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Background: Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. Methods: The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. Results: A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P P P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P P P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. Conclusions: Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

Introduction: Recreational and medical cannabis use in the United States has been increasing in recent years in light of state efforts to decriminalize and legalize its use. Its legal status has long precluded extensive research into its adverse effects, especially as it pertains to the realm of vascular and cerebrovascular outcomes. To date, minimal research has been completed on the sequelae of cannabis in cerebrovascular hospital admissions. Methods: A query of the 2012-2015 Nationwide Inpatient Sample searched for patients admitted with cerebrovascular related ICD-9 diagnoses. These patients were then grouped by the presence of concurrent diagnosis of cannabis use disorder, and compared with respect to various peri- and postoperative complications, all-cause mortality, discharge disposition, length of stay, and hospitalization costs. Propensity score matching was utilized to control for potential baseline confounders. Results: A total of 900,023 patients met inclusion/exclusion criteria, 7,231 (0.80%) of whom had cannabis use disorder. After controlling for baseline characteristics, these patients had higher rates of inpatient mortality (odds ratio [OR] 1.99; p=0.034), and non-routine discharge, as well as increased lengths of stay (6.3 vs 5.9 days, p Conclusions: Based on a national trends analysis, chronic cannabis use appears to be associated with increased perioperative morbidity and mortality among patients admitted for cerebrovascular diagnoses. Physicians should ensure that a thorough drug use history is taken, and that affected patients be adequately informed of associated risks. Further research can elucidate further the effect on specific cerebrovascular diagnoses such as stroke and aneurysms.

Introduction: In New York City (NYC), expanding the reach of thrombectomy-capable stroke centers (TSC) is key to combating socioeconomic disparities in stroke care. The Area Deprivation Index (ADI), a validated, neighborhood-level composite measure (scored 1-100) that includes income, education, employment, and housing quality, has informed healthcare delivery but has not been used to identify disadvantaged neighborhoods with poor access to stroke care. We sought to evaluate the impact of establishing Mount Sinai Queens Hospital (MSQ) as a TSC in 2017 on transfer times and to explore the association between ADI and stroke care access. Methods: Thrombectomy patient pick-up addresses were obtained through Emergency Medical Services runsheets from June 2016 to July 2021 and matched to census-tract level ADI scores from Neighborhood Atlas. Preliminary analyses compared both ADIs and time to stroke care access in both Queens and Manhattan. The primary outcome measure was the duration between ambulance arrival and groin puncture. Simple linear regression and T-tests were used to assess the association between ADI and time to groin puncture by borough. Results: Among 517 cases between 2016-2021, the average ADI of pick-up locations was 10.35 (range: 1 - 70.5). Across all centers, higher ADI (greater deprivation) was significantly associated with increased time to groin puncture (p = 0.024). Notably, Queens patients were picked up in census tracts with higher ADI (p=0.0289) but had a faster pick up to groin puncture time (p=0.006). Conclusions: Across urban census tracts, a higher ADI was associated with delays in access to thrombectomy. Thrombectomy centers in areas with higher ADI can play a role in reducing healthcare disparities for stroke patients.

Purpose: To determine the effect of general anesthesia on clopidogrel resistance among patients undergoing intracranial stenting procedures Background: Clopidogrel resistance is associated with increased periprocedural thromboembolic complications in neurovascular stenting procedures. Clopidogrel is metabolized by cytochrome P450 system to an active drug that irreversibly binds to the platelet ADP receptor P2Y12 and inhibits downstream platelet aggregation. General anesthetics are commonly used in intracranial stenting procedures and are known to inhibit cytochrome P450 monooxygenases. Therefore we hypothesized that the use of common general anesthetics would be associated with increased clopidogrel resistance. Methods: We conducted a retrospective chart review of 41 patients who underwent intracranial stenting and coiling procedures under general anesthesia from 2010-2013. We analyzed the 35/41 who had platelet assays performed within twenty-four hours both before and after the procedure (VerifyNow, Accumetrics, Inc., San Diego, CA, USA). P2Y12 reaction unit (PRU) was used to measure platelet resistance, with values ≤178 indicating increased bleeding risk, 179-238 therapeutic, and ≥239 thrombogenic. Pre-procedural and post-procedural mean PRU values were compared using t tests to determine the effect of general anesthesia on clopidogrel resistance. Results: We found significantly increased post-procedure PRUs compared to pre-procedure PRUs. Mean PRU twenty-four hours before procedure was 214±34 (95% CI 180-248) compared with 260±25.24 (95% CI 235-285) twenty-four hours after the procedure (p Conclusion: Clopidogrel resistance is increased following endovascular stenting procedures. We propose that this occurs through competitive interaction with CYP isoforms by general anesthetics. We are not aware of any prior studies demonstrating an association between general anesthetics and clopidogrel resistance. Further prospective studies are needed to further define this observation.

Background: Capillary malformation-arteriovenous malformation (CM-AVM) syndrome is an autosomal dominant disorder caused by mutations in the RASA1 gene. The hallmark is cutaneous capillary malformations. High flow AVMs occur in about 1/3 of patients, with cerebral malformations in about 10%. We evaluate the clinical and radiographic features of cerebral malformations in CM-AVM patients. Methods: Since 2006, pediatric patients presenting to our center with head and neck high flow vascular malformations have been screened for capillary malformations. Our database of pediatric head and neck vascular malformations was reviewed for patients with capillary malformations. Patients with only facial arteriovenous malformations were excluded. Clinical and radiographic features were reviewed. Results: 9 patients were found to have high flow head and neck malformations and CM. 1 patient with an ear AVM was excluded. Of the remaining, 4 patients had confirmed positive genetic mutation in the RASA1 gene. All four of these patients had complex pial arteriovenous fistulas - One was supratentorial and three were in the posterior fossa. One premature infant with a complex posterior fossa lesion and heart failure died shortly after birth. One infant with mild heart failure is on medication and awaiting treatment. The other two were asymptomatic and treated with embolization. These patients are neurologically intact and reaching developmental milestone. 3/4 patients had first degree relative with CM with or without AVM. One patient with vein of Galen malformation and CM has tested negative for RASA1 mutation. The other three patients have not yet been tested. Of these, two have pial arteriovenous fistula which have been treated. One 2 year old had a multifocal dural arteriovenous fistula. Conclusion: Cerebral vascular anomalies in CM-AVM syndrome are often complex lesions. Thus far, all confirmed RASA1 mutation patients at our center have pial arteriovenous fistulas. Vein of Galen malformation and dural AVM may also be associated. Pediatric patients with these diagnoses should be screened for CM. The diagnosis of CM-AVM with RASA1 mutation plays a role in family planning and screening of other family members.