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BACKGROUND AND PURPOSE: Few studies assess nonstenotic carotid plaques on CTA, and the causative role of these plaques in stroke is not entirely clear. We used CTA to determine the prevalence of nonstenotic carotid plaques (

Introduction EXCELLENT (NCT03685578) is a prospective, single-arm, multicenter, real-world international registry of mechanical thrombectomy (MT) for stroke with the EmboTrap device as first line treatment. The study entails thrombus analysis of specimens collected with each MT pass. Aim of the Study To compare rates of mRS 0–2 at 90 days and clot characteristics in subjects with and without first pass effect (FPE). Methods FPE was defined as mTICI 2c/3 after one pass and non-FPE as mTICI 2c/3 after >1 pass as adjudicated by an independent core lab. Clot analysis was performed by independent central labs blinded to clinical data. mRS at 90 days was scored by investigators blinded to procedural data. Results Overall mTICI2c/3 rates were 63.7% (326/512). FPE was achieved in 37.1% (190/512) and non-FPE in 26.6% (136/512) subjects. 90 day mRS 0–2 or equal to pre-stroke was achieved in 47.2% (75/159) with FPE and in 42.1% (51/121) non-FPE patients. All-cause 90-day mortality was 19.1% (34/178) in subjects with FPE and 26.4% (34/129) in subjects with non-FPE. Major thrombus components (mean% ±SD) were as follows: RBC: FPE 45.88±20.54, non-FPE 39.08±18.23, and first pass mTICI Conclusions The high rate of ‘real-world’ FPE observed in EXCELLENT was associated with improved clinical outcomes. Clots retrieved with FPE had higher RBC and lower fibrin content compared to non FPE and to first pass mTICI Disclosure EXCELLENT is sponsored by Cerenovus. Dr. Jovin is a consultant for Neuravi, Codman Neurovascular, Stryker (PI DAWN; unpaid), Fundacio Ictus (PI REVASCAT; unpaid), and holds stock in Anaconda, Silk Road, and Blockade Medical.

Introduction Endovascular management of wide-necked bifurcation aneurysms poses a therapeutic challenge as coiling often requires the use of multiple adjunctive stent constructs to achieve successful embolization without compromising parent vessel integrity. The Neuroform Atlas Stent System is a novel low-profile, intraluminal remodeling device. The study aims to investigate the safety and efficacy of the Y-configuration constructs with the ATLAS stent for aneurysm coil embolization. Methods Patients undergoing Y-stent assisted coil embolization in the ATLAS IDE trial (Investigational Device Exemption) were identified. The primary efficacy end point was complete aneurysm occlusion (Raymond-Roy class 1) on 12-month angiography, in the absence of retreatment or parent artery stenosis (>50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee. Result A total of 60 patients of were identified. The mean age was 59 and 28.3% were men. The median aneurysm size was 6.7mm with a median neck size of 4.3 mm. Aneurysm locations were as follows: basilar apex (56.7%), basilar trunk (3.3%), anterior communicating artery (20%), anterior cerebral artery (3.3%), internal cerebral artery (3.3%) and middle cerebral artery (13.3%). The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 81.1% of patients. Overall, 1.7% (1/60) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions In the ATLAS IDE aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive Y-stent coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with low rates of morbidity. Disclosures A. Jadhav: None. S. Desai: None. R. Hanel: None. D. Frei: None. A. Khaldi: None. S. Hetts: None. O. Zaidat: None. B. Jankowitz: None.

Background: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. Aims: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. Methods: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in 4 countries (2/1/2020 - 06/16/2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). Results: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) of whom were female and 96/172 (55.8%) were between the ages 60-79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130 - 280/100,000) and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p Conclusions: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19 associated cerebrovascular complications, therefore aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.

Introduction The Penumbra SMART COIL® System includes a novel generation of embolic coils comprising complex and WAVE shape properties with varying levels of softness to promote dense packing and durable long-term occlusion. We present the final analysis of 997 patients at 68 U.S./Canada sites with up to 1-yr follow-up in the SMART registry to assess the utility of the SMART COIL System in the treatment of intracranial aneurysms and other malformations. Materials and Methods The SMART registry is a prospective, multi-center registry assessing the embolization of neurovascular lesions using the Penumbra SMART COIL System. Procedures must employ ≥75% of SMART, PC400, or POD coils to meet inclusion criteria. SMART registry endpoints included retreatment rates through 1-yr (±6-mo) follow-up, procedural device-related serious adverse events (SAE), and the ability to achieve adequate occlusion at immediate post-procedure. Results This analysis of 997 patients (72.1% female; mean age 59.6±13.0 yr) included cerebral aneurysms (91.0%, 907/997); arteriovenous malformations (1.1%); fistulae (4.1%); and other lesions (3.8%). Aneurysms, of which 31.8% were ruptured, were small (≤10 mm) in 85.3% (774/907) of patients, large (>10 mm to 25 mm) in 14.4% (131/907), and giant (>25 mm) in 0.2% (2/907); 63.5% (555/874) of patients had wide-neck aneurysms (dome-to-neck ratio For all lesions, median coil deployment time, defined as the time from the first coil deployed until the last coil detached, was 16.0 min (IQR 8.0–32.0), and median time of fluoroscopic exposure was 37.0 min (IQR 24.0–56.0). Stent-assisted coiling was performed in 5.7% of patients, and balloon-assisted coiling was performed in 18.7% of patients. Median packing density (calculated for aneurysms only) was 29.1% [IQR 21.0–38.8]. For aneurysms, Raymond Occlusion Class (RROC) I and II was achieved in 79.7% (719/902) of cases at immediate post-procedure and in 90.1% (643/714) at 1-yr follow-up, with a recanalization rate of 12.8% (91/710) and a retreatment rate of 7.1% (52/733). In multivariate models, a large or giant aneurysm size (odds ratio [OR]=2.45, p=0.0030), balloon-assisted coiling (OR=1.84, p=0.0195), ruptured aneurysm status (OR=3.91, p For non-aneurysm lesions, complete angiographic occlusion was achieved in 85.2% (23/27) of lesions post-procedure, with a recanalization rate of 6.1% (3/49) and a retreatment rate of 1.9% (1/53) at 1-yr follow-up. Overall, procedural device-related serious adverse events (SAE) were observed in 2.6% (26/997) of subjects. Conclusion The final results of the SMART Registry, a prospective registry with 997 subjects, demonstrate that the SMART COIL System achieves safe and adequate embolization in a wide variety of neurovascular lesions with low retreatment rates over 1 yr. Large aneurysm size and balloon-assisted coiling were predictive of incomplete occlusion at 1-yr and retreatment through 1-yr follow-up. Disclosures A. Spiotta: None. M. Park: None. R. Bellon: None. B. Bohnstedt: None. C. Schirmer: None. R. DeLeacy: None. D. Fiorella: None. B. Woodward: None. B. Baxter: None. S. Kale: None. O. Zaidat: None. P. Sunenshine: None. A. Yoo: None. M. Kabbani: None. K. Liu: None. R. Starke: None. A. Reeves: None. K. Snyder: None. T. Sivapatham: None. T. Dumont: None.

Introduction/Purpose Initial clinical evidence has shown that coiling with the SMART COIL® System (Penumbra, Inc.) is a safe and durable treatment option for intracranial aneurysms.1–5 The WAVE™ Extra Soft Coil (WAVE) is part of the SMART Coil System and is specifically designed as a fill and finish coil. The primary objective of the SURF study, a post-market registry, is to assess the utility of WAVE as a fill and finish coil to support adequate occlusion at one year follow-up. A secondary objective is to compare the ability of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA) to detect incomplete occlusion in the coiled aneurysms. Materials and Methods SURF is a post-market, prospective, multicenter, single-arm, observational study that will enroll approximately 800 consecutive patients at up to 50 centers in North America. Patients age ≥ 18 years, having embolization of intracranial aneurysms, with WAVE as the final finishing coil and Penumbra SMART COIL System accounting for at least 75% of total number of coils implanted, will be included. All subjects will be followed for approximately 1 year. The primary efficacy endpoint is adequate occlusion defined as Raymond-Roy Occlusion Class I and II at final follow-up. The primary safety endpoints are serious adverse events (SAE) within 24 hours post-procedure and device-related SAE up to 7 days or discharge. Imaging will be analyzed by an independent core lab to assess aneurysm occlusion rates at follow-up. Imaging modalities include DSA, computed tomography angiography (CTA), and/or MRA. A comparative analysis between imaging modalities will be performed for patients with DSA and MRA. Results The trial is currently recruiting. Enrollment began November 2019 and the estimated date for study completion is June 2023. Imaging and clinical data collection and core laboratory review are ongoing. Conclusion We report the design of the SURF study, a post-market registry that evaluates the safety and performance of the Penumbra SMART COIL System, including WAVE as a fill and finish coil, in the treatment of intracranial aneurysms. References Daniel B, Henrik S, Ioannis T, Veit R, Marios-Nikos P. SMART coils for intracranial aneurysm repair - a single center experience. BMC Neurol. 2020 Jan 29;20(1):38. Sokolowski JD, Ilyas A, Buell TJ, Taylor DG, Chen CJ, Ding D, Raper DMS, Liu KC. SMART coils for intracranial aneurysm embolization: Follow-up outcomes. J Clin Neurosci 2019 Jan;59:93–97. Ilyas A, Buell TJ, Chen CJ, Ding D, Raper DMS, Taylor DG, Sokolowski JD, Liu KC. SMART coils for intracranial aneurysm embolization: Initial outcomes. Clin Neurol Neurosurg 2018 Jan;164:87–91. Spiotta AM, Fargen KM, Lena J, Chaudry I, Turner RD, Turk AS, Huddle D, Loy D, Bellon R, Frei D. Initial Technical Experience with the SMART Coil for the Embolization of Intracranial Aneurysms. World Neurosurg 2017 Jan;97:80–85. Stapleton CJ, Torok CM, Patel AB. Early experience with the Penumbra SMART coil in the endovascular treatment of intracranial aneurysms: Safety and efficacy. Interv Neuroradiol 2016 Dec;22(6):654–658. Disclosures C. Schirmer: None. I. Kaminsky: None. M. Chaudry: None. O. Zaidat: None. A. Alshekhlee: None. P. Ramakrishnan: None. M. Taqi: None.

Background and purpose Stent-assisted coil embolization using the new generation Neuroform Atlas™ Stent System has shown promising technical, safety, and clinical feasibility and efficacy. Here, we present the one year angiographic and efficacy results of the anterior circulation cohort in the ATLAS Investigational Device Exemption (IDE) Trial. Methods ATLAS IDE is a prospective, multicenter, single-arm, open label study of unruptured wide-necked (neck ≥4 mm or dome-to-neck ratio 50% at the target location. The primary safety endpoint was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary endpoints was performed by an imaging core laboratory and the Clinical Events Committee for ATLAS. Results A total of 182 patients with unruptured wide-necked anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) Caucasian. Mean aneurysm size and dome-to-neck ratio was 6.1±2.2 mm and 1.2±0.3, respectively. Sixty-four (35.2%) aneurysms were located in the anterior communicating artery. Mean procedure duration was 110.2±47.0 minutes. Technical success was achieved in 100% (182/182) of patients. Follow-up imaging data at 12 months was available in 84.1% (153/182) of patients. The primary efficacy endpoint was achieved in 84.7% [95%CI: 78.6,90.9] of subjects and the incidence of primary safety endpoint failure was 4.4% (8/182; 95%CI: 1.9, 8.5). Conclusion In the ATLAS IDE anterior circulation cohort pre-market approval study, the Neuroform ATLAS stent with adjunctive coiling demonstrated high rates of long-term complete occlusion at 12 months, with excellent technical success and safety. Disclosures O. Zaidat: None. R. Hanel: None. E. Sauvageau: None. A. Aghaebrahim: None. E. Lin: None. A. Jadhav: None. T. Jovin: None. A. Khaldi: None. R. Gupta: None. A. Johnson: None. D. Frei: None. D. Loy: None. A. Malek: None. G. Toth: None. A. Siddiqui: None. J. Reavey-Cantwell: None. A. Thomas: None. S. Hetts: None. B. Jankowitz: None.

Background and purpose Limited data exists on the benefit of mechanical thrombectomy (MT) in acute ischemic stroke patients presenting with low ASPECTS (Alberta Stroke Program Early Computed Tomography (CT) Score). The aim of this substudy was investigate the outcome of low ASPECTS (0–5) patients undergoing mechanical thrombectomy in the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) Registry. Methods Data from the STRATIS Registry, a prospective, multicenter, non-randomized, observational study of AIS LVO patients treated with the Solitaire stent-retriever as the first choice therapy within 8 hours from symptoms onset, was used to identify patients with baseline ASPECTS 0–5. CT ASPECTS was adjudicated by a core lab blinded to clinical outcomes. Results A total of 57/763 (7.5%) patients had a baseline ASPECTS 0–5, of which 10 were ASPECTS 0–3 and 47 ASPECTS 4–5. Mean baseline NIHSS was 19.9±5.1. The majority of patients presented with ICA (42.1%) and M1 (47.4%) occlusions. IV-rtPA was administered in 68.4%. Mean onset to arterial puncture was 276±102.9 minutes and puncture to reperfusion time was 45.3±25.3 minutes. The majority of patients (85.5%) achieved substantial reperfusion (mTICI≥2b). Ninety-day outcome was reported in 52/57 (91.2%). The rate of good functional outcome (mRS≤2) was 28.8% (versus 59.7% in ASPECTS 6–10 group, p Conclusion In the STRATIS Registry, low ASPECTS 0–5 is associated with lower functional outcomes in patients undergoing mechanical thrombectomy. Clinical outcome in low ASPECTS may be age dependent. Prospective studies are needed to understand the benefit of MT in this patient population. Disclosures O. Zaidat: None. D. Liebeskind: None. A. Jadhav: None. S. Ortega-Gutierrez: None. V. Szeder: None. D. Haussen: None. D. Yavagal: None. M. Froehler: None. R. Jahan: None. T. Yao: None. N. Mueller-Kronast: None.

Background A significantly large number of patients with emergent large vessel occlusion (ELVO) fail to achieve favorable outcomes despite successful recanalization. Why some patients do not achieve functional independence despite successful revascularization is an important question. There is a paucity of prospective data on the predictors of unfavorable outcomes despite successful recanalization during mechanical thrombectomy for ELVO. Objective This study was performed to determine the predictors of unfavorable outcomes in patients receiving successful recanalization (modified thrombolysis in cerebral infarct, mTICI grade ≥2b) in a prospective multicenter cohort of patients with ELVO. Methods This was a secondary analysis of data collected from ARISE II study (Analysis of Revascularization in Ischemic Stroke With EmboTrap). ARISE II was a prospective, multicenter single arm study on the efficacy of EmboTrap Revascularization Device. Patients who achieved mTICI score of 2b or greater within 3 passes were included in this study. Patients with incomplete follow up were excluded from the study. A univariate and multivariate logistic regression was performed to determine the independent predictors of unfavorable outcomes at 90 days (defined as mRS 3–6). The variables tested as predictors included age, gender, collateral grade, ASPECTS, mode of transfer, National health institute stroke scale (NIHSS) score, use of intravenous tissue plasminogen activator, number of passes, clot location, final mTICI and symptomatic intracranial hemorrhage (sICH). Odds ratio (OR) with 95% confidence interval (CI) were reported. Results One hundred seventy six patients were included in this secondary analysis of ARISE II data. Unfavorable outcomes (mRS=3–6) at 3 months were seen in 52 (29.6%) patients. Females constituted 54.88% of total population. Mean age was 67.15 years. Mean NIHSS score was 15.85±4.71. M1 was the most common site of occlusion with 54.55% followed by M2 (25.0%) and ICA (15.91%). Delay from stroke onset to the deployment of stent retriever was 3.97±1.44 hours. Ninety (51.14%) patients required a single pass. On univariate logistic regression analysis age, ASPECTS, collateral grade, time from stroke onset to the deployment of stent retriever, duration of procedure, NIHSS score, and sICH were found to be significant predictors of unfavorable outcomes. On multivariate analysis collateral grade (OR, 0.24, 95% CI 0.06–0.94, p value 0.04), NIHSS score (OR 1.28, 95% CI 1.15–1.43, p value Conclusion Collateral grade, NIHSS score at presentation, and number of passes are independent predictors of unfavorable outcomes at 90 days. Disclosures A. Siddiqui: 1; C; Co-investigator NIH/NINDS 1R01NS091075. 2; C; Canon Medical System US, Boston Scientific, Amnis Therapeutics, Cerebrotech Medical Systems, Silk Road, Corindus Inc., Blockade Medical, Guidepoint Global Consulting, Imperative Care, Integra LifeSciences Corp, Medtronic, MicroVention, Q’Apel Medical Inc, Rapid Medical, Rebound Therapeutics Corp., Serenity Medical Inc, Silk Road Medical, StimMed, Stryker, Three Rivers Medical, VasSol, W.L. Gore & Associates. M. Waqas: None. T. Andersson: 2; C; Neuravi, Ablynx, Amnis Therapeutics, Medtronic, Rapid Medical, Stryker. J. Saver: 1; C; Medtronic-Abbott, Neuravi. H. Mattle: None. H. Bozorgchami: None. R. Chapot: None. A. Narata: None. A. Yoo: 1; C; Penumbra, Neuravi, Cerenovus. M. Ribo: None. O. Zaidat: 2; C; Stryker, Medtronic, Neuravi, Penumbra.

Introduction Swift and complete revascularization in large vessel occlusion (LVO) stroke is associated with better functional outcomes. First pass effect (FPE), achievement of TICI 2C/3 revascularization on the first pass, is a new metric of technical success of endovascular thrombectomy (EVT). We aim to identify predictors of FPE and TICI 3 revascularization in the ARISE II study. Methods Anterior circulation LVO [ACLVO-internal carotid (ICA) and middle cerebral artery (MCA-M1)] strokes from the ARISE II study were used for this analysis. Core-lab adjudicated TICI scores after the first pass of EmboTrap were collected. FPE and modified FPE (mFPE) were defined as first pass achievement of TICI 2C/3 and TICI ≥2B, respectively. Demographic, clinical and radiographic parameters were analyzed. Multivariable logistic regression was performed to identify predictors. Results A total of 161 ACLVOs underwent thrombectomy in the ARISE II study. Mean age was 67 ±13 years and 43% (n=69) were male. Mean NIHSS and median ASPECTS were 16 ±5 and 10, respectively. While FPE was achieved in 37% (n=59), mFPE was seen 43% (n=69) patients. Multivariable logistic regression was performed using age, sex, use of IV-tpA, BMI, NIHSS, vascular risk factors, ASPECTS, collateral status (ASITN), occlusion location and use of balloon-guided catheter as variables. While absence of ICA occlusion (p=0.07, OR-8.6, 0.8–90) can predict FPE, there were no independent predictors of mFPE. Independent predictors of TICI 3 after 3 passes include use of balloon guide catheter (p=0.01, OR-0.033, 0.003–0.535) and higher ASITN score(p=0.04, OR-10.2, 1–100). Conclusion Absence of internal carotid artery occlusion predicts FPE and the use of balloon guide catheter and favorable collaterals predicts complete revascularization. These results support the consideration of routine BGC use with the Embotrap device to achieve complete revascularization. Disclosures A. Jadhav: None. S. Desai: None. D. Liebeskind: None. A. Yoo: None. H. Bozorgchami: None. M. Ribo: None. J. L: None. H. Mattle: None. T. Andersson: None. O. Zaidat: None.

Background and purpose Recent data suggests that intra-arterial (IA) thrombolytics may be a safe rescue therapy (RT) for acute ischemic stroke (AIS) patients after failed mechanical thrombectomy (MT); however, its safety and efficacy in MCA occlusions remains unclear. Here, we investigate the use of IA tissue plasminogen activator (IA-rtPA) as RT in MCA occlusions in the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) Registry. Methods The STRATIS Registry was a prospective, multicenter, non-randomized, observational study of AIS LVO patients treated with the Solitaire stent-retriever as the first choice therapy within 8 hours from symptoms onset. Clinical and angiographic outcomes were compared in patients with MCA occlusions treated with and without IA-rtPA. Results A total of 680/938 (72.5%) patients with IA-tPA use harbored MCA occlusions, of which 585 (86.0%) and 95 (14.0%) were in the no IA-rtPA and IA-rtPA groups, respectively. Baseline demographics were well-balanced between the cohorts. The majority of MCA occlusions were located in the M1 segment, with 76.1% in the no IA-rtPA group and 74.7% in the IA-rtPA group (p=0.80). IV-rtPA was administered in 64.4% and 71.6% of the no IA-rtPA and IA-rtPA patients (p=0.20). Median IA-rtPA dose was 4mg (IQR 2–10) in the IA-rtPA cohort. Onset to puncture time was less than 6 hours in 88.6% (597/674) of patients. Mean onset to arterial puncture time was shorter in the IA-rtPA group (196.7±109.9 versus 228.2±97.9 minutes, p=0.004); however, mean puncture to procedure end time was longer in the IA-rtPA group than the no IA-rtPA group (74.5±41.5 versus 59.5±33.6 minutes). Mean number of passes (2.0±1.2 versus 1.6±1.0, p=0.005) and rate of distal embolization (53.4% versus 72.1%, p=0.001) were significantly higher in the IA-rtPA group. The rate of substantial reperfusion (mTICI≥2b) was similar in the cohorts (89.9% versus 86.0%, p=0.28). Rates of symptomatic intracranial hemorrhage (sICH) (1.7% versus 2.2%, p=0.68), good functional outcome (mRS≥2, 60.5% versus 58.0%, p=0.85), and mortality (13.9% versus 13.6%, p=0.96) at 90days did not differ between the two groups. Conclusion Use of IA-rtPA as rescue therapy after failed mechanical thrombectomy in MCA occlusions was not associated with an increased risk of sICH or mortality in the STRATIS Registry. More studies are needed to understand the safety and efficacy of IA thrombolysis as rescue therapy in this patient population. Disclosures A. Castonguay: None. S. Zaidi: None. M. Jumaa: None. O. Zaidat: None. D. Liebeskind: None. H. Salahuddin: None. N. Mueller-Kronast: None.

Rationale The EmboTrap Revascularization Device has been shown to be effective in achieving successful reperfusion in emergent large vessel occlusion (ELVO) patients, with clinical outcomes comparable to existing stent retriever devices. Prospective multicenter data on the real-world experience with EmboTrap is not available. Aim The primary objective of the study is to assess the efficacy of routine, real-world experience of the EmboTrap and to explore the associations between imaging characteristics at presentation, including volume of core and penumbra, final infarct volume, histologic clot characteristics, subject comorbidities, revascularization rate, and clinical outcomes. Design This is a prospective, global, multi-center, single-arm, observational registry. Up to 1000 subjects at 50 different sites in Europe and US may be enrolled in the study. Adult patients (>18 years) with angiographically confirmed ELVO, and treated with EmboTrap as first attempted device will be eligible for participation in the study. Patients with confirmed pregnancy or enrolled in another investigational clinical trial will be excluded. This study will utilize expanded thrombolysis in cerebral infarction score (eTICI) and an independent Core Imaging Laboratory to assess baseline CT/MR imaging (e.g. ASPECTS, infarct volume, clot location, perfusion), procedural angiography (eTICI score for every pass, emboli to new territories, collateral score) and post-procedure CT/MR imaging (infarct volume, intracranial hemorrhage). All imaging will be read independently by an experienced Imaging Core Lab blinded to all clinical data. In addition, an independent Core Laboratory will also perform clot analysis. Study outcomes Pre-specified endpoints of the study include successful revascularization (modified thrombolysis in cerebral infarction score ≥ 2b), first pass effect (eTICI ≥ 2c in a single pass without rescue), number of passes, functional independence assessed as modified Rankin Score of ≤ 2 at 90 days, 2 rates of embolization to new territory, symptomatic intracranial hemorrhage at 24 hours and all-cause mortality at 90 days. Analysis Standard descriptive statistical summaries will be provided. For categorical endpoints, two-sided exact 95% confidence intervals will be presented. Regression analyses will be conducted to determine the association between baseline subject comorbidities, clot characteristics and reperfusion, with a focus on imaging findings. The plan for per pass analysis both by an independent core imaging laboratory and by an independent clot analysis laboratory sets apart this registry from other similar studies. In addition, the reperfusion assessment by the independent core lab will be using innovative eTICI. Disclosures A. Siddiqui: 1; C; Co-investigator NIH/NINDS 1R01NS091075. 2; C; Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA Inc, Cerebrotech Medical Systems, Cerenovus, Corindus Inc., Endostream Medical Ltd, Guidepoint Global Consulting, Imperative Care, Integra LifeSciences Corp, Medtronic, MicroVention, Q’Apel Medical Inc, Rapid Medical, Rebound Therapeutics Corp., Serenity Medical Inc, Silk Road Medical, StimMed, Stryker, Three Rivers Medical, VasSol, W.L. Gore & Associates. 4; C; Amnis Therapeutics, Apama Medical, Blink TBI Inc, Buffalo Technology Partners Inc, Cardinal Consultants, Cerebrotech Medical Systems, Cognition Medical, Endostream Medical Ltd, Imperative Care, International Medical Distribution Partners, Neurovascular Diagnostics Inc, Q’Apel Medical Inc, Rebound Therapeutics Corp, Rist Neurovascular In, Serenity Medical, Silk Road Medical, StimMed, Synchron, Three Rivers Medical Inc, Viseon Spine. T. Andersson: 2; C; Neuravi, Ablynx, Amnis Therapeutics, Medtronic, Rapid Medical, Stryker. S. De Meyer: None. K. Doyle: None. J. Fiehler: None. W. Hacke: None. R. Hanel: 2; C; Three Rivers Medical, Medtronic, Microvention, Codman, Stryker. T. Jovin: 2; C; Neuravi, codman, Medtronic, Stryker, Silk Road, Anaconda, Blockade Medical. D. Kallmes: None. D. Liebeskind: None. A. Yoo: 2; C; Cerenovus. O. Zaidat: 2; C; Stryker, Medtronic, Neuravi, Penumbra. R. Nogueria: 2; C; Neuravi, Medtronic, Penumbra, Stryker.

Background and Purpose— Previous work that predated the availability of the safer stent-retriever devices has suggested that general anesthesia (GA) may have a negative impact on outcomes in patients with acute ischemic stroke undergoing endovascular therapy. Methods— We reviewed demographic, clinical, procedural (GA versus local anesthesia [LA], etc), and site-adjudicated angiographic and clinical outcomes data from consecutive patients treated with the Solitaire FR device in the investigator-initiated North American SOLITAIRE Stent-Retriever Acute Stroke (NASA) Registry. The primary outcomes were 90-day modified Rankin Scale, mortality, and symptomatic intracranial hemorrhage. Results— A total of 281 patients from 18 centers were enrolled. GA was used in 69.8% (196/281) of patients. Baseline demographic and procedural factors were comparable between the LA and GA groups, except the former demonstrated longer time-to-groin puncture (395.4±254 versus 337.4±208 min; P =0.04), lower National Institutes of Health Stroke Scale (NIHSS; 16.2±5.8 versus 18.8±6.9; P =0.002), lower balloon-guide catheter usage (22.4% versus 49.2%; P =0.0001), and longer fluoroscopy times (39.5±33 versus 28±22.8 min; P =0.008). Recanalization (thrombolysis in cerebral infarction ≥2b; 72.94% versus 73.6%; P =0.9) and rate of symptomatic intracranial hemorrhage (7.1% versus 11.2%; P =0.4) were similar but modified Rankin Scale ≤2 was achieved in more LA patients, 52.6% versus 35.6% (odds ratio, 1.4 [1.1–1.8]; P =0.01). In multivariate analysis, hypertension, NIHSS, unsuccessful revascularization, and GA use (odds ratio, 3.3 [1.6–7.1]; P =0.001) were associated with death. When only anterior circulation and elective GA patients were included, there was a persistent difference in good outcomes in favor of LA patients (50.7% versus 35.5%; odds ratio, 1.3 [1.01–1.6]; P =0.04). Conclusions— The NASA Registry has demonstrated that clinical outcomes and survival are significantly better in patients treated with LA, without increased symptomatic intracranial hemorrhage risk. Future trials should prospectively evaluate the effect of GA on outcomes.

International audience; BACKGROUND AND PURPOSE:Mechanical thrombectomy is beneficial for patients with acute ischemic stroke and a proximal anterior occlusion, but it is unclear if these results can be extrapolated to patients with an M2 occlusion. The purpose of this study was to examine the technical aspects, safety, and outcomes of mechanical thrombectomy with a stent retriever in patients with an isolated M2 occlusion who were included in 3 large multicenter prospective studies.MATERIALS AND METHODS:We included patients from the Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR), Solitaire With the Intention For Thrombectomy (SWIFT), and Solitaire With the Intention for Thrombectomy as Primary Endovascular Treatment (SWIFT PRIME) studies, 3 large multicenter prospective studies on thrombectomy for ischemic stroke. We compared outcomes and technical details of patients with an M2 with those with an M1 occlusion. All patients were treated with a stent retriever. Imaging data and outcomes were scored by an independent core laboratory. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score of 2b/3.RESULTS:We included 50 patients with an M2 and 249 patients with an M1 occlusion. Patients with an M2 occlusion were older (mean age, 71 versus 67 years; P = .04) and had a lower NIHSS score (median, 13 versus 17; P < .001) compared with those with an M1 occlusion. Procedural time was nonsignificantly shorter in patients with an M2 occlusion (median, 29 versus 35 minutes; P = .41). The average number of passes with a stent retriever was also nonsignificantly lower in patients with an M2 occlusion (mean, 1.4 versus 1.7; P = .07). There were no significant differences in successful reperfusion (85% versus 82%, P = .82), symptomatic intracerebral hemorrhages (2% versus 2%, P = 1.0), device-related serious adverse events (6% versus 4%, P = .46), or modified Rankin Scale score 0-2 at follow-up (60% versus 56%, P = .64).CONCLUSIONS:Endovascular reperfusion therapy appears to be feasible in selected patients with ischemic stroke and an M2 occlusion.

Background and Purpose: Recent randomized clinical trial (RCTs) demonstrated efficacy of mechanical thrombectomy using stent-retrievers in acute ischemic stroke (AIS) patients. The main purpose of TRevo ACute Ischemic StroKe (TRACK) stent-retriever thrombectomy multicenter registry is to demonstrate safety and efficacy in real life clinical practice. Methods: The investigator-initiated TRACK multicenter registry recruited 24 sites in north America to submit demographic, clinical, site-adjudicated angiographic, and outcome data on consecutive AIS patients treated with Trevo stent-retriever device as the first treatment option. Standard clinical safety (symptomatic intracranial hemorrhage (sICH), and mortality) and efficacy (revascularization and disability) outcomes and predictors of clinical outcome were analyzed. Results: 624 patients were enrolled in the TRACK registry. Median age was 68 years (range 16-94, 118 (18.1%) >80), male gender was 51.4%, and 67.7% were white. The median National Institutes of Health Stroke Severity Scale (NIHSS) was 17 (IQR 13-22). Transfer cases were 50.6% with IV-rtPA use in 318 cases (51.3%). Median onset to groin puncture (OTG) time was 283 min (IQR 198.5-443), and groin puncture to revascularization was 66 min (IQR 37.5-103). Anterior circulation occlusion was 86.2% (MCA/M2 in 55.2% followed by ICA in 15.9% and M2 in 12.7%). Use of GA was in 389 cases (62.3%), number of passes were ≤ 3 in 92% of the cases (1: 45.2%, 2:28%, and 3:18.7%), 291 (46.7%) had BGC use. Rescue use was seen in 21.7%. Revascularization of ≥ TIMI 2 was 81.8% and ≥ TICI 2b was 70%. The primary outcome of mRS of ≥ 2 was 48.3% in the full cohort, and 50.6% in TREVO-2 like group. sICH and mortality were 7.2%, and 20.1% in the full cohort vs 6.9% and 17.5% in the TREVO-2 like group, respectively. The independent predictors of clinical outcome were lower baseline NIHSS, younger age, use of BGC, successful recanalization, and no general anesthesia (GA). Conclusions: The real life clinical practice Trevo registry demonstrated good clinical outcome and high rate of recanalization. Younger age, lower baseline NIHSS, use of balloon guide catheter, successful recanalization, and avoiding endotrachaeal GA independent predictors of good clinical outcome.

We, as a group of international multi-disciplinary neurointerventional societies involved in the endovascular management of acute ischemic stroke, have put forth these training guidelines. We believe that a neuroscience background, dedicated neurointerventional training, and stringent peer review and quality assurance processes are critical to ensuring the best possible patient outcomes. Well-trained neurointerventionalists are a critical component of an organized and efficient team needed to deliver clinically effective mechanical thrombectomy for acute ischemic stroke patients.

Background: The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial showed that patients with symptomatic 70% to 99% intracranial arterial stenosis are at particularly high risk of ipsilateral stroke on medical therapy: 18% at 1 year (95% CI = 3% to 24%). The Wingspan intracranial stent is another therapeutic option but there are limited data on the technical success of stenting and outcome of patients with 70% to 99% stenosis treated with a Wingspan stent. Methods: Sixteen medical centers enrolled consecutive patients treated with a Wingspan stent in this registry between November 2005 and October 2006. Data on stenting indication, severity of stenosis, technical success (stent placement across the target lesion with Results: A total of 129 patients with symptomatic 70% to 99% intracranial stenosis were enrolled. The technical success rate was 96.7%. The mean pre and post-stent stenoses were 82% and 20%. The frequency of any stroke, intracerebral hemorrhage, or death within 30 days or ipsilateral stroke beyond 30 days was 14.0% at 6 months (95% CI = 8.7% to 22.1%). The frequency of ≥50% restenosis on follow-up angiography was 13/52 (25%). Conclusion: The use of a Wingspan stent in patients with severe intracranial stenosis is relatively safe with high rate of technical success with moderately high rate of restenosis. Comparison of the event rates in high-risk patients in Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) vs this registry do not rule out either that stenting could be associated with a substantial relative risk reduction (e.g., 50%) or has no advantage compared with medical therapy. A randomized trial comparing stenting with medical therapy is needed. GLOSSARY: FDA = Food and Drug Administration; HDE = Humanitarian Device Exemption; ICH = intracerebral hemorrhage; WASID = Warfarin-Aspirin Symptomatic Intracranial Disease.

Background Pure subdural hematoma (without subarachnoid, intraventricular, or intraparenchymal hemorrhage) due to a rupture intracranial aneurysm is a rare pathology. Most reported cases involve an aneurysm along the internal carotid artery, posterior communicating artery, or middle cerebral artery. No reports have documented an aneurysm along the intracranial portion of a branch from the occipital artery. Case presentation Patient is a 70 year old female, history of hypertension, congestive heart failure, renal artery stenosis, gout, who presented with sudden onset severe excruciating headaches, associated with spinning sensation, nausea, and emesis. No history of trauma. Neurological examination was unremarkable. CT head demonstrated a tentorial subdural hematoma. CTA head revealed a 4 mm aneurysm along the peripheral left inferior cerebelllum and 3 mm aneurysm adjacent to the right sigmoid sinus, both without clear visualization of the parent vessels. Diagnostic angiogram revealed bilateral aneurysms along the transmastoid branches of the intracranial portion of both occipital arteries. Consequently, these branches were embolized, with no residual filling of the aneurysms. Post-procedure, she remained neurologically well. She was monitored appropriately for vasospasm, and discharged home 10 days after presentation. Conclusion Rupture of aneurysms along intracranial branches of the occipital artery can lead to pure subdural hematoma along the tentorium. For non-traumatic acute subdural hematoma, vigilance should be directed towards a vascular etiology. Disclosures H. Nguyen: None. N. Doan: None. S. Shabani: None. M. Gelsomino: None. O. Zaidat: None.

There are only limited epidemiological studies evaluating the association between vertebrobasilar dolichoectasia (VBD) and outcomes. This study was designed to elucidate the outcome and prognosis of adults diagnosed with VBD by magnetic resonance angiography (MRA) and to ascertain if these outcomes were independent of known vascular risk factors.A cohort study was designed to compare VBD cases identified retrospectively from a computerised database of MRA reports with age and sex matched controls evaluated after a 4-7 year period, and 1440 MRA reports were reviewed. The inclusion criteria were ageor =18 years and a radiological diagnosis of VBD. Patients were excluded if there was haemodynamically significant stenosis or occlusion of the posterior circulation. Data were obtained by medical record review and telephone questionnaires. The primary outcome measure was transient or fixed posterior circulation dysfunction (PCD), with a secondary outcome measure of all cause mortality.Sixty four VBD cases were obtained, and 19 cases (30%) were excluded due to refusal and/or insufficient follow up data. From the same computerised database, 45 controls were selected by consecutive sampling. The mean age at follow up was 73.4 years for VBD cases and 73.1 years for controls, with a median follow up period of 64 months. VBD was associated with fixed/transient PCD (p = 0.0001; estimated adjusted odds ratio (OR) of 20.6 and confidence interval (CI) of 4.4 to 95.3), and with all cause mortality (OR = 3.6 CI 1.3 to 10.3); (p = 0.018). VBD cases had 36% mortality, with 50% occurring within 34 months of the initial diagnosis. The VBD cumulative survival curve was statistically different from the controls (p = 0.012 by Mantel-Cox log rank test).This study suggests that VBD may be an independent risk factor for stroke. VBD cases had an increased likelihood for PCD, all cause mortality, and reduced cumulative survival independent of other vascular risk factors in this cohort. Larger population based prospective studies are required to verify these results.