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The objective of this paper is to present a narrative review of the use of triptans in the treatment of trigeminal neuralgia (TN), as well as to outline possible therapeutic mechanisms of action.TN is a debilitating neuropathic disorder with a variety of surgical and pharmacological treatments currently available. Despite treatment being heavily individually tailored, some patients remain refractory to management. The use of triptans for the treatment of TN has been commented on in the literature, yet major trials showing their effectiveness are lacking.A narrative review of current literature was conducted to identify published original research analyzing the usage of triptans in TN via PubMed and Google Scholar.Limited case reports and studies have been done to analyze the use of triptans for the treatment of TN. Despite the limited results, the studies that have been done show some promise for triptans as an alternative treatment, in particular to those with refractory TN. Given the incapacitating nature of TN, another alternative treatment may be of benefit to those patients and can help reduce its associated morbidity.Patients with refractory TN may find relief of symptoms from the use of triptans. Larger clinical trials are needed to help determine which patients would benefit from their use as well as specific dosing. Caution should be given regarding the long-term use of triptans, in particular for the typical patient population with TN.

Background The clinical efficacy of mechanical thrombectomy has been unequivocally demonstrated in multiple randomized clinical trials. However, these studies were performed in carefully selected centers and utilized strict inclusion criteria. Aim We aimed to assess the clinical effectiveness of mechanical thrombectomy in a prospective registry. Methods A total of 2008 patients from 76 sites across 12 countries were enrolled in a prospective open-label mechanical thrombectomy registry. Patients were categorized into the corresponding cohorts of the SWIFT-Prime, DAWN, and DEFUSE 3 trials according to the basic demographic and clinical criteria without considering specific parenchymal imaging findings. Baseline and outcome variables were compared across the corresponding groups. Results As compared to the treated patients in the actual trials, registry-derived patients tended to be younger and had lower baseline ASPECTS. In addition, time to treatment was earlier and the use of intravenous tissue plasminogen activator (IV-tPA) and general anesthesia were higher in DAWN- and DEFUSE-3 registry derived patients versus their corresponding trials. Reperfusion rates were higher in the registry patients. The rates of 90-day good outcome (mRS0-2) in registry-derived patients were comparable to those of the patients treated in the corresponding randomized clinical trials (SWIFT-Prime, 64.5% vs. 60.2%; DAWN, 50.4% vs. 48.6%; Beyond-DAWN: 52.4% vs. 48.6%; DEFUSE 3, 52% vs. 44.6%, respectively; all P > 0.05). Registry-derived patients had significant less disability than the corresponding randomized clinical trial controls (ordinal modified Rankin Scale (mRS) shift odds ratio (OR), P Conclusion Our study provides favorable generalizability data for the safety and efficacy of thrombectomy in the “real-world” setting and supports that patients may be safely treated outside the constraints of randomized clinical trials.

Chiari Malformation Type I (CM) includes a range of cranial abnormalities at the junction of the skull with the spine, with common symptoms including pain and headaches. Currently, CM pain is managed medically through anti-inflammatory drugs, muscle relaxants, and opioids, while surgical management includes posterior fossa decompression. Given the adverse effects of opioid use, and an ongoing opioid epidemic, there is a need for safe, non-opioid alternatives for clinical pain management. This systematic review was performed to provide an update on the current literature pertaining to the treatment of CM pain with non-opioid alternatives. A literature search was performed in June 2022 utilizing the PubMed and Google Scholar databases, and articles were identified that included information regarding non-opioid pain management in CM patients. A total of 90 articles were obtained from this search, including 10 relevant, drug-specific studies. Two independent reviewers selected and included all relevant articles based on the chosen search criteria to minimize bias risk. Currently available treatments for neurosurgical pain management include anticonvulsants, corticosteroids, NSAIDs, anti-inflammatory drugs, NMDA receptor antagonists, local anesthetics, nerve blocks, scalp blocks, and neuromuscular blocks. While more information is needed on the use of non-opioid pain management, the present literature provides potential evidence of its efficacy amongst the CM patient population, on account of the success that non-opioid pain management has demonstrated within other neurological pain syndromes. Further research into non-pharmacological pain management would also benefit the CM population and could be generalized to related conditions.

Introduction Currently, the most effective treatment strategy for adults with hydrocephalus involves cerebrospinal fluid diversion by means of a shunt system, most commonly ventriculoperitoneal shunts (VPS). Ventriculoperitoneal shunting is associated with high complication and/or revision rates, in part due to the high-profile programmable valve designs. Thus, the valve-agnostic cranial implant (VACI) was designed and investigated as a safe and effective method of reducing the valve's high profile and is currently undergoing clinical trials. As such, the objective of this study was to collate preliminary, multi-institutional data of early outcomes using a VACI approach for patients requiring VPS by way of an Institutional Review Board approved registry. Methods A total of 25 adult patients across 4 institutions and 6 surgeons underwent VACI placement for VPS based on preoperative evaluation and perceived benefit. Patient demographics, operative details, and preliminary outcomes are presented here. Results Valve-agnostic cranial implant placement via a limited size craniectomy at time of shunt revision was performed with no adverse events. Over an average follow-up period of 1 year (394 ± 178 days), 92% of patients experienced no major shunt-related or scalp-related complications. There were 2 cases with a major complication requiring reoperation: 1 shunt tubing extrusion and 1 case of meningitis. The most frequent postsurgical intervention seen in this study was related to adjustment of drainage: a non-invasively performed valve reprogramming after initial shunt placement when proper flow rate is being established. Of the 8 cases of drainage adjustment, all but 1 (88%) were receiving a VPS for the first time, with the exception undergoing a fourth shunt revision. All instances of improper flow were treated non-surgically and remediated effectively via shunt reprogramming in clinic. Removal of the VACI was not indicated in any treatment course. In this way, all complications as they relate to the shunt valve were minor and required nonsurgical intervention, and no complications reported were directly or indirectly caused by using the VACI. Conclusion Preliminary findings from this multicenter trial suggest promising outcomes with a low complication rate for patients with hydrocephalus undergoing VACI placement during VPS. Ongoing research will continue to provide a more robust clinical picture of VACI in hydrocephalus management as more data becomes available.

In this review, we examine the postulated mechanisms of therapeutic effect of ketogenic diets in the treatment of gliomas, review the completed clinical trials, and discuss further directions in this field. Cancers including gliomas are characterized by derangements in cellular metabolism. In vitro and animal studies have revealed that dietary interventions to reduce glucose and glycolytic pathways in gliomas may have a therapeutic effect. Early trials in patients with malignant gliomas have shown feasibility, but are not robust enough yet to demonstrate clinical applicability. Therapies for malignant gliomas of the brain are increasingly using a multi-targeted approach. The use of ketogenic diets and its variants may offer a unique and promising anti-glioma treatment by exploiting metabolic alterations seen in cancers including gliomas seen at the cellular level, which may work in concert with other therapies.

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.

BACKGROUND Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm. OBJECTIVE To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT). METHODS HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up. RESULTS A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms. CONCLUSION Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms. VIDEO ABSTRACT

Improved Patient Outcomes In A Specialized Neurological Emergency Department Introduction: Stroke is now the fifth leading cause of death in the U.S., but remains the leading cause of long term disability. Target: Stroke helps hospitals achieve improved stroke outcomes through reduced door-to-needle times for eligible stroke patients. Phase III of the American Heart Association/American Stroke Association initiative set more aggressive targets for timely treatment with IV alteplase. To achieve rapid treatment times and better patient outcomes, we created a neurologic emergency department (Neuro ED). Neuro ED hours are staffed by emergency physicians with specialized neuroscience training and administer IV alteplase independently, compared to the traditional ED (TED) where emergency providers consult neurology. Methods: This is a retrospective observational study from 2019-2021 comparing outcomes of acute ischemic stroke patients who received IV alteplase following implementation of the Neuro ED compared to a TED. The following metrics were calculated for each patient: Door to Needle times (DTN), door to CT times (DTCT), and pre and post National Institute of Health Stroke Scale (NIHSS) Results: 74 patients were treated in the Neuro ED and 45 patients were treated in the TED. Average DTN times in the Neuro ED were 27 minutes compared to 65 minutes in the TED. Patients treated in the Neuro ED achieved DTN times of 45 min or less 87% of cases, while only 24% of the time in the TED. Patients treated in the Neuro ED achieved DTN times of 30 min or less 65% of cases, with only 4% of cases in the TED. Average DTCT times in the Neuro ED were 8 minutes faster than the TED. No differences in admission NIHSS were found with an average of 8.75, but a significant improvement was found in discharge NIHSS. Average discharge NIHSS was 3.8 for Neuro ED stroke patients compared with 5.6 for TED patients (p Conclusion: Implementation of a Neuro ED led to swift management and improved symptoms for stroke patients. A dedicated Neuro ED is highly effective in improving DTN times, DTCT times, and overall stroke outcomes.

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

BackgroundChronological heterogeneity in neurological improvement after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke is commonly observed in clinical practice. Understanding the temporal progression of functional independence after EVT, especially delayed functional independence in patients who do not improve early, is essential for prognostication and rehabilitation. We aim to determine the incidence of early functional independence (EFI) and delayed functional independence (DFI), identify associated predictors after EVT, and develop the Delayed Functional Independence After Neurothrombectomy (DEFIANT) score.MethodsDemographic, clinical, radiological, treatment, and procedural information were analyzed from the Trevo Registry (patients undergoing EVT due to anterior LVO using the Trevo stent retriever). Incidence and predictors of EFI (modified Rankin Scale (mRS) score 0–2 at discharge) and DFI (mRS score 0–2 at 90 days in non-EFI patients) were analyzed.ResultsA total of 1623 patients met study criteria. EFI was observed in 45% (730) of patients. Among surviving non-EFI patients (884), DFI was observed in 35% (308). Younger age (p=0.003), lower discharge National Institutes of Health Stroke Scale (NIHSS) score (phttps://bit.ly/3KZRVq5).ConclusionApproximately 45% of patients experience EFI. About one-third of non-early improvers experience DFI. Younger age, lower discharge NIHSS score, and absence of any hemorrhage were independent predictors of DFI among non-early improvers.

BACKGROUND Implantable shunt devices are critical and life saving for hydrocephalus patients. However, these devices are fraught with high complication rates including scalp dehiscence, exposure, and extrusion. In fact, high shunt valve profiles are correlated with increased complications compared to those with lower profiles. As such, we sought a new method for integrating shunt valves for those challenging patients presenting with scalp-related complications. OBJECTIVE To safely implant and integrate a hydrocephalus shunt valve device within a customized cranial implant, in an effort to limit its high-profile nature as a main contributor to shunt failure and scalp breakdown, and at the same time, improve patient satisfaction by preventing contour deformity. METHODS A 64-yr-old male presented with an extruding hydrocephalus shunt valve and chronic, open scalp wound. The shunt valve was removed and temporary shunt externalization was performed. He received 2 wk of culture-directed antibiotics. Next, a contralateral craniectomy was performed allowing a new shunt valve system to be implanted within a low-profile, customized cranial implant. All efforts were made, at the patient's request, to decrease the high-profile nature of the shunt valve contributing to his most recent complication. RESULTS First-in-human implantation was performed without complication. Postoperative shunt identification and programming was uncomplicated. The high-profile nature of the shunt valve was decreased by 87%. At 10 mo, the patient has experienced no complications and is extremely satisfied with his appearance. CONCLUSION This first-in-human experience suggests that a high-profile hydrocephalus shunt device may be safely integrated within a customized cranial implant.

Objective Carotid artery stenosis is frequently diagnosed through screening tests with noninvasive imaging. Because of differences noted between the various modalities, we sought to investigate our experience comparing noninvasive imaging (ultrasound, computed tomography angiography, magnetic resonance angiography) with invasive imaging (digital subtraction angiography). Methods In a multicenter retrospective analysis, 249 carotid vessels were reviewed based on angiography with the associated noninvasive imaging. Results Overall, medical or surgical decision management was changed in 43% (107/243) of cases investigated with digital subtraction angiography owing to a discrepancy between the measured percentage stenosis. In patients with potentially treatable carotid stenosis, angiography revealed nonsignificant stenosis 25.7% of the time. Conclusions Angiography should be considered the confirmatory test for degree of stenosis in certain patients before definitive surgical treatment.

Background The effect of time from stroke onset to thrombectomy in the extended time window remains poorly characterized. Aim We aimed to analyze the relationship between time to treatment and clinical outcomes in the early versus extended time windows. Methods Proximal anterior circulation occlusion patients from a multicentric prospective registry were categorized into early (≤6 h) or extended (>6–24 h) treatment window. Patients with baseline National Institutes of Health Stroke Scale (NIHSS) ≥ 10 and intracranial internal carotid artery or middle cerebral artery-M1-segment occlusion and pre-morbid modified Rankin scale (mRS) 0–1 (“DAWN-like” cohort) served as the population for the primary analysis. The relationship between time to treatment and 90-day mRS, analyzed in ordinal (mRS shift) and dichotomized (good outcome, mRS 0–2) fashion, was compared within and across the extended and early windows. Results A total of 1603 out of 2008 patients qualified. Despite longer time to treatment (9[7–13.9] vs. 3.4[2.5–4.3] h, p Conclusions The impact of time to thrombectomy on outcomes appears to be time dependent with a steep influence in the early followed by a less significant plateau in the extended window. However, every effort should be made to shorten treatment times regardless of ischemia duration.

Introduction: A 2013 study supported by the American Academy of Neurology showed an 11% shortage of neurologists with a projected 19% shortage by 2025. An additional supply of 3000 neurologists is needed by 2025 to meet the looming demand. To help ease the shortage, teleneurology has been implemented by neurologists, mainly for acute stroke patients. We present our model of emergency physician Stroke Champions (SCs) to direct care for stroke patients. Methods: Administering thrombolytics for stroke is a key component of emergency medicine core competencies. Our health system consists of 4 hospitals; a main hub and 3 spoke hospitals. The hub hospital innovatively developed a Neurologic Emergency Department (Neuro ED) with 5 board certified emergency physicians dedicated to caring for patients with any type of neurological complaint. The Neuro ED physicians are also designated as SCs that have specialized training to provide teleneurology to fellow emergency physicians caring for acute stroke patients at the additional hospitals. This supplementary training consists of a mini neurology fellowship with rotations through the neurologic ICU, specialized stroke floor, neurointerventional suite, and neuroradiology. Results: Over a 90-day period the command center received 67 phone calls for patients that met stroke alert criteria. Calls entailed managing BP, dosing alteplase, and recommendations for advanced neuroimaging. Most importantly, the SCs extensively reviewed inclusion and exclusion criteria for IV alteplase with the spoke emergency physician. Three patients were deemed eligible for IV alteplase, with no cases of intracranial hemorrhage. Seven patients required transfer and was facilitated by the SCs, reducing any delays. Reasons for transfer included 3 cases of hemorrhagic stroke, 3 large vessel occlusions for mechanical thrombectomy - one of which received IV alteplase, and 1 brain tumor. Conclusion: Teleneurology is a reliable means of reaching and treating stroke patients. With the severe current shortage of neurologists in the U.S., we now demonstrate a promising alternative of emergency physician Stroke Champions providing telestroke care. This model has produced a high success rate raising the standard of acute neurological care.

Background and Purpose: The clinical efficacy of mechanical thrombectomy (MT) has been unequivocally demonstrated in multiple randomized clinical trials (RCTs). However, these studies were performed in carefully selected centers and utilized strict inclusion criteria. We aim to assess the clinical effectiveness of MT by comparing the specific RCT populations with corresponding patient cohorts derived from a prospective registry. Methods: A total of 2008 patients from 76 sites across 12 countries were enrolled in a prospective open-label MT registry. Patients were categorized into the corresponding cohorts of the SWIFT-Prime, DAWN, and DEFUSE 3 trials based on the age, baseline NIHSS, occlusion site, IV tPA use, pre-morbid mRS and time to treatment criteria used in the RCTs without considering specific parenchymal imaging findings. Baseline and outcome variables were compared across the corresponding groups. Results: As compared to the treated patients in the actual trials, registry-derived patients tended to be younger and had lower baseline ASPECTS. In addition, time to treatment was earlier and the use of IV tPA and general anesthesia were higher in DAWN- and DEFUSE 3-registry derived patients versus their corresponding trials. Reperfusion rates were higher in the registry patients. The rates of 90-day good outcome (mRS 0-2) in registry-derived patients were comparable to those of the patients treated in the corresponding RCTs (SWIFT-Prime, 64.5% vs 60.2%; DAWN, 50.4% vs 48.6%; Beyond-DAWN: 52.4% vs 48.6%; DEFUSE 3, 52% vs 44.6%, respectively; all P>0.05). Registry-derived patients had significant less disability than the corresponding RCT controls (ordinal mRS shift OR, P Conclusion: Our study provides favorable generalizability data for the safety and efficacy of thrombectomy in the “real-world” setting and supports that patients may be safely treated outside the constraints of RCTs and strict guidelines.

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

Background and Purpose: Advanced imaging has been increasingly used for patient selection in endovascular stroke therapy. The impact of imaging selection modality on endovascular stroke therapy clinical outcomes in extended time window remains to be defined. We aimed to study this relationship and compare it to that noted in early-treated patients. Methods: Patients from a prospective multicentric registry (n=2008) with occlusions involving the intracranial internal carotid or the M1- or M2-segments of the middle cerebral arteries, premorbid modified Rankin Scale score 0 to 2 and time to treatment 0 to 24 hours were categorized according to treatment times within the early (0–6 hour) or extended (6–24 hour) window as well as imaging modality with noncontrast computed tomography (NCCT)±CT angiography (CTA) or NCCT±CTA and CT perfusion (CTP). The association between imaging modality and 90-day modified Rankin Scale, analyzed in ordinal (modified Rankin Scale shift) and dichotomized (functional independence, modified Rankin Scale score 0–2) manner, was evaluated and compared within and across the extended and early windows. Results: In the early window, 332 patients were selected with NCCT±CTA alone while 373 also underwent CTP. After adjusting for identifiable confounders, there were no significant differences in terms of 90-day functional disability (ordinal shift: adjusted odd ratio [aOR], 0.936 [95% CI, 0.709–1.238], P =0.644) or independence (aOR, 1.178 [95% CI, 0.833–1.666], P =0.355) across the CTP and NCCT±CTA groups. In the extended window, 67 patients were selected with NCCT±CTA alone while 180 also underwent CTP. No significant differences in 90-day functional disability (aOR, 0.983 [95% CI, 0.81–1.662], P =0.949) or independence (aOR, 0.640 [95% CI, 0.318–1.289], P =0.212) were seen across the CTP and NCCT±CTA groups. There was no interaction between the treatment time window (0–6 versus 6–24 hours) and CT selection modality (CTP versus NCCT±CTA) in terms of functional disability at 90 days ( P =0.45). Conclusions: CTP acquisition was not associated with better outcomes in patients treated in the early or extended time windows. While confirmatory data is needed, our data suggests that extended window endovascular stroke therapy may remain beneficial even in the absence of advanced imaging.

Acute carotid terminus occlusion (CTO) is responsible for up to 5% of acute ischemic strokes secondary to emergent large vessel occlusion (ELVO) and up to 20% of acute internal carotid artery (ICA) occlusions.1 The term "CTO" has also been used to describe occlusions in the supra-clinoid segment or at the bifurcation of the ICA. Compared to other ELVOs, patients with CTO present with higher stroke severity and larger infarct volume, likely to be a result of disruption of direct Circle of Willis collaterals across the anterior communicating artery (AComA) and posterior communicating artery (PComA).2,3 Similary, CTO is usually associated with worse prognosis compared to other ELVOs in general. With regard to response to treatment, previous studies have reported significantly lower recanalization rates with intravenous alteplase with CTO compared to M1 segment occlusion. With regard to the safety and efficacy of mechanical thrombectomy, prior reports provide conflicting results with some reporting lower successful recanalization rates with CTO compared to M1 occlusion, and others reporting similar results. In our experience, we have found that successful recanalization of CTO can be achieved with a similar approach to M1 occlusions utilizing a direct aspiration first pass technique (ADAPT).3,4 Herein, we present a case of CTO for which we performed mechanical thrombectomy using ADAPT. This procedure was an emergent standard of care procedure for which a consent was not required and so not obtained.

BackgroundFirst pass effect (FPE), defined as near-total/total reperfusion of the territory (modified Thrombolysis in Cerebral Infarction (mTICI) 2c/3) of the occluded artery after a single thrombectomy attempt (single pass), has been associated with superior safety and efficacy outcomes than in patients not experiencing FPE.ObjectiveTo characterize the clinical features, incidence, and predictors of FPE in the anterior and posterior circulation among patients enrolled in the Trevo Registry.MethodsData were analyzed from the Trevo Retriever Registry. Univariate and multivariable analyses were used to assess the relationship of patient (demographics, clinical, occlusion location, collateral grade, Alberta Stroke Program Early CT Score (ASPECTS)) and device/technique characteristics with FPE (mTICI 2c/3 after single pass).ResultsFPE was achieved in 27.8% (378/1358) of patients undergoing anterior large vessel occlusion (LVO) thrombectomy. Multivariable regression analysis identified American Society of Interventional and Therapeutic Neuroradiology (ASITN) levels 2–4, higher ASPECTS, and presence of atrial fibrillation as independent predictors of FPE in anterior LVO thrombectomy. Rates of modified Rankin Scale (mRS) score 0–2 at 90 days were higher (63.9% vs 53.5%, pConclusionTwenty-eight percent of patients undergoing anterior LVO thrombectomy and 24% of patients undergoing basilar artery occlusion thrombectomy experience FPE. Independent predictors of FPE in anterior circulation LVO thrombectomy include higher ASITN levels, higher ASPECTS, and the presence of atrial fibrillation.

As capabilities for endovascular treatment of intracranial vascular pathologies continue to expand, the need for access to the distal internal carotid artery with rigid support catheter systems continues to increase. One of the dominant factors limiting this access is patient anatomy, specifically vessel tortuosity. Increased tortuosity of the carotid siphon is a frequently encountered anatomic variant and may complicate endovascular procedures in adults and children.1,2 Failed attempts to navigate the carotid siphon with a distal access catheter carry a risk of vessel injury and treatment failure. For this reason, techniques that aid in supporting safe advancement of a distal access catheter across a tortuous carotid siphon are essential.3,4 In this video, we demonstrate 2 ways in which this may be accomplished. The first technique uses a larger diameter microcatheter, such as the AXS Offset catheter (Stryker, Kalamazoo, Michigan), to increase support for the distal access catheter, while the second uses a buddy wire technique to accomplish this increased support. Both of these techniques can help increase the safety of navigating a tortuous carotid siphon and increase the likelihood of successful treatment. The procedures shown were performed with the informed consent of the patients.

BackgroundThere is a paucity of data regarding mechanical thrombectomy (MT) in distal arterial occlusions (DAO). We aim to evaluate the safety and efficacy of MT in patients with DAO and compare their outcomes with proximal arterial occlusion (PAO) strokes.MethodsThe Trevo Registry was a prospective open-label MT registry including 2008 patients from 76 sites across 12 countries. Patients were categorized into: PAO: intracranial ICA, and MCA–M1; and DAO: MCA–M2, MCA–M3, ACA, and PCA. Baseline and outcome variables were compared across the PAO vs DAO patients with pre-morbid mRS 0–2.ResultsAmong 407 DAOs including 350 (86.0%) M2, 25 (6.1%) M3, 10 (2.5%) ACA, and 22 (5.4%) PCA occlusions, there were 376 DAO with pre-morbid mRS 0–2 which were compared with 1268 PAO patients. The median baseline NIHSS score was lower in DAO (13 [8–18] vs 16 [12–20], PConclusionEndovascular therapy in DAO appears to result in a comparable safety and technical success profile as in PAO. The potential benefits of DAO thrombectomy should be investigated in future randomized trials.

Since the International Subarachnoid Aneurysm Trial,1 endovascular treatment has been the favored treatment for appropriate ruptured intracranial aneurysms. While our endovascular technology has advanced to allow us to treat the majority of intracranial aneurysms, simple coil embolization is still the most common modality. This video demonstrates the fundamentals of aneurysm catheterization and coiling for safe treatment. In addition, the set-up and devices are detailed. This video is to add to the library of basic techniques that will aid a large number of practitioners. This patient consented to endovascular treatment. The video demonstrates endovascular coil embolization of a posterior communicating artery aneurysm in a 76-yr-old female who presented with a subarachnoid hemorrhage. Image of biplane suite in video used courtesy of Siemens Medical Solutions USA, Inc. Illustration at 5:12 reprinted from Yasargil MG, et al, Microneurosurgery IV B, p. 9, Thieme, New York, 1995.

BackgroundThe COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US.MethodsThe interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020.ResultsThere were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, PConclusionWe present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center.

Background Vein of Galen aneurysmal malformations (VOGMs) are pial arteriovenous fistulas possessing Galenic venous drainage most commonly presenting during the neonatal period and infancy, with initial discovery during adulthood quite rare. Objectives and methods We conducted a literature survey of the PubMed database in order to identify Galenic pial arteriovenous fistulas (GPAVFs) with major manifestation or initial presentation during adulthood. Inclusionary criteria included pial AVFs with Galenic drainage with major manifestation or initial presentation at, or older than, 18 years. Exclusionary criteria included exclusive pediatric onset of symptomatology attributable to GPAVFs without a new onset major presentation during adulthood, exclusive or major dural arterial supply, arteriovenous malformations with Galenic drainage, developmental venous anomalies with Galenic drainage, isolated varices or anomalies of the vein of Galen, and any lesions with uncertainty regarding true GPAVF nature. Results Our search generated 1589 articles. Excluding duplicates, 26 cases met criteria for evaluation. Mean age was 34.1 +/− 2.53 years. Clinical presentations of GPAVFs among adults included headache, intracranial hemorrhage, seizures, and focal neurologic deficits. Management strategies included observation (n = 5), emergent ventriculostomy or Torkildsen shunt (n = 3), cerebrospinal fluid diversion via ventriculoperitoneal shunting (n = 4), microsurgical obliteration or thrombectomy (n = 4), transarterial and/or transvenous embolotherapeutic obliteration (n = 7), and concurrent embolotherapy and radiosurgical irradiation (n = 1). Conclusions GPAVFs in adults often present with symptomatology of mild severity and may be effectively managed conservatively, though occasionally present catastrophically or may be treated via cerebrospinal fluid diversion, microsurgical obliteration, or endovascular embolization. Severity sufficient to require emergent intervention portended a poor outcome.

Background Intravenous (IV) alteplase with mechanical thrombectomy has been found to be superior to alteplase alone in select patients with intracranial large vessel occlusion. Current guidelines discourage the use of antiplatelet agents or heparin for 24 h following alteplase. However, their use is often necessary in certain circumstances during thrombectomy procedures. Objective To study the safety and outcomes in patients who received blood thinning medications for thrombectomy after IV Tissue-Type plasminogen activator (tPA). Methods This is a multicenter retrospective review of the use of antiplatelet agents and/or heparin in patients within 24 h following tPA administration. Patient demographics, comorbidities, bleeding complications, and discharge outcomes were collected. Results A series of 88 patients at 9 centers received antiplatelet medications and/or heparin anticoagulation following IV alteplase for revascularization procedures requiring stenting. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 14.6. Reasons for use of a stent included internal carotid artery occlusion in 74% of patients. Thrombolysis in cerebral infarction (TICI) 2b-3 revascularization was accomplished in 90% of patients. The rate of symptomatic intracranial hemorrhage (sICH) was 8%; this was not significantly different than the sICH rate for a matched group of patients not receiving antiplatelets or heparin during the same time frame. Functional independence at 90 d (modified Rankin Scale 0-2) was seen in 57.8% of patients. All-cause mortality was 12%. Conclusion The use of antiplatelet agents and heparin for stroke interventions following IV alteplase appears to be safe without significant increased risk of hemorrhagic complications in this group of patients when compared to control data and randomized controlled trials.

International audience; Background and purpose: The purpose of this study was to evaluate the safety and effectiveness of mechanical thrombectomy (MT) in patients with acute ischaemic stroke related to isolated and primary posterior cerebral artery (PCA) occlusions amongst the patients enrolled in the multicentre post‐market Trevo Registry.Method: Amongst the 2008 patients enrolled in the Trevo Registry with acute ischaemic stroke due to large vessel occlusion treated by MT, 22 patients (1.1%) [10 females (45.5%), mean age 66.2 ± 14.3 years (range 28–91)] had a PCA occlusion [17 P1 (77.3%) and five P2 occlusions (22.7%)]. Recanalization after the first Trevo (Stryker, Fremont, CA, USA) pass and at the end of the procedure was rated using the modified Thrombolysis in Cerebral Infarction (mTICI) score. Procedure‐related complications (i.e. groin puncture complication, perforation, symptomatic haemorrhage, embolus in a new territory) were also recorded. The modified Rankin Scale at 90 days was assessed.Results: Median National Institutes of Health Stroke Scale at admission was 14 (interquartile range 8–16). Stroke aetiology was cardio‐embolic in 68.2% of cases. Half of the patients (11/22) received intravenous tissue plasminogen activator. 54.5% of the patients were treated under general anaesthesia. Reperfusion (i.e. mTICI 2b or 3) after first pass was obtained in 65% of cases. Final mTICI 2b–3 reperfusion was obtained in all cases. Only one (4.5%) procedure‐related complication was recorded (puncture site) that resolved after surgery. At 90‐day follow‐up, modified Rankin Scale 0–2 was obtained in 59% of the patients and 9.1% died within the first 3 months after MT.Conclusion: Mechanical thrombectomy for PCA occlusions seems to be safe (

BACKGROUND The effect of endovascular thrombectomy that is performed more than 6 hours after the onset of ischemic stroke is uncertain. Patients with a clinical deficit that is disproportionately severe relative to the infarct volume may benefit from late thrombectomy. METHODS We enrolled patients with occlusion of the intracranial internal carotid artery or proximal middle cerebral artery who had last been known to be well 6 to 24 hours earlier and who had a mismatch between the severity of the clinical deficit and the infarct volume, with mismatch criteria defined according to age (= 80 years). Patients were randomly assigned to thrombectomy plus standard care (the thrombectomy group) or to standard care alone (the control group). The coprimary end points were the mean score for disability on the utility-weighted modified Rankin scale (which ranges from 0 [death] to 10 [no symptoms or disability]) and the rate of functional independence (a score of 0, 1, or 2 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating more severe disability) at 90 days. RESULTS A total of 206 patients were enrolled; 107 were assigned to the thrombectomy group and 99 to the control group. At 31 months, enrollment in the trial was stopped because of the results of a prespecified interim analysis. The mean score on the utility-weighted modified Rankin scale at 90 days was 5.5 in the thrombectomy group as compared with 3.4 in the control group (adjusted difference [Bayesian analysis], 2.0 points; 95% credible interval, 1.1 to 3.0; posterior probability of superiority, >0.999), and the rate of functional independence at 90 days was 49% in the thrombectomy group as compared with 13% in the control group (adjusted difference, 33 percentage points; 95% credible interval, 24 to 44; posterior probability of superiority, >0.999). The rate of symptomatic intracranial hemorrhage did not differ significantly between the two groups (6% in the thrombectomy group and 3% in the control group, P = 0.50), nor did 90-day mortality (19% and 18%, respectively; P = 1.00). CONCLUSIONS Among patients with acute stroke who had last been known to be well 6 to 24 hours earlier and who had a mismatch between clinical deficit and infarct, outcomes for disability at 90 days were better with thrombectomy plus standard care than with standard care alone. (Funded by Stryker Neurovascular; DAWN ClinicalTrials.gov number, NCT02142283.)

Flow diversion has been a game-changer in the treatment of wide-neck large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms as well as large vertebral artery aneurysms. Prior to their existence, carotid sacrifice or clipping with or without external to internal carotid artery bypass was the mainstay of treatment. Prior to flow diversion, endovascular coil embolization was often not effective as a stand-alone treatment because of the fact that many of these aneurysms present with symptoms created by mass effect on the cavernous sinus cranial nerves by the aneurysm. Packing the aneurysm with coils did nothing to alleviate the mass effect and did not prevent flow from entering the aneurysm. The continued flow causes coil compaction and aneurysm enlargement. Flow diversion addressed both these issues by diverting flow from the aneurysm while allowing the aneurysm to slowly thrombose and shrink. The video is a step-by-step account of this procedure in a 72-yr-old male with a large recurrence of a previously coiled cavernous ICA aneurysm. The procedure was performed following informed consent.

BackgroundRecent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice.MethodsTwenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH).ResultsA total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90-day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH.ConclusionThe TRACK Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations.

Background and Objective: The first pass effect (FPE; achieving complete recanalization with a single thrombectomy device pass) has been shown to be associated with higher rates of good clinical outcomes in patients with acute ischemic stroke. Here, we investigate clinical and radiographic factors associated with FPE in a large U.S. post-marketing registry (TRACK, Trevo Stent-Retriever Acute Stroke). Methods: We analyzed the TRACK database (multicenter registry of 634 patients from 23 centers from March 2013 through August 2015), which 609 patients were included in the final analysis. FPE was defined as a single pass/use of device, TICI 2c/3 recanalization, and no use of rescue therapy. Analysis of individual patient data from TRACK were performed to analyze clinical and radiographic characteristics associated with FPE as well-compared clinical outcomes defined as modified Rankin Scale (mRS) score at 30 and 90 days from hospital discharge to the non-FPE group. Results: The rate of FPE in TRACK was 23% (140/609). There was no association between patient demographics and FPE, including age (p = 0.36), sex (p = 0.50), race (p = 0.50), location of occlusion (p = 0.26), baseline NIHSS (p = 0.62), or past medical history. There was no difference in the use of a balloon-guide catheter or general anesthesia (49 and 57% with FPE vs. 47 and 64%, p = 0.63 and p = 0.14, respectively). Clinical outcomes were significantly associated with FPE; 63 vs. 44% in non-FPE patients achieved mRS 0-2 at 90 days (p = 0.0004). Conclusion: Our study showed that achieving complete recanalization with a single thrombectomy pass using the Trevo device was highly beneficial. The most common clinical factors that are used to determine eligibility for endovascular therapy, such as NIHSS severity, location of occlusion or patient age were not predictive of the ability to achieve FPE.

Background and objective The first pass effect (FPE) has become a novel measure for neurointerventionalists, achieving a complete recanalization with a single thrombectomy device pass, which has been shown to be associated with higher rates of good clinical outcomes. We describe and expand the FPE to one of a large US post-marketing registry (TRACK, Trevo Stent-Retriever Acute Stroke) to elucidate the effect of a single device pass and clinical outcome. Methods TRACK was a core-laboratory adjudicated multicenter registry of 634 patients from 23 centers aimed to evaluate the use of the Trevo device in everyday clinical practice. The TRACK registry was utilized to identify an FPE subgroup (n=140). Baseline features including demographics and clinical data were compared with the non-FPE patients (n=469). Clinical outcome measures included modified Rankin Scale score (mRS) at 30 and 90 days, National Institutes of Health Stroke Scale (NIHSS) score, symptomatic intracranial hemorrhage (sICH), and mortality. FPE was defined as a single pass/use of a device with TICI 2c/3 recanalization, and no use of rescue therapy. Results 609 patients were included in the FPE (140/609, 23%) vs non-FPE (469/609, 77%) subgroup analysis from the TRACK registry. There was no association between patient demographics and FPE group, including age (p=0.36), sex (p=0.50), race (p=0.49), location of occlusion (p=0.26), baseline NIHSS (p=0.61) past medical history including hypertension (p=0.57), atrial fibrillation (p=0.55), diabetes mellitus (p=0.74), hyperlipidemia (p=0.28), coronary artery disease (p=0.27), or history of smoking (p=0.12). The non-FPE group was associated with higher use of intraarterial tPA (FPE: 11% vs non-FPE: 23%). The onset to puncture time in minutes was not significantly different between groups (p=0.31); however, the total procedural time, total fluoroscopic time, and puncture to reperfusion time had significantly shorter mean time in FPE group (p Conclusion The achievement of complete revascularization from a single Trevo Stent-Retriever device pass is associated with higher rates of good clinical outcomes. Additionally, FPE in our subgroup registry analysis was associated with shorter procedural times, lower NIHSS at discharge, and significantly lower rates of EDT. Our analysis was not able to identify any patient demographics that would be associated to achieve first pass effect. Further research is warranted to confirm findings and identify additional factors achieving good clinical outcome after thrombectomy. Disclosures M. Mokin: 2; C; Claret Medical, Nogueira-Stryker Neurovascular (Trevo-2 Trial Principal Investigator; DAWN Trial Principal Investigator, TREVO Registry Steering Committee), Medtronic (SWIFT Trial Steering Committee; SWIFT-Prime Trial Steering Committee ; STAR Trial Angiographic Core Lab), Penumbra (3D Separator Trial Executive Committee), Neuravi (ARISE-2 Steering Committee), Genentech (Physician Advisory Board), Allm Inc (Physician Advisory Board). C. Primiani: None. A. Castonguay: None. R. Nogueira: None. D. Haussen: None. J. English: None. S. Satti: 2; C; Stryker Neurovascular. J. Chen: None. H. Farid: None. C. Borders: None. E. Veznedaroglu: None. M. Binning: None. A. Puri: None. N. Vora: None. R. Budzik: None. G. Dabus: None. I. Linfante: 2; C; Metronic, Stryker, Penumbra, and Cordis. V. Janardhan: None. A. Alshekhlee: None. M. Abraham: None. R. Edgell: None. M. Taqi: None. R. El Khoury: None. A. Majjhoo: None. M. Kabbani: None. M. Froehler: None. I. Finch: None. S. Ansari: None. R. Novakovic: None. T. Nguyen: None. O. Zaidat: 6; C; overall PI for TRACK, Arise II, Co-PI Therapy Trial, Steering committee STRATIS registry.

Background: Combined neuroprotection with endovascular therapy may improve clinical outcomes of only a subset of individuals treated for acute ischemic stroke. The risk/benefit profile of adjunctive treatment may not warrant neuroprotection with successful reperfusion, yet many other individuals have poor outcomes despite revascularization. We hypothesized that optimal candidates for adjunctive neuroprotection may be defined by analyses of subjects with poor clinical outcome despite successful reperfusion in the Trevo Retriever Registry. Methods: The Trevo Retriever Registry dataset was analyzed to define the subset of cases with poor clinical outcome (day 90 mRS 4-6) after successful reperfusion (eTICI 2b50, 2b67, 2c, 3). Multivariate analyses were used to identify predictors of poor outcome using these distinct definitions of successful reperfusion. The influence of covariates, including TLSW, baseline clinical and imaging variables (e.g. ASPECTS, ASITN collateral grade), on defining such optimal neuroprotective candidates was delineated. Results: Successful reperfusion adjudicated by core lab, defined as eTICI ≥ 2b50 included 1,162 subjects, with eTICI ≥ 2b67 in 920, eTICI ≥ 2c in 652 and eTICI 3 in 209. Poor outcome (day 90 mRS 4-6) occurred in 316/1162 (27%) with eTICI ≥ 2b50, 243/920 (26%) with eTICI ≥ 2b67, 172/652 (26%) with eTICI ≥ 2c and 61/209 (29%) with eTICI 3. Across all subsets, multivariate analyses to predict poor outcome after successful reperfusion identified increased age (per year, OR 1.04-1.05, all p= Conclusions: Neuroprotection combined with endovascular therapy may optimally target stroke patients with worse collaterals, diabetes or increased age. Trial design for neuroprotection with revascularization in AIS should leverage these data.

Background: Two recent trials showed a strong benefit of thrombectomy in the extended window. However, these studies were performed in selected centers and utilized strict inclusion criteria. We aim to evaluate the outcomes of thrombectomy in a large prospective cohort treated outside the rigid clinical trial setting. Methods: Trevo Registry patients with ICA, MCA-M1 or M2 occlusions and pre-morbid mRS0-2 were categorized according to time-from-last-seen-well (TLSW) to puncture as early (0-6hours) vs. late (6-24hours). Uni- and multivariate analyzes were performed to identify good outcome (90-day mRS0-2) predictors. Subgroup analyses were performed for the basic DAWN (age >=18, NIHSS >=10, ICA or M1 occlusion, pre-morbid mRS 0-1) and DEFUSE 3 (age 18-90, NIHSS >=6, ICA or MCA-M1 occlusion, mRS 0-2) trial criteria. Results: As compared to the late (n=430), early patients (n=1173) were older (70 vs 68, p=0.011) and had higher IV tPA use (69 vs 25%, p= 6 (1.37 [1.07-1.75]), DM (0.58 [0.44-0.77]), and time to treatment (0.98 [0.97-1.00]) were independent predictors of good outcomes. Imaging modality did not predict outcomes. Similar findings were observed in the early versus late DAWN-like (n=709 vs 257) and DEFUSE 3-like (n=855 vs 273) cohorts. There was great similarity between the outcomes of the Trevo Registry subsets vs their analogous RCTs: early DAWN-like vs SWIFT Prime (90-day mRS 0-2: 57.5 vs 60%; 90-day mRS 6: 11.% vs 9%), Late DAWN-like vs DAWN (50.2 vs 48.6%; 10.6 vs 18%), and Late DEFUSE 3-like vs DEFUSE 3 (52 vs 45%; 10.3 vs 14%). Conclusions: Our study provides favorable data for the generalizability of the safety and efficacy of thrombectomy in the “real-world” setting.

Background: Time to reperfusion (TTR) is commonly cited in clinical outcome after endovascular treatment of acute ischemic stroke, yet collaterals may set the pace of ischemia. Real-world data on fast and slow progressors also remain scarce. We analyzed the impact of TTR on clinical outcome in real-world data using core lab adjudicated angiography, interventional steps and corresponding reperfusion. Methods: 16 key time intervals were calculated from workflow (time of symptom onset, door, picture, puncture) and core lab metrics (clot visualization, first deployment, first reperfusion, final angiography) in real-world data from the Trevo Retriever Registry. These 16 variations of TTR were analyzed overall and by collateral status (ASITN 0-1 versus 2 versus 3-4) to determine the relationship with 90-day clinical outcomes. Results: Real-world data on endovascular therapy from 1,441 subjects in the Trevo Retriever Registry were analyzed to relate TTR with clinical outcomes. Overall metrics for TTR are shown in Table 1. TTR was not linked with collateral status. Using a multivariate model incorporating known predictors, there was no influence of TTR using any of the 16 definitions on clinical outcome. Better collateral status on DSA prior to revascularization showed a potent relationship with 90-day mRS (p Conclusions: Collaterals transform time to reperfusion, linking fast and slow progressors with subsequent clinical outcomes. TTR may be standardized based on these 16 key epochs in endovascular stroke therapy to document workflow metrics. Time is relative, even when measured with detailed, standardized metrics.

Multiple recent randomized trials have shown that mechanical thrombectomy for acute ischemic stroke is superior to IV tissue plasminogen activator alone. Technologic advances have made this a relatively safe procedure. However, complications may occur, especially as more of these procedures are performed. Complication recognition, avoidance, and proper management are paramount in ensuring the best outcomes for patients.

Background Recent randomized controlled trials show benefit of thrombectomy for large vessel occlusion in stroke. Real‐world data aid in assessing reproducibility of outcomes outside of clinical trials. The Trevo Retriever Registry is a multicenter, international, prospective study designed to assess outcomes in a large cohort of patients. Methods and Results The Trevo Registry is a prospective database of patients with large vessel occlusion treated with the Trevo device as the first device. The primary end point is revascularization based on modified Thrombolysis in Cerebral Infarction score and secondary end points include 90‐day modified Rankin Scale, 90‐day mortality, neurological deterioration at 24 hours, and device/procedure related adverse events. Year 2008 patients were enrolled at 76 centers in 12 countries. Median admission National Institutes of Health Stroke Scale was 16 (interquartile range, 11–20). Occlusion sites were internal carotid artery (17.8%), middle cerebral artery (73.5%), posterior circulation (7.1%), and distal vascular locations (1.6%). A modified Thrombolysis in Cerebral Infarction 2b or 3 was achieved in 92.8% (95% CI, 91.6, 93.9) of procedures, with 55.3% (95% CI, 53.1, 57.5) of patients achieving modified Rankin Scale ≤2 at 3 months. Patients meeting revised 2015 American Heart Association criteria for thrombectomy had a 59.7% (95% CI , 56.0; 63.4) modified Rankin Scale 0 to 2 at 3 months, whereas 51.4% treated outside of American Heart Association criteria had modified Rankin Scale 0 to 2. 51.4% (95% CI , 49.6, 55.4). Symptomatic intracranial hemorrhage rate was 1.7% (95% CI , 1.2, 2.4). Conclusions The Trevo Retriever Registry represents real‐world data with stent retriever. The registry demonstrates similar reperfusion rates and outcomes in the community compared with rigorous centrally adjudicated clinical trials. Future subgroup analysis of this cohort will assist in identifying areas of future research. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 02040259.

Introduction Immediate treatment has been shown to decrease the recurrence of cerebrovascular accidents following transient ischemic attacks (TIA), prompting the use of a specialized neurologic emergency department (Neuro ED) to triage patients. Despite these findings, there is little evidence supporting the notion that hospital admission improves post-TIA outcomes. Through the lens of a Neuro ED, this retrospective chart review of TIA patients examines whether hospital admission improves 90-day outcomes. Materials and Methods Two hundred sixty charts of patients discharged with TIA diagnosis were reviewed. These charts encompassed patients with TIA who presented to a main emergency department (ED) or Neuro ED from January 2014 to April 2015. Demographic information, admission ABCD 2 scores, admission National Institutes of Health Stroke Scale scores, and admission Modified Rankin Scale, and reason for any return visits within 90 days were collected. Results This review shows that patients triaged by the Neuro ED were admitted at a lower rate than those seen by the standard ED. Further, patients triaged by the Neuro ED experienced lower readmission and recurrence of stroke or TIA within 90 days. Conclusions These results provide preliminary support for the notion that discharging appropriate TIA patients, with adequate follow-up, will not adversely affect the recurrence of TIA or stroke within 90 days.

Background and purpose Little attention was paid to the transition of care for stroke that may partially explain the long-term trend of stroke rates. We aimed to test the trend of hospitalization attributable to stroke in US adults. Methods Data from National Hospital Discharge Surveys 1980–2010 in patients aged ≥18 (n = 6,527,304) were analyzed to examine the trend of patients with first-list diagnoses of stroke. Stroke comorbidities were classified in stroke patients with second- to seven-listed diagnoses of coronary heart disease, hypertension, diabetes, arrhythmias, or hyperlipidemia. Stroke trends by survey years and birth cohorts were analyzed using univariate, multivariate, and birth cohorts methods. Results Of the total study sample, the prevalence of hospitalization due to stroke was 22.99%, 30.00%, and 27.03% in years of 1980–1989, 1990–1999, and 2000–2010 in males, and 17.30%, 22.04%, and 19.34% in females, respectively. Overall, hospitalization rates in stroke patients significantly increased among adults aged Conclusion A significant increase in stroke hospitalization rate was observed in adults aged

OBJECT The authors sought to determine whether flow diversion with the Pipeline Embolization Device (PED) can approximate microsurgical decompression in restoring function after cranial neuropathy following carotid artery aneurysms. METHODS This multiinstitutional retrospective study involved 45 patients treated with PED across the United States. All patients included presented between November 2009 and October 2013 with cranial neuropathy (cranial nerves [CNs] II, III, IV, and VI) due to intracranial aneurysm. Outcome analysis included clinical and procedural variables at the time of treatment as well as at the latest clinical and radiographic follow-up. RESULTS Twenty-six aneurysms (57.8%) were located in the cavernous segment, while 6 (13.3%) were in the clinoid segment, and 13 (28.9%) were in the ophthalmic segment of the internal carotid artery. The average aneurysm size was 18.6 mm (range 4–35 mm), and the average number of flow diverters placed per patient was 1.2. Thirty-eight patients had available information regarding duration of cranial neuropathy prior to treatment. Eleven patients (28.9%) were treated within 1 month of symptom onset, while 27 (71.1%) were treated after 1 month of symptoms. The overall rate of cranial neuropathy improvement for all patients was 66.7%. The CN deficits resolved in 19 patients (42.2%), improved in 11 (24.4%), were unchanged in 14 (31.1%), and worsened in 1 (2.2%). Overtime, the rate of cranial neuropathy improvement was 33.3% (15/45), 68.8% (22/32), and 81.0% (17/21) at less than 6, 6, and 12 months, respectively. At last follow-up, 60% of patients in the isolated CN II group had improvement, while in the CN III, IV, or VI group, 85.7% had improved. Moreover, 100% (11/11) of patients experienced improvement if they were treated within 1 month of symptom onset, whereas 44.4% (12/27) experienced improvement if they treated after 1 month of symptom onset; 70.4% (19/27) of those with partial deficits improved compared with 30% (3/10) of those with complete deficits. CONCLUSIONS Cranial neuropathy caused by cerebral aneurysm responds similarly when the aneurysm is treated with the PED compared with open surgery and coil embolization. Lower morbidity and higher occlusion rates obtained with the PED may suggest it as treatment of choice for some of these lesions. Time to treatment is an important consideration regardless of treatment modality.

IntroductionThe Solitaire stent retriever registry showed improved reperfusion, faster procedure times, and better outcome in acute stroke patients with large vessel occlusion treated with a balloon guide catheter (BGC) and Solitaire stent retriever compared with a conventional guide catheter. The goal of this study was to evaluate whether use of a BGC with the Trevo stent retriever improves outcomes compared with a conventional guide catheter.MethodsThe TRACK registry recruited 23 sites to submit demographic, clinical, and site adjudicated angiographic and outcome data on consecutive patients treated with the Trevo stent retriever. BGC use was at the discretion of the physician.Results536 anterior circulation patients (of whom 279 (52.1%) had BGC placement) were included in this analysis. Baseline characteristics were notable for younger patients in the BGC group (65.4±15.3 vs 68.1±13.6, P=0.03) and lower rate of hypertension (72% vs 79%, P=0.06). Mean time from symptom onset to groin puncture was longer in the BGC group (357 vs 319 min, P=0.06).Thrombolysis in Cerebral Infarction 2b/3 scores were higher in the BGC cohort (84% vs 75.5%, P=0.01). There was no difference in reperfusion time, first pass effect, number of passes, or rescue therapy. Good clinical outcome at 3 months was superior in patients with BGC (57% vs 40%; P=0.0004) with a lower mortality rate (13% vs 23%, P=0.008). Multivariate analysis demonstrated that BGC use was an independent predictor of good clinical outcome (OR 2; 95% CI 1.3 to 3.1, P=0.001).ConclusionsIn acute stroke patients presenting with anterior circulation large vessel occlusion, use of a BGC with the Trevo stent retriever resulted in improved reperfusion, improved clinical outcome, and lower mortality.