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Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only.Methods We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-of-bias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach.Results Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found low-certainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD -0.7%, 95% CI -3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI -0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only.Conclusion Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.

Introduction: Acute large vessel occlusion (LVO) can be secondary to thromboembolism or intracranial atherosclerotic disease (ICAD). Data on LVO management due to underlying ICAD are scarce. We hypothesized that patients with ICAD have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods: We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between January 14, 2018 and October 24, 2021. Presence of ICAD at LVO site was determined by the interventionalist. We compared in-hospital mortality, 90-day mortality, and 90-day modified Rankin Scale (mRS) scores between those with and without ICAD, in unadjusted and adjusting logistic regression models. Results: Among 215 patients (mean age 67.1±16.0 years; 60.5% female; 80.5% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p=0.027 and 29.0% vs. 14.7%, p=0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p=0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p=0.054). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p=0.003 and 52.6% vs. 26.6%, p=0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p=0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4). Conclusions: Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT. Further research is warranted to understand factors associated with worse outcomes and investigate alternative interventional approaches and medical management in this high-risk population.

Introduction: There is clinical equipoise behind bridging intravenous thrombolysis (BT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis comparing BT versus EVT alone. Methods: We conducted a model-based cost-utility analysis comparing the cost-effectiveness of BT vs EVT only for patients with acute ischemic stroke. We used a decision tree to examine the short-term costs and outcomes at 90 days after the index stroke, and developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. Clinical outcome inputs were derived from our systematic review. We considered the impact of disability and recurrent stroke on mortality risk, health-related quality of life, and costs. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Probabilistic analysis was used to calculate the reference case estimates. Results: The average costs per patient were estimated to be $55,503, $57,814, $68,183, and $84,946 for EVT only strategy, and $47,311, $49,556, $59,625, and $75,898 for BT over 90-day, 1-year, 5-year, and 20-year, respectively. The cost saving of EVT only strategy was driven by the avoided medication costs of IVT (ranging from $8,193 to $9,048). The additional thrombolytics led to slight decrease in QALY estimate during the 90-day time horizon (loss of 0.0016 QALY), but a small gain over 1-year, 5-year, and 20-year time horizons (0.0108, 0.0638, and 0.1481 QALY). With similar outcomes and less cost, the EVT only strategy was cost-effective compared with BT. Analyses with longer time horizon show lower probabilities of EVT only strategy being cost-effective. At a fixed willingness to pay threshold of $50,000, the probabilities of EVT only to be cost-effective were 100%, 100%, 99.0%, and 65.9% over 90-day, 1-year, 5-year, and 20-year time horizons. At the willingness to pay thresholds of $100,000 per QALY, the probabilities of EVT only strategy being cost-effective was 22.8% over the 20-year time horizon. Conclusions: Our cost-effectiveness model suggested that bridging with thrombolytics may not be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion.

Despite the proven benefit of stent retrievers, challenges to rapid revascularization of large vessel occlusions (LVO) persist. Current stent retrievers have limited effectiveness for removing organized thrombi. The NeVa device is a novel stent retriever designed with openings in the basket cell structure (“drop zones”) intended to capture organized thrombi within the central scaffold during retrieval. Prospective, multicenter, open label, single arm, FDA-regulated IDE study to evaluate the performance of the NeVa device for recanalizing occluded intracranial vessels including ICA, M1/M2 MCA, and vertebrobasilar arteries, within 8 hours of onset. Primary endpoint was rate of eTICI 2b-3 within 3 NeVa passes, tested for non-inferiority against a performance goal of 72% with a margin of -10%. Additional efficacy endpoints included first pass effect to eTICI 2b-3 (FPE) and 90-day mRS 0-2. Primary safety endpoint was 90-day mortality. (ClinicalTrials.gov NCT04514562) (Site-adjudicated revascularization results are reported here. Final core lab results will be presented at the conference.) From April 1, 2021 to April 28, 2022, 139 subjects were enrolled at 25 centers in the US and Europe. Mean age was 67 ± 13 years; 47% were female. Median NIHSS score was 16 (IQR: 12-20). Occlusions were 14 (10%) ICA, 85 (61%) M1, 38 (27%) M2, 1 (1%) Basilar and 1 (1%) PCA. Mean time to first pass was 19 ± 12 minutes. eTICI 2b-3 within 3 NeVa passes occurred in 87.8% (122/139; CI 81.1%,92.7%; non-inferiority p

Introduction: The optimal antiplatelet therapy regimen for neuroendovascular procedures remains unclear. This study investigates the safety and feasibility of intravenous dose-adjusted cangrelor for neurovascular interventions. Methods: We conducted a retrospective review of consecutive patients who underwent neuroendovascular procedures and were placed on intravenous cangrelor between September 1, 2020 and March 13, 2022. Demographic characteristics, interventional variables, and clinical outcomes were collected. Results: Fifty patients were included. The mean age (years) was 56.0 ± 18.6, and 26 (52.0%) were males. Most patients were African American (n=39/48, 81.3%). The most common comorbidities were hypertension (n=25/49, 51.0%), active smoking status (n=14/40, 35.0%), and prior ischemic stroke (n=13/49, 26.5%). Intravenous thrombolysis was used in 4 patients (8.0%). Cangrelor infusion was used for the following procedures: embolization (n=10/50, 20.0%), embolization and stent placement (n=9/50, 18.0%), thrombectomy alone (n=5/50, 10.0%), thrombectomy and stent placement (n=10/50, 20.0%), and stent placement only (n=14/50, 28.0%). Stent placement occurred intracranially, remainder of carotid, and both intracranial and carotid arteries in 18, 12, and 3 patients, respectively. PRU levels were measured in 48 patients (96.0%), with 26 patients (54.2%) achieving a PRU level of 50-150 greater than or equal to 50% of the time. Approximately 51.5% of the patients had a favorable functional outcome with modified Rankin Scale (mRS) score of 0 to 2 at 90 days (n=17/33). During 1-year follow up, approximately 4 patients had recurrent or new strokes (9.5%), 1 patient had in-stent thrombosis (2.9%) and 1 patient with symptomatic sICH (2.4%), both while not on antiplatelet therapy, and 2 patients with asymptomatic ICH (4.8%). When stratified by PRU level, there were no significant differences in sICH (p=0.841) or asymptomatic ICH (p=0.853). Conclusions: To our knowledge, this is the first report in the largest cohort to date to demonstrate the safety and effectiveness of intravenous dose-adjusted cangrelor use for neuroendovascular procedures. Comparative studies to standard dose maintenance cangrelor are necessary.

Title: Prehospital Transport Protocol for Comprehensive Stroke Center Triage is Associated with Reduced Last Known Well to Arrival Times for Intracranial Hemorrhage Background: In September 2018, we implemented a prehospital routing protocol for patients with suspected severe stroke and large vessel occlusion using the 3 Item Stroke Scale (3I-SS). Patients who have a 3I-SS score of ≥4 and have a known last normal time of ≤6 hours were transported to the closest Comprehensive Stroke Center (CSC). While the impact on endovascular treatment for ischemic stroke is more established, the effect of this transport policy on patients with intracerebral hemorrhage (ICH) is unknown. Objective/Methods: The objective of the study was to determine if implementation of a regional CSC transport protocol reduced last known well (LKW) to hospital arrival time for patients with ICH. Data was retrospectively reviewed all patients with a primary diagnosis of ICH from Get With The Guidelines®(GWTG) Stroke regional registry between January 2018 to May 2019 (8 month pre and 8 months post-implementation) and consisting of 16 Primary Stroke Centers (PSCs) and 8 CSCs. We analyzed LKW-arrival times to compare median times in the pre- vs. post-implementation periods. Results: There were 501 ICH cases in the pre-implementation period (mean age 66, 43.3% Black, and 52.3% male) and 548 in the post-implementation period (mean age 66, 41.0% Black, and 54.3% male). In the post-implementation period, median LKW to hospital arrival time was 255 minutes vs. 270.5minutes in the pre-implementation period (P value 0.029). LKW to hospital arrival times for those patients arriving from EMS decreased from a median 112.5 minutes to 81 minutes (P value 0.034). Conclusions: A prehospital direct-to-CSC transport protocol resulted in a substantial decrease in the median LKW to hospital arrival times for ICH patients, driven especially by EMS-arriving patients. Prehospital protocols could increase access to time sensitive life-saving therapies for ICH.

Objective There is a growing use of ticagrelor in patients undergoing neuroendovascular procedures, especially those who demonstrate clopidogrel resistance. While multiple dosages are studied in the cardiology literature, the optimal dose for patients with neurological pathology has yet to be established. Here, we describe a single center experience involving 39 patients who underwent neuroendovascular procedures that then received an adjusted lower dose of ticagrelor. Methods A retrospective chart review was performed between 2013 and 2017 for patients on dual anti-platelet therapy (DAPT) for either cervical or intracranial vascular pathologies, as well as stenting of the neurovasculature, including carotid arteries. Patients were placed on ticagrelor if their measured P2Y12 reaction units (PRU) responses to clopidogrel were outside the expected range in our center using the VerifyNow™ P2Y12 test. All patients were maintained on a dose of 45 mg twice daily except for one patient who received 22.5 mg twice daily. Responsiveness to ticagrelor were measured utilizing the VerifyNow™ P2Y12 test. Results The mean number of days for follow-up post treatment initiation was 532 days. A total of 39 patients were included in the analysis. Of these, 8 patients (21%) received implantation of intracranial stents (5 patients received pipeline embolization devices, 1 patient received stent-assisted coiling, and 2 patients received intracranial stents for atherosclerotic disease). Fourteen patients (35%) received carotid angioplasty and stenting. Seventeen patients (44%) did not receive permanent implantation of a stent. All patients on the lower dose ticagrelor of 45 mg twice daily achieved responsiveness (i.e., PRU < 194). Hemorrhagic transformation of ischemic stroke occurred in one patient (2.5%). No other hemorrhagic complications were encountered. No thromboembolic events were recorded aside from one patient (2.5%) with intracranial atherosclerotic disease who had an ischemic event. Conclusions A lower dose of ticagrelor (45 mg twice daily) appears to be safe and effective in this small cohort of patients who are resistant to clopidogrel per P2Y12 testing and who have increased risk of ischemic or hemorrhagic strokes due to neurovascular pathologies and implants. Further randomized studies are required to confirm these findings.

Background: There is a growing use of Ticagrelor in patients undergoing neuroendovascular procedures, especially those who demonstrate Clopidogrel resistance. While multiple dosages are studied in the cardiology literature, the optimal dose for patients with neurological pathology has yet to be established. Here we describe a single center experience involving 39 patients who underwent neuroendovascular procedures that then received an adjusted lower dose of Ticagrelor Methods: A retrospective chart review was performed between 2013 and 2017 for patients on dual antiplatelet therapy (DAPT) for either cervical or intracranial vascular pathologies, as well as stenting of the neurovasculature, including carotid arteries. Patients were placed on Ticagrelor if their measured PRU responses to Clopidogrel were outside the expected range in our center using the P2Y12 test. All patients were maintained on a dose of 45mg BID except for one patient who received 22.5 mg BID. Responsiveness to Ticagrelor were measured utilizing the P2Y12 test Results: The mean number of days for follow up post treatment initiation was 532 days. A total of 39 patients were included in the analysis. Of these, 8 patients (21%) received implantation of intracranial stents (5 patients received pipeline embolization devices, 1 patient received stent assisted coiling, and 2 patients received intra-cranial stents for atherosclerotic disease). Fourteen patients (35%) received carotid angioplasty and stenting. Seventeen patients (44%) did not receive permanent implantation of a stent. All patients on the lower dose Ticagrelor of mg BID achieved responsiveness per the P2Y12 test. Hemorrhagic transformation of ischemic stroke occurred in one patient (2.5%). No other hemorrhagic complications were encountered. No thromboembolic events were recorded aside from one patient (2.5%) with intracranial atherosclerotic disease who had an ischemic event Conclusion: A lower dose of Ticagrelor (45 mg BID) appears to be a safe and effective in this small cohort of patients who are resistant to Clopidogrel per P2Y12 testing and who have increased risk of ischemic or hemorrhagic strokes due to neurovascular pathologies and implants. Further randomized studies are required to confirm these findings

Background: In September 2018, we implemented a prehospital routing protocol for patients with suspected severe stroke and large vessel occlusion using the 3 Item Stroke Scale (3I-SS). Patients who have a 3I-SS score of ≥4 and have a known last normal time of ≤6 hours were transported to the closest Comprehensive Stroke Center (CSC). While the impact on endovascular treatment for ischemic stroke is more established, the effect of this transport policy on patients with intracerebral hemorrhage (ICH) is unknown. Objective/Methods: The objective of the study was to determine if implementation of a regional CSC transport protocol reduced last known well (LKW) to hospital arrival time for patients with ICH.Data was retrospectively reviewed all patients with a primary diagnosis of ICH from Get With The Guidelines® (GWTG) Stroke regional registry between January 2018 to May 2019 (8 month pre and 8 months post-implementation) and consisting of 16 Primary Stroke Centers (PSCs) and 8 CSCs. We analyzed LKW-arrival times to compare median times in the pre- vs. post-implementation periods. Results: There were 501 ICH cases in the pre-implementation period (mean age 66, 43.3% Black, and 52.3% male) and 548 in the post-implementation period (mean age 66, 41.0% Black, and 54.3% male). In the post-implementation period, median LKW to hospital arrival time was 255 minutes vs. 270.5 minutes in the pre-implementation period (P value 0.029). LKW to hospital arrival times for those patients arriving from EMS decreased from a median 112.5 minutes to 81 minutes (P value 0.034). Conclusions: A prehospital direct-to-CSC transport protocol resulted in a substantial decrease in the median LKW to hospital arrival times for ICH patients, driven especially by EMS-arriving patients. Prehospital protocols could increase access to time sensitive life-saving therapies for ICH.

Introduction: Acute large vessel occlusion (LVO) can be secondary to thromboembolism or underlying intracranial atherosclerotic disease (ICAD). Data on the management of LVO due to underlying ICAD are scarce. Hypothesis: We hypothesized that patients with ICAD would have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods: We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between 01/2018 and 05/2021. Presence of underlying ICAD at the site of LVO was determined by the treating interventionalist. We compared outcomes including in-hospital mortality and 90-day modified Rankin Scale (mRS) between those with and without underlying ICAD, adjusting for relevant covariates using logistic regression. Results: Among 195 patients (mean age 67.4+15.1 years, 56.9% female, 81% black, median NIHSS score 15), underlying ICAD was present in 39 (20.0%). Stent-retrievers were used 196 patients with only 3 having rescue stent placement. There were no significant differences in baseline factors amongst the two groups except diabetes was more common (69.2% vs. 49.7%, p=0.028) and intravenous thrombolysis provided less often (17.9% vs. 36.5%, p=0.027) in those with ICAD. TICI 2B or higher was achieved in 82.1% of ICAD compared with 94.3% of non-ICAD patients (p=0.012). Mortality was more common (50.0% vs. 30.8%, p=0.025) and good functional outcome (mRS 0-2) at 90 days was less common (10.8% vs. 30.0%, p=0.002) in the ICAD group. Adjusting for age, diabetes, intravenous thrombolysis, baseline NIHSS score, and final TICI score, underlying ICAD was an independent predictor of mRS 0-2 at 90 days (OR 4.5, 95% CI 1.4-14.2, p=0.010). Conclusion: Underlying ICAD is associated with 4.5-fold increase in poor functional outcome in patients with LVO undergoing traditional MT. Further research is needed to understand factors associated with poor outcomes investigate alternative interventional approaches and medical management in this high-risk population.

Background: A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. Methods: This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. Results: Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140–720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51–1.73]; P =0.84), death (aHR, 0.78 [95% CI, 0.22–2.76]; P =0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48–1.73]; P =0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15–0.82]; P =0.02). Conclusions: In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.

Arteriovenous malformations (AVMs) in the pediatric population are relatively rare but reportedly carry a higher rate of rupture than in adults. This could be due to the fact that most pediatric AVMs are only detected after rupture. We aimed to review the current literature regarding the natural history and the clinical outcome after multimodality AVM treatment in the pediatric population, as optimal management for pediatric AVMs remains controversial. A multidisciplinary approach using multimodality therapy if needed has been proved to be beneficial in approaching these lesions in all age groups. Microsurgical resection remains the gold standard for the treatment of all accessible pediatric AVMs. Embolization and radiosurgery should be considered as an adjunctive therapy. Embolization provides a useful adjunct therapy to microsurgery by preventing significant blood loss and to radiosurgery by decreasing the volume of the AVM. Radiosurgery has been described to provide an alternative treatment approach in certain circumstances either as a primary or adjuvant therapy.

Background and Purpose: There are limited data on the optimal duration of dual antiplatelet therapy for secondary stroke prevention in patients with symptomatic intracranial atherosclerotic disease. Methods: Consecutive patients presenting with high-grade (70-99%) symptomatic intracranial stenosis from January 1, 2011, to December 31, 2013, and evaluated within 30 days of the index event were eligible for this analysis. All patients underwent treatment with aspirin plus clopidogrel for a target duration of 12 months along with aggressive medical management based on the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) protocol; all patients were given gastrointestinal prophylaxis for the duration of their aspirin and clopidogrel treatment. Clinical and safety outcomes of our cohort were compared with the medical arm of the SAMMPRIS trial cohort (n = 227). Results: Our cohort included 25 patients that met the inclusion criteria. Achievement of blood pressure and LDL cholesterol targets were similar between our cohort and the SAMMPRIS cohort. At 1 year, the rates of stroke, myocardial infarction or vascular death were 0% in our cohort and 16% in the SAMMPRIS cohort (p = 0.03). At 1 year, major bleeding rates were similar between our cohort and the SAMMPRIS cohort (4 vs. 2.2%, p = 1.0). Conclusion: A prolonged course of dual antiplatelet therapy for symptomatic intracranial atherosclerotic disease may be associated with less vascular events with no increase in hemorrhagic complications.

Background and Purpose— Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with extremely poor prognosis. The best treatment approach to acute stroke in this setting is unknown. We sought to determine clinical outcomes in patients with acute ischemic stroke attributable to ICA occlusion treated with intravenous (IV) systemic thrombolysis or intra-arterial endovascular therapy. Methods— Using the PubMed database, we searched for studies that included patients with acute ischemic stroke attributable to ICA occlusion who received treatment with IV thrombolysis or intra-arterial endovascular interventions. Studies providing data on functional outcomes beyond 30 days and mortality and symptomatic intracerebral hemorrhage (sICH) rates were included in our analysis. We compared the proportions of patients with favorable functional outcomes, sICH, and mortality rates in the 2 treatment groups by calculating χ 2 and confidence intervals for odds ratios. Results— We identified 28 studies with 385 patients in the IV thrombolysis group and 584 in the endovascular group. Rates of favorable outcomes and sICH were significantly higher in the endovascular group than the IV thrombolysis-only group (33.6% vs 24.9%, P =0.004 and 11.1% vs 4.9%, P =0.001, respectively). No significant difference in mortality rate was found between the groups (27.3% in the IV thrombolysis group vs 32.0% in the endovascular group; P =0.12). Conclusions— According to our systematic review, endovascular treatment of acute ICA occlusion results in improved clinical outcomes. A higher rate of sICH after endovascular treatment does not result in increased overall mortality rate.

Background and Purpose: Platelet function testing in neurointerventional (NI) procedures is still controversial. We compared the clinical outcomes between antiplatelet responders and nonresponders based on the results of the VerifyNow (VN) testing method. Methods: This is a retrospective single-center analysis of all consecutive patients who underwent NI stenting procedures from January 2007 through July 2013 and had documented preprocedural aspirin (ASA) and clopidogrel VN assays. Patients were divided into two groups based on their responsiveness to antiplatelet. Baseline characteristics, good functional outcome measured by the modified Rankin Scale (mRS) at 90 days, combined procedural complication rate defined as postprocedural stroke, in-stent thrombosis, and intraoperative rupture were compared between the two groups. Results: Our cohort included 37 patients: 26 were in the responder group (RG) and 11 were in the nonresponder group (NRG). Baseline characteristics were similar between the two groups. Even though the combined complication rate was similar between the two groups [NRG: 2/11 (18%) vs. RG: 2/26 (7%); p = 0.33], there was a trend for a higher rate of good functional outcome (90-day mRS: 0-2) in the RG (22/22, 100%) as compared to the NRG (8/10, 80%) (p = 0.0907). Conclusion: Overall, utilizing the VN antiplatelet function testing did not significantly change the clinical outcome after the NI procedures. Larger randomized trials are warranted to provide a better understanding of the utility of the antiplatelet testing in NI stenting procedures.

Background: Early reperfusion is critical for favorable outcomes in acute ischemic stroke (AIS). Stent retrievers lead to faster and more complete reperfusion than previous technologies. Our aim is to compare the cost-effectiveness of stent retrievers to the previous mechanical thrombectomy devices. Methods: Retrospective review of endovascularly treated large-vessel AIS. Data from all consecutive patients who underwent thrombectomy from January 2012 through November 2012 were collected. Baseline characteristics, the total procedural cost, the rates of successful recanalization [modified thrombolysis in cerebral ischemia (mTICI) scores of 2b or 3], and the length of stay at the hospital were compared between the stent retriever (SR) and the non-stent retriever (NSR) groups. Results: After excluding the patients who underwent concomitant extracranial stenting (n = 22) or received intra-arterial tissue plasminogen activator only (n = 6), the entire cohort included 150 patients. The cost of the reperfusion procedure was significantly higher in the SR compared to the NSR group (USD 13,419 vs. 9,308, p Conclusion: The procedural costs of thrombectomy for AIS are increasing and account for the bulk of hospitalization reimbursement. The impact of these expenditures in the long-term sustainability of stroke centers deserves greater consideration. While it is likely that the SR technology results in higher rates of optimal reperfusion, better clinical outcomes, and shorter lengths of stay, larger studies are needed to prove its cost-effectiveness.

sICH was higher in the IAT group, partial or complete recanalization and good functional outcome at 90 days were significantly higher in this group. The US FDA required a second confirmatory study in order to approve IAT as a standard therapy in AIS. However, for multiple reasons, including the development of the potentially safer and more effective clot retrieval devices, such a study never substantialized.

Background: The objective of our study was to identify factors on MRI neuroimaging and echocardiography as part of routine workup of patients with cryptogenic ischemic stroke (IS) or transient ischemic attack (TIA) to identify those patients who are likely to have paroxysmal atrial fibrillation (PAF) as detected by subsequent outpatient mobile cardiac outpatient telemetry (MCOT). Methods: All cryptogenic IS or TIA patients seen at Emory University Hospital and The Emory Clinic from 2009-2013 and who underwent outpatient MCOT were included in this analysis.Using logistic regression, we analyzed the association between lesions seen on MRI FLAIR sequences with PAF and categorized them as the following: Cortical lesions (CL), defined as T2-hyperintense cortical-based infarcts; high subcortical (HS) T2-hyperintense lesions, defined as Results: Of 132 patients included in this analysis, 17 (13%) had evidence of newly diagnosed PAF on MCOT (mean duration of monitoring=25 days); median age was 72 (IQR: 64-79), 50% were women, diabetes was present in 23%, hypertension in 76%, dyslipidemia in 64%, and active tobacco use in 8%. CL seen on baseline MRI were found to be significant predictors of PAF (OR 5.2, 95 % CI: 1.3-19; p=0.01). HS lesions were not found to be a significant predictor of PAF. On baseline echocardiography, patients who had PAF (vs non-PAF) had significantly higher mean LA diameter (4.2 vs 3.7 cm, p=0.03), lower tissue Doppler velocity (a’) (5.5 vs 13.5 cm/s, p=0.03), a trend toward higher left atrium volume index (LAVI) (37.5 vs 29.2, p=0.07) and mean LAVI/late diastolic Doppler velocity (A) (0.67 vs. 0.37, P= 0.006). The Areas under the Curve (AUC) for the parameters were: LA diameter 71.4%, a’ 92.6%, LAVI 74.6%, LAVI/A 62.5%, LAVI/a’ 67.9%. Conclusion: Cortical-based infarcts seen on MRI FLAIR sequences and baseline echocardiographic variables may help to predict cryptogenic ischemic stroke or TIA patients who are likely to have PAF identified on outpatient MCOT.

Objective: Intravenous thrombolysis is still the only FDA approved therapy for acute ischemic stroke since the NINDS trial. The introduction of more aggressive and alternative acute stroke interventions and techniques has given rise to wide body of contemporary literature reporting patient outcomes across the various treatment modalities; these outcomes have yet to be comprehensively quantified and reviewed. The existing data is still lacking solid evidence of correlation between successful recanalization and good outcome. Methods: Data were collected through Medline search. Analysis of 140 articles published between the years 1985 - 2011 was done to compare clinical outcomes, complication and mortality rates between non-revascularized and revascularized groups in the setting of acute stroke therapy. Search key words included recanalization, reperfusion, thrombolysis, modified Rankin Scale (mRS), in combination with ischemic stroke and cerebral ischemia. Results: Pooled analysis of 140 studies including 4,313 patients conveyed recanalization rate. Based on recanalization status, mRS was accessible in 110 studies, Symptomatic Intracranial Hemorrhage (sICH) in 60 studies and mortality rate in 86 studies. Patients with successful recanalization had better chance of having good functional outcome measured by mRS at 90 days (OR, 4.99; 95% CI, 4.21 to 5.91). sICH rate was not statistically different between the two groups (OR, 1.25; 95% CI, 0.90 to 1.73). Mortality rate was less in patients with successful recanalization compared with non-recanalized (OR, 2.77; 95% CI, 2.27 to 3.38). Interpretation: Our results suggest a strong relationship between successful revascularization and better functional outcome with less mortality rate.

Background and Purpose: Early reperfusion is the keystone in (AIS) therapy. Here, we compare the angiographic, radiographic, and clinical outcomes amongst the three device categories currently available. Methods: Retrospective review of a prospective collected database of large vessel AIS in a large academic center. Data from all consecutive patients who underwent clot retrieval using Merci, Penumbra, or Stent-Retrievers (Solitaire, n=31 or Trevo, n=20) from September 2010 to July 2012 were analyzed. Baseline characteristics were compared across the 3 groups. The outcome measures included the rates of recanalization (TICI 2b-3), symptomatic intracebral hemorrhage (sICH, defined as any parenchymal hematoma e.g. PH-1/PH-2), final infarct volume, 90-day mortality, and independent functional outcomes (modified Rankin Scale, mRS 0-2) at 90 days. Results: The entire cohort included 242 patients with a mean age of 65.5 and median baseline NIHSS 20. The median ASPECTS score was 8. There were no significant differences in terms of baseline characteristics amongst the 3 device groups. No differences in the rate of sICH (5.9% vs. 6.02% vs. 7.41%, for Stent retrieval, Penumbra and Merci respectively, P= 0.91), mean procedure time (90.6, 76.23 and 75.3 min for Stent retrieval, Penumbra and Merci respectively, P= 0.05), and the volume of infarction (70.4, 58.02, and 65.61 cc for Stent retrieval, Penumbra and Merci respectively, P = 0.47) between the Stent-Retriever, Penumbra, and Merci groups, respectively. However, the rates of reperfusion (88.2 % vs. 77.1% vs. 69.1 %, p= 0.041) and 90-day functional independence (54.9 % vs. 43.4 % vs. 24.7%, p=0.0015) were significantly higher with Stent-Retrievers as compared to Penumbra or Merci treatments. There was no significant difference in the rate of 90-day mortality amongst the different devices (33.33%, 26.51% and 40.74% for Stent-Retriever, Penumbra, and Merci groups, respectively, P= 0.1549). Conclusion: Our initial data suggest a potential superiority of the Stent-Retriever technology to both Penumbra and Merci devices. Differences between Stent-Retrievers and Penumbra were much smaller in our experience and additional comparison in a randomized prospective fashion is warranted.

Background: Patients with symptomatic carotid artery stenosis presenting with TIA or minor stroke have a risk of recurrent devastating stroke of 21% within 2weeks and 32% within 12 weeks. Efficacy of early endarterectomy (CEA) has already been proven. However, data on ideal timing of Carotid Artery Stenting (CAS) is still lacking. Methods: A prospective observational cohort of elective endovascular procedures at our hospital was queried for consecutive cases of internal carotid artery stenting for minor symptomatic atherosclerotic stenosis inclusive of the years 2009-2011. A total of 438 patients were studied with the primary outcome measured as a combined incidence of major perioperative complications (stroke, Myocardial Infarction MI or death) at 90 days from procedure time, was compared between patients based on timing of procedure relative to onset of symptoms. Patients were stratified into four treatment groups: those treated urgently (0-2 days), early (3-7 days), routinely (8-14 days), or late (15-90 days). Incidence of the primary outcome was compared between groups using the Fisher’s exact test (SAS software, Cary NC). Results: Stent implantation was successful in all cases (100%). Combined incidence of major perioperative complications of stroke, MI or death at 90 days was 7% in the urgently treated group 0-2 days (10 out of 143), 11% in the early treated group 3-7 days (10 out of 110), 3% in the routinely treated group 8-14 days (3 out of 100) and 7% in the late treatment group 15-90 days (6 out of 85). Mortality was only reported in the urgently treated group and it was as high as 3% (5 out of 143). Conclusion: Little data is available regarding urgent carotid stenting post minor stroke or TIA. Out data suggest that the safest period to perform carotid artery stenting in symptomatic atherosclerotic stenosis is between 8-14 days with a rate of all combined major perioperative complications as low as 3%. Randomized and double-blinded trial is warranted to study this further.

Background: Transcranial Doppler (TCD) monitoring is commonly used to identify cerebral vasospasm in patients with subarachnoid hemorrhage (SAH) though its utility after day 10 has been questioned. The objective of our study was to determine the frequency of vasospasm by TCD in SAH patients who underwent prolonged monitoring (beyond day 10). Methods: We retrospectively identified all SAH patients seen at Emory University Hospital in 2011 who underwent TCD monitoring beyond 10 days. Outcomes of interest included cerebral vasospasm on TCD and delayed ischemic neurological deficit (DIND) beyond day 10. Results: Of 93 patients who met inclusion criteria, 66 (71%) experienced vasospasm and 28 (31%) developed DIND beyond day 10; of patients with DIND, TCD identified vasospasm in 24 (86%). Vasospasm on TCD was a predictor of DIND in univariate analysis (OR 3.29; 95% CI 1.015 to 10.63) but was not significant in multivariable analysis when adjusted for admission Hunt and Hess score. Conclusion: Prolonged TCD monitoring (beyond day 10) identified a high frequency of cerebral vasospasm in our subset of patients though was not a significant predictor of DIND in multivariable analysis. Prolonged TCD monitoring needs to be evaluated in a prospective study to determine its utility as a predictor of DIND.

Background and Purpose: Time to reperfusion is an essential factor in determination of outcomes in (AIS). We sought to establish the effect of the procedural time on the clinical and radiographic outcomes of AIS patients undergoing intra-arterial therapy. Methods: Retrospective review of a prospectively collected database of endovascularly treated large vessel AIS in a large academic center. Data from all consecutive patients who underwent mechanical thrombectomy from September 2010 to July 2012 were analyzed. The variable of interest was procedural time (defined as time from groin puncture to end of procedure). Outcome measures included the rates of symptomatic intracebral hemorrhage (sICH, defined as any parenchymal hematoma e.g. PH-1/PH-2), final infarct volume, 90-day mortality, and independent functional outcomes (modified Rankin Scale, mRS 0-2) at 90 days. Results: The entire cohort included 242 patients with a mean age of 65.5+/- 14.2 and median baseline NIHSS 20. Of the patients 49.38% were females. The median ASPECTS score was 8. The mean procedure time was significantly shorter in patients with good outcome (86.73 vs. 73.13 respectively, P-value: 0.0228). However, after controlling for ASPECTS score, type of retrieval device, TICI score, volume of infarct, interval from symptoms onset to puncture, and co-morbidities, this association did not prove to be significant (P-value = 0.7101). Patients with SICH had significantly higher mean procedure time than patients without SICH (79.65 vs. 104.5 respectively; P-value: 0.0319) which remained significant when controlling to the previous factors (OR = 0.974 with a 95 % CI of (0.957, 0.991). There was no correlation between the volume of infarction and the procedure time (r = 0.10996, P-value: 0.0984). There was no association between procedure time and 90-day mortality (77.8 vs. 88.2 minutes in survivals vs. deaths respectively; P-value: 0.0958). Conclusion: Our data support an association between the risk of SICH and a longer procedure time while no definite association between procedural times and the final infarction volume or long-term functional outcomes was found after adjustment for multiple imbalances.

Background and Purpose: Acute ischemic stroke due to large vessel occlusion is associated with a poor prognosis. With no consensus about the best treatment option, various treatment modalities including conservative management, intravenous tissue plasminogen activator, and endovascular approach are currently being used. Methods: Retrospective data including demographic information, baseline NIHSS score, site of occlusion (based on CTA, MRA or angiogram), type of treatment and clinical outcomes were collected from 4 centers in the United States during the period of 2010-2011. Results: A total of 423 were included in final analysis: 175 patients received conservative medical management, 54 patients received intravenous (IV) thrombolysis alone, and 194 patients had endovascular treatment (with or without prior IV tPA). Younger patients were more likely to receive endovascular treatment (p Conclusions: Our study represents real world experience on the management and outcomes of acute ischemic strokes due to large vessel occlusion. Our results help understand natural history of strokes with large vessel occlusion, as well as modern trends in managing these patients with intravenous and intraarterial treatment approaches.

Objective. Endovascular interventions for acute ischemic stroke have been widely adopted on the basis of single-arm registries that reported high recanalization rates with limited complications. We conducted a retrospective cohort study to compare the clinical outcomes in acute ischemic stroke patients who underwent endovascular treatment with patients who were treated with standard medical therapy alone at our institution. Methods. The study group consisted of two cohorts of patients with acute ischemic stroke over a 4-year period: 260 patients underwent endovascular treatment and 597 patients were treated with best medical therapy alone. All patients from the medical group presented with a NIHSS score of >8 and were ineligible for IV tPA. Clinical outcomes at discharge and at 3 months were compared. Results. Compared with the medical group, the endovascular group had a significantly greater proportion of patients who were discharged home (21.2% vs 8.7%, p Conclusion. In our study, endovascular therapy provides a better functional outcome compared with standard medical therapy in select patients. Ultimately, determination of efficacy of endovascular therapy for acute ischemic stroke compared with best medical therapy will depend on results of randomized trials.

Objective: To use the Computed Tomography Perfusion (CTP) parameters at the time of hospital admission, including Cerebral Blood Volume (CBV) and Permeability Surface area product (PS), to identify patients with higher risk to develop hemorrhagic transformation in the setting of acute stroke therapy with intravenous thrombolysis. Methods: Retrospective study that compared admission CTP variables between patients with Hemorrhagic Transformation (HT) acute stroke and those with no hemorrhagic transformation. Both groups received standard of care intravenous thrombolysis with tPA. Twenty patients presented to our stroke center between the years 2007 - 2011 within 3 hours after stroke symptoms onset. All patients underwent two-phase 320 slice CTP which creates CBV and PS measurements. Patients were divided into two groups according to whether or not they had HT on a follow up CT head without contrast, done within 36 hours of the thrombolysis therapy. Clinical, demographic and CTP variables were compared between the HT and non-HT groups using logistic regression analyses. Results: HT developed in 8 (40%) patients. Patients with HT had lower ASPECT score ( P =.03), higher NIHSS on admission ( P= .01) and worse outcome ( P= .04) compared to patients who did not develop HT. Baseline blood flow defects were comparable between the two groups. The mean PS for the HT group was 0.53 mL/min/100g brain tissue, which was significantly higher than that for the non-HT group of 0.04 mL/min/100g brain tissue ( P Conclusions: Admission CTP measurements might be useful to predict patients who are at higher risk to develop hemorrhagic transformation after acute ischemic stroke therapy.

Background and objectives: Current American Stroke Association/American Heart Association recommendations on the management of acute ischemic stroke do not recommend early use of heparin owing to increased risk of bleeding complications. However, for select patients, such as those with strokes associated with intraluminal thrombus, intravenous (IV) heparin might prove to be beneficial. Methods: We conducted a retrospective analysis of acute ischemic stroke cases associated with intraluminal thrombus of intracranial and extracranial arteries in the corresponding vascular territories to identify patients in whom treatment with IV heparin resulted in near-complete or complete lysis of the thrombus. Imaging findings from computed tomographic (CT) perfusion and angiography, magnetic resonance imaging, and/or digital subtraction angiography were used to describe the location of intraluminal thrombus immediately before and after treatment with IV heparin. Results: Eighteen patients with confirmed intraluminal thrombus by CT angiography (CTA) received treatment with IV heparin alone (median duration 3.5 days; range 1-8 days). The median NIHSS score was 2.5 (range 0-15) on admission and 1 (range 0-9) at discharge. Nine patients had complete lysis, and 9 patients had partial lysis of the thrombus with improved flow distal to the location of the thrombus. None of the patients developed intracranial hemorrhage. Conclusion: For strokes associated with intraluminal thrombus, IV heparin might prove to be an effective treatment strategy. Further studies are necessary to evaluate the efficacy and safety of treatment with IV heparin in those patients.

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

INTRODUCTION: Transient ischemic attacks (TIA) are generally milder forms of cerebral ischemia, without end organ damage. However, infarction or permanent ischemia is seen in TIA. The use of perfusion techniques such as cerebral blood volume (CBV), time to peak (TTP), mean transit time (MTT), and cerebral blood flow (CBF) provide real time data about ischemia. Whole brain CT perfusion studies are limited to only a few dozen stroke centers that have high detector row CT scanners. OBJECTIVE: To demonstrate that TIA's have significant numbers of perfusion deficits using whole brain 320 detector row CT perfusion, and to show an association between the ABCD2 score and the presence of perfusion deficit using whole brain perfusion. METHODS: We retrospectively reviewed all TIA patients for CT perfusion deficits at our "Gold+, JACHO" stroke center from 2008 to 2010. Exclusion criteria included patients who did not receive a CT scan during the study period and all ischemic or hemorrhagic stroke patients as confirmed by MRI or CT. Patients that had an ABCD2 score at time of imaging/admission were included in the study. Perfusion imaging was reviewed at admission by a neurologist and a radiologist; and reports stated if a perfusion deficit was noted, type (CBV, TTP, MTT, CBF) and vascular territory. RESULTS: Of 368 TIA patients, 66 patients had perfusion deficits. The largest group of patients had MCA territory involved at 52 of 66 (78.79%). The second largest of the groups was 11 (16.67%) with PCA territory or posterior fossa involved. Lastly 3 patients had ACA territory involvement (4.55%).The most common perfusion abnormality was increased TTP with 48 patients(72.73%). Increased MTT was noted in 17 patients (25.76%) and change in CBF in 14 patients (21.21%); and 6 patients with decreased CBV (9.09%). Using logistic regression, the components of ABCD2 score (age, blood pressure, character of symptoms, history of diabetes, and duration of symptoms) were reviewed in relation to the presence of perfusion deficit. Increased age greater than 65, hypertension (both systolic and diastolic) at the time of the TIA, patients that had weakness rather than only speech abnormalities, and duration of symptoms longer than an hour were all more likely to have a perfusion deficit. However, a history of diabetes or hypertension was not associated with a higher likelihood of perfusion deficit. DISCUSSION: The ABCD2 score can determine whether TIA patients are admitted for other diagnostic tests. Attention to CT perfusion in association with ABCD2 scores may better address potential risk factors of secondary stroke. CONCLUSION: There are perfusion deficits in TIA patients using 320 detector row whole brain perfusion protocol. Also, worsening criteria in each of the ABCD2 score modalities, except diabetes, is associated with a higher likelihood of a perfusion deficit.

Correlation Between Recanalization Rate and Good Clinical Outcome in Acute Ischemic stroke, A Meta-Analysis. Emad Nourollahzadeh, Omar Kass-Hout, Maxim Mokin, Rachel Aliotta, Kenneth Snyder, Adnan Siddiqui, Elad Levy, Tareq Kass-Hout Background: Early recanalization is strongly associated with improved functional outcomes and reduced mortality in acute ischemic stroke (AIS). This is the rationale that stands behind the use of intravenous (IV) or intra-arterial (IA) thrombolytics and the growing list of mechanical thrombectomy devices. There has been multiple small sized studies that have reported this positive association, however, we are lacking a recent review compilation demonstrating this. Methods: Data were collected through Medline search. We analyzed all articles published between the years 2002-2011 comparing various clinical outcomes including modified Rankin Scale (mRS) at 90 days, symptomatic intracranial hemorrhage (sICH), and mortality rate between non-revascularized and revascularized groups in the setting of AIS therapy. Search key words included recanalization, reperfusion, thrombolysis, thrombectomy, modified rankin scale, in combination with ischemic stroke and cerebral ischemia. Results: Seventy three studies reporting recanalization rate on 4,390 patients were analyzed. Recanalization rate through various intervention approaches were extracted (IV thrombolytic 32%, IA 58%, mechanical thrombectomy 89%, and combined thrombolytic/Mechanical 91%). Correlation between clinical outcomes and different revascularization therapies, location of the occlusion and the time from symptom onset to revascularization was only stratified in 68 studies. Patients with successful revascularization defined as Thrombolysis In Myocardial Infarction (TIMI) of 2-3 had a better functional clinical outcome compared to non-revascularized group (Pooled odds ratio 6.01; 95% CI 4.87 to 7.18). Mortality rate was reduced in patients that were revascularized (Pooled odds ratio 0.32; 95% CI 0.18 to 0.41). Symptomatic intracranial hemorrhage rate were reduced for the non-revascularized group, however it was not significant ( P = 0.31). Conclusion: This meta-analysis further supports the positive correlation between revascularization rate and good functional outcome and reduced mortality rate in AIS.

Background There is limited knowledge on the radiographic features of thrombolysis-induced hemorrhage. The factors that influence early hematoma expansion have not been elucidated. Methods Patients presenting with a symptomatic intracerebral hemorrhage (ICH) as a result of intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) for acute ischemic stroke and had noncontrast computed tomographic (CT) scans of the head were included in this retrospective study. Calculation of hematoma volumes was obtained. Analysis of covariance was used to evaluate for the effect of baseline blood pressure (BP) on initial hematoma volume and further growth. Results Of 267 patients who were treated with intravenous tPA for acute ischemic stroke at our facility between January 1, 2005 and December 31, 2009, 17 patients developed symptomatic ICH and were included in the final analysis. There was a positive correlation between baseline level of systolic BP after thrombolysis and initial hematoma volume (r = 0.46; P = .03) but not for the diastolic BP (r = 0.07; P = .40). There was a significant increase in mean hematoma volume expansion when comparing results between the first and second CT scans (median 9 hours, 22 minutes; 14.9 ± 19.6 cm 3 to 26.0 ± 26.7 cm 3 ; P = .04). There was also a negative association between the reduction of systolic BP and hematoma growth (r = -0.67; P = .02), but no correlation with change in diastolic BP (r = -0.22; P = .28). Conclusions Once diagnosed, thrombolysis-induced symptomatic ICH undergoes significant early expansion in size. Systolic BP may play a role in hematoma expansion.