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Background Angiographic reperfusion after endovascular thrombectomy in acute ischemic stroke is commonly graded using volume-based reperfusion scores such as the modified thrombolysis in cerebral infarct score. The location of non-reperfused regions is not included in modified thrombolysis in cerebral infarct score. We studied the predictive ability of an eloquence-based reperfusion score. Methods Consecutive cases of endovascular thrombectomy for anterior circulation strokes performed between January 2018 and April 2020 were included. Digital subtraction angiograms were reviewed by two blinded neurointerventionalist operators. Incomplete reperfusion was further classified by lobar regions lacking reperfusion to create various cohorts. Outcomes were graded four to seven days post-procedure with the National Institute of Health Stroke Scale (NIHSS) and 90 days post-procedure with the modified Rankin Scale. Results One hundred patients were identified. Via multivariate analysis, we found that frontal lobe non-reperfusion (mean difference (MD) = −1.60, p = 0.002) and occipital lobe non-reperfusion (MD = −1.68, p = 0.001) were associated with worse mental status improvement while left-sided stroke (MD = 2.02, p Conclusions Eloquence-based reperfusion assessment is an important predictor for functional outcomes after thrombectomy.

Introduction Endovascular therapy has shown to be safe and effective for the treatment of cerebral dural arteriovenous fistulas; however, recurrence after complete occlusion is not uncommon, and the timing of recurrence remains unknown. Methods A retrospective single-center cohort study was conducted from January 2005 to December 2020. Patients with high-grade (≥Borden II–Cognard IIB) dural arteriovenous fistulas treated with endovascular therapy were included in this study. Clinical and angiographic characteristics were collected for hospitalization and at follow-up. Results A total of 51 patients with a median age of 61 years were studied; 57% were female. High-flow symptoms related to the high-flow fistula were the most common presentation (67%), and 24% presented with intracranial hemorrhage. Transverse-sigmoid (26%) and cavernous (26%) sinuses were the most common dural arteriovenous fistula locations. A total of 40 patients (70%) had middle meningeal arterial feeders and 4 (7%) had deep cerebral venous drainage. The mean number of embolization procedures per patient was 1.4. Transarterial access was the most frequent approach (61%). Onyx alone was the most common embolic agent (26%). Complete occlusion rate was achieved in 46 patients (80.1%). Last mean radiographic follow-up time was 26.7 months for all 57 dural arteriovenous fistulas. Dural arteriovenous fistula recurrence after radiographic resolution at last treatment was seen in six cases (6/46, 13.1%). Mean time for recurrence was 15.8 months. Mean time of last clinical follow-up was 46.1 months for the 51 patients (100%). A total of 10 (20%) experienced any procedural complications, among which two (4%) became major thromboembolic events. Conclusion Endovascular therapy is safe and effective for the treatment of high-grade dural arteriovenous fistulas. Given the significant recurrence rate of embolized dural arteriovenous fistulas even after 2 years, long-term angiographic follow-up might be needed.

An 88-year-old woman with a medical history of diabetes, hypertension, and atrial fibrillation presented to the emergency room after being found unresponsive with a NIH Stroke Scale score of 23 and Glasgow Coma Scale score of 3. She was unresponsive to painful stimuli. Noncontrast CT demonstrated bilateral thalamic infarcts (figure 1A).

Background The value of clot imaging in patients with emergent large vessel occlusion (ELVO) treated with thrombectomy is unknown. Methods We performed retrospective analysis of clot imaging (clot density, perviousness, length, diameter, distance to the internal carotid artery (ICA) terminus and angle of interaction (AOI) between clot and the aspiration catheter) of consecutive cases of middle cerebral artery (MCA) occlusion and its association with first pass effect (FPE, TICI 2c-3 after a first attempt). Results Patients ( n = 90 total) with FPE had shorter clot length (9.9 ± 4.5 mm vs. 11.7 ± 4.6 mm, P = 0.07), shorter distance from ICA terminus (11.0 ± 7.1 mm vs. 14.7 ± 9.8 mm, P = 0.048), higher perviousness (39.39 ± 29.5 vs 25.43 ± 17.6, P = 0.006) and larger AOI (153.6 ± 17.6 vs 140.3 ± 23.5, P = 0.004) compared to no-FPE patients. In multivariate analysis, distance from ICA terminus to clot ≤13.5 mm (odds ratio (OR) 11.05, 95% confidence interval (CI) 2.65–46.15, P = 0.001), clot length ≤9.9 mm (OR 7.34; 95% CI 1.8–29.96, P = 0.005), perviousness ≥ 19.9 (OR 2.54, 95% CI 0.84–7.6, P = 0.09) and AOI ≥ 137°^ (OR 6.8, 95% CI 1.55–29.8, P = 0.011) were independent predictors of FPE. The optimal cut off derived using Youden’s index was 6.5. The area under the curve of a score predictive of FPE success was 0.816 (0.728–0.904, P Conclusions Clot imaging predicts the likelihood of achieving FPE in patients with MCA ELVO treated with the aspiration-first approach.

BackgroundThe benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3.MethodsThis is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage.ResultsThe unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041).ConclusionsComplete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

Background and Purpose: The modified Thrombolysis in Cerebral Infarct (mTICI) score is used to grade angiographic outcome after endovascular thrombectomy. We sought to identify factors that decrease the accuracy of intraprocedural mTICI. Methods: We performed a 2-center retrospective cohort study comparing operator (n=6) mTICI scores to consensus scores from blinded adjudicators. Groups were also assessed by dichotomizing mTICI scores to 0–2a versus 2b–3. Results: One hundred thirty endovascular thrombectomy procedures were included. Operators and adjudicators had a pairwise agreement in 96 cases (73.8%). Krippendorff α was 0.712. Multivariate analysis showed endovascular thrombectomy overnight (odds ratio [OR]=3.84 [95% CI, 1.22–12.1]), lacking frontal (OR, 5.66 [95 CI, 1.36–23.6]), or occipital (OR, 7.18 [95 CI, 2.12–24.3]) region reperfusion, and higher operator mTICI scores (OR, 2.16 [95 CI, 1.16–4.01]) were predictive of incorrectly scoring mTICI intraprocedurally. With dichotomized mTICI scores, increasing number of passes was associated with increased risk of operator error (OR, 1.93 [95 CI, 1.22–3.05]). Conclusions: In our study, mTICI disagreement between operator and adjudicators was observed in 26.2% of cases. Interventions that took place between 22:30 and 4:00, featured frontal or occipital region nonperfusion, higher operator mTICI scores, and increased number of passes had higher odds of intraprocedural mTICI inaccuracy.

Background and Purpose: Mechanical thrombectomy (MT) is a time-dependent therapy that is only available at a limited number of hospitals. As such, patients that live at a considerable distance of those specialized centers often require rapid interhospital emergent evacuation with Helicopter Emergency Medical Services (HEMS) to be considered for MT. It is not known whether the use of HEMS is equitable across different groups of patients. Methods: Acute ischemic stroke patients emergently transferred to another facility were identified in a retrospective review of a large Medicare claims database. Mode of transportation (HEMS, advanced, or basic ground ambulances) was determined by CPT codes. Distance from patient's residence to the closest center with MT capabilities was calculated. Generalized linear mixed logit models were used to determine the odds of HEMS relative to ground services for Hispanic and non-Hispanic black (NHB) patients relative to non-Hispanic white (NHW) patients while controlling for confounders. Results: A total of 8027 patients that underwent emergent interhospital transportation were analyzed. HEMS utilization was 18.1% for NHB, 20.6% for Hispanics, and 21.6% for NHW (P = .054). In adjusted analyses for confounders, including distance to a MT-capable hospital, Hispanic patients were less likely than NHWs to be transported by HEMS. While that association had marginal significance for the whole United States (OR = .76; 95% CI, .57-1.01; P = .055), it was statistically significant for patients living in the southern region of the United States (OR = .6; 95% CI, .40-.92; P = .019). Discussion: Our findings suggest there is a disparity in the use of HEMS in Hispanic stroke patients compared to NHW. Such a disparity may delay arrival to a MT-capable hospital, delay treatment times, or lead to ineligibility for MT altogether. Given the known benefit of MT and known existing disparities in stroke treatment and outcomes, it is important to further investigate and address disparities in mode of interhospital transportation.

Background: The use of Pipeline Embolization Device (PED) is approved by the US Food and Drug Administration (FDA) to treat aneurysms located between the petrous and superior hypophyseal segments of the internal carotid artery. The purpose of this study is to evaluate the feasibility and efficacy of treating aneurysms outside the FDA approved anatomical locations. Furthermore, we analyze the safety of our antiplatelet protocol. Methods: Data on all patients treated with PED at our center from March 2015 to December 2017 were reviewed. Only patients with aneurysms treated with PED as off label use were included. Procedural complications and long-term functional outcome measured by modified Rankin Scale (mRS) were recorded. Tirofiban maintenance infusion was administered intravenously after PED deployment. None of the patients had platelet function testing. Results: A total of 36 patients harboring 36 aneurysms were included in the study. Mean age was 58.2 years ±14.6. Nineteen were women (52.8%) and most aneurysms were unruptured (80.6%). There were no intraoperative complications. Five patients experienced postoperative complications – 4 ischemic strokes and one groin hematoma. None led to any significant disability at follow-up. Thirty-one patients (86.1%) achieved an mRS of 0–2 at follow-up. A Raymond-Roy classification of 1 was achieved in 78.9% of patients. Conclusion: The use of PED to treat aneurysms located outside the circle of Willis is feasible and effective. Our novel antiplatelet protocol did not require platelet function assay testing and did not lead to a higher rate of thrombo-embolic events compared to what has been previously reported.

Background Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke worldwide and is associated with a high risk of stroke recurrence. We sought to perform a literature review of the epidemiology, pathophysiology, and treatment options. Methods A literature review on recent studies evaluating the epidemiology, risk factors, clinical presentation, and treatment was reviewed. ICAD is particularly common in Africa and Asia. Results Although the medical management of ICAD has improved over the past decade, a subgroup of patients with ICAD remains at significantly high risk of stroke recurrence, and newer studies that aim at improving our understanding of ICAD and evaluating new treatment methods are currently under way. Conclusion ICAD remains a common cause of stroke worldwide; further studies evaluating treatment options to prevent stroke recurrence are urgently needed.

Background Stenting and flow diversion for aneurysmal sub arachnoid hemorrhage (aSAH) require the use of dual antiplatelet therapy (DAPT). Objective To investigate whether DAPT is associated with hemorrhagic complication following placement of external ventricular drains (EVD) in patients with aSAH. Methods Rates of radiographically identified hemorrhage associated with EVD placement were compared between patients who received DAPT for stenting or flow diversion, and patients who underwent microsurgical clipping or coiling and did not receive DAPT by way of a backward stepwise multivariate analysis. Results Four hundred forty-three patients were admitted for aSAH management. Two hundred ninety-eight patients required placement of an EVD. One hundred twenty patients (40%) were treated with stent-assisted coiling or flow diversion and required DAPT, while 178 patients (60%) were treated with coiling without stents or microsurgical clipping and did not receive DAPT. Forty-two (14%) cases of new hemorrhage along the EVD catheter were identified radiographically. Thirty-two of these hemorrhages occurred in patients on DAPT, while 10 occurred in patients without DAPT. After multivariate analysis, DAPT was significantly associated with radiographic hemorrhage [odds ratio: 4.92, 95% confidence interval: 2.45-9.91, P = .0001]. We did not observe an increased proportion of symptomatic hemorrhage in patients receiving DAPT (10 of 32 [31%]) vs those without (5 of 10 [50%]; P = .4508). Conclusion Patients with aSAH who receive stent-assisted coiling or flow diversion are at higher risk for radiographic hemorrhage associated with EVD placement. The timing between EVD placement and DAPT initiation does not appear to be of clinical significance. Stenting and flow diversion remain viable options for aSAH patients.

Background and Purpose: Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for “Y-stent”-assisted coiling embolization of wide-neck bifurcation aneurysms. Methods: Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed. Results: Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro­cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I–II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I–II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases. Conclusions: In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.

The treatment of palpebral and periorbital fistulas may be challenging due to the presence of multiple anastomosis with eloquent ophthalmic and intracranial vascular territories. Moreover, cosmetic and functional characteristics of this area pose unique challenges to open surgical approaches and endovascular therapy. We review the advantages and disadvantages of different liquid embolics in treating palpebral and periorbital fistulas as we describe three successfully treated cases. Moreover, we describe important anatomical landmarks that should be considered at the time of treatment of these lesions.

BackgroundIn response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied.MethodsA prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders.Results458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (PConclusionWe observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.

Time is the key factor in brain survivability in acute stroke treatment.1 The therapeutic effects of intravenous recombinant tissue Plasminogen Activator (IV rtPA) are highly dependent on time.1-3 Stroke patients presenting within the first 60 minutes, or the golden hour, are the most likely to benefit from recanalization therapy.1-3 Thus, making rapid clinical and imaging evaluation of stroke patients of upmost importance and very difficult to complete within the golden hour time window. Based on Get with the Guidelines-Stroke Program (April 2003 to October 2009), less than one-third of patients treated with IV rtPA have door-to-needle times of less than 60 minutes.4

Introduction: Due to advancements in the field of endovascular neurosurgery, use of intracranial stenting and flow diversion (ISFD) in the treatment of acute aneurysmal subarachnoid hemorrhage (aSAH) is on the rise. ISFD requires dual antiplatelet therapy (DAPT), which poses a challenge when patients undergo placement of an external ventricular drain (EVD) or ventriculo-peritoneal-shunt (VPS). We describe our experience with the use of intravenous tirofiban in similar settings. Methods: Patients with aSAH between July 2017 and June 2018 requiring intravenous tirofiban for ISFD after EVD placement and subsequent VPS were included in our retrospective study. Patients were started on intravenous tirofiban at maintenance dose prior to IFSD and continued until transitioned to DAPT after removal of EVD with or without VPS. Intravenous tirofiban was held 4 hours prior to EVD removal/VPS placement and resumed 2 hours later followed by loading dose of DAPT. Patients were monitored in ICU and CT head obtained 24-hours after the procedure. Results: 15 patients (mean age 55 years, 14 females and 1 male) with aSAH who required ISFD and were placed on intravenous tirofiban for 3-18 days. In total, 21 procedures were performed with placement of 16 EVDs (one patient had bilateral EVDs) and 5 VPS. Two patients had clinically asymptomatic small track hemorrhages and 1 patient had a retroperitoneal hemorrhage and thrombocytopenia. No thromboembolic complications were reported. We encountered an 18% risk of hemorrhages, which compares favorably to our previously published 22% risk of all hemorrhages with DAPT. Conclusions: The continuous infusion of tirofiban in patients with aSAH who require ISFD is feasible and has hemorrhagic complication rate similar to the use of DAPT.

Objective: The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%-7% per year despite receiving the best medical therapy. We propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA. Methods: The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients. Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Results: Four types (A-D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2-6 months' follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). Conclusions: The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.

Endovascular mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke patients with large vessel occlusions. The success of MT is mainly due to the development of new-generation devices that allow higher rates of successful revascularization with lower complications. In this chapter, we review the evolution of MT devices and technologies.

Objective: The purpose of this study is to compare long-term functional outcome for patients who receive intravenous alteplase (tPA) at a primary stroke center (spoke) through telestroke c...

The objective of this study is to determine the impact of intraventricular hemorrhage (IVH) on the cognitive prognosis of subarachnoid hemorrhage (SAH) due to ruptured cerebral aneurysm, independent of the presence of intraparenchymal hemorrhage, hydrocephalus or vasospasm.A Retrospective review of a prospectively collected database of patients with aneurysmal SAH from July 2009 to November 2016 was performed. Patients were included if they had a saccular aneurysm with a Hunt-Hess grade (HHG) 1-3. Those who underwent craniectomy/clipping and those with vasospasm were excluded. Patients with IVH were grouped into 5 groups depending on the blood distribution in the ventricles. Functional outcomes studied were modified Rankin score (mRS) 0-2, cognitive impairment and memory impairment, and the presence of amnesia to the event. A univariate followed by a multivariate analysis ware performed.A total of 443 patients were identified and 124 patients met the criterion. There were no significant differences in the proportion of patients with mRS of 0-2 between patients with IVH and those without IVH but with EVD (external ventricular drain). There was a higher proportion of cognitive deficits in patients with IVH (71.95%), compared to those without (31.58%; p = 0.01). Patients with IVH had a higher rate of anterograde amnesia (100% vs. 4.3% p 0.0001), lower rate of mRS 0-2 (78% vs 100% p 0.001), and higher rate of cognitive impairment (71.9% vs. 13% p 0.0001) compared with those who did not require an EVD. Grade 3 and grade 4 were shown to have lower rate of patients with mRS 0-2 and a higher rate of cognitive impairment. In multivariate analysis, independent predictors of cognitive and memory impairment were increasing HHG (OR = 155.33; P 0.01), ACOM/A1/ACA/anterior choroidal aneurysms, (OR = 5.24; P = 0.04), increasing Fischer scale (OR = 6.93; P = 0.01), and increasing IVH grade (OR = 6.9; P = 0.01). Only worse HHG (OR = 2704.22; P = 0.01) and IVH grade 2-4 were associated (perfect predictor, OR cannot be extracted) with anterograde amnesia.IVH is an independent prognosticator of SAH cognitive outcomes. The effect of IVH drainage and other intraventricular therapies on SAH course is an attractive topic for further investigation.

Introduction: Overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around »7% per year. We propose 1) a radiographic classification of COICA to determine the technical success and safety of endovascular recanalization of symptomatic COICA and 2) assess changes in systemic blood pressure following successful revascularization. Methods: Radiographic imaging of 100 consecutive subjects with COICA was analyzed. A classification of COICA based on morphology and location of occlusion in addition to presence or absence of reconstitution of the distal ICA was utilized. Sixteen symptomatic COICA in 15 subjects refractory to medical therapy (4/15, 26.7% female) from 2016-17 were included. Carotid occlusion was defined as 100% occlusion of the vessel lumen based on CT or MR angiography and confirmed by digital subtraction angiogram. Results: Four types (A-D) of radiographic COICA were identified. Type A 29%, Type B 28%, Type C 33%, and Type D 10%. Types A/B were more amenable to safer revascularization than types C/D. Recanalization was successful in 68.75% (11/16 [Type A: 4/4; Type B: 3/3; Type C: 3/4; Type D: 1/5]) of the subjects. Perioperative complications was 4/16, 25%; [0/4 in Type A; 1/3 in type B; 2/4 in type C, and 1/5 in type D]. None of these complications led to permanent morbidity or mortality. Ten of fifteen (62.5%) subjects had improvement in symptoms during 2-6 month follow-up. Eight of ten subjects (80%) with revascularization had significant decrease in systolic blood pressure [SBP) following revascularization [baseline SBP= 141±9 vs. follow-up SBP= 123±8; 95% CI; -25.57 to -10.42; p=0.0001]. The remaining five subjects failing revascularization had no significant change in SBP [Baseline SBP=137±6 vs. follow-up SBP=135±11; 95% CI: -14.92 to 10.9; p=0.73]. Conclusion: This pilot study suggests that our proposed classification of COICA may be a useful guide to determine technical feasibility and safety of revascularization of symptomatic COICA using endovascular techniques. Successful revascularization may lead to significant decrease in SBP post procedure. A phase-2 trial to assess the safety and efficacy of this technique and to validate COICA classification in larger cohort is warranted.

Objective Treatment of ruptured posterior circulation dissecting aneurysms is technically challenging with potentially high morbidity and mortality. We sought to assess the safety and feasibility of using a flow-diversion device (FDD) and a specific acute antiplatelet aggregation protocol in the management of ruptured dissecting aneurysms. Methods Subjects with ruptured dissecting aneurysms treated during a 3-year period were retrospectively identified from a prospective registry. Intraoperative complications, morbidity, and mortality were recorded. Tirofiban maintenance infusion without bolus was administered intravenously immediately after deployment of the FDD, and almost all patients were loaded with dual antiplatelet (aspirin and clopidogrel) post procedure. Clinical follow-up evaluation and modified Rankin Scale were assessed. Results Nine subjects with ruptured posterior circulation dissecting aneurysms were treated with an FDD: 5 vertebral artery, 2 basilar artery, and 2 posterior inferior cerebellar artery aneurysms. Average World Federation of Neurosurgical Societies score was 2 (range 1–5). Seven patients had external ventricular drain placed acutely for hydrocephalus. Eight patients received tirofiban infusion without bolus after FDD. No intraoperative complications occurred. Two subjects developed asymptomatic intraparenchymal hemorrhage found on surveillance noncontrast computed tomography. One subject suffered a major intraparenchymal hemorrhage and died a few days post intervention after additional anticoagulation was started for a left ventricular assist device. Follow-up modified Rankin Scale within 12 months was 0 in 3 subjects, 1 in 3 subjects, 2 in 1 subject, and 4 in 1. Conclusions Treatment of dissecting posterior circulation aneurysms with FDDs is feasible and a potential alternative to deconstructive techniques.

We examined platelet transfusion (PTx) in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, hypothesizing that rates of PTx would vary among hospitals and depend on whether patients were on an antiplatelet therapy or underwent intracerebral hemorrhage (ICH) surgical treatment.The ERICH study is a prospective observational study evaluating risk factors for ICH among whites, blacks, and Hispanics. We identified factors associated with PTx, examined practice patterns of PTx across the United States, and explored the association of PTx with mortality and poor outcome (modified Rankin Scale score 4-6).Nineteen centers enrolled 2572 ICH cases; 11.7% received PTx. Factors significantly associated with PTx were antiplatelet use before onset (odds ratio [OR], 5.02; 95% confidence interval [CI], 3.81-6.61, P .0001), thrombocytopenia (OR, 13.53; 95% CI, 8.43-21.72, P .0001), and ventriculostomy placement (OR, 1.85; 95% CI, 1.36-2.52, P .0001). Blacks were less likely (OR, .57; 95% CI, .41-0.80) to receive PTx. Among patients who received PTx, 42.4% were not on an antiplatelet therapy before onset. Twenty-three percent of patients on antiplatelet therapy received PTx, but percentages varied from 0% to 71% across centers. There was no difference in mortality or poor outcome at 3 months between patients receiving PTx and those who did not.The frequency of PTx for ICH varies across academic centers. Thrombocytopenia, antiplatelet use, vascular risk factors, and ventriculostomy placement were associated with PTx. PTx was not associated with improved outcomes. We anticipate reduced PTx use over time given recent clinical trial data suggesting its use could be harmful; however, the issue of whether surgical management warrants PTx remains.

The incidence of acute ischaemic stroke with mild neurological deficits (called mild ischaemic stroke [MIS]) is increasing, and studies show that a large percentage of untreated patients have poor long-term outcomes. Many physicians do not, however, routinely treat patients with MIS with intravenous recombinant tissue plasminogen activator (rtPA)--the only thrombolytic therapy currently approved by the FDA. Here, we discuss the reasons why physicians do not treat patients with MIS and we review the studies published to date regarding the potential risks and benefits of administering rtPA in this patient population. We then provide our perspective on why patients with MIS should be treated with intravenous rtPA and we highlight the need for a randomized clinical trial to address treatment of MIS.

Cardiac embolism, primarily from atrial fibrillation (AF), is implicated in a quarter of all ischemic strokes. In the setting of AF, contraindications to traditional therapies can create a clinical dilemma when choosing an agent for secondary stroke prophylaxis. Newer horizons in the medical and surgical management of AF have helped us choose from a wide variety of available therapies, the best possible management. In this article, we review the current trends in AF management including newer oral anticoagulants as well as surgical devices from a neurologist's view.

BackgroundFavorable imaging profile according to the Alberta Stroke Program Early CT Score (ASPECTS) on non-contrast head CT is a key criterion for the selection of patients with ischemic stroke from large vessel occlusion (LVO) for IA revascularization therapies.ObjectiveTo analyze factors associated with changes in ASPECTS during inter-hospital transfer and to determine how deterioration of ASPECTS affects eligibility for endovascular procedures.MethodsWe analyzed factors associated with changes in ASPECTS during inter-hospital transfer and their potential impact on eligibility for IA stroke therapies in patients with anterior circulation ischemic strokes. Clinical and demographic characteristics between patients with favorable (ASPECTS ≥6) and unfavorable (ASPECTS ResultsStroke evolution towards unfavorable ASPECTS occurred in 13/42 (31%) patients who initially had a favorable imaging profile at outside hospitals. A higher National Institutes of Health Stroke Scale (NIHSS) score was the only significant predictor of ASPECTS decay, whereas other clinical characteristics, such as the use of IV thrombolysis and site of LVO, were similar between the two groups.ConclusionsIn our cohort, one out of three patients became ineligible for IA thrombectomy because of unfavorable ASPECTS ‘decay’ following inter-hospital transfer. Except for NIHSS severity, baseline clinical factors could not identify which patients were at risk for ASPECTS deterioration.

Background and objectives: Enrollment into acute stroke trials is usually limited to weekday working hours. As a result, a large portion of eligible patients do not receive the opportunity to participate in these trials, hence enrollment rate suffers. We share our experience regarding the feasibility and implementation of a 24/7 enrollment plan for two acute ischemic stroke (AIS) trials. We also compare differences in patients’ characteristics enrolled during working hours ( WH ) vs. after hours+weekend ( AH ). Methods: Data used for this study is from a single-center that actively enrolls AIS patients into 2 time-sensitive, tPA-adjunctive clinical trials (CLOTBUST-HF & ARTSS-2). This center implemented a 24/7 on-call system for research coordinators to respond after-hours (5:01pm-6.59am) and on weekends. Approach for AH comprises a coordinated effort that includes: prompt call to on-call coordinator if in-house physician identifies a potential eligible patient; on-call physician delivers IV-tPA and introduces the study; study PI accesses the electronic medical record from home and if applicable the randomization website to screen and prepare for enrollment. The coordinator arrives at ED to assist in-house physician with study procedures. We conducted descriptive analyses that explore differences between WH (Mon-Fri: 7am-5pm) vs. AH (Mon-Thurs: 5.01pm-6.59am and Fri-Mon: 5.01pm-6.59am). Results: During 01/2010 - 05/2013, a total of 34 patients were eligible for the 2 trials of whom 33 were enrolled. 17/33 (52%) patients were enrolled AH and had lower NIHSS scores and longer onset-to-tPA times. Table includes data comparing the groups. Conclusion: 24/7 research enrollment for AIS patients is feasible and increased recruitment by 106% with no delays in randomization or initiation of investigational treatments. Reproducibility in other centers should be explored. Efforts to provide 24/7 coverage should be evaluated as a way to improve recruitment rates.

In the April issue of Stroke , we have yet another study on the safety of tissue-type plasminogen activator (tPA) for patients with stroke mimics (SM). Zinkstok et al1 conducted a multicenter retrospective analysis of patients with SM treated with tPA at primary and community hospitals. With 100 patients reported in the largest series to date, the authors found, like all the previous cohort studies, a low rate of symptomatic intracerebral hemorrhage and death.2,3 There were no instances of orolingual edema or fatal intracerebral hemorrhages. The incidence of SM in their cohort among all tPA-treated patients was on the lower end of other reports: 2% to 31%.2,4–6 This rate is also much lower than the 7% misdiagnosis rate reported for emergency departments in which tPA was administered without a stroke team evaluation.7 In fact, …

Background and Objectives: Early neurological improvement (ENI) at 2-hours post thrombolysis has recently been proposed to most accurately predict recanalization when repeat vascular imaging is not available. However, these studies analyzed recanalization at a delayed time point (≥24 hours). The Argatroban tPA Stroke Study (ARTSS-1), is a recently completed NIH sponsored, Phase IIa, prospective, open-label, safety and activity study of Argatroban and rtPA in patients with ischemic stroke ( NCT00268762 ). We hypothesized 2-hour recanalization correlates with ENI (NIHSS improvement of 20% or greater from baseline). Methods: A total of 65 patients with intracranial large vessel occlusive disease were given standard dose (0.9mg/kg) tPA and a 100 μg/kg bolus of argatroban followed by infusion of 1 μg/kg per minute for 48 hours adjusted to a PTT of 1.75 times baseline. Pre-tPA vessel imaging using TCD or CTA confirmed intracranial occlusions. A multivariate logistic regression tested whether recanalization at 2 hours was associated with ENI after controlling for age, NIHSS, clot location (ICA, MCA or vertebrobasilar). We analyzed whether patients with ENI had statistically significant greater odds of an excellent mRS (0 or 1) at day 7. Results: Recanalization data was available for 47 patients at 2-hours. ENI occurred at 2-hours in 46% patients. Patients with any recanalization (complete or partial) at 2-hours were more likely to experience ENI (OR 3.4; 95% CI 0.71-16.6, p=0.124). This association strengthened when 2-hour complete recanalization was analyzed (OR 5.4; 95% CI 0.98-29.2, p=0.053). In an unadjusted analysis, patients with ENI at 2-hours were five times more likely to have excellent mRS outcomes at day 7 (OR 4.7; 95% CI 1.4-15.6, p=0.01). In the adjusted model, the association remained significant (OR 3.8; 95%CI 1.1-13.4, p=0.041). Conclusion: Two-hour recanalization is predictive of early neurological improvement and better early clinical outcomes in patients treated with combination Argatroban and tPA. A randomized, controlled clinical trial of this promising adjunctive therapy is warranted and ongoing (ARTSS-2 trial, NCT01464788 ).

Although the 2 National Institute of Neurological Disorders and Stroke (NINDS) trials1 and subsequent studies from Europe (ECASS-3, IST-3)2,3 established intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of symptom onset as an effective treatment for acute ischemic stroke, the ability of IV rtPA to predictably result in an excellent outcome is still limited; in most cases, IV rtPA treatment is not enough to produce complete recanalization.4,5 Intraarterial (endovascular) treatment (IAT) is superior to IV rtPA in opening arteries, particularly when coupled with mechanical thrombectomy, with recanalization rates up to 87%.6,7 There is increasing evidence that IAT has a therapeutic role in large artery occlusions.8,9 In addition, faster time to angiographic reperfusion is a predictor of good clinical outcome with IAT.10 Thus, there is a need for a quick and accurate strategy to identify IV rtPA nonresponders with large artery occlusion to select those patients who would benefit from IAT. Mechanical Embolus Removal in Cerebral Ischemia (MERCI), Multi MERCI, and Solitaire With the Intention For Thrombectomy (SWIFT) are just a few of the studies that have used the concept of IV rtPA failure as inclusion criteria to enroll subjects in their studies. But what exactly is the definition of IV tPA nonresponder or failure? To date, there is no clear and consistent designation for this subgroup in the stroke literature. How do the characteristics of the clot influence response to IV rtPA? Is there a time window that should define IV rtPA failure? Should imaging modalities to assess vessel recanalization be used to define IV rtPA failure? Should early clinical change be criteria to differentiate IV rtPA responders from nonresponders? Accurate and rapid identification …

Background Favorable imaging profile according to the Alberta Stroke Program Early CT Score (ASPECTS) on noncontrast head CT is a key criterion for the selection of patients with ischemic stroke from large vessel occlusion (LVO) for intra-arterial (IA) revascularization therapies. Objective The goal of our study was to analyze factors associated with changes in ASPECTS during inter-hospital transfer and to determine their impact on eligibility for endovascular procedures. Methods We analyzed factors associated with changes in ASPECTS during inter-hospital transfer and their potential impact on eligibility for IA stroke therapies in patients with anterior circulation ischemic strokes. Clinical and demographic characteristics between patients with favorable and unfavorable imaging on repeat CT were compared. Favorable ASPECTS profile was defined as ASPECTS ≥6, and unfavorable ASPECTS Results Of the 50 transferred patients with anterior circulation LVO, 42 had favorable ASPECTS ≥6 on CT imaging performed at outside hospital. 19 (45%) of those 42 patients presented to an outside facility within 6 hours of stroke onset (mean time from symptom onset to head CT, 295 ± 61 min), whereas in 23 patients CT showed favorable ASPECTS with stroke onset beyond the 6 hour window (mean time from symptom onset to outside CT, 603 ± 224 min). Stroke evolution towards unfavorable ASPECTS occurred in 13 (31%) out of 42 patients who initially had favorable imaging profile at outside hospitals. Higher NIHSS score was the only significant predictor of ASPECTS decay, whereas other clinical characteristics such as the use of intravenous thrombolysis and site of LVO (ICA versus MCA M1/M2) were similar between both groups. Conclusions Our study showed that during inter-hospital transfer, one out of three patients with stroke from anterior circulation LVO becomes ineligible for IA thrombectomy based on CT ASPECTS imaging criteria alone. Except for NIHSS severity, no other baseline clinical factors could identify which patients were at risk of ASPECTS deterioration. Our study indicates the critical importance of rapid transfer of all stroke patients with suspected LVO to endovascular-capable hospitals. Disclosures M. Mokin: None. R. Gupta: 1; C; Zoll, WellStar foundation. 2; C; Stryker Neurovascular, Covidien, Penumbra, Rapid medical. 6; C; Penumbra, Inc. W. Guerrero: None. D. Rose: 3; C; Boehringer Ingelheim Pharmaceuticals, Chiesi-USA. W. Burgin: None. S. Sivakanthan: None.

Background Heat stress results in multiorgan failure and CNS injury. There a few case reports in the literature on the neurological consequences of heat stress. Case presentation We describe a patient with heat stress presenting with encephalopathy and bilateral cerebral, cerebellar, and thalamic lesions and intraventricular hemorrhage on MRI. Conclusion Heat stress should be in the differential diagnosis of patients presenting with encephalopathy and elevated serum inflammatory markers especially if the history suggests a preceding episode of hyperthermia.

Infection is a well-known cause of cerebral vasculopathy and vasculitis. We report a 36-year-old woman with cerebral vasculitis and ischemic stroke secondary to herpes simplex virus (HSV). MRI studies revealed a pontine stroke with basilar artery stenosis and vessel wall gadolinium enhancement. This case demonstrates the ability of HSV to cause a focal brainstem vasculitis and the utility of enhanced MRI in the diagnosis of stroke related to HSV central nervous system vasculitis.

Emergency medicine physicians are often faced with the challenging task of differentiating true acute ischemic strokes from stroke mimics. We present a case that was initially diagnosed as acute stroke. However, perfusion CT and EEG eventually led to the final diagnosis of status epilepticus. This case further asserts the role of CT perfusion in the evaluation of patients with stroke mimics in the emergency room setting.

Background and Purpose: We present three patients with acute ischemic stroke who underwent computed tomography perfusion (CTP) imaging utilizing an Aquilion ONE (Toshiba Medical Systems, Nasu, Japan) 320-dectector row CT scanner using a Singular Value Decomposition Plus (SVD+) algorithm to generate perfusion maps. These MTT maps may prove to be a sensitive and specific predictor of ischemic penumbra (IP) and infarct core (IC). Methods: Patients, who presented with an acute ischemic stroke, received high quality whole-brain CTP scans and a follow up MRI or non-contrast CT (NCCT) scan, and underwent successful pharmacological and/ or interventional reperfusion procedures were selected for evaluation. A neuroradiologist utilizing Vitrea FX 3.1 software reviewed images, and the IC volumes were calculated. Results: A comparison was made between the volumes of infarct core utilizing SVD+ MTT maps and DWI MR sequences or a sub-acute NCCT. There was a correlation between the infarct core volume measured on MTT and final infarct volume on follow up imaging. However due to limitations associated with a small sample size, a statistical correlation cannot be definitively calculated from this data set. Conclusions: Utilization of the SVD+ MTT map may allow for a more accurate assessment of the infarct core and surrounding salvageable tissue as compared to cerebral blood flow/cerebral blood volume (CBF/CBV) mismatch though further studies are required to validate this observation.

Sigma receptors are putative targets for neuroprotection following ischemia; however, little is known on their mechanism of action. One of the key components in the demise of neurons following ischemic injury is the disruption of intracellular calcium homeostasis. Fluorometric calcium imaging was used to examine the effects of sigma receptor activation on changes in intracellular calcium concentrations ([Ca 2+ ] i ) evoked by in vitro ischemia in cultured cortical neurons from embryonic rats. The sigma receptor agonist, 1,3-di- o -tolyl-guanidine (DTG), was shown to depress [Ca 2+ ] i elevations observed in response to ischemia induced by sodium azide and glucose deprivation. Two sigma receptor antagonists, metaphit [1-(1-(3-isothiocyanatophenyl)-cyclohexyl)-piperidine] and BD-1047 ( N -[2–3,4-dichlorophenyl)-ethyl]- N -methyl-2-(dimethylamino)ethylamine), were shown to blunt the ability of DTG to inhibit ischemia-evoked increases in [Ca 2+ ] i , revealing that the effects are mediated by activation of sigma receptors and not via the actions of DTG on nonspecific targets such as N -methyl-d-aspartate receptors. DTG inhibition of ischemia-induced increases in [Ca 2+ ] i was mimicked by the σ-1 receptor-selective agonists, carbetapentane, (+)-pentazocine and PRE-084 [2-(4-morpholinethyl) 1-phenylcyclohexanecarboxylate hydrochloride], but not by the sigma-2-selective agonist, ibogaine, showing that activation of sigma-1 receptors is responsible for the effects. In contrast, DTG, carbetapentane, and ibogaine blocked spontaneous, synchronous calcium transients observed in our preparation at concentrations consistent with sigma receptor-mediated effects, indicating that both sigma-1 and sigma-2 receptors regulate events that affect [Ca 2+ ] i in cortical neurons. Our studies show that activation of sigma receptors can ameliorate [Ca 2+ ] i dysregulation associated with ischemia in cortical neurons and, thus, identify one of the mechanisms by which these receptors may exert their neuroprotective properties.

Object Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant internal carotid artery (ICA) occlusion, and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. The authors report their experience with acute ischemic stroke patients who suffered tandem ICA/MCA (TIM) occlusions and underwent intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial MCA mechanical thrombectomy. Methods In a retrospective analysis of their stroke database (2008–2011), the authors identified 2 patients with TIM occlusion treated with intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy. They examined early neurological improvement defined by a greater than 10-point reduction of National Institutes of Health Stroke Scale (NIHSS) score and an improved modified Rankin Scale (mRS) score at 60 days. Successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2 or 3 was also evaluated. Results In both patients a TICI score of 2b or 3 was achieved, signifying successful recanalization. In addition, both patients had a reduction in the NIHSS score by greater than 10 points and an mRS score of 0 at 60 days. Conclusions Tandem occlusions of the cervical ICA and MCA may be successfully treated using the multimodality approach of intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy.

Objective: MTT map is a sensitive and specific map differentiating ischemic penumbra (IP) from infarct core (IC) in acute stroke. Background We present eight patients with acute ischemic stroke who presented to our emergency department and underwent computed tomography perfusion (CTP) imaging utilizing the Toshiba Aquilion ONE 320-dectector row CT scanner running a Singular Value Decomposition Plus (SVD+) algorithm to generate perfusion maps. Design/Methods: A retrospective analysis of patients who presented with an acute ischemic stroke was performed. Patients receiving a high quality whole-brain CTP scan without evidence of hemorrhage on initial or follow-up CT who additionally underwent follow up MRI with DWI within 48 hours were included. Vitrea FX 3.1 software was utilized by a single, blinded neuroradiologist to process images. At risk territory was defined by the area of delayed perfusion on the time to peak map. The IC volume on the MTT map, as determined by values less than 3 seconds within this at risk territory, was measured on each slice. The total IC volumes were calculated by taking the sum of the IC on individual slices multiplied by the thickness of each slice. Pearson correlation was applied to assess for statistical correlation between IC on CTP and area of restriction on follow up DWI. Results: A comparison was made between the volumes of infarct core utilizing SVD+ MTT maps and DWI MR sequences. There was a significant correlation between infarct core volumes measured on MTT and infarct volumes on follow up DWI (r = 0.79). Conclusions: Although further studies are required to validate this observation, preliminary studies suggest that utilization of the SVD+ MTT map may allow for an accurate assessment of the infarct core and surrounding salvageable tissue. The additional information garnered from accurate interpretation of the SVD+ MTT maps may further guide clinicians in critical decision making during acute ischemic events. Disclosure: Dr. Dababneh has nothing to disclose. Dr. Guerrero has nothing to disclose. Dr. Wilson has nothing to disclose. Dr. Mocco has received personal compensation for activities with Concentric Inc as a consultant. Dr. Bennett has nothing to disclose. Dr. Hoh has received personal compensation for activities with Codman Neurovascular. Dr. Yuzeforich-Khanna has nothing to disclose. Dr. Peters has received personal compensation for activities with Toshiba as a speaker. Dr. Waters has nothing to disclose.