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Background and Purpose— Mechanical thrombectomy (MT) devices have led to improved reperfusion and clinical outcomes in acute ischemic stroke patients with emergent large vessel occlusions; however, less than one-third of patients achieve complete reperfusion. Use of intraarterial thrombolysis in the context of MT may provide an opportunity to enhance these results. Here, we evaluate the use of intraarterial rtPA (recombinant tissue-type plasminogen activator) as rescue therapy (RT) after failed MT in the North American Solitaire Stent-Retriever Acute Stroke registry. Methods— The North American Solitaire Stent-Retriever Acute Stroke registry recruited sites within North America to submit data on acute ischemic stroke patients treated with the Solitaire device. After restricting the population of 354 patients to use of RT and anterior emergent large vessel occlusions, we compared patients who were treated with and without intraarterial rtPA after failed MT. Results— A total of 37 and 44 patients was in the intraarterial rtPA RT and the no intraarterial rtPA RT groups, respectively. Revascularization success (modified Thrombolysis in Cerebral Infarction ≥2b) was achieved in more intraarterial rtPA RT patients (61.2% versus 46.6%; P =0.13) with faster times to recanalization (100±85 versus 164±235 minutes; P =0.36) but was not statistically significant. The rate of symptomatic intracranial hemorrhage (13.9% versus 6.8%; P =0.29) and mortality (42.9% versus 44.7%; P =0.87) were similar between the groups. Good functional outcome (modified Rankin Scale score of ≤2) was numerically higher in intraarterial rtPA patients (22.9% versus 18.4%; P =0.64). Further restriction of the RT population to M1 occlusions only and time of onset to groin puncture ≤8 hours, resulted in significantly higher successful revascularization rates in the intraarterial rtPA RT cohort (77.8% versus 38.9%; P =0.02). Conclusions— Intraarterial rtPA as RT demonstrated a similar safety and clinical outcome profile, with higher reperfusion rates achieved in patients with M1 occlusions. Prospective studies are needed to delineate the role of intraarterial thrombolysis in MT.

Background and Purpose— Mechanical thrombectomy has been shown to improve clinical outcomes in patients with acute ischemic stroke. However, the impact of balloon guide catheter (BGC) use is not well established. Methods— STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter study of patients with large vessel occlusion treated with the Solitaire stent retriever as first-line therapy. In this study, an independent core laboratory, blinded to the clinical outcomes, reviewed all procedures and angiographic data to classify procedural technique, target clot location, recanalization after each pass, and determine the number of stent retriever passes. The primary clinical end point was functional independence (modified Rankin Scale, 0–2) at 3 months as determined on-site, and the angiographic end point was first-pass effect (FPE) success rate from a single device attempt (modified Thrombolysis in Cerebral Infarction, ≥2c) as determined by a core laboratory. Achieving modified FPE (modified Thrombolysis in Cerebral Infarction, ≥2b) was also assessed. Comparisons of clinical outcomes were made between groups and adjusted for baseline and procedural characteristics. All participating centers received institutional review board approval from their respective institutions. Results— Adjunctive technique groups included BGC (n=445), distal access catheter (n=238), and conventional guide catheter (n=62). The BGC group had a higher rate of FPE following first pass (212/443 [48%]) versus conventional guide catheter (16/62 [26%]; P =0.001) and distal access catheter (83/235 [35%]; P =0.002). Similarly, the BGC group had a higher rate of modified FPE (294/443 [66%]) versus conventional guide catheter (26/62 [42%]; P P =0.003). The BGC group achieved the highest rate of functional independence (253/415 [61%]) versus conventional guide catheter (23/55 [42%]; P =0.007) and distal access catheter (113/218 [52%]; P =0.027). Final revascularization and mortality rates did not differ across the groups. Conclusions— BGC use was an independent predictor of FPE, modified FPE, and functional independence, suggesting that its routine use may improve the rates of early revascularization success and good clinical outcomes. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02239640.

Supplemental Digital Content is available in the text., Background: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. Methods: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. Results: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P

Background and Purpose— Mechanical thrombectomy with stent retrievers has become standard of care for treatment of acute ischemic stroke patients because of large vessel occlusion. The STRATIS registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) aimed to assess whether similar process timelines, technical, and functional outcomes could be achieved in a large real world cohort as in the randomized trials. Methods— STRATIS was designed to prospectively enroll patients treated in the United States with a Solitaire Revascularization Device and Mindframe Capture Low Profile Revascularization Device within 8 hours from symptom onset. The STRATIS cohort was compared with the interventional cohort of a previously published SEER patient-level meta-analysis. Results— A total of 984 patients treated at 55 sites were analyzed. The mean National Institutes of Health Stroke Scale score was 17.3. Intravenous tissue-type plasminogen activator was administered in 64.0%. The median time from onset to arrival in the enrolling hospital, door to puncture, and puncture to reperfusion were 138, 72, and 36 minutes, respectively. The Core lab–adjudicated modified Thrombolysis in Cerebral Infarction ≥2b was achieved in 87.9% of patients. At 90 days, 56.5% achieved a modified Rankin Scale score of 0 to 2, all-cause mortality was 14.4%, and 1.4% suffered a symptomatic intracranial hemorrhage. The median time from emergency medical services scene arrival to puncture was 152 minutes, and each hour delay in this interval was associated with a 5.5% absolute decline in the likelihood of achieving modified Rankin Scale score 0 to 2. Conclusions— This largest-to-date Solitaire registry documents that the results of the randomized trials can be reproduced in the community. The decrease of clinical benefit over time warrants optimization of the system of care. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT02239640.

Introduction/Purpose Since 2012, our team of neurointerventional physicians have performed over 600 intracranial arterial thrombectomies with stent-retrievers. Thrombectomy in the ICA and M1 segments has been shown in randomized trials to reduce permanent disability and is now the standard of care. The time window has continued to expand. However, less is known about outcomes for thrombectomy performed in distal branches, such as near the M2–3 junction or within the M3 segments. Current guidelines state that thrombectomy in these locations may be performed in carefully selected patients, however data is limited. Materials and methods A retrospective review of our stroke database from 2012–2018 was undertaken to find cases of MCA interventions involving the distal third of the M2 insular segment or the M3 opercular segment. Isolated ICA, M1 and proximal M2 branch occlusions, as well as proximal occlusions that resulted in distal emboli post-thrombectomy, were excluded. Patients were selected for intervention based on noncontrast CT head, CTA, CT perfusion results; onset time; and clinical exam. Distal vessel thrombectomies were performed with the use of a stent-retriever device. Pre-intervention scans were compared to post-intervention scans to evaluate degree of infarct. The baseline and discharge National Institute of Health Stroke Scale, and the modified Rankin Scale at 90 days were used to evaluate the degree of residual deficits. Results A total of 43 patients met the inclusion criteria. Mean age was 69.4 (IQR 60.5–82). 23 (53.5%) were female. Thrombus was categorized as being located completely within the M3 segment in 21 cases (48.8%) and spanning the M2-M3 junction in 22 cases. 6 patients (14.0%) presented with tandem vessel occlusions involving the ICA or a proximal MCA segment, or proximal occlusion that had moved distally between CTA and angiography. 18 patients received intravenous tPA (41.9%). 42 cases were treated with a stent-retriever, and 1 case was treated with intra-arterial tPA. Multiple devices were used, however all were 3–4 mm in diameter, and 39 were 15–20 mm in length. 3 cases used a 4x40 mm device. The mean number of passes with a device was 1.2 (range 1–3). Near or complete reperfusion (mTICI score 2b or greater) was achieved in 40 cases (93.0%). Median initial NIHSS on presentation was 10.5 (IQR 7.8–18). Median discharge NIHSS was 2 (IQR 1–5.3). Initial and discharge NIHSS was not available in 3 patients. 90-day mRS was 0–2 in 17 patients (48.6% of those available) and 3–6 in 18 patients (51.4% of those available). 90-day mRS was not available in 9 patients (18.6% of total), mostly in the earliest cases found in the database. 3 cases of intraparenchymal hemorrhage occurred (7.0%), 2 of which were symptomatic including 1 resultant death. Conclusion Distal middle cerebral artery thrombectomy with stent-retriever devices is achievable and can be safe and technically effective. Randomized controlled trials have not been performed to determine if thrombectomy in or distal to the M2-3 junction is more beneficial than other techniques, such as aspiration thrombectomy, intravenous thrombolysis, or maximum medical therapy. Disclosures B. Donegan: None. J. Loeb: None. C. Martin: None. W. Holloway: None. J. Halpin: None. N. Akhtar: None.

Background and Purpose- Mechanical thrombectomy (MT) devices have led to improved reperfusion and clinical outcomes in acute ischemic stroke patients with emergent large vessel occlusions; however, less than one-third of patients achieve complete reperfusion. Use of intraarterial thrombolysis in the context of MT may provide an opportunity to enhance these results. Here, we evaluate the use of intraarterial rtPA (recombinant tissue-type plasminogen activator) as rescue therapy (RT) after failed MT in the North American Solitaire Stent-Retriever Acute Stroke registry. Methods- The North American Solitaire Stent-Retriever Acute Stroke registry recruited sites within North America to submit data on acute ischemic stroke patients treated with the Solitaire device. After restricting the population of 354 patients to use of RT and anterior emergent large vessel occlusions, we compared patients who were treated with and without intraarterial rtPA after failed MT. Results- A total of 37 and 44 patients was in the intraarterial rtPA RT and the no intraarterial rtPA RT groups, respectively. Revascularization success (modified Thrombolysis in Cerebral Infarction ≥2b) was achieved in more intraarterial rtPA RT patients (61.2% versus 46.6%; P=0.13) with faster times to recanalization (100±85 versus 164±235 minutes; P=0.36) but was not statistically significant. The rate of symptomatic intracranial hemorrhage (13.9% versus 6.8%; P=0.29) and mortality (42.9% versus 44.7%; P=0.87) were similar between the groups. Good functional outcome (modified Rankin Scale score of ≤2) was numerically higher in intraarterial rtPA patients (22.9% versus 18.4%; P=0.64). Further restriction of the RT population to M1 occlusions only and time of onset to groin puncture ≤8 hours, resulted in significantly higher successful revascularization rates in the intraarterial rtPA RT cohort (77.8% versus 38.9%; P=0.02). Conclusions- Intraarterial rtPA as RT demonstrated a similar safety and clinical outcome profile, with higher reperfusion rates achieved in patients with M1 occlusions. Prospective studies are needed to delineate the role of intraarterial thrombolysis in MT.

Background: Basilar artery occlusion (BAO) remains a devastating ischemic stroke subtype leading to high mortality rates and poor outcomes. Recently, mechanical retrieval therapy (MER) became a standard of care and a influential predictor of favorable outcomes in anterior circulation stroke patients. However, the use of MER in AIS patients with BAO is not established. Purpose: Our hospital sees over 1600 stroke patients a year with over 18% of stroke patients receiving MER therapy compared to the national average of 4.3%. We sought to evaluate our BAO patients who received MER therapy for efficacy and outcomes. Methods: Patients presenting to our facility between January 1, 2015 and June 30, 2018 were studied in a retrospective chart review. AIS patients who had BAO were evaluated for types of treatment, age, outcomes, recanalization rate TICI score of >2b, and disability or mortality after stroke. Of the 4,212 stroke patients presenting at our facility in the timeframe, 441 underwent MER therapy with 20 patients having a primary occlusion of basilar artery. Data was analyzed and compared to meta-analysis data. Results: Our patients with BAO had a (mRS) modified Rankin Score (0-2) of 81.8% (95% CI 7.8%, 96.8%) compared to the national average of 42.0% (95% CI 36%, 48%). Reperfusion scores (TICI >2b) in our patients was 90.9 % (95% CI 57.1%, 99.5%), while the reperfusion scores (TICI >2b) in the comparison group as 81% (95% CI 73%, 87%). Our sICH rate was 0.0% (95% CI 0.0%, 31.1%) while the comparison group was 4% (95% CI 2.0%, 8.0%). Our overall mortality rate of our BAO patients was 5.1%, with the comparison group’s mortality rate at 30.1%. There was no significance noted in patients’ ages or in the use of thrombolytics between the two groups. Conclusion: Patients presenting with stroke caused by BAO who receive MER at our facility have more favorable outcomes than those in the systematic review. Potential reasons include shorter time to recanalization, improved catheters and technology, experienced staff and strict attention to seamless transitions of care. MER therapy can be a safe treatment modality for patients with BAO. Further clinical trials are needed to show MER efficacy in patients experiencing a BAO.

Introduction Carotid artery occlusion in the setting of acute stroke with concurrent intracranial involvement is a serious and deadly combination, and can prove to be a challenging endeavor when encountered. The stroke is usually more severe due to poor collaterals and successful revascularization is difficult to achieve, resulting in a higher morbidity and mortality. We aim to assess the revascularization rates and clinical outcomes in this subset of patients treated with endovascular therapy. Materials and methods An IRB approved retrospective chart review of cases presenting with acute ischemic stroke with carotid occlusions and concurrent intracranial involvement treated with endovascular therapy over a 4 year period was conducted. Of these reviewed cases, 75 patients had carotid occlusions with intracranial involvement. The carotid T occlusions and critical ICA stenosis with intracranial flow were excluded from the study. Based on the CT and catheter angiogram findings, the 75 patients fell into two groups: Group A (n=35): Carotid occlusion with underlying atherosclerotic disease/dissection resulting in occlusion and were treated with angioplasty and stenting followed by thrombus retrieval. Group B (n=40): No underlying pathology was found and ICA was occluded due to a large embolus to the ICA with no anterograde flow in the ICA. This group was treated with thrombus retrieval alone. Results Our data shows that the presence of a stent in the ICA does not adversely affect the intracranial recanalization rate (91.4% TICI ≥2 b). There was also no significant increase in hemorrhage rate with revascularization and antiplatelet therapy (2.9%). This finding was especially significant due to the large amount of wake up strokes in our study that were treated with intervention (17.3%). The successful reperfusion rate (TICI ≥2 b) overall in both groups was 82.7%. In the successfully recanalized group, the mortality was 16% compared to the mortality in the unsuccessfully recanalized group (69.2%). Conclusion Our study results show that it is possible to achieve a high success rate of revascularization and clinical outcomes with an endovascular approach to managing carotid occlusion with intracranial involvement. Disclosures B. Donegan: None. I. Akhtar: None. C. Boutwell: None. J. Halpin: None. C. Martin: None. W. Holloway: None. N. Akhtar: None.

Introduction and purpose Time and again we come across cases of acute intraluminal thrombus in the proximal carotid and vertebral arteries without intracranial involvement. They are particularly challenging as the risk of dislodging the thrombus with intervention is high and can result in a potentially worse stroke. We present our experience of seven patients with an acute thrombus in their cervical arteries. The aim of this presentation is to demonstrate the diversity of managements in these patients. Materials and methods We retrospectively reviewed cerebral angiography reports spanning 8 years at our institution retaining cases showing thrombus in carotid or vertebral arteries. With identified cases, medical records were reviewed for stroke presentation, severity, and management. A total of 7 cases were identified. There were four patients with a thrombus in the proximal internal carotid artery and three patients with a thrombus in the proximal vertebral arteries. In all of these cases, the thrombus was due to underlying severe stenosis of the ICA/vertebral origins and was seen on catheter angiogram and CT angiogram as filling defects within the lumen of these vessels. Results 3 patients (2 carotid, 1 vertebral) were treated medically–2 with anticoagulant therapy (heparin/coumadin) in 1 with Aspirin/Clopidogrel. All 3 were admitted to the Intensive Care Unit and closely monitored until there was complete resolution of the acute clot on follow up imaging. Of these 3 patients, 2 patients underwent angioplasty/stenting and 1 patient underwent endarterectomy electively for underlying critical stenoses. 2 patients with an ICA thrombus showed changes of acute/subacute strokes on presenting CT and were considered to be unsuitable for anticoagulation. They were treated with angioplasty and stenting with distal embolic protection. In one patient, the thrombus was successfully trapped within the stent while in the other patient, part of the thrombus embolized to the middle cerebral artery and was subsequently retrieved with a stent retriever. In one patient with a vertebral thrombus, anticoagulation was started but the patient showed evidence of intracranial embolization with new strokes on MRI within the first 24 hours and angioplasty and stenting was performed acutely with no complications. In one patient with vertebral thrombus, anticoagulant therapy was started but the clot embolized into the basilar artery within 1 hour of the start of treatment with significant neurological worsening. No further treatment was performed per family request and the patient died in 48 hours. Conclusion The treatment for acute intraluminal thrombus in the major vessels is very challenging, as the situation is very fluid and can change for worse if the clot embolizes. These patients should be closely observed and the treatment should be customized according to the clinical situation. Disclosures B. Donegan: None. I. Akhtar: None. J. Halpin: None. C. Martin: None. W. Holloway: None. N. Akhtar: None.

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.

Introduction: Carotid artery occlusion in the setting of acute stroke with concurrent intracranial involvement is a serious and deadly combination, and can prove to be a challenging endeavor when encountered. The stroke is usually more severe due to poor collaterals and successful revascularization is difficult to achieve, resulting in a higher morbidity and mortality. We aim to assess the revascularization rates and clinical outcomes in this subset of patients treated with endovascular therapy. Methods: An IRB approved retrospective chart review of cases presenting with acute ischemic stroke with carotid occlusions and concurrent intracranial involvement treated with endovascular therapy over a 4-year period was conducted. Of these reviewed cases, 75 patients had carotid occlusions with intracranial involvement. The carotid T occlusions and critical ICA stenosis with intracranial flow were excluded from the study. Based on the CT and catheter angiogram findings, the 75 patients fell into two groups: 1) Group A (n=35): Carotid occlusion with underlying atherosclerotic disease/dissection resulting in occlusion and were treated with angioplasty and stenting followed by thrombus retrieval. 2) Group B (n=40): No underlying pathology was found and ICA was occluded due to a large embolus to the ICA with no anterograde flow in the ICA. This group was treated with thrombus retrieval alone. Results: Our data shows that the presence of a stent in the ICA does not adversely affect the intracranial recanalization rate (91.4% TICI ≥ 2b). There was also no significant increase in hemorrhage rate with revascularization and antiplatelet therapy (2.9%). This finding was especially significant due to the large amount of wake up strokes in our study that were treated with intervention (17.3%). The successful reperfusion rate (TICI ≥2b) overall in both groups was 82.7%. In the successfully recanalized group, the mortality was 16% compared to the mortality in the unsuccessfully recanalized group (69.2%). Conclusions: Our study results show that it is possible to achieve a high success rate of revascularization and clinical outcomes with an endovascular approach to managing carotid occlusion with intracranial involvement.

Mechanical thrombectomy using retrievable stents or stent retriever devices has become the mainstay of intra-arterial therapy for acute ischemic stroke. The recent publication of a series of positive trials supporting intra-arterial therapy as standard of care for the treatment of large vessel occlusion will likely further increase stent retriever use. Rarely, premature stent detachment during thrombectomy may be encountered. In our multicenter case series, we found a rate of detachment of less than 1% (n = 7/1,067), and all were first-generation Solitaire FR devices. A review of the US Food and Drug Administration database of device experience yielded 90 individual adverse reports of detachment. There were 82, 1 and 7 detachments of Solitaire FR (first generation), Solitaire FR2 (second generation) and Trevo devices, respectively. We conclude with a brief overview of the technical and procedural considerations which may be helpful in avoiding this rare complication.

Background and Purpose— The Solitaire With the Intention for Thrombectomy (SWIFT) and thrombectomy revascularization of large vessel occlusions in acute ischemic stroke (TREVO 2) trial results demonstrated improved recanalization rates with mechanical thrombectomy; however, outcomes in the elderly population remain poorly understood. Here, we report the effect of age on clinical and angiographic outcome within the North American Solitaire-FR Stent-Retriever Acute Stroke (NASA) Registry. Methods— The NASA Registry recruited sites to submit data on consecutive patients treated with Solitaire-FR. Influence of age on clinical and angiographic outcomes was assessed by dichotomizing the cohort into ≤80 and >80 years of age. Results— Three hundred fifty-four patients underwent treatment in 24 centers; 276 patients were ≤80 years and 78 were >80 years of age. Mean age in the ≤80 and >80 cohorts was 62.2±13.2 and 85.2±3.8 years, respectively. Of patients >80 years, 27.3% had a 90-day modified Rankin Score ≤2 versus 45.4% ≤80 years ( P =0.02). Mortality was 43.9% and 27.3% in the >80 and ≤80 years cohorts, respectively ( P =0.01). There was no significant difference in time to revascularization, revascularization success, or symptomatic intracranial hemorrhage between the groups. Multivariate analysis showed age >80 years as an independent predictor of poor clinical outcome and mortality. Within the >80 cohort, National Institutes of Health Stroke Scale (NIHSS), revascularization rate, rescue therapy use, and symptomatic intracranial hemorrhage were independent predictors of mortality. Conclusion— Greater than 80 years of age is predictive of poor clinical outcome and increased mortality compared with younger patients in the NASA registry. However, intravenous tissue-type plasminogen activator use, lower NIHSS, and shorter revascularization time are associated with better outcomes. Further studies are needed to understand the endovascular therapy role in this cohort compared with medical therapy.

Background: Time critical care in the Emergency Department is important for a patient’s survival and recovery. Reductions in disability are attributed to rapid triage and treatment for patients with both small and large vessel strokes. Current guidelines provide recommendations in clinical practice but do not delineate which type of stroke patients should receive heightened levels of triage when they arrive in the ED simultaneously. Purpose: To decrease unintentional care delays by classifying patients who are in need of intravenous tPA, endovascular therapy, or patients receiving no therapy in the initial assessment. Additionally, the number of activations of over 4,000 since 2014 was leading to stroke fatigue and we sought to decrease this fatigue with a tiered triage approach. Methods: Performance improvement initiatives were used to eliminate under used resources while also accounting for overburden of multiple patients in a very busy stroke center. The project prioritized code stroke activations based on acuity into RED, YELLOW and GREEN stroke alerts. RED signified a patient as a possible candidate for IV tPA, YELLOW prioritized the patient as possible endovascular candidate, and GREEN prioritized the patient as having a longer symptom onset initially. Results: The ultimate goal was to improve stroke treatment times while also decreasing activation fatigue. In the RED activations, the door to needle (DTN) time decreased from a mean of 46 minutes in 2014 to a mean of 34 minutes in 2016. In the YELLOW activations, the door to groin puncture mean decreased from 155 minutes to 72 minutes in the same time period. Prioritizing stroke based on acuity has demonstrated efficiency in team members’ time and improved stroke treatment times and treatment rates. Conclusions: Despite the increased influx of stroke patients into comprehensive stroke for endovascular consideration, the patients who were candidates for tPA could be prioritized to minimize delays in tPA treatment. Furthermore, patients with potential treatment for endovascular could be further prioritized and treatment times could also improve. Decreasing activation fatigue and fine tuning flow process helped manage multiple stroke patients at one time and favored improved patient outcomes.

Background: Five recently published randomized trials of endovascular therapy versus medical management, including intravenous thrombolysis, demonstrated strong positive data in support endovascular thrombectomy procedures. The American Heart Association/American Stroke Association released a focused update to specifically incorporate the findings of these trials. Implementing the care these studies show as beneficial requires a mechanism to rapidly transfer large vessel occlusion patients from primary stroke centers to those offering thrombectomy. Purpose: The purpose of the project was to streamline stroke work-up across the various levels of stroke hospitals and to apply rapid routing practices when transferring stroke patients between facilities. We evaluated the changes in stroke systems of care, with an emphasis on the role of pre-hospital stroke triage, inter-hospital transfer, and the two main levels of stroke center certification (primary and comprehensive). Methods: The system stroke steering team, defined four primary processes to reduce transfer times. These included 1) benchmarks for hospital door in to door out times of transferring centers 2) scripted transfer verbiage to designated time critical patients 3) large vessel stroke criteria definitions 4) pre-notification of the endovascular team to treat potential patients presenting with stroke. A reduction in time between initial patient contact and arterial puncture times and measures of patient outcomes were used as indicators of effectiveness. Results: The implementation of four process improvements for large vessel stroke patients was associated with improved treatment times. Mean door to recanalization times decreased from 224 minutes in 2014 to 112 minutes, thus far in 2016. Stroke treatment rates for tPA increased from 19.8% in 2013 to 22.7% in 2016, and endovascular treatment rates of 14.6% to 18.1% in the same time period. Conversely, complication rates from stroke treatment declined within the same period from 7.4% to 3.8%. Conclusion: Within a metropolitan health system, using the above multimodal approach to streamline the transfer of patients from primary to comprehensive centers decreases latency to treatment and is associated with improved outcomes.

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

Background: There are multiple clinical and radiographic factors that influence outcomes after endovascular reperfusion therapy (ERT) in acute ischemic stroke (AIS). We sought to derive and validate an outcome prediction score for AIS patients undergoing ERT based on readily available pretreatment and posttreatment factors. Methods: The derivation cohort included 511 patients with anterior circulation AIS treated with ERT at 10 centers between September 2009 and July 2011. The prospective validation cohort included 223 patients with anterior circulation AIS treated in the North American Solitaire Acute Stroke registry. Multivariable logistic regression identified predictors of good outcome (modified Rankin score ≤2 at 3 months) in the derivation cohort; model β coefficients were used to assign points and calculate a risk score. Discrimination was tested using C statistics with 95% confidence intervals (CIs) in the derivation and validation cohorts. Calibration was assessed using the Hosmer-Lemeshow test and plots of observed to expected outcomes. We assessed the net reclassification improvement for the derived score compared to the Totaled Health Risks in Vascular Events (THRIVE) score. Subgroup analysis in patients with pretreatment Alberta Stroke Program Early CT Score (ASPECTS) and posttreatment final infarct volume measurements was also performed to identify whether these radiographic predictors improved the model compared to simpler models. Results: Good outcome was noted in 186 (36.4%) and 100 patients (44.8%) in the derivation and validation cohorts, respectively. Combining readily available pretreatment and posttreatment variables, we created a score (acronym: SNARL) based on the following parameters: symptomatic hemorrhage [2 points: none, hemorrhagic infarction (HI)1-2 or parenchymal hematoma (PH) type 1; 0 points: PH2], baseline National Institutes of Health Stroke Scale score (3 points: 0-10; 1 point: 11-20; 0 points: >20), age (2 points: 79 years), reperfusion (3 points: Thrombolysis In Cerebral Ischemia score 2b or 3) and location of clot (1 point: M2; 0 points: M1 or internal carotid artery). The SNARL score demonstrated good discrimination in the derivation (C statistic 0.79, 95% CI 0.75-0.83) and validation cohorts (C statistic 0.74, 95% CI 0.68-0.81) and was superior to the THRIVE score (derivation cohort: C statistic 0.65, 95% CI 0.60-0.70; validation cohort: C-statistic 0.59, 95% CI 0.52-0.67; p < 0.01 in both cohorts) but was inferior to a score that included age, ASPECTS, reperfusion status and final infarct volume (C statistic 0.86, 95% CI 0.82-0.91; p = 0.04). Compared with the THRIVE score, the SNARL score resulted in a net reclassification improvement of 34.8%. Conclusions: Among AIS patients treated with ERT, pretreatment scores such as the THRIVE score provide only fair prognostic information. Inclusion of posttreatment variables such as reperfusion and symptomatic hemorrhage greatly influences outcome and results in improved outcome prediction.

BackgroundThe increasing utilization of balloon guide catheters (BGCs) in thrombectomy therapy for ischemic stroke has led to concerns about large-bore sheaths causing vascular groin complications.Objective To retrospectively assess the impact of large large-bore sheaths and vascular closure devices on groin complication rates at a comprehensive stroke center over a 10-year period.MethodsRadiological and clinical records of patients with acute ischemic stroke who underwent mechanical endovascular therapy with an 8Fr or larger sheaths were reviewed. A groin complication was defined as the formation of a groin hematoma, retroperitoneal hematoma, femoral artery pseudoaneurysm, or the need for surgical repair. Information collected included size of sheath, type of hemostatic device, and anticoagulation status of the patient. Blood bank records were also analyzed to identify patients who may have had an undocumented blood transfusion for a groin hematoma.ResultsA total of 472 patients with acute ischemic stroke who underwent mechanical thrombectomy with a sheath and BGC sized 8Fr or larger were identified. 260 patients (55.1%) had tissue Plasminogen Activator (tPA) administered as part of stroke treatment. Vascular closure devices were used in 97.9% of cases (n=462). Two patients were identified who had definite groin complications and a further two were included as having possible complications. There was a very low rate of clinically significant groin complications (0.4–0.8%) associated with the use of large-bore sheaths.ConclusionsThese findings suggest that concerns for groin complications should not preclude the use of BGCs and large-bore sheaths in mechanical thrombectomy for acute ischemic stroke.

Background: The Interventional Management of Stroke III (IMS-III) trial demonstrated no benefit for intravenous recombinant tissue plasminogen activator (IV rt-PA) followed by endovascular therapy versus IV rt-PA alone. However, IMS-III mostly included earlier generation devices. The recent thrombectomy trials have incorporated the stent-retriever technology, but their generalizability remains unknown. Methods: The North American Solitaire Acute Stroke (NASA) registry recruited patients treated with the Solitaire FR™ device between March 2012 and February 2013. The NASA-IMS-III-Like Group (NILG baseline NIHSS score ≥10 who received IV rt-PA) was compared to the IV rt-PA and IV + intra-arterial (IA)-IMS-III groups and the MR CLEAN, ESCAPE, SWIFT Prime, and REVASCAT trial controls to assess the stent-retriever treatment in the ‘real-world' setting. The NILG was also compared to non-IV rt-PA NASA patients to evaluate the impact of IV rt-PA on thrombectomy. Results: A total of 136 of the 354 NASA patients fulfilled criteria for the NILG. Baseline characteristics were well balanced across groups. Time from onset to puncture was higher in NILG than IV+IA-IMS-III patients (274 ± 112 vs. 208 ± 47 min, p < 0.0001). Occlusions involving the intracranial ICA, MCA-M1, or basilar arteries were more common in NILG than IV+IA-IMS-III patients (91.2 vs. 47.2%, p < 0.00001). Modified thrombolysis in cerebral infarction ≥2b reperfusion was higher in NILG than IV+IA-IMS-III patients (74.3 vs. 39.6%, p < 0.00001). A 90-day modified Rankin Scale score ≤2 was more frequent in the NILG than IV+IA-IMS-III patients (51.9 vs. 40.8%, p = 0.03) and MR CLEAN (51.9 vs. 19.1%, p < 0.00001), ESCAPE (51.9 vs. 29.3%, p = 0.0002), SWIFT Prime (51.9 vs. 35.5%, p = 0.02), and REVASCAT (51.9 vs. 28.2%, p = 0.0003) controls. Symptomatic intracranial hemorrhage definitions varied across the different studies with rates ranging from 2.7% (ESCAPE) to 11.9% (NILG). The NILG 90-day mortality (24.4%) was higher than in SWIFT Prime but comparable to all other groups. IV rt-PA was an independent predictor of good outcome in NASA (OR = 2.3, 95% CI 1.2-4.7). Conclusion: Our results support the ‘real-world' applicability of the recent thrombectomy trials.

Background: Annually, over 1500 stroke patients are seen within a large metropolitan health system. The health system encompasses a designated comprehensive (CSC) and multiple primary (PSC) stroke hospitals with varying capabilities to manage stroke patients, resulting in varied care delivery. While CSCs mitigate inconsistencies by establishing a standard of stroke care, one shortcoming of the CSC model is lack of regulation in transfer of patients between centers within a health system containing multiple stroke designations. Purpose: The purpose of the project was to create a streamlined, emergency stroke work-up process across the various levels of stroke hospitals and to apply rapid routing practices for EMS when transferring stroke patients between facilities. These changes could reduce treatment times and optimize resources to facilitate transportation of stroke patients to the appropriate center. Methods: The system stroke steering team, in collaboration with regional EMS directors initiated 5 primary processes to reduce delays. These included 1) door in to door out times of 60 minutes, 2) loading radiology images into a cloud environment, 3) development of EMS algorithms, 4) prompt follow-up reports on stroke transfers, and 5) rapid loop-closure on gaps in the process. A reduction in door-to-therapy time and measures of patient outcome were used as indicators for effectiveness. Results: Implementation of a streamlined ED process and new routing protocol was associated with improved door-to-door times, door-to-treatment times and EMS transport times. Additionally, risk-adjusted mortality decreased from 0.7 in 2012 to 0.3 in 2014. Similarly, thrombolytic complications in intravenous and endovascular patients decreased from 7.5% in 2012 to 1.7% in 2014, while treatment rates in both increased. Conclusion: Within a large health system, utilizing a consistent ED process and new EMS routing protocol could contribute to improved outcomes. This raises the possibility that implementing system routing practices may improve collaboration within stroke systems of care and advance the CSC model.

BackgroundTime to reperfusion following endovascular treatment (ET) predicts outcomes after acute ischemic stroke (AIS).ObjectiveTo assess the time–outcome relationship within reperfusion grades in the North American Solitaire Acute Stroke registry.MethodsWe identified patients given ET for anterior circulation ischemic stroke within 8 h from onset and in whom reperfusion was achieved. Together with clinical and outcome data, site-adjudicated modified Thrombolysis in Cerebral Ischemia (TICI) was recorded. We assessed the impact of time to reperfusion (onset to procedure completion time) on good outcome (modified Rankin Scale 0–2 at 3 months) in patients who achieved TICI 2 or higher reperfusion in multivariable models. We further assessed this relationship within strata of reperfusion grades. A pResultsIndependent predictors of good outcome at 3 months among those achieving TICI ≥2a reperfusion (n=188) were initial National Institutes of Health Stroke Scale score (adjusted OR=0.90, 95% CI 0.85 to 0.95), symptomatic hemorrhage (adj. OR=0.16, 95% CI 0.05 to 0.60), TICI grade (TICI 3: adj. OR=11.52, 95% CI 3.34 to 39.77; TICI 2b: adj. OR=5.14, 95% CI 1.61 to 16.39), and time to reperfusion per 30 min interval (adj. OR=0.91, 95% CI 0.82 to 0.99). There was an interaction between final TICI grade and 30 min time to reperfusion intervals (p=0.001) such that the effect of time was strongest in TICI 2a patients.ConclusionsTime to reperfusion was a strong predictor of outcome following ET for AIS. However, the effect varied by TICI grade such that its greatest effect was in those achieving TICI 2a reperfusion.

Background and Purpose: Time has consistently been cited as a fundamental variable to improve clinical outcomes in stroke. We identified potential to reduce ‘Door to Imaging’ and ‘Door to Groin Puncture’ times at our institution by streamlining the flow process for acute stroke management by the multidisciplinary team. Methods: Retrospective analysis was performed over a 3-month period on all patients who underwent mechanical thrombectomy for symptomatic stroke. Time-interval metrics collected included time from patient arrival to the start of imaging, start of groin puncture and start of revascularization. We then identified weak links in the pathway of stroke care and implemented strategies for change, including early notification of the interventionist by stroke neurologists or the ‘Code Neuro’ stroke nurse, the patient being taken directly to CT on arrival to the Emergency Department if hemodynamically stable and point of care processing of blood tests. Other interventions included enhancement of pre-hospital work-up by Emergency Medical Services and a unified paging system. Following these interventions, another analysis of time-interval metrics was undertaken on a second population of patients, also over a 3-month period. Results: Data on a total of 20 patients prior to change implementation and 22 patients after change were analyzed. The results obtained are tabulated as shown: Conclusion: This quality improvement project was able to successfully demonstrate a reduction in various time-interval metrics following a targeted, and ongoing, initiative to optimize specific response mechanisms in the acute stroke process pathway.

Background: A large community based stroke program began utilizing advanced practice providers (APPs) 24/7 in the 18-bed Neuroscience ICU. The nurses needed 24/7 in-house support in managing these complex patients. Literature shows that APPs impact the length of stay and health care cost. This practice change led to an evaluation of the process of educating and ensuring competency to the APPs. Purpose: The goal was to ensure competency of APPs demonstrated by complete understanding of complex disease management and ongoing skills to manage critical neuro patients. Methods: Core Competency models were designed and used as a framework to aid in critical care specialization. Advanced classes, applicable clinical rotations, and procedure based skills lab were utilized to train the APPs. Initial measures to evaluate efficacy of the model included 14-item knowledge tests administered before and after a critical care symposium. Two versions of the test were administered using a crossover design, and changes in test scores were examined using analysis of variance. Additional competency measures included procedure and skill check-off competencies, neuro-monitoring utilization, provider sign-offs and one-on-one education by system educators. Results: APPs scored significantly higher on the post-test than the pre-test (mean difference = 19.71%, CI:14.3%-25.2%; p-value Conclusions: Utilizing a combination of specially trained critical care physicians, 24/7 accessible neurologists, neurosurgeons and neuro interventionalists on the training of the APPs for this complex patient population is the key to the success of the neurocritical care APP competency model.

Purpose To describe the clinical features of a visual variant Alzheimer's disease, a disorder that might be seen by the ophthalmologist with visual symptoms and signs. Design Retrospective case series. Participants Eight patients with Alzheimer's disease presenting with predominantly visual complaints. Methods A retrospective review of patients at a tertiary care academic center seen by the authors from 1999 to 2001 with Alzheimer's disease and predominantly visual complaints. Results Eight patients with the visual variant of Alzheimer's disease were reviewed. All had seen eye care providers before referral to the neuro-ophthalmology clinic for visual complaints but without a diagnosis. Four patients had homonymous visual field loss, and two had presumed cortical visual impairment. Neuroimaging showed either normal brain (1 patient) or atrophy of the parietal or occipital areas but no structural lesions (7 patients). Fluoro-18-deoxyglucose positron emission tomography scans were performed in five of the cases, and all showed hypoperfusion in the parietooccipital areas. Neuropsychologic testing revealed visuospatial deficits in all 5 patients tested. Conclusions Visual symptoms might be the presenting (or rarely only) manifestation of Alzheimer's disease. Clinicians should be aware of the visual variant of Alzheimer's disease. Neuropsychological testing and magnetic resonance imaging (MRI) provide supporting evidence for the diagnosis. Positron emission tomography scans might be helpful in selected cases, especially those with a normal MRI.

Subcortical and brainstem structures are increasingly becoming recognized as important contributors to higher cognitive functioning. Decision-making is one such function, particularly as viewed within the framework of the somatic marker hypothesis (SMH). The SMH views the participation in decision-making by the body proper as integral to emotional biasing and hence key to choosing in an advantageous manner. This study focuses on the vagus nerves as a possible conduit for somatic afferent signals pertinent to decision-making. We tested eight epileptic patients with implanted left vagus nerve stimulators. To assess decision-making we used the gambling task, which is sensitive to real-life decision-making deficits. Using a counterbalanced design, each participant performed the gambling task under a condition in which low-level vagus nerve stimulation (VNS) was covertly delivered, and another condition in which no VNS was delivered. Participants showed improved performance, that is, made more advantageous choices, in the stimulated relative to the unstimulated condition. Although these results should be viewed as preliminary, they suggest that the vagus nerve is a conduit for afferent somatic signals that can influence decision-making.

BackgroundMechanical thrombectomy with stent-retrievers results in higher recanalization rates compared with previous devices. Despite successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b) of 70–83%, good outcomes by 90-day modified Rankin Scale (mRS) score ≤2 are achieved in only 40–55% of patients. We evaluated predictors of poor outcomes (mRS >2) despite successful recanalization (TICI ≥2b) in the North American Solitaire Stent Retriever Acute Stroke (NASA) registry.MethodsLogistic regression was used to evaluate baseline characteristics and recanalization outcomes for association with 90-day mRS score of 0–2 (good outcome) vs 3–6 (poor outcome). Univariate tests were carried out for all factors. A multivariable model was developed based on backwards selection from the factors with at least marginal significance (p≤0.10) on univariate analysis with the retention criterion set at p≤0.05. The model was refit to minimize the number of cases excluded because of missing covariate values; the c-statistic was a measure of predictive power.ResultsOf 354 patients, 256 (72.3%) were recanalized successfully. Based on 234 recanalized patients evaluated for 90-day mRS score, 116 (49.6%) had poor outcomes. Univariate analysis identified an increased risk of poor outcome for age ≥80 years, occlusion site of internal carotid artery (ICA)/basilar artery, National Institute of Health Stroke Scale (NIHSS) score ≥18, history of diabetes mellitus, TICI 2b, use of rescue therapy, not using a balloon-guided catheter or intravenous tissue plasminogen activator (IV t-PA), and >30 min to recanalization (p≤0.05). In multivariable analysis, age ≥80 years, occlusion site ICA/basilar, initial NIHSS score ≥18, diabetes, absence of IV t-PA, ≥3 passes, and use of rescue therapy were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index=0.80).ConclusionsAge, occlusion site, high NIHSS, diabetes, no IV t-PA, ≥3 passes, and use of rescue therapy are associated with poor 90-day outcome despite successful recanalization.

Patients with pathological laughter and crying (PLC) are subject to relatively uncontrollable episodes of laughter, crying or both. The episodes occur either without an apparent triggering stimulus or following a stimulus that would not have led the subject to laugh or cry prior to the onset of the condition. PLC is a disorder of emotional expression rather than a primary disturbance of feelings, and is thus distinct from mood disorders in which laughter and crying are associated with feelings of happiness or sadness. The traditional and currently accepted view is that PLC is due to the damage of pathways that arise in the motor areas of the cerebral cortex and descend to the brainstem to inhibit a putative centre for laughter and crying. In that view, the lesions 'disinhibit' or 'release' the laughter and crying centre. The neuroanatomical findings in a recently studied patient with PLC, along with new knowledge on the neurobiology of emotion and feeling, gave us an opportunity to revisit the traditional view and propose an alternative. Here we suggest that the critical PLC lesions occur in the cerebro-ponto-cerebellar pathways and that, as a consequence, the cerebellar structures that automatically adjust the execution of laughter or crying to the cognitive and situational context of a potential stimulus, operate on the basis of incomplete information about that context, resulting in inadequate and even chaotic behaviour.

Background and Purpose— Efficient and timely recanalization is an important goal in acute stroke endovascular therapy. Several studies demonstrated improved recanalization and clinical outcomes with the stent retriever devices compared with the Merci device. The goal of this study was to evaluate the role of the balloon guide catheter (BGC) and recanalization success in a substudy of the North American Solitaire Acute Stroke (NASA) registry. Methods— The investigator-initiated NASA registry recruited 24 clinical sites within North America to submit demographic, clinical, site-adjudicated angiographic, and clinical outcome data on consecutive patients treated with the Solitaire Flow Restoration device. BGC use was at the discretion of the treating physicians. Results— There were 354 patients included in the NASA registry. BGC data were reported in 338 of 354 patients in this subanalysis, of which 149 (44%) had placement of a BGC. Mean age was 67.3±15.2 years, and median National Institutes of Health Stroke Scale score was 18. Patients with BGC had more hypertension (82.4% versus 72.5%; P =0.05), atrial fibrillation (50.3% versus 32.8%; P =0.001), and were more commonly administered tissue plasminogen activator (51.6% versus 38.8%; P =0.02) compared with patients without BGC. Time from symptom onset to groin puncture and number of passes were similar between the 2 groups. Procedure time was shorter in patients with BGC (120±28.5 versus 161±35.6 minutes; P =0.02), and less adjunctive therapy was used in patients with BGC (20% versus 28.6%; P =0.05). Thrombolysis in cerebral infarction 3 reperfusion scores were higher in patients with BGC (53.7% versus 32.5%; P P =0.002) and good clinical outcome at 3 months were superior in patients with BGC compared with patients without (51.6% versus 35.8%; P =0.02). Multivariate analysis demonstrated that the use of BGC was an independent predictor of good clinical outcome (odds ratio, 2.5; 95% confidence interval, 1.2–4.9). Conclusions— Use of a BGC with the Solitaire Flow Restoration device resulted in superior revascularization results, faster procedure times, decreased need for adjunctive therapy, and improved clinical outcome.

BackgroundLimited post-marketing data exist on the use of the Solitaire FR device in clinical practice. The North American Solitaire Stent Retriever Acute Stroke (NASA) registry aimed to assess the real world performance of the Solitaire FR device in contrast with the results from the SWIFT (Solitaire with the Intention for Thrombectomy) and TREVO 2 (Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischemic stroke) trials.MethodsThe investigator initiated NASA registry recruited North American sites to submit retrospective angiographic and clinical outcome data on consecutive acute ischemic stroke (AIS) patients treated with the Solitaire FR between March 2012 and February 2013. The primary outcome was a Thrombolysis in Myocardial Ischemia (TIMI) score of ≥2 or a Treatment in Cerebral Infarction (TICI) score of ≥2a. Secondary outcomes were 90 day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage.Results354 patients underwent treatment for AIS using the Solitaire FR device in 24 centers. Mean time from onset to groin puncture was 363.4±239 min, mean fluoroscopy time was 32.9±25.7 min, and mean procedure time was 100.9±57.8 min. Recanalization outcome: TIMI ≥2 rate of 83.3% (315/354) and TICI ≥2a rate of 87.5% (310/354) compared with the operator reported TIMI ≥2 rate of 83% in SWIFT and TICI ≥2a rate of 85% in TREVO 2. Clinical outcome: 42% (132/315) of NASA patients demonstrated a 90 day mRS ≤2 compared with 37% (SWIFT) and 40% (TREVO 2). 90 day mortality was 30.2% (95/315) versus 17.2% (SWIFT) and 29% (TREVO 2).ConclusionsThe NASA registry demonstrated that the Solitaire FR device performance in clinical practice is comparable with the SWIFT and TREVO 2 trial results.

Introduction/purpose Posterior circulation strokes with basilar occlusions have the worse clinical outcomes of all strokes. The outcome data utilizing new generation stent retrievers is sparse as most of the clinical trials evaluating stent retrievers exclude posterior circulation strokes. This retrospective review was undertaken to report our experience with stent retrievers in acute basilar occlusions. Materials/methods From March 2012 to March 2016, we performed thrombus retrieval in 337 patients. Retrospective review revealed 23 patients (7%) with basilar occlusions were treated with stent retrieval and adjuvant therapy. • Patient demographic: ○ 23 patients: 16 males, 7 females ○ Age ranged from 29–87 years (mean: 60.4, median: 63) • Presentation time from symptom onset: ○ 0–3 hours: 4 patients ○ 3–8 hours: 6 patients ○ Time unknown: 13 patients. 9/13 patients: wake up strokes ○ Intravenous TPA was administered in 4/23 patients (17%) ○ Initial non contrast CT scan findings: ○ Negative: 17 patients ○ Positive for patchy strokes: 6 patients ○ Dense basilar artery on CT: 9 patients • Thrombectomy device utilized: ○ Solitaire 4x20mm in 7, 4x40mm in 4, 6x30mm in 9, 6x20mm in 1 patient ○ In one patient solitaire could not be deployed ○ In one patient: Trevo was utilized ○ Balloon guide catheters were used in 10 patients with balloon dilated in the Subclavian artery. In 9 patients, local suction with stent retrievers was applied.o 6/23 patients required stent placement for underlying stenosis Results • NIHSS ○ NIHSS at presentation range from 2–38 (mean: 24, median: 22.5) ○ NIHSS 24 hour post intervention range from 0–38 (mean: 17, median: 13.5) • Number of passes: ○ Pass attempts range from 1–5. Successful 1 st pass achieved in 10 patients (mean number of passes: 2/patient) • TICI scores: ○ Initial TICI pre procedure: TICI 0: 19 patients, TICI 1/2a: 4 patients ○ Final TICI score post procedure: TICI 3: 11, TICI 2c: 2, TICI 2b: 5, TICI 1: 2, and TICI 0: 3 patients. Successful reperfusion (TICI 2b or higher) was achieved in 18/23 patients (78.3%). • Outcome: ○ Modified Rankin Score (MRS) at discharge/90 days: Death (6): 10 patients MRS 0–2 (good clinical outcome group): 7/23 (30%) MRS 3–5: 5 patients 1 patient declined follow up Good clinical outcome group 5/7 patients presented within 6 hours of symptom onset while 2/7 patients presented as wake up strokes. Initial CT findings were negative in all 7 patients. Conclusion Although the successful recanalization rate (TICI 2 b or higher) in basilar occlusions is high (18/23 (78.3%)), the mortality (10/23 (43%)) and morbidity with MRS ≥ 3 (5/23 (22%)) remains disappointingly high. In our study, good clinical outcome (MRS 0–2) was achieved in 30% (7/23) of patients, better than the natural course in basilar occlusions, which is encouraging. This group highlights the value of early presentation and a negative CT as strong predictors of a good outcome. The prognosis in patients with basilar occlusions with positive CT findings and unknown time of onset remain guarded. Disclosures I. Akhtar: None. J. Halpin: None. W. Holloway: None. C. Martin: None. N. Akhtar: None.

Introduction/purpose Stents for the intracranial circulation are approved for stent assisted coiling of brain aneurysms, flow diversion of brain aneurysms and atherosclerotic occlusive disease. These stents are deliverable and approved for intracranial placement of cerebral arteries ranging in size from 2.5 to 4.5 mm. The relatively small stents are unsuitable for skull based internal carotid artery for dissection and venous sinus deployment due to the large diameter of these vessels. Self-expandable cobalt chromium carotid stents are properly sized to these circulations but do not track the curvatures of the intracranial arterial and venous circulations. These self-expanding cobalt chromium carotid stents are available in 6 and 8 mm diameter sizes and, due to the braided design, these implants will track curves when partially deployed. We report a technique of partially deploying a cobalt chromium stent within a 072 intracranial support catheter which has already been positioned distal to the target. This allows the stent to be advanced around curves and unsheathed directly from the catheter thus allowing intracranial stenting of larger vessels. Materials and methods This is a retrospective review of 11 cases in which cobalt chromium stents were placed in the intracranial circulation at our facility over a two year period. These stents were placed with an 072 intracranial support catheter positioned distal to the target. Three stents were placed in distal cervical ICA transitioning into the horizontal petrous ICA. Eight stents were placed in the venous circulation (1 straight sinus to transverse sinus, 5 transverse sinus, 1 transverse-sigmoid junction, 1 sigmoid-jugular junction). In two venous cases, the stents were used to support coil masses. Results All cases in which the cobalt chromium stents were deployed were successful. No neurological sequelae were observed post procedure. Conclusion This technique allows for a wider range of stent sizes to access the tortuous intracranial circulation and provides an additional tool to the neurointerventional surgeon. Disclosures C. Martin: None. I. Akhtar: None. J. Halpin: None. W. Holloway: None. N. Akhtar: None.

Introduction/purpose Endovascular treatment using stent retrievers are now the standard of care in patients with acute ischemic stroke due to proximal middle cerebral artery occlusion. Recent randomized clinical trials have shown stent retriever recanalization rates (TICI 2 b or higher) surpassing 80%. The Solitaire stent retriever is available in different diameters and lengths. More recently, in August 2014, a 4 × 40 device was made available for thrombus retrieval in the US. While there have been many studies comparing the Solitaire to the other mechanical thrombectomy devices, at present, there have been little to no human data comparing the relatively new 4 × 40 Solitaire device with the older 4 × 20 and 4 × 15 devices. In our presentation we will be looking at the cases in which the 4 × 40 device was deployed and compare the recanalization rates to those achieved with cases treated with the 4 × 20 and 4 × 15 in patients with acute stroke. Materials and methods Materials used were the Solitaire Revascularization device in the sizes 4 × 40 mm, 4 × 20 mm, and 4 × 15 mm. All devices are identical in diameter but differ in the working length. Methods This is a retrospective study of 247 stroke patients who underwent clot retrieval using a 4 mm diameter Solitaire device as the first device deployed in a case at Saint Luke’s Hospital of Kansas City from 2012 till January 2016. Of the 247 total patients, 34 had undergone initial endovascular treatment with the Solitaire 4 × 40 device. The remainder were either treated with the 4 × 20 or the 4 × 15 Solitaire devices. Successful recanalization was determined as having a final TICI score of 2b or higher (>50% recanalization). Almost every case was performed with a balloon guide catheter inflated in the neck vasculature with aspiration on the guide catheter during Solitaire retrieval. Results The following Table 1 shows the recanalization rate with the different Solitaire devices. Conclusions The Solitaire 4 × 40 device showed a statistical trend for achieving better recanalization compared to the shorter devices. However due to our small sample size of patients undergoing treatment with the 4 × 40, further investigation is warranted to determine whether this result is maintained in larger sample size such as the STRATUS registry. Disclosures W. Holloway: None. I. Akhtar: None. J. Halpin: None. C. Martin: None. N. Akhtar: None.

To determine whether vascular risk factors, underlying vessel diameter, and/or the type of stent affect restenosis rates for vertebral ostium stents.A single-center retrospective analysis was conducted of 44 patients (31 men; mean age 61 years, range 32-81) who underwent stenting of 48 ostial lesions in the vertebral arteries between 1999 and 2005. Only patients who underwent angiographic follow-up were included in the analysis. Cox regression analysis was utilized for risk factor association with binary restenosis (or =50% versus50%). Stent types and stent categories were compared for differences in binary restenosis rates and lumen gain at follow-up angiography.Twenty-three (48%) of 48 lesions hador =50% stenosis at a mean follow-up of 7.7 months. Cigarette smoking was associated with higher binary restenosis rates (p=0.025), while hypertension, diabetes, hyperlipidemia, history of neck radiation, and known coronary artery and/or peripheral vascular disease were not. Reduced binary restenosis rates and improved lumen gain were seen in cobalt chromium balloon-expandable stents compared to non-cobalt chromium stents (p=0.002 and p=0.002, respectively), stainless steel balloon-expandable stents (p=0.005 and p=0.005), and the S670 stent (p=0.069 and p=0.069). The size of stent used was not associated with risk of restenosis (p=0.756).Cobalt chromium stents were associated with reduced restenosis, while smoking was associated with increased restenosis risk.

OBJECTIVE: We hypothesize that subtle neurological signs at baseline could be present in some "good grade" subarachnoid hemorrhage (SAH) patients and that they would have negative prognostic implications. METHODS: We analyzed data from 1000 patients randomized to the Intraoperative Hypothermia for Aneurysm Surgery Trial (World Federation of Neurological Societies Grades I, II, and III). Nine hundred and forty-four patients had a complete National Institutes of Health Stroke Scale (NIHSS) examination performed at baseline. We analyzed the relationship between baseline NIHSS scores and Glasgow Outcome Scale scores at 3 months. Using stepwise logistic regression, we identified the individual NIHSS items that independently predicted outcome to construct a useful shorter version of the scale for SAH. RESULTS: The NIHSS was abnormal at baseline in 23% of the Grade I patients and 82% of the Grade II patients. Baseline NIHSS scores strongly predicted 3-month outcomes (P < 0.001). The NIHSS items that were relevant to predict outcome were level of consciousness, dysarthria, visual fields, and worst motor score for the arms. Baseline NIHSS-SAH scores also independently predicted 3-month outcomes (P < 0.001). CONCLUSION: Subtle neurological signs at baseline are common in World Federation of Neurological Societies Grades I and II patients and are associated with a worse outcome at 3 months. These signs are not detected by the World Federation of Neurological Societies classification. A better stratification of "good grade" SAH patients to predict long-term outcomes may be desirable for clinical trials and practice. Either using the full NIHSS or a shortened version testing level of consciousness, visual fields, dysarthria and worst arm motor score will help to better stratify "good-grade" SAH patients.

A 44-year-old man with right-sided herpes zoster ophthalmicus (HZO) developed ipsilateral third and sixth cranial nerve palsies and first-division trigeminal (fifth cranial nerve) sensory loss. MRI revealed contrast enhancement of the cisternal and cavernous portions of the third cranial nerve and high signal on a FLAIR sequence within the ipsilateral medulla at the presumed location of the trigeminal nucleus and tract. To our knowledge, this is the first report of the combination of these imaging findings in HZO.

The neural correlates of naming concrete entities such as tools (with nouns) and naming actions (with verbs) are partially distinct: the former are linked to the left inferotemporal (IT) region, whereas the latter are linked to the left frontal opercular (FO) and left posterior middle temporal (MT) regions. This raises an intriguing question: How would such neural patterns be influenced by noun–verb homonymy, specifically, naming tasks in which the target words denote objects or actions (e.g., “comb”)? To explore this, we conducted a PET study in which 10 normal participants named visually presented tools or actions. The factor of homonymy yielded interesting effects: For tools, non-homonymous nouns (e.g., “camera”) activated left IT, whereas homonymous nouns (e.g., “comb”) activated both left IT and left FO. For actions, non-homonymous (e.g., “juggle”) and homonymous (e.g., “comb”) verbs activated left FO, MT, and IT, but there was evidence that the FO and MT activations were less widespread for the homonymous verbs. We also found that retrieval of the same exact words (e.g., “comb” and “comb”) produced differential activation in left MT—there was greater MT activation when the words were being used to name actions, than when they were being used to name tools. Our results suggest that noun–verb homonymy has an important influence on the patterns of neural activation associated with words denoting objects and actions, and that even when the phonological forms are identical, the patterns of neural activation are different according to the demands of the task.

Introduction The relationship between the two angiographic parameters, recanalization and reperfusion, as they relate to clinical outcome of acute stroke patients undergoing endovascular intervention is not well defined. We sought to determine the relationship of recanalization of the primary arterial occlusive lesion (AOL) and global reperfusion of the distal vascular bed in patients treated with endovascular stroke rescue at our institution. Hypothesis We assessed the hypothesis that recanalization and reperfusion scores would comparably predict outcome. Methods 96 angiograms were reanalyzed using recanalization and reperfusion scores by neurointerventionalists blinded to clinical outcome. The AOL score was defined as follows: 0=no recanalization of the primary occlusion; I=incomplete or partial recanalization of the primary occlusion with no distal flow; II=incomplete or partial recanalization of the primary occlusion with distal flow; or III=complete recanalization of the primary occlusion with distal flow. The Thrombolysis in Cerebral Infarction (TICI) Score was defined as follows: 0=no perfusion; 1= penetration, but no distal branch filling; 2a= perfusion with incomplete ( 50%) distal branch filling; and 3=full perfusion with filling of all distal branches. We compared these methods of assessment to one another and with good clinical outcome (modified Rankin Score 0 to 2). Results AOL and TICI scores showed moderate to substantial agreement (κ=0.660, 95% CI (0.518 to 0.801). Good clinical outcome was seen in 60% of patients with AOL II/III scores (p=0.462) and in 71% with TICI 2/3 scores (p=0.854). The two methods did not significantly differ in predicting outcome (p=0.52). Conclusion In conclusion, TICI reperfusion scores and AOL recanalization scores comparably predicted clinical outcome in our patient population. However, further investigation should be performed, possibly with the aid of other imaging modalities, to further differentiate between these parameters and their relationship to clinical outcome.

The Centers for Disease Control and Prevention urge physicians to become familiar with chemical and biological weapons. Preparedness among neurologists is especially important because several of these agents affect the nervous system. This article reviews 4 agents that have a history of military or terrorist use: cyanide poisons, organophosphate poisons, botulinum toxin, and anthrax. Cyanide and organophosphate poisons are characterized by dose-dependent impairment of neurological function with nonspecific symptoms such as headache or dizziness at one end of the spectrum and convulsions and coma at the other. Neurological examinations help clinicians to differentiate these agents from other intoxications. Botulinum toxin has a delayed onset of action and results in descending paralysis and prominent cranial nerve palsies. Anthrax frequently causes fulminating hemorrhagic meningitis. Early recognition of these chemical and biological weapons is key to instituting specific therapy and preventing casualties within the health care team and the community at large.