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In 1981, the dismal outcomes of patients with basilar artery occlusion (BAO) inspired the first reports of intra-arterial thrombolytic treatment in BAO. These reports were among the first to conceptualize that opening an artery could help patients with large vessel occlusion stroke. Whereas multiple anterior circulation LVO trials demonstrated the efficacy of endovascular therapy starting in 2014, proof of benefit for BAO was lacking until 2022. In this commentary, we reflect on how the BASICS (Basilar Artery International Cooperation Study) and BEST (Basilar Artery Occlusion: Endovascular Interventions vs Standard Medical Treatment) trials lay the foundations for clinical trials in BAO, subsequently leading to the positive results of the ATTENTION (Endovascular Treatment for Acute Basilar-Artery Occlusion) and BAOCHE (Basilar Artery Occlusion Chinese Endovascular) trials.

Introduction Two recent trials demonstrated a benefit for endovascular thrombectomy (EVT) in the treatment of basilar artery occlusion (BAO). Considering the expected increase in the utilization of EVT for BAO, we sought to understand the technique preferences of neurointerventionalists currently performing EVT for BAO. Methods We conducted an international online survey of physician opinions on the use of EVT in BAO between January to March 2022. The survey was distributed through stroke and neurointerventional organizations. Survey questions examined selection of patients for the procedure and the techniques currently used for EVT in BAO. Results More than 3,000 participants were invited yielding 1,245 respondents, of which 543 were classified as neurointerventionalists across 52 countries and included in this analysis. Most neurointerventionalists would proceed to EVT for occlusions of the V4 segment, the basilar artery, or the PCA, without regard for prior IVT. For BAO of embolic etiology, aspiration only thrombectomy was the preferred method with 50.3% of neurointerventionalists. For BAO of intracranial atherosclerotic disease (ICAD) etiology, combined stent retriever and aspiration thrombectomy was the preferred method with 40.5% of neurointerventionalists (Figure 1). The majority of neurointerventionalists (88.0%) would proceed to stenting after three or fewer failed passes for patients with BAO of ICAD etiology. In patients undergoing stenting, aspirin and clopidogrel was the most common antiplatelet regime (52.4%). Conclusions Amongst the surveyed neurointerventionalists, the most common techniques for EVT of patients with BAO were contact aspiration or combined stent retriever with aspiration thrombectomy. For patients with BAO due to ICAD, the majority of neurointerventionalists were willing to stent and do so most often after three or fewer failed passes and with the use of dual antiplatelet medications. Further study is needed to determine the optimal technique for EVT of BAO with or without ICAD.

Introduction: Pilot data suggests that organized post-stroke care enhances achievement of secondary prevention goals in stroke patients. We aimed to further investigate whether organized post-stroke care favourably affects stroke recurrence and survival. Methods: Prospective, quasi-experimental study of consecutive stroke patients admitted at two tertiary stroke centers in Saxony, Germany. According to health insurance provider status, patients were non-randomly assigned to either 12-months post-stroke pathway plus conventional care or conventional care alone. The organized post-stroke care pathway was facilitated by certified case managers and included pre-scheduled home- and phone visits aiming at educational intervention and achievement of guideline-based secondary prevention treatment goals. Primary outcomes were stroke recurrence and vascular death at 12-months. Further outcomes included favourable functional outcome (i.e. mRS 0-1), health-related quality of life and vascular risk factor control at 12-months. Results: In total, 1109 patients were recruited between 11/2011 and 12/2020. Of these, 1009 patients (91%) were assigned to organized post-stroke care and 100 (9%) to conventional care (mean age 70.6±12.8 years, 54% male, median NIHSS 3 [IQR, 1-5] points, 77.5% AIS, 17.9% TIA and 4.6% ICH). Baseline demographics and clinical characteristics were well balanced between both groups (p≥0.05). At 12-months, recurrent stroke rate was lower in the post-stroke care than in the conventional care group (5.5% vs. 14%; aOR 0.35, 95%CI 0.18-0.66; p=0.001). This association was not modified by stroke severity (TIA/minor stroke versus major stroke). Vascular death occurred in 0.2% in the post-stroke care and 3% in the conventional care group (aOR 0.07, 95%CI 0.01-0.41; p=0.003). Organized post-stroke care more frequently yielded individual treatment goals for hypertension, lipids, HbA1c, body-mass-index and secondary prevention adherence than conventional care (p Conclusions: Our results substantiate the effectiveness of case management-based post-stroke care in unselected stroke patients.

Introduction: Recent meta-analytic evidence supported efficacy and safety of bridging intravenous thrombolysis (IVT) prior to endovascular therapy (EVT) for large vessel occlusion (LVO) but large confirmatory trials are still lacking and optimal candidates for treatment have been a topic of contention lately. Objectives: We aimed to determine a cut-off in treatment times that allows identification of those who would benefit most from bridging IVT. Methods: We analyzed prospectively collected data from consecutive LVO patients who underwent EVT at a tertiary stroke center in Germany from 01/2017 to 12/2021. Patients underwent detailed cardiovascular phenotyping, repeated cranial imaging, and received standardized multidisciplinary stroke unit care. Functional outcome was assessed via modified Rankin scale three months after discharge. Ordinary ridge regression models were built to assess the impact of treatment time cut-offs on functional outcome with adjustment for age, sex, cardiovascular risk factors, baseline NIHSS, cerebrovascular territory, ASPECT score, stroke etiology and carotid artery stenting. Results: Out of 935 patients who had undergone EVT, 170 received bridging IVT (median age 74 [63-82, IQR], 52.4% females), fulfilled our criteria and were included in our analysis. Overall, onset-to-recanalization time but not onset-to-needle time was associated with functional outcome (β1=0.36, 95%CI [0.14,0.58], p=0.001 vs. p=ns). However, those who received EVT with a time delay longer than 190 minutes additionally displayed an association of onset-to-needle time and functional outcome (β1=0.64, 95%CI [0.25,1.04], p=0.02 vs. β2= 2.96, 95%CI [1.32,4.60], p=0.016). Conclusions: Our data indicates that the beneficial effect of swift bridging IVT on functional outcome is most pronounced in cases where initiation of subsequent EVT is substantially delayed.

Background: Two early basilar artery occlusion (BAO) randomized controlled trials did not establish superiority of endovascular thrombectomy (EVT) over medical management. While many providers continue to recommend EVT for acute BAO, perceptions of equipoise in randomizing patients with BAO to medical management may differ between clinician specialties. Methods: We conducted an international survey (1/1/22-3/31/22) regarding management strategies in acute BAO prior to the announcement of 2 trials indicating superiority of EVT, and compared responses between interventionalists (INT) and non-interventionalists (nINT). Selection practices for routine EVT based on neuroimaging and clinical features were compared between the two groups using descriptive statistics. Results: Among the 1245 respondents (nINT=702), INT more commonly believed that EVT was superior to medical management in acute BAO (98.5% vs. 95.1%, p0.05), although nINT more commonly preferred perfusion imaging (24.2% vs. 19.7%, p=0.04). Among respondents who indicated they would randomize to medical management, INT were more likely to randomize when the NIHSS was ≥10 (15.9% vs. 6.9%, p Conclusions: Following the publication of two neutral clinical trials in BAO EVT, most stroke providers believed EVT to be superior to medical management in carefully selected patients, with most indicating they would not randomize a patient to medical treatment. There were small differences in preference of advanced neuroimaging, although these preferences were unsupported by clinical trial data.

Background Current stroke guidelines recommend advanced imaging (computed tomography [CT] perfusion or magnetic resonance imaging) prior to endovascular therapy (EVT) in patients with late presentation of large vessel occlusion. Adherence to guidelines may be constrained by resources or timely access to imaging. We sought to understand the factors which influence late window imaging selection for EVT candidates with large vessel occlusion. Methods We conducted an international survey from January to May 2022. The questions aimed to identify advanced imaging and treatment decisions based on access to imaging, time delays, and simulated patient scenarios. Results There were 3000 invited participants and 1506 respondents, the majority (89.6%) from comprehensive stroke centers in high‐income countries. Neurointerventionalists comprised 31.8% and noninterventionalists 68.2% of respondents. Overall, 70.7% reported routine use of advanced imaging for late EVT selection, and 63.6% reported its usage in every case. There was greater availability of advanced imaging in comprehensive stroke centers versus primary stroke centers (67.0% versus 33.7%; P P Conclusion Current guidelines for imaging late window EVT candidates are inconsistent with imaging decisions by physicians. Most respondents consider an imaging delay of greater than 20 minutes unacceptable. Access to advanced imaging was greater in comprehensive stroke centers and high‐income countries. In the case of limited access most respondents would consider EVT based on CT only.

Buerger disease (thromboangiitis obliterans [TAO]) typically occurs in men younger than 40–45 years who have a history of heavy tobacco use.

Background and Purpose: This study aims to assess the number of patients with acute ischemic cerebrovascular events seeking in-patient medical emergency care since the implementation of social distancing measures in the coronavirus disease 2019 (COVID-19) pandemic. Methods: In this retrospective multicenter study, data on the number of hospital admissions due to acute ischemic stroke or transient ischemic attack and numbers of reperfusion therapies performed in weeks 1 to 15 of 2020 and 2019 were collected in 4 German academic stroke centers. Poisson regression was used to test for a change in admission rates before and after the implementation of extensive social distancing measures in week 12 of 2020. The analysis of anonymized regional mobility data allowed for correlations between changes in public mobility as measured by the number and length of trips taken and hospital admission for stroke/transient ischemic attack. Results: Only little variation of admission rates was observed before and after week 11 in 2019 and between the weeks 1 and 11 of 2019 and 2020. However, reflecting the impact of the COVID-19 pandemic, a significant decrease in the number of admissions for transient ischemic attack was observed (−85%, −46%, −42%) in 3 of 4 centers, while in 2 of 4 centers, stroke admission rates decreased significantly by 40% and 46% after week 12 in 2020. A relevant effect on reperfusion therapies was found for 1 center only (thrombolysis, −60%; thrombectomy, −61%). Positive correlations between number of ischemic events and mobility measures in the corresponding cities were identified for 3 of 4 centers. Conclusions: These data demonstrate and quantify decreasing hospital admissions due to ischemic cerebrovascular events and suggest that this may be a consequence of social distancing measures, in particular because hospital resources for acute stroke care were not limited during this period. Hence, raising public awareness is necessary to avoid serious healthcare and economic consequences of undiagnosed and untreated strokes and transient ischemic attacks.

Introduction: Stroke accounts for 4% of patients with acute vertigo, which is missed in up to one third of cases. Hypothesis: We hypothesized that detection of stroke underlying acute vertigo using HINTS plus (head-impulse test, nystagmus type, test of skew, hearing loss) can be improved by videooculography for automated analysis of head-impulse test (V-HIT). Materials and Methods: We evaluated patients with acute vestibular syndrome (AVS) presenting to the emergency room using HINTS plus and V-HIT-assisted HINTS plus in a randomized sequence. In addition, patients underwent cranial MRI and caloric testing. Image-confirmed posterior circulation stroke or vertebrobasilar TIA were defined as reference standard to calculate accuracy of applied vertigo assessment protocols. After study completion, we repeated statistical analysis for a third protocol that was composed post hoc by replacing the results of head-impulse test with those derived from caloric testing in the HINTS plus protocol. Results: We included 30 AVS patients (ages 55.4 ± 17.2 years, 14 females). Of these, 11 (36.7%) had MRI-confirmed posterior circulation ischemic stroke (n=4) or vertebrobasilar TIA (n=7). Conducting V-HIT-assisted HINTS plus as part of the emergency work up was feasible and displayed a tendency toward higher accuracy than conventional HINTS plus (sensitivity: 81.8%, 95%CI 48.2-97.7%; specificity 31.6%, 95%CI 12.6-56.6% vs. sensitivity 72.7%, 95%CI 39.0-94.0%; specificity 36.8%, 95%CI 16.3-61.6%). (Figure) The new caloric-supported algorithm displayed high accuracy (sensitivity 100%, 95%CI 66.4%-100%; specificity 66.7%, 95%CI 41%-86.7%). Conclusions: Our study provides pilot data on the capacity of videooculography to improve accuracy of acute vertigo assessment using HINTS plus and indicates potential value of acute caloric testing as integrative part of standardized AVS emergency work up.

Background Statistical models to predict outcomes after endovascular therapy for acute ischemic stroke often incorporate baseline (pretreatment) variables only. We assessed the performance of stroke outcome prediction models for endovascular therapy in stroke in an iterative fashion using baseline, treatment‐related, and posttreatment variables. Methods Data from the ESCAPE‐NA1 (Safety and Efficacy of Nerinetide [NA‐1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) trial were used to build 4 outcome prediction models using multivariable logistic regression: model 1 included baseline variables available before treatment decision making, model 2 included additional treatment‐related variables, model 3 additional posttreatment variables that become available early (within 24–48 hours), and model 4 later (beyond 48 hours) after endovascular therapy. The primary outcome was functional independence (90‐day Modified Rankin Scale score 0–2). Model performance was compared using the area under the receiver operating characteristic curve (AUC). Shapley values were used to determine marginal contributions of variables to outcome variance in the regression models. Results Among 1105 patients, functional independence was achieved by 666 (60.3%). When using baseline variables only (model 1), the AUC was 0.74 (95% CI, 0.71–0.77); this iteratively improved when treatment and posttreatment variables were added to the models (model 2: AUC, 0.77; 95% CI, 0.74–0.80; model 3: AUC, 0.80; 95% CI, 0.77–0.83; model 4: AUC, 0.82; 95% CI, 0.79–0.85). With baseline variables alone, 26% of patients who achieved functional independence were erroneously classified as not achieving functional independence. Even with the most comprehensive model, 19.8% of patients were misclassified as such. Patient age contributed most to outcome variance (Shapley value, 0.28), followed by severe adverse events including pneumonia (0.16) and intracranial hemorrhage at 24‐hours imaging (0.13). Conclusions A substantial contribution to outcomes after endovascular therapy comes from factors unrelated to currently collected baseline patient variables. One‐fifth of patients achieving functional independence were misclassified as not achieving independence, even with the most comprehensive model. Our findings suggest that the achievable accuracy of current outcome prediction models is limited, and caution should be used when applying them in clinical practice.

Introduction: To explore kidney safety profile of osmotic diuretic mannitol in patients with malignant middle cerebral artery (MCA) infarction. Methods: We analyzed data from consecutive patients with malignant MCA infarction (01/2008-12/2017). Malignant MCA infarction was defined according to clinical and radiographic DESTINY criteria. Clinical and laboratory variables were collected for all patients. We compared clinical endpoints including acute kidney failure (AKF; according to Kidney Disease: Improving Global Outcomes [KDIGO] definition) and hemodialysis between patients who received mannitol and those who did not. Multivariable model was built to explore predictor variables of AKF, in-hospital death and functional outcome at discharge. Results: Overall, 228 patients with malignant MCA infarction were analyzed: median age 67 years (IQR, 56-76), 58% men, median NIHSS 23 (17-32) points. Decompressive craniectomy was performed in 103/228 (45.2%) patients. Mannitol was administered in 100/228 (43.9%) patients over an average of 85 (30.3-139.3) hours. Average dosage was 700 (250-1050) g. Patients treated with mannitol more frequently suffered from AKF (40% vs. 7.9%; p0.05). Conclusions: Acute kidney failure appears to be a frequent complication of osmotic diuretic mannitol in patients with malignant MCA infarction. Given the lack of evidence supporting effectiveness of mannitol in these patients, its use should be carefully considered.

Introduction: Recent studies linked coronavirus disease 2019 (COVID-19) to thromboembolic complications likely mediated by increased blood coagulability and inflammatory endothelial impairment. Objective: We aimed to assess the risk of acute stroke in patients with COVID-19 related to clinical severity of the disease. Methods: We conducted an observational multicenter cohort study in four participating hospitals in Saxony, Germany to characterize consecutive patients with laboratory-confirmed COVID-19 who experienced acute stroke during hospitalization. Furthermore, we performed a systematic review using PubMed/MEDLINE, EMBASE, Cochrane Library and bibliographies of identified articles following PRISMA guidelines including data from observational studies of acute stroke in COVID-19 patients. Data was extracted by two independent reviewers and pooled with multicenter data to calculate risk ratios (RR) and 95% confidence intervals (95%CIs) for acute stroke related to COVID-19 severity using random effects model. Between-study heterogeneity was assessed using Cochran’s Q and I 2 -statistics. PROSPERO identifier : CRD42020187194. Results: Of 165 patients hospitalized for COVID-19 (49.1% males, median age 67 [57-79], 72.1% severe or critical) included in the multicenter study, overall stroke rate was 4.2% (95%CI: 1.9-8.7). Systematic literature search identified two observational studies involving 576 patients that were eligible for meta-analysis. Among 741 pooled COVID-19 patients overall stroke rate was 2.9% (95%CI: 1.9-4.5). Risk of acute stroke was increased for patients with severe compared to non-severe COVID-19 (RR 4.12, 95%CI 1.7-10.25; p=0.002) with no evidence of heterogeneity (I 2 =0%, p=0.82). Conclusions: Synthesized analysis of data from our multicenter study and previously published cohorts demonstrate that severity of COVID-19 is associated with an increased risk of acute stroke, underscoring the necessity of neurological monitoring in patients infected with SARS-CoV-2.

Background: Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase. The recent Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial demonstrated that increased reperfusion with TNK compared to alteplase prior to endovascular thrombectomy (EVT) in large vessel occlusion ischaemic strokes. However, only 6 patients with basilar artery occlusion (BAO) were included. We aimed to investigate the efficacy of TNK versus alteplase before EVT in patients with basilar artery occlusion (BAO). Methods: Clinical and procedural data of consecutive BAO diagnosed on CT Angiography or MR Angiography from the multisite international Basilar Artery Treatment and MANagement (BATMAN) collaboration were retrospectively analysed. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or absence of retrievable thrombus at the time of the initial angiographic assessment. Results: We included 119 BAO patients treated with intravenous thrombolysis prior to EVT; mean age 68 (SD 14), median NIHSS 16 (IQR 7-32). Eleven patients were treated with TNK (0.25mg/kg or 0.4mg/kg) and 108 with alteplase (0.9mg/kg). Overall, 113 patients had catheter angiography or early repeat imaging after thrombolysis. Reperfusion of greater than 50% of the ischemic territory or absence of retrievable thrombus occurred in 4/11 (36%) of patients treated with TNK vs 8/102 (8%) treated with alteplase (p=0.02). Onset-to-needle time did not differ between the two groups (p=0.4). Needle-to-groin-puncture time was 61 (IQR 33-100) mins in patients reperfused with TNK vs 111 (IQR 86-198) mins in patients reperfused with alteplase (p=0.048). Overall, the rate of symptomatic haemorrhage was 3/119 (2.5%). No differences were found in the rate of symptomatic intracranial haemorrhage (p=0.3) between the two thrombolytic agents. Conclusions: Despite shorter needle-to-groin-puncture times, tenecteplase was associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare tenecteplase with alteplase in BAO patients before endovascular thrombectomy are warranted.

Introduction: Hypothermia may be neuroprotective in acute ischemic stroke. Stroke patients with anterior circulation large vessel occlusion (acLVO) who receive endovascular therapy (EVT) are frequently hypothermic after the procedure. We sought to analyze whether this unintended hypothermia was associated with improved functional outcome. Methods: We extracted data of consecutive patients (01/2016-04/2019) from our prospective EVT database that includes all patients screened for EVT at our center. We included patients with acLVO who received EVT and analyzed recanalization (mTICI 2b-3) and complications (i.e., pneumonia, bradyarrhythmia, venous thromboembolism) during the hospital course. We assessed functional outcome at 3 months and analyzed risk ratios (RR) for good outcome (mRS scores 0-2) and mortality of patients who were hypothermic (> 36°C) after EVT. We compared the frequency of complications and calculated RRs for good outcome and mortality in the subgroup with recanalization. Results: Among 674 patients with anterior circulation ischemic stroke, 372 patients received EVT for acLVO (178 [47%] male, age 77 years [65-82], NIHSS score 16 [12 - 20]). Of these, 186 patients (50%) were hypothermic (median [IQR] temperature 35.2°C [34.7-35.6]) and 186 patients were normothermic (media temperature 36.4 [36.2-36.8]) after EVT. At 3 months, 54 of 186 (29.0%) hypothermic patients compared with 65 of 186 (35.0%) normothermic patients had a good outcome (RR, 0.83; 95%CI 0.62-1.12) and 52 of 186 (27.9%) hypothermic patients compared with 46 of 186 (24.7%) normothermic patients had died (RR, 1.13; 95%CI 0.8-1.59). This relation was consistent in 307 patients (82.5% of all EVTs) with successful recanalization (good outcome: RR, 0.85; 95%CI 0.63-1.14.; mortality: RR, 1.05; 95%CI 0.7-1.57). More hypothermic patients suffered pneumonia (37.8% vs. 24.7%; p=0.003) or bradyarrhythmia (55.6% vs. 18.3%; p Conclusion: Unintended hypothermia following EVT for acLVO was not associated with improved functional outcome or reduced mortality but an increased complication rate in patients with acute ischemic stroke.

Introduction: In patients with acute ischaemic stroke (AIS) dysregulation of cardiac function with decreased heart rate variability (HRV) due to impaired integrity of the autonomic nervous system is a frequent complication which is associated with increased mortality and worsening of clinical outcome. HRV biofeedback has previously been suggested to improve cardiac autonomic function by increasing parasympathetic tone. Hypothesis: We hypothesized that HRV biofeedback can be used to complement stroke unit care and alleviate autonomic cardiac dysfunction following AIS. Methods: We randomly allocated patients with AIS to either receive 9 sessions of HRV (n=24) or sham (n=24) biofeedback in addition to standard stroke unit care. These patients underwent detailed assessment of autonomic cardiac function including analysis of HRV via standard deviation of NN intervals (SDNN) and spectral analysis. Furthermore, we assessed vasomotor and sudomotor autonomic function, severity of autonomic symptoms and neurological and functional outcomes. Results: We included 48 patients (19 females, ages 65±14 years, baseline NIHSS 2.2 ± 2.2, mean ± standard deviation). Patients who had undergone HRV biofeedback displayed improved cardiac function compared to baseline (SDNN 72.6 ± 52.4 ms vs. 45.5 ± 34.7 ms, p Discussion: HRV biofeedback can modulate autonomic cardiac function post AIS to increase HRV and alleviate autonomic symptoms which might be beneficial in facilitating recovery from functional impairment. This seems to be mediated by a predominantly parasympathetic mechanism of action.

Introduction: The selective serotonin reuptake inhibitors (SSRIs) fluoxetine, citalopram and escitalopram have been suggested to improve functional recovery after acute ischemic stroke (AIS) due to modulation of autonomic cardiovascular and inflammatory pathways independently of changes in depressivity. Although sertraline has shown highest degree of tolerability and efficacy among SSRIs in the treatment of depression, its effects on functional recovery from AIS remain unknown. Hypothesis: We hypothesized that sertraline is associated with improved functional recovery from AIS which is paralleled by alleviation of autonomic symptoms and depressivity. Methods: We analyzed data of an ongoing prospective observational study in AIS patients who were admitted to our stroke center from 03/2017 to 08/2018 and had no disability pre-stroke (mRS 0-1). Patients who received sertraline for post stroke depression or improvement of recovery following institutional protocol and those not receiving any SSRI were include. Assessment of cardiovascular risk factors, neurological deficits (NIHSS), symptoms of depression (Beck’s depression inventory) and autonomic disturbances (autonomic symptom questionnaire) were assessed at baseline, discharge and after three months. Results: We present data from 61 patients (70 [20] years, median [IQR], NIHSS: 7.0 [6.0], 23 females) receiving sertraline post-stroke and 27 untreated patients (71.0 [21.0] years, NIHSS: 5.0 [3.0], 13 females). Cardiovascular risk profiles showed no differences between groups (p=ns). Patients treated with sertraline compared to untreated patients tended to achieve favorable functional outcome (3-month mRS 0-2) and functional independence (3-month mRS 0-1) more frequently (52% vs. 41.7% and 18% vs. 12.5%, p=ns) and displayed enhanced decrease of NIHSS scores from admission to discharge (24.1% vs. 17.3%, p2 =0.63) symptoms after 3 months, independently of depressivity. Discussion: Our data support the hypothesis of improved functional recovery from AIS in patients receiving sertraline de novo after AIS which might in parts be mediated by modulation of autonomic pathways.

Introduction: While data from randomized controlled trials suggest an overall benefit of endovascular therapy (EVT) in older patients suffering from anterior circulation large vessel occlusion (acLVO), real world evidence is lacking. We aimed to explore the likelihood of achieving favorable stroke outcomes in octogenarians undergoing EVT for acLVO. Methods: We prospectively studied consecutive ischemic stroke patients aged 80 years or older who were considered for EVT due to acLVO at our tertiary stroke center (01/2016-06/2018). We compared clinical characteristics and efficacy outcomes including 90-days functional independence (i.e., mRS scores 0-2) and 90-days survival among patients who underwent EVT and those who did not undergo EVT. A multivariable regression model was built to identify predictors of favorable outcomes. Results: In total, 185 patients aged 80 years or older were prospectively screened for EVT eligibility during the 30-months study period: median age was 84 years (interquartile range, 82-88); 30% were men; median NIHSS score was 18 (interquartile range, 14-21) points. Of these patients, 97 (52.4%) were eventually treated for proximal acLVO. The main reasons to withhold EVT were large infarct size (54.6%) and recanalization (30.7%), followed by unknown time window (5.7%), lack of perfusion mismatch or collaterals (4.5%) and early clinical improvement (2.3%). No differences according to vascular risk factors, baseline imaging and clinical variables were evident among both groups. There was a non-significant trend toward survival (50.6% versus 37.3%, p=0.09) but not functional independence (9.9% versus 5.3%, p=0.39) at 90 days in patients who underwent EVT compared with the non-EVT group. In the multivariable model, favorable outcomes were not predicted by pre-stroke disability, stroke severity, infarct size or treatment with intravenous tPA. Conclusions: While age alone should not exclude patients from endovascular therapy, diminished likelihood of favorable outcomes may challenge postacute stroke care in octogenarians.

Background: Recent clinical trials have proven efficacy of endovascular therapy (EVT) for anterior circulation large vessel occlusion (acLVO). The DAWN and DEFUSE 3 trials have selected patients for EVT beyond 6h from symptom onset. We sought to determine how many patients of our center would qualify to apply advanced DAWN or DEFUSE 3 imaging criteria based on clinical symptoms and imaging with non-contrast CT (NCCT) and CT angiography (CTA). Methods: We prospectively registered consecutive ischemic stroke patients who were screened for EVT eligibility between 01/2016 and 12/2017. Of these patients, we identified those who fulfilled DAWN (age ≥18years, pre-morbid mRS score ≤1 , NIHSS score ≥10, onset-to-CT time 6-24 hours) and DEFUSE 3 (age 18- 90 years, pre-morbid mRS score ≤2, NIHSS score ≥6, onset-to-CT time 6-16 hours) inclusion criteria, respectively. Of these, we identified patients with acLVO on CTA and early ischemic changes in ≤1/3 of the middle cerebral artery territory (DAWN) or NCCT-ASPECTS >6 (DEFUSE-3), respectively. Results: Among 1011 patients who presented during the study period, 362 patients (36%) had an onset-to-CT time between 6-24 hours and 244 patients (24%) between 6-16 hours. Among the 6-24 hours cohort, 62 patients had an NIHSS score ≥10. Of these, 30 patients had acLVO of whom 13 patients had early ischemic changes ≤1/3 of the MCA territory on NCCT. Among the 6-16 hours cohort, 69 patients had an NIHSS score ≥6. Of these, 33 patients had acLVO of whom 18 patients had a NCCT-ASPECTS >6. Despite early ischemic changes in ≤1/3 of the MCA territory in 320 patients presenting >6 hours from symptom onset, no acute vascular imaging was performed in 108 patients. Overall, 19 patients (2% of the complete cohort) fulfilled clinical and imaging criteria utilized in DAWN or DEFUSE-3 trials. Of these, only 10 patients (1% of the complete cohort) received additional perfusion CT of whom 7 patients eventually underwent EVT. Conclusions: Only a minority (2%) of patients in our cohort would have qualified to apply advance imaging criteria based on DAWN or DEFUSE-3 trials for EVT beyond 6 hours from stroke onset. However, the positive results of these trials may have an impact on future assessment of EVT eligibility in patients presenting at a later time window.

Introduction: Density of hyperdense middle cerebral artery sign (HMCAS) quantified via Hounsfield units (HU) on CT may predict clot composition and stroke TOAST subtype, with clots from cardioembolism displaying lower HMCAS densities due to fibrin predominance than erythrocyte-dominant clots originating from large artery atherosclerosis (LAA). Hypothesis: We hypothesized that embolic stroke of undetermined source (ESUS) is linked to higher density of HMCAS due to its high probability of a cardiac source and that HMCAS as a surrogate marker of clot composition predicts successful reperfusion following endovascular therapy (EVT). Methods: We analyzed data from an ongoing prospective observational study (since 01/2016) in consecutive patients with acute ischemic stroke (AIS) undergoing EVT for proximal occlusion of the middle cerebral artery (MCA) detected on CT-angiography and confirmed on digital subtraction angiography. Stroke subtypes were determined according to TOAST and ESUS criteria. On thin-slice (1.5mm) non-contrast CT, a blinded neuroradiologist assessed average and maximum HU values for HMCAS. Multiple regression analyses were undertaken to explore the association of HMCAS density normalized for contralateral MCA (HMCAS ratio) with stroke subtypes and major reperfusion (TICI 2b/3) following EVT. Results: In this interim analysis 110 out of 253 patients were included (55.1% females, ages 74 [64-80], median [IQR], baseline NIHSS 17 [13-20], 76 with IVT before EVT) of which 19 (17.8%) had ESUS, 65 (60.8%) had cardioembolism and 23 (21.5%) had LAA. Density analyses showed HMCAS ratios of 1.26 ± 0.22 (mean ± SD) in the entire cohort with no differences among subgroups (ESUS: 1.19 ± 0.26, LAA: 1.24 ± 0.25, cardioembolic stroke: 1.29 ± 0.19, p = ns), the latter being also true for HMCAS ratios of maximum HU values and absolute HU values (p = ns). On multivariate regression model adjusted for intravenous tPA and onset to groin puncture time, HMCAS average ratio did not predict major reperfusion (per 1-unit HU increase: 2.13; [0.25-18.29], OR [95% CI]) or stroke subtype. Discussion: Density analysis of HMCAS appears not to be helpful in detection of ESUS, diagnostic discrimination between stroke subtypes, or prediction of reperfusion following EVT.

Introduction: A recent exploratory analysis suggested comparable outcomes among ischemic stroke patients undergoing endovascular therapy (EVT) for anterior circulation large vessel occlusion (acLVO), regardless whether selected via telestroke or admitted directly to an EVT-capable stroke center. The aim of this study was to determine the benefit of EVT in prospectively registered telestroke patients undergoing EVT for acLVO. Methods: We studied consecutive patients with acLVO who underwent EVT at our tertiary stroke center between January 2016 and March 2018. All transferred patients received repeated vascular imaging at our center. We compared clinical and imaging variables as well as safety and efficacy outcomes including symptomatic intracranial hemorrhage (sICH), major reperfusion (mTICI 2b/3), 90-days favorable functional outcome (mRS ≤2) and 90-days survival between patients transferred from telestroke hospitals and patients directly admitted to our stroke center. Results: Of 513 prospectively registered ischemic stroke patients screened for EVT eligibility during the 27-months study period, 164 had acLVO and eventually underwent EVT: median age 76 years (interquartile range, 66-82); 46% men; median NIHSS score 17 (13-20) points. Of these patients, 73 (44.5%) were transferred from a telestroke hospital and 91 (55.5%) were directly admitted to our tertiary stroke center. While telestroke patients had longer onset-to-needle (median: 128 [95-150] vs. 103 [87-122] min; p=0.051) and onset-to-groin puncture (median: 295.5 [248-340] vs. 180 [132-220] min; 0.05) in clinical and imaging variables were present between the two groups. The rates of sICH (2.7% vs. 1.1%; p=0.586), major reperfusion (80.8% vs. 76.9%; p=0.545), 90-days favorable functional outcome (23.9% vs. 28.9%; p=0.481) and 90-days survival (73.2% vs. 67.0%; p=0.393) were similar between telestroke and directly admitted patients. Conclusions: Our prospective data confirms that telestroke and directly admitted ischemic stroke patients have comparable outcomes following EVT for acLVO.