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Background: Telemedicine has enabled hospitals without stroke specialists to efficiently triage acute ischemic stroke patients; however, ~10-15% of patients with posterior circulation stroke present with visual loss, visual field deficit, or visual obscuration that can only be detected by thorough bedside examination. We have developed a novel, provisionally patented, device which allows for remote visual field assessment in patients with suspected stroke. The Eye Telestroke Exam Device consists of 3D goggles and custom software that tracks a patient’s eye movements when they respond to visual stimuli within the goggle’s screens and verbal commands given by the remote Neurology specialist. The device system is designed to pair (via Bluetooth technology) with any telemedicine system and will allow the remote examiner to perform a detailed visual field examination remotely. Objective: In this pilot study, we aim to evaluate the sensitivity and specificity of the Telestroke Eye Exam device to evaluate visual fields in healthy individuals and in patients who already have suffered a posterior circulation stroke and have permanent visual field deficits. Methods and Design: The Eye Telestroke Exam Device for Improved Triage in Stroke (EYE-TEST) Pilot study is a 2-arm, prospective study of patients with either a history of posterior circulation stroke with visual disturbances (stroke group) or patients with no visual disturbances (control). A roll in phase of 5 patients in each group will be performed, prior to enrollment of 20 patients into each arm. Investigators performing the device exam will be blinded to patient history. Device performance (sensitivity and specificity) will be compared to conventional bedside visual field assessment in each group. The device exam will be repeated twice for each patient. Results: The roll-in phase of the EYE-STUDY showed 100% sensitivity and specificity for detecting visual field disturbances in the stroke group. No abnormalities were detected in the control group. Conclusion: Enrollment into the study is ongoing and estimated study completion will occur October 2022. Final results of the EYE-TEST study will be presented at ISC 2023. Results of this study will inform future design iterations and studies.

Purpose of the ReviewThis article summarizes a broad range of the most recent advances and future directions in stroke diagnostics, endovascular robotics, and neuromodulation.Recent FindingsIn the past 5 years, the field of interventional neurology has seen major technological advances for the diagnosis and treatment of cerebrovascular diseases. Several new technologies became available to aid in complex prehospital stroke triage, stroke diagnosis, and interpretation of radiologic findings. Robotics and neuromodulation promise to expand access to established treatments and broaden neuroendovascular indications.SummaryMobile applications offer a solution to simplify prehospital diagnostic and transfer decisions. Several prehospital devices are also under development to improve the accuracy of detection of large vessel occlusion (LVO). Artificial intelligence is now routinely used in early diagnosis of LVO and for detecting salvageability of the affected brain parenchyma. Technological advances have also paved the way to incorporate endovascular robotics and neuromodulation into practice. This may expand the deliverability of established treatments and facilitate the development of cutting-edge treatments for other complex neurologic diseases.

Background and Purpose: The safety and benefit of mechanical thrombectomy in the treatment of acute ischemic stroke patients with M2 segment middle cerebral artery occlusions remain uncertain. Here, we compare clinical and angiographic outcomes in M2 versus M1 occlusions in the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) Registry. Methods: The STRATIS Registry was a prospective, multicenter, nonrandomized, observational study of acute ischemic stroke large vessel occlusion patients treated with the Solitaire stent-retriever as the first-choice therapy within 8 hours from symptoms onset. Primary outcome was defined as functional disability at 3 months measured by dichotomized modified Rankin Scale. Secondary outcomes included reperfusion rates and rates of symptomatic intracranial hemorrhage. Results: A total of 984 patients were included, of which 538 (54.7%) had M1 and 170 (17.3%) had M2 occlusions. Baseline demographics were well balanced within the groups, with the exception of mean baseline National Institutes of Health Stroke Scale score which was significantly higher in the M1 population (17.3±5.5 versus 15.7±5.0, P ≤0.001). No difference was seen in mean puncture to revascularization times between the cohorts (46.0±27.8 versus 45.1±29.5 minutes, P =0.75). Rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction≥2b) were similar between the groups (91% versus 95%, P =0.09). M2 patients had significantly increased rates of symptomatic ICH at 24 hours (4% versus 1%, P =0.01). Rates of good functional outcome (modified Rankin Scale score of 0–2; 58% versus 59%, P =0.83) and mortality (15% versus 14%, P =0.75) were similar between the 2 groups. There was no difference in the association of outcome and onset to groin puncture or onset to successful reperfusion in M1 and M2 occlusions. Conclusions: In the STRATIS Registry, M2 occlusions achieved similar rates of successful reperfusion, good functional outcome, and mortality, although increased rates of symptomatic ICH were demonstrated when compared with M1 occlusions. The time dependence of benefit was also similar between the 2 groups. Further studies are needed to understand the benefit of mechanical thrombectomy for M2 occlusions. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02239640.

BACKGROUND AND PURPOSE: Recent data suggest that intra-arterial thrombolytics may be a safe rescue therapy for patients with acute ischemic stroke after unsuccessful mechanical thrombectomy; however, safety and efficacy remain unclear. Here, we evaluate the use of intra-arterial rtPA as a rescue therapy in the Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry. MATERIALS AND METHODS: STRATIS was a prospective, multicenter, observational study of patients with acute ischemic stroke with large-vessel occlusions treated with the Solitaire stent retriever as the first-line therapy within 8 hours from symptom onset. Clinical and angiographic outcomes were compared in patients having rescue therapy treated with and without intra-arterial rtPA. Unsuccessful mechanical thrombectomy was defined as any use of rescue therapy. RESULTS: A total of 212/984 (21.5%) patients received rescue therapy, of which 83 (39.2%) and 129 (60.8%) were in the no intra-arterial rtPA and intra-arterial rtPA groups, respectively. Most occlusions were M1, with 43.4% in the no intra-arterial rtPA group and 55.0% in the intra-arterial rtPA group (P = .12). The median intra-arterial rtPA dose was 4 mg (interquartile range = 2–12 mg). A trend toward higher rates of substantial reperfusion (modified TICI ≥ 2b) (84.7% versus 73.0%, P = .08), good functional outcome (59.2% versus 46.6%, P = .10), and lower rates of mortality (13.3% versus 23.3%, P = .08) was seen in the intra-arterial rtPA cohort. Rates of symptomatic intracranial hemorrhage did not differ (0% versus 1.6%, P = .54). CONCLUSIONS: Use of intra-arterial rtPA as a rescue therapy after unsuccessful mechanical thrombectomy was not associated with an increased risk of symptomatic intracranial hemorrhage or mortality. Randomized clinical trials are needed to understand the safety and efficacy of intra-arterial thrombolysis as a rescue therapy after mechanical thrombectomy.

Introduction: Acute basilar artery (BA) occlusion represents a catastrophic form of acute ischemic stroke. Mechanical thrombectomy (MT) for this disease is frequently performed, despite the lack of level I evidence. In this study, we aim to identify predictors of good outcome in patients with basilar artery occlusions who underwent MT within 24 hours from last seen normal. Method: We conducted a retrospective review study of patients who underwent MT for acute basilar artery occlusions, between October 2012 and October 2018 at our center. The primary endpoint was good functional outcome (modified Rankin Score < 3) at three months. Baseline demographics, clinical, procedural, and radiographic parameters were recorded. We performed a multivariate analysis to determine the predictors of good clinical outcome. Results: Our study included 62 patients with basilar artery occlusions treated within 24 hours from last seen normal: 58% of patients achieved good outcome at 90 days. Age, baseline NIHSS, baseline risk factors and rate of IV tPA administration were comparable between the two groups. Patients with good functional outcome at 90 days were less likely to have a history of stroke (13.9% vs 50%, p = 0.005), more likely to have a higher PC-ASPECTS (10 vs 8, p = 0.0003), and higher successful recanalization rate (91.7% vs 63.6%, p= 0.01). There was a numerically higher number of patients who achieved good outcome within the early time window (less than 6 hours from last seen normal) compared to the 6-24hr time window (50% vs 31.8%, p=0.23). On multivariate logistic regression analysis, the only independent predictor of good functional outcomes was PC-ASPECTS (OR 2.65, 95 % CI 1.47- 4.75, p= 0.00114). Conclusion: In our cohort of patients with BA occlusion who underwent MT, PC- ASPECTs was an independent predictor of good outcome. Prospective studies are warranted to validate our findings.

Modified first pass effect (mFPE) of TICI 2B or greater is an independent predictor of clinical outcome in patients who undergo mechanical thrombectomy (MT). Location of the occlusion in the M1 segment may affect the mFPE and may influence clinical outcomes. A comparison of mFPE between occlusions of the proximal and distal (sparing lenticulostriate branches) M1 segments of the MCA has yet to be performed. We aim to examine the interaction between first pass effect and clinical outcomes in proximal versus distal M1 occlusions. We performed retrospective analysis of patients who underwent MT between 2014 and 2020. Patients were included if they were treated for M1 occlusion within 24 hours from last seen normal, and achieved successful recanalization (TICI2b or greater). Patients were excluded if they were not successfully recanalized, or if they had other intracranial or multifocal occlusions. A total of 264 patients were included in this analysis. Ninety two patients had proximal M1 occlusions and 172 had distal M1 occlusions. Patients with proximal M1 occlusions had higher NIHSS (median 18 vs. 16, p=0.003), lower ASPECTS (mean 8.5 vs 9, p=0.02), and were less likely to be females (44.6% vs. 62.8%, p=0.006). Modified first pass effect was achieved in 45.3% of distal M1 occlusions compared to 31.9% of proximal (p=0.047). Excellent clinical outcome, defined as mRS of 0-1 at 90 days was higher in distal occlusion group (38.8% vs. 24.7%, p=0.03). Additionally, the proximal occlusion group was more likely to experience any grade of hemorrhagic transformation (HT) (37.4 vs. 23.3, p=0.02). Other baseline characteristics and time metrics did not differ between the two groups. In a multivariate analysis of predictors of excellent outcome in the overall cohort, ASPECTS (OR=1.39, p = 0.026) and proximal occlusion site (OR=0.485, p=0.037) were the only two independent predictors. Therefore, mFPE was not a predictor of excellent outcome when adjusted for exact location of occlusion.

Introduction: First pass effect (FPE) defined as TICI 3 recanalization or greater is an independent predictor of clinical outcome in patients who undergo mechanical thrombectomy (MT). The first pass effect may be impacted by device-related factors, thrombus composition, or collateral circulation flow dynamics. In this study, we aim to examine the impact of first pass effect on clinical outcomes in patients with MCA M1 occlusions. Methods: A retrospective analysis of all patients with MCA M1 occlusion who underwent successful mechanical thrombectomy (TICI 2b or greater) between 2014-2020 at two thrombectomy stroke centers was performed. Location of occlusion was recorded as proximal MCA (involvement of the lenticulostriate vessels) or distal. Patients were excluded if they were not successfully recanalized or if they had multifocal intracranial occlusions. Patient characteristics, time metrics, procedural data, and 90 day clinical outcomes were collected. The primary outcome of interest was first pass effect, defined as TICI 3 after a single pass. Results: A total of 261 patients achieved successful recanalization of MCA occlusions in our cohort, with 70 (26.8%) patients achieving a first pass effect. Baseline demographics, rates of IV-tPA administration, and time metrics were similar between the FPE and non-FPE group. Proportion of proximal MCA and distal MCA occlusions were similar between groups as well (38.2% vs. 25.7%; p=0.08). Rates of excellent clinical outcomes were significantly higher in the FPE group compared to the non-FPE group (46.3% vs. 29.9%; p=0.02). In a multivariate analysis, proximal MCA occlusion was a significant predictor of first pass effect. Conclusion: First pass effect in middle cerebral artery M1 occlusions is a significant predictor of an excellent clinical outcome. Patients with a proximal MCA M1 occlusion are more likely to achieve a first pass effect compared to patients with a distal MCA occlusion.

Background Prehospital triage scores aim to identify large vessel occlusions (LVOs) in the field; however, their real‐world performance and accuracy across a 24‐hour period remains unknown. In this study, we compare the positive predictive value of the prehospital Rapid Arterial occlusion Evaluation (RACE) score for the detection of LVO during working hours and nonworking hours. Methods We performed a retrospective review of all patients presenting with a RACE score of ≥5 at one comprehensive and one thrombectomy‐capable hospital between July 2015 and December 2019. Patients were dichotomized to those presenting during “working hours” (7:00 am to 6:00 pm on weekdays) or “nonworking hours” (6:01 pm to 6:59 am on weekdays or anytime during weekends). The primary outcome was diagnosis of LVO. Secondary outcomes included diagnosis of acute neurovascular syndromes, door‐to‐treatment time metrics, and a modified Rankin Scale of ≤2 in those undergoing mechanical thrombectomy. Results Of the 701 patients with RACE score ≥5, 687 patients were included (355 nonworking hours and 332 working‐hours cohorts). Mean age was 71 and 72 years in the nonworking hours and working hours groups, respectively ( P =0.13). Median National Institutes of Health Stroke Scale and baseline demographics were comparable between the 2 groups. There was no significant difference in the diagnosis of LVO (36.3% versus 34.6%; P =0.69) or final discharge diagnosis. The positive predictive value of the RACE score for the detection of an acute neurovascular syndrome (transient ischemic attack and stroke) was improved during nonworking hours (76.3% versus 67.8%; P =0.01). In patients undergoing mechanical thrombectomy, rates of good clinical outcome were similar (44.7% versus 48%; P =0.76), despite the shorter door‐to‐groin‐puncture and revascularization times during working hours. Conclusions The RACE score shows a consistent positive predictive value in determining LVO during working and nonworking hours. However, it is more accurate in determining acute neurovascular syndromes during nonworking hours, which is driven by a decrease in stroke mimics during this time.

Introduction Multiple studies have shown that faster treatment times for ischemic strokes result in improved clinical outcomes. Pre-hospital triage scores aim to identify large vessel occlusions in the field and allow earlier activation of stroke teams in the hospital. Objective To compare the sensitivity of the pre-hospital Rapid Arterial oCclusion Evaluation (RACE) score for the detection of large vessel occlusions during working hours and non-working hours. Methods We retrospectively reviewed all patients presenting with a RACE score of ≥ 5 to one comprehensive and one thrombectomy capable hospital between July 2015 and December 2019. Baseline demographics, time of hospital arrival, presenting NIHSS score, intravenous tPA and mechanical thrombectomy metrics, ninety day modified Rankin scores, discharge disposition, and final discharge diagnosis were recorded. Patients presenting between 7 AM to 6 PM during weekdays were considered to present during ‘Working hours’ whereas patients presenting between 6 PM - 7 AM on weekdays or anytime during weekends were considered to present during ‘Non-working hours’. The primary outcome of interest was diagnosis of large vessel occlusion. Secondary outcomes included diagnosis of neurovascular event, discharge diagnosis, and good clinical outcome defined as ninety day modified Rankin Scale (mRS) of ≤ 2. Results Over a 4.5 year period, this study analyzed 687 patients who presented to the hospital via Emergency Medical Services with a RACE score of 5 or more. The average age of the cohort was 71.4 years and women comprised 55% of the cohort. Median NIHSS was comparable in the Working (13) and Non-working (14; p=0.48) groups. Intravenous tPA administration (21.7% vs. 26.5%; p=0.15) and risk factors including hypertension, diabetes mellitus, previous stroke, and prevalence of atrial fibrillation were comparable between the two groups. There was no significant difference in the diagnosis of large vessel occlusion (36.4% vs 34.6%) or final discharge diagnosis. Sensitivity of the RACE score for detection of neurovascular events (TIA, ischemic stroke, intracranial hemorrhage) was improved during non-working hours (75.1%) compared to working hours (67.2%; p=0.02). Although door to groin puncture & recanalization times were shorter during working hours, there was no significant difference in the rate of good clinical outcomes (54.1% vs. 51.5%; p=0.76) in patients undergoing mechanical thrombectomy. Conclusion The sensitivity of the RACE score for detecting large vessel occlusions does not vary significantly during working and non-working hours. However, patients who present with high RACE scores during working hours are more likely to have a diagnosis of a stroke mimic than those presenting off hours. Disclosures E. Hitomi: None. M. Jumaa: None. S. Zaidi: None. J. Shawver: None. A. Korsnack: None. A. Castonguay: None. R. Burgess: None. V. Kung: None. H. Salahuddin: None.

Objective Intensive blood pressure (BP) management after mechanical thrombectomy (MT) may be beneficial in patients with acute anterior circulation (AC) Ischemic stroke (IS) due to large vessel occlusion (LVO). We sought to evaluate the efficacy of Nicardepine (NCR) vs. Clevidipine (CLV) in IS patients with LVO who underwent successful MT. Methods With IRB approval, we retrospectively collected data on consecutive patients with isolated MCA M1 occlusion who underwent successful MT (TICI score of 2B or 3). Patient demographics, baseline characteristics, time efficiencies, procedural data, incidence of hemorrhagic transformation (HI) and symptomatic ICH per ECASS II criteria on 24H head CT, and clinical outcomes were recorded. We also recorded duration from recanalization to optimal BP control (ROBP), IV drip utilized (NCR vs. CLV), number of SBP excursions, and total duration of time outside the target SBP in first 24H. Results We identified 111 patients between 2017 and 2020, 57 patients required a drip (43 NCR, 14 CLV), and 54 patients were managed with prn medications. Median NIHSS was higher in the drip group (18, IQR 13-21) vs. 15.5 (IQR 9-20), p value= 0.03. There was no significant difference in the rate of good clinical outcome defined as mRs of 0-2 or return to baseline (47.4 vs 61.1%, p value=0.18); rate of any HI (29.8% vs. 27.8%, p value=0.84) and sICH(5.3% vs 0%, p value=0.24) between the two groups ( drip vs. no drip). When comparing the NCR to CLV groups, median ROBP was significantly shorter in the CLV group, 5min (IQR 0.75-7) vs. 17min (IQR 6-35), p value= 0.003; and total duration of time outside the pre-specified BP range was 37.5 min (IQR 19-120) vs. 118 min (57-227) consecutively, p value=0.045. HT rates (14.3% vs. 34.9%, p value=0.19), sICH rates (0 vs. 7%, p value=0.57), and rate of good clinical outcome (64.3% vs. 41.9%, p value=0.22) were similar between the two groups (CLV vs. NCR). In a Multivariate analysis, after adjusting for age, gender, IV tPA administration, drip used and time out of range; NIHSS (OR 0.8, CI 0.70-0.91, p=0.0008) and ROBP (OR=1.05, CI 1.0-1.1, p value=0.032) were independent predictors of good clinical outcome. Conclusion CLV achieved faster ROBP time and better BP control after MT. Further prospective studies are needed. Disclosures M. Oliver: None. J. Shawver: None. H. Salahuddin: None. S. Desai: None. S. Zaidi: None. M. Jumaa: None.

Acute arterial strokes in children are rare but can potentially cause lasting and often permanent neurological deficits. Mechanical thrombectomy has a well-established efficacy and safety profile in adult stroke management, but in the pediatric population, it is yet to be proven efficacious and safe. We present a case of a seven-year-old male who presented with multiple episodes of generalized tonic-clonic seizures after sustaining a neck injury by falling from a trampoline. National Institutes of Health (NIH) on presentation was 21. Neurological exam revealed dilated nonreactive pupils, dysconjugate gaze, severe dysarthria, bilateral ptosis, and movement of upper and lower extremities only to noxious stimuli. Magnetic resonance imaging (MRI) of brain without contrast revealed infarcted areas in the left pons, midbrain, and cerebellar regions. Computed tomographic angiogram (CTA) of head demonstrated left vertebral artery dissection with associated complete occlusion of the distal basilar artery. Successful recanalization was achieved with mechanical thrombectomy six hours after presentation. Mechanical thrombectomy treatment resulted in a significant neurological recovery with NIH of 1. This case supports the growing evidence of the efficacy and safety of mechanical thrombectomy in children.

Introduction: Mechanical Thrombectomy often requires immediate antiplatelet therapy when emergent stenting is needed. Intravenous cangrelor (CGR) is a potent reversible intravenous antiplatelet with a fast onset, a short half-life, and predictable pharmacokinetics. We sought to evaluate the safety and efficacy of this drug in MT patients. Methods: We performed a retrospective case control study at a CSC between 3/2016 and 4/2020. Patients who received intravenous CGR within 6 hours of admission (between 10/2019 - 4/2020) were compared with patients with anterior circulation tandem MCA occlusions who required stenting and oral antiplatelet therapy (between 3/16 - 10/19), prior to the availability of CGR at our facility. Results: We identified 35 patients, 12 of whom received IV CGR and 23 received acute oral antiplatelets for tandem occlusions. Average age of the cohort was 68.5 ± 13.4. Baseline characteristics including co-morbidities, rate of IV tPA, and time metrics were similar between the two groups. In the CGR group, nine patients had tandem anterior circulation occlusions, two had basilar occlusions, and one patient had an MCA occlusion secondary to severe stenosis. Eleven of the twelve patients in the CGR group required acute stenting. Intravenous CGR was used for an average of 20.2 hours after which patients were transitioned to aspirin and ticagrelor (33%) or clopidogrel (67%). Successful recanalization was achieved in all patients who received IV-CGR and in 95.7% of the tandem group. Final infarct volumes were comparable between the CGR and tandem cohorts (7.1 vs 15.5 ml; p=0.75). There were two cases of asymptomatic hemorrhage in both the CGR group and the tandem cohort, and one case of symptomatic ICH in the tandem cohort. Final functional outcomes (83.3% vs 60.9%; p=0.259) and mortality at three months (13% vs. 17%; p=1) were similar between the two groups. Conclusions: IV CGR is a promising medication for patients with acute ischemic stroke who require an immediate antiplatelet effect and is comparable in safety and efficacy to oral antiplatelets in the acute period of ischemic stroke. Larger prospective studies on the efficacy and safety of CGR in neurointervention are warranted.

BackgroundWe report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm.MethodsConsecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020–2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up.ResultsA total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3–4) to post-treatment (0–2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0–2) was noted in 51.5% of patients (median follow-up 6 months).ConclusionsThe Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.

Introduction/Purpose In the past five years, red blood cell distribution width (RDW) values have been used in cardiovascular research to predict outcomes in patients with atherosclerotic disease. Since large vessel occlusion (LVO) ischemic strokes share a similar pathogenesis to acute coronary artery syndromes, recent studies have attempted to elucidate the relationship between RDW values and acute ischemic strokes (AIS). Thus far, the studies have shown an association between AIS and an increased RDW. We explored this relationship in a subset of patients with a severe neurological presentation at our institution to better understand the clinical significance of RDW in various cerebrovascular pathologies. Materials and Methods Patients with Rapid Arterial oCclusion Evaluation (RACE) scores >4 were used for this analysis. A retrospective analysis of hematological indices was undertaken with IRB approval. Complete blood counts (CBCs), complete metabolic panels (CMPs), and coagulation studies drawn at the time of ED arrival were reviewed for each patient. For statistical analysis, multi-way ANOVA, t-Tests, and Chi-square analyses were conducted in ‘R’ to assess these indices across different diagnostic groups. Results This study included 492 patients with pre-hospital RACE scores >4 as identified by EMS in the pre-hospital setting. Final diagnoses were the following: ischemic stroke (IS) without large vessel occlusion (LVO) - 14.8%; IS with LVO - 37%; TIA - 6.5%, ICH - 13.8%; stroke mimics - 27.9%. We separately analyzed red cell distribution width (RDW), neutrophil count, lymphocyte count, mean corpuscular hemoglobin (MCH), platelet to lymphocyte ratios, and neutrophil to lymphocyte ratios. Patients who suffered from any cerebrovascular accident (CVA) had a lower RDW than mimics (p=0.02). Further analysis revealed RDW to be significantly decreased in the ICH cohort (p=0.02) compared to the stroke mimics, but did not differ from the other diagnoses. When controlling for anticoagulation status or gender, RDW and the platelet-lymphocyte ratios were not significantly different across diagnoses. Conclusion Although recent studies have implicated a significant relationship between an increased RDW and the occurrence of AIS, our study does not support this finding. Contrarily, with a larger cohort than in those of previous retrospective studies, we found patients with acute cerebral infarcts across all ages to have significantly lower RDW values when compared with stroke mimics. Efforts for the identification of a reliable hematologic biomarker in addition to RACE scores for the timely diagnosis of ischemic stroke remains a priority in the initial pre-admission work-up. CBCs remain rapid and cost-effective tools upon admission, and should be further analyzed to identify other hematologic indices that can aid in the diagnosis of ischemic stroke. Further studies are warranted to completely define how blood tests are implicated in post-stroke outcomes. Disclosures G. Dawod: None. N. Henkel: None. N. Karim: None. H. Salahuddin: None. J. Shawver: None. S. Zaidi: None. M. Jumaa: None.

Data comparing the effect of age on outcomes of patients who underwent either endovascular coiling (EVC) or neurosurgical clipping (NSC) for ruptured intracranial aneurysms remains limited.To better elucidate the preferred intervention for ruptured aneurysm management by presenting the results of our systematic review of the literature that evaluated the potential advantages of the two interventions between different age groups.Systematic review of PubMed and Embase was performed (2002 - June 10, 2019) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2013 guidelines. Median ages of EVC and NSC cohorts were 54 and 56, respectively. Ages below the median were used in our "younger" cohort; ages above the median were used in our "older" cohort.We reviewed 13 studies on 7,137 patients. In the younger cohort, there were 2840 (EVC: 1412, NSC: 1428) patients. In the older cohort, there were 4297 (EVC: 2552, NSC: 1745) patients. Overall, there was a significant difference in functionality between EVC (77.70%) and NSC (69.23%) (OR=1.69; 95% C.I.: 1.10-2.60, p = 0.0212). In our younger cohort, functionality was significantly different between EVC (77%) and NSC (69%) (OR=1.54; 95% C.I.: 1.29-1.84, p0.001). For the older cohort, there was no significant difference in functionality, complications, or efficacy.We have highlighted the importance of considering age prior to deciding which intervention is most appropriate for ruptured aneurysms, with higher morbidity and mortality with NSC versus EVC in the younger population.

Background and objectives RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19. Materials and methods Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site. Results Ten patients were identified, 7 women, ages 21 – 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1). Conclusions Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.

Background: The number of elderly patients suffering from ischemic stroke is rising. Randomized trials of mechanical thrombectomy (MT) generally exclude patients over the age of 80 years with baseline disability. The aim of this study was to understand the efficacy and safety of MT in elderly patients, many of whom may have baseline impairment. Methods: Between January 2015 and April 2017, 96 patients ≥80 years old who underwent MT for stroke were selected for a chart review. The data included baseline characteristics, time to treatment, the rate of revascularization, procedural complications, mortality, and 90-day good outcome defined as a modified Rankin Scale (mRS) score of 0–2 or return to baseline. Results: Of the 96 patients, 50 had mild baseline disability (mRS score 0–1) and 46 had moderate disability (mRS score 2–4). Recanalization was achieved in 84% of the patients, and the rate of symptomatic hemorrhage was 6%. At 90 days, 34% of the patients had a good outcome. There were no significant differences in good outcome between those with mild and those with moderate baseline disability (43 vs. 24%, p = 0.08), between those aged ≤85 and those aged > 85 years (40.8 vs. 26.1%, p = 0.19), and between those treated within and those treated beyond 8 h (39 vs. 20%, p = 0.1). The mortality rate was 38.5% at 90 days. The Alberta Stroke Program Early CT Score (ASPECTS) and the National Institutes of Health Stroke Scale (NIHSS) predicted good outcome regardless of baseline disability (p < 0.001 and p = 0.009, respectively). Conclusion: Advanced age, baseline disability, and delayed treatment are associated with sub­optimal outcomes after MT. However, redefining good outcome to include return to baseline functioning demonstrates that one-third of this patient population benefits from MT, suggesting the real-life utility of this treatment.

Background: Limited data exists on the benefits of mechanical thrombectomy (MT) in acute ischemic stroke patients on new oral anticoagulants (NOAC). The aim of our study is to examine the safety and efficacy of MT in NOAC patients at our center. Methods: A retrospective review of our prospective MT database was performed for this study. Baseline characteristics, National Institutes of Health Stroke Scale (NIHSS) score, revascularization rate, symptomatic intracranial hemorrhage rate (sICH), and 90-day mortality and favorable outcomes were compared in MT patients on NOAC (MT-NOAC) versus those who were not on NOAC (MT). Results: From July 2012 to December 2018, 553 AIS patients underwent treatment with MT, with 36 patients on NOAC (6.5%). Median age was similar (73 versus 74), with 52.8% and 52.0% (p=0.8) female in the MT-NOAC and MT groups, respectively. Median baseline NIHSS score (17 IQR10-21 versus 17 IQR 12-21, p=0.75) and ASPECTS (9 IQR 8-9, p=0.80) were similar between the groups. Atrial fibrillation was more prevalent in the MT-NOAC group (80.6% versus 37.7%, p= Conclusion: MT in patients on NOAC appears to be safe and efficacious. As our study is limited by sample size, larger prospective studies are needed to understand the safety and efficacy of MT in AIS patients on NOAC.

Central nervous system pain is an unpleasant emotional experience due to abnormal processing of information due to a lesion or disease affecting the processing of somatosensory information. Sensation of pain is continuously modulated at the spinal cord level by descending influences and at the brain stem and cortical levels via interconnected pain networks. Neuroplasticity is central to pathological pain, may be initiated by pathology anywhere in the CNS, and occurs at molecular, neuronal, and network levels. Common causes of CPS include central poststroke pain (CPSP), spinal cord injury, and multiple sclerosis. Central pain syndromes are difficult to diagnose as they often coexist with other types of pain and may occur months or years after the initial injury, and there is lack of a clear, widely accepted diagnostic criteria. Diagnosis requires a history consistent with central nervous system pathology and neurologic signs of abnormal pain processing such as allodynia and hyperalgesia. Medications used for treatment of CPS aim to target different pathophysiological mechanisms and include antidepressants, anticonvulsants, cannabinoids, and other drugs. Management of CPS can be challenging as patients often require combinations of medications attained through slow titration and a process of trial and error. Despite this, most patients still experience incomplete pain relief. Neuromodulatory techniques such as transcranial magnetic stimulation, spinal cord stimulation, and deep brain stimulation are promising treatments in select patients. Ultimately, management of CPS requires a multidisciplinary approach with the aggressive treatment of other causes of pain, optimal management of depression and other psychosocial factors, and use of cognitive behavioral therapy, medications, and if needed, neuromodulatory techniques.

Background and Purpose: The role of intra-arterial (IA) thrombolysis in modern endovascular therapy is not well-understood. Here, we surveyed neurointerventionalists to understand their current clinical practices and opinions of IA thrombolysis in the new era of mechanical thrombectomy (MT). Method: A 24-question anonymous survey was distributed via email to the members of the Society of Vascular and Interventional Neurology. Results: One hundred and four responses were included in the analysis. Most respondents were interventional neurologists (76.9%) and had ≥5-years in neuro-interventional practice (80.8%). IA thrombolytics are presently used by 60.6%. Aspiration plus stent-retriever was the most common MT approach used with IA-thrombolysis (66.0%). IA-thrombolysis was used in mainly three approaches: (1) treatment of primary distal occlusions, (2) as rescue after proximal occlusion thrombectomy, and (3) or as adjunct therapy to primary MT approach. The most frequent IA-rtPA dose was 3-10 mg, with 1 mg/min infusion rate (56.6%). 84.9% do not have a standardized protocol for administering IA-rtPA. About half (50.9%) believed there should be no time limit for administering IA lytic if there is a favorable imaging profile, while 30.2% indicated ≤6 h. Most respondents (76.5%) would consider using IA-tenecteplase in a trial setting. Only 12.9% felt there was no role for IA thrombolysis in modern endovascular practice. Respondents with ≥10-years' experience were less supportive of the future of IA lytic (98.0 vs. 76.4%, p = 0.006). Conclusion: IA-thrombolysis is currently used in clinical practice; however, there is no clear consensus on best practices or criteria for administration. Further studies are needed to define the role of IA-thrombolysis in the context of MT.

Background and purpose Recent data suggests that intra-arterial (IA) thrombolytics may be a safe rescue therapy (RT) for acute ischemic stroke (AIS) patients after failed mechanical thrombectomy (MT); however, its safety and efficacy in MCA occlusions remains unclear. Here, we investigate the use of IA tissue plasminogen activator (IA-rtPA) as RT in MCA occlusions in the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) Registry. Methods The STRATIS Registry was a prospective, multicenter, non-randomized, observational study of AIS LVO patients treated with the Solitaire stent-retriever as the first choice therapy within 8 hours from symptoms onset. Clinical and angiographic outcomes were compared in patients with MCA occlusions treated with and without IA-rtPA. Results A total of 680/938 (72.5%) patients with IA-tPA use harbored MCA occlusions, of which 585 (86.0%) and 95 (14.0%) were in the no IA-rtPA and IA-rtPA groups, respectively. Baseline demographics were well-balanced between the cohorts. The majority of MCA occlusions were located in the M1 segment, with 76.1% in the no IA-rtPA group and 74.7% in the IA-rtPA group (p=0.80). IV-rtPA was administered in 64.4% and 71.6% of the no IA-rtPA and IA-rtPA patients (p=0.20). Median IA-rtPA dose was 4mg (IQR 2–10) in the IA-rtPA cohort. Onset to puncture time was less than 6 hours in 88.6% (597/674) of patients. Mean onset to arterial puncture time was shorter in the IA-rtPA group (196.7±109.9 versus 228.2±97.9 minutes, p=0.004); however, mean puncture to procedure end time was longer in the IA-rtPA group than the no IA-rtPA group (74.5±41.5 versus 59.5±33.6 minutes). Mean number of passes (2.0±1.2 versus 1.6±1.0, p=0.005) and rate of distal embolization (53.4% versus 72.1%, p=0.001) were significantly higher in the IA-rtPA group. The rate of substantial reperfusion (mTICI≥2b) was similar in the cohorts (89.9% versus 86.0%, p=0.28). Rates of symptomatic intracranial hemorrhage (sICH) (1.7% versus 2.2%, p=0.68), good functional outcome (mRS≥2, 60.5% versus 58.0%, p=0.85), and mortality (13.9% versus 13.6%, p=0.96) at 90days did not differ between the two groups. Conclusion Use of IA-rtPA as rescue therapy after failed mechanical thrombectomy in MCA occlusions was not associated with an increased risk of sICH or mortality in the STRATIS Registry. More studies are needed to understand the safety and efficacy of IA thrombolysis as rescue therapy in this patient population. Disclosures A. Castonguay: None. S. Zaidi: None. M. Jumaa: None. O. Zaidat: None. D. Liebeskind: None. H. Salahuddin: None. N. Mueller-Kronast: None.

BackgroundData on the implementation of prehospital large vessel occlusion (LVO) scales to identify and triage patients with acute ischemic stroke (AIS) in the field are limited, with the majority of studies occurring outside the USA.ObjectiveTo report our long-term experience of a US countywide emergency medical services (EMS) acute stroke triage protocol using the Rapid Arterial oCclusion Evaluation (RACE) score.MethodsOur prospective database was used to identify all consecutive patients triaged within Lucas County, Ohio by the EMS with (1) a RACE score ≥5, taken directly to an endovascular capable center (ECC) as RACE-alerts (RA) and (2) a RACE score ResultsBetween July 2015 and June 2018, 492 RA and 1147 SA were triaged within our five-hospital network. Of the RA, 37% had AIS secondary to LVOs. Of the 492 RA and 1147 SA, 125 (25.4%) and 38 (3.3%), respectively, underwent MT (OR=9.9; 95% CI 6.8 to 14.6; pConclusionsWe have demonstrated the long-term feasibility of a countywide EMS-based prehospital triage protocol using the RACE Scale within our hospital network.

BackgroundEarly identification and transfer of patients with acute stroke to a primary or comprehensive stroke center results in favorable outcomes.ObjectiveTo describe implementation and results of an emergency medical service (EMS)-driven stroke protocol in Lucas County, Ohio.MethodAll county EMS personnel (N=464) underwent training in the Rapid Arterial oCclusion Evaluation (RACE) score. The RACE Alert (RA) protocol, whereby patients with stroke and a RACE score ≥5 were taken to a facility that offered advanced therapy, was implemented in July 2015. During the 6-month study period, 109 RAs were activated. Time efficiencies, diagnostic accuracy, and mechanical thrombectomy (MT) outcomes were compared with standard ‘stroke-alert’ (N=142) patients from the preceding 6 months.ResultsAn increased treatment rate (25.6% vs 12.6%, pConclusionsOur results indicate that EMS adaptation of the RA protocol within Lucas County is feasible and effective for early triage and treatment of patients with stroke. Using this protocol, we can significantly improve treatment times for both systemic thrombolysis and MT.

Background and Purpose: We previously reported on the successful implementation of a EMS-driven bypass protocol using the Rapid Arterial oCclusion Evaluation (RACE) score for triage of acute strokes. Here, we describe the long-term results of our RACE alert protocol. Methods: Patients with a RACE score > 5, who are last seen normal within 12 hours, wakeup with stroke symptoms, or have unknown time of symptoms onset were directly transferred as RACE alerts (RA) to our two stroke centers (one primary with interventional capabilities and one comprehensive) with interventional capacity in Lucas County, Ohio. Data including baseline demographics, RACE score, diagnosis, treatments and procedures, and clinical and angiographic outcomes were captured in a prospective database. Results: From July 2015 to July 2018, 511 RAs were triaged. Median age of RA patients was 73 (IQR 63-82), 55.8% were female, and median RACE score was 7 (IQR 5-8). Median time from 911 dispatch to ER was 31 minutes (IQR 22-38) and onset to arrival was 85 minutes (IQR 47-307). Of the 511 RAs, 52.3% were diagnosed with an ischemic stroke, 13.5% intracerebral hemorrhage, 6.5% transient ischemic attack, 12.9% seizure, and 7.8% encephalopathy. The rate of IV-tPA use was 24.5% and median door to needle time was 33 min (IQR 24-48). The rate of mechanical thrombectomy (MT) was 24.3%, with median door to puncture and door to revascularization times of 64 (IQR 48.5-78.5) and 91 minutes (IQR 79.3-114.8), respectively. The majority of occlusions were MCA (73.2%). Successful revascularization (TICI≥2b) was achieved in 84.7%. Ninety-day favorable outcome (mRS 0-2) and mortality was 47.2% and 25.4% in patients who underwent MT. Conclusions: Our results show the long-term feasibility and efficiency of an EMS-driven early stroke triage protocol using the RACE score.

Introduction: The distal hyperintensity vessel (DHV) on FLAIR images is a linear/serpentine shaped hyperintensity that is seen not infrequently in acute ischemic stroke or transient ischemic attack (TIA). Previous studies reported that DHV could predict large vessel occlusion or stenosis and correlate with outcome. The purpose of this study is to evaluate whether presence of DHV is associated with high risk of recurrent ischemic stroke in symptomatic intracranial atherosclerotic severe stenosis. Methods: We retrospectively reviewed patients who presented with ischemic stroke or TIA to a University-affiliated Comprehensive Stroke Center from 2010 to 2015. Patients with etiology due to 70-99% atherosclerosis stenosis of intracranial carotid artery or middle cerebral artery were enrolled. Patients with atrial fibrillation or other cardiac embolism, ipsilateral extracranial carotid artery > 50% stenosis, artery dissection, hypercoagulation state, Moyamoya or other non-atherosclerotic vasculopathy were excluded. FLAIR images were reviewed by two neuroradiologists and one vascular neurologist for the presence of DHV. A quantitative scoring system of maximum 7 based on ASPECTS distribution is applied to grade the extent of DHV. The primary measure is ischemic stroke in the territory of qualifying artery during follow up. Univariate and multivariate logistic regressions were used to identify predictors of recurrent ischemic stroke. Results: Out of 106 patients enrolled, 53 (50%) were found to have DHV (median score of 3.03 ± 1.47). There were more non-whites in DHV group than in non-DHV group (p=0.0314). During follow up, 17 (32%) patients in DHV group had recurrent ischemic stroke compared to 6 (11%) patients in non-DHV group (p=0.0087). The presence of DHV was the only factor associated with recurrent ischemic stroke with OR of 3.074 (95% CI 1.079 - 8.761, p=0.036) by multivariate logistic regression. There is a tendency of high risk of recurrent ischemic stroke for high DHV score with Pearson Correlation R value of 0.7. Conclusions: The presence of DHV is associated with higher risk of recurrent ischemic stroke in symptomatic intracranial atherosclerotic severe stenosis. Confirmation of this finding in large prospective studies is needed.

Background: Mechanical thrombectomy (MT) for ischemic stroke can be performed under local anesthesia (LA), conscious sedation (CS), or general anesthesia (GA). The need for monitoring by anesthesia providers may be resource intensive. We sought to determine differences in outcomes of MT when sedation is performed by an anesthesia team compared to sedation-trained providers. Methods: We performed a retrospective analysis on patients who were screened by a pre-hospital stroke severity screening tool and underwent MT at two stroke centers. Baseline characteristics, time metrics, sedatives, peri-procedural intubation, complications, and outcomes were recorded. Good outcome was defined as modified Rankin score of ≤2. Results: We analyzed 104 patients (sedation-trained provider = 63, anesthesia team = 41) between July 2015 and December 2017. In the sedation-trained provider group, four patients required intervention by an anesthesia team. There were no differences in patients receiving LA (sedation-trained provider 24% vs. anesthesia team 27% p = 0.82), CS (70 vs. 63%, p = 0.53), or GA (6 vs. 10%, p = 0.71) between groups. Sedation-trained providers were more likely to use only one drug during the procedure (62 vs. 34%, p = 0.009). The rate of procedural complications (9.5 vs. 4.5%, p = 0.48), good outcome (56 vs. 39%, p = 0.11), and mortality (22 vs. 24%, p = 0.82) was similar between groups. Sedation by provider type did not predict functional outcome or mortality at 3 months. Conclusions: Sedation-trained providers are capable of delivering appropriate sedation without compromising patient safety. The use of "as needed" anesthesia teams for MT may have considerable effect on resource allocation and cost.

Background and Purpose: To determine recent treatment and outcome trends in patients undergoing elective surgical clipping (SC) or endovascular therapy (EVT) for unruptured intracranial aneurysms (UIAs) in the United States. Methods: Data were extracted and analyzed from the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for all patients admitted for elective EVT or SC of UIAs between 2011 and 2014. Treatment trends, in-hospital mortality, complication rates, length of stay (LOS) and total hospital costs were evaluated and analyzed. Results: A total of 31,070 patients with UIAs were included in our analysis, of which 14,411 and 16,659 underwent elective SC and EVT, respectively. There was no significant difference in in-hospital mortality rates between the 2 groups. EVT was associated with lower in-hospital complication rates, decreased median LOS (.8 days versus 3.3 days, P ≤ .0001), and an increased likelihood of discharge to home (92.9% versus 72.9%, P = .0001). Median total hospital charges were similar in both treatment cohorts. Independent predictors of mortality in the elective population were age over 40 years ( P ≤ .0001), weekend treatment ( P ≤ .0001), and high co-morbidity status ( P ≤ .0001). Conclusions: In-hospital mortality rates were similar in elective EVT and SC UIA patients; however, EVT was associated with lower in-hospital complication rates and shorter LOS.

Introduction: Our objective was to determine trends in treatment preference and in-hospital complications of patients undergoing elective and non-elective treatment for unruptured intracranial aneurysms (UIA) in the United States over a 12-year period. Methods: We identified patients from the National Inpatient Sample database who were electively or non-electively admitted to the hospital with a primary ICD 9 diagnosis of unruptured intracranial aneurysm (437.3) from 2002 to 2014. We identified the method of treatment (surgical clipping or endovascular coiling) and studied in-hospital complications. Results: We identified 111,811 patients with UIAs between 2002 to 2014. Of these patients, 89,599 (80.1%) of patients were electively admitted. Approximately 47% (42,112) of patients underwent surgical clipping, while 53% (47,487) of patients underwent endovascular coiling. Of 22,212 patients who were admitted non-electively, 38.6% (8570) patients underwent surgical clipping and 61.4% (13,642) underwent endovascular coiling. There was a significantly higher proportion of patients treated with endovascular coiling for non-electively admitted patients as compared to elective admissions. For electively treated UIAs there were no significant differences in in-hospital mortality between the two treatment groups. Iatrogenic cerebrovascular accidents and intracranial hemorrhage were significantly less common in the endovascular coiling group throughout the study period. For non-electively treated UIAs, there was no significant difference in hospital mortality over the 12-year period. The rate of iatrogenic cerebrovascular accidents was generally lower for endovascular coiling with the exception of 2003. Endovascular coiling resulted in a significantly lower rate of iatrogenic cerebrovascular accidents in 2004 and 2008-2012. Intracranial hemorrhage was significantly less common in the endovascular group in 2004 and 2008-2014. Conclusions: Endovascular therapy has lower rates of in-hospital iatrogenic cerebrovascular accidents, and similar rates of mortality. The rate of endovascular and surgical therapies has plateaued since approximately 2005.

Background: Middle cerebral artery division (M2) occlusion was significantly underrepresented in recent mechanical thrombectomy (MT) randomized controlled trials, and the approach to this disease remains heterogeneous. Objective: To conduct a systematic review and meta-analysis of outcomes at 90 days among patients undergoing MT for M2 middle cerebral artery (MCA) occlusions. Methods: Five clinical databases were searched from inception through September 2016. Observational studies reporting 90-day modified Rankin Scale scores for patients undergoing MT for M2 MCA occlusions with an M1 MCA control group were selected. The primary outcome of interest was good clinical outcome 90 days after MT of an M1 or M2 MCA occlusion. Secondary outcomes of interest included mortality and excellent clinical outcome, recanalization rates, significant intracerebral hemorrhage, and procedural complications. Results: A total of 323 publications were identified, and 237 potentially relevant articles were screened. Six studies were included in the analysis (M1 = 1,203, M2 = 258; total n = 1,461). We found no significant differences in good clinical outcomes (1.10 [95% CI, 0.83-1.44]), excellent clinical outcomes (1.07 [0.65-1.79]), mortality at 3 months (0.85 [0.58-1.24]), recanalization rates (1.06 [0.32-3.48]), and significant intracranial hemorrhage (1.19 [0.61-2.30]). Conclusions: MT of M2 MCA occlusions is as safe as that of main trunk MCA occlusions, and comparable in terms of clinical outcomes and hemorrhagic complications. Randomized clinical trials are needed to assess the impact of MT in patients with M2 occlusions, given that M1 MCA occlusions have different natural histories than M2 occlusions.

BackgroundOver half of patients who receive intravenous tissue plasminogen activator for middle cerebral artery division (MCA-M2) occlusion do not recanalize, leaving a large percentage of patients who may need mechanical thrombectomy (MT). However, the outcomes of MT for M2 occlusion have not been well characterized.ObjectiveTo determine if MT of M2 occlusion is as safe and efficacious as current standard-of-care MT for M1 occlusions.MethodsWith institutional review board approval, we retrospectively reviewed records of 212 patients undergoing MT for isolated MCA M1 or M2 occlusions during a 36-month period (Sept 2013 to Sept 2016) at two centres. Treatment variables, clinical outcomes, and complications in each group were recorded.ResultsThere were 153 M1 MCA occlusions and 59 M2 MCA occlusions. No statistically significant difference was found in the rate of mortality (20% in M1 vs 13.6% in M2, p=0.32), excellent (34.5% vs 37.3%, p=0.75) or good (51% vs 55.9%, p=0.54) clinical outcomes between the two groups. Infarct volumes (48.4 mL vs 46.2 mL, p=0.62) were comparable between the two groups, as were the rates of hemorrhagic (3.3% vs 3.4%, p=1.0) and procedural complications (3.3% vs 5.1%, p=0.69).ConclusionOur data on MT targeting M2 occlusions demonstrates reasonable safety and functional outcomes. Further randomized clinical trials are needed to clarify which patients may benefit from MT for M2 occlusions.

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

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

Study Design: A prospective study on spinal tuberculosis (TB) at a tertiary care hospital in an endemic region. Purpose: The aim of the study is to reiterate the importance of conservative management of spinal TB. Overview of Literature: Spinal tuberculosis can present with wide spectrum of symptoms, with back pain being the most common symptom. It is the leading cause of non-traumatic paraplegia in developing countries. There is an emerging trend to operate on patients early with spinal TB. Methods: Forty-seven (M=14, F=33) patients were enrolled in the study during the four year study period. Initially, all the patients were subjected to computed tomography guided percutaneous needle aspiration (PCNA) followed by antituberculous therapy (ATT) for 12 months. Indications for surgery included patients with moderate to severe symptoms in which PCNA either failed, was impossible to carry out, or produced minimal improvement within 48 hours. Results: Presenting complaints included pain (95.7%), weakness (85.1%) and sphincter involvement (12.8 %). On the magnetic resonance imaging, a paravertebral abscess was seen in 37 (78.7%), disc and body destruction in 29 (61.7%), and an epidural abscess in 12 (25.9%) patients. Of the 47 patients, 9 (19.1%) required surgery, 4 of whom had failed PCNA attempts and 5 demonstrated indications despite successful PCNA. Conclusions: The results of conservative treatment consisting of PCNA and ATT for at least 12 months in compliant patients are excellent. A combined approach using clinical staging, PCNA, and ATT can minimize surgical intervention in most patients. However, ATT remains to be the cornerstone of management of spinal TB.