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Background Systems of care surrounding endovascular therapy for stroke have garnered much attention in recent years. In‐hospital metrics, such as “door‐to‐puncture” and procedure times have been areas for quality improvement. The temporal trend and clinical significance of prehospital “onset‐to‐door” time, however, remains unknown. Methods We performed a systematic review of time metric data from all published randomized controlled and investigational device exemption trials involving endovascular therapy for stroke between 2005 and 2019 (n=26). Second, we conducted a record‐level observational analysis on a total of 3512 patients from 3 real‐world registries (Mechanical Embolus Removal in Cerebral Ischemia [MERCI], Thrombectomy REvascularization of Large Vessel Occlusions in Acute Ischemic Stroke [TREVO], and TREVO Stent‐Retriever Acute Stroke [TRACK]), together with 4 prospective trials (MERCI trial, Multi‐MERCI, TREVO‐EU, and TREVO‐2). Only patients receiving mechanical thrombectomy within 9 hours from onset‐to‐puncture time were included. Predictors of good outcome were identified using generalized linear mixed modeling. Results Door‐to‐puncture times (slope=−5.83 min/y; R 2 =0.25; P =0.046), procedure times (slope=−3.78 min/y; R 2 =0.54; P 2 =0.57; P 2 P =0.806). Pooled analysis from record‐level data demonstrated a similar temporal trend where door‐to‐puncture, procedure, and onset‐to‐reperfusion times declined by an average of 12 minutes (R 2 =0.45; P 2 =0.27; P 2 =0.18; P 2 =0.34; P =0.005). In a backward‐selection regression model, onset‐to‐door time was found to be a significant predictor of patient outcomes, where every hour delay in hospital arrival correlated with a 14% reduction in the odds of a good outcome. Conclusions “Door‐to‐puncture” and procedure times have seen significant improvements over the past decade. The prehospital component of “onset‐to‐door” time, however, has remained stagnant. This presents an unrealized opportunity to enhance patient outcomes through improved systems of care in the prehospital setting.

Introduction Currently, the most effective treatment strategy for adults with hydrocephalus involves cerebrospinal fluid diversion by means of a shunt system, most commonly ventriculoperitoneal shunts (VPS). Ventriculoperitoneal shunting is associated with high complication and/or revision rates, in part due to the high-profile programmable valve designs. Thus, the valve-agnostic cranial implant (VACI) was designed and investigated as a safe and effective method of reducing the valve's high profile and is currently undergoing clinical trials. As such, the objective of this study was to collate preliminary, multi-institutional data of early outcomes using a VACI approach for patients requiring VPS by way of an Institutional Review Board approved registry. Methods A total of 25 adult patients across 4 institutions and 6 surgeons underwent VACI placement for VPS based on preoperative evaluation and perceived benefit. Patient demographics, operative details, and preliminary outcomes are presented here. Results Valve-agnostic cranial implant placement via a limited size craniectomy at time of shunt revision was performed with no adverse events. Over an average follow-up period of 1 year (394 ± 178 days), 92% of patients experienced no major shunt-related or scalp-related complications. There were 2 cases with a major complication requiring reoperation: 1 shunt tubing extrusion and 1 case of meningitis. The most frequent postsurgical intervention seen in this study was related to adjustment of drainage: a non-invasively performed valve reprogramming after initial shunt placement when proper flow rate is being established. Of the 8 cases of drainage adjustment, all but 1 (88%) were receiving a VPS for the first time, with the exception undergoing a fourth shunt revision. All instances of improper flow were treated non-surgically and remediated effectively via shunt reprogramming in clinic. Removal of the VACI was not indicated in any treatment course. In this way, all complications as they relate to the shunt valve were minor and required nonsurgical intervention, and no complications reported were directly or indirectly caused by using the VACI. Conclusion Preliminary findings from this multicenter trial suggest promising outcomes with a low complication rate for patients with hydrocephalus undergoing VACI placement during VPS. Ongoing research will continue to provide a more robust clinical picture of VACI in hydrocephalus management as more data becomes available.

Improved Patient Outcomes In A Specialized Neurological Emergency Department Introduction: Stroke is now the fifth leading cause of death in the U.S., but remains the leading cause of long term disability. Target: Stroke helps hospitals achieve improved stroke outcomes through reduced door-to-needle times for eligible stroke patients. Phase III of the American Heart Association/American Stroke Association initiative set more aggressive targets for timely treatment with IV alteplase. To achieve rapid treatment times and better patient outcomes, we created a neurologic emergency department (Neuro ED). Neuro ED hours are staffed by emergency physicians with specialized neuroscience training and administer IV alteplase independently, compared to the traditional ED (TED) where emergency providers consult neurology. Methods: This is a retrospective observational study from 2019-2021 comparing outcomes of acute ischemic stroke patients who received IV alteplase following implementation of the Neuro ED compared to a TED. The following metrics were calculated for each patient: Door to Needle times (DTN), door to CT times (DTCT), and pre and post National Institute of Health Stroke Scale (NIHSS) Results: 74 patients were treated in the Neuro ED and 45 patients were treated in the TED. Average DTN times in the Neuro ED were 27 minutes compared to 65 minutes in the TED. Patients treated in the Neuro ED achieved DTN times of 45 min or less 87% of cases, while only 24% of the time in the TED. Patients treated in the Neuro ED achieved DTN times of 30 min or less 65% of cases, with only 4% of cases in the TED. Average DTCT times in the Neuro ED were 8 minutes faster than the TED. No differences in admission NIHSS were found with an average of 8.75, but a significant improvement was found in discharge NIHSS. Average discharge NIHSS was 3.8 for Neuro ED stroke patients compared with 5.6 for TED patients (p Conclusion: Implementation of a Neuro ED led to swift management and improved symptoms for stroke patients. A dedicated Neuro ED is highly effective in improving DTN times, DTCT times, and overall stroke outcomes.

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

BACKGROUND Implantable shunt devices are critical and life saving for hydrocephalus patients. However, these devices are fraught with high complication rates including scalp dehiscence, exposure, and extrusion. In fact, high shunt valve profiles are correlated with increased complications compared to those with lower profiles. As such, we sought a new method for integrating shunt valves for those challenging patients presenting with scalp-related complications. OBJECTIVE To safely implant and integrate a hydrocephalus shunt valve device within a customized cranial implant, in an effort to limit its high-profile nature as a main contributor to shunt failure and scalp breakdown, and at the same time, improve patient satisfaction by preventing contour deformity. METHODS A 64-yr-old male presented with an extruding hydrocephalus shunt valve and chronic, open scalp wound. The shunt valve was removed and temporary shunt externalization was performed. He received 2 wk of culture-directed antibiotics. Next, a contralateral craniectomy was performed allowing a new shunt valve system to be implanted within a low-profile, customized cranial implant. All efforts were made, at the patient's request, to decrease the high-profile nature of the shunt valve contributing to his most recent complication. RESULTS First-in-human implantation was performed without complication. Postoperative shunt identification and programming was uncomplicated. The high-profile nature of the shunt valve was decreased by 87%. At 10 mo, the patient has experienced no complications and is extremely satisfied with his appearance. CONCLUSION This first-in-human experience suggests that a high-profile hydrocephalus shunt device may be safely integrated within a customized cranial implant.

Introduction: A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists with a projected 19% shortage by 2025. An additional supply of 3000 neurologists is needed by 2025 to meet the looming demand. To help ease the shortage, teleneurology has been implemented by neurologists, mainly for acute stroke patients. We present our model of emergency physician Stroke Champions (SCs) to direct care for stroke patients. Methods: Administering thrombolytics for stroke is a key component of emergency medicine core competencies. Our health system consists of 4 hospitals; a main hub and 3 spoke hospitals. The hub hospital innovatively developed a Neurologic Emergency Department (Neuro ED) with 5 board certified emergency physicians dedicated to caring for patients with any type of neurological complaint. The Neuro ED physicians are also designated as SCs that have specialized training to provide teleneurology to fellow emergency physicians caring for acute stroke patients at the additional hospitals. This supplementary training consists of a mini neurology fellowship with rotations through the neurologic ICU, specialized stroke floor, neurointerventional suite, and neuroradiology. Results: Over a 90-day period the command center received 67 phone calls for patients that met stroke alert criteria. Calls entailed managing BP, dosing alteplase, and recommendations for advanced neuroimaging. Most importantly, the SCs extensively reviewed inclusion and exclusion criteria for IV alteplase with the spoke emergency physician. Three patients were deemed eligible for IV alteplase, with no cases of intracranial hemorrhage. Seven patients required transfer and was facilitated by the SCs, reducing any delays. Reasons for transfer included 3 cases of hemorrhagic stroke, 3 large vessel occlusions for mechanical thrombectomy - one of which received IV alteplase, and 1 brain tumor. Conclusion: Teleneurology is a reliable means of reaching and treating stroke patients. With the severe current shortage of neurologists in the U.S., we now demonstrate a promising alternative of emergency physician Stroke Champions providing telestroke care. This model has produced a high success rate raising the standard of acute neurological care.

Background and Purpose: The clinical efficacy of mechanical thrombectomy (MT) has been unequivocally demonstrated in multiple randomized clinical trials (RCTs). However, these studies were performed in carefully selected centers and utilized strict inclusion criteria. We aim to assess the clinical effectiveness of MT by comparing the specific RCT populations with corresponding patient cohorts derived from a prospective registry. Methods: A total of 2008 patients from 76 sites across 12 countries were enrolled in a prospective open-label MT registry. Patients were categorized into the corresponding cohorts of the SWIFT-Prime, DAWN, and DEFUSE 3 trials based on the age, baseline NIHSS, occlusion site, IV tPA use, pre-morbid mRS and time to treatment criteria used in the RCTs without considering specific parenchymal imaging findings. Baseline and outcome variables were compared across the corresponding groups. Results: As compared to the treated patients in the actual trials, registry-derived patients tended to be younger and had lower baseline ASPECTS. In addition, time to treatment was earlier and the use of IV tPA and general anesthesia were higher in DAWN- and DEFUSE 3-registry derived patients versus their corresponding trials. Reperfusion rates were higher in the registry patients. The rates of 90-day good outcome (mRS 0-2) in registry-derived patients were comparable to those of the patients treated in the corresponding RCTs (SWIFT-Prime, 64.5% vs 60.2%; DAWN, 50.4% vs 48.6%; Beyond-DAWN: 52.4% vs 48.6%; DEFUSE 3, 52% vs 44.6%, respectively; all P>0.05). Registry-derived patients had significant less disability than the corresponding RCT controls (ordinal mRS shift OR, P Conclusion: Our study provides favorable generalizability data for the safety and efficacy of thrombectomy in the “real-world” setting and supports that patients may be safely treated outside the constraints of RCTs and strict guidelines.

Acute carotid terminus occlusion (CTO) is responsible for up to 5% of acute ischemic strokes secondary to emergent large vessel occlusion (ELVO) and up to 20% of acute internal carotid artery (ICA) occlusions.1 The term "CTO" has also been used to describe occlusions in the supra-clinoid segment or at the bifurcation of the ICA. Compared to other ELVOs, patients with CTO present with higher stroke severity and larger infarct volume, likely to be a result of disruption of direct Circle of Willis collaterals across the anterior communicating artery (AComA) and posterior communicating artery (PComA).2,3 Similary, CTO is usually associated with worse prognosis compared to other ELVOs in general. With regard to response to treatment, previous studies have reported significantly lower recanalization rates with intravenous alteplase with CTO compared to M1 segment occlusion. With regard to the safety and efficacy of mechanical thrombectomy, prior reports provide conflicting results with some reporting lower successful recanalization rates with CTO compared to M1 occlusion, and others reporting similar results. In our experience, we have found that successful recanalization of CTO can be achieved with a similar approach to M1 occlusions utilizing a direct aspiration first pass technique (ADAPT).3,4 Herein, we present a case of CTO for which we performed mechanical thrombectomy using ADAPT. This procedure was an emergent standard of care procedure for which a consent was not required and so not obtained.

Flow diversion has been a game-changer in the treatment of wide-neck large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms as well as large vertebral artery aneurysms. Prior to their existence, carotid sacrifice or clipping with or without external to internal carotid artery bypass was the mainstay of treatment. Prior to flow diversion, endovascular coil embolization was often not effective as a stand-alone treatment because of the fact that many of these aneurysms present with symptoms created by mass effect on the cavernous sinus cranial nerves by the aneurysm. Packing the aneurysm with coils did nothing to alleviate the mass effect and did not prevent flow from entering the aneurysm. The continued flow causes coil compaction and aneurysm enlargement. Flow diversion addressed both these issues by diverting flow from the aneurysm while allowing the aneurysm to slowly thrombose and shrink. The video is a step-by-step account of this procedure in a 72-yr-old male with a large recurrence of a previously coiled cavernous ICA aneurysm. The procedure was performed following informed consent.

Background: Combined neuroprotection with endovascular therapy may improve clinical outcomes of only a subset of individuals treated for acute ischemic stroke. The risk/benefit profile of adjunctive treatment may not warrant neuroprotection with successful reperfusion, yet many other individuals have poor outcomes despite revascularization. We hypothesized that optimal candidates for adjunctive neuroprotection may be defined by analyses of subjects with poor clinical outcome despite successful reperfusion in the Trevo Retriever Registry. Methods: The Trevo Retriever Registry dataset was analyzed to define the subset of cases with poor clinical outcome (day 90 mRS 4-6) after successful reperfusion (eTICI 2b50, 2b67, 2c, 3). Multivariate analyses were used to identify predictors of poor outcome using these distinct definitions of successful reperfusion. The influence of covariates, including TLSW, baseline clinical and imaging variables (e.g. ASPECTS, ASITN collateral grade), on defining such optimal neuroprotective candidates was delineated. Results: Successful reperfusion adjudicated by core lab, defined as eTICI ≥ 2b50 included 1,162 subjects, with eTICI ≥ 2b67 in 920, eTICI ≥ 2c in 652 and eTICI 3 in 209. Poor outcome (day 90 mRS 4-6) occurred in 316/1162 (27%) with eTICI ≥ 2b50, 243/920 (26%) with eTICI ≥ 2b67, 172/652 (26%) with eTICI ≥ 2c and 61/209 (29%) with eTICI 3. Across all subsets, multivariate analyses to predict poor outcome after successful reperfusion identified increased age (per year, OR 1.04-1.05, all p= Conclusions: Neuroprotection combined with endovascular therapy may optimally target stroke patients with worse collaterals, diabetes or increased age. Trial design for neuroprotection with revascularization in AIS should leverage these data.

Background: Two recent trials showed a strong benefit of thrombectomy in the extended window. However, these studies were performed in selected centers and utilized strict inclusion criteria. We aim to evaluate the outcomes of thrombectomy in a large prospective cohort treated outside the rigid clinical trial setting. Methods: Trevo Registry patients with ICA, MCA-M1 or M2 occlusions and pre-morbid mRS0-2 were categorized according to time-from-last-seen-well (TLSW) to puncture as early (0-6hours) vs. late (6-24hours). Uni- and multivariate analyzes were performed to identify good outcome (90-day mRS0-2) predictors. Subgroup analyses were performed for the basic DAWN (age >=18, NIHSS >=10, ICA or M1 occlusion, pre-morbid mRS 0-1) and DEFUSE 3 (age 18-90, NIHSS >=6, ICA or MCA-M1 occlusion, mRS 0-2) trial criteria. Results: As compared to the late (n=430), early patients (n=1173) were older (70 vs 68, p=0.011) and had higher IV tPA use (69 vs 25%, p= 6 (1.37 [1.07-1.75]), DM (0.58 [0.44-0.77]), and time to treatment (0.98 [0.97-1.00]) were independent predictors of good outcomes. Imaging modality did not predict outcomes. Similar findings were observed in the early versus late DAWN-like (n=709 vs 257) and DEFUSE 3-like (n=855 vs 273) cohorts. There was great similarity between the outcomes of the Trevo Registry subsets vs their analogous RCTs: early DAWN-like vs SWIFT Prime (90-day mRS 0-2: 57.5 vs 60%; 90-day mRS 6: 11.% vs 9%), Late DAWN-like vs DAWN (50.2 vs 48.6%; 10.6 vs 18%), and Late DEFUSE 3-like vs DEFUSE 3 (52 vs 45%; 10.3 vs 14%). Conclusions: Our study provides favorable data for the generalizability of the safety and efficacy of thrombectomy in the “real-world” setting.

Background: Time to reperfusion (TTR) is commonly cited in clinical outcome after endovascular treatment of acute ischemic stroke, yet collaterals may set the pace of ischemia. Real-world data on fast and slow progressors also remain scarce. We analyzed the impact of TTR on clinical outcome in real-world data using core lab adjudicated angiography, interventional steps and corresponding reperfusion. Methods: 16 key time intervals were calculated from workflow (time of symptom onset, door, picture, puncture) and core lab metrics (clot visualization, first deployment, first reperfusion, final angiography) in real-world data from the Trevo Retriever Registry. These 16 variations of TTR were analyzed overall and by collateral status (ASITN 0-1 versus 2 versus 3-4) to determine the relationship with 90-day clinical outcomes. Results: Real-world data on endovascular therapy from 1,441 subjects in the Trevo Retriever Registry were analyzed to relate TTR with clinical outcomes. Overall metrics for TTR are shown in Table 1. TTR was not linked with collateral status. Using a multivariate model incorporating known predictors, there was no influence of TTR using any of the 16 definitions on clinical outcome. Better collateral status on DSA prior to revascularization showed a potent relationship with 90-day mRS (p Conclusions: Collaterals transform time to reperfusion, linking fast and slow progressors with subsequent clinical outcomes. TTR may be standardized based on these 16 key epochs in endovascular stroke therapy to document workflow metrics. Time is relative, even when measured with detailed, standardized metrics.

Background: Time to mechanical thrombectomy is a significant driver of outcomes in acute ischemic stroke (AIS) patients presenting with large vessel occlusion (LVO). We aimed to evaluate predictors of onset to groin puncture (OTG), groin puncture to reperfusion (GTR), and onset to reperfusion (OTR) times in AIS patients treated with the Trevo stent-retriever. Methods: The investigator-initiated TRACK registry recruited 23 clinical sites to submit demographic, clinical, site-adjudicated angiographic, and outcome data on consecutive patients treated with the Trevo device. We included patients treated Results: Among 433 patients analyzed (mean age 66.8 +/- 14.6 years; median NIHSS score 18; 88% anterior circulation), the median times were: OTG 240, GTR 64, and OTR 321 minutes. In multivariable analysis (Table), the independent predictors were: 1) OTG: transfer status and general anesthesia (GA) use; 2) GTR: 1 pass attempt only, use of rescue therapy, GA use, and baseline mRS >1; and 3) OTR: transfer status, use of perfusion imaging, anterior circulation LVO, use of rescue therapy, and 1 pass attempt only. Conclusions: Major pre-treatment contributors to delays to reperfusion in AIS patients treated

Background: The delay and dispersion of collateral circulation to the MCA territory is readily available prior to endovascular thrombectomy for acute ischemic stroke (AIS). Factors associated with collateral grade have never been established in such an extensive population, reflecting diverse subjects from around the world. Largescale data from the Trevo Retriever Registry enables mapping of the MCA collaterome for the first time. Methods: The Imaging and Angiography Core Lab of the Trevo Retriever Registry independently conducted prospective evaluation of angiography in more than 1,500 subjects. Collaterals were systematically scored using ASITN grade prior to thrombectomy. Descriptive statistics detailed the distribution of collateral grades and analyses with demographic, imaging and clinical variables to explore key associations with routinely acquired registry data. Results: 890 subjects (68.5 ± 15.1 years; 54.6% women; baseline NIHSS median 15 (10-19)) with AIS due to MCA occlusion had angiography of collateral circulation centrally adjudicated. Proximal M1 MCA occlusion was noted in 671/890 (75.4%). Collateral grade prior to thrombectomy included grade 4 or most robust collaterals in 38/890 (4.3%), 3 in 294/890 (33.0%), 2 in 467/890 (52.5%), 1 in 80/890 (9%) and 0 or none in 11/890 (1.2%). Baseline collaterals at angiography and pre-procedure ASPECTS were closely correlated (r=0.439, p6s) hypoperfusion at-risk (r=-0.10, n=391; p=0.043) volumes. First pass mTICI≥2b occurred in 553/858 (64.5%) with final mTICI≥2b in 824/890 (92.6%). Collateral grade prior to thrombectomy (each 1-point increment, after adjustment for other predictors) was strongly associated (OR 1.38 95%CI (1.12-1.7), p=0.002) with good clinical outcomes (mRS 0-2) at 90 days. Conclusions: Largescale mapping of collaterals prior to MCA thrombectomy reveals marked variation in the extent and functional impact of the collaterome. The preponderance of partial perfusion in the downstream ischemic territory prompts the need to investigate and leverage the protective nature of the collaterome in AIS.

Introduction: Approximately 2/3 of all AIS present with NIHSS 0-5. While it has been demonstrated that LVO can be found in ~10-20% of all low NIHSS patients, outcome data in this population remains scarce. Indeed, only 14/1766 patients in the recent endovascular RCTs had baseline (b) NIHSS in the 0-5 range. Yet, the presence of LVO in the setting of low NIHSS is associated with ~10-fold increase in subsequent deterioration. We aim to describe the outcomes in a large cohort of low NIHSS patients undergoing thrombectomy. Methods: Patients derived from a large prospective multicenter international stent-retriever registry (Trevo Registry, n=2,010). Baseline and outcome variables were compared according to bNIHSS 0-8 vs >8 and bNIHSS 0-5 vs >5. The primary and secondary efficacy endpoints were the rates of 90-day mRS 0-2 and mTICI 2b-3, respectively. Safety endpoints included sICH and 90-day mortality. Results: A total of 1,985 patients were included. As compared with patients with higher baseline NIHSS, low baseline NIHSS (0-8, n=342; 0-5, n=160) patients were younger, had less comorbidities and better functional status, more frequently had MCA-M2 or vertebrobasilar occlusions, less frequently received IV tpa, and underwent thrombectomy at later times (Table 1). The reperfusion outcomes were nearly the same. There were no significant differences in procedure-related complications, which were overall low (Table 2). The rates of 90-day mRS 0-2 were significantly higher in the lower NIHSS patients (p Conclusion: Despite safe and efficacious endovascular reperfusion, low-NIHSS LVO patients have a relatively high proportion of bad outcomes. This supports the notion that many of "mildly" presenting patients do not fare well. A randomized clinical trial including immediate endovascular treatment in this patient population is warranted.

Background and Aims: Balloon Guide Catheter (BGC) use during thrombectomy treatment in Stroke patients has been reported to have positive effects on revascularization, procedural characteristics, and clinical outcomes. We evaluate the use of BGC in an open-label large prospective TREVO Retriever Registry of real world patients to determine predictors of good ‘clinical’ outcomes. Method: Consecutive Trevo Registry patients that had Balloon Guide Catheter (BGC) used during their thrombectomy procedure were identified; a subset of patients who fulfilled the criteria (ICA and/or MCA-M1/M2 occlusion with pre-morbid mRS 0-1, TLSW ≤6 hrs) within the cohort were also identified. Multivariate analysis was performed to identify the predictors of good outcomes in BGC thrombectomy patients. Results: A total of 1031 BGC treated Trevo Registry patients (overall enrolled, n=2010) qualified for analysis, of which 605 patients fulfilling the subset criteria were identified. The mean age of BGC/stent retriever patients was 67.5 with a median (IQR) baseline NIHSS of 15(11-19). Occlusion location of the BCG group was ICA -20.4%, M1- 57.1%, M2/M3-20.3%, and Posterior 1.8%. In the overall BGC cohort, the median (IQR) time to treatment was (4.2 (3.0,6.5)- hrs.) with conscious/local sedation used in 63.4% and general anesthesia used in 37.3% of cases. The median number of passes with Trevo stent retriever was 1 and revascularization (mTICI ≥ b) was achieved in 92.8% of cases. The sICH rate was low at 1.9% (20/1031) with a low rate of vessel perforation (0.2%). At 90 days post stroke, 56.0% of patients achieved functional independence (mRS 0-2) with 63.7% of the subset of “guidline “ BGC patients achieving functional independence at 90 days. Multivariate logistic regression showed age (aOR 0.97 [0.96, 0.99] P Conclusion: Data from Trevo Registry demonstrate the use of BGC in thrombectomy procedure is safe, and leads to a reduction of disability in ischemic stroke patients.

Introduction: The recent thrombectomy trials were largely limited to patients with small strokes on presentation. Methods: Patients derived from a large prospective multinational stent-retriever registry (Trevo Registry, n=2,010). Baseline NCCT SPECTS and CTP Core Volumes (rCBF70mL if age 50mL if age >70-80 years; >30mL if age >80 years) vs. not on CTP. The primary and secondary efficacy endpoint were the rates of 90-day mRS 0-2 and mTICI 2b-3, respectively. Safety endpoints included sICH and 90-day mortality. Results: As compared with patients with higher baseline ASPECTS (n=1037), low baseline ASPECTS (0-4, n=78; 5, n=78) patients were younger, had higher stroke severity, and tend to have less comorbidities and undergo thrombectomy at later times (Table 1a). TICI-3 reperfusion was higher in the higher-ASPECTS group but other reperfusion outcomes were nearly the same. Safety outcomes were comparable. Rates of 90-day mRS 0-2 were significantly higher in the high-ASPECTS group (p Conclusion: Patients with large baseline cores as measured by either NCCT or CTP may still achieve favorable outcomes with endovascular treatment. A randomized clinical trial in this patient population is warranted.

Background: Routine use of advanced imaging versus ASPECTS for imaging triage of endovascular thrombectomy candidates has not been evaluated on a large scale to date. Ischemic core may be defined by ASPECTS or perfusion imaging, yet these variable definitions likely reflect different pathophysiology as perfusion may fluctuate and ASPECTS lesions may be time-dependent. Methods: The Trevo Retriever Registry was a prospective, open-label, consecutive enrollment, multicenter, international registry with more than 65 enrolling sites worldwide. The Imaging and Angiography Core Lab systematically adjudicated more than 1,500 subjects, scoring ASPECTS and separately processing perfusion imaging. Ischemic core volume on perfusion imaging was defined as rrCBF Results: 488 subjects (68.3±14.4 years; 53.3% women; baseline NIHSS median 15 (10-19) with anterior circulation occlusions were evaluated with both ASPECTS and perfusion imaging prior to thrombectomy. Arterial occlusions included 87/487 (17.9%) ICA and 296/487 (60.8%) proximal M1 MCA, treated with thrombectomy at median 4.7 (3.3-7.9) hours from time last known well (TLKW). ASPECTS was median 8 (7-9) with ischemic core lesions of median 18 (4.9-39.2) cc. At-risk hypoperfusion (Tmax>6s) lesions were median 109.8 (62-156.9) cc. TLKW was associated with ASPECTS (r=-0.18, p Conclusions: Largescale, systematic evaluation of ASPECTS and perfusion imaging prior to thrombectomy reveals discrepancy in the definition of ischemic core and the prediction of clinical outcomes after revascularization. ASPECTS is time-dependent, yet reliably predicts outcomes in routine clinical practice.

Background: Endovascular therapy (EVT) effectiveness is established in ischemic strokes with large vessel occlusion (LVO) in the terminal ICA and M1, which was extended up to 24 hrs by recent DAWN trial results. However this benefit is not as well established in more distal (M2) occlusions, especially late presenters (beyond 6 hrs). We evaluated thrombectomy outcomes in M2 occlusions as compared to ICA/M1 across early and late time windows. Methods: In a prospective, multicenter, single arm, international registry (Trevo Retriever Registry), anterior circulation LVOs were stratified on clot location into M2 vs ICA/M1 and dichotimized into early vs late (0-6 vs 6-24 hrs). 90 day mRS (0-1 excellent, 0-2 good) were the primary outcomes; sICH and dissection were the secondary (safety) outcomes. Multivariate analyses identified pre-procedure variables independently correlating with good outcome in M2s. Results: 1581 patients were identified (1265 ICA/M1, 316 M2). The M2 and ICA/M1 groups were similar (age in both 68.4), IV-tPA (69.1 vs 69.7%, p=0.8) and same median/IQR ASPECTS 8 (7-9). M2 patients had lower NIHSS (13 vs 16, p Conclusion: Excellent and good outcomes may be achieved in distal LVO isolated to M2 similar to those with proximal occlusions. A benefit that can be reached up to 24 hrs.

Objective: The Trevo Registry was designed to assess real world outcomes of the Trevo Retriever in patients experiencing ischemic stroke. It is the largest prospective study for acute stroke intervention, with 2010 patients enrolled and 90 day outcomes in 1873 patients. The primary endpoint is revascularization status based on post-procedure TICI score and secondary endpoints include 90-day mRS, 90-day mortality, neurological deterioration at 24 hours and device/procedure related adverse events. Methods: The study was a prospective, open-label, consecutive enrollment, multi-center, international registry of patients who underwent mechanical thrombectomy for acute stroke using the Trevo stent retriever as the initial device. Results: The median NIHSS at admission was 16 (IQR 11-20). Most patients (70.8%) were treated at Conclusions: The Trevo Retriever Registry represents the first 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. Due to the fact that this data represents real world use of the Trevo Retriever, (e.g. subjects pre-stroke mRS >1 (29%) and those treated 6-24 hours after stroke symptoms (29%), this data cannot be compared to the results from recent trials with restricted eligibility criteria. Future subgroup analysis of this large cohort will help to identify areas of future research to enhance outcomes further with this treatment modality.

Background and Aims: Intravenous tPA remains the standard of care, with MT currently indicated within 8 hours for IV tPA failures or patients with IV tPA contraindications. Whether LVO patients should receive IV tPA treatment or instead be triaged directly to MT therapy is currently unknown but greatly debated. The Trevo Registry is a real world, multi-center, international study of mechanical thrombectomy (MT) patients treated from 0-24 hours. Evaluation of the Trevo Registry clinical and procedurals outcomes of MT patients treated with or without IV tPA could provide insight into the benefit of IV tPA in MT patients. We hypothesized that in MT patients treated within 8 hours, pretreatment with intravenous tPA would lead to better clinical outcomes compared to patients who did not receive IV tPA. Method: Consecutively enrolled patients treated within 8 hours with ICA, M1, or M2 occlusions were selected for analysis. Univariate and multivariable regressions were conducted to identify clinical and radiographic independent variables that correlate best with the dependent variable of functional outcome: mRS 0-2, with a focus on intravenous tPA treatment. Results: A total of 1183 Trevo Registry patients (overall enrolled, n=2010) qualified for analysis, of whom 380 were not treated with IV tPA. Demographics were similar, however atrial fibrillation (46.3% vs 27.2%) and previous ischemic stroke (14.1% vs 7.5%) were higher in the no IV tPA group. The median time to treatment was similar (3.8 vs. 3.6 hrs). First pass mTICI ≥ 2B (63.6% vs 66.4%) and final revascularization (91.1% vs 92.8%) were similar between no IV tPA and IV tPA groups.Unadjusted, there were similar rates of functional outcome (90 day mRS 0-2; 60.9% vs. 62.5%). After adjustment, patients who did not receive IV-tPA had similar rates of good outcome (aOR 1.08, 95% CI [0.87-1.34]. P=0.58) as well as reduction (shift) in disability (aOR 1.08, 95% CI [0.87-1.34]. P=0.49). Safety outcomes (mortality, sICH) were similar between both groups. Conclusion: In the Trevo Registry of MT patients treated within 8 hours, patients who did not receive IV tPA had similar endovascular and clinical outcomes as patients pretreated with IV tPA. The added benefit of IV tPA for MT patients should be further investigated.

Background: The DAWN trial showed EVT effectiveness in the late time window (6-24 hrs), however, DAWN patients were carefully selected based on advanced perfusion imaging, CTP and MRI. Similar to the early window (0-6 hrs), simple imaging (CT) and other clinical variables may select patients for thrombectomy beyond 6 hours. We evaluated a largescale, real world practice for predictors that could identify patients who may benefit from EVT in the late time window. Methods: Patients with LVO in the anterior circulation (M1, M2, ICA) from a prospective, single arm, multicenter, international registry (Trevo Retriever Registry) treated in the late window LSN to groin puncture (GP) (6-24 hrs) were included. Univariate and multivariate analyses assessed factors independently correlating with good outcome (90 day mRS 0-2). Furthermore, patients outcomes were compared based on their baseline imaging selection CT vs CTP and MRI. Results: 549 patients were treated beyond 6 hours. The average age was 67, median/IQR ASPECTS 8(6-9), median/IQR NIHSS was 15 (9-20), median/IQR time LSN to GP (hr) was 9.7 (7.3-13.6) and IV-tPA rate were 22.8%. CT was the only imaging selection method in 15.9%, while additional advanced imaging was utilized in the remaining patients; CTP (70%), and MRI(14.1%). Good outcomes were observed in 51.4% of late window patients. Age (aOR 0.96, 95% CI 0.94-0.98, p Conclusion: Simple imaging and clinical variables can identify patients that could benefit from thrombectomy in the late window. Importantly, ASPECTS reliably predicted good outcome beyond 6 hours without adjunctive benefit from adding advanced perfusion imaging, a finding that may simplify patients selection to facilitate and generalize the intervention in the late window to wide, real world practice.

Background: The efficacy of endovascular therapy (EVT) in randomized clinical trials (RCTs) for acute strokes due to large vessel occlusion (LVO) led to AHA guidelines recommending EVT as standard of care for selected patients. However, many conditions were under-represented in the RCTs: ASPECTS 6 hrs and M2/ distal/ posterior circulation occlusions. Objective: We evaluated EVT outcomes in these populations compared to counterparts represented in the RCTs. Methods: A large multicenter international prospective cohort study of LVO patients treated with stent retriever thrombectomy (TREVO Registry) between 11/2013 and 4/2016 was analyzed. 90 day mRS was the primary outcome (0-2 good outcome). Multivariate logistic regression modeling was employed to evaluate EVT impact in the different groups. Results: Of 1000 patients, 81 had NIHSS p< 0.001 compared with NIHSS ≥6) (Table 1). Over 80 yo, however, had low odds of independence (aOR 0.3, 95% CI 0.2-0.5; p 6 hrs, 51% had a good outcome (aOR 0.78, 95% CI 0.55-1.1; p =0.17) compared to ≤6 hrs. Nearly half of patients with ASPECTS 6 hrs. Fig 2 demonstrates the likelihood of good outcome by clot location. M2 and distal occlusions had the highest good outcome probabilities while proximal ICAs had the lowest (48.1%). More than half of vertebrobasilar patients achieved independence (54.8%). Conclusion: While effectiveness cannot be determined in the absence of medically treated controls, our analyses of real world data show several groups outside AHA guidelines may benefit from EVT. In particular, further study is needed to examine EVT benefits for mild stroke and M2 occlusions.

Background: While faster reperfusion with EVT leads to better outcomes in acute ischemic stroke due to large vessel occlusion (LVO), most LVO patients present to outside hospitals without EVT capability. Treating physicians are often unsure if EVT would confer benefit upon arrival to tertiary hospitals given inter-facility transfer delays. Objective: We evaluated independent predictors of good outcome in transferred patients treated with EVT to devise a score that may assist treating physicians to make transfer and treatment decisions. Methods: Transfer patients were analyzed in a multicenter international prospective cohort study of LVO patients treated with stent retriever thrombectomy (TREVO Registry) from 11/2013 to 4/2016. Independent factors correlating with good outcome after EVT were identified using univariate and multivariate analyses. We devised a score to identify patients with LVO at the referral facility who may benefit from EVT. Results: Of 1000 patients enrolled, 226 were anterior circulation occlusions, transferred and treated within 0-8 hrs (Table 1). Age, stroke severity, glucose level, M2 occlusion and achieving onset to groin puncture ≤ 5 hr were independent factors associated with good outcome (Table 2). Other clinical variables were analyzed, as in ASPECTS, but were not significant. A 10 point score was devised (Table 3). Patients with a score of 0-4 had 4 times the odds of good outcome compared to a score of 5-9 (aOR 4.3, 95% CI 1.9-9.9; p p Conclusion: A simple transfer score may be an effective triage method to identify patients at remote facilities who may benefit from EVT upon transfer. Further validation is necessary to confirm these findings.

Introduction: Endovascular stroke therapy has become the gold standard treatment for large vessel occlusion. The Joint Commission has certified hospitals as Comprehensive stroke centers (JCCSC) based on rigorous standards in the hopes of identifying centers of excellence. We sought to determine if JCCSC have faster door to reperfusion times compared to non-JCCSC. Methods: The TREVO registry is a multicenter international real world registry assessing angiographic and clinical outcomes with the Trevo device being used in the first pass. We defined a CSC as certified by the Joint Commission as of July 1, 2016. Demographic information, times within the hospital, angiographic results and clinical outcomes were analyzed between the JCCSC and non-JCCSC institutions. Results: A total of 507 patients (329 JCCSC, 178 non-JCCSC) have completed data in the Trevo registry to date. There are a higher proportion of patients with ASPECTS < 7 being treated at JCCSC vs. non-JCCSC (8.8% vs. 0.0%, p Conclusions: Patients treated at a JCCSC had faster procedural times, without faster door to procedure times when compared to non-JCCSC centers. Outcomes were no different, due to imbalances in stroke severity at baseline and a higher proportion of patients with ASPECTS < 7 being treated.

Objective: The Trevo Registry is designed to assess real world outcomes of the Trevo Retriever in patients experiencing ischemic stroke. This is the largest prospective study for acute stroke intervention, with 1247 patients currently enrolled and 90 day outcomes in 1021 patients. The primary endpoint is revascularization status based on post-procedure TICI score and secondary endpoints include 90-day mRS, 90-day mortality, neurological deterioration at 24 hours and device/procedure related adverse events. Methods: The study is a prospective, open-label, consecutive enrollment, multi-center, international registry of patients undergoing mechanical thrombectomy for acute stroke using the Trevo stent retriever as the initial device. Enrollment is expected to reach 2000 subjects at up to 100 sites. Results: As of August 13, 2016 a total of 1247 patients were enrolled. The median NIHSS at admission was 16 (IQR 11-20). Most patients (66.2%) were treated at >/= 6 hours from last known normal with a median procedure time of 50 minutes (32-77). The occlusion site was M1 or M2 in 74.5%. General anesthesia was employed in 46.6% of procedures. TICI 2b or 3 revascularization was 92.8% with an average of 1.6 passes with the device. Median NIHSS at 24 hours and discharge was 6 and 4 respectively. Fifty-five percent of patients had mRS ≤2 at 3 months and the overall mortality rate was 15.4%. Patients treated after 8 hours of symptom onset had a 94.9% revascularization rate and 52.8% mRS ≤2 at 3 months. The symptomatic ICH rate was 1.2%. Patients who met the revised AHA criteria for thrombectomy were found to have 58.4% mRS 0-2 at 90 days. Conclusions: The Trevo Retriever Registry represents the first 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. Due to the fact that this data represents real world use of the Trevo Retriever, (e.g. subjects pre-stroke mRS >1 (16.5%) and those treated 6-24 hours after stroke symptoms (33.8%), this data cannot be compared to the results from recent trials with restricted eligibility criteria. Future subgroup analysis of this large cohort will help to identify areas of future research to enhance outcomes further with this treatment modality.

Background: Endovascular thrombectomy (EVT) substantially increases the likelihood of good outcome in acute ischemic strokes due to large vessel occlusion (LVO). Expediting EVT to achieve faster reperfusion is an important factor that correlates with good outcome. Ultra-early intervention in the first 3 “golden” hours from onset was not well characterized in recent trials. Objective: We sought to assess the impact of early treatment within the first 3 hours on clinical outcomes in large, real life, world-wide practice. Methods: We analyzed a multicenter international prospective cohort study of LVO patients treated with stent retriever thrombectomy (TREVO Registry) between11/2013 and 4/2016. We stratified patients based on treatment time, onset to groin puncture (GP), into 3 groups: 0-3, 3-6, >6 hrs. 90 day mRS was the primary outcome (0-2 good outcome). Logistic regression modeling was performed to evaluate the impact of treatment within the golden 3 hours on outcomes and to determine the independent factors associated with EVT initiation within 3 hours. Results: In the 905 patients, GP occurred in: 23.1% 0-3 hrs, 44.3% 3-6 hrs and 32.6% >6 hrs. Table 1 shows similar baseline characteristics among the groups. Patient-level predictors of treatment within 3 hrs were age (aOR 1.1 per decade of age ≥18) and good ASPECTS (aOR 1.2 per point). No hospital-level predictors of early treatment were found. Patients treated within 3 hrs have a higher likelihood of good outcome as compared to those treated >3 hrs (aOR 2.0, 95% CI 1.4-2.9; p Conclusion: Early thrombectomy of LVO strokes, within the first three hours provides the highest impact compared with later time windows. Streamlining processes to deliver rapid intervention within 3 hours would improve clinical outcomes.

Background: Endovascular thrombectomy trials established efficacy in acute ischemic stroke, yet real-world data on device effectiveness is warranted. Core lab adjudication of angiography is required to validate reperfusion, providing evidence and detailed data beyond randomized, controlled trials. We report the largest endovascular therapy registry data linking independent core lab data on reperfusion with clinical outcomes. Methods: The Trevo Retriever Registry is a prospective, open-label, consecutive enrollment, multicenter, international registry with more than 65 enrolling sites worldwide. An independent Imaging Core Lab, blind to all other data, evaluates the angiography with a battery of various TICI scores (mTICI, oTICI, oTICI2C) to define reperfusion. Statistical analyses examined TICI reperfusion and association with clinical outcomes considering expansive data collected in the registry. Results: 506 enrolled subjects (mean age 68.2 ± 14.2 yrs; 53% female) had core lab adjudicated angiography as of July 2016, including 21.5% > 80 years old. Baseline NIHSS was median 15.0 (9.0, 20.0) with time from onset to CT of median 4.0 (1.7, 9.7) hrs. Core lab adjudicated arterial occlusion sites were: 53% M1, 24% ICA, 16% M2, 4% Basilar and 2% other. Time to reperfusion (oTICI ≥ 2A) was median 30.0 (19.0, 42.0) min. Core lab adjudicated revascularization was mTICI ≥ 2B in 90.4% (95%CI 87.4, 92.9), oTICI ≥ 2B in 82.3% (95%CI 78.6, 85.6) and oTICI2C ≥ 2C in 45.0% (95%CI 40.5, 49.6). mRS of 0-2 at 90 days was achieved in 57.3% (95%CI 52.5, 62.1). Extensive clinical, laboratory and stroke workflow variables were considered, yet only male sex (OR 0.62 (95% CI 0.38, 0.99) was an independent predictor of successful reperfusion (oTICI ≥ 2B) while age (OR 0.96 (95% CI 0.94, 0.97), NIHSS (OR 0.91 (95% CI 0.88, 0.94) and diabetes (OR 0.54 (95% CI 0.33, 0.88) predicted mRS 0-2 at 90 days. Conclusions: Proven reperfusion rates after endovascular stroke therapy excel in the real-world translation of thrombectomy devices around the globe, leading to good outcomes after stroke.

Background: Most endovascular stroke therapy studies and subsequent guidelines restrict intervention based on ASPECTS. A wide range of ASPECTS scores may be encountered in practice and individual patient benefit may be realized even at low ASPECTS. We examined large-scale data on outcomes after endovascular therapy, stratified by baseline ASPECTS in the Trevo Retriever Registry. Methods: The independent Imaging Core Lab of the Trevo Retriever Registry prospectively determines ASPECTS on baseline imaging acquired immediately prior to endovascular thrombectomy. ASPECTS scores and regional involvement were analyzed with respect to site of arterial occlusion, effect of time from symptom onset, co-morbidities and clinical outcomes, based on ASPECTS strata. Results: Baseline ASPECTS data was reviewed by the Imaging Core Lab in 426 subjects with anterior circulation stroke enrolled in the Trevo Retriever Registry, as of July 2016. Mean age was 68.8 ± 13.7 yrs, with 20.9% > 80 years old. Baseline NIHSS was median 15.0 (10.0, 19.0). Onset to CT was median 3.8 (1.5, 9.0) hrs, with median ASPECTS of 8.0 (7.0, 9.0), ranging from 3-10. Baseline ASPECTS 0-7 occurred in 118/426 (27.7%) subjects, including 39.0% of ICA, 27.1% M1 and 16.9% M2/3 arterial occlusions at angiography. Baseline clinical variables predicting ASPECTS included age and NIHSS, whereas the ASPECTS score was mildly associated with final TICI2C reperfusion (r=0.24, p Conclusions: Discrete ASPECTS strata may influence outcomes of endovascular therapy conducted in routine practice around the world, yet individuals with low ASPECTS may still achieve reasonable outcomes.

Background: While endovascular therapy (EVT) is effective for large vessel occlusions (LVO), most patients present to hospitals without EVT capability and are transferred for intervention, delaying treatment. Objective: We evaluated outcomes in LVO patients treated with thrombectomy who were transferred compared to those presenting directly to EVT facilities. Methods: In a large multicenter international prospective cohort study of LVO patients treated with stent retriever thrombectomy (TREVO Registry), patients were stratified by initial presentation into transferred (TNS) vs direct (DIR). 90 day mRS was the primary outcome (0-1 excellent, 0-2 good outcomes); sICH and reperfusion by mTICI were secondary outcomes. Outcomes were compared in the 2 groups (0-8 hrs onset to groin puncture (GP) then in time matched 3-8 hrs subgroups for validation). Logistic regression identified independent predictors of good outcome in TNS patients. Results: We identified 540 patients (230 TNS; 310 DIR) (Fig 1). TNS patients were younger and had longer onset to GP times (4.6 vs 3.1 hrs; p p p =0.4) (Fig 2) and no difference in the time matched 3-8 hrs subgroups (59.2% DIR vs 56.3% TNS, p =0.6). Fig 3 plots good outcome probabilities over time, showing similar confidence interval bands. Younger age (OR 0.95), lower NIHSS (OR 0.90), glucose level < 170 mg/dL (OR 2.4), distal clot location (M2) (OR 1.7), excellent reperfusion (mTICI≥2b) (OR 2) and time to GP Conclusion: While excellent outcomes were higher in directly-presenting patients, EVT-treated transfers may achieve similar good outcomes. The association between earlier EVT after transfer and better outcomes emphasizes the need to streamline the transfer process.

Stroke is the fourth leading cause of death in the United States. Intracranial atherosclerotic disease accounts for 8%-10% of ischemic stroke in the United States. So far, surgical bypass has not proved to be superior to medical therapy. As both medical and endovascular therapies for intracranial atherosclerosis evolve, so too do the guidelines for treatment. Initial reports on the results of stent placement for symptomatic high-grade intracranial atherosclerotic disease were encouraging; however, recent trials suggest that initial medical management may be preferable. Currently, intracranial angioplasty and stenting for symptomatic intracranial atherosclerosis is now more controversial. Further trials are necessary to help determine which patients are ideal for endovascular therapies.

BACKGROUND: Simulation is an increasingly useful means of teaching in the era of duty hour restrictions. Since the completion of our diagnostic cerebral angiography simulator curriculum pilot program, we have performed this resident course at 2 Congress of Neurological Surgeons (CNS) annual meetings with larger participant numbers. OBJECTIVE: To report the ongoing results of these courses. METHODS: A 120-minute simulator-based training course was performed at 2 CNS annual meetings. Precourse written and simulator skills assessments were performed, followed by instructor-guided training on an endovascular simulator. Postcourse written and simulator practical assessments were then performed and compared with precourse scores. RESULTS: Thirty-seven neurosurgery resident participants completed the course module: 16 completed the first course provided and 21 completed the second. Posttest written scores were significantly higher than pretest scores (mean ± SEM, 8.5 ± 0.40.3 vs 4.9 ± 0.3; P < .001). Instructor assessments of practical posttest scores of participants were significantly higher than pretest practical scores for both the CNS 2011 and CNS 2012 groups (P < .001). CONCLUSION: The expansion of a curriculum-based, cerebral angiography simulator pilot program to trainees through courses at national neurosurgical meetings demonstrated excellent results with significant improvements in written test scores and instructor assessments of participant technical skills. With ever-expanding improvements in simulation technology and realism, simulator training for cerebral angiography may become an integral component of resident training in the future.

Background: The promising results of the Solitaire Flow Restoration (FR) With the Intention for Thrombectomy (SWIFT) trial recently led to Food and Drug Administration (FDA) approval of the Solitaire FR stent retriever device for recanalization of cerebral vessels in patients with acute ischemic stroke. Objective: To report the early postmarket experience with this device since its FDA approval in the United States, which has not been previously described. Methods: We conducted a retrospective analysis of consecutive acute ischemic strokes cases treated between March 2012 and July 2012 at 10 United States centers where the Solitaire FR was used as a single device or in conjunction with other intraarterial endovascular approaches. Results: A total of 101 patients were identified (mean age, 64.7 years; mean admission National Institutes of Health Stroke Scale [NIHSS] score, 17.6). Intravenous thrombolysis was administered in 39% of cases; other endovascular techniques were utilized in conjunction with the Solitaire FR in 52%. Successful recanalization (Thrombolysis in Myocardial Infarction 2/3) was achieved in 88%. The rate of symptomatic intracranial hemorrhage within the first 24 hours was 15%. In-hospital mortality was 26%. At 30 days, 38% of patients had favorable functional outcome (modified Rankin scale score ≤2). Severity of NIHSS score on admission was a strong predictor of poor outcome. Conclusion: Our study shows that a variety of other endovascular approaches are used in conjunction with Solitaire FR in actual practice in the United States. Early postmarket results suggest that Solitaire FR is an effective tool for endovascular treatment of acute ischemic stroke.

The pipeline embolization device (PED) is the latest technology available for intracranial aneurysm treatment.To report early postmarket results with the PED.This study was a prospective registry of patients treated with PEDs at 7 American neurosurgical centers subsequent to Food and Drug Administration approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Follow-up data included degree of aneurysm occlusion and delayed ( 30 days after the procedure) complications.Sixty-two PED procedures were performed to treat 58 aneurysms in 56 patients. Thirty-seven of the aneurysms (64%) treated were located from the cavernous to the superior hypophyseal artery segment of the internal carotid artery; 22% were distal to that segment, and 14% were in the vertebrobasilar system. A total of 123 PEDs were deployed with an average of 2 implanted per aneurysm treated. Six devices were incompletely deployed; in these cases, rescue balloon angioplasty was required. Six periprocedural (during the procedure/within 30 days after the procedure) thromboembolic events occurred, of which 5 were in patients with vertebrobasilar aneurysms. There were 4 fatal postprocedural hemorrhages (from 2 giant basilar trunk and 2 large ophthalmic artery aneurysms). The major complication rate (permanent disability/death resulting from perioperative/delayed complication) was 8.5%. Among 19 patients with 3-month follow-up angiography, 68% (13 patients) had complete aneurysm occlusion. Two patients presented with delayed flow-limiting in-stent stenosis that was successfully treated with angioplasty.Unlike conventional coil embolization, aneurysm occlusion with PED is not immediate. Early complications include both thromboembolic and hemorrhagic events and appear to be significantly more frequent in association with treatment of vertebrobasilar aneurysms.

Background The Enterprise Vascular Reconstruction Device and Delivery System (Cordis; the Enterprise stent) was approved for use in conjunction with coiling of wide-necked aneurysms in 2007. No published long-term aneurysm occlusion or complication data exist for the Enterprise system. Objective We compiled data on consecutive patients treated with Enterprise stent-assisted coiling of aneurysms from 9 high-volume neurointerventional centers. Methods A 9 center registry was created to evaluate large volume data on the delayed safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution prior to May 2009. Results Two-hundred twenty-nine patients with 229 aneurysms, 32 of which were ruptured aneurysms, were included in the study. Mean clinical and angiographic follow-up was 619.6 ± 26.4 days and 655.7 ± 25.2 days, respectively. Mean aneurysm size was 9.2 ± 0.4 mm. Fifty-nine percent of patients demonstrated 100% coil obliteration and 81% had 90% or higher occlusion at last follow-up angiography. A total of 19 patients (8.3%) underwent retreatment of their aneurysms during the follow-up period. Angiographic in-stent stenosis was seen in 3.4% and thromboembolic events occurred in 4.4%. Overall, 90% of patients who underwent Enterprise-assisted coiling had a modified Rankin Scale score of 2 or less at last follow-up. A poor modified Rankin Scale score was strongly associated with rupture status (P Conclusion Although this study is limited by its retrospective nature, the Enterprise stent system appears to be an effective, safe, and durable treatment for intracranial aneurysms when used in conjunction with coiling.

BACKGROUND Stent-assisted coiling of intracranial aneurysms with self-expanding stents has widened the applicability of neuroendovascular therapies to those aneurysms previously considered "uncoilable" because of poor morphology. The Enterprise Vascular Reconstruction Device and Delivery System (Cordis) has demonstrated promising initial short-term results. However, the rates of delayed in-stent stenosis or thrombosis are not known. OBJECTIVE To report midterm results of the Enterprise stent system. METHODS A 10-center registry was created to provide a large volume of data on the safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution. Available follow-up data were evaluated for the incidence of in-stent stenosis, thrombosis, and aneurysm occlusion. RESULTS In total, 213 patients (176 females) with 219 aneurysms were treated with the Enterprise stent. One hundred ten patients had undergone delayed angiography (≥ 30 days from stent placement, mean follow-up 174.6 days). Forty percent of patients demonstrated total occlusion with 88% having ≥ 90% aneurysm occlusion. Six percent of patients had delayed (>30 days) angiographic findings, of which 3% demonstrated significant (≥ 50%) in-stent stenosis or occlusion. Seven delayed thrombotic events occurred (3%), along with 2 additional immediate periprocedural events. All 7 delayed events were concomitant to cessation of double-antiplatelet therapy. CONCLUSION Midterm occlusion rates are excellent, and stenosis and thrombosis rates are comparable to other available neurovascular stents. Interruption of antiplatelet therapy appears to be a factor in those developing delayed stenosis or thrombosis.

Background Ventriculostomy infections create significant morbidity. To reduce infection rates, a standardized evidence-based catheter insertion protocol was implemented. A prospective observational study analyzed the effects of this protocol alone and with antibiotic-impregnated ventriculostomy catheters. Objective To compare infection rates after implementing a standardized protocol for ventriculostomy catheter insertion with and without the use of antibiotic-impregnated catheters. Methods Between 2003 and 2008, 1961 ventriculostomies and infections were documented. A ventriculostomy infection was defined as 2 positive CSF cultures from ventriculostomy catheters with a concurrent increase in cerebrospinal fluid white blood cell count. A baseline (preprotocol) infection rate was established (period 1). Infection rates were monitored after adoption of the standardized protocol (period 2), institution of antibiotic-impregnated catheter A (period 3), discontinuation of antibiotic-impregnated catheter A (period 4), and institution of antibiotic-impregnated catheter B (period 5). Results The baseline infection rate (period 1) was 6.7% (22/327 devices). Standardized protocol (period 2) implementation did not change the infection rate (8.2%; 23/281 devices). Introduction of catheter A (period 3) reduced infections to 1.0% (2/195 devices, P=.0005). Because of technical difficulties, this catheter was discontinued (period 4), resulting in an increase in infection rate (7.6%; 12/157 devices). Catheter B (period 5) significantly decreased infections to 0.9% (9 of 1001 devices, P=.0001). The Staphylococcus infection rate for periods 1, 2, and 4 was 6.1% (47/765) compared with 0.2% (1/577) during use of antibiotic-impregnated catheters (periods 3 and 5). Conclusion The use of antibiotic-impregnated catheters resulted in a significant reduction of ventriculostomy infections and is recommended in the adult neurosurgical population.

Objective Endovascular treatment of intracranial aneurysms is less invasive than surgical repair but poses a higher risk for aneurysm recurrence, which may necessitate retreatment, thus adding to the long-term risk. Cerebrovascular neurosurgeons from 8 institutions in the United States and Puerto Rico collaborated to assess the risk of retreatment for residual or recurrent aneurysms after the initial endovascular coiling. Methods Data were prospectively recorded for 311 patients with coiled intracranial aneurysms who underwent 352 retreatment procedures after angiographic or clinical recurrence (hemorrhage after initial coiling). Results analyzed included procedural complications and procedure-related morbidity. Morbidity was classified as major (modified Rankin scale score > 3) or minor, and temporary ( 30 days). Results Retreatment mortality was 0.85% per procedure and 0.96% per patient. Treatment-related rates were 0.32% per patient (0.28% per procedure) for permanent or temporary major disability; 1.29% for permanent minor disability (1.14% per procedure); and 1.61% for temporary minor disability (1.42% per procedure). Total risk for death or permanent major disability was 1.28% per patient and 1.13% per procedure. Conclusion Retreatment poses a low risk for patients with recurrences of intracranial aneurysms after initial coiling; this risk is smaller than that posed by the initial endovascular therapy. The risk of disability associated with retreatment for aneurysm recurrence after coiling must be considered prospectively in the choice of treatment but with the recognition that its effects are low in the overall management risk.

OBJECTIVE: Endovascular treatment of intracranial aneurysms is a less invasive alternative than surgical repair. However, the higher risk of recurrence after coiling necessitates regular angiographic surveillance, which has associated risks. To date, the risk of surveillance angiography has not been quantified in patients with intracranial aneurysms treated by endovascular embolization. METHODS: Angiograms performed for the surveillance of coiled intracranial aneurysms in patients treated at 8 institutions were recorded prospectively. Of 3086 patients eligible for surveillance angiography according to each institution's protocol during the study period, 2243 patients (72.7%) underwent this procedure. Data were reviewed retrospectively, including the results of each angiogram, angiographic complications, and morbidity resulting from the procedure. Morbidity was classified as major (modified Rankin Scale score ≥3) or minor (modified Rankin Scale score

OBJECTIVE Intravascular coil embolization of cerebral aneurysms has proved to be a safe and effective treatment in certain patient groups; however, this treatment is relatively new, and the long-term outcomes are unknown. One of the known complications is refilling of the aneurysm dome, which is seen in follow-up studies. This patient population poses unique technical difficulties for the neurosurgeon. We present a series of 18 patients who underwent surgery for residual aneurysms after coil remobilization. METHODS During a 5-year period, we performed surgery in 18 patients who had previously undergone coil embolization for their aneurysms. Of these aneurysms, four were in the anterior communicating artery, five were in the posterior communicating artery, three were in the internal carotid artery, three were in the posteroinferior cerebellar artery, and three were in the middle cerebral artery. One patient presented with rupture, one presented with acute IIIrd cranial nerve palsy, and the rest of the aneurysms were found on routine follow-up angiograms. Fifteen aneurysms were clipped, and in three patients, they were wrapped because the clip could not be placed adequately. RESULTS There were no major complications in any of the patients, and all had uneventful recoveries. The presence of coils in the aneurysm dome and/or neck made clipping and exposure of the aneurysm neck difficult, resulting in incomplete neck obliteration in three patients. CONCLUSION Operative clipping after previous coil embolization in aneurysms poses a unique problem for neurosurgeons. With the increasing use of coil embolization, this patient population will undoubtedly increase. The neurosurgeon should be aware of the difficulties and pitfalls encountered in these patients.

OBJECTIVE: Despite proven safety of endovascular coil embolization of intracranial aneurysms, the potential need for retreatment remains criticized. The goal of this prospective study was to assess the safety, durability, and effect on recanalization rates of the Cerecyte (Micrus Corp., Sunnyvale, CA) bioactive coil. METHODS: Two hundred twelve ruptured and unruptured aneurysms in 176 patients were prospectively enrolled in a database registry during a 12-month period. Adverse clinical outcomes directly attributed to the use of the Cerecyte coil were documented. Angiographic outcomes were determined immediately after coil embolization and during follow-up studies. All patients who received stent assistance or a non-Cerecyte coil were excluded. Two independent endovascular surgeons reviewed follow-up films. Any discrepancy was deemed a recurrence. RESULTS: After exclusion criteria, 81 patients with 89 aneurysms were available for a minimum of 6 months of follow-up. Of those 89 aneurysms, 65% were ruptured aneurysms and were treated in the acute setting. The mean size of the aneurysm was 7 mm. The mean angiographic follow-up period was 11.2 months. Recurrences requiring retreatment as a result of dome filling were identified in six aneurysms (6.7%). Four aneurysms (4%) developed compaction of more than 20%, which was defined as interstitial filling of the fundus. There was one thromboembolic event leading to permanent neurological deficit. No cases of chemical meningitis or delayed hydrocephalus occurred. CONCLUSION: The Cerecyte bioactive coil seems to be safe and effective for use in both ruptured and unruptured aneurysms. The bioactive polymer within the coils allows similar handling characteristics of a bare platinum coil. Studies to assess longterm outcomes with direct comparison to platinum coils and alternative bioactive coils are warranted.

OBJECTIVE: The purpose of this study is to analyze anterior communicating artery (AComA) aneurysm morphology and its relationship to the limitations and feasibility of endovascular coil embolization. METHODS: One hundred twenty-three patients were treated with endovascular coil embolization for AComA aneurysms. Aneurysm morphology was classified into six categories according to the projection of the aneurysm (anterior, posterior/superior, or inferior) and neck size (< 4 mm or ≥ 4 mm). The following categories were used: Class A1, anterior projection and neck of aneurysm less than 4 mm; Class A2, anterior projection and neck of aneurysm 4 mm or more; Class B1, posterior (superior) projection and neck of aneurysm less than 4 mm; Class B2, posterior (superior) projection and neck of aneurysm 4 mm or more; Class C1, inferior projection and neck of aneurysm less than 4 mm; and Class C2, inferior projection and neck of aneurysm 4 mm or more. Endovascular procedures were categorized as either successful or unsuccessful according to specific criteria. In addition, patients were followed for recanalization. Clinical follow-up data was obtained at discharge and after 6 months and was classified according to the Glasgow Outcome Scale. RESULTS: Complete or near complete aneurysm occlusion was observed in 108 (88%) patients, partial embolization was performed in three (2.4%) patients, and embolization was attempted in 12 (9.7%) patients. Successful embolization for AComA aneurysms was performed in 86 out of 123 (70%) patients or 77.5% (86 out of 111 patients) of those patients in whom embolization was possible. Statistical analysis demonstrated that anterior projecting aneurysms were more likely to be successfully coiled than either inferior or posterior/superior directed AComA aneurysms. In addition, inferiorly projecting AComA aneurysms and wide-neck aneurysms had a significantly higher rate of recanalization. CONCLUSION: Endovascular coil embolization of AComA aneurysms shows good outcome in our study. Despite advanced modern techniques, there are limitations in the endovascular approach to AComA aneurysms. Consideration of aneurysm morphology may be used to guide approaches in the treatment of AComA aneurysms.

Objective The long-term durability of the endovascular occlusion of cerebral aneurysms is one of the major factors limiting the more widespread use of this technique. Long-term occlusion of wide-necked aneurysms has improved with new assistive devices that seem to improve aneurysm occlusion while protecting the parent vessel. We report the use of a new intracranial stent--the Neuroform microstent--in the treatment of patients with wide-necked cerebral aneurysms. Methods Patients identified as harboring wide-necked intracranial aneurysms were evaluated for stent-assisted coiling. After appropriate anticoagulation was performed, depending on whether the aneurysm was ruptured or unruptured, the Neuroform stent was delivered across the neck of the aneurysm and deployed with a coil pusher. After stent placement, standard coil occlusion of the aneurysm was achieved in the majority of cases. Results Fifty-six patients were identified as having wide-necked intracranial aneurysms suitable for stent-assisted coiling. A total of 49 aneurysms in 48 patients were treated with this procedure. In eight cases, stent deployment failed. Forty-one of the aneurysms were initially stented, followed by coil placement. Six aneurysms were stented only, and one aneurysm was initially coiled, followed by stent placement. There were five deaths (8.9%), one of which occurred secondary to a stroke after the procedure (1.8%). Four patients (7%) experienced thromboembolic events, three of which were considered to have been secondary to the procedure (5.3%). In addition, there were two femoral pseudoaneurysms. The overall complication rate was 10.7%. Five patients were available for follow-up angiographic evaluation, and their cases are discussed. Conclusion Intracranial stenting may overcome important technical limitations in current endovascular therapy by improving the occlusion of wide-necked aneurysms while protecting the parent vessel.

OBJECTIVE To review our experience and examine the size at which aneurysms ruptured in our patient population. METHODS Patient charts and angiograms for all patients admitted with a diagnosis of subarachnoid hemorrhage to the Thomas Jefferson/Wills Eye Hospital between April 1996 and March 2000 were reviewed. RESULTS Of the 362 cases reviewed, definite measurements of the ruptured aneurysm were obtained in 245. The data clearly showed that most ruptured aneurysms presenting to our institution were less than 10 mm in diameter. We found that, regardless of location on the circle of Willis, 85.6% of all aneurysms presenting with rupture were less than 10 mm. Review by location shows that aneurysms of the anterior communicating artery most often presented with rupture at sizes less than 10 mm (94.4%). A large number of ruptured posterior communicating artery aneurysms also presented at sizes less than 10 mm (87.5%). This trend continued for all aneurysm sites in our review. The incidence of subarachnoid hemorrhage in Western countries is estimated at 10 per 100,000 people per year. Recent reports have indicated that aneurysms less than 10 mm in size are unlikely to rupture. CONCLUSION We argue that the risk of small aneurysms rupturing is not insignificant, especially those of the anterior communicating artery. Our findings indicate that surgery on unruptured aneurysms should not be predicated on aneurysm size alone.

Background and Purpose: Based on promising results of the Solitaire FR With the Intention for Thrombectomy (SWIFT) trial, Solitaire FR stent retriever device recently received the Food and Drug Administration (FDA) approval for recanalization of cerebral vessels in patients with acute ischemic stroke. Real world experience with this device since its FDA approval in the United States has not been previously described. Methods: We conducted retrospective analysis of consecutive acute ischemic strokes cases from March 2012 to July 2012 in 10 centers within the United States, where Solitaire FR was used as a single device or in conjunction with other intra-arterial endovascular approaches. Results: A total of 107 patients were identified (mean age, 64 years; male gender, 51%; mean admission NIHSS score 17). Mean time from symptom onset to angiogram (groin puncture) was 4 hrs 47 min. Intravenous thrombolysis with tissue plasminogen activator (tPA) was administered in 37% of cases. Other endovascular techniques utilized in conjunction with Solitaire FR included intra-arterial thrombolysis with tPA (12% of patients), aspiration thrombectomy with Penumbra system (29%) and stenting (17%). Complete recanalization (TIMI 2-3) was achieved in 88% of patients. The rate of sICH within the first 24 hours was 15%. In-hospital mortality was 24%. 30-day clinical follow up data was available on 82 (77%) patients. Of those, 28 patients (34%) had favorable functional outcome (defined as modified Ranking Scale,mRS≤2) and 22 patients (27%) had excellent functional outcome (mRS≤1) at 30 days. Three or more passes with the Solitaire device was associated with a higher incidence of mortality compared with patients requiring 1 or 2 passes only (43% and 18% respectively, p = 0.011). No statistically significant correlation between clot location or length and outcome was evident. Use of other devices with the Solitaire FR was correlated with worsened outcome (p=0.037). Conclusions: This is the first study describing real-world experience with Solitaire FR device outside the SWIFT trial in the United States. Out study shows that variety of other endovascular approaches are used in conjunction with Solitaire FR.