Search

Background and Purpose: Hemorrhagic transformation can occur as a complication of endovascular treatment for acute ischemic stroke. This study aimed to determine whether ischemia depth as measured by admission CTP metrics can predict the development of hemorrhagic transformation at 24 hours., Materials and Methods: Patients with baseline CTP and 24-hour follow-up imaging from the ESCAPE-NA1 trial were included. RAPID software was used to generate CTP volume maps for relative CBF, CBV, and time-to-maximum at different thresholds. Hemorrhage on 24-hour imaging was classified according to the Heidelberg system, and volumes were calculated. Univariable and multivariable regression analyses assessed the association between CTP lesion volumes and hemorrhage/hemorrhage subtypes., Results: Among 408 patients with baseline CTP, 142 (35%) had hemorrhagic transformation at 24-hour follow-up, with 89 (63%) classified as hemorrhagic infarction (HI1/HI2), and 53 (37%), as parenchymal hematoma (PH1/PH2). Patients with HI or PH had larger volumes of low relative CBF and CBV at each threshold compared with those without hemorrhage. After we adjustied for baseline and treatment variables, only increased relative CBF <30% lesion volume was associated with any hemorrhage (adjusted OR, 1.14; 95% CI, 1.02-1.27 per 10 mL), as well as parenchymal hematoma (adjusted OR, 1.23; 95% CI, 1.06-1.43 per 10 mL). No significant associations were observed for hemorrhagic infarction., Conclusions: Larger "core" volumes of relative CBF <30% were associated with an increased risk of PH following endovascular treatment. This particular metric, in conjunction with other clinical and imaging variables, may, therefore, help estimate the risk of post-endovascular treatment hemorrhagic complications., (© 2024 by American Journal of Neuroradiology.)

Background and Purpose: Biological sex is known to have an impact on quality metrics of acute stroke. We aimed to determine whether COVID positivity accentuates this effect and constitutes worse outcome., Methods: The present analysis was based on the Global COVID-19 Stroke Registry, a retrospective, international, cohort study of consecutive ischemic stroke patients receiving intravenous thrombolysis and/or endovascular thrombectomy between 1 March 2020 and 30 June 2021. We investigated differences between the sexes in patient characteristics, acute stroke metrics as well as post-stroke outcome in COVID-positive and COVID-negative stroke patients undergoing acute revascularization procedures., Results: A total of 15,128 patients from 106 centers were recorded in the Global COVID-19 Stroke Registry, 853 (5.6%) of whom were COVID-positive. Overall, COVID-positive individuals were treated significantly slower according to every acute stroke metric compared to COVID-negative patients. We were able to show that key quality indicators in acute stroke treatment were unfavorable for COVID-negative women compared to men (last-seen-well-to-door time + 11 min in women). Furthermore, COVID-negative women had worse 3-month outcomes (3-month modified Rankin Scale score [interquartile range] 3.0 [4.0] vs. 2.0 [3.0]; p < 0.01), even after adjusting for confounders. In COVID-positive individuals no such difference between the sexes, either in acute management metrics or in 3-month outcome, was seen., Conclusion: Known sex-related differences in acute stroke management exist and extend to times of crisis. Nevertheless, if patients were COVID-19-positive at stroke onset, women and men were treated the same, which could be attributed to structured treatment pathways., (© 2024 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Objective: Reperfusion therapy is highly beneficial for ischemic stroke. Reduction in both infarct growth and edema are plausible mediators of clinical benefit with reperfusion. We aimed to quantify these mediators and their interrelationship., Methods: In a pooled, patient-level analysis of the EXTEND-IA trials and SELECT study, we used a mediation analysis framework to quantify infarct growth and cerebral edema (midline shift) mediation effect on successful reperfusion (modified Treatment in Cerebral Ischemia ≥ 2b) association with functional outcome (modified Rankin Scale distribution). Furthermore, we evaluated an additional pathway to the original hypothesis, where infarct growth mediated successful reperfusion effect on midline shift., Results: A total 542 of 665 (81.5%) eligible patients achieved successful reperfusion. Baseline clinical and imaging characteristics were largely similar between those achieving successful versus unsuccessful reperfusion. Median infarct growth was 12.3ml (interquartile range [IQR] = 1.8-48.4), and median midline shift was 0mm (IQR = 0-2.2). Of 249 (37%) demonstrating a midline shift of ≥1mm, median shift was 2.75mm (IQR = 1.89-4.21). Successful reperfusion was associated with reductions in both predefined mediators, infarct growth (β = -1.19, 95% confidence interval [CI] = -1.51 to -0.88, p < 0.001) and midline shift (adjusted odds ratio = 0.36, 95% CI = 0.23-0.57, p < 0.001). Successful reperfusion association with improved functional outcome (adjusted common odds ratio [acOR] = 2.68, 95% CI = 1.86-3.88, p < 0.001) became insignificant (acOR = 1.39, 95% CI = 0.95-2.04, p = 0.094) when infarct growth and midline shift were added to the regression model. Infarct growth and midline shift explained 45% and 34% of successful reperfusion effect, respectively. Analysis considering an alternative hypothesis demonstrated consistent results., Interpretation: In this mediation analysis from a pooled, patient-level cohort, a significant proportion (~80%) of successful reperfusion effect on functional outcome was mediated through reduction in infarct growth and cerebral edema. Further studies are required to confirm our findings, detect additional mediators to explain successful reperfusion residual effect, and identify novel therapeutic targets to further enhance reperfusion benefits. ANN NEUROL 2023;93:793-804., (© 2022 American Neurological Association.)

Background and Objectives: To determine the impact of endovascular therapy for large vessel occlusion stroke in patients with vs those without premorbid disability., Methods: We performed a post hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive patients with stroke treated with the Trevo device as first-line endovascular thrombectomy (EVT) at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions, and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) score ≥2 (premorbid disability [PD]) vs premorbid mRS score of 0 to 1 (no PD [NPD]). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS score from the patient's premorbid mRS score., Results: Of the 634 patients in TRACK, 407 patients were included in our cohort, of whom 53 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20 of 53) of patients with PD and 16.7% (59 of 354) of patients with NPD ( p < 0.001), while death occurred in 39.6% (21 of 53) and 14.1% (50 of 354) ( p < 0.001), respectively. The adjusted odds ratio of no accumulated disability for patients with PD was 5.2 (95% confidence interval [CI] 2.4-11.4, p < 0.001) compared to patients with NPD. However, the adjusted odds ratio for death in patients with PD was 2.90 (95% CI 1.38-6.09, p = 0.005)., Discussion: In this study of patients with anterior circulation acute ischemic stroke treated with EVT, we found that PD was associated with a higher probability of not accumulating further disability compared to patients with NPD but also with higher probability of death., Classification of Evidence: This study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with PD compared to those without disability were more likely not to accumulate more disability but were more likely to die., (© 2021 American Academy of Neurology.)

Background and Purpose: Basilar artery occlusion (BAO) leads to high rates of morbidity and mortality, despite successful recanalization. The discordance between flow restoration and long-term functional status clouds clinical decision-making regarding further aggressive care. We sought to develop and validate a practical, prognostic tool for the prediction of 3-month favorable outcome after acute reperfusion therapy for BAO., Methods: This retrospective, multicenter, observational study was conducted at four high-volume stroke centers in the USA and Europe. Multivariate regression analysis was performed to identify predictors of favorable outcome (90-day modified Rankin scale scores 0-2) and derive a clinically applicable prognostic model (the Pittsburgh Outcomes after Stroke Thrombectomy-Vertebrobasilar (POST-VB) score). The POST-VB score was evaluated and internally validated with regard to calibration and discriminatory ability. External validity was assessed in patient cohorts at three separate centers., Results: In the derivation cohort of 59 patients, independent predictors of favorable outcome included smaller brainstem infarct volume on post-procedure magnetic resonance imaging (P < 0.01) and younger age (P = 0.01). POST-VB score was calculated as: age + (10 × brainstem infarct volume). POST-VB score demonstrated excellent discriminatory ability [area under the receiver-operating characteristic curve (AUC) = 0.91] and adequate calibration (P = 0.88) in the derivation cohort (Center A). It performed equally well across the three external validation cohorts (Center B, AUC = 0.89; Center C, AUC = 0.78; Center D, AUC = 0.80). Overall, a POST-VB score < 49 was associated with an 88% likelihood of favorable outcome, as compared to 4% with a score ≥ 125., Conclusions: The POST-VB score effectively predicts 3-month functional outcome following acute reperfusion therapy for BAO and may aid in guiding post-procedural care., (© 2020 European Academy of Neurology.)

Background and Purpose: There is a paucity of data regarding antiplatelet management strategies in the setting of stent-assisted coiling/flow diversion for ruptured intracranial aneurysms. This study aimed to identify current challenges in antiplatelet management during stent-assisted coiling/flow diversion for ruptured intracranial aneurysms and to outline possible antiplatelet management strategies., Materials and Methods: The modified DELPHI approach with an on-line questionnaire was sent in several iterations to an international, multidisciplinary panel of 15 neurointerventionalists. The first round consisted of open-ended questions, followed by closed-ended questions in the subsequent rounds. Responses were analyzed in an anonymous fashion and summarized in the final manuscript draft. The statement received endorsement from the World Federation of Interventional and Therapeutic Neuroradiology, the Japanese Society for Neuroendovascular Therapy, and the Chinese Neurosurgical Society., Results: Data were collected from December 9, 2019, to March 13, 2020. Panel members achieved consensus that platelet function testing may not be necessary and that antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms can follow the same principles. Preprocedural placement of a ventricular drain was thought to be beneficial in cases with a high risk of hydrocephalus. A periprocedural dual, intravenous, antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor was preferred as a standard approach. The panel agreed that intravenous medication can be converted to oral aspirin and an oral P2Y12 inhibitor within 24 hours after the procedure., Conclusions: More and better data on antiplatelet management of patients with ruptured intracranial aneurysms undergoing stent-assisted coiling or flow diversion are urgently needed. Panel members in this DELPHI consensus study preferred a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor., (© 2020 by American Journal of Neuroradiology.)

Introduction: Stroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and fetus. Pregnancy was an exclusion criterion in endovascular thrombectomy (EVT) trials and so there are no evidence-based treatment recommendations in this subgroup. The objective of this study was to evaluate the safety and feasibility of mechanical thrombectomy in large vessel occlusion (LVO) stroke in pregnancy., Methods: Patients with AIS due to LVO treated with EVT during pregnancy between 2000 and 2019 were identified at seven tertiary care centers. After IRB approval, retrospective analysis of prospectively maintained stroke/endovascular databases was performed., Results: A total of seven subjects were identified. The average age was 33.2 years (range 25-38 years) and the average initial National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15 (range 9-28). Three patients received IV tissue plasminogen activator. Techniques of EVT included stent retriever thrombectomy, stent retriever-assisted continuous aspiration, direct contact aspiration, and multimodal techniques including a rescue balloon mounted coronary stent placement. While one patient was noted to have petechial hemorrhage, no individuals developed parenchymal hematoma. Mean discharge NIHSS score was 1.7 (range 0-5)., Conclusion: EVT is a safe and effective treatment for acute stroke secondary to LVO in this series of pregnant patients. While EVT for acute stroke is standard of care in select patient populations, our study suggests that treatment should be considered in the gravid population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Endovascular treatment (EVT) for tandem occlusion (TO) of the anterior circulation is complex but effective. The effect of extracranial internal carotid artery (EICA) lesion severity on the outcomes of EVT is unknown. In this study we investigated the effect of EICA lesion severity on the outcomes of tandem occlusion EVT., Methods: A multicenter retrospective TITAN (Thrombectomy In TANdem lesions) study that included 18 international endovascular capable centers was performed. Patients who received EVT for atherosclerotic TO with or without EICA lesion intervention were included. Patients were divided into two groups based on the EICA lesion severity (high-grade stenosis (≥90% North American Symptomatic Carotid Endarterectomy Trial) vs complete occlusion). Outcome measures included the 90-day clinical outcome (modified Rankin Scale score (mRS)), angiographic reperfusion (modified Thrombolysis In Cerebral Ischemia (mTICI) at the end of the procedure), procedural complications, and intracranial hemorrhage at 24 hours follow-up., Results: A total of 305 patients were included in the study, of whom 135 had complete EICA occlusion and 170 had severe EICA stenosis. The EICA occlusion group had shorter mean onset-to-groin time (259±120 min vs 305±202 min; p=0.037), more patients with diabetes, and fewer with hyperlipidemia. With respect to the outcome, mTICI 2b-3 reperfusion was lower in the EICA occlusion group (70% vs 81%; p=0.03). The favorable outcome (90-day mRS 0-2), intracerebral hemorrhage and procedural complications were similar in both groups., Conclusion: Atherosclerotic occlusion of the EICA in acute tandem strokes was associated with a lower rate of mTICI 2b-3 reperfusion but similar functional and safety outcomes when compared with high-grade EICA stenosis., Competing Interests: Competing interests: MH has received honoria for consultancy and proctoring for Medtronic, Stryker, and Microvention. RN has received honoria from Stryker Neurovascular for TREVO 2 trial (Thrombectomy Revascularisation of Large Vessel Occlusions in Acute Ischemic Stroke) and DAWN Trial (Trevo and Medical Management Versus Medical Management Alone in Wake Up and Late Presenting Strokes), from Medtronic for SWIFT (Solitaire FR With the Intention for Thrombectomy) and SWIFT PRIME Trials (Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke) Steering Committee, and STAR Trial core laboratory (significant), from Penumbra for 3D Separator Trial Executive Committee, and from Neuravi for ARISE-2 (Analysis of Revascularization in Ischemic Stroke With EmboTrap) Steering Committee; AHS reports grants from National Institutes of Health/NINDS/NIBIB, University at Buffalo, personal fees from Hotspur, Intratech Medical, StimSox, Valor Medical, Blockade Medical, and Lazarus Effect, non-financial support from Codman & Shurtleff, Concentric Medical, ev3/Covidien Vascular Therapies, GuidePoint Global Consulting, Penumbra, Stryker, Pulsar Vascular, MicroVention, Lazarus Effect, Blockade Medical, other from null, outside the submitted work. AS has stock from Penumbra and received honoria for consultancy and proctoring for Penumbra, and Stryker. FT has received honoria for consultancy and proctoring for Medtronic, Stryker Codman, and Balt., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: Flow diversion is an established method to treat complex intracranial aneurysms. The natural history of flow-diversion treatment failure resulting in aneurysm remnants is not well-defined. We aimed to delineate the clinical and angiographic features of this entity., Materials and Methods: Review of a prospectively maintained Pipeline Embolization Device data base from inception to October 2017 was performed for aneurysms that demonstrated residual filling on follow-up imaging. Procedural and follow-up clinical details were recorded. Independent, blinded, angiographic assessment of occlusion was performed on the basis of the O'Kelly-Marotta scale. Aggregated outcomes were analyzed using the Fisher exact and Mann-Whitney U tests for categoric and continuous variables, respectively (statistical significance, α = .05)., Results: During the study period, 283 sequential patients were treated; 87% (246/283) were women. The median patient age was 55 years (interquartile range, 47-65 years). Six-month follow-up imaging was available in 83.7% (237/283) of patients, which showed 62.4% (148/237) complete occlusion (class D, O'Kelly-Marotta grading scale). Adjunctive coiling ( P = .06), on-label Pipeline Embolization Device use ( P = .04), and multiple device constructs ( P = .02) had higher rates of complete occlusion at 6 months. Aneurysm remnants were identified in 25 cases on long-term follow-up imaging (median, 16 months; interquartile range, 12-24 months). No patient with an aneurysm remnant after flow diversion presented with delayed rupture or other clinical sequelae, with a median clinical follow-up of 31 months (interquartile range, 23-33 months)., Conclusions: Aneurysm remnants after flow diversion are infrequent with minimal clinical impact. When appropriate, the presence of overlapping devices and possibly adjunctive coiling may result in higher rates of complete occlusion., (© 2019 by American Journal of Neuroradiology.)

Background: The Low-profile Visualized Intraluminal Support (LVIS) Junior stent is newly approved for the treatment of wide-necked intracranial aneurysms., Objective: To report our multicenter experience with use of the LVIS Jr device., Methods: The neurointerventional databases of the participating institutions were retrospectively reviewed for aneurysms treated with LVIS Jr from the time of Food and Drug Administration approval until February 2016. All patients in the study period were included. Clinical presentation, aneurysm location, aneurysm size, vessel size, procedural complications, clinical and imaging follow-up were included in the analysis., Results: Eighty-five patients (54 female and 31 male) met the inclusion criteria for the study. Sixty-eight (80%) of the aneurysms were unruptured and the remainder were ruptured. The most common location of the treated aneurysms was anterior communicating artery (36%), middle cerebral artery bifurcation (22%), and basilar terminus (15%). The mean aneurysm size was 6.1 mm. The mean minimum parent vessel size was 2.3 mm. The LVIS Jr was successfully deployed in all but one case (99%). Initial angiographic results demonstrated Roy-Raymond class 1-2 occlusions in 61/84 patients (73%). At 6 months, 85% of the patients seen at follow-up had Roy-Raymond class 1-2 aneurysm occlusion. No procedure-related deaths occurred. Two cases of procedure-related complications (intraprocedural rupture and delayed rupture at day 2) were seen, leading to permanent neurologic morbidity. Both these cases were in patients with ruptured aneurysms., Conclusions: The LVIS Jr is a technically feasible, safe, and effective treatment for wide-necked intracranial aneurysms. Early results are promising but will need to be corroborated with longer-term follow-up., Competing Interests: Competing interests: GD: consultant MicroVention. RAH: consultant, unrestricted educational grant MicroVention. DKL: research grant, advisory board and speaker MicroVention., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Endovascular therapy seems to benefit a subset of patients with large vessel occlusion strokes. We aimed to develop a clinically useful tool to identify patients who are likely to benefit from endovascular therapy., Methods: In a derivation cohort of consecutively treated patients with anterior circulation large vessel occlusion (Grady Memorial Hospital, N=247), independent predictors (p<0.1) of good outcome (90-day modified Rankin scale score (mRS) 0-2) were determined using logistic regression to derive the Pittsburgh Response to Endovascular therapy (PRE) score as a predictor of good outcome. The PRE score was validated in two institutional cohorts (University of Pittsburgh Medical Center (UPMC): N=393; Unitat d'Ictus Vall d'Hebron: N=204) and its discriminative power for good outcome was compared with other validated tools. Benefit of successful recanalization was assessed in PRE score groups., Results: Independent predictors of good outcome in the derivation cohort (age, baseline National Institute of Health Stroke Scale (NIHSS) score and Alberta Stroke Program Early CT Score (ASPECTS)) were used in the model: PRE score=age (years)+2×NIHSS-10 × ASPECTS. PRE score was highly predictive of good outcome in the derivation cohort (area under the curve (AUC)=0.79) and validation cohorts (UPMC: AUC=0.79; UIVH: AUC=0.72) with comparable rates of good outcome in all PRE risk quartiles. PRE was superior to Totaled Health Risks In Vascular Events (THRIVE) (p=0.03) and Stroke Prognostication using Age and NIHSS (SPAN) (p=0.007), with a trend towards superiority to Houston Intra-Arterial Therapy 2 (HIAT2) (p=0.06) and iSCORE (p=0.051) in predicting good outcomes. Better outcomes were associated with successful recanalization in patients with PRE scores -24 to +49 but not in patients with PRE scores <-24 or ≥ 50., Conclusions: The PRE score is a validated tool that predicts outcomes and may facilitate patient selection for endovascular therapy in anterior circulation large vessel occlusions., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Rationale: Endovascular treatment has been shown to restore blood flow effectively. Second-generation medical devices such as stent retrievers are now showing overwhelming efficacy in clinical trials, particularly in conjunction with intravenous recombinant tissue plasminogen activator., Aims and Design: This statistical analysis plan utilizing a novel, sequential approach describes a prospective, individual patient data analysis of endovascular therapy in conjunction with intravenous recombinant tissue plasminogen activator agreed upon by the Thrombectomy and Tissue Plasminogen Activator Collaborative Group., Study Outcomes: This protocol will specify the primary outcome for efficacy, as 'favorable' outcome defined by the ordinal distribution of the modified Rankin Scale measured at three-months poststroke, but with modified Rankin Scales 5 and 6 collapsed into a single category. The primary analysis will aim to answer the questions: 'what is the treatment effect of endovascular therapy with intravenous recombinant tissue plasminogen activator compared to intravenous tissue plasminogen activator alone on full scale modified Rankin Scale at 3 months?' and 'to what extent do key patient characteristics influence the treatment effect of endovascular therapy?'. Key secondary outcomes include effect of endovascular therapy on death within 90 days; analyses of modified Rankin Scale using dichotomized methods; and effects of endovascular therapy on symptomatic intracranial hemorrhage. Several secondary analyses will be considered as well as expanding patient cohorts to intravenous recombinant tissue plasminogen activator-ineligible patients, should data allow., Discussion: This collaborative meta-analysis of individual participant data from randomized trials of endovascular therapy vs. control in conjunction with intravenous thrombolysis will demonstrate the efficacy and generalizability of endovascular therapy with intravenous thrombolysis as a concomitant medication., (© 2015 World Stroke Organization.)

Background and Purpose: We sought to determine hospital and patient characteristics associated with the use of endovascular therapy for acute ischemic stroke and to analyze trends in clinical outcome., Methods: Data were from Get With The Guidelines-Stroke hospitals from April 1, 2003, to June 30, 2013. We looked at trends in number of hospitals providing endovascular therapy, the use of endovascular therapy in these hospitals and clinical outcomes. We analyzed hospital and patient characteristics associated with endovascular therapy use., Results: Of 1087 hospitals, 454 provided endovascular therapy to ≥1 patient in the study period. From 2003 to 2012, proportion of hospitals providing endovascular therapy increased by 1.6% per year (from 12.9% to 28.9%; P<0.0001), with a modest drop to 23.4% in 2013. Utilization of endovascular therapy increased from 0.7% to 2% (P<0.001) with a modest drop to 1.9% in 2013. The overall rate of symptomatic intracerebral hemorrhage among endovascular therapy treated patients was 9.7%. In multivariable analyses, patient outcomes after endovascular therapy improved over time, with reductions in in-hospital mortality (29.6% in 2004 to 16.2% in 2013; P=0.002); and from late 2010, reduction in symptomatic intracerebral hemorrhage (11% in 2010 to 5% in 2013; P<0.0001), increased independent ambulation at discharge (24.5% in 2010 to 33% in 2013; P<0.0001) and discharge home (17.7% in 2010 to 26.1% in 2013; P<0.0001). Trends for these outcomes persist in the analyses adjusted for baseline National Institutes of Health Stroke Scale., Conclusion: The use of endovascular therapy increased modestly nationally from 2003 to 2012 and decreased in 2013. Clinical outcomes improved notably from 2010 to 2013, coincident with more experience and newer thrombectomy devices., (© 2015 American Heart Association, Inc.)

Background: In 2011, the Brain Attack Coalition proposed door-to-treatment times of 2 hours as a benchmark for patients undergoing intra-arterial therapy (IAT). We designed the Rapid Reperfusion Registry to capture the percentage of stroke patients who meet the target and its impact on outcomes., Methods and Results: This is a retrospective analysis of anterior circulation patients treated with IAT within 9 hours of symptom onset. Data was collected from December 31, 2011 to December 31, 2012 at 2 centers and from July 1, 2012 to December 31, 2012 at 7 centers. Short “Door-to-Puncture” (D2P) time was hypothesized to be associated with good patient outcomes. A total of 478 patients with a mean age of 68±14 years and median National Institutes of Health Stroke Scale (NIHSS) of 18 (IQR 14 to 21) were analyzed. The median times for IAT delivery were 234 minutes (IQR 163 to 304) for “last known normal-to-groin puncture” time (LKN-to-GP) and 112 minutes (IQR 68 to 176) for D2P time. The overall good outcome rate was 39.7% for the entire cohort. In a multivariable model adjusting for age, NIHSS, hypertension, diabetes, reperfusion status, and symptomatic hemorrhage, both short LKN-to-GP (OR 0.996; 95% CI [0.993 to 0.998]; P<0.001) and short D2P times (OR 0.993, 95% CI [0.990 to 0.996]; P<0.001) were associated with good outcomes. Only 52% of all patients in the registry achieved the targeted D2P time of 2 hours., Conclusions: The time interval of D2P presents a clinically relevant time frame by which system processes can be targeted to streamline the delivery of IAT care nationally. At present, there is much opportunity to enhance outcomes through reducing D2P.

Background: Recanalization and angiographic reperfusion are key elements to successful endovascular and interventional acute ischemic stroke (AIS) therapy. Intravenous recombinant tissue plasminogen activator (rt-PA), the only established revascularization therapy approved by the US Food & Drug Administration for AIS, may be less effective for large artery occlusion. Thus, there is enthusiasm for endovascular revascularization therapies, which likely provide higher recanalization rates, and trials are ongoing to determine clinical efficacy and compare various methods. It is anticipated that clinical efficacy will be well correlated with revascularization of viable tissue in a timely manner., Method: Reporting, interpretation, and comparison of the various revascularization grading methods require agreement on measurement criteria, reproducibility, ease of use, and correlation with clinical outcome. These parameters were reviewed by performing a Medline literature search from 1965 to 2011. This review critically evaluates current revascularization grading systems., Results and Conclusion: The most commonly used revascularization grading methods in AIS interventional therapy trials are the thrombolysis in cerebral ischemia (TICI, pronounced "tissy") and thrombolysis in myocardial ischemia (TIMI) scores. Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme. Other grading systems may be used for research and correlation purposes. A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.

Background and purpose: Tandem anterior circulation lesions in the setting of acute ischemic stroke (AIS) are a complex endovascular situation that has not been specifically addressed in trials. We determined the predictors of successful reperfusion and good clinical outcome at 90 days after mechanical thrombectomy (MT) in patients with AIS with tandem lesions in a pooled collaborative study. Methods: This was a retrospective analysis of consecutive patients presenting to 18 comprehensive stroke centers with AIS due to tandem lesion of the anterior circulation who underwent MT. Results: A total of 395 patients were included. Successful reperfusion (modified thrombolysis in cerebral infarction score 2b–3) was achieved in 76.7%. At 90 days, 52.2% achieved a good outcome (modified Rankin Scale score 0–2), 13.8% suffered a parenchymal hematoma and 13.2% were dead. Lower National Institutes of Health Stroke Scale score [odds ratio (OR), 1.26; 95% confidence intervals (CI), 1.07–1.48, P = 0.004], Alberta Stroke Program Early CT Score ≥7 (OR, 2.00; 95% CI, 1.07–3.43, P = 0.011), intravenous thrombolysis (OR, 1.47; 95% CI, 1.01–2.12, P = 0.042) and stenting of the extracranial carotid lesion (OR, 1.63; 95% CI, 1.04–2;53, P = 0.030) were independently associated with successful reperfusion. Lower age (OR, 1.58; 95% CI, 1.26–1.97, P < 0.001), absence of hypercholesterolemia (OR, 1.77; 95% CI, 1.10–2.84, P = 0.018), lower National Institutes of Health Stroke Scale scores (OR, 2.04; 95% CI, 1.53–2.72, P < 0.001), Alberta Stroke Program Early CT Score ≥7 (OR, 2.75; 95% CI, 1.24–6.10, P = 0.013) and proximal middle cerebral artery occlusion (OR, 1.59; 95% CI, 1.03–2.44, P = 0.035) independently predicted a good 90‐day outcome. Conclusions: Intravenous thrombolysis and emergent stenting of the extracranial carotid lesion were predictors of a successful reperfusion after MT of patients with AIS with tandem lesion of the anterior circulation. [ABSTRACT FROM AUTHOR]