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BackgroundFew studies have explored the association between stroke thrombectomy (ST) volume and hospital accreditation with clinical outcomes.ObjectiveTo assess the association of ST case volume and accreditation status with in-hospital mortality and home discharge disposition using the national Medicare Provider Analysis and Review (MEDPAR) database.MethodsRates of hospital mortality, home discharge disposition, and hospital stay were compared between accredited and non-accredited hospitals using 2017–2018 MEDPAR data. The association of annual ST case volume with mortality and home disposition was determined using Pearson’s correlation. Median rate of mortality and number of ST cases at hospitals within the central quartiles were estimated.ResultsA total of 29 355 cases were performed over 2 years at 847 US centers. Of these, 354 were accredited. There were no significant differences between accredited and non-accredited centers for hospital mortality (14.8% vs 14.5%, p=0.34) and home discharge (12.1% vs 12.0%, p=0.78). A significant positive correlation was observed between thrombectomy volume and home discharge (r=0.88; 95% CI 0.58 to 0.97, p=0.001). A significant negative relationship was found between thrombectomy volume and mortality (r=−0.86; 95% CI −0.97 to −0.49, p=0.002). Within the central quartiles, the median number of ST cases at hospitals with mortality was 24/year, and the median number of ST cases at hospitals with home discharge rate was 23/year.ConclusionA higher volume of ST cases was associated with lower mortality and higher home discharge rate. No significant differences in mortality and discharge disposition were found between accredited and non-accredited hospitals.

BackgroundThere is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT).MethodsThis was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration.ResultsIn the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0–2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0).ConclusionsPrior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO.

Background Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions. Methods This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 and December 2018. The study cohort was divided into 2 groups based on the location of occlusion (proximal vs. distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery, or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale score 0–2. Results A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared with the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; P = 0.03) and a lower rate of successful reperfusion (78% vs. 84%; P = 0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality, or procedure-related complications between the 2 groups. Successful reperfusion, age, and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group. Conclusions Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.

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.

BackgroundThe Woven EndoBridge (WEB) device is approved in the USA for treatment of unruptured wide-neck bifurcation aneurysms. However, the safety and effectiveness of the WEB device in the treatment of ruptured intracranial aneurysms is not clear. We aim to evaluate the perioperative safety and effectiveness of the WEB device in patients with ruptured intracranial aneurysms.MethodsThis retrospective study, conducted at eight centers in the USA, included patients with ruptured intracranial aneurysms treated with the WEB device in the setting of subarachnoid hemorrhage (SAH). Safety outcomes included intraoperative complications such as vessel perforation, thromboembolic events, and postoperative hemorrhagic or thromboembolic complications based on radiologic imaging. The primary effectiveness outcome was adequate (complete and neck remnant) aneurysm occlusion, according to the Raymond–Roy classification.ResultsA total of 91 patients with 94 ruptured intracranial aneurysms were included (mean age 57.7±15.2 years; 68.1% women; 82.9% wide-necked). Aneurysms were located in the anterior communicating artery (42/94, 44.6%), middle cerebral artery (16/94, 17%), and basilar artery (15/94, 16%). Adequate occlusion was achieved in 48.8% (41/84) and 80.0% (40/50) at discharge and last follow-up (mean of 3.4 months), respectively. At discharge, procedural-related morbidity was 3.3% (3/91) and there was no procedure-related mortality. No re-rupture or delayed aneurysm rupture was observed.ConclusionsThis study demonstrates the perioperative safety and effectiveness of the WEB device for the treatment of patients with ruptured intracranial aneurysms in the setting of SAH, with low periprocedural morbidity and mortality. Long-term follow-up is warranted.

BackgroundMechanical thrombectomy (MT) is the standard-of-care treatment for stroke patients with emergent large vessel occlusions. Despite this, little is known about physician decision making regarding MT and prognostic accuracy.MethodsA prospective multicenter cohort study of patients undergoing MT was performed at 11 comprehensive stroke centers. The attending neurointerventionalist completed a preprocedure survey prior to arterial access and identified key decision factors and the most likely radiographic and clinical outcome at 90 days. Post hoc review was subsequently performed to document hospital course and outcome.Results299 patients were enrolled. Good clinical outcome (modified Rankin Scale (mRS) score of 0–2) was obtained in 38% of patients. The most frequently identified factors influencing the decision to proceed with thrombectomy were site of occlusion (81%), National Institutes of Health Stroke Scale score (74%), and perfusion imaging mismatch (43%). Premorbid mRS score determination in the hyperacute setting accurately matched retrospectively collected data from the hospital admission in only 140 patients (46.8%). Physicians correctly predicted the patient’s 90 day mRS tertile (0–2, 3–4, or 5–6) and final modified Thrombolysis in Ischemic Cerebral Infarction score preprocedure in only 44.2% and 44.3% of patients, respectively. Clinicians tended to overestimate the influence of occlusion site and perfusion imaging on outcomes, while underestimating the importance of pre-morbid mRS.ConclusionsThis is the first prospective study to evaluate neurointerventionalists’ ability to accurately predict clinical outcome after MT. Overall, neurointerventionalists performed poorly in prognosticating patient 90 day outcomes, raising ethical questions regarding whether MT should be withheld in patients with emergent large vessel occlusions thought to have a poor prognosis.

BackgroundRecent clinical trials have shown that mechanical thrombectomy is superior to medical management for large vessel occlusion for up to 24 hours from onset. Our objective is to examine the safety and efficacy of thrombectomy beyond the standard of care window.MethodsA retrospective review was undertaken of the multicenter Stroke Thrombectomy and Aneurysm Registry (STAR). We identified patients who underwent mechanical thrombectomy for large vessel occlusion beyond 24 hours. We selected a matched control group from patients who underwent thrombectomy in the 6–24-hour window. We used functional independence at 3 months as our primary outcome measure.ResultsWe identified 121 patients who underwent thrombectomy beyond 24 hours and 1824 in the 6–24-hour window. We selected a 2:1 matched group of patients with thrombectomy 6–24 hours as a comparison group. Patients undergoing thrombectomy beyond 24 hours were less likely to be independent at 90 days (18 (18.8%) vs 73 (34.9%), P=0.005). They had higher odds of mortality at 90 days in the adjusted analysis (OR 2.34, P=0.023). Symptomatic intracerebral hemorrhage and other complications were similar in the two groups. In a multivariate analysis only lower number of attempts was associated with good outcomes (OR 0.27, P=0.022).ConclusionsMechanical thrombectomy beyond 24 hours appears to be safe and tolerable with no more hemorrhages or complications compared with standard of care thrombectomy. Outcomes and mortality in this time window are worse compared with an earlier time window, but the rates of good outcomes may justify this therapy in selected patients.

OBJECTIVETraditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device.METHODSThis study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications.RESULTSA total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2.CONCLUSIONSPulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist’s armamentarium, especially with regard to its off-label use.

BackgroundClot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion.MethodsClot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis.ResultsAmong all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034).ConclusionsClot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy.

To assess the impact of COVID-19 on neurovascular research and deal with the challenges imposed by the pandemic.MethodsA survey-based study focused on randomized controlled trials (RCTs) and single-arm studies for acute ischemic stroke and cerebral aneurysms was developed by a group of senior neurointerventionalists and sent to sites identified through the clinical trials website (https://clinicaltrials.gov/), study sponsors, and physician investigators.ResultsThe survey was sent to 101 institutions, with 65 responding (64%). Stroke RCTs were being conducted at 40 (62%) sites, aneurysm RCTs at 22 (34%) sites, stroke single-arm studies at 37 (57%) sites, and aneurysm single-arm studies at 43 (66%) sites. Following COVID-19, enrollment was suspended at 51 (78%) sites—completely at 21 (32%) and partially at 30 (46%) sites. Missed trial-related clinics and imaging follow-ups and protocol deviations were reported by 27 (42%), 24 (37%), and 27 (42%) sites, respectively. Negative reimbursements were reported at 17 (26%) sites. The majority of sites, 49 (75%), had put new trials on hold. Of the coordinators, 41 (63%) worked from home and 20 (31%) reported a personal financial impact. Remote consent was possible for some studies at 34 (52%) sites and for all studies at 5 (8%) sites. At sites with suspended trials (n=51), endovascular treatment without enrollment occurred at 31 (61%) sites for stroke and 23 (45%) sites for aneurysms. A total of 277 patients with acute ischemic stroke and 184 with cerebral aneurysms were treated without consideration for trial enrollment.ConclusionWidespread disruption of neuroendovascular trials occurred because of COVID-19. As sites resume clinical research, steps to mitigate similar challenges in the future should be considered.

BackgroundInfection from the SARS-CoV-2 virus has led to the COVID-19 pandemic. Given the large number of patients affected, healthcare personnel and facility resources are stretched to the limit; however, the need for urgent and emergent neurosurgical care continues. This article describes best practices when performing neurosurgical procedures on patients with COVID-19 based on multi-institutional experiences.MethodsWe assembled neurosurgical practitioners from 13 different health systems from across the USA, including those in hot spots, to describe their practices in managing neurosurgical emergencies within the COVID-19 environment.ResultsPatients presenting with neurosurgical emergencies should be considered as persons under investigation (PUI) and thus maximal personal protective equipment (PPE) should be donned during interaction and transfer. Intubations and extubations should be done with only anesthesia staff donning maximal PPE in a negative pressure environment. Operating room (OR) staff should enter the room once the air has been cleared of particulate matter. Certain OR suites should be designated as covid ORs, thus allowing for all neurosurgical cases on covid/PUI patients to be performed in these rooms, which will require a terminal clean post procedure. Each COVID OR suite should be attached to an anteroom which is a negative pressure room with a HEPA filter, thus allowing for donning and doffing of PPE without risking contamination of clean areas.ConclusionBased on a multi-institutional collaborative effort, we describe best practices when providing neurosurgical treatment for patients with COVID-19 in order to optimize clinical care and minimize the exposure of patients and staff.

BackgroundFew studies have examined the trends in clinical and economic outcomes of patients with acute ischemic stroke (AIS) who receive endovascular therapy (ET) in the real-world setting.ObjectiveTo evaluate characteristics and trends in clinical and economic outcomes among commercially insured patients with AIS undergoing ET between 2011 and 2017.MethodsPatients with AIS undergoing ET from January 1, 2011 to June 30, 2017 were identified from administrative claims contained in the IBM MarketScan Commercial and Medicare Supplemental databases. The Mann–Kendall trend test was performed to examine clinical and economic trends.Between 2011 and 2017, 3411 patients (mean age 62.85±15 years) with a primary diagnosis of AIS underwent ET (coverage: Commercial 59%, n=2008; Medicare Supplemental 41%, n=1403). In the Commercial cohort, discharge to home increased significantly (from 29.54% to 39.18%, pConclusionsAlthough with some variation across the samples studied, outcomes including discharge to home, length of stay, readmission, and total cost associated with endovascular stroke therapy seemed to have improved between 2011 and 2017. Index admission cost remained unchanged.

BackgroundA study was undertaken to determine the incidence of acute ischemic stroke (AIS) and strokes related to large (LVO) and medium (MVO) vessel occlusions, and to estimate annual mechanical thrombectomy (MT) volume, past trends and future growth.MethodsA population-based analysis was performed to estimate the rate of AIS, LVOs (internal carotid artery terminus, M1 branch of the middle cerebral artery, basilar artery) and MVOs (M2 and M3 branches of the middle cerebral artery, anterior and posterior cerebral arteries). MT estimates were determined from multiple governmental data sources. Annual US numbers were adjusted for population growth.ResultsThe incidence of AIS is estimated at 216 (95% CI 199 to 238)/100 000 persons/year or 718 191 (95% CI 661 483 to 791 121) AIS/year in the USA. A vascular occlusion was observed in 21% of patients with AIS (95% CI 15 to 29). The rate of LVO was 24/100 000 persons/year (95% CI 19 to 31) or 80 075 (95% CI 62 457 to 104 375) LVOs/year, and the rate of MVO was 20/100 000 persons/year or 65 798 (95% CI 45 555 to 95 110) MVOs/year. MT estimates for 2021 are 39 164 procedures with a flattening of the growth curve from 2019 (9%, 2020–2021; 4%, 2019–2020) as opposed to initial steep growth from 2015 to 2018. Current MT procedures represent 5% of all AIS, 27% of all vascular occlusions (LVO+MVO) and 38% of all LVO and M2 occlusions. The current trajectory indicates a future growth of 5–10%/year for the next several years.ConclusionA decline in MT growth is observed. The incidence of LVO+MVO is estimated at 44/100 000 persons/year or almost 144 000 large and medium vessel strokes annually. Of these, currently an estimated 27% undergo an MT procedure, indicating an opportunity for growth. Further expansion may require focusing on the elderly, medium vessel strokes and workflow efficiencies from diagnosis to treatment.

Introduction Limited data is available about the outcomes of mechanical thrombectomy (MT) in stroke patients presenting with a large core infarct. We aim to investigate the safety and efficacy of MT in patients with large vessel occlusion and Alberta Stroke Program Early CT Score (ASPECTS) of 2-5. Methods Data from Stroke Thrombectomy and Aneurysm Registry (STAR), which combined the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia, was interrogated. We identified thrombectomy patients presenting with an occlusion in the Internal carotid artery (ICA) or M1 segment of the middle cerebral artery (MCA). Multivariable regression analysis was performed to assess factors associated with favorable 90-day outcome (modified Rankin scale 0-3), including interaction terms between ASPECTS 2-5 and receiving MT in the extended window (≥ 6 hours from symptom-onset). Results Among MT patients who presented with ICA or M1 occlusion, 2132 had ASPECTS≥6 and 213 patients had ASPECTS 2-5. Patients in the low ASPECTS group were younger (70 vs. 72 years old, P=0.003) and more likely to present with an ICA occlusion (47.9% vs. 28.8%, P Conclusion More than one in three patients presenting with ASPECTS (2-5) may achieve favorable 90-day functional outcome following MT. Favorable outcome was 4 times higher in low ASPECTS patients who had successful recanalization. The effect of low ASPECTS on 90-day outcome did not differ in patients presenting in the early versus extended MT window. Disclosures E. Almallouhi: None. S. Al Kasab: None. Z. Hubbard: None. G. Porto: None. A. Alawieh: None. R. Chalhoub: None. E. Bass: None. P. Jabbour: None. R. Starke: None. S. Wolfe: None. A. Arthur: None. I. Maier: None. J. Grossberg: None. A. Rai: None. M. Park: None. J. Mascitelli: None. M. Psychogios: None. R. De Leacy: None. D. Raper: None. T. Dumont: None. M. Levitt: None. A. Polifka: None. J. Osbun: None. R. Crosa: None. J. Kim: None. W. Casagrande: None. M. Mokin: None. C. Matouk: None. A. Shaban: None. I. Fragata: None. A. Yoo: None. A. Spiotta: 1; C; Stryker, Penumbra, and Medtronic. 2; C; Penumbra, Stryker, Cerenovus, Terumo.

Introduction Chronic subdural hematoma (cSDH) is one of the most common neurosurgical diseases with an incidence of 1-5.3 cases per 100,000 that increases significantly with age. When symptomatic, these lesions are often treated by surgery, an approach which does not directly address the underlying pathophysiology of chronic inflammation and neovascularization of the dura and has a high incidence of recurrence. Middle meningeal artery (MMA) embolization has emerged as a potential minimally invasive endovascular treatment option that may substitute for surgery or serve as an adjunct. TRUFILL n-BCA is potentially well suited as a liquid embolic in this procedure given that it is non-caustic, rapidly deployed, and able to be injected in a highly targeted fashion. Here we present the protocol for a randomized clinical trial to evaluate the safety and effectiveness of n-BCA embolization of the MMA for the treatment of cSDH. Methods This investigational trial is a prospective, multi-center, open-label, randomized controlled study in which up to 376 subjects will be randomized to receive standard of care (SOC) alone or SOC and TRUFILL n-BCA MMA embolization for the treatment of cSDH. The study is designed to evaluate the effectiveness and safety of MMA in two cohorts - a surgical cohort and a non-surgical cohort. Results Study EndpointsThe primary study effectiveness endpoint is the incidence of residual or re-accumulation of the cSDH (>10 mm) at 6 months as assessed by an independent core laboratory OR re-operation or surgical procedure on the hematoma within 6 months post randomization. Secondary effectiveness endpoints include mean reduction of hematoma volume at 3, 6 and 12 months compared to baseline, reduction > 50% in hematoma volume at 3, 6 and 12 months as well as others. Secondary safety endpoints include death, stroke, myocardial infarction or thromboembolic complications within 3, 6 and 12 months as well as others. Secondary health economics endpoints include hospital days, intensive care unit days, and change in the EQ-5D-5L score at discharge and 6 months compared to baseline. Conclusion Middle meningeal artery embolization with n-BCA is an emerging treatment strategy for cSDH. An appropriately powered trial like the MEMBRANE Study will provide high level evidence on the potential safety and efficacy of this treatment paradigm. Disclosures C. Kellner: 1; C; Penumbra, Siemens, Cerebrotech, Viz.AI, Minnetronix. 4; C; Metis Innovative. F. Al-Mufti: None. R. Gupta: None. B. Jankowitz: None. R. Starke: None. A. Rai: None.

BackgroundAtrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT.MethodsThis international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared.Results6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis.ConclusionIn this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers.

IntroductionThe endovascular stent-assisted coiling approach for the treatment of cerebral aneurysms is evolving rapidly with the availability of new stent devices. It remains unknown how each type of stent affects the safety and efficacy of the stent-coiling procedure.MethodsThis study compared the outcomes of endovascular coiling of cerebral aneurysms using Neuroform (NEU), Enterprise (EP), and Low-profile Visualized Intraluminal Support (LVIS) stents. Patient characteristics, treatment details and angiographic results using the Raymond–Roy grade scale (RRGS), and procedural complications were analyzed in our study.ResultsOur study included 659 patients with 670 cerebral aneurysms treated with stent-assisted coiling (NEU, n=182; EP, n=158; LVIS, n=330) that were retrospectively collected from six academic centers. Patient characteristics included mean age 56.3±12.1 years old, female prevalence 73.9%, and aneurysm rupture on initial presentation of 18.8%. We found differences in complete occlusion on baseline imaging, defined as RRGS I, among the three stents: LVIS 64.4%, 210/326; NEU 56.2%, 95/169; EP 47.6%, 68/143; P=0.008. The difference of complete occlusion on 10.5 months (mean) and 8 months (median) angiographic follow-up remained significant: LVIS 84%, 251/299; NEU 78%, 117/150; EP 67%, 83/123; P=0.004. There were 7% (47/670) intra-procedural complications and 11.5% (73/632) post-procedural-related complications in our cohort. Furthermore, procedure-related complications were higher in the braided-stents vs laser-cut, P=0.002.ConclusionsThere was a great variability in techniques and choice of stent type for stent-assisted coiling among the participating centers. The type of stent was associated with immediate and long-term angiographic outcomes. Randomized prospective trials comparing the different types of stents are warranted.

IntroductionAccurate estimation of the incidence of large vessel occlusion (LVO) is critical for planning stroke systems of care and approximating workforce requirements. This systematic review aimed to estimate the prevalence of LVO among patients with acute ischemic stroke (AIS), with emphasis on definitions and methods used by different studies.MethodsA systematic literature review was performed to search for articles on the prevalence of LVO and AIS. All articles describing the frequency of LVO frequency among AIS patients were included. Studies without consecutive recruitment or confirmation of LVO with CT angiography or MR angiography were excluded. Heterogeneity of the studies was assessed; meta-regression was performed to estimate the effect of LVO definition and study methods on LVO prevalence.Results18 articles met the inclusion criteria: 5 studies presented population based estimates; 13 provided single hospital experiences (5 prospective, 8 retrospective). The AIS denominator (number of all AIS) from which LVO rates were generated was variable. Nine different definitions were used, based on occlusion site. Significant heterogeneity existed among the studies (I2=99%, PConclusionThe heterogeneity of LVO estimates was remarkably high. The method of AIS denominator determination was the most significant predictor of LVO estimates. Studies with a standardized LVO definition and methods of AIS estimation are necessary to estimate the true prevalence of LVO among patients with AIS.

BackgroundThrombectomy is an efficacious treatment for acute ischemic stroke (AIS). However, relatively few studies to date have specifically examined the impact and clinical implications of age on outcomes for thrombectomy in anterior AIS.ObjectiveTo provide a snapshot of patient metrics and outcomes with respect to age following thrombectomy for anterior AIS to supplement the current body of data for predictors of clinical outcomes in a real-world setting.MethodsData were collected for 20 consecutive patients with AIS treated with thrombectomy at 15 high-volume stroke centers across North America between 2015 and 2016. Patients with anterior occlusions were dichotomized based on whether they were older or younger than 80 years. Ordinal logistic regression analyzed how clinical variables impacted disability using 90-day modified Rankin Scale (mRS) scores.ResultsAdequate revascularization (TICI ≥2B) was achieved in 92.3% of patients aged ConclusionThis analysis affirms age is a significant determinant of 90-day mRS scores following thrombectomy for large vessel anterior AIS. Further investigation into risks faced by elderly patients during thrombectomy may provide actionable information to help refine patient selection and improve outcomes.

BackgroundPolymer coating embolism due to vascular medical device use is an increasingly recognized iatrogenic complication. This phenomenon has been linked with various adverse effects including neuroinflammation, acute ischemic stroke, cerebral hemorrhage, and death. Notably, procedure- and device-specific risks of this complication are poorly investigated. In this study, we evaluate the detectable frequency of intra-arterial polymer coating delamination among patients who underwent endovascular thrombectomy for treatment of acute ischemic stroke due to large vessel occlusion.MethodsNinety-two cerebral thrombectomy specimens were retrospectively analyzed for the presence of polymer coating particulates. Histologic findings were correlated with demographic and procedural details and patient outcomes.ResultsEvidence of polymer coating deposition was found in 30 of 92 extracted thrombi (33%). No correlation between intrathrombus polymer deposition and use of a specific thrombectomy device such as a stent retriever, aspiration catheter, or guide catheter was found. However, heterogeneous patterns of device use suggest a number of culprit devices. A trend toward longer procedure times and multiple thrombectomy passes was noted in positive cases. Intrathrombus polymer deposition was not associated with adverse clinical outcomes as measured by the 90-day modified Rankin Scale (mRS); however, small sample size and follow-up intervals limit interpretation. Ninety-day outcomes based on mRS may not fully capture the clinical effects of acute and/or delayed intracerebral polymer complications.ConclusionIn light of documented adverse neurologic effects, the frequency of intrathrombus polymer particulates indicates the need for consensus testing methods and large-scale long-term prospective clinical device trials, with inclusion of relevant endpoints to better assess biomaterial and device risks to patients.

Summary Background Stent retriever thrombectomy of large-vessel occlusion results in better outcomes than medical therapy alone. Alternative thrombectomy strategies, particularly a direct aspiration as first pass technique, while promising, have not been rigorously assessed for clinical efficacy in randomised trials. We designed COMPASS to assess whether patients treated with aspiration as first pass have non-inferior functional outcomes to those treated with a stent retriever as first line. Methods We did a multicentre, randomised, open label, blinded outcome, core lab adjudicated non-inferiority trial at 15 sites (ten hospitals and four specialty clinics in the USA and one hospital in Canada). Eligible participants were patients presenting with acute ischaemic stroke from anterior circulation large-vessel occlusion within 6 h of onset and an Alberta Stroke Program Early CT Score of greater than 6. We randomly assigned participants (1:1) via a central web-based system without stratification to either direct aspiration first pass or stent retriever first line thrombectomy. Those assessing primary outcomes via clinical examinations were masked to group assignment as they were not involved in the procedures. Physicians were allowed to use adjunctive technology as was consistent with their standard of care. The null hypothesis for this study was that patients treated with aspiration as first pass achieve inferior outcomes compared with those treated with a stent retriever first line approach. The primary outcome was non-inferiority of clinical functional outcome at 90 days as measured by the percentage of patients achieving a modified Rankin Scale score of 0–2, analysed by intent to treat; non-inferiority was established with a margin of 0·15. All randomly assigned patients were included in the safety analyses. This trial is registered at ClinicalTrials.gov, number: NCT02466893. Findings Between June 1, 2015, and July 5, 2017, we assigned 270 patients to treatment: 134 to aspiration first pass and 136 to stent retriever first line. A modified Rankin score of 0–2 at 90 days was achieved by 69 patients (52%; 95% CI 43·8–60·3) in the aspiration group and 67 patients (50%; 41·6–57·4) in the stent retriever group, showing that aspiration as first pass was non-inferior to stent retriever first line (p non-inferiority =0·0014). Intracranial haemorrhage occurred in 48 (36%) of 134 in the aspiration first pass group, and 46 (34%) of 135 in the stent retriever first line group. All-cause mortality at 3 months occurred in 30 patients (22%) in both groups. Interpretation A direct aspiration as first pass thrombectomy conferred non-inferior functional outcome at 90 days compared with stent retriever first line thrombectomy. This study supports the use of direct aspiration as an alternative to stent retriever as first-line therapy for stroke thrombectomy. Funding Penumbra.

BackgroundThe efficacy of endovascular thrombectomy (ET) for acute ischemic stroke (AIS) in octogenarians is still controversial.ObjectiveTo evaluate, using a large multicenter cohort of patients, outcomes after ET in octogenarians compared with younger patients.MethodsData from prospectively maintained databases of patients undergoing ET for AIS at seven US-based comprehensive stroke centers between January 2013 and January 2018 were reviewed. Demographic, procedural, and outcome variables were collected. Outcomes included 90-day modified Rankin Scale (mRS) score, postprocedural National Institutes of Health Stroke Scale score, postprocedural hemorrhage, and mortality. Univariate and multivariate analyses were performed to assess the independent effect of age ≥80 on outcome measures. Subgroup analyses were also performed based on location of stroke, success of recanalization, or ET technique used.ResultsRates of functional independence (mRS score 0–2) after ET in elderly patients were significantly lower than for younger counterparts. Age ≥80 was independently associated with increased mortality and poor outcome. Age ≥80 showed an independent negative prognostic effect on outcome even when patients were divided according to thrombectomy technique, location of stroke, or success of recanalization. Age ≥80 independently predicted higher rate of postprocedural hemorrhage, but not success of recanalization. Baseline deficit and number of reperfusion attempts, but not Thrombolysis in Cerebral Infarction score were associated with lower odds of good outcome.ConclusionThe large effect size of ET on AIS outcomes is significantly diminished in the elderly population when using comparable selection criteria to those used in younger counterparts. This raises concerns about the risk–benefit ratio and the cost-effectiveness of performing this procedure in the elderly before optimizing patient selection.

Introduction: Patients with poor baseline images were excluded from most clinical trials so the data about whether these patients could benefit from MT remains unknown. In this study, we aim to investigate the safety and efficacy of MT in patients with large vessel occlusion (LVO) and large core infarct (LCI). Methods: The Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We included thrombectomy patients presenting with LVO within 24 hours and with a LCI as defined by Alberta Stroke Program Early CT Score (ASPECTS) < 6. Patients presenting within 6 hours of last known normal (LKN) were considered in the early window and patients presenting after 6 hours were considered in the late window. 90-day outcomes were assessed. We used a logistic regression model to assess the factors associated with good 90-day outcome in patients in the early and late windows. Results: 144 patients were included in this study (table). Median age was 69 and 92 (64%) patients were treated in the early MT window. ICA was the most common site of occlusion (48.6%) and ADAPT was used in 34.7%. Admission NIHSS was 17.5. Successful recanalization (TICI>2b) was achieved in 84.7% and median procedure time was 54 minutes. sICH hemorrhage was observed in 22 (15.3%). Median mRS was 4 at 90 days. Favorable outcome was observed in 41 patients (28.5%) and mortality occurred in in 59 (41%). There was no difference in 90-day functional outcome between patients in early and late windows. In patients presenting in the early window, age (aOR=0.905, p=0.0002) and baseline NIHSS (aOR=0.909, p=0.0423) were independently associated with 90-day outcome. In patients presenting in the late window, only age (aOR=0.934, p=0.0069) was independently associated with good outcome. Conclusion: More than one in four patients presenting with ASPECTS

BackgroundThe PerfusiOn imaging Selection of Ischemic sTroke patIents for endoVascular thErapy (POSITIVE) trial was designed to evaluate functional outcome in patients with emergent large vessel occlusion (ELVO) presenting within 0–12 hours with pre-specified bifurcated arms of early and late window presentation, who were selected for endovascular thrombectomy with non-vendor specific commercially available perfusion imaging software. Recent trials demonstrating the benefit of thrombectomy up to 16–24 hours following ELVO removed equipoise to randomize late window ELVO patients and therefore the trial was halted.MethodsUp to 200 patients were to be enrolled in this FDA-cleared, prospective, randomized, multicenter international trial to compare thrombectomy and best medical management in patients with ELVO ineligible for or refractory to treatment with IV tissue plasminogen activator (IV-tPA) selected with perfusion imaging and presenting within 0–12 hours of last seen normal. The primary outcome was 90-day clinical outcome as measured by the raw modified Rankin Scale (mRS) with scores 5 and 6 collapsed (mRS shift analysis).ResultsThe POSITIVE trial suspended enrollment with the release of results from the DAWN trial and was stopped after the release of the DEFUSE 3 trial results. Thirty-three patients were enrolled (21 for medical management and 12 for thrombectomy). Twelve of the 33 patients were enrolled in the 6–12 hour cohort. Despite the early cessation, the primary outcome demonstrated statistically significant superior clinical outcomes for patients treated with thrombectomy (P=0.0060). The overall proportion of patients achieving an mRS score of 0–2 was 75% in the thrombectomy cohort and 43% in the medical management cohort (OR 4.00, 95% CI 0.84 to 19.2).ConclusionPOSITIVE supports the already established practice of delayed thrombectomy for appropriately selected patients presenting within 0–12 hours selected by perfusion imaging from any vendor. The results of the POSITIVE trial are consistent with other thrombectomy trials. The statistically significant effect on functional improvement, despite the small number of patients, reinforces the robust benefits of thrombectomy.Clinical trial registrationNCT01852201

International audience; Abstract BACKGROUND Randomized controlled trials evaluating mechanical thrombectomy (MT) for acute ischemic stroke predominantly studied anterior circulation patients. Both procedural and clinical predictors of outcome in posterior circulation patients have not been evaluated in large cohort studies. OBJECTIVE To investigate technical and clinical predictors of functional independence after posterior circulation MT while comparing different frontline thrombectomy techniques. METHODS In a retrospective multicenter international study of 3045 patients undergoing MT for stroke between 06/2014 and 12/2018, 345 patients had posterior circulation strokes. MT was performed using aspiration, stent retriever, or combined approach. Functional outcomes were assessed using the 90-d modified Rankin score dichotomized into good (0-2) and poor outcomes (3-6). RESULTS We included 2700 patients with anterior circulation and 345 patients with posterior circulation strokes. Posterior patients (age: 60 ± 14, 46% females) presented with mainly basilar occlusion (80%) and were treated using contact aspiration or ADAPT (39%), stent retriever (31%) or combined approach (19%). Compared to anterior strokes, posterior strokes had delayed treatment (500 vs 340 min, P

BackgroundThe coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT).MethodsWe used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020).ResultsWe identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, PConclusionThe COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.

Introduction Mechanical Thrombectomy (MT) is the standard of care for patients presenting with emergent large vessel occlusion (ELVO) with salvageable tissue. A subgroup of ELVO is refractory to reperfusion due to underlying intracranial atherosclerosis (ICAS), often requiring rescue therapy with balloon angioplasty, stenting or both. Whether such rescue therapy is safe and effective remains to be established. The purpose of this study is to investigate the safety, efficacy, and long-term outcomes of MT for ELVO related ICAS. Methods We queried the databases of 11 thrombectomy-capable centers in the US and Europe included in STAR (Stroke Thrombectomy and Aneurysm Registry). In this analysis, we included patients who underwent rescue therapy (balloon angioplasty and/or stenting) in the setting of ELVO due to underlying ICAS. A matched sample was produced by matching on the variables of age, admission NIHSS, and location of the occlusion. Results Out of 2827 thrombectomy patients included in STAR at the time of this analysis, 190 patients required rescue therapy for ELVO with underlying ICAS. Balloon angioplasty was performed on 116 patients, and 113 patients had intracranial stenting. On multivariate analysis, after controlling for age, sex, race, hypertension, diabetes, prior stroke, NIHSS on admission and location of occlusion; compared to angioplasty alone, or stenting alone, combination therapy with angioplasty and stenting was associated with higher odds of favorable long-term functional outcome (mRS 0–2) (OR 4.404, 95% CI 1.318–9.712; P=0.021).in the matched analysis, 161 rescue therapy patients matched to a similar number of controls. There was no difference in age, race, sex, rate of IV tPA administration, ASPECTS score, or onset to groin time. Successful first attempt rate was lower (52% vs. 22%, p=0.001) and procedural time was longer in the rescue therapy group (47 min vs. 31 min, p≤0.001). There was no difference in symptomatic intracranial hemorrhage (7.5% vs. 5.6%, p=0.49), or favorable long term functional outcome (modified Rankin scale 0–2) (42.2% vs. 50.9%, p=0.118) between patients in the rescue therapy and control groups. Conclusion In patients with ELVO with underlying ICAS requiring rescue therapy, despite longer procedural time and lower rate of first pass revascularization, rescue therapy appears to be safe with similar rate of favorable long-term functional outcomes compared to patients with large vessel occlusion from embolic source. Disclosures S. Al Kasab: None. E. Almallouhi: None. I. Maier: None. A. Arthur: None. J. Kim: None. R. De Leacy: None. A. Rai: None. S. Keyrouz: None. K. Fargen: None. T. Dumont: None. P. Kan: None. R. Starke: None. A. Spiotta: None.

Introduction Acute ischemic strokes (AIS) due to large vessel occlusion (LVO) occur more frequently in elderly patients, resulting in more severe symptoms and worse outcomes after treatment. The purpose of this study is to evaluate the age-dependent outcomes of Endovascular Thrombectomy (ET) in the real world, using a large dataset from the Stroke Thrombectomy and Aneurysm Registry (STAR). Methods All patients undergoing endovascular thrombectomy for AIS at 12 comprehensive stroke centers between January 2013 and December 2018 were included. Data were retrospectively collected by reviewing patient charts and procedure notes. The primary endpoint was the modified Rankin Score (mRS) at 90-days after the procedure, which was dichotomized into good outcome (mRS 0–2) or poor outcome (mRS 3–6). Results Out of the 3850 patients that underwent mechanical thrombectomy, 2,827 patients (mean age 69±14, 49% female) had 90-day follow-up and were included in this study. When adjusting for confounding variables using multivariate logistic regressions, increased age was found to be an independent predictor of poor outcome (OR=1.4, p Conclusion Higher age is an independent predictor of worse outcome and increased mortality in patients undergoing ET for AIS. Baseline deficits, ASPECT score, and number of attempts, but not complete revascularization rates, were associated with better outcomes in elderly patients. Our findings underline the need for further refinement of selection criteria for elderly patients being considered for ET. Disclosures R. Chalhoub: None. A. Alawieh: None. S. Kasab: None. D. Pullmann: None. A. Arthur: None. J. Kim: None. R. De Leacy: None. M. Psychogios: None. I. Maier: 6; C; Microvention, Cerenovus. A. Rai: 6; C; Stryker Neurovascular, Microvention, Cerenovus. S. Keyrouz: 6; C; PORTOLA. K. Fargen: 6; C; Cerebrotech Medical. R. Starke: 1; C; NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, BEE Aneurysm Foundation, NIH. 6; C; Penumbra, Medtronic, Cerenovus, InNeuroCo, Abbott. A. Spiotta: 1; C; Penumbra. 6; C; Penumbra, Cerenovus.

Introduction: Aspiration thrombectomy using the ADAPT technique has been shown to have similar efficacy to stent retriever thrombectomy (SRT) in randomized trials of proximal large vessel occlusions. In this work, we investigated the differences in technical and clinical outcomes between ADAPT and SRT for distal vessel occlusions from the Stroke Thrombectomy and Aneurysm Registry (STAR). Methods: Patients undergoing thrombectomy for acute ischemic stroke at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Data was collected retrospectively from patient charts, procedure notes, and patient follow-up in neurology clinics for patients with isolated distal artery occlusion including MCA2, MCA3/4, ACA1/2, and PCA2/3. Clinical endpoint was the modified Rankin score (mRS) at 90-days, and technical outcomes were procedure time, total attempts, and mTICI scores. Results: A total of 464 patients (mean age 69±13.5 years) were treated with ADAPT (56%) or SRT (44%) for distal occlusions during the study period. Patients in the ADPAT group were mainly treated using 3MAX (36%), 4MAX (21%), ACE68/64 (20%), 5MAX/ACE (12%). SRT group included the use of Trevo (50%), Solitaire (44%), or both (5%). There were no significant differences in rates of good outcomes or successful recanalization between ADAPT and SRT groups on multivariate logistic regression analysis controlling for significant confounding variables (p>0.1). Use of SRT in distal occlusions was an independent predictor of longer procedure times compared to ADAPT on linear regression (coefficient=23, p Conclusions: Both SRT and ADAPT thrombectomy lead to comparable rates of favorable outcome for distal vessel occlusion. SRT requires longer procedures and may be associated with higher rates of hemorrhage. Further randomized trials are needed to confirm whether either techniques may provide a better safety or efficacy profile in distal vessel occlusions.

Introduction: Clinical trials have proven the safety and efficacy of mechanical thrombectomy (MT) with intravenous alteplase (tPA) compared to tPA alone in patients presenting with large vessel occlusion (LVO). The impact of tPA prior to MT on procedural metrics, successful revascularization, symptomatic hemorrhage and long-term functional outcome has not been established from large scale real-world studies. In this study we evaluate the impact of tPA prior to MT on procedural times, immediate and long-term outcomes. Methods: The STAR registry combined prospectively maintained databases of 11 thrombectomy-capable stroke centers in the US, Europe and Asia. Patients who received mechanical thrombectomy with or without intravenous tPA prior to MT were included in these analyses. Baseline characteristics, procedural time, successful revascularization (TICI ≥ 2B), symptomatic intracranial hemorrhage (PH2), and long-term functional outcomes were compared between the two groups. Results: Total of 1869 patients were included in this analysis. Of those, 907 received tPA prior to MT. Baseline features and outcomes are summarized in table 1. There were more white patients in the non-tPA group, and more patients in this group had atrial fibrillation and hyperlipidemia; otherwise there were no differences in baseline features between the two groups. Median NIHSS on admission was 16 in both groups, median ASPECTS was 9 in the tPA group versus 8 in the non-tPA group, p=0.208. Patients in the tPA group had higher rate of successful revascularization, lower number of revascularizations attempts and were more likely to achieve excellent long-term functional outcome. There was no difference in procedural time, rate of symptomatic hemorrhage or length of hospital stay. Conclusion: Bridging therapy with intravenous tPA prior to mechanical thrombectomy may facilitate MT and yield to better long-term functional outcome.

Background: Standard mechanical thrombectomy (MT) techniques utilized include aspiration thrombectomy (ADAPT), stent retriever (SR), and a combination of both (Solumbra). Many studies compare outcomes between ADAPT and SR; however, there has yet to be a large multicenter investigation comparing ADAPT and SR to Solumbra. Methods: All patients from the participating STAR collaboration who underwent MT from 2015-2019 were included. Patients were analyzed by first MT technique utilized (ADAPT, SR, or Solumbra). Univariable and multivariable linear regression was utilized to analyze the MT technique association to number of thrombectomy attempts and procedure time. Univariable and multivariable logistic regression was utilized to determine the association between MT technique and the following outcomes: recanalization, symptomatic hemorrhage, 90-day functional independence, or 90-day mortality. P value less than 0.5 was considered significant. Results: A total of 2515 MT for stroke were identified: 1155 (46%) ADAPT, 735 (29%) SR, 625 (25%) Solumbra. Patients who received Solumbra MT were older (p Conclusion: Compared to standard ADAPT and SR thrombectomy, the Solumbra technique for MT is a longer procedure that results in an increased likelihood of hemorrhage and 90-day mortality.

Introduction: Recently completed randomized controlled trials comparing aspiration thrombectomy (ADAPT) to stent retriever thrombectomy (SRT) demonstrated similar clinical outcomes, but faster thrombectomy procedure time in the ADAPT group. This study evaluates the difference in technical outcomes between ADAPT and SRT combined with balloon-guide catheters (BGC). Methods: Patients undergoing thrombectomy for acute ischemic stroke at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Data was collected retrospectively from patient charts, procedure notes, and patient follow-up in neurology clinics. Clinical endpoint was the modified Rankin score (mRS) at 90-days, and technical outcomes were procedure time, total attempts, and mTICI scores. Results: The study included 2,016 patients (mean age 69±15) who underwent stroke thrombectomy using ADAPT (46%), SRT (46%), or SRT+BGC (8%). Similar baseline characteristics were observed between the three groups, and no significant difference in mRS scores at 90-days between the three groups in univariate and multivariate analyses. Thrombectomy performed using SRT+BGC required significantly shorter procedure time compared to SRT (35 vs 61 min, p0.1). However, use of SRT+BGC required significantly lower number of aspiration attempts compared to ADAPT (median 1 vs. 2, p Conclusions: This study shows that although ADAPT allows for faster procedure time compared to SRT, the use of BGC in SRT allows for a comparable procedure time to ADAPT with similar overall rates of favorable outcome, complications and hemorrhage. Mortality was higher with the use of BGC compared to ADAPT.

Introduction: Radiological hemorrhagic transformation (rHT) and symptomatic intracranial hemorrhage (sICH) remain a major complication of mechanical thrombectomy (MT) in acute stroke. Our aim is to identify independent predictors of rHT and sICH. Methods: A retrospective multicenter international study across the US and Europe included 2499 patients, 18 years or older, who underwent EVT for acute stroke from 2015-2019. rHT is defined as any intracranial hemorrhage post MT and subgrouped per ECASS II as petechial (HI), parenchymal hematoma without (PH1) and with mass effect (PH2) and subarachnoid hemorrhage (SAH). sICH was defined as presence of PH2 or SAH. Functional outcomes were described using the 90-day modified Rankin score (mRS) as “good” 0-2 or “poor” 3-6. Multivariable logistic regression model was used to identify predictors of rHT and sICH. Results: 600 (24%) had rHT and 145 (5.8%) had sICH. On multivariable regression model, independent predictors for both rHT and sICH were higher admission NIHSS (OR 1.03, p Conclusion: Compared to posterior circulation, anterior circulation strokes have higher rates of rHT and sICH. Baseline hyperlipidemia is protective for rHT or sICH post MT and this association needs further study. Clinical severity of stroke, poor ASPECTS on admission and higher thrombectomy attempts are associated with higher rates of rHT or sICH. Both rHT and sICH are independently associated with poor functional outcomes.

BackgroundAtrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT).ObjectiveTo determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT.MethodsWe performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.ResultsAF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (pConclusionsIn patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

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.

Background The management of intracranial aneurysm (IA) is challenging. Clinicians often rely on varied and intuitively disparate ways of evaluating rupture risk that may only partially take into account complex hemodynamic and morphologic factors. We developed a prototype of a clinically oriented, streamlined, computational platform, AView, for rapid assessment of hemodynamics and morphometrics in clinical settings. To show the potential clinical utility of AView, we report our initial multicenter experience highlighting the possible advantages of morphologic and hemodynamic analysis of IAs. Methods AView software was deployed across 8 medical centers (6 in the United States, 2 in Japan). Eight clinicians were trained and used the AView software between September 2012 and January 2013. Results We present 12 illustrative cases that show the potential clinical utility of AView. For all, morphology and hemodynamics, flow visualization, and rupture resemblance score (a surrogate for rupture risk) were provided. In 3 cases, AView could confirm the clinicians' decision to treat; in 3 cases, it could suggest which aneurysms may be at greater risk among multiple aneurysms; in 5 cases, AView could provide additional information for use during treatment decisions for ambiguous situations. In one stent-assisted coiling case, flow visualization predicted that the intuitive choice for stent placement could have resulted in sacrifice of an anterior cerebral artery due to blockage by coils and led clinicians to reconsider treatment plans. Conclusions AView has the potential to confirm decisions to treat IAs, suggest which among multiple aneurysms to treat, and guide treatment decisions. Furthermore, the flow visualization it affords can inform aneurysm treatment planning and potentially avoid poor outcomes.

BackgroundM2 occlusions may result in poor outcomes and potentially benefit from endovascular therapy. Data on the rate of M2 strokes is lacking.MethodologyPatients with acute ischemic stroke discharged over a period of 3 years from a tertiary level hospital in the ‘stroke belt’ were evaluated for M2 occlusions on baseline vascular imaging. Regional and national incidence was calculated from discharge and multicounty data.ResultsThere were 2739 ICD-9 based AIS discharges. M2 occlusions in 116 (4%, 95% CI 3.5% to 5%) patients constituted the second most common occlusion site. The median National Institute of Health Stroke Scale (NIHSS) score was 12 (IQR 5–18). Good outcomes were observed in 43% (95% CI 34% to 53%), poor outcomes in 57% (95% CI 47% to 66%), and death occurred in 27% (95% CI 19% to 37%) of patients. Receiver operating characteristics curves showed the NIHSS to be predictive of outcomes (area under the curve 0.829, 95% CI 0.745 to 0.913, p3 for NIHSS score ≥9 versus 30 (±34)cm3 for NIHSS score ConclusionM2 occlusions can present with serious neurological deficits and cause significant morbidity and mortality. Patients with M2 occlusions and higher baseline deficits (NIHSS score ≥9) may benefit from endovascular therapy, thus potentially expanding the category of acute ischemic strokes amenable to intervention.

Rationale Efficacy of mechanical thrombectomy for acute stroke due to large vessel occlusion initiated beyond 6 h of time last seen well has not been demonstrated in randomized trials. Aim To establish whether subjects considered to have substantial areas of salvageable brain based on age-adjusted clinical core mismatch who can undergo endovascular treatment within 6–24 h from time last seen well (TLSW) have better outcomes at three months compared to subjects treated with standard medical therapy alone. Age-adjusted clinical core mismatch is defined by age (≤80 or >80 years), baseline National Institutes of Health Stroke Scale (NIHSS) (10–20 or ≥21), and core size (0–20 cm3 in subjects older than 80 and, in subjects younger than 80, 0–30 cm3 with NIHSS 10–20 and 31–50 cm3 with NIHSS ≥21). Design Prospective, randomized, multicenter, Bayesian adaptive-enrichment, open label trial with blinded endpoint assessment. For the purpose of enrolment, ischemic core size will be evaluated by CT perfusion or magnetic resonance imaging-diffusion-weighted imaging measured by automated software (RAPID). Procedures Subjects with acute ischemic stroke due to computed tomography angiography- or magnetic resonance angiogram-proven arterial occlusion of the intracranial internal carotid and/or proximal middle cerebral artery (M1) with age-adjusted clinical core mismatch in whom treatment can be initiated between 6 and 24 h from TSLW are randomized in a 1:1 ratio to receive mechanical embolectomy with the Trevo device or medical management alone. Sequential interim analyses allowing adaptation of enrolment criteria or stopping new enrolment for futility or predicted success will occur in every 50 randomized patients starting at 150 to a maximum of 500 patients. Study outcomes The primary endpoint is the modified Rankin Scale score at 90 days. The primary safety outcome is stroke-related mortality at 90 days. Analysis The primary endpoint, expressed as a utility-weighted modified Rankin Scale score is analyzed using a Bayesian posterior probability with adjustment for ischemic core size. For regulatory reasons, a nested co-primary endpoint analysis was added consisting of the proportion of subjects with modified Rankin Scale 0–2 between the active and control groups also analyzed using a Bayesian model.

Background and Purpose: To describe the final results of the TARGET Registry, a multicenter, real-world study of patients with intracranial aneurysms treated with new generation TARGET Coils. Methods: The TARGET Registry is a prospective, single-arm study with independent medical event monitoring and core-lab adjudication. Patients with de novo intracranial aneurysms were embolized with either TARGET-360° or helical coils in 12 US centers. The primary outcome was aneurysm packing density (PD), which was assessed immediately post-procedure. The secondary outcomes were immediate and long-term aneurysm occlusion rate using the Raymond Scale, and independent functional outcome using the modified Rankin Scale (mRS). A secondary analysis investigated the influence of the use of 100% 360-complex coils on clinical and angiographic outcomes. Results: 148 patients with 157 aneurysms met the inclusion and exclusion criteria. 58 (39.2%) patients with ruptured and 90 (61.8%) with unruptured aneurysms were treated using TARGET 360°, helical Coils, or both. Median age was 58.3 (IQR 48.1-67.4), 73% female, and 71.6% were Caucasian. Median follow-up time was 5.9 (IQR 4.0-6.9) months. The majority were treated with TARGET 360-coils (63.7%), followed by mixed and helical coils only. Peri-procedural morbidity and mortality was seen in 2.7% of patients. A good outcome at discharge (mRS 0-2) was seen in 89.9% of the full cohort, and in 84.5 and 93.3% in the ruptured and unruptured patients, respectively. The median packing density was 28.8% (IQR 20.3-41.1). Long-term complete and near complete occlusion rate was seen in 90.4% of aneurysms and complete obliteration was seen in 66.2% of the aneurysms. No significant difference in clinical and angiographic outcomes were noted between the pure 360-complex coiling vs. mixed 360-complex/Helical coiling strategies. In a multivariate analysis, predictors for long-term aneurysm occlusion were aneurysm location, immediate occlusion grade, and aneurysm size. The long-term independent functional outcome was achieved in 128/135 (94.8%) patients and all-cause mortality was seen in 3/148 (2%) patients. Conclusion: In the multicenter TARGET Registry, two-thirds of aneurysms achieved long-term complete occlusion and 91.0% achieved complete or near complete occlusion with excellent independent functional outcome. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01748903.

Objectives: Limited studies have examined economic outcomes of endovascular coiling (EVC) and/ or surgical clipping (SC) for unruptured intracranial aneurysm (UIA) from a payer perspective. This study evaluated trends in payments for index admission and 365-day follow-up (including index admission) among UIA patients treated with EVC or SC. Methods: A retrospective analysis of Truven MarketScan® Commercial Claims and Encounters (CCAE) database was conducted. The study sample included patients aged ≥ 18 years with a diagnosis of UIA who underwent EVC or SC between 2011 and 2016 (index hospitalization). The following exclusion criteria were applied: patients with a history of subarachnoid hemorrhage (SAH) or EVC/SC treatment in 12 months baseline; concurrent diagnosis of SAH during index hospitalization or lack of continuous enrollment in 12 months baseline period. Using Mann-Kendall test, we examined trends in payments for index admission and 365-day all-cause healthcare utilization (medical services and prescription). All costs were adjusted to 2016 US dollar. Results: A total of 3,294 patients met the eligibility criteria. The mean age of patients was 52.53 years (SD= 8.64) and 76.56% were female. The proportions of patients treated with EVC (vs. SC) increased from 67.80% in 2011 to 75.84% in 2016 (p= 0.01). The average index admission cost was $54,853 and the mean 365-day follow-up cost was $89,398. Mean index admission cost was $52,163 in 2011 and $64,193 in 2016 (p= 0.19). However, mean 365-day all-cause follow-up costs increased from $87,741 in 2011 to $94,096 in 2016 (p= 0.04). Conclusions: The 365-day all-cause follow-up costs associated with endovascular and surgical treatment among UIA patients increased significantly over the study period. There is significant economic burden for UIA patients undergoing neurointerventional procedures.

BackgroundThrombectomy for anterior large vessel occlusion less than 24 hours since last known well is now standard of care. Certain aspects of clinical trials may limit generalizability to ’real-world' practice.ObjectiveTo compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting.MethodsData from the most recent 20 consecutive patients with AIS treated with mechanical thrombectomy between 2015 and 2016 were collected from 15 high-volume stroke centers across North America for a total of 300 cases. Patients with proximal anterior large vessel occlusions were dichotomized by primary treatment technique. Ordinal logistic regression assessed the effects of clinical variables on patient disability using 90-day modified Rankin Scale (mRS) scores.ResultsAdequate revascularization (Thrombolysis in Cerebral Infarction ≥2b) was ultimately achieved in 91.2% of first-line direct aspiration (ADAPT) cases with an average of 1.9±1.9 passes and in 87.5% of stent retriever cases with an average of 1.7±1.0 passes. Time from groin puncture to revascularization was shorter for ADAPT cases. The mean 90-day mRS score for both groups was 3.0±2.4. Number of passes using primary technique, and postintervention intracranial hemorrhage, were significant predictors of 90-day mRS scores after ADAPT, while age and preprocedure mRS score were predictive of outcomes following first-line stent retriever.ConclusionsOur data show similar adequate revascularization rates and 90-day functional outcomes for first-line direct aspiration and stent retrievers for anterior large vessel occlusion in a real-world setting. These results support the findings of other prospective trials evaluating the two techniques.

BackgroundThe purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive.MethodsStroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated.ResultsOverall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive.ConclusionNearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.

BackgroundData on large vessel strokes are important for resource allocation and infrastructure development.ObjectiveTo determine an annual incidence of large vessel occlusions (LVOs) and a thrombectomy eligible patient population.MethodsAll patients with acute ischemic stroke discharged over 3 years from a tertiary-level hospital serving a large geographic area were evaluated for an LVO (M1, internal carotid artery terminus, basilar artery). The incidence of LVO was determined for the hospital's 4-county primary service area (PSA, population 210 000) based on each county's discharges and extrapolated to the US population. ‘Thrombectomy eligibility’ for anterior circulation LVOs was based on time (onset Results1157 patients were discharged from the hospital's PSA, of whom 129 (11.1%, 95% CI 9.5% to 13.1%) had an LVO. This translated into an LVO incidence of 24 per 100 000 people per year (95% CI 20 to 28). 20 per 100 000 people per year had anterior circulation LVOs (95% CI 19 to 22), of whom 10/100 000/year (95% CI 8 to 11) were ‘thrombectomy eligible’. An additional 5/100 000/year (95% CI 3 to 6) presented with favorable ASPECTS after 6 hours of symptom onset. Basilar occlusion incidence was estimated at 4/100 000/year (95% CI 2 to 5). These rates yield 77 569 (95% CI 65 835 to 91 091) new LVOs per year in the USA. An estimated 10 284 mechanical thrombectomy procedures were performed in 2015.ConclusionsThis study estimates an LVO incidence of 24 per 100 000 person-years (95% CI 20 to 28). A current estimated annual thrombectomy rate of three procedures per 100 000 people indicates significant potential increase in the volume of endovascular procedures and the need to develop systems of care.

IntroductionNo studies have sought to provide a quantitative or qualitative critique of research in the field of neurointerventional surgery.ObjectiveTo analyze recent publications from the Journal of Neurointerventional Surgery (JNIS) to test a new method for assessing research and collaboration.MethodsWe reviewed all JNIS Online First publications from 25 February 2015 to 24 February 2016. All publications—human or non-human research, systematic reviews, meta-analyses, or literature reviews—were included; editorials and commentaries were excluded. For each publication, study design, number of patients, authors, contributing centers, and study subject were recorded. Level of evidence was defined using a new scale.ResultsA total of 206 articles met inclusion criteria. Only 4% were prospective studies. Twenty-eight per cent of scientific research featured patient series of nine or less. The majority of publications were categorized as low-level evidence (91%). Forty-seven per cent involved individuals from a single center, with 87% having collaboration from three or fewer centers. International collaboration was present in 19%. While 256 institutions from 31 countries were represented, 66% were represented in only one publication.ConclusionsWe queried JNIS Online First articles from a 1-year period in a pilot study to test a new method of analyzing research quality and collaboration. The methodology appears to adequately quantify the studies into evidence tiers that emulate previously published, widely accepted scales. This may be useful for future comparison of peer-reviewed journals or for studying the quality of research being performed in different disease processes or medical specialties.

BackgroundDelays in delivering endovascular stroke therapy adversely affect outcomes. Time-sensitive treatments such as stroke interventions benefit from methodically developed protocols. Clearly defined roles in these protocols allow for parallel processing of tasks, resulting in consistent delivery of care.ObjectiveTo present the outcomes of a quality-improvement (QI) process directed at reducing stroke treatment times in a tertiary level academic medical center.MethodsA Six-Sigma-based QI process was developed over a 3-month period. After an initial analysis, procedures were implemented and fine-tuned to identify and address rate-limiting steps in the endovascular care pathway. Prospectively recorded treatment times were then compared in two groups of patients who were treated ‘before’ (n=64) or ‘after’ (n=30) the QI process. Three time intervals were measured: emergency room (ER) to arrival for CT scan (ER–CT), CT scan to interventional laboratory arrival (CT–Lab), and interventional laboratory arrival to groin puncture (Lab–puncture).ResultsThe ER–CT time was 40 (±29) min in the ‘before’ and 26 (±15) min in the ‘after’ group (p=0.008). The CT–Lab time was 87 (±47) min in the ‘before’ and 51 (±33) min in the ‘after’ group (p=0.0002). The Lab–puncture time was 24 (±11) min in the ‘before’ and 15 (±4) min in the ‘after’ group (pConclusionsA protocol-driven process can significantly improve efficiency of care in time-sensitive stroke interventions.

BackgroundBurnout takes a heavy toll on healthcare providers. We sought to assess the prevalence and risk factors for burnout among neurointerventional (NI) non-physician procedural staff (nurses and technologists) given increasing thrombectomy demands.MethodsA 41-question online survey containing questions including the Maslach Burnout Inventory-Human Services Survey for Medical Personnel was distributed to NI nurses and radiology technologists at 20 US endovascular capable stroke centers.Results244 responses were received (64% response rate). Median (IQR) composite scores for emotional exhaustion were 25 (15–35), depersonalization 6 (2–11), and personal accomplishment 39 (35–43). Fifty-one percent of respondents met established criteria for burnout. There was no significant relationship between hospital thrombectomy volume, call frequency, call cases covered, or length of commute. On multiple logistic regression analysis, feeling under-appreciated by hospital leadership (OR 4.1; PConclusionsThis survey of US NI non-physician procedural staff demonstrates a self-reported burnout prevalence of 51%. This was driven more by interaction with leadership and physician staff than by thrombectomy procedural volume and stroke call. Attrition among NI non-physician procedural staff is high.

Background: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. Methods: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. Results: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). Conclusions: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.

Background: Various techniques are used to enhance the results of mechanical thrombectomy with stent-retrievers, including proximal arrest with balloon guide catheter (BGC), conventional large bore proximal catheter (CGC), or in combination with local aspiration through a large-bore catheter positioned at the clot interface (Aspiration-Retriever Technique for Stroke [ARTS]). We evaluated the impact of ARTS in the North American Solitaire Acute Stroke (NASA) registry. Summary: Data on the use of the aspiration technique were available for 285 anterior circulation patients, of which 29 underwent ARTS technique, 131 CGC, and 125 BGC. Baseline demographics were comparable, except that ARTS patients are less likely to have hypertension or atrial fibrillation. The ARTS group had more ICA occlusions (41.4 vs. 22% in the BGC, p = 0.04 and 26% in CGC, p = 0.1) and less MCA/M1 occlusions (44.8 vs. 68% in BGC and 62% in CGC). Time from arterial puncture to reperfusion or end of procedure with ARTS was shorter than with CGC (54 vs. 91 min, p = 0.001) and was comparable to the BGC time (54 vs. 67, p = 0.11). Final degree of reperfusion was comparable among the groups (TICI [modified Thrombolysis in Cerebral Infarction] score 2b or higher was 72 vs. 70% for CGC vs. 78% for BGC). Procedural complications, mortality, and good clinical outcome at 90 days were similar between the groups. Key Messages: The ARTS mechanical thrombectomy in acute ischemic stroke patients appears to yield better results as compared to the use of CGCs with no significant difference when compared to BGC. This early ARTS technique NASA registry data are limited by the earlier generation distal large bore catheters and small sample size. Future studies should focus on the comparison of ARTS and BGC techniques.

Background and Purpose— Failure to recanalize predicts mortality in acute ischemic stroke. In the North American Solitaire Acute Stroke registry, we investigated parameters associated with mortality in successfully recanalized patients. Methods— Logistic regression was used to evaluate baseline characteristics and recanalization parameters for association with 90-day mortality. A multivariable model was developed based on backward selection with retention criteria of P P ≤0.10), then refit to minimize the number of excluded cases (missing data). Results— Successfully recanalized patients had lower mortality (25.2% [59/234] versus 46.9% [38/81] P P =0.205). However, mortality was significantly higher in patients with symptomatic intracranial hemorrhage (72% [23/32] versus 26% [73/281]; P P P c index=0.72), proximal occlusion, initial National Institutes of Health Stroke Scale≥18, and use of rescue therapy remained significant independent predictors of 90-day mortality. Conclusions— Failure to recanalize and presence of symptomatic intracranial hemorrhage resulted in increased mortality. Despite successful recanalization, proximal occlusion, high National Institutes of Health Stroke Scale, and need for rescue therapy were predictors of mortality.