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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: Mechanical thrombectomy is standard of care for acute ischemic stroke secondary to LVO however MT failure (MTF) occurs in approximately 15% of cases. Objective: Investigate patient and procedural characteristics that predict MTF. Methods: Retrospective review of prospectively collected, Stroke Thrombectomy and Aneurysm Registry. Patients who underwent MT for LVO were included and categorized by MT Success (MTS) or MTF, defined as mTICI≥2b or Results: A total of 8452 patients were analyzed, and 1301(15.4%) experienced MTF.MTF patients were older(73 vs.71, p=0.008)had higher poor premorbid mRS(10.8% vs 8.4%, p=0.17).Onset to puncture was greater in MTF group(442 vs.411 min, p=0.006).There were more ICA occlusions(15.6% vs. 13.5%)and basilar occlusions(7.8% vs.6.2%)in the MTF group and more M1 occlusions(42.2%vs.37.5%)in the MTS group (p Conclusion: MTF is associated with more complications and worse outcome. Final use of aspiration and rescue intracranial stenting may increase chances of recanalization.

Background: First-pass efficacy (FPE) has been established as an important predictor of favorable functional outcomes after endovascular thrombectomy (ET) in anterior circulation strokes. In this retrospective cohort study, we investigate predictors and clinical outcomes of FPE in posterior circulation strokes (pcAIS). Methods: The Stroke Thrombectomy and Aneurysm Registry database was used to identify pcAIS patients who achieved FPE. Their baseline characteristics and outcomes were compared with the non-FPE group. The primary outcome was a 90-day modified Rankin Scale (mRS) of 0–3. Univariate (UVA) and multivariate (MVA) analyses were done to evaluate predictors of FPE. Safety outcomes included distal emboli, vessel rupture, symptomatic intracranial hemorrhage, and mortality. Results: Of 359 patients, 179 (50%) achieved FPE. Clot burden, occlusion site, and ET technique-related variables were similar between the two groups except for shorter procedure time with FPE. The primary outcome was significantly better with FPE (56.4% vs. 32.8%, p

OBJECTIVE Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. METHODS A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12–18 (adolescent) and 19–25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. RESULTS Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0–2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to–groin puncture and groin puncture–to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0–6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01). CONCLUSIONS Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.

Background Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited. Methods We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015–2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever. Results In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p = 0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p Conclusions Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.

Introduction: Mechanical thrombectomy (MT) for acute stroke is the current standard of care treatment. Level 1 evidence for efficacy of thrombectomy has been established in multiple randomized controlled trials on selective patient populations; however, the high effect size of MT had led multiple centers in the US and globally to expand their patient selection to include populations that were not studied in major trials. To provide ongoing data on MT outcomes in different patient populations from the real-world, we have initiated an international multicenter initiative, STAR (Stroke Thrombectomy and Aneurysm Registry). Methods: STAR is a multicenter and international platform to curate patient outcome data after MT for acute ischemic stroke at comprehensive stroke centers. STAR includes all patients who underwent MT for acute ischemic stroke irrespective of age, time from onset, ASPECT score, and NIHSS. Patients were curated from 01/2015 to date and is prospectively maintained. Patient charts are reviewed for demographics, baseline functioning, and admission deficits. Procedure notes are reviewed for technical variables and technical outcomes. Clinical outcomes were collected at 90-day follow-up by stroke neurologist. Results: A total of 24 centers globally have enrolled in STAR. By December 2018, the total number of enrolled and verified patients in STAR was 3,850 (mean age 69±14, 51% females). Anterior circulation strokes were treated in 89% of cases, average NIHSS on admission was 15.5±7, and 73% had pre-stroke mRS below 2. Around 51% of patients received IV-tPA. Mechanical thrombectomy was performed using aspiration (45%), stent retriever (28%), primary combined approach (24%) or intracranial stenting (3%). Successful recanalization was achieved in 84% of cases, the rate of favorable outcome (mRS 0-2) was 41%, and mortality was 25%. Complication rate was 6% and rate of symptomatic post-procedural hemorrhage was 6%. Conclusions: STAR represent a large real-world international registry for outcomes after MT, and constitutes a statistically robust platform to study real-world practice outcome in patient sub-populations that are under-represented in randomized trials. Link: https://medicine.musc.edu/departments/neurosurgery/star

Key Points Question What is the 90-day outcome for patients with stroke presenting with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5 who underwent mechanical thrombectomy? Findings In this multicenter cohort study of 2345 patients presenting with an intracranial internal carotid artery or M1 occlusion who underwent mechanical thrombectomy, 213 [9.1%] had an ASPECTS of 2 to 5, and 22% of these patients achieved favorable 90-day outcomes (modified Rankin scale score of 0-2). Patients who achieved successful recanalization were nearly 5 times more likely to achieve favorable outcomes compared with patients who had unsuccessful recanalization. Meaning This study suggests that patients with a low ASPECTS on presentation may achieve 90-day functional independence after mechanical thrombectomy if they achieve successful recanalization., Importance Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. Objective To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. Design, Setting, and Participants This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score. Exposure All patients underwent MT in one of the included centers. Main Outcomes and Measures A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset). Results A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64). Conclusions and Relevance In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window., This cohort study uses data from the Stroke Thrombectomy and Aneurysm Registry to investigate the safety and effectiveness of mechanical thrombectomy for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score of 2 to 5.

Background: Patients with symptomatic carotid artery stenosis presenting with TIA or minor stroke have a risk of recurrent devastating stroke of 21% within 2weeks and 32% within 12 weeks. Efficacy of early endarterectomy (CEA) has already been proven. However, data on ideal timing of Carotid Artery Stenting (CAS) is still lacking. Methods: A prospective observational cohort of elective endovascular procedures at our hospital was queried for consecutive cases of internal carotid artery stenting for minor symptomatic atherosclerotic stenosis inclusive of the years 2009-2011. A total of 438 patients were studied with the primary outcome measured as a combined incidence of major perioperative complications (stroke, Myocardial Infarction MI or death) at 90 days from procedure time, was compared between patients based on timing of procedure relative to onset of symptoms. Patients were stratified into four treatment groups: those treated urgently (0-2 days), early (3-7 days), routinely (8-14 days), or late (15-90 days). Incidence of the primary outcome was compared between groups using the Fisher’s exact test (SAS software, Cary NC). Results: Stent implantation was successful in all cases (100%). Combined incidence of major perioperative complications of stroke, MI or death at 90 days was 7% in the urgently treated group 0-2 days (10 out of 143), 11% in the early treated group 3-7 days (10 out of 110), 3% in the routinely treated group 8-14 days (3 out of 100) and 7% in the late treatment group 15-90 days (6 out of 85). Mortality was only reported in the urgently treated group and it was as high as 3% (5 out of 143). Conclusion: Little data is available regarding urgent carotid stenting post minor stroke or TIA. Out data suggest that the safest period to perform carotid artery stenting in symptomatic atherosclerotic stenosis is between 8-14 days with a rate of all combined major perioperative complications as low as 3%. Randomized and double-blinded trial is warranted to study this further.

AIM: The ERAIS study was designed to test the safety of the Enterprise stent as the primary intraarterial device in cerebral revascularization. METHODS: Twenty patients with acute ischemic stroke within 8 hours of stroke symptom onset with contraindication to IV thrombolysis or with no clinical improvement 1 hour after administration of IV thrombolysis were prospectively enrolled between July 2010 and June 2012 after consultation with the local IRB and FDA. The Enterprise stent was deployed across the occlusion. Alternatively, the stent was used as a thrombectomy device based on operator preference. RESULTS: All patients had major intracranial vessel occlusion (TIMI 0), with an average preoperative NIHSS score of 15.5±1.3. The primary target vessels where the stents were deployed were the MCA in 15 patients, ICA in 2, basilar artery in 2 and tandem ICA-MCA in 1.The stent was deployed in 13 patients and used as a thrombectomy device and thus retrieved in 7 patients. Twenty-four stents were used in 20 patients. The time from start of procedure to TIMI 2/3 recanalization was 43±21 minutes. Recanalization to TIMI 2/3 flow was achieved in 18 (90%) of 20 patients. Three major complications were noted (15%), including 2 MIs and 1 ischemic stroke in a distribution other than the qualifying vessel. Eight minor complications were noted. Seven (35%) patients died within 30 days of revascularization. Ten patients (50%) improved to an mRS score of 0-2 within 30 days post-intervention. CONCLUSION: The Enterprise stent is equivalent in efficiency and has comparable acceptable adverse events when compared to previously published results with the Wingspan stent in the SARIS trial and confirms the high recanalization rate achieved with stent-assisted revascularization in selected patients. This is the first reported prospective FDA-approved trial with the Enterprise stent as the primary intraarterial stroke revascularization device.