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Background: Moyamoya disease is a chronic, progressive cerebrovascular disease involving occlusion or stenosis of the terminal portion of the internal carotid artery. We conducted an updated systematic review and meta-analysis to investigate clinical and angiographic outcomes comparing direct, combined, and indirect bypass for the treatment of moyamoya disease in adults. Methods: Two independent authors performed Preferred Reporting Items for Systematic reviews and Meta-Analyses guided literature searches in December 2021 to identify articles reporting clinical/angiographic outcomes in adult moyamoya disease patients undergoing bypass. Primary end points used were ischemic and hemorrhagic strokes, clinical outcomes, and angiographic revascularization. Study quality was evaluated with Newcastle-Ottawa and the Oxford Center for Evidence-Based Medicine scales. Results: Four thousand four hundred fifty seven articles were identified in the initial search; 143 articles were analyzed. There were 3827 direct, 3826 indirect, and 3801 combined bypasses. Average length of follow-up was 3.59±2.93 years. Pooled analysis significantly favored direct (odds ratio [OR], 0.62 [0.48–0.79]; P P P P =0.0001) and combined (OR, 0.53 [0.41–0.69]; P P P P =0.0001) over indirect bypass for early stroke, late stroke, late intracerebral hemorrhage, and favorable outcomes, respectively. Indirect bypass was favored over combined (OR, 3.1 [1.7–5.6]; P P P P =0.002) and combined (OR, 0.23 [0.12–0.43]; P P P =0.01). Conclusions: Based on combined meta-analysis (43 articles) and pooled analysis (143 articles), the existing literature indicates that combined and direct bypasses have significant benefits for patients suffering from late stroke and hemorrhage versus indirect bypass. Combined bypass was favored over indirect bypass for favorable outcomes. This is a strong recommendation based on low-quality evidence when utilizing the Grades of Recommendation, Assessment, Development, and Evaluation system. These findings have important implications for bypass strategy selection.

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P P P P P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

Background and Purpose— EG-1962 is a sustained release formulation of nimodipine administered via external ventricular drain in patients with aneurysmal subarachnoid hemorrhage. A randomized, open-label, phase 1/2a, dose-escalation study provided impetus for this study to evaluate efficacy and safety of a single intraventricular 600 mg dose of EG-1962 to patients with aneurysmal subarachnoid hemorrhage, compared with standard of care oral nimodipine. Methods— Subjects were World Federation of Neurological Surgeons grades 2–4, modified Fisher grades 2–4 and had an external ventricular drain inserted as part of standard of care. The primary end point was the proportion of subjects with favorable outcome at day 90 after aneurysmal subarachnoid hemorrhage (extended Glasgow outcome scale 6–8). The proportion of subjects with favorable outcome at day 90 on the Montreal cognitive assessment, as well as the incidence of delayed cerebral ischemia and infarction, use of rescue therapy and safety were evaluated. Results— The study was halted by the independent data monitoring board after planned interim analysis of 210 subjects (289 randomized) with day 90 outcome found the study was unlikely to achieve its primary end point. After day 90 follow-up of all subjects, the proportion with favorable outcome on the extended Glasgow outcome scale was 45% (65/144) in the EG-1962 and 42% (62/145) in the placebo group (risk ratio, 1.01 [95% CI, 0.83–1.22], P =0.95). Consistent with its mechanism of action, EG-1962 significantly reduced vasospasm (50% [69/138] EG-1962 versus 63% [91/144], P =0.025) and hypotension (7% [9/138] versus 10% [14/144]). Analysis of prespecified subject strata suggested potential efficacy in World Federation of Neurological Surgeons 3–4 subjects (46% [32/69] EG-1962 versus 32% [24/75] placebo, odds ratio, 1.22 [95% CI, 0.94–1.58], P =0.13). No safety concerns were identified that halted the study or that preclude further development. Conclusions— There was no significant increase in favorable outcome for EG-1962 compared with standard of care in the overall study population. The safety profile was acceptable. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02790632.

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

Background: Acute ischemic strokes outcomes may be less favorable in elderly patients. Whether transferring octogenarians with large vessel occlusion (LVO) for endovascular thrombectomy (EVT) results in similar outcomes to younger patients is uncertain. Methods: A pooled cohort from 6 centers (Europe, US) from 1/2014 to 5/2020 of pts with (ICA, M1, M2) LVO transferred for EVT ≤ 24 hrs from LKW. Patients were stratified into < 80 vs ≥ 80 years old. We compared 90 day functional independence and safety outcomes and assessed for predictors of good outcome (mRS 0-2) and profound disability (mRS 5-6). Results: Of 1176 pts received EVT as transfers, 216 (18%) were octogenarians. Baseline NIHSS was higher in octogenarians [19 (14, 22) vs 17 (12, 21), p Milder strokes (aOR 0.88, 95%CI 0.86-0.91, p Conclusion: EVT may be associated with lower independence rates in transferred octogenarians with LVO. Milder stroke severity, earlier presentation and IV thrombolysis increased the odds of good outcomes in octogenarians. Severe strokes and later treatment were associated with profound disability. Optimized selection and workflow is warranted in transferring elderly patients for EVT.

Background: The degree to which the COVID-19 pandemic has affected systems of care, in particular those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence (AI) platform. Methods: Data were derived from the Viz Platform, an AI application designed to optimize the workflow of acute stroke patients. Neuroimaging data on suspected stroke patients across 97 hospitals in 20 US states were collected in real-time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of CTA, CTP, Large vessel occlusions (LVOs) (defined according to the automated software detection), and severe strokes on CTP (defined as those with hypoperfusion volumes>70mL) normalized as number of patients per day per hospital. Data from the pre-pandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23,223 patients were included. The incidence of LVO on CTA and severe strokes on CTP were 11.2%(n=2,602) and 14.7%(n=1,229/8,328), respectively. There were significant declines in the overall number of CTAs (-22.8%;1.39 to 1.07 patients/day/hospital,p Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This underscores the broader application of AI neuroimaging platforms for the real-time monitoring of stroke systems of care.

Background: Direct To Angio (DTA) for transferred large vessel occlusions (LVO) lowers time to endovascular thrombectomy (EVT), reperfusion and potentially improves outcomes. Safety and efficacy of DTA in late time window and on-call hours is unknown. Methods: Pooled cohort from 6 centers (EU, US) from 1/14-5/20 (ICA, M1, M2) LVO pts transferred for EVT≤24 hrs from LKW. Pts stratified into with repeat imaging (RI) (CT+/- CTA/CTP) and without RI (DTA). We compared time metrics, good outcome (90 day mRS 0-2), safety (sICH, mortality) and assessed the impact of arrival for EVT; regular (M-F, 8am-5pm) vs on-call hrs. Propensity matched analysis was done. Results: Of 1178 EVT transfers, 334 (28%) were DTA. DTA pts had more tPA (61% vs 51%, p=0.002), trended to lower NIHSS 17 (12, 20) vs 17 (13, 21), p=0.07 and lower LKW to arrival 268 (190, 430) min vs 280 (190, 518), p=0.097. Groin puncture (GP) was faster with DTA (p6-24, p=0.88 for interaction). In propensity matched 75 pairs, DTA had shorter time to EVT (19 min vs 52, p Conclusion: In pooled, non-randomized data DTA may result in faster treatment, safe and better functional outcomes, during all hours and treatment windows. Repeat imaging may be reasonable with prolonged transfer times. Optimal EVT workflow in transfers may result in faster, safe reperfusion with higher good outcomes.

Supplemental Digital Content is available in the text., Background and Purpose: Stent-assisted coil embolization using the new generation Neuroform Atlas Stent System has shown promising safety and efficacy. The primary study results of the anterior circulation aneurysm cohort of the treatment of wide-neck, saccular, intracranial, aneurysms with the Neuroform Atlas Stent System (ATLAS trial [Safety and Effectiveness of the Treatment of Wide Neck, Saccular Intracranial Aneurysms With the Neuroform Atlas Stent System]) are presented. Methods: ATLAS IDE trial (Investigational Device Exemption) is a prospective, multicenter, single-arm, open-label study of wide-neck (neck ≥4 mm or dome-to-neck ratio 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. Results: A total of 182 patients with wide-neck anterior circulation aneurysms at 25 US centers were enrolled. The mean age was 60.3±11.4 years, 73.1% (133/182) women, and 80.8% (147/182) white. Mean aneurysm size was 6.1±2.2 mm, mean neck width was 4.1±1.2 mm, and mean dome-to-neck ratio was 1.2±0.3. The most frequent aneurysm locations were the anterior communicating artery (64/182, 35.2%), internal carotid artery ophthalmic artery segment (29/182, 15.9%), and middle cerebral artery bifurcation (27/182, 14.8%). Stents were placed in the anticipated anatomic location in all patients. The study met both primary safety and efficacy end points. The composite primary efficacy end point of complete aneurysm occlusion (Raymond-Roy 1) without parent artery stenosis or aneurysm retreatment was achieved in 84.7% (95% CI, 78.6%–90.9%) of patients. Overall, 4.4% (8/182, 95% CI, 1.9%–8.5%) of patients experienced a primary safety end point of major ipsilateral stroke or neurological death. Conclusions: In the ATLAS IDE anterior circulation aneurysm cohort premarket approval study, the Neuroform Atlas stent with adjunctive coiling met the primary end points and demonstrated high rates of long-term complete aneurysm occlusion at 12 months, with 100% technical success and

Introduction: We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) and mild neurological deficits defined as National Institutes of Health Stroke Scale scores Methods: The primary efficacy outcome was three-month functional independence (FI; mRS-scores of 0-2) that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included three-month favorable functional outcome (FFO; mRS-scores of 0-1) and mRS-scores distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. Results: We evaluated 336 AIS patients with mELVO (mean age: 63±15 years, 45% women). Patients treated with IVT (n=162) had higher FI (85.6% vs. 74.8%, p=0.027) with lower mRS scores at hospital discharge (p=0.034) compared to the rest. Three-month mRS-scores tended to be lower in the IVT group (p=0.069). No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality (p>0.1). IVT was associated with higher likelihood of 3-month FI (OR=2.19, 95%CI: 1.09-4.42), 3-month FFO (OR=1.99, 95%CI: 1.10-3.57) and functional improvement at discharge [cOR (per 1-point decrease in mRS-score)=2.94, 95%CI: 1.67-5.26] and at 3 months (cOR=1.72, 95%CI: 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders including mechanical thrombectomy. Conclusion: IVT is independently associated with higher odds of improved discharge and three-month functional outcomes in AIS patients with mELVO. IVT does not increase the risk of systemic or intracranial bleeding.

Introduction: Endovascular thrombectomy (ET) for treating acute stroke in the real-world has expanded beyond the selection criteria used in major trials, and currently includes posterior circulation strokes. Posterior circulation stroke is believed to have worse outcomes than anterior circulation stroke, and its outcomes following ET are still being studied. We explored the major determinants of functional recovery after ET for posterior circulation stroke in a large cohort of patients from the Stroke Thrombectomy and Aneurysm Registry (STAR). Methods: STAR includes patients undergoing ET for acute ischemic stroke at 12 comprehensive stroke centers in the US and globally. Data on patient demographics, technical and clinical outcomes was reviewed retrospectively from patient charts and procedure notes. Primary outcomes was the modified Ranking Score (mRS) at 90 days dichotomized into favorable (mRS 0-2) and poor outcome (mRS 3-6). Results: A total of 3850 patients were reviewed, of which 345 patients (mean age 60±14) were treated for posterior circulation stroke with predominantly basilar artery occlusion (80%). Patients were treated using aspiration thrombectomy (ADAPT, 39%), stent retriever thrombectomy (31%), combined approach (19%) or intracranial stenting (7%). The overall rate of favorable outcome was 33%. Patients with diabetes, high NIHSS on admission, and proximal occlusions had significantly higher odds of poor functional outcomes on multivariate analysis (p Conclusions: Despite similar rates of functional recovery after ET for anterior circulation stroke between stent retriever and ADAPT, our analysis demonstrates that in posterior circulation stroke, ADAPT may lead to better functional outcomes compared to stent retriever without differences in safety profiles.

Background and Purpose— The purpose of this study is to evaluate the relationship between neutrophil-to-lymphocyte ratio (NLR) at admission with safety and efficacy outcomes in acute stroke patients with large vessel occlusion after mechanical thrombectomy. Methods— Consecutive large vessel occlusion patients treated with mechanical thrombectomy during a 4-year period were evaluated. Outcome measures included symptomatic intracranial hemorrhage, 3-month mortality, successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b/3), and 3-month functional independence (modified Rankin Scale scores of 0–2). Results— A total of 293 large vessel occlusion patients underwent mechanical thrombectomy (median admission NLR, 3.5; interquartile range [IQR], 1.7–6.8). In initial univariable analyses, higher median admission NLR values were documented in patients with symptomatic intracranial hemorrhage (8.5; IQR, 4.7–11.3) versus (3.9; IQR, 1.9–6.5); P P =0.004. Lower NLR values were recorded in patients with 3-month functional independence (3.7; IQR, 1.7–6.5) versus (4.3; IQR, 2.6–8.3); P =0.039. After adjustment for potential confounders, a 1-point increase in NLR was independently associated with higher odds of symptomatic intracranial hemorrhage (odds ratio, 1.11; 95% CI, 1.03–1.20; P =0.006) and 3-month mortality (odds ratio, 1.08; 95% CI, 1.01–1.16; P =0.014). Conclusions— Higher admission NLR is an independent predictor of symptomatic intracranial hemorrhage and 3-month mortality in large vessel occlusion patients treated with mechanical thrombectomy, and it may identify a target group for testing adjunctive anti-inflammatory therapies.

Introduction: Exposure to Interventional Neurology (IN) for Neurology trainees varies from site to site and from year to year, depending on training program needs, political climate, and trainee interest. With new stroke trials expanding the indications and manpower needs for endovascular stroke therapy (EST), we sought to determine the current exposure of Neurology residents and fellows to the burgeoning field. Methods: Neurology residency and Vascular Neurology (VN) fellowship programs were identified from the ACGME database available online. Electronic surveys were distributed to Neurology residency program directors and Vascular Neurology fellowship directors for further distribution to their trainees. Results: A total of 250 programs were invited to participate, from which 76 trainees completed the survey. A range of training levels was captured (22% PGY2, 40% PGY3/4, 30% VN fellows). 72% of respondents had >4 months of exposure to VN in their residency training, though exposure to NeuroICU was less (majority 2 months. Respondents overall felt comfortable with acute stroke treatment decisions, with 60% comfortable or very comfortable with IV tPA decisions and 86% for EST in both early and late windows. While 65% of respondents felt welcomed in the angiography suite and 72% felt a background in Neurology is a good preparation for the field, only 41% agreed that pursuing training and a career in IN is straightforward. Conclusion: Neurology trainees and VN fellows have limited residency exposure to IN, and while most feel well prepared for the field, less than half feel that access to a career in IN is readily available. Efforts to expand exposure to IN and creating consistent pathways for training will be paramount to address the current and urgent patient care needs for EST.

Introduction: Extracranial Internal carotid artery (ExICA) stenting may be required during mechanical thrombectomy (MT) for anterior circulation large vessel occlusions (ACLVO) with coexisting ExICA steno-occlusive disease. We sought to evaluate the safety of acute dual antiplatelet therapy (DAP) in this high-risk MT subgroup. Methods: Consecutive ACLVO patients treated with MT were evaluated during a five-year period. All patients receiving ExICA stenting during MT were also acutely treated with DAP coupled with heparin or eptifibatide drips. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS. Complete reperfusion (CR) was defined as modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT. Final infarct volume (FIV) on brain MRI was assessed at 24-48 hours using standardized methodology. Safety outcomes included symptomatic Intracranial Hemorrhage (sICH) documented by SITS-MOST criteria, infarct in new unaffected territory (INT) determined according to ESCAPE trial methodology and three-month mortality. We also assessed 3-month functional outcomes using modified Rankin Scale (mRS) scores. Results: Among 309 ACLVO patients treated with MT, 24 received additional ExICA stenting. Eptifibatide and heparin drips were administered in 15 (65% of stenting subgroup: 9 patients: aspirin + clopidogrel, 6 patients: aspirin + ticagrelor) and 8 (35% of stenting subgroup: 6 patients: aspirin + clopidogrel, 2 patients: aspirin + ticagrelor) cases respectively. Patients with and without ExICA stenting had similar (p>0.1) median baseline NIHSS-scores (15 vs. 16 points) and ASPECTS (10 vs. 10 points). The two groups did not differ (p>0.1) in terms of median FIV (20 vs. 15 cm 3 ) and median 3-month mRS-scores (2 vs. 2). Patients with ExICA stenting had similar (p>0.1) rates of sICH (5% vs. 8%), INT (0% vs. 9%), CR (74% vs. 70%) and 3-month mRS-scores of 0-2 (55% vs. 51%) compared to the rest. Conclusions: DAP coupled with eptifibatide or heparin drips does not appear to increase peri-procedural complications or to worsen clinical outcome of ELVO patients treated with MT and ExICA stenting.

Background: We conducted a case-control study to assess the relative safety and efficacy of Apollo assisted minimally invasive endoscopic surgery (MIS) for clot evacuation in patients with basal-ganglia intracerebral hemorrhage (ICH). Methods: We evaluated consecutive patients with acute basal ganglia ICH at a single center over a 42-month period. Patients received either best medical management according to established guidelines (controls) or Apollo assisted MIS (cases) with best medical management. The following outcomes were compared before and after propensity-score matching (PSM): in-hospital mortality, discharge National Institutes of Health Stroke Scale (NIHSS) score, discharge disposition, modified Rankin Scale scores at discharge and at 3 months. Results: Among 224 ICH patients, 19 (8.5%) underwent MIS [mean age 50.9±10.9; 26.3% female, median ICH volume 40 (IQR; 25-51)]. The interventional cohort was younger with higher ICH volume and stroke severity as compared to the medically managed cohort. After PSM, 18 patients in the MIS cohort were matched to 54 medically managed individuals. The two cohorts did not differ in any of the baseline characteristics. The median ICH volume at 24 hours was lower in the intervention group [40cm 3 (IQR:25-50) vs. 15cm 3 (IQR:5-20), p0.4). Conclusions: Minimally invasive Apollo assisted endoscopic hematoma evacuation was associated with lower rates of in-hospital mortality in patients with spontaneous basal ganglia ICH. These findings support a randomized controlled trial of MIS versus medical-management for ICH.

Introduction: It currently remains unclear whether pre-treatment with intravenous thrombolysis (IVT) provides any additional benefits to emergent large vessel occlusion (ELVO) patients undergoing mechanical thrombectomy (MT). We sought to evaluate the impact of pretreatment with IVT on the rate and the speed of complete reperfusion (CR) in LVO patients treated with MT in a high-volume tertiary care stroke center. Methods: Consecutive ELVO patients treated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. Standard safety [symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST definition] and efficacy outcomes [CR (modified Thrombolysis in Cerebral Infarction IIb/III), 3-month functional independence (FI; modified Rankin Scale scores of 0-2)] were compared between patients who underwent combined IVT and MT (IVT+MT) vs. direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes (DP) required to achieve CR were also documented. Results: A total of 287 and 132 patients were treated with IVT+MT and dMT respectively. The IVT+MT group had higher CR (74% vs. 63%; p=0.023) and FI (52% vs.38%; p=0.008) rates and shorter median GPTBRT (48 vs. 70 min; p Conclusions: IVT pretreatment increases the rates of CR and shortens the duration of endovascular procedure by requiring fewer DP in ELVO patients treated with MT.

Background: It is unknown if repeat imaging of transfer patients for endovascular thrombectomy (EVT) results in better patient selection and improved clinical outcomes or if bypassing repeat imaging and direct transfer to the angiosuite is safe, saves time and improve outcomes. Methods: A multicenter retrospective cohort was pooled from 6 centers (Europe and US) from 1/2014 to 4/2018 of patients with anterior circulation occlusion (ICA, M1, M2) transferred for EVT up to 24 hours from last known well. Patients were divided based on imaging acquisition at the EVT center into those who underwent any repeat imaging (CT+/- CTA, CTP) and those who bypassed imaging and went directly to the angiosuite. We compared good outcome (90 day mRS 0-2) and safety (sICH, mortality) between the two groups. Results: Of 646 patients, 559 received EVT and 87 were excluded for poor imaging profiles. In patients who received EVT, 173 (31%) had no repeat nd 386 (69%) had repeat images. The two groups had similar age and NIHSS. ASPECTS was lower in the repeat images group 8(7-10) when compared to ASPECTS from the outside facility in the non-repeat 9(8-10), p Conclusion: In patients transferred for EVT, repeat imaging resulted in treatment delays without improving good outcome. Direct angio suite access may result in more patients treated safely who achieve good outcome.

Background: Recent extended window (EW) trials support the benefit of mechanical thrombectomy (MT) in anterior circulation emergent large vessel occlusions (ELVO). However, only up to 1.7% of consecutive acute ischemic strokes (AIS) were eligible for EW-MT using clinical trial selection criteria. We examined eligibility and outcomes of EW-MT in consecutive ELVOs using pragmatic selection criteria. Methods: We prospectively evaluated consecutive patients presenting between 6-24 hours that underwent MT using selection criteria consisting of only non-contrast CT (ASPECTS > 6), CTA occlusion + good collateral scores (JNIS 2016;8:559-562). Effectiveness outcomes included TICI 2b-3 and 3-month modified Rankin Scores (mRS); safety outcomes included in-hospital mortality and symptomatic intracerebral hemorrhage (sICH). Results: 767 consecutive AIS patients presented within 6-24 hour window, and of these 48 (6%) anterior circulation ELVOs underwent MT (mean age 63±17 years; 56% men; median NIHSS 16 [IQR 10-19]; median groin puncture to recanalization 53 minutes [IQR 41-85]). Median ASPECTS was 9 (IQR 8-10), and 79% (n=38) of patients had good CTA collateral grade. Occlusions were primarily M1 MCA (46%), with 29% tandem occlusions. Successful recanalization (mTICI 2b or 3) was achieved in 73% (n=35), while 6% (n=3) of patients developed sICH. In-hospital mortality was 25% (n=12), however 40% (n=19) achieved 3-month mRS 0-2. Conclusions: The use of standard of care CT/CTA yields an acceptable rate of MT eligibility, allowing a group of patients facing likely death or severe disability to obtain reasonable safety and effectiveness outcomes.

Introduction: There are contradictory data concerning the preventive role of intravenous thrombolysis (IVT) in preventing infarct in a new previously unaffected territory (INT) in emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We sought to evaluate the potential association of IVT pretreatment with the likelihood of INT complicating MT in a high-volume tertiary care stroke center. Methods: Consecutive ELVO patients reated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. INT was defined using standardized methodology proposed by ESCAPE investigators. Collateral status was graded using ASITN/SIR criteria. The association of INT with 3-month functional independence (FI) defined as modified Rankin Scale scores of 0-2 was also investigated. Results: A total of 419 consecutive ELVO patients received MT [mean age 64±15 years, 50% men, median NIHSS-score 16 points (IQR:11-20), 69% IVT pretreatment). The incidence of INT was lower in patients treated with combination therapy (IVT & MT) than in patients treated with direct MT respectively (10% vs. 20%; p=0.011). INT occurred more frequently in patients with posterior circulation occlusion (28% vs. 10%; p Conclusions: IVT pretreatment is not independently associated with lower likelihood of INT in LVO patients treated with MT. INT does not appear to independently affect 3-month functional outcomes.

Introduction: There is mounting evidence indicating that first pass (FP) complete reperfusion (CR) may reduce peri-procedural complications for emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We investigated the impact of device passes (DP) on the clinical outcomes of ELVO patients who achieved CR following treatment with MT in a high-volume tertiary care stroke center. Methods: Consecutive ELVO patients with CR (modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT were evaluated during a five-year period. Baseline stroke severity was assessed by NIHSS-score. The numbers of DP during the procedure were documented. Standard safety outcomes included symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST criteria and three-month mortality. Standard efficacy outcomes included neurological improvement at 24 hours (determined by the relative reduction in NIHSS-score compared to baseline) and functional improvement at three months [determined as the shift in modified Rankin Scale (mRS) scores]. Results: Among 258 ELVO patients achieving CR during MT the rate of FPCR was 67% (n=173). Patients with FPCR had greater median relative NIHSS-reduction at 24 hours (46% vs. 33%; p=0.033), lower median mRS-scores at three months (2 vs. 3; p=0.034) and lower three-month mortality rates (12% vs. 26%; p=0.005) compared to the rest. The two groups did not differ in sICH rates (5% vs. 10%; p=0.200). FPCR was associated with lower odds of three-month mortality (OR:1.64; 95%:1.03-2.61; p=0.036) on multivariable logistic regression models adjusting for potential confounders (demographics, risk factors, occlusion site, collateral status, stroke severity, onset to groin puncture time, baseline blood pressure and serum glucose values). Conclusions: FPCR appears to impact favourably clinical outcomes in ELVO patients treated with MT. CR following FP results in greater neurological and functional improvement at 24 hours and 3 months respectively.

Background and Purpose- Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) ≥6. However, EVT benefit for mild deficits large vessel occlusions (NIHSS,6) is uncertain. We evaluated EVT efficacy and safety in mild strokes with large vessel occlusion. Methods- A retrospective cohort of patients with anterior circulation large vessel occlusion and NIHSS6 presenting within 24 hours from last seen normal were pooled. Patients were divided into 2 groups: EVT or medical management. Ninety-day mRS of 0 to 1 was the primary outcome, mRS of 0 to 2 was the secondary. Symptomatic intracerebral hemorrhage was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time last seen normal to presentation, center, IV alteplase, Alberta Stroke Program early computed tomographic score, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results- Two hundred fourteen patients (EVT, 124; medical management, 90) were included from 8 US and Spain centers between January 2012 and March 2017. The groups were similar in age, Alberta Stroke Program early computed tomographic score, IV alteplase rate and time last seen normal to presentation. There was no difference in mRS of 0 to 1 between EVT and medical management (55.7% versus 54.4%, respectively; adjusted odds ratio, 1.3; 95% CI, 0.64-2.64; P=0.47). Similar results were seen for mRS of 0 to 2 (63.3% EVT versus 67.8% medical management; adjusted odds ratio, 0.9; 95% CI, 0.43-1.88; P=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5% EVT, 48.4% medical management; odds ratio, 1.17; 95% CI, 0.54-2.52; P=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance ( P=0.07). Symptomatic intracerebral hemorrhage rates were higher with thrombectomy (5.8% EVT versus 0% medical management; P=0.02). Conclusions- Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHSS,6) receiving thrombectomy irrespective of thrombus location, with increased symptomatic intracerebral hemorrhage rates, consistent with the guidelines recommending the treatment for NIHSS ≥6. There was a signal toward benefit with EVT only in M1 occlusions; however, this needs to be further evaluated in future randomized control trials.

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) carries high mortality rates, and disparities have been reported between Caucasian and African American (AA) patients. But little large-scale data are available to examine such differences. The purpose of this study is to compare demographics and mortality outcomes for Caucasian and AA aSAH subjects using both nationwide and midsouth regional datasets. Methods: The nationwide sample was selected from inpatient Cerner Health Facts EMR data made available through UTHSC Center for Biomedical Informatics. The midsouth regional sample was selected from the Semmes Murphey neurosurgical clinic EMR. All subjects were selected by ICD-9 code and were seen from 2004-2016. Available demographics included age, race, gender, and admission Glasgow Coma Scale (GCS) score. Primary outcome was mortality at any time in the first month post-admission. Descriptive statistics were calculated and associations with mortality outcomes examined using t-tests, chi squares, and ANOVA as appropriate. Significance was set at p ≤0.05. Results: In the nationwide dataset (N=3,924, 24% AA, 57% female), AA aSAH patients were nearly 8 years younger than Caucasians (mean age 53.7 ± 17.6 vs 61.4 ± 18.9, p p p p =0.16). Despite an improvement in these demographic disparities locally, regional AA have similar GCS scores as the nationwide sample ( p =0.85) and are more likely than Caucasians to die within 1 month of admission regionally ( p =0.003) and nationwide ( p =0.0007). Conclusions: AA aSAH patients experience increased mortality as compared to Caucasians both nationwide and regionally. From this limited observational data it is not clear what other factors could be contributing to these disparities in mortality. Future work in such disparities should include more complete demographic and clinical data, information on health services access, quality, and utilization, and preexisting comorbidities.

Introduction: High rates of recanalization of Emergent Large Vessel Occlusion (ELVO) provide an opportunity to examine retrieved thrombi. We studied device and endothelial (ET) interactions to evaluate ET injury and the relationship between thrombi and Acute Ischemic Stroke (AIS) mechanism. Methods: Prospective registry examining immunohistochemical characteristics of retrieved thrombi in ELVO patients. Thrombi were categorized histopathologically and ET injury quantified by CD34 staining and immunohistochemistry, ELISA and reverse transcribed quantitative PCR to detect ET components. ET mRNA expression of CD31 was quantified from thrombi RNA. Plasma at the thrombectomy site was tested for ET derived biomarkers: microparticles (MPs), soluble Intercellular Cell Adhesion Molecule-1 (sICAM1) and soluble Thrombomodulin (sTM). Statistical analysis was performed with unpaired student’s t-tests and chi-square tests. Results: Twenty-five patients (age 68±3 , NIHSS 16±2, 48% female) were enrolled. The most common sites of occlusion were the MCA (9) and ICA (7). Eighty eight % of patients required three or less attempts at recanalization and 71 % achieved TICI 2b or 3. Histopathology demonstrated fibrin rich (5), erythrocytic (2), layered (7), and serpentine (11) thrombi and four were CD 34 positive. Levels of plasma biomarkers were: sTM 2.2±0.4 ( 3 revascularization attempts had higher levels of sTM (5.5±0.4 vs 1.7±0.2, p Conclusions: ET markers can be detected in the retrieved thrombi and plasma milieu of ELVO patients. ET markers relate to increasing number of attempts at thrombectomy indicating ET disruption. sTM and sICAM are more common in patients with cardioembolic stroke and may serve as thrombus associated markers of AIS mechanism.

Introduction: Administration of tPA in the first 60 min post-onset, the golden hour (GH), is associated with improved functional outcomes but remains unachievable in the vast majority of patients. We sought to identify independent predictors of IVT in the GH in a prospective, multi-center study. Methods: AIS patients treated with IVT during a five-year period in two tertiary care stroke centers were evaluated. Demographics, vascular risk factors, onset to treatment time, door-to-needle time (DTN) admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. The etiopathogenic mechanism of AIS was documented using TOAST criteria. Subjects with in-hospital stroke or treated in the mobile stroke unit were excluded. Results: Out of total 658 IVT-treated AIS patients (mean age 64±15 years; 50% men; median NIHSS-score 6, IQR: 4-12) we identified 26 (4%) subjects treated in the GH (mean age 62±15 years; 46% men; median NIHSS-score 8, IQR: 4-12). GH patients had shorter median DTN (23 min, IQR: 18-44 vs. 38 min, IQR: 26-49). DTN 2 30 min was more prevalent in the GH group (62% vs. 20%; p Conclusions: Shorter DTN is the only independent predictor of IVT initiation within the GH. Continued improvements in systems of acute stroke care should aim to further reduce DTN in order to increase the availability of tPA delivery in the GH.

Background and Purpose— Intraventricular hemorrhage is associated with high mortality and poor functional outcome. The use of intraventricular fibrinolytic (IVF) therapy as an intervention in intraventricular hemorrhage is an evolving therapy with conflicting reports in the literature. The goal of this study is to investigate the impact of IVF on mortality, functional outcome, ventriculitis, shunt dependence, and rehemorrhage. Methods— During March and April 2014, a systematic literature search was performed identifying 1359 articles. Of these, 24 met inclusion criteria. A random effects meta-analysis was performed using both pooled and subset analysis based on study type. Results— Our meta-analysis demonstrated that IVF reduced mortality in intraventricular hemorrhage by nearly half (relative risk [RR], 0.55; 95% confidence interval [CI], 0.42–0.71; P P =0.0003), and also decreased the rate of shunt dependence (RR, 0.62; 95% CI, 0.42–0.93; P =0.02). IVF was not found to be associated with increased rates of ventriculitis (RR=1.46; 95% CI, 0.77–2.76; P =0.25) or rehemorrhage (RR=1.06; 95% CI, 0.66–1.70; P =0.80). We detected no evidence of publication bias. Conclusions— Our meta-analysis showed that IVF is safe and could be an effective strategy for the treatment of intraventricular hemorrhage. It may reduce mortality, improve functional outcome, and diminish the need for permanent ventricular shunting, while not increasing the risk of ventriculitis or rehemorrhage.

Background and Purpose— The timely diagnosis of stroke at the initial examination is extremely important given the disease morbidity and narrow time window for intervention. The goal of this study was to develop a supervised learning method to recognize acute cerebral ischemia (ACI) and differentiate that from stroke mimics in an emergency setting. Methods— Consecutive patients presenting to the emergency department with stroke-like symptoms, within 4.5 hours of symptoms onset, in 2 tertiary care stroke centers were randomized for inclusion in the model. We developed an artificial neural network (ANN) model. The learning algorithm was based on backpropagation. To validate the model, we used a 10-fold cross-validation method. Results— A total of 260 patients (equal number of stroke mimics and ACIs) were enrolled for the development and validation of our ANN model. Our analysis indicated that the average sensitivity and specificity of ANN for the diagnosis of ACI based on the 10-fold cross-validation analysis was 80.0% (95% confidence interval, 71.8–86.3) and 86.2% (95% confidence interval, 78.7–91.4), respectively. The median precision of ANN for the diagnosis of ACI was 92% (95% confidence interval, 88.7–95.3). Conclusions— Our results show that ANN can be an effective tool for the recognition of ACI and differentiation of ACI from stroke mimics at the initial examination.

Background: Recent recommendations for mechanical thrombectomy (MT) of acute ischemic stroke (AIS) patients with emergent large-vessel occlusions (ELVO) appropriately award top tier evidence (TTE) to the same selective criteria that were employed in recent clinical trials. We sought to evaluate the safety and efficacy of MT in AIS patients with ELVO who fail TTE criteria in a prospective multi-center study. Methods: Data on consecutive AIS patients with ELVO who underwent mechanical thrombectomy were collected from 6 high-volume endovascular centers. Standard safety and efficacy outcomes were compared between patients meeting and failing TTE criteria. Results: TTE criteria for MT were fulfilled in 349 (60%) cases (mean age 63±18 years; 47% men; median admission NIHSS-score 17 points, interquartile range 14-21), whereas 234 (40%) patients did not meet TTE criteria (mean age 62±19 years; 53% men; median admission NIHSS-score 16 points, interquartile range 9-21). (Table 1) The two most common reasons for failing TTE criteria were location of intracranial occlusion (n=144) and treatment window (n=108). In multivariate logistic regression models adjusting for potential confounders cases failing TTE criteria had similar safety (three-month mortality and symptomatic intracranial hemorrhage) and efficacy (three-month functional independence) outcomes with patients meeting TTE. Location of occlusion and proposed time-window according to TTE was also not related to any safety or efficacy outcome. (Table 2) Conclusions: Approximately 40% of AIS patients with ELVO offered MT do not fulfill TTE criteria for MT. Our multi-center experience indicates that MT may be offered to these patients with similar safety and efficacy to ELVO cases meeting TTE. Evidence-based medicine requires that health care providers understand published data and how those data might apply to a given patient’s treatment options. In a changing treatment environment this is a dynamic process.

Introduction: Recently, five published major randomized controlled clinical trials have demonstrated that timely mechanical thrombectomy (MT) of acute ischemic strokes (AIS) with emergent large vessel occlusion (ELVO) is safe and improves functional outcomes. However, data evaluating the efficacy and safety of MT in ELVO patients with concomitant cervical internal carotid artery (cICA) occlusion is limited. The purpose of this study is to evaluate efficacy and safety of MT in ELVO patients with concomitant cICA occlusion Methods: We prospectively analyzed consecutive AIS patients with anterior circulation ELVO who underwent stent-retriever or primary aspiration thrombectomy at two tertiary stroke centers. Outcome measures in our study were 3-month mortality and modified ranking scale (mRS), as well as symptomatic intracranial hemorrhage (sICH). Safety and efficacy outcomes were compared between ELVO patients with and without concomitant cICA occlusion. Results: A total of 137 AIS patients had anterior circulation ELVO and underwent MT (age 63 ± 14, 49% male, median NIHSS 17, IQR [13-20]). ELVO patients with concomitant cICA occlusion (n=19) did not differ in terms of rates of sICH (0% versus 11%, p=0.21), complete recanalization (68 % versus 68%, p=1.00), onset to groin puncture time (minutes [IQR] 268 [211-379] versus 225 [165-312], p=0.47), 3-month mortality (35% versus 26 %, p=0.55), and mRS of 0-2 at 3 months (41% versus 45%, p=0.80) when compared with ELVO patients without concomitant cICA occlusion (n=118). Admission NIHSS was higher among ELVO patients with concomitant cICA occlusion (median [IQR], 18 [15-22] versus 16 [12-19], p=0.01), and they tended to have higher groin puncture to recanalization time (minutes [IQR] 74 [42-97] versus 49 [38-78], p=0.09). The ordinal shift analysis did not show any difference in favorable outcomes in two groups in unadjusted analyses or after adjustment for admission NIHSS and groin to recanalization time (common OR=0.78 [95% CI: 0.27-2.29, p=0.66]). Angioplasty was performed in 11 of 19 ELVO patients with concomitant cICA occlusion. Three patients required stent placement. Discussion: Our study indicates that MT can be performed safely and effectively in ELVO patients with concomitant cICA occlusion.

Background: An increasing shortage of vascular neurologists forced an academic provider to find a city-wide solution to offer 24x7 access to intravenous thrombolysis (IVT) across independent and competing health care systems in the area. We sought to prospectively evaluate the annual IVT treatment delivery in our population and compare it to leading stroke centers worldwide. Methods: The largest single ER system and 3 other independent hospital providers in the area agreed to work with a single practice plan vascular neurology team (catchment area of 1,344,127 individuals). All acute ischemic stroke patients that were treated with IVT across all primary or tertiary care centers in our area were prospectively documented over a 12-month period (January-December 2015). A literature search was performed using narrative review methodology to document similar population-based treatment rates across leading stroke centers in North America, Europe and Australasia. Results: A total of 552 patients received IVT with tissue plasminogen activator (tPA) in 2015. Single ER system delivered 433 IV tPA treatments and 119 more patients were treated in the remaining hospitals. The annual tPA treatment rate was 41 per 100.000 individuals (95%CI: 38-44) favorably comparable to published annual treatment rates from leading international stroke centers (Table, 1998 thru 2015). Conclusions: A city-wide vascular neurology team can attend to patient populations across competing health care systems in the U.S. and deliver IVT at volumes and rates above those reported by leading treatment centers worldwide. Communities with competing systems can improve tPA delivery by sharing vascular neurology resources.

Background and Purpose— Intraprocedural rupture (IPR) is a well known complication of intracranial aneurysm treatment. Risks and predictors of IPR and its impact on outcome have not been clearly established. Methods— Potential predictors of IPR were evaluated in patients treated in the Cerebral Aneurysm Rerupture After Treatment (CARAT) study using multivariate logistic regression with stepwise elimination stratified by treatment modality. Periprocedural death or disability was defined as death or a change of ≥2 points on the Modified Rankin Scale at discharge compared to before treatment. Results— IPR occurred in 14.6% of 1010 patients (299 coiled, 711 clipped): 19% with clipping and 5% with coiling ( P P =0.001); among those coiled, 63% with IPR had periprocedural death or disability compared to 15% without IPR ( P Conclusions— IPR was common in patients undergoing treatment of ruptured aneurysms, particularly with surgical clipping. The frequency of IPR with new disability was similar in the surgical and endovascular treatment groups. Coronary artery disease, hyperlipidemia, race, COPD, and lower Hunt and Hess Grade were associated with greater risk of IPR, which may reflect differences in vessel fragility but requires further confirmation.

Background and Purpose— Patients with posterior circulation strokes have been excluded from recent randomized endovascular stroke trials. We reviewed the recent multicenter experience with endovascular treatment of posterior circulation strokes to identify the clinical, radiographic, and procedural predictors of successful recanalization and good neurological outcomes. Methods— We performed a multicenter retrospective analysis of consecutive patients with posterior circulation strokes, who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including A Direct Aspiration First Pass Technique [ADAPT] approach). We correlated clinical and radiographic outcomes with demographic, clinical, and technical characteristics. Results— A total of 100 patients were included in the final analysis (mean age, 63.5±14.2 years; mean admission National Institutes of Health Stroke Scale score, 19.2±8.2). Favorable clinical outcome at 3 months (modified Rankin Scale score ≤2) was achieved in 35% of patients. Successful recanalization and shorter time from stroke onset to the start of the procedure were significant predictors of favorable clinical outcome at 90 days. Stent retriever and aspiration thrombectomy as primary treatment approaches showed comparable procedural and clinical outcomes. None of the baseline advanced imaging modalities (magnetic resonance imaging, computed tomographic perfusion, or computed tomography angiography assessment of collaterals) showed superiority in selecting patients for thrombectomy. Conclusions— Time to the start of the procedure is an important predictor of clinical success after thrombectomy in patients with posterior circulation strokes. Both stent retriever and aspiration thrombectomy as primary treatment approaches are effective in achieving successful recanalization.

Background&Purpose: Despite recent landmark RCTs showing significant survival and functional outcome benefits with HCT compared with medical therapy (MT) in patients with malignant MCA infarction (MMCAI), HCT rates have not substantially increased in the US. It is difficult for patients’ families to reconcile the wishes of the patient with the possibility of poor functional outcome. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). Subjects&Methods: We evaluated in a retrospective cohort study design consecutive patients with acute MMCAI treated in two tertiary care centers during a seven-year period. Pre-treatment NIHSS, NIHSS at discharge and modified Rankin Scale (mRS) at three months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4 respectively. Results: A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria [mean age 59±15 years, 52% men, median admission NIHSS-score: 19 points (IQR: 16-22]. Cases were younger (51±11 vs 68±13 years; p0.05) in terms of other baseline characteristics. The rates of FI and SWSD at three months were higher in cases than controls [16% vs 0% (p=0.031) & 62% vs 0% (p Conclusions: HCT is a critical and effective therapy for patients with MMCAI but cannot provide a gurantee of functional recovery. Refusal of HCT by medical decision makers is common and reflects the complexity of issues under consideration in terms of patient outlook beyond the reduction of mortality following acute MMCAI.

Objective: We sought to determine the safety of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients harboring unruptured intracranial aneurysm (UIA) in a prospective, multi-center study. Methods: We prospectively analyzed data from consecutive AIS treated with IVT during a 4-year period at four tertiary-care stroke centers. All patients routinely underwent CT or MR angiography during hospitalization. The presence of UIA was documented on the basis of neuroradiology reports. Symptomatic intracranial hemorrhage (sICH) was defined as imaging evidence of ICH combined with an increase in NIHSS-score of ≥4 points. Results: Our multicenter study evaluated a total of 1398 AIS patients treated with IVT with available neurovascular imaging data. The presence of concomitant UIAs was identified in 42 cases (3.0%, 95%CI by adjusted Wald method: 2.2%-4.1%) harboring a total of 48 IAs. Four of the forty-two (8%) AIS patients had multiple aneurysms. The mean maximum diameter of UIA was 4.3±2.7mm ranging between 2-15 mm. Nearly all UIA were saccular (45/48, 94%) and the majority were located in the anterior circulation (29/48; 61%). The maximum diameter was ≥7mm and ≥10mm in 6 (12.5%) and 3 (6.3%) cases respectively. The rates of symptomatic and asymptomatic ICH were 2.4% (95%CI by adjusted Wald method: 0%-12.6%) and 7.1% (95%CI by adjusted Wald method: 1.8%-19.7%) respectively. The single sICH reported in our multi-center study was not caused by aneurysmal rupture, since the incidental aneurysm was located in the posterior communicating artery in the hemisphere that was contralateral to the sICH. The rates of in-hospital mortality and favorable functional outcome at hospital discharge (defined as modified Rankin Scale score of 0-1) were 2.4% (95%CI by adjusted Wald method: 0%-12.6%) and 50.0% (95%CI by adjusted Wald method: 35.5%-64.5%) respectively. Conclusions: Our prospectively collected multi-center data indicate the potential safety of IVT in AIS patients with UIA.

Background & Purpose: Up to 30% of treated patients for suspected acute ischemic stroke (AIS) could be stroke mimic (SM). Using a balanced clinical dataset, we have developed a supervised learning method from artificial intelligence to classify AIS/transient ischemic attack (TIA) and SM in an emergency room (ER) setting. Methods: We labeled and randomly partitioned consecutive patients who received intravenous thrombolysis for suspected AIS in three tertiary centers during a three year period. The clinical data includes patients’ demographic information, past medical history, blood pressure and glucose level at presentation, NIH Stroke Scale, and presence of facial weakness. The clinical data were used to create a balanced training and testing set. We developed an Artificial Neural Network (ANN) model on patients’ clinical data, using the training set ( Figure 1). The model was used to classify the diagnosis of AIS/TIA versus SM. The ANN model was subsequently assessed using the testing set. In addition, we compared the ANN model with three regression models (ordinary least squares, logistic, and reduced logistic model). Results: In total 803 patients (mean age 62±15 years, 52% men, median admission NIHSS-score: 6 points, IQR 3-11) were analyzed. Data from 56 random patients, not included in the training set, were used to test the model. Of 56 predictions, 49 were correct (19 out of 20 correct prediction for SM, and 30 out of 36 correct prediction for AIS/TIA). Additional analysis indicated that the model detects SM with 95% sensitivity (95%, CI: 73-99%) and 83% specificity (95%, CI: 66-93%). We further performed a 10-fold cross validation to better estimate the performance of the model. In addition, the three regression models were comparable to the ANN model at a specific adjusted threshold. Conclusions: This study highlights a potential for ANN to discriminate AIS/TIA and SM. This model can be further optimized and integrated in patient management software in an ER setting.

Introduction: Five RCTs demonstrated the superiority of endovascular therapy (EVT) over best medical management (MM) for acute ischemic strokes (AIS) with large vessel occlusion (LVO) in the anterior circulation. Patients with M2 occlusions, however, were underrepresented (95 randomized; 51 EVT treated). Evidence from RCTs of the benefit of EVT for M2 occlusions is lacking, as reflected in the recent AHA guidelines. Methods: A retrospective cohort was pooled from 10 academic centers from 1/12 to 4/15 of AIS patients with LVO isolated to M2 presenting within 8 hours from last known normal (LKN). Patients were divided into EVT and MM groups. Primary outcome was 90 day mRS (good outcome 0-2); secondary outcome was sICH. Logistic regression compared the 2 groups. Univariate and multivariate analyses evaluated predictors of good outcome in the EVT group. Results: Figure 1 shows participating centers, 522 patients (288 EVT and 234 MM) were identified. Table (1) shows baseline characteristics. MM treated patients were older and had higher IV tPA treatment rates, otherwise the 2 groups were balanced. 62.7 % EVT patients had mRS 0-2 at 90 days compared to 35.4 % MM (figure 2). EVT patients had 3 times the odds of good outcome as compared to MM patients (OR: 3.1, 95% CI:2.1-4.4, P Conclusion: Despite inherent limitations of its retrospective design, our study suggests that EVT may be effective and safe for distal LVO (M2) relative to best MM. A trial randomizing M2 occlusions to EVT vs. MM is warranted to confirm these findings.

Background: Evidence for endovascular treatment of anterior circulation strokes is well developed. However, patients with posterior circulation strokes have been excluded from recent randomized endovascular stroke trials. Objective: To evaluate outcomes of posterior circulation strokes treated with modern endovascular therapy since the FDA approval of stent retrievers, and to identify predictors of clinical outcomes and complications in this specific population of stroke patients. Methods: We performed a multicenter retrospective analysis of consecutive patients with posterior circulation strokes who underwent thrombectomy with stent retrievers or primary aspiration thrombectomy (including the ADAPT approach). We correlated favorable clinical outcomes with demographic, clinical and technical characteristics. Results: A total of 84 patients were included in this study (mean age, 63.5 years; mean admission NIHSS score, 19.2). Favorable clinical outcome at 3 months, defined as mRS score 0-2 was achieved in 34 (40%) patients. NIHSS score < 20, the use of conscious sedation rather than general anesthesia and successful recanalization (TICI 2b/3) were significant predictors of favorable clinical outcome at 90 days. The use of baseline advanced imaging (CT perfusion, multi-phase CTA or MRI) for patient selection was not associated with improved outcomes. In patients with the time of symptom onset to femoral puncture < 6 hours, mRS 0-2 at 3 months was achieved in 51.2% of cases. Treatment initiated beyond the 6-hour window resulted in 30.2% rate of mRS 0-2 at 3 months. Conclusions: Severity of admission NIHSS score, recanalization success and the type of anesthesia strongly correlate with clinical outcomes in endovascular therapy of posterior circulation strokes. The highest rate of long-term favorable outcomes was achieved in patients whose thrombectomy was initiated within the first 6 hours of stroke onset. However, even when started beyond the 6 hours window, endovascular treatment of posterior circulation strokes is feasible.

Background: Symptomatic intracranial hemorrhage (sICH) is the most feared complication of IVT for ischemic stroke, and patients who have cerebral microbleeds (CMBs) can potentially be at greater risk. This study aims to assess the association between the number and location of CMBs on MRI and the incidence of sICH post IVT. Subjects & Methods: We analyzed consecutive IVT-treated patients during a 5-year period (2010-2014) at a tertiary care stroke center. Patients without pre or within 24-hour post-treatment MRI were excluded from the study. All neuroimaging studies were examined by two independent readers and a third reader as a tie-breaker. CMBs were defined according to recent consensus recommendations for MRI studies as round or oval, hypointense lesions with associated blooming on T2*-weighted MRI and can be up to 10 mm in diameter. Outcome measures in our study were occurrences of sICH and were defined according to European Cooperative Acute Stroke Study (ECASS)-III criteria combined with clinical deterioration of ≥4 points on NIHSS, or death. Results: Of 589 IVT patients (mean age 61±15 years, 51% men, median admission NIHSS: 6 points [IQR 3-11]), 97 patients had CMBs on T2*-MRI. Ten patients had more than 10, while the remaining 87 patients had 1-10 CMBs on T2*-MRI. The rates of sICH did not differ between patients with and without CMBs (4.1% vs. 3.5%; p=0.75). However, sICH occurred more frequently (p=0.0031) in patients with >10MBs (30 %, 95%CI by the adjusted Wald method: 10%-61%) than in patients with 1-10 CMBs (1 %, 95%CI: 0%-7%). After adjusting for potential confounders, the presence of >10 CMBs on T2*-MRI was independently (p=0.0004) associated with a higher likelihood for sICH [OR: 13.4, 95% CI: 3.2-55.9] in multivariate logistic regression analyses. Among patients with sICH in >10 CMBs group, one patient developed multiple ICHs in different regions and one developed a large thalamic ICH remote from the infarcted area. In both these patients the location of ICHs corresponded to the location of CMBs on T2*-MRI. The third patient developed sub-arachnoid hemorrhage. Conclusions: Our findings indicate a higher risk of sICH after IVT when more than 10 CMBs are present. However, it does not demonstrate an increased risk of sICH among patients who have ≤ 10 CMBs.

Background & Purpose: High pre-treatment systolic blood pressure (SBP) levels have been associated with lower recanalization rates after endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with emergent large vessel occlusion (ELVO). We sought to evaluate the association of of pre-treatment SBP with other outcome measures after EVT including final infarct volume (FIV) and favorable outcome (FO) at three-months. Methods: We conducted a retrospective cohort study evaluating AIS patients presenting with anterior circulation ELVO in a tertiary care stroke center during a 4-year period. Admission stroke severity was documented using NIHSS-score. Pre-treatment SBP and DBP were measured using automated cuff. Two investigators calculated the FIV using ABC/2 methodology. FO was defined as mRS score of 0-2 at 3 months. Results: Our study population consisted of 116 patients with anterior circulation ELVO (mean age 63±13 years, 51% male, median admission NIHSS-score: 17 points, IQR 14-21, median FIV: 30cm3, IQR: 8-94) who were treated with EVT. Systemic thrombolysis was administered in 75 patients (65%). A total of 38 patients (33%) achieved FO, while in-hospital and three-month mortalities were 27% and 31% respectively. Higher pre-treatment SBP was positively correlated to increased FIV (r: +0.225; p=0.020). Patients with FFO had lower pretreatment SBP (151±24mmHg vs 165±28mmHg; p= 0.010), while pretreatment SBP levels were higher in patients who died during hospitalization (169±34mmHg vs 156±24mmHg; p=0.043). A 10mmHg increment in pretreatment SBP was independently (p=0.010) associated with an increase of 12cm3 in FIV (95%CI: 3-21) in multiple linear regression models adjusting for demographics, vascular risk factors, pretreatment DBP, admission NIHSS, intravenous thrombolysis, onset to revascularization and successful revascularization. A 10mmHg increment in pretreatment SBP was independently (p=0.012) associated with a lower likelihood of FFO at three months (OR: 0.64; 95%CI: 0.45-0.91) in multiple logistic regression models adjusting for multiple confounders. Conclusion: Higher pretreatment SBP is an independent predictor of increased FIV and lower likelihood of three-month FFO in patients with ELVO who undergo EVT.

Background&Purpose: Experimental and retrospective clinical data have indicated that sulfonylurea drugs (SUD) may confer protection against cerebral swelling and hemorrhagic transformation in AIS. We sought to determine whether pretreatment and in-hospital use of SUD may be associated with better outcomes in diabetic AIS patients treated with IVT. Subjects&Methods: We retrospectively analyzed prospectively collected data of consecutive AIS treated with IVT during a three-year period. Pre-treatment NIHSS, NIHSS at 48 hours and modified Rankin Scale (mRS) at discharge were documented. Symptomatic intracerebral hemorrhage (sICH) was defined as imaging evidence of ICH with NIHSS increase of 4 points within 72 hours. Early neurological improvement was defined as a NIHSS-score decrease of ≥4 points or a NIHSS-score of 0 at 48 hours. Cerebral edema was documented by neuroradiology reports. Favorable functional outcome (FFO) was defined as mRS of 0-1. Results: A total of 148 diabetic AIS patients fulfilled the study inclusion criteria (mean age 64±11 years, 49% men, median admission NIHSS-score: 8 points). We identified 42 patients pre-treated with SUD (mean age 65±11 years, 50% men, median admission NIHSS-score: 8 points) all of whom continued to receive these medications during hospitalization. Demographic characteristics, vascular risk factors and admission NIHSS-scores did not differ (p>0.1) between patients pretreated (cases) and non-pretreated with SUD (controls). The prevalence of complications and favorable outcomes did not differ (p>0.1) between cases and controls: sICH (2% vs. 5%), cerebral edema (5% vs 4%), early neurological improvement (42% vs 43%), in-hospital mortality (12% vs 5%) and FFO (22% vs 32%). Conclusions: Pretreatment and in-hospital use of SUD appears not to be associated with early favorable outcomes and lower likelihood of potential complications in diabetic AIS patients treated with IVT.

Background & Purpose: No eligibility screening logs were kept to support recent mechanical thrombectomy (MT) RCTs establishing safety and efficacy for acute ischemic stroke (AIS). We sought to evaluate the potential eligibility for MT among consecutive AIS patients in a prospective multicenter study. Methods: We prospectively evaluated consecutive patients admitted with the diagnosis of AIS in three tertiary care stroke centers during a twelve-month period. Admission stroke severity was documented using NIHSS-score, while all patients underwent baseline neurovascular imaging using MRA/CTA. Potential eligibility for MT was evaluated using inclusion criteria from MR CLEAN & REVASCAT as these protocols utilized imaging and selection methods that most closely mirrored everyday clinical practice. Results: Our study population consisted of 1161 AIS patients (mean age 66±14 years, 55% men, median admission NIHSS-score: 5 points, IQR 2-8). A total of 86 (7%, 95%CI: 6%-9%) and 66 (6%, 95%CI: 4%-7%) patients fulfilled the inclusion criteria for MR CLEAN & REVASCAT respectively, while 57 cases were eligible for inclusion in both trials (5%, 95%CI: 4%-6%). There was no evidence of heterogeneity (p>0.150) regarding the eligibility of AIS for MT across the three participating centers. Absence of proximal intracranial occlusion (70%), followed by hospital arrival outside the eligible time window (31% for MR CLEAN 6-hour window & 29% for REVASCAT 8-hour window), low baseline NIHSS-score (16% below the 2 point cut-off of MR Clean & 46% below the 6 point cut-off of REVASCAT) and posterior circulation cerebral ischemia (16%) were the four most common reasons for ineligibility for MT. Conclusion: Our everyday clinical practice experience suggests that approximately one out of fourteen to seventeen consecutive AIS may be eligible for MT if inclusion criteria for MR CLEAN and REVASCAT are strictly adhered to. Delayed presentation from symptom onset represents the only modifiable MT exclusion factor.

Background and Purpose— Observational studies indicate that outpatient cardiac monitoring detects previously undiagnosed atrial fibrillation (AF) in 5% to 20% of patients with recent stroke. However, it remains unknown whether the yield of monitoring exceeds that of routine clinical follow-up. Methods— In a pilot trial, we randomly assigned 40 patients with cryptogenic ischemic stroke or high-risk transient ischemic attack to wear a Cardionet mobile cardiac outpatient telemetry monitor for 21 days or to receive routine follow-up alone. After thorough investigation, we excluded patients with documented AF or other apparent stroke pathogenesis. We contacted patients and their physicians at 3 months and at 1 year to ascertain any diagnoses of AF or recurrent stroke or transient ischemic attack. Results— The baseline characteristics of our cohort broadly matched those of previous observational studies of monitoring after stroke. In the monitoring group, patients wore monitors for 64% of the assigned days, and 25% of patients were not compliant at all with monitoring. No patient in either study arm received a diagnosis of AF. Cardiac monitoring revealed AF in zero patients (0%; 95% confidence interval, 0%–17%), brief episodes of atrial tachycardia in 2 patients (10%; 95% confidence interval, 1%–32%), and nonsustained ventricular tachycardia in 2 patients (10%; 95% confidence interval, 1%–32%). Conclusions— In the first reported randomized trial of cardiac monitoring after cryptogenic stroke, the rate of AF detection was lower than expected, incidental arrhythmias were frequent, and compliance with monitoring was suboptimal. Our findings highlight the challenges of prospectively identifying stroke patients at risk for harboring paroxysmal AF and ensuring adequate compliance with cardiac monitoring. Clinical Trial Registration— URL: http://clinicaltrials.gov . Unique Identifier: NCT00715533

Background & Purpose: The outcomes of patients with acute ischemic stroke (AIS) due to basilar artery occlusion (BAO) are poor. Endovascular therapy (EVT) improves rates of recanalization. We hypothesized that good collateral patterns by pre-treatment CT Angiography (CTA) would predict favorable outcome after EVT. Methods: We conducted a retrospective chart review of patients presenting with AIS due to BAO in a tertiary care stroke center during a four-year period. BAO was diagnosed by CTA in all cases, who received EVT as standard of care. Admission stroke severity was documented using NIHSS-score. Pretreatment collateral score (CS) for posterior circulation was defined as follows: 0 - no posterior communicating artery (PCOM), 1- unilateral PCOM, 2- bilateral PCOM. Complete recanalization was defined by Thrombolysis in Cerebral Infarction (TICI) scores of 2b or 3. Favorable outcome was defined as modified Rankin Scale score (mRS) of 0-2 at three months. Results: Our study population consisted of 15 AIS patients (age range; 31-84 years, median admission NIHSS-score: 21, range 2-38 points) who underwent EVT. Systemic thrombolysis was administered in 4 patients (27%). Seven of 15 patients (47%) had bilateral PCOMs, while unilateral PCOM was diagnosed in 2 cases (13%). Patients with bilateral PCOMs tended to have less severe stroke (p=0.199) at admission in comparison to patients with absent/unilateral PCOM (median NIHSS-score 18 vs. 28 points). The rate of favorable outcome was higher in patients with bilateral PCOMs (71%) in comparison to patients with absent or unilateral PCOM (0%; p=0.014). Patients with bilateral PCOMs tended to have higher recanalization in comparison with patients with absent/unilateral PCOM (86% vs. 33%, p= 0.076). CONCLUSION: Presence of bilateral PCOMs on pre-treatment CTA is associated with lower baseline stroke severity, higher rates of complete recanalization and favorable outcome in patients with AIS due to BAO who are treated with EVT. Future prospective studies including a larger sample of patients are required to define the potential association of posterior circulation collateral status with favorable outcome in this subgroup of ischemic stroke patients.

Introduction: The benefits of IV TPA and endovascular AIS therapy (EVT) have been demonstrated to be time dependent. We hypothesized that a stroke unit embedded in the emergency department (ED) would provide more efficient delivery of acute ischemic stroke (AIS) therapy and result in improved clinical outcomes. Methods: Retrospective chart review was performed of the University of Tennessee Health Science Center prospective database of AIS from January 2011 to December 2012 to identify patients treated with IV TPA with or without EVT. The ED stroke unit (EDSU) is run by nurses trained to clinical competencies of our institution’s neurocritical unit. EDSU nurses are only assigned two patients within the unit. Baseline characteristics and details of treatment were abstracted for patients treated in the EDSU and general ED population. Univariate analysis was performed with Chi Square and Student's T-tests. Stepwise multivariate regression analysis (sMVR) was performed to compare characteristics and outcome of patients treated in the two ED locations. Results: A total of 160 patients were treated with IV TPA during the study period with 70 treated in the EDSU. Thirty-three patients also received EVT. The average age was 62.2 and mean NIHSS was 10.8. Univariate analysis demonstrated that cocaine use (8.4% vs. 0.0, p=0.02) and smoking (73% vs. 30%, p=0.01) were more common in the ED population while previous stroke (59.0% vs. 21.6%p=0.006) was significantly more frequent in the EDSU group. NIHSS at presentation and discharge were lower in the EDSU (9.4 vs. 12.0, p = 0.006 and 4.3 vs. 6.1, p=0.03). Door-to-needle (DTN) for IV TPA and door to arterial puncture (DAP) for EVT were both significantly shorter in the EDSU (58.7 vs. 74.9 minutes, p=0.0002 and 101 vs. 155, p=0.003). sMVR confirmed that patients in the EDSU had significantly shorter DTN for IV TPA (p=0.0005) and DAP for EVT (p=0.02). sMVR also demonstrated that improved outcome was due to significantly shorter IV TPA DTN time (p=0.04) regardless of location. Conclusion: The implementation of an EDSU improved the delivery of time sensitive acute ischemic stroke therapies resulting in improved outcomes. This study supports the investment of resources in ED systems of care specifically tailored to AIS.

Specialized Teams React On Key Examinations: The Impact of Triage in Acute Ischemic Stroke Category: Emergency Care/Systems Background and Purpose: The Brain Attack Coalition recommends the initiation of thrombolytic therapy in ischemic strokes within 60 minutes of hospital arrival. Poor compliance in our Emergency Department with door to needle (DTN) challenged us to identify care strategies to rapidly identify, evaluate, and implement care in the acute stroke population. In 2012, we integrated resources caring for ST Elevation Myocardial Infarctions (STEMI) and acute strokes to form the Time is Tissue unit that would result in improved compliance. Methods: Specialized training was provided to Emergency Medical Services (EMS) and the STEMI unit staff in acute stroke recognition and care. Acute stroke patients identified by EMS bypassed standard triage and the Time is Tissue unit was responsible for care from arrival through disposition. Results: A retrospective and concurrent chart review was performed from January 2011 to June 2013 on 232 patients (100%) receiving rt-PA. The research confirmed that specialized teams increased compliance for DTN. An unexpected finding was rt-PA volume increased 117% when comparing 2011 to 2012 without a significant change in presenting ischemic stroke volume. Conclusion: Our strategy of aligning processes and utilizing specialized teams to meet time and quality goals resulted in exceptional gains in the volume of patients identified to receive rt-PA and improvement in DTN times.

INTRODUCTION: Non-contrast head CT (NCCT) is the standard radiologic test performed in the emergency department (ED) for patients presenting with symptoms of acute stroke. Early ischemic changes (EIC) in NCCT are often missed by ED physicians and on-call radiologists. We assessed the hypothesis that detection of EIC can be improved by a standardized method of image evaluation. METHODS: Retrospective chart review was performed of the University of Tennessee Health Science Center prospective database of acute ischemic stroke from January - July 2012. Patients treated with IV TPA who had NCCT as the initial neuroimaging exam were identified and additional baseline characteristics were noted. EIC was defined as findings consistent with: 1) Hyperdense MCA/basilar artery sign 2) Sulcal effacement 3) Basal ganglia/subcortical hypodensity and 4) Loss of cortical gray-white differentiation. Initial NCCT was reviewed by a blinded neurology resident (except presenting complaints). First, images were reviewed with standard window settings of center and width level of 40 and 100 Hounsfield units (HU). Then, all images were interpreted with ”stroke windows” of center 35 and width of 30 HU. This was compared with the radiologists’ final report. Final interpretations based on "stroke windows" were compared with follow up imaging studies to assess accuracy. Fisher’s exact test was used for statistical analysis. RESULTS: NCCTs of 50 patients (42% females) with an average age 75.4 years and mean NIHSS of 13.4 were reviewed. The mean time to CT from symptom onset was 97.7 minutes. Out of 50 patients, radiologists detected EIC in 9 patients while authors detected EIC in 35 patients (18% vs. 70% with 100% accuracy; p < 0.0001). Hyperdense MCA sign although most commonly reported by radiologists, was better appreciated with "stroke windows" (14% and 56%; p CONCLUSIONS: EIC although common in acute ischemic stroke are often missed by the interpreting radiologists. We conclude that the rates of detection can be significantly improved with standardized “Stroke Windows”. This has important implications in regards to rapid diagnosis and treatment of acute ischemic stroke.

Background: Diagnosis of atrial fibrillation (AF) as a cause of stroke or TIA is important because it identifies patients who may benefit from anticoagulation. Observational studies indicate that outpatient cardiac monitoring detects previously undiagnosed AF in 5-20% of patients with stroke, but these studies may overestimate the rate of AF if selection bias prompts analysis and publication. It is also unknown whether the yield of cardiac monitoring is higher than that of routine clinical follow-up. Methods: In a pilot trial, we randomly assigned consecutive patients with cryptogenic ischemic stroke or high-risk TIA (ABCD 2 score ≥ 4) to wear a Cardionet mobile cardiac outpatient telemetry monitor for 21 days after discharge, or to not wear a monitor. We excluded patients with a known history of AF, AF detected by inpatient cardiac telemetry (at least 24 hours required), a definite small-vessel etiology, a source found by vascular imaging or echocardiography, an obvious culpable systemic illness such as endocarditis, or inability to provide written, informed consent. All patients received routine clinical follow-up from their primary care physician and neurologist. We contacted patients and their physicians 3 months after discharge and used validated questionnaires to inquire about clinical diagnoses of AF and recurrent stroke or TIA. Results: The target enrollment of 40 patients was completed over 18 months. The mean age was 67 years (± 13), 23 (58%) were men, and 32 (80%) had at least one vascular risk factor; the baseline characteristics of our cohort were broadly similar to those in prior observational studies of cardiac monitoring after stroke. Our prespecified feasibility criteria were met, with full follow-up on 38 patients (95%) and successful completion of monitoring in 15 of the 20 patients (75%) randomized to monitoring. Overall, patients wore monitors for 64% of the assigned days. No patient in either study arm received a diagnosis of AF. Cardiac monitoring revealed AF in zero patients (0%, 95% CI 0-17%), brief episodes (< 10 seconds) of atrial tachycardia in two patients (10%, 95% CI 1-32%) and nonsustained ventricular tachycardia in two patients (10%, 95% CI 1-32%). There were no recurrent strokes; recurrent TIAs occurred in two patients assigned to the control group. Conclusions: The results of our pilot trial indicate that randomizing patients to outpatient cardiac monitoring after stroke is feasible. However, rates of AF detection were lower than expected, which may be due to publication bias in prior observational studies or selection of lower risk patients in our trial. Furthermore, 25% of patients assigned to undergo monitoring were not compliant. These results suggest that an adequately powered randomized trial of cardiac monitoring after stroke may require large numbers of participants.

BACKGROUND: The presence of residual aneurysm after microsurgical clipping carries a risk of aneurysm growth and rupture. Digital subtraction angiography (DSA) is the gold standard to determine the adequacy of clipping post-operatively. Intra-operative Indocyanine green (ICG) angiography is increasingly utilized to confirm optimal clip positioning across the neck and to evaluate adjacent vasculature. We evaluated the correlation between ICG and DSA in clipped intracranial aneurysms. METHODS: This is a retrospective study of patients who underwent craniotomy and microsurgical clipping of intracranial aneurysms with ICG between January 2010 and May 2011. A chart review was performed to abstract the baseline characteristics and details of presentation of patients, details of the operative reports of clipping were reviewed, and pre and post clipping angiographic images were reviewed to determine the adequacy of clipping. Post-clipping DSA was evaluated by two physicians not involved in the care of the patient for the presence of residual aneurysm and patency of branch vessels/parent artery. RESULTS: Twelve patients (58 % female, mean age 53.6) underwent clipping of intracranial aneurysms with ICG and had post-operative DSA. Operative reports indicated complete clipping of all aneurysms without compromise of branch vessels. Postoperative DSA was performed in follow-up ranging from 1 day to 6 months. Seventeen aneurysms were clipped, seven patients (58.3%) presented with subarachnoid hemorrhage. Thirteen aneurysms were located in the anterior circulation (avg. size 7.3mm) and four in the posterior circulation (avg. size 6.6mm). Four patients had two aneurysms clipped in the same setting. Of the 17 aneurysms treated 5 aneurysms demonstrated a residual on DSA not identified on ICG. The residual sizes ranged from 0.8-4.3 mm with an average size of 1.2mm. There was no apparent predilection to location; three were in the anterior and two in the posterior circulation. Post-operative DSA demonstrated no branch occlusions, two patients demonstrated slow flow in the posterior communicating artery, and there was no compromise of the parent vessel in any cases. CONCLUSION: Intra-operative ICG is useful in the microsurgical clipping of intracranial aneurysms to ensure patency of branch vessels. However, the presence of residual aneurysm and subtle changes in flow in branch vessels is best seen by DSA. This has important clinical implications in regards to immediate post-operative management, the need for delayed follow-up imaging, and decisions to re-treat incompletely clipped aneurysms.

Response: We appreciate Nguyen and Raymond’s comments on our work regarding intraprocedural rupture (IPR) of intracranial aneurysms and are glad they have given us the opportunity to underline the exploratory nature of our analysis. …