Characteristics: Between 1997 and 2010, 108 patients underwent endovascular surgery for acute cerebral ischemia. 66 of these patients were treated within 8 h of symptom onset. These patients had a mean age of 66.8±19.5 years (range 5–94); 55% were female. The patients had a baseline modified Ranking score of 1.1±1.2. Cerebrovascular risk factors included: hypertension (63%), dyslipidemia (55%), atrial fibrillation (42%), diabetes mellitus (20%), known cerebrovascular or cardiovascular disease (35%), and current or former smoking (18%). Patients most often presented with motor symptoms (weakness, hemiparesis, hemiplegia—85%), followed by speech difficulty (aphasia or dysarthria—38%), loss of consciousness/altered mental status (28%), and sensory abnormalities (tingling, numbness, dizziness, tinnitis, nausea—9%). 67% of events were witnessed, 23% were unwitnessed, and 6% occurred upon awakening. At presentation, the mean NIH stroke score was 15.3±6.2. Etiology of the events was 83% cardioembolic or thromboembolic, 9% in situ thrombosis, and 8% stenotic. The vessels most often acutely occluded were M1-MCA (56%), M2-MCA (30%), cervical ICA (5%), intracranial ICA (17%), and basilar (17%). Medical Intervention: 37% of patients received intravenous tissue plasminogen activator given at a mean of 2±0.7 h post-ictus; of those who did not (n=38), the most common reason was exceeding the time window for ictus onset to proposed IV-tPA treatment (45%). Endovascular Intervention: All of the patients in this sample underwent at least one endovascular intervention. 53% underwent intra-arterial thrombolysis (mean dose of IA-tPA 8.7±6.2 mg), 76% underwent mechanical thrombectomy (88% MERCI type, 12% Penumbra type), 18% underwent angioplasty (8% extracranial, 92% intracranial), and 15% underwent stenting (20% extracranial, 80% intracranial). 56% of patients were recanalized to TICI 2b or 3, with a mean recanalization time of 7.2±3.2 h. Intra-operative complications included vessel rupture (n=1) and iatrogenic distal large vessel embolization (n=1). 7.6% of patients had evidence of post-op hemorrhagic conversion on follow up head CT. Outcomes: At discharge, mean NIH-SS was 9.6±7.6, and mean mRS was 4±1.7. When subdividing based on intervention type, significant differences were found for post-treatment mRS (p=0.03, Kruskal-Wallis), change in mRS (p=0.01), and change in NIH-SS (p=0.01). At an average of 5.9±7.9 months of follow-up, mean NIH-SS was 3.3±3.2, and mean mRS was 2.4±1.5). When subdividing based on intervention type, significant differences were found for change in mRS (p=0.03), and change in NIH-SS (p=0.002). Conclusion Endovascular interventions for cerebral ischemia are useful tools in the treatment of acute cerebral ischemia. The difference in clinical outcomes based on intervention subgroups may be associated with the adoption of newer therapeutic modes and warrants further investigation.

Purpose Meningiomas often benefit from preoperative embolization in order to reduce operative blood loss and associated morbidity. Intraarterial (IA) administration of contrast directly into the external carotid artery (ECA) and internal carotid artery (ICA) branches supplying the tumor during the embolization procedure maps out the blood vessels supplying the tumor as well as evaluating which portions of the tumor are successfully devascularized prior to surgery. Whereas IA digital subtraction x-ray angiography (DSA) is the gold standard for embolization guidance, IA perfusion MRI may offer increased sensitivity to residual areas of vascularized tumor. Materials and Methods Studies were performed in a combined “XMR” suite wherein an x-ray angiography unit (Integris V5000, Philips Medical Systems) is coupled in-line to a 1.5 T MR scanner (Intera, Philips Medical Systems), allowing easy patient movement between the two imaging modalities during endovascular procedures. We evaluated 14 patients with selective IA T2* dynamic susceptibility contrast (DSC) perfusion MR during preoperative embolization. Eight of these patients were also evaluated with intraprocedural IA T1 weighted perfusion MR. IA perfusion was performed with dilute Gd injected initially into the external carotid and subsequently into the common carotid. The selected carotid artery was confirmed to be providing vascular supply to the tumor by prior angiographic evaluation. The portion of the tumor demonstrated to be associated with external or internal carotid supply, based on IA MR perfusion measures, were correlated with DSA obtained during each procedure. IA perfusion assessments were additionally compared to preoperative conventional MRI and IV T2* perfusion MR studies. Results Both T2* and T1 IA perfusion MR techniques were more sensitive than DSA at detecting vascularized tumor prior to or following embolization. The T1 technique was subject to less susceptibility artifact, and thus performed better than the T2* technique at the skull base and near aerated paranasal sinuses. Both IA MR perfusion techniques demonstrated tighter arterial input functions than the IV MRI perfusion technique due to contrast administration directly into cervicocerebral arteries. Similarly, time enhancement curves for the IA MR perfusion methods demonstrated reduced mean transit time and lack of a recirculation peak as comparted to the IV MR perfusion method. IA MR perfusion methods were good at differentiating ECA from ICA supply to individual tumors. However, vascular variants such as anterior falx artery or ethmoidal artery tumor supply arising from the ophthalmic artery (ICA branches outside the blood brain barrier) presented interpretive challenges for MRI but were readily apparent on DSA. Conclusion IA MR perfusion techniques appear to be a useful adjunct to DSA in determining tumor vascularity and the source of that blood supply during DSA guided preoperative embolization procedures.

Background In light of the negative results of three randomised trials for endovascular acute ischemic stroke therapy, proper patient selection has become a critical area of focus for endovascular therapy. The Stroke Prognostication using Age and NIH Stroke Scale (SPAN) index, a score that combines age and NIHSS, demonstrated that SPAN-100 positive patients did not benefit from IV-tPA. Here, we sought to evaluate the predictive value of SPAN index in a real-life cohort of patients undergoing endovascular therapy. Method Using data from the investigator-initiated, multicenter North American Solitaire Stent-Retriever Acute Stroke (NASA) Registry, the SPAN index was calculated for each patient (age plus NIHSS). A cohort of SPAN-100 positive (SPAN ≥ 100) patients was identified and compared to SPAN-100 negative (SPAN Results Of 354 patients in the NASA Registry, 308 had available baseline NIHSS scores and 90-day mRS scores. 68/354 (22.1%) patients were SPAN-100 positive. Mean age of patients that were SPAN-100 positive was 83.9 ± 5.6 years vs. 62.8 ± 13.3 years in the SPAN-100 negative cohort (p = Conclusion Analysis of the NASA Registry demonstrated that SPAN-100 positive is significantly associated with worse clinical outcome and higher mortality rate at 90 days compared to SPAN-100 negative patients. SPAN-100 was shown as an independent predictor of clinical outcome and may be useful tool in the selection of patients for endovascular therapy. Disclosures A. Castonguay: None. O. Zaidat: 1; C; Stryker Neurovascular, Covidien Neurovascular. 2; C; Covidien Neurovascular. R. Novakovic: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. I. Linfante: None. G. Dabus: None. T. Malisch: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. A. Yoo: None. A. Abou-Chebl: None.

Background and purpose The natural history of perimedullary arteriovenous fistulae (PMAVFs), also known as type IV spinal cord AV fistulae, is incompletely understood. Both open surgical and endovascular approaches have been described as treatment modalities for this disease. The goal of this study was to evaluate the long term outcome of patients with PMAVFs treated at a single tertiary care institution. Materials and methods We conducted a retrospective study on 32 patients with PMAVFs, evaluated between 1983 and 2009. Data were gathered by reviewing outpatient clinic notes, operative and radiological reports, and spinal angiograms. The PMAVFs were categorized into one of three types based on the angiographic imaging criteria. Pretreatment and post-treatment ambulation and micturition symptoms were quantified using the Aminoff and Logue scale (ALS). Results 30 patients underwent corrective procedures, four by embolization alone, 11 by surgery alone and 15 patients received a combination of the two. 28 patients underwent follow-up spinal angiography, with residual shunting noted in six patients. Mean follow-up period was 54 months (range 1–228). Analysis of the ALS scores revealed that treatment of PMAVFs, independent of modality, resulted in significant improvement in ambulation, but inconsistent changes in micturition. In addition, residual fistula at the time of follow-up angiogram was associated with worsened neurologic status or lack of improvement. Outcome analysis based on fistula type showed dramatic improvement in ALS ambulation scores (62%) for type 3 fistulae compared with type 1 and 2 (26%, 27%, respectively). Conclusion Significant improvement in ambulation, but not micturition, was observed following treatment. Residual fistula on follow-up angiography was associated with progressive worsening or lack of improvement in neurologic function. Patients with type 3 fistulae were shown to benefit most from treatment, with marked improvement in post-treatment ambulation scores. As endovascular and surgical techniques continue to evolve, further studies are warranted.

Introduction/Purpose IMS3 demonstrated no significant difference between treatment with IV-rtPA alone or IV-rtPA plus IA therapy. However, the trial included only earlier generations of thrombectomy devices and did not evaluate the efficacy of newer devices. Here, we present data on an “IMS-III-Like group” from The North American SOLITAIRE Acute Stroke (NASA) Registry, a repository database of the newer generation Solitaire Stent-retriever. An exploratory analysis was performed to compare these results to the IMS3 IV and IV/IA groups. Materials and Methods The investigator-initiated NASA Registry recruited sites to submit data on consecutive patients treated with Solitaire-FR. A cohort similar to the IMS-III IV-rtPA+Solitaire-FR population (NASA-IMS3 Matched Group (NIMG)) was identified and compared to the recently published results of the IMS3 IV and IV/IA groups. Good clinical outcome was defined as a 90-day mRS ≤2. Successful recanalisation was defined as TIMI ≥2. SICH was defined as any parenchymal haematoma, SAH, or IVH associated with a worsening of the NIHSS score by 4 or more within 24 hours. Results 354 acute ischaemic stroke patients were enrolled in the NASA Registry from 24 centres. The cohorts were comprised of: 156 NIMG versus 434 and 222 in the IMS3 IV/IA and IV only groups, respectively. Baseline demographics were similar between cohorts: Median age 70 (NIMG); 69 (IMS3 IV/IA); 70 (IMS3 IV). Initial median NIHSS was higher in NIMG (19) compared to the IMS3 IV/IA (17) and IMS3 IV groups (18). mTICI > 2b rate was 69.9% in NIMG versus 39.6% in the IMS III IV/IA. Interestingly, mTICI 3 rate was 41% in NIMG vs 2.2% in the IMS III IV/IA group. The 90-day mRS outcome was available in 88.5% (138/156) of NIMG patients. A good outcome of mRS?2 was demonstrated in 51.5% (71/138), compared to 40.8% (169/415) in IMS3 IV/IA and 38.7% (83/215) in IM3 IV alone groups. 90-day mortality was 24.6% in NIMG versus 19.1% and 21.6% in IMS3 IV/IA and IV alone groups, respectively. Conclusion In the NASA registry, the NASA-IMS3 Matched Group (NIMG) demonstrated a higher rate of good clinical outcome (51.5%) compared to the IMS3 IV/IA (40.8%) and IV alone (34.6%) groups. Disclosures R. Nogueira: None. A. Castonguay: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. I. Linfante: None. G. Dabus: None. T. Malisch: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. A. Yoo: None. A. Abou-Chebl: None. P. Chen: None. O. Zaidat: None.

Background and Purpose Children with brain AVMs are more likely than adults to present with hemorrhage. Prior studies have also demonstrated that AVMs in children are more frequently located deep within the brain than in adults. We sought to determine in greater detail which angioarchitectural features differ between children and adults with brain AVMs. Methods Under an IRB approved protocol, an institutional brain AVM database collected prospectively since 2001 was queried. Only patients with nidal AVMs were included for analysis; those with vein of Galen malformations, dural AV fistulas, or non-Galenic pial AV fistulas were excluded. Demographic and angioarchitecture information was abstracted and analyzed with Cox univariate and multivariable models. Results Children were more likely to present with AVM hemorrhage than adults (Abstract O-023 table 1). There was an over-representation of Hispanic children as compared to adults when patients were identified by self-reported or parent-reported ethnicity. Although the size of AVM nidus did not differ significantly between children and adults, the location and venous drainage did differ (Abstract O-023 table 2). Several angioarchitectural features did not differ significantly in their frequency between children and adults, including: AVM side, cerebellar hemispheric location, presence of arterial aneurysms not related to shunt flow, dural arterial supply, pial to pial arterial collaterialization, moyamoya-like changes, sharp vs diffuse AVM nidal border, nidal aneurysms, number of draining veins, and venous sinus thrombosis. There were non-significant trends toward increasing venous stenosis (p=0.061) and venous reflux (p=0.084) being more frequent in adults as compared to children. Children were more likely to have exclusively deep venous drainage than adults (p Conclusions Although children with brain AVMs were more likely to come to clinical attention due to hemorrhage than their adult counterparts at our institution, high risk features such as venous stenosis and feeding artery aneurysms were underrepresented in those children. AVMs and their draining veins were also more likely to be located deep within the brain in children, raising the possibility that centrally-located AVMs may arise earlier in development or be more likely to come to clinical attention early in life. Competing interests S Hetts: Silk Road Medical. H Kim: None. D Cooke: None. J English: Silk Road Medical. N Gupta: None. C Stout: None. W Kim: None. C Dowd: None. V Halbach: None. R Higashida: None. M Lawton: None. W Young: None.

Background and purpose Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (SAH) is a significant cause of morbidity and mortality. We review our experiences using percutaneous transluminal angioplasty (PTA) and intra-arterial (IA) verapamil infusion for treating medically refractory cases. Materials and methods Retrospective review of SAH patients admitted from July 2003 to January 2008. Results Of 546 patients admitted with SAH, 231 patients (42%) developed symptomatic CV and 189 patients (35%) required endovascular therapy. A total of 346 endovascular sessions were performed consisting of a single angioplasty, 286 IA verapamil infusions and 59 combined therapies. PTA was performed on 151 vessel segments and IA verapamil infused in 720 vessel segments. IA verapamil doses ranged from 2.0 to 30.0 mg per vessel segment and 3.0 to 55.0 mg per treatment session. Repeat treatments were necessary in 182 patients (96%) for persistent, recurrent or worsening CV. There were six treatment related complications (1.7%) of which two (0.6%) resulted in clinical worsening. No deaths were attributable to endovascular therapy. At follow-up, 115 patients (61%) had a good outcome and 55 patients (29%) had a poor outcome. Sixteen patients died from causes related to SAH while three died from other medical complications. Conclusion Endovascular treatments are an integral part of managing patients with medically refractory CV. In our experience, PTA and IA verapamil are safe with a very low complication rate but further studies are required to determine appropriate patient selection and treatment efficacy.