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Introduction Elderly individuals are at an increased risk for stroke and are responsible for a substantial portion of the total stroke burden. The safety and efficacy of thrombectomy in nonagenarians is not fully understood, as they have traditionally been excluded from major endovascular trials. Recent literature suggests 7% of patients have functional independence at 3 months following medical management. This research aims to determine the outcomes of thrombectomy in patients ≥ 90 years with proximal intracranial occlusion. Methods We performed a multicenter retrospective analysis of consecutive acute ischemic stroke patients with M1 occlusion treated within 24 hours from the time of last known well who were greater than 89 years of age. Patient demographics, periprocedural metrics, and discharge and 90-day modified Rankin Scale (mRS) scores were collected. Successful recanalization was defined as TICI 2B or better. Favorable outcome was defined as 90-day mRS≤2 for patients prestroke mRS 2. Results Seventy-one patients over 89 years old were identified. Fifty-two (73.2%) were female. Pre-stroke mRS scores were available for 70 patients. The baseline median mRS was 2. Successful recanalization was achieved in 95.8% of patients. TICI 2C or greater was accomplished in 64.8% of cases. Functional outcome data at 90-days were available for 57 patients (80.2%). At three months, 7 total patients had an mRS between 0–2 (12.3%), and an additional 11 patients had an mRS of 3 (19.2%). The rate of 90-day mortality was 42%. Conclusions Mechanical thrombectomy in nonagenarians is technically feasible with high rate of successful reperfusion and it may improve clinical outcome. More research is needed to determine if thrombectomy results in significantly better functional outcomes than medical management for nonagenarians. Disclosures S. Majidi: None. J. Vargas: 2; C; Cerenovus, Medtronic. 4; C; Truvic. J. Blalock: None. H. Hawk: None. S. Nimjee: None. A. Zakeri: None. M. Mokin: 2; C; Medtronic, Cerenovus. 4; C; Endostream, Serenity medical. R. Kellogg: None. G. Cortez: None. A. Aghaebrahim: None. E. Sauvageau: None. R. Hanel: 1; C; Stryker, Medtronic. 2; C; Stryker, Medtronic, Balt, Cerenovus, Microvention, Q’Apel, Rapid Medical. 4; C; Scientia, RisT, Corindus. R. DeLeacy: None. A. Siddiqui: 1; C; NIH-NINDS R21 NS109575-01. 2; C; Cerenovus, Imperitive Care, Medtronic, Microvention, Penumbra, Q’Apel. 4; C; Imperitive Care, Q’Apel, Rist, Truvic. A. Turk: 2; C; Imperitive Care, Stryker, Microvention, Penumbra, BALT, Cerenovus. 4; C; Imperitive Care. M. Oselkin: None. E. Marlin: None. R. Turner: 2; C; Q’apel, Cerenovus, Siemens. 4; C; Q’APel. I. Chaudry: 2; C; Cerenovus, Q’Apel. 4; C; Q’Apel. J. Milburn: None.

Introduction Endovascular management of wide-necked bifurcation aneurysms poses a therapeutic challenge as coiling often requires the use of multiple adjunctive stent constructs to achieve successful embolization without compromising parent vessel integrity. The Neuroform Atlas Stent System is a novel low-profile, intraluminal remodeling device. The study aims to investigate the safety and efficacy of the Y-configuration constructs with the ATLAS stent for aneurysm coil embolization. Methods Patients undergoing Y-stent assisted coil embolization in the ATLAS IDE trial (Investigational Device Exemption) were identified. The primary efficacy end point was complete aneurysm occlusion (Raymond-Roy class 1) on 12-month angiography, in the absence of retreatment or parent artery stenosis (>50%) at the target location. The primary safety end point was any major stroke or ipsilateral stroke or neurological death within 12 months. Adjudication of the primary end points was performed by an independent Imaging Core Laboratory and the Clinical Events Committee. Result A total of 60 patients of were identified. The mean age was 59 and 28.3% were men. The median aneurysm size was 6.7mm with a median neck size of 4.3 mm. Aneurysm locations were as follows: basilar apex (56.7%), basilar trunk (3.3%), anterior communicating artery (20%), anterior cerebral artery (3.3%), internal cerebral artery (3.3%) and middle cerebral artery (13.3%). The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 81.1% of patients. Overall, 1.7% (1/60) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions In the ATLAS IDE aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive Y-stent coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with low rates of morbidity. Disclosures A. Jadhav: None. S. Desai: None. R. Hanel: None. D. Frei: None. A. Khaldi: None. S. Hetts: None. O. Zaidat: None. B. Jankowitz: None.

Background Imaging clot characteristics such as clot density and perviousness (the latter is defined as a difference in regional clot density values between computed tomography angiography (CTA) and non-contrast CT [NCCT]), can be used as an imaging marker characterizing red blood cell and fibrin composition of the clot serving. We aimed to examine whether clot density and perviousness were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in the COMPASS Trial: a Direct Aspiration First Pass Technique trial. Methods Clot density (Hounsfield units, HU) and perviousness were measured by two operators who were blind to all the final angiographic and clinical outcomes except for the knowledge of stroke laterality. NCCT and CTA images were co-registered to accurately localize clot on both imaging modalities. The values were then matched with angiographic and clinical outcome data of the first pass for each randomization arm. Univariate and multivariate analysis was carried out to assess the association of clot density and perviousness using SPSS version 25. Results Of the original 270 patients included in the COMPASS trial, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). There was no difference between the groups in regards to gender distribution, age, laterality and side of large vessel occlusion, smoking status of patients, and comorbidities. There was also no difference between the aspiration and stent retriever first randomization groups in regards to baseline clot Hounsfield units (HU) on NCCT (49.9 ±8.2 vs. 47.8 ±8.7, P=0.11), and perviousness (26.84 ±21.8 vs. 22.8 ±19.9, P=0.20). For the aspiration first group, there was a difference in mean perviousness values among patients who achieved TICI 2c-3 vs. TICI 2b vs. TICI 0–2a (33.1 ±26, 35.9 ±25.1, and 19.0 ±14.2, respectively; P=0.016). There was no difference between clot HU density on NCCT among these 3 groups (48.8 ±8.5, 50.1 ±7.2, and 51.0 ±8.4, P=0.56). In the stent retriever first group, there was no difference in perviousness or HU density of clot in patients with TICI 2c/3, TICI 2b or TICI 0–2a after first pass (perviousness 21.6 ±17.0, 22.4 ±18.04 and 22.6 ±22.9, P=0.97; HU on NCCT 48.7 ±9.1, 49.7 ±6.5 and 46.7 ±9.0, P=0.47).In multivariate analysis using a model that included use of intravenous tPA, balloon guide catheter use, onset to groin puncture and age, perviousness of more than 10 was the only independent factor predictive of successful recanalization (defined as TICI 2b-3) after first pass in the aspiration first group with odds ratio of 3.4 (95% CI 1.0 -12.0). We did not find any significant predictors of successful reperfusion (TICI 2b-3) after first pass in the stent retriever first group. Conclusions Clot perviousness values are associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy. Additional research is needed to determine if clot perviousness may be used to identify patients who are more likely to have successful recanalization with aspiration when deciding between aspiration versus stent retriever first approaches. Disclosures M. Mokin: 1; C; NIH R21NS109575. 2; C; Medtronic, Canon medical, Cerenovus. 4; C; Serenity medical, Synchron, VICIS, Endostream. M. Waqas: None. J. Fifi: 1; C; Stryker, Penumbra, Microvention. 4; C; Cerebrotech, The Stroke Project. R. De Leacy: 1; C; Penumbra. 6; C; Cerenovus, Siemens. D. Fiorella: 1; C; Penumbra, Cerenovus, Stryker. 6; C; Genentech, Shape Memory Medical. E. Gu: None. E. Levy: 6; C; Penumbra, NextGen Biologics, Rapid Medical, Cognition Medical, Three Rivers Medical, Stryker, MedX, Endostream Medical. K. Snyder: 6; C; Penumbra, Canon Medical Systems, Medtronic, Jacobs Institute; and other from Neurovascular Diagnostics. R. Hanel: 6; C; Penumbra, Endostream, Cerebrotech, Synchron, InNeuroCo, Medtronic, Microvention, Stryker, Cerenovus; Elum, Three Rivers. A. Aghaebrahim: None. K. Woodward: 6; C; Penumbra. H. Hixson: 6; C; Penumbra. M. Chaudry: 6; C; Penumbra, Pulsar Vascular, Medtronic, Microvention, Codman, Blockade. A. Spiotta: 6; C; Penumbra, Pulsar Vascular, Stryker, Microvention. A. Rai: 6; C; Penumbra, Microvention, Stryker. D. Frei: 6; C; Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical, Siemens. J. Delgado Almandoz: 6; C; Penumbra, Medtronic. M. Kelly: 6; C; Penumbra, Medtronic, Endostream. A. Arthur: 6; C; Penumbra. B. Baxter: 6; C; Penumbra, Medtronic, Stryker, Viz, and 880 Medical. J. English: 6; C; Penumbra, Medtronic, Stryker, Route 92 Medical. I. Linfante: 6; C; Penumbra, Medtronic, Stryker, Microvention, InNeuroCo, andThree Rivers. K. Fargen: 6; C; Penumbra and Cerebrotech. A. Turk III: 6; C; Penumbra, Pulsar Vascular, Codman, Microvention, Medtronic, Blockade. A. Siddiqui: 6; C; Amnis Therapeutics, Serenity Medical, Silk Road Medical, Rebound Therapeutics, Penumbra Medtronic, Three Rivers Medical, Microvention, Imperative Care, Cerenovus, Endostream Medical, StimMed, Claret M. J. Mocco: 6; C; Penumbra, Cerebrotech, Rebound Therapeutics, TSP, Lazarus Effect, Medina, Pulsar Vascular, Blockade.

Introduction Patients over 80 years old account for one third ischemic strokes in the developed world, with an overall poor outcome. Although current guidelines do not recommend an upper age limit for endovascular approach, the benefit in the elderly population is still uncertain. In spite of efforts to identify criteria associated with good outcomes in this age range, literature has not found any yet. We aimed to use novel tools being reported in stroke literature, such as First Pass Effect (FPE) and Hypoperfusion Intensity Ratio (HIR), to optimize elderly patient selection for thrombectomy. Methods A single-center retrospective analysis of a prospectively maintained large vessel occlusion database (2014–2019) was conducted. We included patients ≥80 years old with acute ischemic stroke that underwent endovascular thrombectomy. First pass thrombectomy was defined as single attempt obtaining TICI 2b or higher without distal embolization, as previously stated in literature. Collaterals were assessed based on HIR (good collaterals Results A total 146 patients were included in the study. Mean age was 87.8±4.12 (range 80–100) and 65.75% were female. Pre-stroke functional independence (baseline mRS 0–2) was seen in 64.1%. Median time of onset to groin puncture was 261.5 minutes and mean time from groin puncture to recanalization was 37.15 minutes. Good collaterals were seen in 50.9% of patients. Successful reperfusion (TICI 2b or higher) was achieved in 87.1%. The rates of good outcome (mRS 0–2), acceptable outcome (mRS 0–3) and poor outcome (mRS 4–6) at 90 days were 18.5%, 38.1% and 43.4%, respectively. Multivariate logistic regression indicated that pre-stroke functional independence (p=0.0008), good collaterals (p=0.0009), use of stent retriever (Solitaire, p=0.035; Trevo, p=0.032) and balloon guide catheter (p=0.028) were associated with good outcome. Conclusions In our retrospective cohort of elderly patients treated with thrombectomy, the baseline characteristics that appear to influence in the rate of good outcome were the pre-stroke functional independence and the presence of good collaterals. Although previous studies with younger populations showed promising use of First Pass Effect measure to predict good outcome in patients who underwent thrombectomy, we did not find any significant association in patients ≥80-year-old. Preference for the use of stent-retriever and balloon guide-catheter may shorten the time to reperfusion and therefore, provide better outcomes. We emphasize the need of further studies to improve selection criteria for endovascular thrombectomy in this population. Disclosures A. Monteiro: None. G. Cortez: None. Y. Murtaza: None. A. Aghaebrahim: None. E. Sauvageau: None. R. Hanel: 2; C; Microvention, Codman, Stryker, Medtronic.

Introduction The benefit of endovascular thrombectomy (ET) is well established in patients with small anterior circulation infarctions and large penumbra. However, this benefit is not proven in patients with a baseline large core infarction. This subpopulation was excluded from major thrombectomy clinical trials. The purpose of this study was to report the outcome of patients with large baseline core based on CTP who underwent stroke thrombectomy at 4 large stroke centers. Methods Prospectively collected large vessel occlusion databases were queried to identify patients with large baseline infarct cores (CBF greater than 30% ≥ 50 mL; based on Computed Tomography Perfusion [CTP] processed by RAPID Software [iSchemaView]). All patients treated with thrombectomy were included in the study. Modified Rankin Scale (mRS) was used for evaluation of clinical outcomes at baseline and 90 days. Demographic information, baseline clinical data, radiological features (infarct core size, penumbra and collaterals) and follow-up were collected. Results A total of 75 patients were included in the study. Mean age was 65 ±14.9 years and 45.3% were male. Median infarct core was 75.5 mL (IQR 39) and median ASPECTS was 7 (range 3–10). Close to half (50.7%) of patients received IV tPa. Only 8.3% of patients had good collaterals. Mean time to groin puncture was 373±384 minutes and 88% of patients achieved TICI 2b or higher. Rates of good outcome (mRS 0–2) and acceptable outcome (mRS 0–3) were 28.4% and 35.5% respectively. Rate of Parenchymal Hematoma type 2 was 10.6%. The rate of good outcome was significantly higher in patients treated Conclusions Acute stroke thrombectomy may be beneficial in some patients with large core based on CTP especially those who present early ( Disclosures A. Aghaebrahim: None. S. Desai: None. A. Monteiro: None. M. Granja: None. G. Agnoletto: None. G. Cortez: None. D. Gonsales: None. C. Legault: None. C. Powers: None. A. Jadhav: None. E. Sauvageau: None. G. Albers: 5; C; CEO of RAPID Software (iSchema View). T. Jovin: None. R. Hanel: 2; C; Microvention, Codman, Stryker, Medtronic.

Introduction The use of flow diversion has been widely accepted to treat intracranial aneurysms located in the anterior circulation. However, flow diversion remains controversial and less optimistic for the treatment of posterior circulation aneurysms since publications have reported higher rates of adverse outcomes and mortality, especially when treating non-saccular aneurysms. The primary outcome measures were to evaluate the procedure-related mortality and the occurrence of major neurological complications during the peri-procedural period (within 30 days) and delayed neurological events (≥30 days). Secondary endpoints included the all-cause mortality rate, functional outcomes at discharge and at the last clinical follow-up as well as the rate of aneurysm occlusion at the last imaging follow-up. Methods This is an observational retrospective study. We reviewed our database to identify patients with IAs that underwent endovascular treatment between February 2011 and December 2016. The inclusion criteria consisted of patients aged 18 or older with unruptured posterior circulation aneurysms that were treated with the Pipeline Embolization Device (PED). Patients with ruptured aneurysms were excluded. A neurological complication was defined as an ischemic stroke and/or intracranial hemorrhage. If the symptoms resolved within 7 days was considered minor and if they persisted longer than 7 days was defined as major. Results A total of 31 patients with 34 aneurysms met inclusion criteria for the study. The mean age was 58.7±14.1 years. Sixteen patients were female (51.6%). The mean aneurysm size was 8.3±5.6 mm (range, 1.5–28). A total of 17 aneurysms were classified as saccular (group 1) and 17 as non-saccular (group 2). Major neurological complications within 30 days occurred more frequent in the group 2 in 6.3% (1/17) compared with the group 1. Also, minor neurological complications occurred in 18.8% (3/16) in the group 2 whereas in the group 1 occurred in 13.3% (2/16). Delayed major neurological complications occurred in both groups (13.3% vs 12.5%). The all-cause mortality rate was 6.5% (2/31) but none occurred within the peri-procedural period. At the last imaging follow-up, the aneurysm was occluded in 75% (12/16) in the group 1 whereas it occurred in 68.8% in the group 2. Based on the last clinical follow-up, 87.1% (24/29) of patients had a favorable outcome (mRS 0–2). Conclusion Treatment of posterior circulation aneurysms with flow diversion is a feasible option regardless of lesion morphology, however, it should be considered after discarding other options. Disclosures P. Aguilar-Salinas: None. L. Brasiliense: None. J. Lima: None. A. Aghaebrahim: None. E. Sauvageau: None. R. Hanel: 1; C; Microvention. 2; C; Medtronic; Stryker; Microvention; Codman. 4; C; Blockade Medical.

Introduction The optimal management of intracranial arterial stenosis is unclear in particular in patients who have failed medical management. We now report a multicenter experience of endovascular recanalization of intracranial artherosclerotic stenosis refractory to medical therapy. Methods Retrospective multicenter case series of consecutive endovascularly treated patients presenting with symptomatic (TIA or stroke) who have failed medical therapy. All of the patients were considered to be in the high-risk category with unstable symptomatic intracranial stenosis and progression or recurrence of their symptoms despite the best medical management who required endovascular intervention either with stenting and/or balloon angioplasty. Results Fifty patients presented with recurrent TIAs (n=26) or strokes (n=24) were treated in 5 stroke centers from 2011 to 2017. All patients underwent best medical management in the decision of the stroke neurologist and were enroll in this study only if they had recurrent or progression of symptoms despite their medical therapy. The majority of lesions were located in the M1 segment (15/50). There was one periprocedural vessel perforation resulting in patient death, one case of groin hematoma, one intraprocedure hemorrhage, and one periprocedural stroke. Twelve patients (24%) had restenosis on follow up imaging and 80% (33/41) of patients were symptom free at 90 day follow-up. Three patients had a stroke in the territory of the stenosis and 5 patients had recurrent TIAs. Conclusion Endovascular recanalization of unstable intracranial atherosclerotic stenosis who have failed medical therapy is feasible and safe. Disclosures P. Aguilar-Salinas: None. R. Hanel: 1; C; Microvention. 2; C; Medtronic; Stryker; Microvention. 4; C; Blockade Medical. E. Sauvageau: None. D. Lopes: 2; C; Microvention. A. Saied: None. T. Jovin: 2; C; Medtronic. 3; C; Blockade Medical; Silk Road Medical. A. Jadhav: None. L. Kaustubh: None. L. Brasiliense: None. T. Dumont: None. J. Cherian: None. P. Kan: None. A. Aghaebrahim: None.