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Introduction: Randomized clinical trials have demonstrated an improvement in outcomes with endovascular treatment of large vessel occlusions, however studies evaluating the effectiveness of endovascular treatment of smaller vessels of the anterior circulation are lacking. We present initial data from two tertiary care centers with a focus on outcomes of patients with isolated middle cerebral artery (MCA) M2 occlusions. Methods: With institutional review board approval, we retrospectively reviewed medical records of patients who underwent mechanical thrombectomy (MT) between September 2013 and June 2016. The following data was collected: demographics, stroke risk factors, intravenous tPA use, MT treatment times, grade of recanalization, complications, and 3 month modified Rankin Scores. A favorable clinical outcome was defined as a modified Rankin Scale (mRS) 0-2 at 90 days. Results: A total of 50 patients were included in this analysis with 19 (38%) women and 31 (62%) men, with a mean age of 70 (63-80) years. One patient had an occlusion of both superior and inferior divisions of the middle cerebral artery (MCA) artery, 20 had occlusion of the inferior M2 artery, and the remaining 29 had occlusion of the superior division of the MCA. Baseline characteristics are summarized below. Average door to groin time was 75 (46-112) minutes, mean procedure time was 30 (25-47) minutes, and mean onset of symptoms to recanalization time was 220 (156-305) minutes. Of the cohort, 22 patients had a change of mRS of 3 or more at the time of discharge, 25 (50%) patients had a favorable outcome at 3 months, and 4 (8%) patients were lost to follow up. Ten (20%) patients developed hemorrhagic infarction and five (10%) developed parenchymal hematoma. Conclusions: Our data on MT targeting M2 occlusions demonstrates reasonable safety, recanalization rates, complications, and functional outcomes. Randomized studies are needed to confirm the benefit of pursuing MCA M2 occlusions with MT.

Back Ground: Rapid Arterial Occlusion Evaluation Scale (RACE) was first instituted in Barcelona and described in 2014 to successfully assess stroke severity and identify patients with acute stroke with large vessel occlusion (LVO) at pre-hospital setting by medical emergency technicians. Objective: We instituted Rapid Arterial Occlusion Evaluation Scale (RACE) hospital bypass protocol (RA) in Lucas county, Ohio since July 2015. Our aim in this study is to evaluate the sensitivity of our RACE protocol in identifying cerebro-vascular accidents and furthermore to identify ischemic CVAs from the cohort. Method: All county EMS personnel (N=464) underwent training in the Rapid Arterial Occlusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke symptoms, who were last seen normal less than 12 hours and had a RACE score ≥5 were taken to a facility that has neuro-interventional capacity, was implemented in July 2015. An IRB approved prospective DB was maintained during that period. Patient’s stroke characteristics, type of acute treatment and final diagnosis on discharge were reviewed for the purpose of this abstract. Our results were comparable to the Spanish study done in Barcelona in 2014. Results: Between Jul 2016-Jun 2016 186 RAs were activated. The discharge diagnoses included ischemic stroke N=91 (49%), ICH N=26 (14%) and TIA N=17(9%). The rate of stroke mimic was N=52 (28%) of the total RACE alerts. These included seizures (12%), metabolic encephalotpathy (12%) and others including sepsis and migraines. Of the patients presenting as RA, 33% underwent IV tPA treatment ± mechanical thrombectomy. Conclusion: Results from our prospective county wide data is comparable to prior studies. RACE score may be scalable to other EMS systems to triage potential LVOs for direct transfer to centers with interventional capabilities.

Background: The efficacy of endovascular treatment in improving functional outcome in acute ischemic stroke has been established. However, it is unclear if there is any beneficial effect on mortality in stroke patients undergoing prompt endovascular treatment. Methods: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus were searched from inception through June 2015 for randomized controlled trials that compared endovascular treatment to the current standard of care in acute ischemic stroke. Studies were selected if they had short-term (90 day) mortality as a measured outcome. Mortality was pooled and odds ratio (OR) was calculated using the Mantel-Haenszel method using a fixed effect model. Results: There were 10 studies with 2835 participants in our analysis. There were 224/1513 (14.8%) deaths reported in the endovascular treatment arm and 214/1322 (16.2%) deaths in the current standard of care arm. There was no difference in 90 day mortality between endovascular treatment and current standard of care (OR 0.86, 95% CI= 0.70-1.06, p =0.51; I2 = 0%). The Figure shows forest plot comparing 90-day mortality in the endovascular treatment arm and the current standard of care arm in patients with acute ischemic stroke. There was visual estimation of publication bias which was not confirmed by trim and fill method. Conclusions: In this meta-analysis we did not find any short term mortality benefit with rapid endovascular treatment as compared to current standard of care. With the improvement demonstrated in functional outcomes, endovascular intervention represents a paradigm shift in stroke therapy. However, more studies are needed to look at both short and long-term survival and cost effectiveness of the modality.

Objective: Elevated blood glucose levels adversely affect the outcome of patients with acute ischemic stroke (AIS). We sought to study the predictive value of admission hemoglobin A1c (HbA1c) in AIS patients’ outcomes following intra-arterial stroke treatment (IAT). METHODS: We reviewed records of AIS patients who underwent IAT at our center from July 2012 - July 2013. The following data were collected and analyzed: patients’ demographics, baseline characteristics, treatment times and methods, rate of symptomatic and asymptomatic intracerebral hemorrhage, and favorable clinical outcome defined as modified Rankin score (mRS) ≤ 2 at 90 days or at last observation for patients treated within the last 90 days. HbA1c level was checked as part of routine stroke admission orders on all patients. RESULTS: Seventy consecutive patients who underwent IAT were identified. There were 42 (60%) females with mean cohort age of 64.4. The median ASPECT score was 9 (IQR 8-9) and baseline median National Institute of Health Stroke Scale Score was 18 (IQR 14-21). Overall 33 (47.1%) patients had favorable outcome. There were 15/70 (21.4%) asymptomatic and 2/70 (2.8%) symptomatic hemorrhages following IAT. Patients who developed hemorrhagic complications (17/70, 24%) following IAT had higher mean HbA1c levels (6.5 vs 5.9), however this finding was not statistically significant (ttest, p=0.09). Patients with favorable outcomes had lower mean admission HbA1c 5.9 (95% CI 5.6-6.2) versus 6.4 (95% CI 5.9-6.8). This finding was statistically significant (t-test, p 0.04). Multivariate logistic regression model identified low age (OR 0.93, 95%CI 0.88-0.99, p=0.03) as the only predictor of favorable outcome. CONCLUSION: Our study results indicate that admission HbA1c is a predictor of outcome in patients undergoing IAT for AIS. The value of this finding should be explored in a larger cohort.

Objective: We sought to compare the clinical outcomes of patients who underwent Intra-arterial Treatment (IAT) IAT with or without IV tPA pretreatment at our center. METHODS: We reviewed records of AIS patients who underwent IAT at our center from July 2012 - Jul 2013. The following data were collected and analyzed: patients’ demographics, baseline characteristics, treatment times and methods, rate of symptomatic and asymptomatic intracerebral hemorrhage, and favorable clinical outcome defined as modified Rankin score (mRS) ≤ 2 at 90 days or at last observation for patients treated within the last 89 days RESULTS: Seventy consecutive patients who underwent IAT were identified. Overall 33 (47.1%) patients had favorable outcome. There were 15/70 (21.4%) asymptomatic and 2/70 (2.8%) symptomatic hemorrhages following IAT. Pretreatment with IV tPA 32/70 (45.7%) had no significant impact on the rate of asymptomatic (6/32, 18.7% versus 9/38, 23.6%) or symptomatic (1/32, 0.03% versus 1/38, 0.03%) ICH, p=0.8. There were no instances of retroperitoneal or groin hemorrhagic complications in either group. Rate of recanalization was comparable between the IV tPA (26/32, 81.2%) and non-IV tPA groups (32/38, 84.2%).Also the rate of favorable outcome was comparable between the IV tPA pretreatment (15/32, 46.8%) and non-IV tPA (18/38, 47.3%) groups. In a multivariate analysis, young age was the only predictor of favorable clinical outcome in this cohort (OR: 0.93; 95%CI: 0.88-0.99; p=0.03). CONCLUSION: Our results suggest that IV tPA pretreatment has no impact on eventual patient outcome following endovascular stroke treatment. This finding may be helpful in designing future randomized trials.

Background: The aim of this pilot study was to prospectively determine safety and feasibility of Conscious sedation (CS) with dexmedetomidine in stroke patients undergoing intra-arterial therapy (IAT). Methods: This industry sponsored prospective single arm study was conducted with institutional IRB approval. The following data points were collected: demographics, pre-procedure NIHSS, mean time to treatment, treatment modalities, sedation and procedure times and the use of adjunctive sedation medications. Outcome measures included intraprocedural pain scores and Richmond agitation sedation scale (RASS), recanalization score, intraprocedural complications, conversion to GA, modified Rankin scale at 30 days as well as a personal account of the patients experience during the procedure. Results: Fifty- one patients were enrolled in this study of which 41 patients underwent acute stroke therapy and were included in this analysis. Baseline characteristics are included in table 1. Site of occlusion was the MCA in 27 patients, ICA-terminus in 10 patients and BA in 4 patients. IAT was performed using the MERCI device in 30 patients, Penumbra device in 3, manual aspiration in 5, and angioplasty and stenting in 3 patients. Adjunctive IA tPA was administered in 6 patients. All patients tolerated treatment under CS. The mean procedural RASS was 0 and the mean pain score was 1. Thrombolysis in Cerebral Ischemia (TICI) 2B/3 recanalization was achieved in 32 patients (78%). Two intra-procedural wire perforations (5%) were recorded. Ten patients (24%) had a mRs of < 2 at 30 days and 6 patients died (14%). Thirty-one patients described their experience. Only 6 patients were able to remember having the procedure of which 1 had a negative experience. Conclusion: To our knowledge, this is the first prospective study to evaluate the safety and efficacy of CS in stroke patients who undergo IAT. In our cohort, CS was safe, feasible and well tolerated.

Background: Because acute stroke due to basilar artery occlusion (BAO) without recanalization (spontaneous or treated) carries a poor prognosis, recanalization treatment is increasingly initiated beyond conventional time windows. We report our experience with endovascular treatment for this condition when patients are selected without regards to time window considerations. Methods: A retrospective review of a prospectively acquired database comprising 667 patients treated with endovascular therapy for acute stroke due to large vessel intracranial occlusions from 2000 to date. All patients presenting with BAO were included. Selection of patients occurred at the discretion of the treating stroke neurologist not necessarily based on time but based on clinical and imaging characteristics that led to the belief in a reasonable chance of a good outcome. Successful recanalization was expressed as Thrombolysis in Myocardial Infarction (TIMI) score ≥ 2. Favorable outcomes were considered 3 month modified Rankin Score (mRS) ≤ 2. Any parenchymal hematoma (PH) was considered symptomatic. Results: We identified 85 patients. Median age: 63. Median admission NIHSS: 18 (IQR 11-29). Male sex: 57.6%. Median time from last seen well (TLSW) to groin puncture: 774 min (12.9 hrs) (IQR 324min-2262min). Median procedure duration: 105.5 min (IQR 67min-145min). 18% of patients received IV tPA. TIMI 2-3 recanalization occurred in 87% of patients treated. Favorable outcomes were noted in 34% of patients. mRS of 3 was achieved in 9.4%. Mortality was 46%. PH was noted in 8.2% of patients. Treatment modalities included IA lytics (56.4%), MERCI device (39%), Penumbra (6%), Manual Aspiratoin Thrombectomy (27%), Stenting (42%), Angioplasty (46%). In 76.4% of patients the procedure was carried out in intubated state. In multivariate analysis, age (OR 0.94, P=0.007, 95% CI 0.89-0.98), successful recanalization (OR 16, P=0.027, 95% CI 1.38-197.56) and admission glucose (OR 0.98, P=0.033, 95%CI 0.97-0.99) were found to be significantly associated with favorable outcomes. Of note TLSW to treatment initiation was not found in univariate or multivariate analyses to be significantly associated with favorable outcomes. Conclusions: This single center experience indicates that endovascular treatment in selected patients with BAO without time window considerations is associated with similar rates of symptomatic hemorrhage (SICH) and rates of favorable outcomes compared to available literature data where selection is based on strict time windows. The role of time as selection criteria for treatment of BAO should be clarified by future prospective trials.