Search

Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.

OBJECTIVE Despite advances in endovascular techniques, mechanical thrombectomy (MT) fails to achieve successful reperfusion in approximately 20% of patients. This study aimed to identify common etiologies and predictors of failed thrombectomy in a contemporary series. METHODS A prospectively maintained database of MT patients between January 2013 and August 2021 was interrogated. Failed MT was defined as a final modified Thrombolysis in Cerebral Infarction score < 2b. Demographic data, procedural details, stroke etiology, and anatomical data in patients who underwent MT with subsequent failed reperfusion were collected. RESULTS Of a total 1010 MT procedures, 120 (11.9%) were unsuccessful. The mean patient age was 66.8 years; 51.5% of patients were male, and 61.1% were White. The most common failure location was intracranial (93.3%) followed by failure at the arch (3.3%) and neck (3.3%). Among patients with intracranial failure, underlying intracranial atherosclerosis (ICAS) was the cause of failure in 84 patients (70%). Compared with patients with successful MT, patients with failed MT had a longer onset to puncture time (p = 0.012) and onset to groin time (p = 0.04). Rescue stenting was performed in 45 cases: 39 patients (4.4%) with successful MT and 6 (5.0%) with MT failure (p = 0.765). Multivariate analysis demonstrated that diabetes mellitus (p = 0.009) was independently associated with unsuccessful reperfusion. CONCLUSIONS Failed MT was encountered in approximately 12% of MT procedures. The most common cause of failed MT was underlying ICAS. Further studies to evaluate better ways of early identification and treatment of ICAS-related large-vessel occlusion are warranted.

Background: Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes. Methods: This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death. Results: Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days ( P P =0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5–3.2], P P =0.04). No significant association was found between trajectory group and hemorrhagic transformation. Conclusions: Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.

We present longitudinal data regarding the outcomes and evolution of mechanical thrombectomy (MT) using a direct aspiration first pass technique.To evaluate the impact of increasing aspiration catheter size.This is a planned analysis of a prospective cohort study that enrolled all patients who underwent a direct aspiration first pass technique MT in a comprehensive stroke center from January 2013 to December 2020. We did exploratory analysis of the characteristics and outcomes of patients who had intracranial internal carotid artery or M1 segment of middle cerebral artery occlusion based on the aspiration catheter bore size (small [041, 054, 058, and 060 inch] vs medium [0.064 and 0.068 inch] and medium vs large [0.071, 0.072, and 0.074 inch]).During the 8-year study period, a total of 1004 patients were included. Median age was 69 years, 49% were female patients, and 60.6% were White. Symptomatic hemorrhagic transformation was observed in 47 patients (4.7%), and 366 patients (36.5%) achieved the modified Rankin scale of 0 to 2 at 90 days after the stroke. For patients with intracranial internal carotid artery or M1 occlusion, medium-bore aspiration catheters were more likely to achieve successful recanalization after first aspiration attempt (63.9% vs 51.4%, P = .015) and had a faster groin-to-reperfusion time (16 vs 20 minutes, P = .001) when compared with small-bore catheters. However, these differences were not significant when comparing medium-bore with large-bore catheters.Medium-bore catheters had better performance measures compared with small-bore catheters. However, large-bore catheters did not show significantly better performance results that suggest a plateau effect.

Introductions: Clinical trials have shown that aspiration thrombectomy is as safe and effective as stent-retriever thrombectomy. Multiple improvements have been made to the aspiration technique over the last few years. In this study, we aim to assess the effect of aspiration catheter bore size on the outcomes of A direct aspiration first pass technique (ADAPT) thrombectomy. Methods: We included patients who underwent ADAPT thrombectomy for M1 or internal carotid artery terminus (ICA-T) occlusions in the Stroke Thrombectomy and Aneurysm (STAR) database. Patients included between July 2016 and July 2022. We compared baseline characteristics, procedural metrics and outcomes between patients who underwent thrombectomy using small bore (0.035”-0.060”), medium bore (0.062”-0.068”) and large bore (0.070”-0.074”) catheters. Results: A total of 1158 patients were included; 576 (49.7%) females, 645 (70%) White, and 464 (40.6%) received IV-tPA. No difference was noticed in age, sex, and vascular risk factors between the 3 different groups. There was higher rate of IV-tPA in the small-bore catheter group (48.8%) compared to the medium and large bore catheter groups (38.4% and 36.7%, respectively) (P=0.03). Procedure duration was shorter when using medium (20 min) and large (18 min) compared to small bore catheters (30 min) (P=0.01). Both medium and large bore catheters were associated with higher rate of successful recanalization (88.9% and 87.9%, respectively) compared to small bore catheters (81.6%) (P=0.010). However, the difference in successful recanalization or procedure duration between medium and large bore catheters was not significant. No difference was noted in the rate of symptomatic hemorrhagic transformation (sICH) (4.7%, 5.3%, and 7.1%; P=0.345), 90-day favorable outcome (modified Rankin Scale 0-2) (41.8%, 39.3%, 40.8%; P=0.766) or 90-day mortality (18.1%, 23.5%, 24.4%; P=0.111) between the groups. Conclusions: Higher rate of successful recanalization and shorter procedure duration were observed when using medium and large bore aspiration catheters compared with small bore catheters in ADAPT technique. However, these procedural benefits were not observed when comparing large bore to medium bore catheters.

Introduction: Management of anterior circulation emergent large vessel occlusion with tandem carotid occlusion (TCO) remains a challenge during mechanical thrombectomy (MT). To day, there is no consensus regarding emergent carotid stenting (ECS) in the setting of MT with TCO. We aimed to compare the outcomes of ECS versus conservative management (MT alone) among patients with TCO. Methods: Data from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 was interrogated. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the ICA or MCA were included in the analyses. We compared baseline, procedural charecteristics, successful reperfusion (mTICI 2b-3), favorable 90-day good outcomes (mRS 0-2), intravenous tPA administration and symptomatic ICH between patients who did or did not undergo ECS. Multivariate regression was performed adjusting for variables of clinical importance. Propensity score matching for IV tPA use was performed to explore its safety with stenting. Results: Among 9812 thrombectomy patients, 688 patients had TCO; 132 underwent emergent stenting and 444 had MT alone. Patients who did not undergo ECS had a higher prevalence of atrial fibrillation (33.9% Vs 9.2%, P Conclusion: ECS during MT for TCO appears to be safe and is associated with better clinical and angiographic outcomes compared to conservative management.

Background: While mechanical thrombectomy (MT) has become the standard of care for acute stroke patients presenting with large vessel occlusion (LVO) and salvageable brain tissue, limited data is currently available regarding the benefits of MT in patents with medium vessel occlusions (MeVO) especially in the posterior circulation (P2 occlusions). Methods: We used the Stroke Thrombectomy and Aneurysm registry (STAR) which included data from 35 stroke centers in North America, Europe, Asia, and South America. We included patients who presented with MeVO in the M2, M3 or P2 segments and underwent MT. We used a Generalized Linear Model to assess the relationship between location of occlusion and outcomes. Results: 9812 patients were included in STAR at the time of this analysis; 43 underwent MT for P2 occlusion, 130 underwent MT for M3 occlusion; and 1273 underwent MT for M2 occlusion. There was no difference in age, sex, race, rate of IV-tPA and stroke severity between patients in all 3 groups (Table 1). There was a trend toward lower rate of atrial fibrillation in patients with P2 and M3 occlusions. Patients with P2 occlusions were less likely to achieve successful recanalization (modified treatment in cerebral infarction score≥2b); intraarterial thrombolysis was used less in P2 occlusions (4.7% compared to 16.2% in M3 occlusions and 10.1% in M2 occlusions). However, there was no difference in the rate of successful first pass. On multivariable analysis, P2 occlusions were not associated with hemorrhagic transformation (OR 2.0, 95% CI 0.7-5.7, P 0.186), 90-day mortality (OR 0.5, 95% CI 0.2-1.4, P 0.183), or 90-day favorable outcome (OR 2.0, 95% CI 0.9-4.4, P 0.084). Conclusions: In this multicenter study, there was no significant difference in safety and efficacy of MT in patients with MeVOs in posterior circulation (P2 occlusions) compared to M2 and M3 occlusions. Improved techniques for successful recanalization are needed for posterior circulation MeVOs.

Background: Despite advances in endovascular techniques, mechanical thrombectomy fails to achieve successful revascularization in approximately 20% of patients. This study evaluates the incidence, and identifies the etiologies and predictors of failed thrombectomy in a contemporary series. Methods: A prospectively maintained database of MT between January 2013 and August 2021 was interrogated. We gathered demographic data, clinical presentation, procedural details and etiology of MT failure on adult patients who underwent MT with subsequent failed recanalization. Angiographic images were interpreted by an independent neuro-interventionalist. Results: Out of a total of 1010 thrombectomies, 120 (11.9%) were unsuccessful. Mean age was 66.8, 51.5% were male and 61.1% were Caucasian. The most common failure location was intracranially (93.3%) followed by failure at the arch and neck (3.3% each). Of those who failed intracranially, underlying intracranial stenosis (ICAS) was seen in 84 patients (70%). Compared to successful MT, failed MT patients had longer onset to puncture time (444 vs 351 minutes, p=0.012) and longer procedural time (55 vs 23 minutes, p= Conclusion: Failed MT was encountered in approximately 12% of cases. The most common cause of failed MT was underlying ICAS. Further studies to evaluate better treatment modalities of ICAS related LVO are warranted.

Introduction Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. Methods A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0–2). Secondary endpoints included complications and radiographic occlusion at follow-up. Results A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. Conclusion Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.

Background: Adjusting for inflation for longitudinal economics analyses is essential to account for changes in monetary valuation. Inflation calculators are common as they provide fast results with minimal resource expenditure. However, their sensitivity to new, high-cost interventions is unknown.Methods: We analyzed hospital payments for acute ischemic stroke survivors from the 2018 5% Medicare Limited Data Sets from the Centers for Medicare and Medicaid Services (CMS). Patients were stratified by severity using the Stroke Administrative Severity Index (SASI) score, which is a validated measure used to describe stroke severity at hospital discharge. Next, we inflated previously published 2014 payments using the US Consumer Price Index: Medical Care (CPI) rates from 2014 to 2018. Results: The inflated 2014 hospital care payments for Mild stroke survivors increased from $6,850 to $7,593, Moderate from $8,456 to $9,373 and Severe from $9,688 to $10,739. After comparing CPI inflated estimates from 2014 to 2018 we found that Mild and Moderate SASI levels were slightly less costly in the true 2018 payments than the inflated 2014 payments, while Severe SASI patients were $2,117 more costly than the 2014 adjusted costs. Our results indicate noteworthy differences in actual versus inflation-adjusted payments particularly for Severe stroke survivors. This is likely due to the emergence and integration of high-cost endovascular thrombectomies (eVT) into standard practice. Conclusions: Though inflation calculators are less resource intensive than cost analyses, they do not necessarily capture true cost changes for stroke survivors. This is one of many reasons that health economists should collaborate with clinicians to discuss clinical factors that may significantly influence longitudinal cost comparisons.

Background and purpose Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. Materials and methods This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. Results Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate ( p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. Conclusions This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.

Introduction: Observational studies have found an increased risk of hemorrhagic transformation and worse functional outcomes in patients with higher systolic blood pressure variability (BPV). However, the time-varying behavior of BPV after endovascular thrombectomy (EVT) and its effects on functional outcome have not been well characterized. Patients and methods: We analyzed data from an international cohort of patients with large-vessel occlusion stroke who underwent EVT at 11 centers across North America, Europe, and Asia. Repeated time-stamped blood pressure data were recorded for the first 72 h after thrombectomy. Parameters of BPV were calculated in 12-h epochs using five established methodologies. Systolic BPV trajectories were generated using group-based trajectory modeling, which separates heterogeneous longitudinal data into groups with similar patterns. Results: Of the 2041 patients (age 69 ± 14, 51.4% male, NIHSS 15 ± 7, mean number of BP measurements 50 ± 28) included in our analysis, 1293 (63.4%) had a poor 90-day outcome (mRS ⩾ 3) or a poor discharge outcome (mRS ⩾ 3). We identified three distinct SBP trajectories: low (25%), moderate (64%), and high (11%). Compared to patients with low BPV, those in the highest trajectory group had a significantly greater risk of a poor functional outcome after adjusting for relevant confounders (OR 2.2; 95% CI 1.2–3.9; p = 0.008). In addition, patients with poor outcomes had significantly higher systolic BPV during the epochs that define the first 24 h after EVT ( p Discussion and conclusions: Acute ischemic stroke patients demonstrate three unique systolic BPV trajectories that differ in their association with functional outcome. Further research is needed to rapidly identify individuals with high-risk BPV trajectories and to develop treatment strategies for targeting high BPV.

BackgroundThe safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone.MethodsThis is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups.ResultsA total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0–2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes.ConclusionPretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.

Background: Previous studies have shown that primary stroke centers (PSCs) have shorter door to needle (DTN) time than non-PSCs hospitals. We aimed to validate these findings in a high-volume teles...

Introduction Clinical trials have proven the efficacy of mechanical thrombectomy in stroke patients with large-vessel occlusion presenting within 24 hours of symptom onset. Extending the thrombectomy window to 24 hours resulted in a higher number of thrombectomies being performed. However, little is known about the impact of the extended thrombectomy window on the telestroke call burden. Methods We used the prospectively maintained database of a telestroke network covering a large geographic area in the Southeast USA. We included patients presenting between January 2015 and December 2019. We compared the characteristics and outcomes between patients who presented before and after the publication of the extended window thrombectomy trials. Results A total of 9041 patients presented with stroke-like symptoms during the study period. Of these, 4995 presented after February 2018. There was no difference in the patient demographics in both groups. However, patients in the post extended window group had a lower National Institute of Health Stroke Scale on presentation (3 vs. 4; p Discussion The number of telestroke consults nearly doubled after the publication of the extended thrombectomy window trials, with an increase in the number of thrombectomies performed. These findings have important operational implications for hospitals implementing telestroke call coverage.

To estimate the marginal cost differences and care delivery process of a telerehabilitation versus outpatient session.This study used a time-driven activity-based costing (TDABC) approach including 1) observation of rehabilitation sessions and creation of manual time stamps, 2) structured and recorded interviews with two occupational therapists familiar with outpatient therapy and two therapists familiar with telerehabilitation, 3) collection of standard wages for providers, and 4) the creation of an iterative flowchart of both an outpatient and telerehabilitation session care delivery process.Telerehabilitation and outpatient therapy evaluation.Three therapists familiar with care deliver for telerehabilitation or outpatient therapy INTERVENTIONS: Not applicable.Marginal cost difference between telerehabilitation and outpatient therapy evaluations.Overall, telerehabilitation ($225.41) was more costly than outpatient therapy ($168.29) per session for a cost difference of $57.12. Primary time drivers of this finding were initial phone calls (0 mins for OP therapists versus 35 mins for TR) and post documentation (5 mins for OP versus 30 mins for TR) demands for telerehabilitation.Telerehabilitation is an emerging platform with the potential to reduce costs, improve healthcare inequities, and facilitate better patient outcomes. Improvements in documentation practices, staffing, technology, and reimbursement structuring would allow for a more successful translation.

Background and Purpose: The impact of the coronavirus disease 2019 (COVID-19) pandemic on stroke systems has not been systematically evaluated. Our study aims to investigate trends in telestroke consults during the pandemic. Methods: We did retrospective chart review of consecutive patients seen through a telestroke network in South Carolina from March 2019 to April 2020. We dichotomized patients to preCOVID-19 pandemic (March 2019 to February 2020) and during COVID-19 pandemic (March to April 2020). Results: A total of 5852 patients were evaluated during the study period, 613 (10.5%) were seen during the pandemic. The median number of weekly consults dropped from 112 to 77 during the pandemic, P =0.002. There was no difference in baseline features; however, Black patients were less likely to present with strokes during the pandemic (13.9% versus 29%, P ≤0.002). Conclusions: The COVID-19 pandemic has led to a significant drop in telestroke volume. The impact seems to disproportionately affect Black patients.

Background: The growth of telestroke services expanded the reach of acute stroke treatment. However, ethnic disparities in receiving such treatment have not been fully assessed. Materials and Metho...

Background: Studies show that telestroke (TS) improves rural access to care and outcome for stroke patients receiving TS services, but population health impacts of TS are not known. We examine impacts associated with South Carolina's (SC) statewide TS network on an entire state population of patients suffering acute ischemic stroke (AIS) as TS became available across SC counties. Methods: A population health study using Donabedian's conceptual model and an ecological design to describe the change observed over time in use of thrombolysis and endovascular therapy (EVT) as the SC TeleStroke Network (SCTN) diffused across SC counties. Changes in county rates of stroke mortality and discharge destination are reported. The unit of interest is the population rate for AIS patients living in a SC county. Patients’ county of residence at the time of hospitalization defined county cohorts. Relative risks were estimated using logistic regression adjusted for age >75 years. Results: Overall tissue plasminogen activator (tPA) rate was 6.28%, and EVT rate was 1.10%. Patients living where SCTN was available had a 25% higher likelihood of receiving tPA (adjusted relative risk [ARR] = 1.25, 95% confidence interval [CI] = 1.15–1.36) and lower risks of mortality (ARR = 0.91; 95% CI = 0.84–0.99) or discharge to skilled nursing (ARR = 0.93; 95% CI = 0.89–0.97). Conclusions: TS diffusion affects the structure of the health system serving a county, as well as the processes of care delivered in the emergency department; these changes are associated with measurable population health improvements. Results support a population benefit of TS implementation.

BackgroundThe transradial approach (TRA) has gained increasing popularity for neuroendovascular procedures. However, the experience with TRA in neuroangiography is still in early stages in most centers, and the safety and feasibility of this approach have not been well established. The purpose of this study is to report the safety and feasibility of TRA for neuroendovascular procedures.MethodsWe reviewed charts from six institutions in the USA to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedures through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, complications, and whether there was a crossover to transfemoral access.ResultsA total of 2203 patients were included in the study (age 56.1±15.2, 60.8% women). Of these, 1697 (77%) patients underwent diagnostic procedures and 506 (23%) underwent interventional procedures. Successfully completed procedures included aneurysm coiling (n=97), flow diversion (n=89), stent-assisted coiling (n=57), balloon-assisted coiling (n=19), and stroke thrombectomy (n=76). Crossover to femoral access was required in 114 (5.2%). There were no major complications related to the radial access site. Minor complications related to access site were seen in 14 (0.6%) patients.ConclusionIn this early stage of transforming to the ‘radial-first’ approach for neuroendovascular procedures, TRA was safe with low complication rates for both diagnostic and interventional procedures. A wide range of procedures were completed successfully using TRA.

Background: Patients aged ≥80 years are often underrepresented in stroke trials. Observational studies have shown that older patients have worse outcomes compared with younger patients, but outcome...

Background: Over the past decade, tele-stroke networks have been shown to remarkably improve our ability to provide timely treatments for stroke patients. Data on the economic impact of tele-stroke networks are scarce. Our aim is to assess the economic impact associated with the adoption of tele-stroke in local, geographically defined areas in the state of South Carolina (SC). Methods: Data were extracted from SC All-payer hospital discharges database from 2014-1017. Patients included were admitted with primary diagnosis ICD-9 codes for acute ischemic stroke. SC tele-stroke tracking data was used to assign county exposure. Data was analyzed using multivariable logistic, Poisson and gamma regression models with robust error variance in Proc Genmod to estimate effects. Multiple variables were assessed including tPA treatment, mechanical thrombectomy, and cost of in-hospital and follow up care for readmissions or ED visits in patients that had tele-stroke available in-county compared to those that did not. Results: A total of 33,603 patients were included in these analyses. A total of 2,799 patients received tPA and 695 patients received mechanical thrombectomy. Estimated mean hospital payments were $13,715 (SD $15,742) for patients with tele-stroke available compared to $14,065 (SD $15,477) where tele-stroke was not available (P=0.0002). Total mean payments were significantly higher for patients without tele-stroke availability ($34,560 SD $51,049) compared to patients with tele-stroke available ($31,744, SD $45,517) (P Conclusion: Our results indicate that tele-stroke presence in geographic locations improves treatment and outcomes in patients with acute ischemic stroke and may be expected to have an economic benefit. We observed a significant population-level association between availability of tele-stroke and mean hospital payments, follow up payments, and follow up ER visit payments.

IntroductionStroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and fetus. Pregnancy was an exclusion criterion in endovascular thrombectomy (EVT) trials and so there are no evidence-based treatment recommendations in this subgroup. The objective of this study was to evaluate the safety and feasibility of mechanical thrombectomy in large vessel occlusion (LVO) stroke in pregnancy.MethodsPatients with AIS due to LVO treated with EVT during pregnancy between 2000 and 2019 were identified at seven tertiary care centers. After IRB approval, retrospective analysis of prospectively maintained stroke/endovascular databases was performed.ResultsA total of seven subjects were identified. The average age was 33.2 years (range 25–38 years) and the average initial National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15 (range 9–28). Three patients received IV tissue plasminogen activator. Techniques of EVT included stent retriever thrombectomy, stent retriever-assisted continuous aspiration, direct contact aspiration, and multimodal techniques including a rescue balloon mounted coronary stent placement. While one patient was noted to have petechial hemorrhage, no individuals developed parenchymal hematoma. Mean discharge NIHSS score was 1.7 (range 0–5).ConclusionEVT is a safe and effective treatment for acute stroke secondary to LVO in this series of pregnant patients. While EVT for acute stroke is standard of care in select patient populations, our study suggests that treatment should be considered in the gravid population.

Background and Purpose: Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race. Methods: Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days. Results: Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72–84), compared with 63 years (54–74) for NHB, and 71 years (60–80) for NHW patients ( P P P P Conclusions: Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.

ImportanceThere is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy.ObjectiveTo assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI).Design, Setting, and ParticipantsIn this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022.ExposuresSelection by NCCT, CTP, or DWI.Main Outcomes and MeasuresPrimary outcome was functional independence (modified Rankin scale 0-2) at 90 days.ResultsAmong 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups.Conclusions and RelevanceIn this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.

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

Background The adoption of endovascular techniques for treatment of pericallosal artery aneurysms (PAAs) has been comparatively gradual due to anatomic and technological factors. We conducted a retrospective cohort study to evaluate the outcomes of PAA treatment with coiling and flow diversion at our institution. Methods This was a retrospective study of patients treated endovascularly for PAAs from December 2007 to January 2019. Results In total, 33 patients with 34 aneurysms were included (25 aneurysms ruptured, 9 unruptured or recurrent). Of the ruptured group, 22 were coiled (88%) and rest treated with flow diversion. Initial angiographic follow up rate was 72%, at median of 159 days. Overall recurrence rate was 40% (10/25) at median of 376 days, all among coiled aneurysms. 6 recurrent aneurysms were retreated with further coiling (2) and flow diversion (4). Of the unruptured/recurrent group, 5 were coiled (55%) and remainder treated with flow diversion. Angiographic follow-up rate was 100% at median of 267 days. Recurrence rate was 22% (2/9), both in coiled aneurysms. Overall, 27 aneurysms were coiled, 9 treated with flow diversion and 3 with “partial” flow diversion. All aneurysms treated with pipeline flow diversion achieved 100% occlusion. No re-rupture or new rupture was observed. Good clinical outcome (modified Rankin Scale 0–2) was seen in 79% of patients. Conclusions Our study demonstrates that endovascular coiling for PAAs is associated with a definite rate of recurrence, which has to be monitored with timely angiography. We also demonstrate the excellent effectiveness of flow diversion for PAAs with either presentation.

Phosphogypsum is a solid by-product waste generated from phosphoric acid industry. This paper presents the effectiveness of mixing Phosphogypsum with crushed limestone to use this blend as road base course. Seven percentages (0, 5, 10, 15, 20, 25 and 30%) of Phosphogypsum were replaced from crushed limestone mixture dry weight. The influence of blending Phosphogypsum with crushed limestone was evaluated by preparing and testing mixture with several percentages of phosphogypsum and crushed limestone to determine some of their properties as maximum dry density, optimum moisture content, un-soaked California bearing ratio, soaked California bearing ratio, swelling percent and California bearing ratio after a series of wetting-drying cycles. The results indicate that the mechanical characteristics were improved by adding phosphogypsum to the crushed limestone mixtures.

Introduction This study evaluated the impact of establishing an inpatient teleneurology consultation service alongside an already established telestroke network on the stroke transfers to the hub. The study also aimed to assess the financial impact of establishing this network. Methods Prospectively collected data on all stroke patients evaluated through our telestroke and teleneurology networks between January 2008 and March 2018 were interrogated. For all spokes (eight sites) that had both teleneurology and telestroke services, we compared the rate of transfers to the hub before and after the establishment of the teleneurology network in August 2014. The cost reduction was estimated using the Medicare 5% standard analytic files. Results A total of 4296 stroke patients were evaluated during the study period. Of these, 2493 were seen before and 1803 were seen after the implementation of the teleneurology network at the included sites. Patients in the pre-teleneurology group were older (66.4 years ( SD = 14.7 years) vs. 67.8 years ( SD = 15.1 years); p = 0.002). Otherwise, there were no differences in baseline characteristics. Patients in the pre-teleneurology group were more likely to be transferred to the telestroke hub (29.4% vs. 20.2%; p Discussion The implementation of an inpatient teleneurology network was associated with a significant reduction in the transfer rate of stroke patients to hospitals with a higher level of care and could lead to a significant cost reduction.

Despite the wide utilization of mechanical thrombectomy (MT) for acute ischemic stroke treatment, little is known about the incidence of early post-thrombectomy seizures, its predictors, and association with long-term outcome.Using a prospective registry of mechanical thrombectomy in ischemic stroke between January 2013 and July 2017, we identified patients who developed a seizure within 7 days (early seizure) of qualifying event. Backward stepwise regression analysis was used to assess independent predictors of seizure occurrence and the association between seizure and functional outcome (modified Rankin scale of 0-2 vs. ≥3).A total of 459 patients were included in the final analysis. Mean age was 67.5 (SD 15.1), and 49.9% of patients were female. Successful recanalization (TICI≥2B) was achieved in 92.8% of patients. Eleven (2.4%) patients developed at least one seizure. Only an Alberta Stroke Program Early CT (ASPECT) score of6 was independently associated with the occurrence of early seizures [Odds ratio, 95% confidence interval: 8.188, (2.219-30.214); P = .002]. On multivariate analysis, early seizures were associated with 90-day mortality rate [OR,6.487; 95% confidence interval, (1.481-28.405); P = .013] and poor functional outcome (OR, 4.7; 95% confidence interval (1.08-20.83); p = .039).In the studied cohort, 2.4% of ischemic stroke patients treated with MT developed at least one seizure within 7 days of stroke onset. A low ASPECT score was associated with the occurrence of early seizures. The occurrence of seizures was associated with 90-day mortality and poor functional outcome.