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Prior studies suggest an association between Vitamin K antagonists (VKA) and cerebral microbleeds (CMBs); less is known about nonvitamin K oral anticoagulants (NOACs). In this observational study we describe CMB profiles in a multicenter cohort of 89 anticoagulation‐related intracerebral hemorrhage (ICH) patients. CMB prevalence was 51% (52% in VKA‐ICH, 48% in NOAC‐ICH). NOAC‐ICH patients had lower median CMB count [2(IQR:1–3) vs. 7(4–11); P

Background and Purpose: Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale. Methods: We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes. Results: Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were P =0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P Conclusions: We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.

BackgroundThe coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT).MethodsWe used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020).ResultsWe identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, PConclusionThe COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.

BackgroundElevated systolic blood pressure (SBP) after mechanical thrombectomy (MT) correlates with worse outcome. However, the association between SBP reduction (SBPr) and outcome after successful reperfusion with MT is not well established.ObjectiveTo investigate the association between SBPr in the first 24 hours after successful reperfusion and the functional and safety outcomes of MT.MethodsA multicenter retrospective study, which included 10 comprehensive stroke centers, was carried out. Patients with acute ischemic stroke and anterior circulation large vessel occlusions who achieved successful reperfusion via MT were included. SBPr was calculated using the formula 100×([admission SBP−mean SBP]/admission SBP). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3–6 at 90 days. Safety endpoints included symptomatic intracerebral hemorrhage, mortality, and requirement for hemicraniectomy during admission. A generalized mixed linear model was used to study the association between SBPr and outcomes.ResultsA total of 1361 patients were included in the final analysis. SBPr as a continuous variable was inversely associated with poor outcome (OR=0.97; 95% CI 0.95 to 0.98; p20%), the rate of poor outcome was highest in the first group.ConclusionSBPr in the first 24 hours after successful reperfusion was inversely associated with poor outcome. No association between SBPr and safety outcome was found.

Background and Purpose Mechanical thrombectomy (MT) is demonstrated to improve functional outcome of patients with anterior circulation strokes with emergency large vessel occlusion (ELVO). Despite successful recanalization (SR), a proportion of these patients require decompressive hemicraniectomy (DHC). We aimed to study the predictors of DHC in successfully recanalized anterior circulation ELVO patients. Methods Consecutive anterior circulation ELVO patients treated with MT during a 6-year period in a tertiary stroke center were evaluated. Only patients with SR (mTICI 2b, 2c or 3) after MT were included in the analysis. Baseline demographic, clinical and procedural variables were compared between the patients who required DHC after successful recanalization vs. who did not. Collaterals for anterior circulation ELVO (ie, poor (collateral score=0) vs. good (collateral score=1, 2 and 3) were reported using a methodology that has been shown to predict clinical outcome. Good functional outcome was defined as mRS score of 0–2 at 3 months. Univariable and multivariable logistic regression analyses were used to determine the predictors of DHC. Results Of 453 successfully recanalized anterior circulation ELVO patients, 47 underwent DHC (mean age 58±13 years, 53% male, median admission NIHSS-score: 17 points, IQR 13–21). The patients in DHC group were younger in age (mean age in years±SD; 58±13 vs. 65±15, p=0.004), had higher admission systolic blood pressure (mmHg: 167±33 vs. 155±30, p=0.010), higher admission diastolic blood pressure (mmHg: 95±28 vs. 87±19, p=0.019), higher admission blood glucose levels (mg/dl: 170±88 vs. 142±66, p=0.008), similar median admission NIHSS (17 (IQR: 13–21) vs. 15 (IQR: 11–20), p=0.087), lower median ASPECTS (9 (IQR: 8–10) vs. 10 (IQR: 9–10), p=0.002), and poor collaterals on pre-treatment CT angiogram (% with poor collaterals: 75% vs. 26%, p Conclusion Higher blood glucose levels on admission, poor collateral pattern on CT angiography and higher number of passes during MT were independently associated with DHC in anterior circulation EVLO patients achieving SR at the end of MT. Of these, admission glucose levels and number of passes during MT are potentially modifiable factors. Disclosures N. Goyal: None. G. Tsivgoulis: None. A. Pandhi: None. M. Ishfaq: None. J. Goyanes: None. A. Deep: None. D. Alsbrook: None. S. Singh: None. G. Zaid: None. D. Hoit: None. C. Nickele: None. V. Inoa: None. D. Dornbos: None. A. Alexandrov: None. A. Arthur: None. L. Elijovich: None.

Introduction: Blood pressure (BP) is an important modifiable parameter after endovascular thrombectomy (EVT). Observational studies have found associations between elevated BP after EVT with hemorrhagic transformation and poor functional outcome. However, blood pressure course after EVT has not been well characterized and optimal hemodynamic management in the immediate post-stroke period remains unresolved. We utilized blood pressure data up to 72 hours after EVT to identify distinct systolic BP (SBP) trajectories and studied their associations with functional outcome. Methods: We retrospectively studied a multicenter cohort of 1060 patients with large-vessel occlusion stroke who underwent EVT. BP was recorded non-invasively recorded at least hourly for the first 72 hours. Functional outcome was assessed using the modified Rankin scale (mRS). Favorable functional outcome was defined as mRS &lt. Latent variable mixture modeling was applied to identify patient subgroups that have comparable SBP trajectories. All analyses were adjusted for age, admission NIHSS, and recanalization status. Results: One thousand sixty patients (mean age 70±15, mean NIHSS 16) were included in the analysis. Five distinct SBP trajectories were identified: (1) low (17%), (2) moderate (38%), (3) moderate-to-high (21%), (4) high-to-moderate (17%), and (5) high (7%) (Figure 1A). SBP trajectory group was an independent predictor of functional outcome at discharge (p=0.001) and 90 days (p=0.010, Figure 1B). Patients with high and high-to-moderate SBP trajectories had a significantly higher odds of an unfavorable outcome at 90 days (adjusted OR 2.3, 95%CI 1.2 - 4.3, p=0.01 and adjusted OR 4, 95% CI 1.5-10.7, p=0.06, respectively) Conclusions: During the first 72 hours after EVT, acute ischemic stroke patients show distinct SBP trajectories, which differ in relation to functional outcome. The findings may help recognize potential candidates for future blood pressure control trials.

Introduction: With more widespread anticoagulant use, anticoagulation-associated intracerebral hemorrhage (ICH) represents an increasing proportion of all ICH. We hypothesized that c ombining ischemic and hemorrhagic stroke risk estimation can guide treatment decisions, with more precision than ischemic risk estimation alone. Methods: We enrolled consecutive patients with anticoagulation-associated ICH in 15 centers in USA, Europe and Asia from 2015-2017. Each patient was assigned annual baseline ischemic stroke and hemorrhage risk based on their CHA 2 DS 2 -VASc and HAS-BLED scores without and with index ICH taken into account. We computed a net risk by subtracting the hemorrhagic from the ischemic risk. If the sum was positive the patient was assigned a “Favorable” indication for anticoagulation; if negative an “Unfavorable”. We compared clinical and neuroimaging characteristics between the two groups. Results: Our cohort comprised 357 patients (59% male, median age 76 [68-82] years). 69% used vitamin-K antagonists (VKA), 31 % Non vitamin K antagonist (NOAC). 191 (53.5%) of patients had a favorable indication for anticoagulation prior to their ICH event; the rest 166 (46.5%) had an unfavorable indication. Those with an unfavorable indication were younger (72[66-80] vs 78[73-84] years, p=0.001, had a lower CHA 2 DS 2 -VASc score (3[3-4] vs 5[4-6], p Conclusions: In this anticoagulation-associated ICH cohort, baseline hemorrhage risk exceeded ischemic risk in ~50% of patients. This finding highlights the need for careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining ~ 50% suffered an ICH although their baseline risk of ischemia exceeded that of hemorrhage which stresses the need for imaging, serum or other biomarkers to allow more precise estimation of hemorrhagic complication risk.

BackgroundIn response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied.MethodsA prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders.Results458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (PConclusionWe observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.

Background and Purpose— The aim of this study was to prospectively validate our prior findings of smaller hematoma volume and lesser neurological deficit in nonvitamin K oral anticoagulant (NOAC) compared with Vitamin K antagonist (VKA)-related intracerebral hemorrhage (ICH). Methods— Prospective 12-month observational study in 15 tertiary stroke centers in the United States, Europe, and Asia. Consecutive patients with premorbid modified Rankin Scale score of 33%] increase), neurological severity measured by National Institutes of Health Stroke Scale score, 90-day mortality, and functional status (modified Rankin Scale score). Results— Our cohort comprised 196 patients, 62 NOAC related (mean age, 75.0±11.4 years; 54.8% men) and 134 VKA related (mean age, 72.3±10.5; 73.1% men). There were no differences in vascular comorbidities, antiplatelet, and statin use; NOAC-related ICH patients had lower median baseline hematoma volume (13.8 [2.5–37.6] versus 19.5 [6.6–52.0] mL; P =0.026) and were less likely to have severe neurological deficits (National Institutes of Health Stroke Scale score of >10 points) on admission (37% versus 55.3%, P =0.025). VKA-ICH were more likely to have significant hematoma expansion (37.4% versus 17%, P =0.008). NOAC pretreatment was independently associated with smaller baseline hematoma volume (standardized linear regression coefficient:−0.415 [95% CI, −0.780 to −0.051]) resulting in lower likelihood of severe neurological deficit (odds ratio, 0.44; 95% CI, 0.22−0.85) in multivariable-adjusted models. Conclusions— Patients with NOAC-related ICH have smaller baseline hematoma volumes and lower odds of severe neurological deficit compared with VKA-related ICH. These findings are important for practicing clinicians making anticoagulation choices.

Ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients often require endotracheal intubation (EI) and mechanical ventilation (MV). Predicting the need for prolonged EI and timing of tracheostomy (TR) is challenging. While TR is performed for about 10–15% of patients in the general intensive care unit (ICU), the rate in the neurological ICU and for stroke patients ranges between 15 and 35%. Thus, we performed an external validation of the recently published SETscore. This is a retrospective review for all patients with IS, non-traumatic ICH, and SAH who required intubation within 48 h of admission to the neurological ICU. We compared the SETscore between tracheostomized versus successfully extubated patients, and early TR (within 7 days) versus late TR (after 7 days). Out of 511 intubated patients, 140 tracheostomized and 105 extubated were included. The sensitivity for a SETscore > 10 to predict the need for TR was 81% (95% CI 74–87%) with a specificity of 57% (95% CI 48–67%). The score had moderate accuracy in correctly identifying those requiring TR and those successfully extubated: 71% (95% CI 65–76%). The AUC of the score was 0.74 (95% CI 0.68–0.81). Multivariable logistic regression models were used to identify other independent predictors of TR. After including body mass index (BMI), African American (AA) race, ICH and a positive sputum culture in the SETscore, sensitivity, specificity, overall accuracy, and AUC improved to 90%, 78%, 85%, and 0.89 (95% CI 0.85–0.93), respectively. In our cohort, performing early TR was associated with improvement in the ICU median length of stay (LOS) (15 vs 20.5 days; p = 0.002) and mean ventilator duration (VD) (13.4 vs 18.2 days; p = 0.005) in comparison to late TR. SETscore is a simple score with a moderate accuracy and with a fair AUC used to predict the need for TR after MV for IS, ICH, and SAH patients. Our study also demonstrates that early TR was associated with a lower ICU LOS and VD in our cohort. The utility of this score may be improved when including additional variables such as BMI, AA race, ICH, and positive sputum cultures.

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.

IMPORTANCE: The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score

International audience; Background and Purpose— Successful reperfusion can be achieved in more than two-thirds of patients treated with mechanical thrombectomy. Therefore, it is important to understand the effect of blood pressure (BP) on clinical outcomes after successful reperfusion. In this study, we investigated the relationship between BP on admission and during the first 24 hours after successful reperfusion with clinical outcomes. Methods— This was a multicenter study from 10 comprehensive stroke centers. To ensure homogeneity of the studied cohort, we included only patients with anterior circulation who achieved successful recanalization at the end of procedure. Clinical outcomes included 90-day modified Rankin Scale, symptomatic intracerebral hemorrhage (sICH), mortality, and hemicraniectomy. Results— A total of 1245 patients were included in the study. Mean age was 69±14 years, and 51% of patients were female. Forty-nine percent of patients had good functional outcome at 90-days, and 4.7% suffered sICH. Admission systolic BP (SBP), mean SBP, maximum SBP, SBP SD, and SBP range were associated with higher risk of sICH. In addition, patients in the higher mean SBP groups had higher rates of sICH. Similar results were found for hemicraniectomy. With respect to functional outcome, mean SBP, maximum SBP, and SBP range were inversely associated with the good outcome (modified Rankin Scale score, 0–2). However, the difference in SBP parameters between the poor and good outcome groups was modest. Conclusions— Higher BP within the first 24 hours after successful mechanical thrombectomy was associated with a higher likelihood of sICH, mortality, and requiring hemicraniectomy.

Background As the randomized controlled trials excluded the patients with emergent large vessel occlusion (ELVO) strokes with low NIHSS Methods Stroke patients with ELVO and NIHSS Results Total of 146 patients with low NIHSS ELVO were included in the study. Of those, 95 (65%) patients (48% male, 71% Caucasians, mean NIHSS 3.6 ±1.3) had excellent outcome (mRS 0–1), while remaining 51 (35%) patients (57% male, 72% Caucasians, mean NIHSS 3.8 ±1.4) had poor outcome (mRS 2–6). The patients who had excellent outcome had lower age at presentation [years, mean (SD) 61.6±17.2 vs. 68.9±18.6; p: 0.012], higher rates of successful recanalization [91.2% vs. 74%; p: 0.012], and shorter groin puncture to recanalization time [minutes, mean (SD): 43.4 ±27.3 vs. 60.4 ±41.5, p=0.008) compared to poor outcome group. The mean baseline ASPECTS tended to higher in excellent outcome group (9.3 ±1.0 vs. 8.9±1.3, p=0.08). In multivariable analyses after adjustment for potential confounders, lower age (OR: 0.96, 95% CI 0.93–0.99, p=0.034), shorter groin puncture to recanalization time (OR: 0.97, 95% CI 0.96–0.99, p=0.003), and successful recanalization (OR: 11.2, 95% CI 1.5–80.4, p=0.016) were independent predictors of excellent outcome at 3 months. Conclusions Our retrospective multi-center study demonstrates that lower age, shorter groin puncture to recanalization time and successful recanalization were independent predictors of excellent outcomes post MT in ELVO patients with NIHSS Disclosures A. Pandhi: None. N. Goyal: None. G. Tsivgoulis: None. K. Malhotra: None. M. Ishfaq: None. M. Frohler: None. A. Spiotta: None. M. Anadani: None. M. Psychogios: None. V. Maus: None. A. Siddiqui: None. M. Waqas: None. P. Schellinger: None. M. Groen: None. O. Saeed:None. C. Krogias: None. D. Richter: None. M. Saqqur: None. P. Bermejo: None. M. Mokin: None. R. Leker: None. A. Katsanos: None. G. Magoufis: None. K. Psychogios: None. V. Lioutas: None. M. VanNostrand: None. V. Sharma: None. M. Paciaroni: None. A. Rentzos: None. H. Shoirah: None. J. Mocco: None. D. Hoit: None. L. Elijovich: None. A. Alexandrov: None. A. Arthur: None.

Background Abnormal restricted diffusion on magnetic resonance imaging is often associated with ischemic stroke or anoxic injury, but other conditions can present similarly. We present six cases of an unusual but consistent pattern of restricted diffusion in bilateral hippocampi and cerebellar cortices. This pattern of injury is distinct from typical imaging findings in ischemic, anoxic, or toxic injury, suggesting it may represent an under-recognized clinicoradiographic syndrome. Despite initial presentation with stupor or coma in the context of obstructive hydrocephalus, patients may have acceptable outcomes if offered early intervention. Methods We identified an ad hoc series of patients at our two institutions between years 2014 and 2017 who presented to the neurocritical care unit with severe, otherwise unexplained cerebellar edema and retrospectively identified several commonalities in history, presentation, and imaging. Results Between two institutions, we identified six patients—ages 33–59 years, four male—with similar presentations of decreased level of consciousness in the context of intoxicant exposure, with acute cytotoxic edema of the cerebellar cortex, hippocampi, and aspects of the basal nuclei. All patients presented with severe cerebellar edema which led to obstructive hydrocephalus requiring aggressive medical and/or surgical management. The five patients who survived to discharge demonstrated variable degrees of physical and memory impairment on discharge and at follow-up. Conclusions We present findings of a potentially novel syndrome involving a distinct pattern of cerebellar and hippocampal restricted diffusion, with imaging and clinical characteristics distinct from ischemic stroke, hypoxic injury, and known toxidromes and leukoencephalopathies. Given the potential for favorable outcome despite early obstructive hydrocephalus, early identification and treatment of this syndrome are critical.

To assess the effectiveness of cilostazol, a selective inhibitor of phosphodiesterase type III, in preventing cerebral ischemia related to cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH).A total of six clinical studies met the inclusion criteria and were included in the meta-analysis. We calculated pooled risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. The primary endpoint was cerebral ischemia related to vasospasm. Secondary endpoints were angiographic vasospasm, new cerebral infarct, mortality, and death or disability at the final follow-up.A total of 136 (22%) of 618 subjects (38 and 98 assigned to cilostazol and control treatments, respectively) with SAH developed cerebral ischemia related to vasospasm. The risk of cerebral ischemia related to vasospasm was significantly lower in subjects assigned to cilostazol treatment (The reduction in rates of cerebral ischemia related to vasospasm and death or disability at follow-up support further evaluation of oral cilostazol in patients with aneurysmal SAH in a large randomized clinical trial.

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: There are mounting data supporting a substantially lower risk of sICH in AIS patients with posterior circulation stroke (PCS) following treatment with IVT. However, stroke location is not included in any of the numerous risk prediction scores for sICH complicating IVT in AIS. We sought to compare the safety and efficacy of IVT for AIS with respect to the location of acute cerebral ischemia in a high-volume tertiary care stroke center. Methods: Consecutive AIS patients treated with IVT during a five-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Stroke location was classified as posterior (PCS) vs. anterior circulation (ACS), and supratentorial (STN) vs. infraterorial (ITN) infarction. Safety of IVT was evaluated using the SITS-MOST sICH definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores. Results: Out of total 1008 IVT-treated AIS patients [52% men, mean age 64±15years, median baseline NIHSS-score: 8 pts (IQR: 4-4)], 181 (18%) had PC and 88 (9%) had STN location. The rates of sICH were lower in patients with PCS [2.8% vs. 6.9%; p=0.039 by Fisher’s exact test (FET)] and ITN infarction (0% vs. 6.7%; p=0.005 by FET). PCS and ITN strokes (OR computed using Firth’s penalized likelihood method for rare events: 0.11; 95%CI: 0.01-1.82) were not independently associated with lower likelihood of sICH on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, baseline stroke severity, serum glucose, BP parameters and ASPECTS, pretreatment with antiplatelets (single or dual), statins and oral anticoagulants. Conclusions: Our study indicates that infarct location appears not to be independently related to the risk of sICH in AIS patients treated with IVT.

Introduction: Current AHA/ASA guidelines recommend keeping blood pressure (BP) Methods: This was a multicenter international retrospective study that included 7 comprehensive stroke centers. Inclusion criteria were anterior circulation large vessel occlusion (LVO) that was treated with MT, and successful recanalization at the conclusion of the procedure. Patients were divided into three groups based on systolic BP (SBP) goals in the first 24 hours post MT. Group 1) included patients with SBP goal ≤140 mm Hg or ≤120 mm Hg; group 2 included patients with SBP goal ≤160 mm Hg; group 3) included patients with SBP goal ≤220 mm Hg or ≤180 mm Hg. Successful recanalization was defined as TICI 2b-3. Outcome measures included symptomatic intracerebral hemorrhage (sICH), 90-day modified Rankin Scale (mRS), and 90-day mortality. Results: A total of 985 patients were included in the study. More patients in group 3 were white and had Afib than groups 1-2. Likewise, more patients in group 3 received IV tPA. Complete recanalization (TICI 2c-3) was achieved in 88.2%, 53.6%, and 73.2% in groups 1,2,3 respectively (p Conclusion: Blood pressure goals ≤140 and ≤160 were associated with favorable functional outcome.

Introduction: Cross-sectional data suggest that IVT in patients with in-hospital (IHS) acute ischemic stroke (AIS) onset is associated with unfavourable outcomes compared to out-of-hospital (OHS) stroke onset patients. We sought to compare safety and efficacy outcomes between IHS and OHS patients treated with IVT. Methods: Consecutive AIS patients treated with IVT during a five-year period in a tertiary care stroke center were prospectively evaluated. Demographics, vascular risk factors, admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS by certified physicians. Three-month functional outcome was evaluated by mRS-score. We compared the following outcomes between IHS and OHS patients: 1.symptomatic intracranial hemorrhage (sICH) 2.favourable functional outcome (FFO) [3-month mRS scores of 0-1], 3.Functional independence (FI) [3-month mRS scores of 0-2], 4. Mortality at three months. Results: Of 1264 IVT-treated AIS patients, we identified 51 (4%) subjects with IHS. Baseline median NIHSS-score was higher in IHS (10 points; IQR: 6-16 vs. 6 points; IQR: 3-12; p=0.004), while median onset-to-treatment was shorter (75 min; IQR: 37-115 vs. 135 min; IQR: 100-185; p0.1) between the two groups in FFO, FI and sICH rates. IHS was associated with higher likelihood three-month mortality (OR: 3.1; 95%CI: 1.2-7.8; p=0.016) on multivariable logistic regression models adjusting for demographics, risk factors, onset-to-treatment time, admission blood pressure and serum glucose levels, baseline NIHSS and ASPECTS. Conclusions: IHS patients treated with IVT have more severe strokes and higher mortality rates compared to OHS patients. IVT for IHS is not associated with higher hemorrhagic complications.

Introduction: Hypertension is a known predictor of poor outcome and hemorrhagic complications after ischemic stroke. However, the effect of blood pressure (BP) on outcome of those undergoing mechanical thrombectomy and especially after successful recanalization is not well understood. In this study, we investigated the association between BP parameters and outcome measures after successful recanalization with MT. Methods: This was a retrospective, multicenter study, involving 7 comprehensive stroke centers, of patients with acute ischemic stroke due to large vessel occlusion who achieved successful recanalization with MT. Systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) were obtained at frequent intervals (at least hourly) for each patient in the first 24 hours following MT. Outcome measures included 90 day-modified Rankin Scale (mRS), 90-day morality, and symptomatic intracerebral hemorrhage (sICH). Successful recanalization was defined as TICI 2b-3, and sICH as any hemorrhage associated with > 4 points increase in NIHSS. A mixed logistic model was used to identify predictors of functional and hemorrhagic outcomes. Results: A total of 989 patients were included, of whom 453 (45.8%) achieved good outcome, defined as an mRS of 0-2. Mean, and maximum SBP were higher in the poor outcome group (131.6 +15 vs. 127 +14.3; p Conclusion: Higher blood pressure was associated with hemorrhagic complications, and worse functional outcome following successful mechanical thrombectomy.

Introduction: blood pressure variability (BPV) in the acute phase following ischemic stroke is associated with worse outcomes, especially in patients with large vessel occlusions. However, the relationship between BPV and outcome after successful recanalization is not well documented. Objective: The aim of this study was to evaluate the association between BPV and outcome after successful recanalization. Methods: This was a retrospective multicenter study of patients with anterior circulation large vessel occlusions who achieved successful recanalization with MT. Successful recanalization was defined as TICI≥2b. BP was recorded in hourly intervals for 24 hours post MT. BPV was defined as the difference between maximum and minimum blood pressure within 24 hours. BPV was calculated for mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP). Outcome measures included 90 days mRS, symptomatic ICH (sICH), and mortality. sICH was defined based on ECASS criteria. Good outcome was defined as mRS 0-2. Results: A total of 985 patients were included. SBP and MAP variability were higher in poor outcome group (65.2±26 vs. 57± 24.6; p Conclusion: Higher blood pressure variability was associated with worse functional outcomes, higher likelihood of symptomatic hemorrhage, and increased mortality.

Background: Chronic kidney disease with reduced glomerular filtration rates (GFR) has been described as a risk factor for hemorrhagic stroke. The goal of this analysis was to determine if baseline GFR can predict long-term outcomes and/or incidence of adverse events in those patients who presented with hemorrhagic stroke. Methods: Retrospective analysis was done using data from the Antihypertensive treatment of acute cerebral hemorrhage II (ATACH-2) trial to determine the effect of baseline GFR on occurrence of adverse events, mortality and death and disability at 90 days. GFR were calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation using specified race, sex and serum creatinine in mg/dl from the National Institute of Diabetes and Digestive and Kidney Disease for estimation in patients age 18 and over. We compared demographic and clinical characteristics of subjects dichotomized into none/mild CKD (GFR ≥60 mL/min/1.73m 2 ) versus those who had moderate/severe CKD (GFR ≤59 mL/min/1.73m 2 ). We performed a multivariate analysis using cox proportional hazard model after adjusting for confounders. Results: Of the total 1000 participants in ATACH-2 trial 562 had baseline creatinine levels out of which there were 122 (21.7%) who had baseline GFR of ≤59 mL/min/1.73m 2 defined as moderate/sever GFR with mean age 65.7 SD± 13.6 and 59.8% were males. Those with moderate to severe GFR had significantly higher rates of previous stroke (26.2% vs 13.6%), congestive heart failure (8.3% vs 1.8%), previous ischemic heart disease (13.1% vs 1.6%), hypertension (88.5% vs 75.2%), hyperlipidemia (37.7% vs 20.7%), and diabetes mellitus (32% vs 14.3%). In the multivariate analysis after adjusting for age, Asian race, white race, hypertension, diabetes, hyperlipidemia and smoking those with moderate to severe GFR had significantly higher risk of death (HR 18.1, 95% confidence interval [CI] 1.3- 278.6; p-vale .033) and unfavorable outcome defined by a 90 day mRS score of 4-6 (HR 1.4, 95% CI 1.1 -1.9; p-value .015).The wide confidence interval in death could be due to small sample size. Conclusion: Patients with moderate to severe GFR at baseline appear to have higher rates of mortality and death and disability with a mRS score of 4-6 at 90 days.

Introduction: There are pilot data indicating that patients with acute ischemic stroke (AIS) due to paradoxical embolism (PxE) via patent foramen ovale (PFO) may respond better to intravenous thrombolysis compared to other stroke subtypes. We sought to compare the safety and efficacy of IVT in AIS patients with and without PxE as their stroke etiopathogenic mechanism in a high-volume tertiary care stroke center. Methods: Consecutive AIS patients treated with IVT during a five-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Presence of PFO was diagnosed by echocardiography, while PxE was determined using the TOAST criteria. Safety of IVT was evaluated using SITS-MOST sICH definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores. Results: Out of total 1301 IVT-treated AIS patients, we identified 51 cases (4%) with PxE due to PFO. Patients with PxE were younger (mean age 52±15 vs. 63±15 years; p0.1) between the two groups. Three-month mortality was lower in the PxE group (0% vs. 9% by Fisher exact test). PxE due to PFO (OR computed using Firth’s penalized likelihood method for rare events: 0.11; 95%CI: 0.01-1.74) was not independently associated with 3-month mortality on multivariable logistic regression models adjusting for potential confounders. Conclusions: Our study indicates that AIS patients with PxE due to PFO have similar response to IVT compared to AIS patients with other underlying mechanisms.

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.

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.

Introduction: There is preliminary data indicating potential racial disparities in use of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to compare “drip and ship” (DNS) tPA use between African-Americans (AA) and Caucasians (CS) in a high-volume tertiary care stroke center. Methods: AIS patients treated with IVT during a seven-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. All patients who received IVT at an outside facility with subsequent transfer to our center were included in the DNS group. Safety of IVT was evaluated SITS-MOST symptomatic intracranial hemorrhage (sICH) definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores. Results: Out of total 1339 IVT-treated AIS patients [51% men, 63% AA, mean age 63±15years, median baseline NIHSS-score: 7 pts (IQR: 3-13)], 521 (39%) were treated using the DNS approach. DNS tPA use was less common in AA compared to CS (33% vs. 51%; p < 0.001). AA race was independently associated with lower likelihood of DNS tPA use (OR: 0.46; 95%CI: 0.35-0.62; p Conclusions: Our study uncovers substantial racial disparities in the selection of AIS patients for DNS thrombolytic therapy that cannot be explained by racial geographic proximity to the primary stroke center.

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.

A three-year-old girl was found altered with an unknown timeline. Gas chromatography mass spectrometry was positive for hydromorphone, dihydrocodeine, and hydrocodone. Initial computed tomography and magnetic resonance imaging suggested a malignant cerebellar edema not confined to a vascular distribution. She received fentanyl boluses on hospital days 0 and 1 before receiving a continuous infusion on day 1. On day 3, she had an episode of acute hypertension and bradycardia. Emergent computed tomography showed an evolving hydrocephalus and similar diffuse edema throughout both cerebellar hemispheres. External ventricular drain was placed to relieve the increased intracranial pressure. Following drain placement and fentanyl discontinuation, the patient recovered, though not without fine- and gross-motor deficits at the four-month follow-up. Our case adds to a handful of case reports of opioid toxicity in pediatric patients that present as toxic leukoencephalopathy. Though the mechanism is poorly understood, it has been suggested to be a consequence of the neurotoxic effects of the drug, which has particular affinity for µ opioid receptors—the primary opioid receptor found in the cerebellum. Clinicians would do well to recognize that this syndrome is primarily caused by direct toxicity rather than ischemia. This case adds insight by suggesting that lipophilic opioid analgesics may worsen this neurotoxicity. When intervening with mechanical ventilation, clinicians should consider avoiding lipophilic opioid drugs for analgesia until the pathogenesis of cerebellar edema is better understood.

Background: Although offered at many centers, there is lack of evidence regarding whether stent placement is superior to best medical treatment for patients with vertebral artery stenosis in preventing new or recurrent brain ischemic events. Methods: Three randomized controlled trials (RCTs) and 1 non randomized comparative study were included. We calculated pooled risk ratio (RR) and 95% confidence intervals (CI) using random effect model. End points were major adverse events including stroke, myocardial infarction (MI) or vascular events within 30 days, new stroke in vascular territory of target vertebral artery; and all cause mortality in follow up period. Results: Of the 352 subjects (136 underwent stent placement) analyzed, 26 patients (7.4%) had stroke in the vascular territory of target vertebral artery. The risk of stroke in the vascular territory of target vertebral artery was not significantly different between the two groups (RR = 1.00; 95% CI 0.37-2.70; P =0.99). The risk of major adverse events including stroke, MI, and/or vascular events was non-significantly higher in patients who underwent stent placement (RR 2.62, 95% CI 0.56 - 12.19, p=0.22). No significant difference in all cause mortality was identified between the two groups on follow up at 3 years (RR 1.03, 95% CI 0.61-1.75, p=0.91). Conclusion: We did not identify any reduction of stroke in Vascular territory of target vertebral artery in our analysis. Further studies are needed to ensure that stent placement performed in current practice is actually efficacious in patients with vertebral artery stenosis.

Introduction: There are preliminary data indicating that pretreatment with dual antiplatelet therapy (DAPT) may increase the risk of symptomatic intracranial hemorrhage (sICH) following intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to identify the safety and efficacy of pretreatment with DAPT in IVT for AIS 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. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Three-month functional status was assessed using modified Rankin Scale (mRS). We compared the following outcomes between DAPT (+) and DAPT (-) patients before and after propensity score matching (PSM): 1.sICH, 2. asymptomatic intracranial hemorrhage (aICH) 3. favourable functional outcome (FFO; mRS scores of 0-1), 4. 3-month mortality. Results: Out of total 790 IVT-treated AIS patients, we identified 58 (7%) pretreated with DAPT (mean age 68±13 years; 57% men; median NIHSS-score 8, IQR: 4-14). The two groups did not differ (p>0.05) in terms of sICH [DAPT(+): 3% vs. DAPT(-): 3%], FFO (64% vs. 50%) and 3-month mortality (9% vs. 9%) in unmatched analyses. DAPT pretreatment was associated with higher odds of aICH before (17% vs. 6%) and after adjustment (OR: 2.4; 95%CI: 1.1-5.5) for potential confounders. After PSM, patients with (n=41) and without (n=82) DAPT pretreatment did not differ in any of the baseline characteristics. The differences in rates of all outcome events were non-significant in the two groups including sICH (2% vs. 1%, p=0.63), aICH (17% vs. 7%, p=0.06) and 3-month mRS (p=0.60; Figure). Conclusions: Pretreatment with DAPT is not associated with higher rates of sICH or three-month mortality and does not reduce the odds of FFO following IVT for AIS. IVT should not be withheld in otherwise eligible candidates due to pretreatment with DAPT.

Objective: Extensive research has long been focused on improving morbidity and mortality related to cerebral vasospasm which is well known as a major complication in subarachnoid hemorrhage (SAH) patients. The aim of this meta-analysis is to assess the effectiveness of cilostazol, a selective inhibitor of phosphodiesterase Type III, on cerebral vasospasm after SAH. Methods: Randomized and non randomized studies that compared effectiveness of cilostazol in SAH were included. A total of 6 trials met the inclusion criteria and were included in the meta-analysis. We calculated pooled risk ratios (RR) and 95% CIs (confidence intervals) using random-effects models. Primary end point was symptomatic vasospasm. Secondary end points were angiographic vasospasm, new cerebral infarct, mortality, and functional outcome i.e Modified Rankin scale ≤ 2. Results: Of the 618 total subjects, total of 136 (22%) symptomatic vasospasm events occurred during the follow-up period. The RR of symptomatic vasospasm was lower in patients treated with Cilostazol (RR = 0.43; 95% CI, 0.31-0.60; P < 0.001). Angiographic vasospasm was also significantly lower among those who received cilostazol as compared to control group (RR 0.67, 95% CI 0.51-0.84, p = .001). Cilostazol was associated with lower likelihood of new cerebral infarct in comparison to best medical therapy (RR 0.33 CI 95% 0.20-0.54, p Conclusion: Cilostazol administration may improve the outcome of patients with SAH. Further studies are needed to confirm this efficacy of cilostazol

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.

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&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.

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.

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