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Background As much of the scope of neurointerventional practice falls outside data covered by existing randomized clinical trials, and, as a result, may have failed to enter into existing guidelines, an evidence‐based framework for guideline and standards development is needed. We establish an evidence‐based framework to guide all subsequent guidelines and brief practice updates produced by the Society of Vascular and Interventional Neurology (SVIN). Methods The SVIN formed the Guidelines and Practice Parameters committee to develop the structure and procedures for guidelines and brief practice updates. Results In this article, the Guidelines and Practice Parameters committee has outlined the process by which the guidelines will be created and approved by the SVIN. Additionally, the Guidelines and Practice Parameters committee has adopted the American College of Cardiology/American Heart Association framework of Class of Recommendation and Level of Evidence. A unique, additional separation of the Expert Opinion endorsement category has been developed when high‐quality evidence does not exist at the time of the publication. Conclusions The SVIN has developed an evidence‐based framework for all guideline statements and brief practice updates. The SVIN guidelines and brief practice updates will guide clinicians in the field of interventional neurology to improve and standardize patient care.

Background and Purpose— It remains unclear how experience influences outcomes after the advent of stent retriever technology. We studied the relationship between site experience and outcomes in the Trevo Acute Ischemic Stroke multicenter registry. Methods— The 24 sites that enrolled patients in the Trevo Acute Ischemic Stroke registry were trichotomized into low-volume (4 cases/month). Baseline features, imaging, and clinical outcomes were compared across the 3 volume strata. A multivariable analysis was performed to assess whether outcomes were influenced by site volumes. Results— A total of 624 patients were included and distributed as low- (n=188 patients, 30.1%), medium- (n=175, 28.1%), and high-volume (n=261, 41.8%) centers. There were no significant differences in terms of age (mean, 66±16 versus 67±14 versus 65±15; P =0.2), baseline National Institutes of Health Stroke Scale (mean, 17.6±6.5 versus 16.8±6.5 versus 17.6±6.9; P =0.43), or occlusion site across the 3 groups. Median (interquartile range) times from stroke onset to groin puncture were 266 (181.8–442.5), 239 (175–389), and 336.5 (221.3–466.5) minutes in low-, medium-, and high-volume centers, respectively ( P =0.004). Higher efficiency and better outcomes were seen in higher volume sites as demonstrated by shorter procedural times (median, 97 versus 67 versus 69 minutes; P P ≤0.0001), and higher rates of good outcome (90-day modified Rankin Scale [mRS], ≤2; 39% versus 50% versus 53.4%; P =0.02). There were no appreciable differences in symptomatic intracranial hemorrhage or 90-day mortality. After adjustments in the multivariable analysis, there were significantly higher chances of achieving a good outcome in high- versus low-volume (odds ratio, 1.67; 95% CI, 1.03–2.7; P =0.04) and medium- versus low-volume (odds ratio, 1.75; 95% CI, 1.1–2.9; P =0.03) centers, but there were no significant differences between high- and medium-volume centers ( P =0.86). Conclusions— Stroke center volumes significantly influence efficiency and outcomes in mechanical thrombectomy.

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

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) as the name suggests was initially thought to only cause a respiratory illness. However, several reports have been published of patients with ischemic strokes in the setting of coronavirus disease 2019 (COVID‐19). The mechanisms of how SARS‐CoV‐2 results in blood clots and large vessel strokes need to be defined as it has therapeutic implications. SARS‐CoV‐2 enters the blood stream by breaching the blood‐air barrier via the lung capillary adjacent to the alveolus, and then attaches to the angiotensin‐converting enzyme II receptors on the endothelial cells. Once SARS‐CoV‐2 enters the blood stream, a cascade of events (Steps 1‐8) unfolds including accumulation of angiotensin II, reactive oxygen species, endothelial dysfunction, oxidation of beta 2 glycoprotein 1, formation of antiphospholipid antibody complexes promoting platelet aggregation, coagulation cascade, and formation of cross‐linked fibrin blood clots, leading to pulmonary emboli (PE) and large vessel strokes seen on angiographic imaging studies. There is emerging evidence for COVID‐19 being a blood clotting disorder and SARS‐CoV‐2 using the respiratory route to enter the blood stream. As the blood‐air barrier is breached, varying degrees of collateral damage occur. Although antiviral and immune therapies are studied, the role of blood thinners in the prevention, and management of blood clots in Covid‐19 need evaluation. In addition to ventilators and blood thinners, continuous aspiration and clot retrieval devices (approved in Europe, cleared in the United States) or cyclical aspiration devices (approved in Europe) need to be considered for the emergent management of life‐threatening clots including PE and large vessel strokes.

Background and Purpose— In acute ischemic stroke, fast and complete recanalization of the occluded vessel is associated with improved outcomes. We describe a novel measure for newer generation devices: the first pass effect (FPE). FPE is defined as achieving a complete recanalization with a single thrombectomy device pass. Methods— The North American Solitaire Acute Stroke Registry database was used to identify a FPE subgroup. Their baseline features and clinical outcomes were compared with non-FPE patients. Clinical outcome measures included 90-days modified Rankin Scale score, National Institutes of Health Stroke Scale score, mortality, and symptomatic intracranial hemorrhage. Multivariate analyses were performed to determine whether FPE independently resulted in improved outcomes and to identify predictors of FPE. Results— A total of 354 acute ischemic stroke patients underwent thrombectomy in the North American Solitaire Acute Stroke registry. FPE was achieved in 89 out of 354 (25.1%). More middle cerebral artery occlusions (64% versus 52.5%) and fewer internal carotid artery occlusions (10.1% versus 27.7%) were present in the FPE group. Balloon guide catheters were used more frequently with FPE (64.0% versus 34.7%). Median time to revascularization was significantly faster in the FPE group (median 34 versus 60 minutes; P =0.0003). FPE was an independent predictor of good clinical outcome (modified Rankin Scale score ≤2 was seen in 61.3% in FPE versus 35.3% in non-FPE cohort; P =0.013; odds ratio, 1.7; 95% confidence interval, 1.1–2.7). The independent predictors of achieving FPE were use of balloon guide catheters and non-internal carotid artery terminus occlusion. Conclusions— The achievement of complete revascularization from a single Solitaire thrombectomy device pass (FPE) is associated with significantly higher rates of good clinical outcome. The FPE is more frequently associated with the use of balloon guide catheters and less likely to be achieved with internal carotid artery terminus occlusion.

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

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

Background and Purpose- It remains unclear how experience influences outcomes after the advent of stent retriever technology. We studied the relationship between site experience and outcomes in the Trevo Acute Ischemic Stroke multicenter registry. Methods- The 24 sites that enrolled patients in the Trevo Acute Ischemic Stroke registry were trichotomized into low-volume (2 cases/month), medium-volume (2-4 cases/month), and high-volume centers (4 cases/month). Baseline features, imaging, and clinical outcomes were compared across the 3 volume strata. A multivariable analysis was performed to assess whether outcomes were influenced by site volumes. Results- A total of 624 patients were included and distributed as low- (n=188 patients, 30.1%), medium- (n=175, 28.1%), and high-volume (n=261, 41.8%) centers. There were no significant differences in terms of age (mean, 66±16 versus 67±14 versus 65±15; P=0.2), baseline National Institutes of Health Stroke Scale (mean, 17.6±6.5 versus 16.8±6.5 versus 17.6±6.9; P=0.43), or occlusion site across the 3 groups. Median (interquartile range) times from stroke onset to groin puncture were 266 (181.8-442.5), 239 (175-389), and 336.5 (221.3-466.5) minutes in low-, medium-, and high-volume centers, respectively (P=0.004). Higher efficiency and better outcomes were seen in higher volume sites as demonstrated by shorter procedural times (median, 97 versus 67 versus 69 minutes; P0.001), higher balloon guide catheter use (40% versus 36% versus 59%; P≤0.0001), and higher rates of good outcome (90-day modified Rankin Scale [mRS], ≤2; 39% versus 50% versus 53.4%; P=0.02). There were no appreciable differences in symptomatic intracranial hemorrhage or 90-day mortality. After adjustments in the multivariable analysis, there were significantly higher chances of achieving a good outcome in high- versus low-volume (odds ratio, 1.67; 95% CI, 1.03-2.7; P=0.04) and medium- versus low-volume (odds ratio, 1.75; 95% CI, 1.1-2.9; P=0.03) centers, but there were no significant differences between high- and medium-volume centers (P=0.86). Conclusions- Stroke center volumes significantly influence efficiency and outcomes in mechanical thrombectomy.

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

Background: Recent reports have raised various concerns about the risk of vessel wall injury while withdrawing current laser-cut stent retrievers during active strut apposition to the vessel walls. The development of braided thrombectomy assist devices in conjunction with aspiration systems may be gentler on the fragile brain vessels and more optimized with regard to the radial force (RF) for vessel diameters of proximal (M1) and distal (M2) large vessel occlusions (LVOs). Methods: Mechanical bench testing of the RF was performed using a radial compression station mounted on a tensile testing machine. The total RF in newtons (N) generated in vessels with diameters ranging from 2.25 to 3 mm as seen in proximal LVOs (∼M1), and in vessel diameters ranging from 1.5 to 2.24 mm as seen in distal LVOs (∼M2), was measured. The outer diameter of each stent was recorded, and an RF ≤1 N was grouped as “low,” while an RF >1 N was grouped as “high” for this analysis. Results: The total RFs of all laser-cut stent retrievers were all higher in the simulated M2 vessels (>1 N) than in the M1 vessels (Conclusions: Novel braided thrombectomy assist devices in conjunction with aspiration systems have lower RFs than existing laser-cut stent retrievers in M1 and M2 vessel diameters. Further in vivo studies are needed to delineate the impact of lowering the RF on vessel wall integrity.

Background and Purpose: To describe the final results of the TARGET Registry, a multicenter, real-world study of patients with intracranial aneurysms treated with new generation TARGET Coils. Methods: The TARGET Registry is a prospective, single-arm study with independent medical event monitoring and core-lab adjudication. Patients with de novo intracranial aneurysms were embolized with either TARGET-360° or helical coils in 12 US centers. The primary outcome was aneurysm packing density (PD), which was assessed immediately post-procedure. The secondary outcomes were immediate and long-term aneurysm occlusion rate using the Raymond Scale, and independent functional outcome using the modified Rankin Scale (mRS). A secondary analysis investigated the influence of the use of 100% 360-complex coils on clinical and angiographic outcomes. Results: 148 patients with 157 aneurysms met the inclusion and exclusion criteria. 58 (39.2%) patients with ruptured and 90 (61.8%) with unruptured aneurysms were treated using TARGET 360°, helical Coils, or both. Median age was 58.3 (IQR 48.1-67.4), 73% female, and 71.6% were Caucasian. Median follow-up time was 5.9 (IQR 4.0-6.9) months. The majority were treated with TARGET 360-coils (63.7%), followed by mixed and helical coils only. Peri-procedural morbidity and mortality was seen in 2.7% of patients. A good outcome at discharge (mRS 0-2) was seen in 89.9% of the full cohort, and in 84.5 and 93.3% in the ruptured and unruptured patients, respectively. The median packing density was 28.8% (IQR 20.3-41.1). Long-term complete and near complete occlusion rate was seen in 90.4% of aneurysms and complete obliteration was seen in 66.2% of the aneurysms. No significant difference in clinical and angiographic outcomes were noted between the pure 360-complex coiling vs. mixed 360-complex/Helical coiling strategies. In a multivariate analysis, predictors for long-term aneurysm occlusion were aneurysm location, immediate occlusion grade, and aneurysm size. The long-term independent functional outcome was achieved in 128/135 (94.8%) patients and all-cause mortality was seen in 3/148 (2%) patients. Conclusion: In the multicenter TARGET Registry, two-thirds of aneurysms achieved long-term complete occlusion and 91.0% achieved complete or near complete occlusion with excellent independent functional outcome. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT01748903.

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

Brain attack care is rapidly evolving with cutting-edge stroke interventions similar to the growth of heart attack care with cardiac interventions in the last two decades. As the field of stroke intervention is growing exponentially globally, there is clearly an unmet need to standardize stroke interventional laboratories for safe, effective, and timely stroke care. Towards this goal, the Society of Vascular and Interventional Neurology (SVIN) Writing Committee has developed the Stroke Interventional Laboratory Consensus (SILC) criteria using a 7M management approach for the development and standardization of each stroke interventional laboratory within stroke centers. The SILC criteria include: (1) manpower: personnel including roles of medical and administrative directors, attending physicians, fellows, physician extenders, and all the key stakeholders in the stroke chain of survival; (2) machines: resources needed in terms of physical facilities, and angiography equipment; (3) materials: medical device inventory, medications, and angiography supplies; (4) methods: standardized protocols for stroke workflow optimization; (5) metrics (volume): existing credentialing criteria for facilities and stroke interventionalists; (6) metrics (quality): benchmarks for quality assurance; (7) metrics (safety): radiation and procedural safety practices.

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

Background: Various techniques are used to enhance the results of mechanical thrombectomy with stent-retrievers, including proximal arrest with balloon guide catheter (BGC), conventional large bore proximal catheter (CGC), or in combination with local aspiration through a large-bore catheter positioned at the clot interface (Aspiration-Retriever Technique for Stroke [ARTS]). We evaluated the impact of ARTS in the North American Solitaire Acute Stroke (NASA) registry. Summary: Data on the use of the aspiration technique were available for 285 anterior circulation patients, of which 29 underwent ARTS technique, 131 CGC, and 125 BGC. Baseline demographics were comparable, except that ARTS patients are less likely to have hypertension or atrial fibrillation. The ARTS group had more ICA occlusions (41.4 vs. 22% in the BGC, p = 0.04 and 26% in CGC, p = 0.1) and less MCA/M1 occlusions (44.8 vs. 68% in BGC and 62% in CGC). Time from arterial puncture to reperfusion or end of procedure with ARTS was shorter than with CGC (54 vs. 91 min, p = 0.001) and was comparable to the BGC time (54 vs. 67, p = 0.11). Final degree of reperfusion was comparable among the groups (TICI [modified Thrombolysis in Cerebral Infarction] score 2b or higher was 72 vs. 70% for CGC vs. 78% for BGC). Procedural complications, mortality, and good clinical outcome at 90 days were similar between the groups. Key Messages: The ARTS mechanical thrombectomy in acute ischemic stroke patients appears to yield better results as compared to the use of CGCs with no significant difference when compared to BGC. This early ARTS technique NASA registry data are limited by the earlier generation distal large bore catheters and small sample size. Future studies should focus on the comparison of ARTS and BGC techniques.

Background: Time to mechanical thrombectomy is a significant driver of outcomes in acute ischemic stroke (AIS) patients presenting with large vessel occlusion (LVO). We aimed to evaluate predictors of onset to groin puncture (OTG), groin puncture to reperfusion (GTR), and onset to reperfusion (OTR) times in AIS patients treated with the Trevo stent-retriever. Methods: The investigator-initiated TRACK registry recruited 23 clinical sites to submit demographic, clinical, site-adjudicated angiographic, and outcome data on consecutive patients treated with the Trevo device. We included patients treated Results: Among 433 patients analyzed (mean age 66.8 +/- 14.6 years; median NIHSS score 18; 88% anterior circulation), the median times were: OTG 240, GTR 64, and OTR 321 minutes. In multivariable analysis (Table), the independent predictors were: 1) OTG: transfer status and general anesthesia (GA) use; 2) GTR: 1 pass attempt only, use of rescue therapy, GA use, and baseline mRS >1; and 3) OTR: transfer status, use of perfusion imaging, anterior circulation LVO, use of rescue therapy, and 1 pass attempt only. Conclusions: Major pre-treatment contributors to delays to reperfusion in AIS patients treated

Background and Purpose— Failure to recanalize predicts mortality in acute ischemic stroke. In the North American Solitaire Acute Stroke registry, we investigated parameters associated with mortality in successfully recanalized patients. Methods— Logistic regression was used to evaluate baseline characteristics and recanalization parameters for association with 90-day mortality. A multivariable model was developed based on backward selection with retention criteria of P P ≤0.10), then refit to minimize the number of excluded cases (missing data). Results— Successfully recanalized patients had lower mortality (25.2% [59/234] versus 46.9% [38/81] P P =0.205). However, mortality was significantly higher in patients with symptomatic intracranial hemorrhage (72% [23/32] versus 26% [73/281]; P P P c index=0.72), proximal occlusion, initial National Institutes of Health Stroke Scale≥18, and use of rescue therapy remained significant independent predictors of 90-day mortality. Conclusions— Failure to recanalize and presence of symptomatic intracranial hemorrhage resulted in increased mortality. Despite successful recanalization, proximal occlusion, high National Institutes of Health Stroke Scale, and need for rescue therapy were predictors of mortality.

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

The presentation of endovascular stroke trials at international stroke conference was a land mark event in acute stroke therapy. This study aims to analyze the rates of utilization of IV r-tPA, with or without mechanical thrombectomy before and after the 2015 International Stroke Conference (ISC) in a large regional tele-stroke network. Methods: A systematic review of prospective telestroke and procedure database was performed for 18 months prior and 18 months post conference. There were three groups included in the analysis. The first group consisted ischemic stroke patients presented within 12 hours of onset including inpatient events, transfers from primary centers and rural clinics. The second group consisted of patients who received IV r-tPA, and the third group consisted of patients who received IV r-tPA and/or underwent mechanical thrombectomy for a demonstrated LVO. Results: A total of 2628 consecutive ischemic stroke events presented within 12 hours of onset were evaluated. In the pre-ISC conference group, there were 1135 ischemic stroke patients. IV r-tPA was given 535 times(47.1%) and mechanical thrombectomy was utilized in addition to IV r-tPA or alone 42 times(3.7%). In the post-ISC conference group, there were 1493 ischemic stroke patients. IV r-tPA was given 642 times(43%) and mechanical thrombectomy was utilized in addition to IV r-tPA or alone 132 times(8.84%). The Chi Square statistical test was performed comparing these groups. When comparing the rate of IV r-tPA usage, there was a significant decrease from the pre-ISC conference group to the post-ISC conference group (P= 0.04). When comparing the rate of mechanical thrombectomy performed, there was a significant increase of greater than double the percentage of thrombectomy procedures performed in the post conference group compared to the preconference group (p< 0.001). Conclusion: There was a significant decrease in IV r-tPA usage but a greater than double the increase in the thrombectomy rate . This may be secondary to increased awareness of benefit of thrombectomy at referral centers. Slightly lower rates of IV r-tPA usage may be secondary to an increase in transfers of patients outside of the 0-4.5 hr window but were deemed candidates for thrombectomy.

Introduction: The presentation of results of endovascular stroke treatment trials at the International Stroke Conference (ISC) in February 2015 was a landmark event in the treatment of acute ischemic strokes. Time to treatment remains the main limiting factor in the success of both endovascular and pharmacological treatment of acute ischemic strokes. This study aims to evaluate if publication of these trials has positively impacted the time to presentation for acute ischemic strokes at a regional tele-stroke network. Methods: Clinical data of all stroke consults from 17 months (October 2013 to February 2015) before, and 17 months (March 2015 to July 2016) after presentation of endovascular trials at ISC 2015 was collected from a prospective regional tele-stroke registry. Trends in time to presentation of acute ischemic strokes in the pre-trials and post-trials period were compared. Results: Prospective data of 7176 consecutive tele-stroke consults is presented. There was a significant increase in proportion of tele-stroke calls for acute ischemic stroke referrals in the post-trials period compared to pre-trials period [2792 (84%) versus 2297 (69%), p=0.002]. On sub-group analysis, this trend was seen in the referrals from urban “in-network” hospitals [p=0.02]. There was no change in the referral pattern from rural “out-of-network” hospitals [p=0.2]. In the post-trials period, there was an increase in the proportion of stroke presentations within 4 1/2 hours “window period” and 4.5 to 12 hours, and a decrease in presentation beyond 12 hours [ 4 ½ hrs: 16% vs. 14%; 4 ½-12 hrs: 36% vs. 33%; >12 hrs: 48% vs. 53%, p=0.009] Conclusions: The advent of landmark stroke trials appears to have increased awareness towards stroke treatment, resulting in higher referrals and earlier time to presentation from urban centers, but not rural centers.

Purpose: The preponderance of evidence suggests that target vessel locations (TVL) are important predictors of outcomes in acute ischemic stroke (AIS). However, few studies have examined in detail their correlation in the natural history of a cohort of patients with ICA, M1 and M2 vessel occlusions who are eligible for, but untreated with, mechanical thrombectomy. Hypothesis: We hypothesize that, similar to the broader stroke cohort, there is a correlation between TVL and outcomes. Methods: The SOS and FIRST trials were prospective, multicenter studies evaluating the natural history of a stroke cohort eligible for mechanical thrombectomy but did not receive the treatment. Enrolled patients presented with symptoms of AIS due to LVO and were refractory or ineligible for rtPA treatment. Functional independence was defined as a mRS score 0-2 at 90 days. Incidence of death, intracranial hemorrhage (ICH), serious adverse events (SAEs), and mortality were assessed for association with TVL. Results: A total of 238 patients (median age: 71) met study criteria. Occlusions were reported in the ICA (32.5%), M1 (54.4%), M2 (8.9%), and basilar artery (1.7%). At 90 days, 9.2% of ICA, 12.1% of MCA M1, 25.0% of MCA M2, and 0.0% of basilar artery patients achieved functional independence as defined by a mRS score of 0-2. Although the rate of SAEs was similar between ICA (83.3%), M1 (81.4%), and basilar artery (75%), the rate was lowered in patients with M2 occlusion (61.9%, p Conclusion: Similar to the broader patients with AIS, there is a significant correlation between TVL and outcomes in patients with LVO eligible for mechanical thrombectomy. Although occlusion of smaller vessels (i.e. M2) predicts better functional outcome, 75% of patients will not reach functional independence.

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

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

Background and Purpose: It remains unclear how experience influences outcomes after the advent of stent-retriever technology. We studied the relationship between site experience and outcomes in the TRevo ACute Ischemic StroKe (TRACK) multicenter registry. Methods: The 24 sites that enrolled patients in the TRACK registry were trichotomized into: low volume (enrolling 1-23 cases, less than 2 cases/ month), medium volume (24-47 cases, 2-4 cases/ month), and high volume sites (> 48 cases, > 4 cases/ month). Demographics, baseline features, and key prognostic presentation characteristics were compared across the three volume strata. Results: The 624 TRACK registry patients were divided into three sub groups: low (n=188 patients, 30.1%), medium (n=175, 28.1%), and high (n=261, 41.8%) volume centers. There were no significant differences in terms of age (mean, 66±16 vs. 67±14 vs. 65±15, p=0.2), baseline NIHSS (mean, 17.6±6.5 vs. 16.8±6.5 vs. 17.6±6.9, p=0.43) or site of occlusion across the 3 groups. Times from stroke onset to groin puncture were shorter in the medium volume sites (310 min) but similar in the low vs. high volumes sites (397 vs. 378 min). Higher efficiency and better outcomes were seen in higher volumes sites as demonstrated by faster times from groin puncture to reperfusion (mean, 89 vs. 82 vs. 65 min, p Conclusions: Clinical volumes have a significant influence in terms of efficiency and outcomes across stroke centers.

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

Summary Intracranial aneurysms can be treated with endovascular or surgical techniques. We provide an objective comparison of these treatments, using data from single-centre studies, multicentre studies with and without independent outcome ascertainment, and randomised clinical trials. We compared the outcomes of patients who were candidates for endovascular treatment, surgical treatment, or both. In patients with ruptured intracranial aneurysms, rates of aneurysm obliteration were higher, and need for second treatment was lower, after surgery than after endovascular treatment. However, in observational studies and randomised trials, outcome at discharge, at 2–6 months, and at 1 year, and later survival, were all better after endovascular treatment than after surgery. The results suggest that the higher rates of incomplete obliteration and retreatment after endovascular treatment do not affect patients' clinical outcome. In observational studies of patients with unruptured intracranial aneurysms, discharge outcomes were better and hospital costs were lower after endovascular treatment than after surgery. These patients showed no difference between the two treatments in 1-year outcomes and later rebleeding, although few data were available for this comparison.

OBJECTIVE: To evaluate the midterm results of intracranial stent-assisted coil embolization in the treatment of wide-necked cerebral aneurysms and to assess the efficacy of various strategies used in stent deployment. METHODS: A retrospective study of 42 patients with 46 wide-necked cerebral aneurysms enrolled in a prospective single-center registry of patients treated with a Neuroform stent (Boston Scientific/Target, Fremont, CA), a flexible self-expanding nitinol stent, was performed. Twenty-seven of 46 aneurysms were unruptured aneurysms, 14 were recanalized aneurysms, and five were acutely ruptured. Thirty-nine aneurysms were located in the anterior and seven in the posterior circulation. Mean aneurysm size was 9.8 mm. Stenting before coiling was performed in 13 of 45 aneurysms (29%), coiling before stenting in 27 of 45 aneurysms (60%), and stenting alone in five of 45 aneurysms (11%). The balloon remodeling technique for coiling before stenting was performed in 77% of patients. Angiographic and clinical follow up was available in 31 patients with 33 aneurysms and ranged from 3 to 24 months. RESULTS: Neuroform stenting was attempted in 46 wide-necked aneurysms (42 patients). Forty-nine stent sessions were performed, including three poststent retreatments. In 46 of 49 sessions (94%), successful deployment of 47 stents for 45 aneurysms was obtained. In 40 aneurysms treated with stent-assisted coiling, angiographic results showed 14 (35%) aneurysm occlusions, 18 (45%) neck remnants, and eight (20%) residual aneurysms. In five recanalized aneurysms treated with stenting alone, no changes were observed in four (80%) aneurysms and one (20%) neck remnant reduced in size. At angiographic follow-up in 30 aneurysms treated with stent-assisted coiling, there were 17 (57%) aneurysm occlusions, seven (23%) neck remnants, and six (20%) residual aneurysms. In three recanalized aneurysms treated with stent alone, two (67%) neck remnants remained unchanged and one (33%) neck remnant decreased in size. Procedural morbidity was observed in two of 42 patients (4.8%) and one patient died. On clinical follow-up, the modified Rankin Scale score was 0 in 27 patients (87%), 1 in three patients (10%), and 2 (3%) in one patient. No aneurysm bled during the follow-up period. CONCLUSION: These results indicate that Neuroform stent-assisted coil embolization is a safe and effective technique in the treatment of wide-necked cerebral aneurysms. Further studies are needed to evaluate the long-term durability of stent-assisted aneurysm occlusion and tolerance to the stent.

✓This 65-year-old man presented to the authors' institution reporting neck swelling. Stage IIIA Hodgkin disease was diagnosed, and a computed tomography scan of the neck revealed a vertebrobasilar artery aneurysm. His medical history was significant for subarachnoid hemorrhage and coma 2 years earlier. Subsequent digital subtraction angiography demonstrated a giant fusiform vertebrobasilar junction aneurysm with associated basilar artery (BA) fenestration. Endovascular treatment of the giant aneurysm was performed by left vertebral artery (VA) occlusion and placement of two Jo-stent coronary stent grafts from the right VA to the BA. The postprocedure course was uneventful. Follow-up angiography performed 1 week postoperatively demonstrated complete exclusion of the aneurysm. This unique case is described and a review of the relevant literature is presented.

Background: There is a significant shortage of neurologists and specialists especially on the weekends in rural hospitals. Regional Tele-stroke networks are developing across the US, and have enabled 24/7 coverage for the management of acute ischemic stroke. The impact of regional Tele-stroke networks on the utilization of intravenous thrombolysis (IV r-tPA) on weekends remains to be understood. Methods: Standardized color-coded algorithms for rapid triage of acute strokes in the emergency room (ER) (Fig: 1) were implemented in 2010 within a regional Tele-stroke network of 122 urban and rural hospitals. All acute stroke consults within the regional Tele-stroke network were prospectively collected in a Tele-stroke registry from January 1, 2012. Demographic factors, days of the week when consultation (Tele-phone or Tele-camera) was performed, time from last known normal (LKN) at time of consultation, and whether IV r-tPA was administered were analyzed. Fisher’s exact p -test was used to calculate 2-tailed p -values ( p ≤0.05 was consider significant). Results: A total of 4,028 consecutive acute stroke consults were performed over a 2 ½ -year period, of which 880 patients had an acute ischemic stroke syndrome within 4.5 hours of LKN. Median age was 65 years (range 16-103 years) and the median NIHSS was 8 (range 0-31). IV r-tPA was given 559 of the 880 patients (63.5%) who met eligibility criteria. Out of the 559 patients, 159 patients were treated with IV r-tpA over the weekend (28.4%, p =0.817). There were no gender differences in the utilization of IV r-tPA. Conclusion: In the era of Tele-stroke, utilization of IV r-tPA over weekends in urban and rural hospitals is a reality. Establishing regional Tele-stroke networks can help avoid the “weekend effect” in treating acute ischemic stroke patients.

Background: Time to reperfusion following endovascular treatment (ET) strongly predicts outcomes after acute ischemic stroke (AIS). However, the impact of time may vary depending on the grade of reperfusion. We sought to assess time-outcome relationship within grades of reperfusion in the North American Solitaire Acute Stroke (NASA) registry. Methods: The investigator-initiated NASA registry recruited 24 clinical sites within North America to submit demographic, clinical, site-adjudicated angiographic, and clinical outcome data on consecutive patients treated with the Solitaire Flow Restoration device. We identified patients treated with anterior circulation ischemic stroke treated within 8 hours. The modified Thrombolysis in Cerebral Ischemia (TICI) was used wherein TICI 2 was divided in TICI 2a (< 50% reperfusion) and TICI 2b (> 50% reperfusion). We assessed the impact of time to reperfusion (onset to procedure completion time) on good outcome (modified Rankin Scale 0-2 at 3 months) in those who achieved at least TICI 2a reperfusion, independent of other relevant covariates using logistic regression analysis. We further assessed this relationship within strata of reperfusion grade. Results: Among 265 eligible patients, 209 (78.9%) had complete data (mean age 68.4 years, median NIHSS score 18). Reperfusion grade was as follows: TICI 3: 35.4%; TICI 2b: 39.7%, TICI 2a: 14.8%; TICI 0-1: 10.0%. Independent predictors of outcome at 3 months among those achieving TICI 2-3 reperfusion were: initial NIHSS score, intravenous tissue plasminogen activator use, symptomatic hemorrhage, and time to reperfusion. For each 30 minutes, the adjusted OR for time to reperfusion was 0.874 (95% CI 0.797-958). There was a significant interaction between final TICI grade and 30-minute time to reperfusion intervals (P=0.001) such that the effect of time was strongest in TICI 2a patients. Conclusions: Time to reperfusion is a strong predictor of outcome following ET for AIS with 13% decreased odds of good outcome per 30-minute delay in achieving TICI 2-3 reperfusion. However, the effect varied by TICI grade such that its greatest effect was in those achieving TICI 2a reperfusion.

Purpose: There have been conflicting reports on the correlation between neurological and functional recoveries in acute ischemic stroke. NIHSS and mRS scores not always correlated in patients after treatment. Since the inconsistencies could be related to the variable effectiveness of treatments, the aim of this study was to test their correlation in patients with large vessel proximal occlusion who are eligible but not treated with endovascular therapy. In addition, we analyzed the data based on trichotomized ASPECTS scores to minimize the confounding influence of the infarct core. Methods: The FIRST Trial is a prospective natural history study of a stroke cohort eligible for but untreated by endovascular therapy and ineligible or refractory to IV rtPA. NIHSS and mRS scores were measured in 93 patients at admission, 24 hour and 7 days after hospital presentation and were analyzed by logistic regression against different core infarct volume as indexed by ASPECTS scores of 8-10, 5-7, and 0-4. Results: Median admission NIHSS score was 18 (IQR 14-23, N=93). The mean and mean increase at 24 h NIHSS both showed correlations with trichotomized ASPECTS, p=0.0064 and 0.0202, respectively. NIHSS at 24 h and 7 days displayed a strong relationship with 90 day mRS 0-2 (p=0.0002, N=67; p=0.0003, N=66). NIHSS had a strong correlation to 90 day mRS scores (continuous), with high 7 day scores correlated with high mRS scores and 7 day NIHSS change negatively correlated to 90 day mRS scores (Spearman correlations, all p Conclusion: These data indicate that there is a strong correlation between neurological and functional recoveries in the natural history of acute ischemic when the confounding influences of treatment and the infarct core are taken into account.

Stroke is the third leading cause of death and the leading cause of long-term disability in the United States. Approximately 80% of all strokes are ischemic and there are limited therapies approved for the treatment of acute ischemic stroke. Understanding the mechanisms of ischemic brain damage is necessary for the development of innovative treatment strategies. In this review, we discuss the hemodynamic and molecular mechanisms of ischemic brain damage and the potential therapeutic strategies, including reperfusion and primary and secondary neuroprotection, and strategies for recovery of function, such as neural plasticity and stem cell transplantation. The effective treatment of ischemic stroke is likely to result from a combination of therapeutic modalities aimed at different mechanisms of ischemic brain damage and delivered at specific times after acute cerebral ischemia.

Background and Purpose— The role of anticardiolipin antibodies (aCLs) as novel risk factors for ischemic stroke and transient ischemic attacks (TIAs) has been a matter of debate. Prior cohort studies included only selected subjects, mostly men. We related serum concentrations of aCLs to incident first ischemic stroke/TIA among men and women in the Framingham Heart Study cohort and offspring. Methods— There were a total of 2712 women (mean age, 59.3 years) and 2262 men (mean age, 58.3 years) free of stroke/TIA at the time of their baseline examinations. An enzyme immunoassay was used to measure aCLs. Optical density of the sample serum compared with the reference serum was defined as the aCL screening ratio (aCL SR). Analyses were based on sex-specific aCL SR quartiles and individual ratios. Results— During the 11-year follow-up, 222 ischemic strokes/TIAs occurred. In multivariate analysis, after adjustment for age, prior cardiovascular disease, systolic blood pressure, diabetes, smoking, C-reactive protein, and total and high-density lipoprotein cholesterol levels, an aCL SR of >0.4 (78% of sample) was significantly associated with an increased risk of ischemic stroke/TIA for women (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.3 to 5.4; absolute risk, 3.2%, 95% CI, 2.2 to 4.3) but not in men (HR, 1.3; 95% CI, 0.7 to 2.4; absolute risk, 4.5%; 95% CI, 3.0 to 6.0). Similar results were obtained when the higher 3 aCL SR quartiles were compared with the lowest. Conclusions— Elevated serum concentrations of aCLs, independently of other cardiovascular risk factors, significantly predict the risk of future ischemic stroke and TIA in women but not in men.

Quality of Life (QOL) is impaired in multiple sclerosis (MS) in part due to physical disability. MS-associated fatigue (MSF) and depression (MSD) are common and treatable features of MS, which could also impact on QOL, independent of physical disability. We prospectively studied 60 consecutive patients with MS. QOL was assessed using Multiple Sclerosis Quality of Life (MSQOL)-54. Group differences in QOL scores were assessed after adjusting for Expanded Disability Status Scale (EDSS), Fatigue Severity Scale (FSS) and Hamilton Depression Inventory scores. MS patients were grouped into relapsing–remitting (RR) or secondary-progressive (SP), MSF (FSS≥5) or MS-nonfatigue (MSNF) (FSS≤4), and MSD or MS-nondepression (MSND). After accounting for disability and depression, fatigue was associated with impaired QOL with respect to health perception (p=0.03) and limitations due to physical dysfunction (p=0.008). After accounting for disability and fatigue, depression was associated with lower QOL with respect to health perception (p=0.02), sexual dysfunction (p=0.03), health distress (p=0.03), mental health (p=0.006), overall QOL (p=0.006), emotional dysfunction (p=0.04), and limitations due to emotional dysfunction (p=0.03). This study demonstrates that fatigue and depression are independently associated with impaired QOL in MS, after accounting for physical disability, suggesting that their recognition and treatment can potentially improve QOL.

Object A decision to treat incidental intracranial aneurysms (IIAs) relies on understanding the risks of treatment and weighing them against the those of aneurysm rupture. Whereas the natural history of IIAs is currently being studied, the risks associated with treating IIAs and factors associated with poor outcome need to be clearly established. Methods In a consecutive series of 125 patients, 160 IIAs were treated either surgically (152 cases) or endovascularly (eight cases). Postprocedural morbidity was defined as a new neurological deficit associated with a score greater than or equal to 3 on the modified Rankin Scale or a score of less than 24 on the Mini-Mental Status Examination. Logistic regression analysis was used to identify predictors of postprocedural morbidity from retrospectively collected data on demographic, clinical, and radiographic characteristics. Treatment of IIAs was not associated with any mortality and was associated with postprocedural morbidity in 17 (13.6%) of 125 patients (early outcome) and eight (6.4%) of patients (late outcome). In the logistic-regression model, treatment of aneurysms (≥13 mm) and posterior circulation aneurysms were independently associated with postprocedural morbidity. In patients in whom postprocedural neurological deficits developed, 12 (70.6%) of 17 and four (23.5%) of 17 patients harbored aneurysms with broad or calcified necks, respectively. Age, comorbidities, multiple aneurysms, specific aneurysm location, and history of subarachnoid hemorrhage related to a different aneurysm were not significantly associated with poor outcome. Conclusions The authors found that IIAs can be safely and effectively treated without causing mortality and with a lower morbidity rate than previously reported. A combination of radiographic variables may be helpful in identifying patients at risk for postprocedural morbidity.

Objective and importance Shaking limb transient ischemic attacks (TIAs) represent a rare clinical syndrome that has been ascribed to focal cerebral ischemia attributable to insufficient brain perfusion, usually resulting from carotid artery occlusive disease. The techniques conventionally used to evaluate this condition are contrast angiography, carotid artery ultrasonography, and magnetic resonance angiography. Treatment consists of internal carotid artery (ICA) endarterectomy or, in the case of complete ICA occlusion, extracranial-intracranial bypass. In this report, two patients with shaking limb TIAs are presented. For one patient, preoperative evaluations included single-photon emission computed tomographic studies with acetazolamide vasodilator challenge; for the second patient, computed tomographic angiography was used to assess vascular anatomic features. Clinical presentation Two patients with severe carotid artery disease presented with brief, recurrent, shaking limb TIAs. Angiograms obtained for Patient 1 demonstrated complete ICA occlusion in association with severe external carotid artery stenosis, whereas preoperative single-photon emission computed tomographic scans revealed a lack of cerebrovascular reserve in response to acetazolamide challenge. Carotid artery duplex ultrasonography and computed tomographic angiography demonstrated severe stenosis of the ICA for Patient 2. Intervention Patient 1 underwent a left external carotid artery endarterectomy. Patient 2 underwent a right ICA endarterectomy. Conclusion After surgery, the shaking limb episodes ceased for both patients. Postoperative single-photon emission computed tomographic scans for Patient 1 demonstrated increased cerebral blood flow in response to acetazolamide challenge. These data provide support for the concept that shaking limb TIAs are related to hemodynamic failure and that improvements in cerebral blood flow through conducting vessels can alleviate the condition.

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

Introduction: Hemorrhage is a well documented consequence after the administration of intravenous alteplase (IV-tPA) in the therapy of ischemic stroke. Serious intracranial bleeding may occur in 6.4 percent of patients within thirty-six hours. Primary stroke centers certified by The Joint Commission (TJC) require neurosurgical coverage or transfer protocols to ensure neurosurgical services are available within two hours. Hypothesis: We assessed the hypothesis that patients receiving IV-tPA for ischemic stroke would not require any type of neurosurgical intervention within two hours. Methods: Ischemic stroke patients who received IV-tPA from January 2010 to June 2013 across 11 hospitals with a regional stroke network were analyzed retrospectively. Of those patients we assessed the prevalence of brain hemorrhage, and further the need for neurosurgical intervention (craniotomy, craniectomy, burr-hole placement, extraventricular drain (EVD) placement) during that inpatient admission. Results: Of the 17,319 inpatient admissions in our regional stroke network, 6,500 patients were admitted for ischemic stroke. Only 2% of all patients treated with IV-tPA had symptomatic brain hemorrhages (10/520). One patient underwent craniotomy for hematoma evacuation after an observation period of six hours (0.2%; 1/520). Conclusions: Symptomatic brain hemorrhage after IV-tPA requiring emergent neurosurgical intervention is rare. The results of this study underscore the relevance of transfer protocols to ensure neurosurgical services are available within two hours but question the need for neurosurgical coverage at designated primary stroke centers.

Background and Purpose: Previous work has suggested that general anesthesia (GA) may have a negative impact on outcomes in acute ischemic stroke (AIS) patients undergoing endovascular therapy, however, those data predated the availability of the safer and possibly more effective stentriever devices. Methods: The investigator-initiated NASA Registry recruited North American sites to submit demographic, clinical, procedural (including use of GA versus local anesthesia [LA]), and site-adjudicated angiographic and clinical outcome data on consecutive patients treated with the Solitaire™ FR device. The primary outcomes were mRS at 90-days, mortality, and sICH. Results: A total of 281 patients from 18 centers were enrolled in this sub-study. GA was utilized in 69.8% (196/281) of patients. Baseline demographics were comparable between the LA and GA groups, except the former demonstrated a longer time to groin puncture (395.4±254 versus 337.4±208min, p=0.04) and slightly lower NIHSS (16.2±5.8 versus 18.8±6.9, p=0.002). Procedural factors were also similar, although lower balloon-guide catheter usage (22.4% versus 49.2%, p=0.0001) and longer fluoroscopy times (39.5±33 versus 28±22.8min, p=0.008) were seen in the LA versus GA cohorts, respectively. Recanalization (TICI≥2a) success (91.8 versus 86.8%, p=0.3) and the rate of sICH (7.1% versus 11.2%, p=0.4) were similar between the LA and GA patients, respectively. The primary outcome of mRS≤2 was achieved in 52.6% and 35.6% (OR 1.4[1.1-1.8], p=0.01) of LA and GA patients, respectively. In a multivariate analysis, hypertension, NIHSS, unsuccessful revascularization, and GA use (OR 3.3(1.6-7.1), p=0.001) were associated with death. To account for potential confounders, when only anterior circulation patients and patients who were electively intubated were included, there was a persistent difference in good outcomes in favor of the LA patients (50.7% versus 35.5%, OR 1.3[1.01-1.6], p=0.04). Conclusions: The NASA Registry has demonstrated that clinical outcomes and survival are significantly better in patients treated without GA without any increase in sICH. Future AIS trials should prospectively evaluate the effect of GA on outcomes.

Introduction: A pre-hospital stroke severity scale that correlates well with an NIHSS of 10 or greater as well as with large vessel occlusions, but is easier and faster to perform than full NIHSS, would be a very useful triaging tool to emergency medical services (EMS). The LEGS score (Lower extremity strength, Eyes/visual fields, Gaze deviation, Speech difficulty) is a 16-point pre-hospital stroke severity scale that is a shortened NIHSS-5. Hypothesis: We assessed the hypothesis that the LEGS score was a useful pre-hospital stroke severity scoring system to identify large vessel acute ischemic strokes. Methods: The LEGS score (0-16) and NIHSS (0-42) were performed in the emergency department over a 6-month period. We retrospectively reviewed those charts for correlation to an NIHSS of 10 or greater and evidence of large-vessel occlusion on either CT or MR Angiography within 48 hours of last known normal. Results: A total of 181 consecutive ischemic stroke patients were evaluated. LEGS score 4 or greater was a good predictor of an NIHSS of 10 or greater (59/181; positive predictive value 92%; and specificity 95%) and false positives noted was 5/181. LEGS score of less than 4 was a good predictor of an NIHSS of less than 10 (108/181; negative predictive value 91%; and sensitivity 95%) and false negatives noted was 10/181. Of those patients 155 underwent intracranial vascular imaging. LEGS score of less than 4 was a good test to rule-out large vessel occlusion (negative predictive value of 86%; 89/103), but had modest sensitivity (69%; 31/45) and positive predictive value (60%; 31/52). The LEGS score of 4 or greater, however, was fairly specific for determining large-vessel occlusions at 81% (89/110). Conclusions: LEGS score of 4 or greater has good correlation with an NIHSS of 10 or greater as well as modest correlation with large vessel occlusion on CT or MR Angiography. This shortened NIHSS-5 may be a useful pre-hospital indicator of patients who may benefit from endovascular intervention.

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