Search

We hypothesized that combining adoptively transferred autologous T cells with a cancer vaccine strategy would enhance therapeutic efficacy by adding antimyeloma idiotype (Id)–keyhole limpet hemocyanin (KLH) vaccine to vaccine-specific costimulated T cells. In this randomized phase 2 trial, patients received either control (KLH only) or Id-KLH vaccine, autologous transplantation, vaccine-specific costimulated T cells expanded ex vivo, and 2 booster doses of assigned vaccine. In 36 patients (KLH, n = 20; Id-KLH, n = 16), no dose-limiting toxicity was seen. At last evaluation, 6 (30%) and 8 patients (50%) had achieved complete remission in KLH-only and Id-KLH arms, respectively (P = .22), and no difference in 3-year progression-free survival was observed (59% and 56%, respectively; P = .32). In a 594 Nanostring nCounter gene panel analyzed for immune reconstitution (IR), compared with patients receiving KLH only, there was a greater change in IR genes in T cells in those receiving Id-KLH relative to baseline. Specifically, upregulation of genes associated with activation, effector function induction, and memory CD8+ T-cell generation after Id-KLH but not after KLH control vaccination was observed. Similarly, in responding patients across both arms, upregulation of genes associated with T-cell activation was seen. At baseline, all patients had greater expression of CD8+ T-cell exhaustion markers. These changes were associated with functional Id-specific immune responses in a subset of patients receiving Id-KLH. In conclusion, in this combination immunotherapy approach, we observed significantly more robust IR in CD4+ and CD8+ T cells in the Id-KLH arm, supporting further investigation of vaccine and adoptive immunotherapy strategies. This trial was registered at www.clinicaltrials.gov as #NCT01426828.

Background Three randomized clinical trials have reported similar safety and efficacy for contact aspiration and stent-retriever thrombectomy. Aim We aimed to determine whether the combined technique (stent-retriever + contact aspiration) was superior to stent-retriever alone as first-line thrombectomy strategy in a patient cohort where balloon guide catheter was universally used. Methods A prospectively maintained mechanical thrombectomy database from January 2018 to December 2019 was reviewed. Patients were included if they had anterior circulation proximal occlusion ischemic stroke (intracranial ICA or MCA-M1/M2 segments) and underwent stent-retriever alone thrombectomy or stent-retriever + contact aspiration as first-line therapy. The primary outcome was the first-pass effect (mTICI2c-3). Secondary outcomes included modified first-pass effect (mTICI2b-3), successful reperfusion (mTICI2b-3) prior to and after any rescue strategy, and 90-day functional independence (mRS ≤ 2). Safety outcomes included rate of parenchymal hematoma type-2 and 90-day mortality. Sensitivity analyses were performed after dividing the overall cohort according to first-line modality into two matched groups. Results A total of 420 patients were included in the analysis (mean age 64.4 years; median baseline NIHSS 16 (11–21)). As compared to first-line stent-retriever alone, first-line stent-retriever + contact aspiration resulted in similar rates of first-pass effect (53% vs. 51%, adjusted odds ratio (aOR) 1.122, 95%CI (0.745–1.691), p = 0.58), modified first-pass effect (63% vs. 60.4%, aOR1.250, 95%CI (0.782–2.00), p = 0.35), final successful reperfusion (97.6% vs. 98%, p = 0.75), and higher chances of successful reperfusion prior to any rescue strategy (81.8% vs. 72.5%, aOR 2.033, 95%CI (1.209–3.419), p = 0.007). Functional outcome and safety measures were comparable between both groups. Likewise, the matched analysis (148 patient-pairs) demonstrated comparable results for all clinical and angiographic outcomes except for significantly higher rates of successful reperfusion prior to any rescue strategies with the first-line stent-retriever + contact aspiration treatment (81.8% vs. 73.6%, aOR 1.881, 95%CI (1.039–3.405), p = 0.037). Conclusions Our findings reinforce the findings of ASTER-2 trial in that the first-line thrombectomy with a combined technique did not result in increased rates of first-pass reperfusion or better clinical outcomes. However, the addition of contact aspiration after initial stent-retriever failure might be beneficial in achieving earlier reperfusion.

BackgroundFirst pass reperfusion (FPR) has been established as a key performance metric in mechanical thrombectomy (MT). The impact of FPR may be more relevant in fast progressors. We aim to study the impact of baseline Alberta Stroke Program Early CT Score (ASPECTS) on non-contrast CT and hypoperfusion intensity ratio (HIR) on CT perfusion on clinical outcomes after FPR.MethodsA prospective MT database was reviewed for patients with isolated occlusion of the intracranial internal carotid artery and/or middle cerebral artery M1 segment who underwent MT with complete reperfusion (modified Thrombolyis in Cerebral Infarction score 2c–3) from January 2012 to May 2019. The overall population was divided into ASPECTS >7 versus ≤7 and the subgroup of patients with baseline CT perfusion was divided into HIR ResultsA total of 436 patients were included in the analyses. FPR was achieved in 254 (58.3%) patients. ASPECTS modified the effect of FPR on clinical outcomes, with FPR predicting good outcomes in patients with ASPECTS ≤7 (46% vs 29%, adjusted OR 3.748; 95% CI 1.590 to 8.838, p=0.003) while no significant effect was detected in those with ASPECTS >7 (62.3% vs 53.1%, adjusted OR 1.372; 95% CI 0.798 to 2.358, p=0.25). Similarly, FPR predicted good outcomes in patients with HIR ≥0.3 (54.8% vs 41.9%, adjusted OR 2.204; 95% CI 1.148 to 4.233, p=0.01) but not in those with HIR ConclusionsThe impact of FPR on functional outcomes is highly dependent on baseline imaging characteristics, with a more prominent influence in patients presenting with lower ASPECTS and/or higher HIR.

Background and Purpose: Several reports have described lower mortality rates in overweight or obese patients as compared to normal weight ones. In the past decade, several studies have investigated the phenomenon, commonly known as the obesity paradox, with mixed results thus far. We sought to determine whether outcomes differ between patients with large vessel occlusion strokes (LVOS) after endovascular therapy (ET) according to their body mass index (BMI). Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients that underwent ET for acute LVOS were categorized according to their BMI into 4 groups: (1) underweight (BMI < 18.5), (2) normal weight (BMI = 18.5–25), (3) overweight (BMI = 25–30), and (4) obese (BMI > 30). Baseline characteristics, procedural radiological as well as outcome parameters where compared. Results: A total of 926 patients qualified for the study, of which 20 (2.2%) were underweight, 253 (27.3%) had a normal weight, 315 (34%) were overweight, and 338 (36.5%) were obese. When compared with normal weight (reference), overweight patients were younger, had higher rates of dyslipidemia and diabetes and higher glucose levels, while obese patients were younger, less often smokers, and had higher rates of hypertension and diabetes and higher glucose levels. Other baseline and procedural characteristics were comparable. The rates of successful reperfusion (modified treatment in cerebral ischemia, 2b–3), parenchymal hematomas, 90-day good clinical outcomes (modified Rankin scale, 0–2), and 90-day mortality were comparable between groups. On multivariate analysis, BMI was not associated with good outcomes nor mortality. Conclusion: In patients treated with mechanical thrombectomy, BMI is not associated with outcomes. However, patients who are overweight or obese have more comorbidities and a higher stroke risk and, thus, should strive for a normal weight.

Background and Purpose Stent-retriever (SR) thrombectomy remains the best proven treatment modality for anterior circulation large vessel occlusion strokes (LVOS). Three randomized clinical trials have reported similar safety and efficacy for contact aspiration (CA) and SR thrombectomy. The ASTER-2 trial compared combined technique (SR + CA) versus SR alone. The study failed to demonstrate differences in terms of final reperfusion and clinical outcomes across the two modalities. However, reperfusion was significantly better after the allocated treatment only with combined technique. We aim to determine whether the combined technique is superior to SR thrombectomy alone as first line strategy in a large single-center cohort where balloon-guide catheter was universally used. Methods A prospectively maintained mechanical thrombectomy database from January 2018 to December 2019 was reviewed. Patients were included if they had anterior circulation LVO due to intracranial ICA or MCA-M1 segment and underwent SR thrombectomy or combined technique as first-line therapy. The cohort was divided into two groups matched for age, baseline NIHSS score, prior IV-tPA, site of occlusion, stroke etiology, use of general anesthesia and balloon guide catheter. The primary outcome was the achievement of first-pass effect (FPE) (mTICI2c-3). Secondary outcomes included modified FPE, number of passes, successful reperfusion (mTICI2b-3) without and after rescue techniques and functional independence (90-day mRS 0–2). Safety outcomes included the rates of parenchymal hematoma (PH) type 2 and 90-day mortality. A secondary analysis was performed for the interaction between different subgroups and thrombectomy modality on successful reperfusion. Results A total of 244 patients (122 pairs) were eligible for the analysis. Patients with first-line combined technique had similar rates of FPE (56.6% vs. 51.6, p=0.44), successful reperfusion without (77% vs. 77.9%, p=0.88) and after (99.2% vs. 99.2%, p=1.00) rescue techniques and 90-day functional independence (46.6% vs. 54.4%, p=0.30) compared to SR thrombectomy. However, first-line combined technique had a significantly higher number of passes and longer reperfusion times compared to SR alone (p=0.005 and p=0.01, respectively). The rates of PH type 2 and 90-day mortality were comparable between both groups. There was no significant interaction between age, prior IV-tPA, site of occlusion and presence of favorable collaterals and the first-line treatment modality in terms of successful reperfusion. Conclusions Our findings reinforce the findings of ASTER-2 in that the first-line thrombectomy with a combined technique did not result in increased rates of successful reperfusion or a better outcome. In contrast with ASTER-2, we did not see any advantage even prior to rescue devices. Disclosures M. Mohammaden: None. D. Haussen: 2; C; Stryker, Vesalio. 4; C; Viz.AI. L. Pisani: None. A. Al-Bayati: None. A. Anderson: None. B. Liberato: None. M. Frankel: None. R. Nogueira: 2; C; Medtronic, Anaconda, Genentech, Brainomix, Viz-AI, Corindus Vascular Robotics.

Introduction: Identification of Large Vessel Occlusion (LVO) in acute ischemic stroke (AIS) patients is critical for proper decision-making. Limited availability of trained experts and delays in LVO recognition can have a detrimental effect on outcomes. We sought to evaluate an artificial intelligence-based algorithm for LVO detection in AIS. Methods: A retrospective analysis of a prospectively-collected database of AIS patients admitted to a large volume stroke center between 2014-2018 was performed. Experienced vascular neurologists graded CTA for presence and site of LVO. Concurrently, studies were analyzed by the Viz-LVO Algorithm® version 1.4 (GA) - a convolutional neural network programmed to detect occlusions from the internal carotid artery terminus (ICA-T) to the sylvian fissure, which would include all MCA M1-segment and most M2-segment lesions. CTA readings were categorized as LVOs (ICA-T, MCA-M1, MCA-M2) versus non-LVOs/more distal occlusions. Comparisons between human and AI-based readings were done by accuracy analysis and calculating Cohen’s kappa. Results: A total of 610 CTAs were analyzed. The AI algorithm rejected 3.4% of the CTAs due to poor quality. Viz-LVO identified LVOs with an overall sensitivity of 81.3%, specificity of 87.8%, and accuracy of 83.2% (AUC 0.845 (95%CI:0.81-0.88, p Conclusion: Our study demonstrates that automated AI reading allows for fast and accurate identification of LVO strokes. Future efforts should be made to improve the detection of the more distal occlusions.

Introduction: Intracerebral hemorrhages (ICHs) accounts for approximately 15% of all strokes but carry high rates of morbidity and mortality. The location and volume of hematoma are strongly associated with outcomes. As novel treatments become established, early detection and proper volume measurement are becoming increasingly important. We aim to evaluate an artificial intelligence-based algorithm (Viz-ICH® v1.4) for ICH detection, volume measurement, and its differentiation from intraventricular hemorrhage (IVH). Methods: We performed single center retrospective analysis of non-contrast CTs (NCCTs), randomly picked from prospective cohort of acute stroke patients, with and without parenchymal ICHs, admitted to our stroke center from 02/14-03/17. Experienced stroke neurologists graded NCCTs with a semi-automated tool (OsiriX MD v.9.0.1) for presence and volume of ICH, and also presence of intraventricular hemorrhage (IVH). AI- and human-based readings were compared. Results: A total of 211 NCCTs were evaluated including 163 ICHs and 48 controls. The ICH location was basal ganglionic in 55.8%, Lobar in 23.3% and posterior fossa in 12% of the cases and 51.5 % of patients had associated IVH with mean volume 41.94 cc. The AI algorithm demonstrated high accuracy for ICH detection and volumetric measurement (Table). The maximal running time of the algorithm was under 15s. Conclusion: The presence and volume of ICHs can be accurately detected by AI Viz-ICH Algorithm, with good differentiation from IVH which will help in early triage of these patients.

Background and Purpose: Ethnic disparities in stroke are well described, with a higher incidence of disability and increased mortality in Blacks versus Whites. We sought to compare the clinical outcomes between those ethnic groups after stroke endovascular therapy (ET). Methods: We performed a retrospective review of the prospectively acquired Grady Endovascular Stroke Outcomes Registry between September 1, 2010 and September 30, 2015. Patients were dichotomized into two groups – Caucasians and African-Americans – and matched for age, pretreatment glucose level, and baseline National Institutes of Health Stroke Scale (NIHSS) score. Baseline characteristics as well as procedural and outcome parameters were compared. Results: Out of the 830 patients treated with ET, 308 pairs of patients (n = 616) underwent primary analysis. African-Americans were younger (p < 0.01), had a higher prevalence of hypertension (p < 0.01) and diabetes (p = 0.04), and had higher Alberta Stroke Program Early CT Score values (p = 0.03) and shorter times to treatment (p = 0.01). Blacks more frequently had Medicaid coverage and less private insurance (29.6 vs. 11.4% and 41.5 vs. 60.3%, respectively, p < 0.01). The remaining baseline characteristics, including baseline NIHSS score and CT perfusion-derived ischemic core volumes, were well balanced. There were no differences in the overall distribution of 90-day modified Rankin scale scores (p = 0.28), rates of successful reperfusion (84.7 vs. 85.7%, p = 0.91), good outcomes (49.1 vs. 44%, p = 0.24), or parenchymal hematomas (6.5 vs. 6.8%, p = 1.00). Blacks had lower 90-day mortality rates (18 vs. 24.6%, p = 0.04) in univariate analysis, which persisted as a nonsignificant trend after adjustment for potential confounders (OR 0.52, 95% CI 0.26–1.03, p = 0.06). Conclusions: Despite unique baseline characteristics, African-Americans treated with ET for large vessel occlusion strokes have similar outcomes as Caucasians. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.

Background: The minimal stroke severity justifying endovascular intervention remains elusive. However, a significant proportion of patients presenting with large vessel occlusion stroke (LVOS) and mild symptoms go untreated and face poor outcomes. We aimed to evaluate the clinical outcomes of patients presenting with LVOS and low symptom scores (National Institutes of Health Stroke Scale [NIHSS] score ≤8) undergoing endovascular therapy (ET). Methods: We performed a retrospective analysis of a prospectively collected ET database between September 2010 and March 2016. Endovascularly treated patients with LVOS and a baseline NIHSS score ≤8 were included. Baseline patient characteristics, procedural details, and outcome parameters were collected. Efficacy outcomes were the rate of good outcome (90-day modified Rankin Scale score 0-2) and of successful reperfusion (modified Treatment in Cerebral Infarction [mTICI] score 2b-3). Safety was assessed by the rate of parenchymal hematoma (parenchymal hematoma type 1 [PH-1] and parenchymal hematoma type 2 [PH-2]) and 90-day mortality. Logistic regression was used to identify predictors of good clinical outcomes. Results: A total of 935 patients were considered; 72 patients with an NIHSS score ≤8 were included. Median [IQR] age was 61.5 years [56.2-73.0]; 39 patients (54%) were men. Mean (SD) baseline NIHSS score, computed tomography perfusion core volume, and ASPECTS were 6.3 (1.5), 7.5 mL (16.1), and 8.5 (1.3), respectively. Twenty-eight patients (39%) received intravenous tissue plasminogen activator. Occlusions locations were as follows: 29 (40%) proximal MCA-M1, 20 (28%) MCA-M2, 6 (8%) ICA terminus, and 9 (13%) vertebrobasilar. Tandem occlusion was documented in 7 patients (10%). Sixty-seven patients (93%) achieved successful reperfusion (mTICI score 2b-3); 52 (72%) had good 90-day outcomes. Mean final infarct volume was 32.2 ± 59.9 mL. Parenchymal hematoma occurred in 4 patients (6%). Ninety-day mortality was 10% (n = 7). Logistic regression showed that only successful reperfusion (OR 27.7, 95% CI 1.1-655.5, p = 0.04) was an independent predictor of good outcomes. Conclusion: Our findings demonstrate that ET is safe and feasible for LVOS patients presenting with mild clinical syndromes. Future controlled studies are warranted.

BACKGROUND AND PURPOSE Chronic hypoperfusion from athero-stenotic lesions is thought to lead to better collateral recruitment compared to cardioembolic strokes. It was sought to compare collateral flow in stroke patients with atrial fibrillation (AF) versus stroke patients with cervical atherosclerotic steno-occlusive disease (CASOD). METHOD This was a retrospective review of a prospectively collected endovascular database. Patients with (i) anterior circulation large vessel occlusion stroke, (ii) pre-treatment computed tomography angiography (CTA) and (iii) intracranial embolism from AF or CASOD were included. CTA collateral patterns were evaluated and categorized into two groups: absent/poor collaterals (CTA collateral score 0-1) versus moderate/good collaterals (CTA collateral score 2-4). CT perfusion was also utilized for baseline core volume and evaluation of infarct growth. RESULTS A total of 122 patients fitted the inclusion criteria, of whom 88 (72%) had AF and 34 (27%) CASOD. Patients with AF were older (P < 0.01) and less often males or smokers (P = 0.04 and P < 0.01 respectively). Baseline National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were comparable between groups. Collateral scores were lower in the AF group (P = 0.01) with patients having poor collaterals in 28% of cases versus 9% in the CASOD group (P = 0.03). Mortality rates (20% vs. 0%; P = 0.02) were higher in the AF patients whilst rates of any parenchymal hemorrhage (6% vs. 26%; P < 0.01) were higher in the CASOD group. On multivariable analysis, CASOD was an independent predictor of moderate/good collaterals (odds ratio 4.70; 95% confidence interval 1.17-18.79; P = 0.03). CONCLUSIONS Atheroembolic strokes seem to be associated with better collateral flow compared to cardioembolic strokes. This may in part explain the worse outcomes of AF-related stroke.

Background and Purpose— Pseudo-occlusion (PO) of the cervical internal carotid artery (ICA) refers to an isolated occlusion of the intracranial ICA that appears as an extracranial ICA occlusion on computed tomography angiography (CTA) or digital subtraction angiography because of blockage of distal contrast penetration by a stagnant column of unopacified blood. We aim to better characterize this poorly recognized entity. Methods— Retrospective review of an endovascular database (2010–2015; n=898). Only patients with isolated intracranial ICA occlusions as confirmed by angiographic exploration were included. CTA and digital subtraction angiography images were categorized according to their apparent site of occlusion as (1) extracranial ICA PO or (2) discernible intracranial ICA occlusion. Results— Cervical ICA PO occurred in 21/46 (46%) patients on CTA (17 proximal cervical; 4 midcervical). Fifteen (71%) of these patients also had PO on digital subtraction angiography. A flame-shaped PO mimicking a carotid dissection was seen in 7 (33%) patients on CTA and in 6 (29%) patients on digital subtraction angiography. Patients with and without CTA PO had similar age (64.8±17.1 versus 60.2±15.7 years; P =0.35), sex (male, 47% versus 52%; P =1.00), and intravenous tissue-type plasminogen activator use (38% versus 40%; P =1.00). The rates of modified Treatment In Cerebral Ischemia 2b-3 reperfusion were 71.4% in the PO versus 100% in the non-PO cohorts ( P P =0.66), 40% versus 66.7% ( P =0.12), and 25% versus 21% ( P =0.77) in PO versus non-PO patients, respectively. Multivariate analysis indicated that PO patients had lower chances of modified Treatment In Cerebral Ischemia 3 reperfusion (odds ratio 0.14; 95% confidence interval 0.02–0.70; P =0.01). Conclusions— Cervical ICA PO is a relatively common entity and may be associated with decreased reperfusion rates.

Background: Idiotypic determinants of the surface immunoglobulin (Ig) associated with a given pt's B-cell lymphoma are unique to that tumor, and can thus serve as a tumor-specific marker. This study aims to use an idiotype DNA vaccine to lengthen the smoldering phase of WM without inducing cross-resistance to available therapies. Administered vaccine used recombinant plasmid DNA encoding a fusion protein, consisting of autologous lymphoma scFv (pt-specific idiotype) and human CCL20 (macrophage inflammatory protein-3 alpha - MIP-3α) chemokine. Targeted delivery of this fusion protein to antigen-presenting cells, and subsequent processing and presentation, is hypothesized to break tolerance and generate an immune response against the idiotype, promoting eradication of antigen-expressing B-cell lymphoma cells. Methods: Pts with sWM received 3 intradermal vaccinations of pt-specific DNA vaccine at 4-week (wk) intervals (wks 0, 4 and 8). Two dose levels (500 µg; 2500 µg) were evaluated in a 3+3 design. The primary objective was to evaluate the vaccine's safety and identify the maximum tolerated dose. Secondary objectives were to assess immunogenicity of the vaccine to generate tumor-specific cellular immune responses. Results: Between 1/2016 - 1/2019, 9 pts (7 men) were treated (500 µg: n = 3; 2500 µg: n = 6). Median age at enrollment was 67 yrs (range 56-78); median time from diagnosis to 1st vaccination was 26.5 mos (8.8-120.9). MYD88 L265P + (6 pts). CXCR4 WHIM + (1 pt). With median follow up of 38 months (range: 8.8-51), 8 pts are known alive; 1 has been lost to follow up. Six have maintained stable disease; 3 have progressed to symptomatic WM at 8, 25, and 28 months respectively, from 1st vaccination). All pts completed planned therapy. No DLTs or Grade 4 AEs occurred. Ten mos. after the 3rd vaccination, 1 pt had a grade 3 pleural effusion and leukopenia with an increase in rheumatoid factor (23.1 IU/mL [normal range 0.0-15.9]) and ANA titer of 1:80; all resolved within 2 mos. Grade 1-2 AEs observed in > 3pts include: leukopenia (6), nausea (5), anemia (4), increased creatinine (4), fatigue (4). Immune correlatives have now been completed in all 9 patients. Analysis is ongoing, and complete data will be presented at the meeting. Serial pre- and post- vaccine samples analyzed by single-cell RNA seq from 3 representative patients (LPL 005, LPL 007, LPL 008) treated at the 2500 mg dose are shown in the Figure. DNA vaccine treatment significantly reduced the number of clonal B-cells in the bone marrow compartment of the 2 patients who have maintained SD (LPL 007 and LPL 008). DNA vaccine treatment also induced increases in monocytes in the tumor microenvironment of these 2 patients. In addition, T-cell receptor (TCR) sequence analysis revealed clear increases in TCR clonal expansions, consistent with a vaccine effect. In contrast, LPL 005, who had the earliest progression to symptomatic phase WM, had an increase in tumor B cells on post vaccine samples, and TCR clonotypes showed no changes. Similar changes were observed with serial bone marrow samples from the remaining patients treated on the trial, correlating with clinical outcome. Conclusions: Idiotype (scFv-CCL20) DNA vaccine therapy appears to be safe in pts with sWM. Preliminary results of serial single cell RNAseq analysis suggest that the tumor immune microenvironment is favorably altered after chemokine-tumor antigen DNA vaccine treatment and these vaccine-induced changes may correlate with clinical outcome. The immunologic changes observed suggest response to this vaccine, and warrant further investigation in a Phase II trial, possibly in combination with immune checkpoint blockade. Disclosures Thomas: Ascentage: Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Research Funding; Genentech: Research Funding; Pharmacyclics: Other: Advisory Boards; Xencor: Research Funding; X4 Pharma: Research Funding. Lee:GlaxoSmithKline: Consultancy, Research Funding; Regeneron: Research Funding; Daiichi Sankyo: Research Funding; Amgen: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Genentech: Consultancy; Sanofi: Consultancy; Genentech: Consultancy. Manasanch:Adaptive Biotechnologies: Honoraria; Glaxo Smith Kline: Honoraria; BMS: Honoraria; Takeda: Honoraria; Quest Diagnostics: Research Funding; Merck: Research Funding; JW Pharma: Research Funding; Novartis: Research Funding; Sanofi: Honoraria, Research Funding. Patel:Nektar: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; Precision Biosciences: Research Funding; Celgene: Consultancy, Research Funding; Cellectis: Research Funding; Poseida: Research Funding; Oncopeptides: Consultancy. Orlowski:Founder of Asylia Therapeutics, Inc., with associated patents and an equity interest, though this technology does not bear on the current submission.: Current equity holder in private company, Patents & Royalties; Laboratory research funding from BioTheryX, and clinical research funding from CARsgen Therapeutics, Celgene, Exelixis, Janssen Biotech, Sanofi-Aventis, Takeda Pharmaceuticals North America, Inc.: Research Funding; STATinMED Research: Consultancy; Sanofi-Aventis, Servier, Takeda Pharmaceuticals North America, Inc.: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen, Inc., AstraZeneca, BMS, Celgene, EcoR1 Capital LLC, Forma Therapeutics, Genzyme, GSK Biologicals, Ionis Pharmaceuticals, Inc., Janssen Biotech, Juno Therapeutics, Kite Pharma, Legend Biotech USA, Molecular Partners, Regeneron Pharmaceuticals, Inc.,: Honoraria, Membership on an entity's Board of Directors or advisory committees. Neelapu:Takeda Pharmaceuticals: Patents & Royalties; Bristol-Myers Squibb: Other: personal fees, Research Funding; Merck: Other: personal fees, Research Funding; Kite, a Gilead Company: Other: personal fees, Research Funding; N/A: Other; Acerta: Research Funding; Karus Therapeutics: Research Funding; Cellectis: Research Funding; Poseida: Research Funding; Unum Therapeutics: Other, Research Funding; Calibr: Other; Adicet Bio: Other; Legend Biotech: Other; Allogene Therapeutics: Other: personal fees, Research Funding; Cell Medica/Kuur: Other: personal fees; Incyte: Other: personal fees; Precision Biosciences: Other: personal fees, Research Funding; Celgene: Other: personal fees, Research Funding; Novartis: Other: personal fees; Pfizer: Other: personal fees. Kwak:CJ Healthcare: Consultancy; Sellas Life Sciences Grp: Consultancy; Enzychem Life Sciences: Membership on an entity's Board of Directors or advisory committees; Antigenics: Other: equity; InnoLifes, Inc: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pepromene Bio: Consultancy, Membership on an entity's Board of Directors or advisory committees; Xeme Biopharma/Theratest: Other: equity; Celltrion Healthcare: Membership on an entity's Board of Directors or advisory committees; Celltrion, Inc.: Consultancy. OffLabel Disclosure: This study aims to use a novel idiotype DNA vaccine to lengthen the smoldering phase of WM without inducing cross-resistance to available therapies.

OBJECTIVE Given temporal changes in diabetes prevalence and stroke incidence, this study investigated age, race, and sex differences in the diabetes–stroke association in a contemporary prospective cohort, the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. RESEARCH DESIGN AND METHODS We included 23,002 non-Hispanic black and white U.S. adults aged ≥45 years without prevalent stroke at baseline (2003–2007). Diabetes was defined as fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or use of glucose-lowering medication. Incident stroke events were expert adjudicated and available through September 2017. RESULTS The prevalence of diabetes was 19.1% at baseline. During follow-up, 1,018 stroke events occurred. Among adults aged CONCLUSIONS In this contemporary cohort, the diabetes–stroke association varied by age, race, and sex together, with a more pronounced effect observed among adults aged

Introduction: The standard reperfusion target for thrombectomy trials has been modified TICI (mTICI) 2b-3 (≥50% ischemic territory). Recently, full reperfusion (mTICI 2c-3) has been recommended as the ideal target. The potential added benefits of additional procedural maneuvers must be balanced against their risks, particularly when dealing with residual distal occlusions often found in mTICI 2b. It remains unknown whether more precise categorization of the mTICI2b strata leads to more reasonable treatment targets. Methods: Retrospective analysis of prospectively collected thrombectomy data spanning Jun 2011-Feb 2018. Inclusion criteria: MCA and intracranial internal carotid artery occlusions. Definitions of reperfusion: mTICI0-1: no or limiteddistal filling; mTICI2a: Results: Of 557 patients, 2.2% had mTICI0-1, 3.6% had mTICI2a, 5.9% had mTICI2b-, 30.2% mTICI2b+, and 58.2% mTICI3. The usage of intravenous tPA was lower in the mTICI2b- vs. mTICI3 (18% vs. 41%;pFigure ). Mortality rates were comparable across the mTICI2b-, mTICI 2b+, and mTICI 3 groups but higher with mTICI2a (40%;p=0.01) and mTICI0-1 (50%;p Conclusion: There is broad variation in outcomes across the different degrees of reperfusion within the mTICI 2b grade. A reperfusion target of 75%-99% (mTICI2b+) may lead comparable rates of independence versus full reperfusion.

Purpose: Carotid web (CaW) is an underrecognized cause of cryptogenic stroke in young patients. The optimal imaging for CaW is unknown. We aim to evaluate the diagnostic accuracy of diverse imaging modalities for the diagnosis of CaW.Methods: Retrospective analysis of institutional neurovascular database was performed to identify patients with multimodal (CT angiogram–CTA, digital subtraction angiogram–DSA, and/or ultrasound–US) imaging diagnosis of CaW or atherosclerosis. Baseline clinical demographics were recorded. Blinded image analysis was performed for each imaging modality by separate readers. Discrepancies were settled by consensus. Two-sided Cohen's Kappa (κ) coefficient was used to evaluate the inter-rater agreement for the etiological diagnosis between imaging modalities.Results: Thirty patients/60 carotids were evaluated by CTA and 55 carotids were included. Patients with symptomatic CaW (n = 20), compared to individuals with atherosclerosis (n = 10), were younger (49 ± 9 vs. 60 ± 8 years; p < 0.01), more commonly female (75% vs. 30%; p = 0.01), and less frequently presented vascular risk factors: Hypertension (40% vs. 100%; p < 0.01), hyperlipidemia (0% vs. 50%; p < 0.01), diabetes (10% vs. 40%; p = 0.05), and smoking (5% vs. 70%; p < 0.01). High inter-rater correlation strength existed for CTA (n = 55; κ = 0.88; p < 0.0001) and DSA (n = 28; κ = 0.86, p < 0.0001) readers for lesion diagnosis while US inter-rater agreement was lower (κ = 0.553; p = 0.001). Across modalities CTA and DSA shared very high strength of agreement (κ = 0.92; p < 0.0001), compared to a less pronounced agreement between US and CTA (κ = 0.553; p = 0.001). The strength of correlation between DSA-CTA was significantly more robust as compared to US-CTA (Z = 3.58; p = 0.0003).Conclusion: CTA and DSA demonstrated comparable and superior performance as compared to US in the diagnosis of CaW.

Background Flavonoids may have beneficial cerebrovascular effects, but evidence from racially and geographically representative cohorts in comprehensive flavonoid databases is lacking. Given racial and geographic disparities in stroke incidence, representative cohort studies are needed. Objectives We evaluated the association between flavonoid intake and incident ischemic stroke in a biracial, national cohort using updated flavonoid composition tables and assessed differences in flavonoid intake by sex, race, and region of residence. Methods We evaluated 20,024 participants in the REGARDS (REasons for Geographic and Racial Differences in Stroke) study, a biracial prospective study. Participants with stroke history or missing dietary data were excluded. Flavonoid intake was estimated by using a Block98 food frequency questionnaire and the USDA's Provisional Flavonoid Addendum and Proanthocyanidin Database. Associations between quintiles of flavonoid intake and incident ischemic stroke were evaluated by using Cox proportional hazards models, adjusting for confounders. Results Over 6.5 y, 524 acute ischemic strokes occurred. Flavanone intake was lower in the Southeastern United States but higher in blacks than in whites. After multivariable adjustment, flavanone intake was inversely associated with incident ischemic stroke (HR: 0.72; 95% CI: 0.55, 0.95; P-trend = 0.03). Consumption of citrus fruits and juices was inversely associated with incident ischemic stroke (HR: 0.69; 95% CI: 0.53, 0.91; P-trend = 0.02). Total flavonoids and other flavonoid subclasses were not associated with incident ischemic stroke. There was no statistical interaction with sex, race, or region for any flavonoid measure. Conclusions Greater consumption of flavanones, but not total or other flavonoid subclasses, was inversely associated with incident ischemic stroke. Associations did not differ by sex, race, or region for the association; however, regional differences in flavanone intake may contribute to regional disparities in ischemic stroke incidence. Higher flavanone intake in blacks suggests that flavanone intake is not implicated in racial disparities in ischemic stroke incidence.

IntroductionThe minimal stroke severity justifying endovascular intervention remains elusive; however, a significant proportion of patients presenting with large vessel occlusion (LVO) and mild symptoms subsequently decline and face poor outcomes.ObjectiveTo evaluate our experience with these patients by comparing best medical therapy with thrombectomy in an intention-to-treat analysis.MethodsAnalysis of prospectively collected data of all consecutive patients with National Institutes of Health Stroke Scale (NIHSS) score ≤5, LVO on CT angiography, and baseline modified Rankin Scale (mRS) score 0–2 from November 2014 to May 2016. After careful discussion with patients/family, a decision to pursue medical or interventional therapy was made. Deterioration (development of aphasia, neglect, and/or significant weakness) triggered reconsideration of thrombectomy. The primary outcome measure was NIHSS shift (discharge NIHSS score minus admission NIHSS score).ResultsOf the 32 patients qualifying for the study, 22 (69%) were primarily treated with medical therapy and 10 (31%) intervention. Baseline characteristics were comparable. Nine (41%) medically treated patients had subsequent deterioration requiring thrombectomy. Median time from arrival to deterioration was 5.2 hours (2.0–25.0). Successful reperfusion (modified Treatment in Cerebral Infarction 2b−3) was achieved in all 19 thrombectomy patients. The NIHSS shift significantly favored thrombectomy (−2.5 vs 0; pConclusionsThrombectomy led to a shift towards a lower NIHSS in patients with LVO presenting with minimal stroke symptoms. Despite the overall perception that this condition is benign, nearly a quarter of patients primarily treated with medical therapy did not achieve independence at 90 days.

Background and Purpose— Intravenous tissue-type plasminogen activator (tPA) treatment in acute stroke has many exclusion criteria. We aimed to assess the safety and efficacy of endovascular therapy (ET) in intravenous (IV) tPA-ineligible patients. Methods— Retrospective analysis of a prospectively collected database of consecutive patients treated with ET within 6 hours of stroke onset between September 2010 and April 2015. Patients treated with IV-tPA followed by ET were compared with those treated with ET alone because of IV-tPA ineligibility. Efficacy and safety end points included the rates of good outcome (90-day modified Rankin scale score ≤2), successful reperfusion (modified Treatment in Cerebral Ischemia 2b-3), parenchymal hematoma (PH-1 and PH-2), and 90-day mortality. Univariate and logistic regression were performed to identify the predictors of outcomes. Results— A total of 422 patients were included. Two hundred and fifty-three (59%) patients received IV-tPA+ET, and 169 (41%), ET alone. Combined IV-tPA+ET patients were slightly younger (64.9±15.2 versus 67.9±14.9 years; P =0.05), more often males (56% versus 44%; P =0.01), and had less hypertension (70% versus 81%; P =0.02) and vertebrobasilar occlusions (3% versus 8%; P =0.02). The remaining baseline characteristics, including National Institutes of Health Stroke Scale score (20 [15–23] versus 19 [15–24]; P =0.85), Alberta Stroke Program Early CT Score (ASPECTS; 8 [7–9] versus 8 [7–9]; P =0.24), and stroke onset to puncture times (235±70 versus 240±81 minutes; P =0.27), were similar across both groups. There were no significant differences in the rates of modified Treatment in Cerebral Ischemia 2b-3 (83% versus 80%; P =0.52), 90-day modified Rankin scale score ≤2 (45% versus 38%; P =0.21), or any PH (3% versus 5%; P =0.21). Unadjusted 90-day mortality was higher with ET alone (21% versus 34%; P Conclusions— IV-tPA-eligible and -ineligible patients seem to have similar outcomes after early ET.

Background and Purpose: Craniocervical fibromuscular dysplasia (FMD) is associated with dissections and with S-shaped curves in the internal carotid artery (ICA). We evaluated the occurrence of S-curves in patients presenting with acute strokes due to ICA steno-occlusive dissections. Methods: This was a retrospective review of the interventional databases of two academic tertiary-care institutions. The presence of ICA S-shaped curves, C-shaped curves, 360-degree loops, as well as classic FMD and atherosclerotic changes at the ICA bulb and curve/loop was determined. Cases of carotid dissections were compared with a control group (consecutive non-tandem anterior circulation strokes). Results: Twenty-four patients with carotid dissections were compared to 92 controls. Baseline characteristics and procedural variables were similar, with the exception of younger age, less frequent history of hypertension, diabetes, atrial fibrillation and stent retriever use in patients with dissections. The rates of mTICI2b-3 reperfusion, parenchymal hematoma, good outcome and mortality were similar amongst groups. The frequency of S-curves (any side without superimposed atherosclerosis) was 29% in the dissection group versus 7% in controls (p < 0.01). S-curves were typically mirror images within the dissection group (85% had bilateral occurrence). The frequency of C-shaped and 360-degree curves was similar between groups. FMD changes within the craniocervical arteries were statistically more common in dissection patients. Ten patients (41%) of the dissection group had S-curves or classic FMD changes. Multivariate analysis indicated that S-curves were independently associated with the presence of dissections. Conclusion: S-shaped ICA curves are predictably bilateral, highly associated with carotid dissections in patients with moderate to severe strokes, and may suggest an underlying presence of FMD.

Purpose Carotid web is an intimal variant of fibromuscular dysplasia that has been associated with recurrent ischemic strokes in the young. The accuracy of different diagnostic tests is unknown. The objective of the present study is to evaluate the diagnostic performance of different imaging modalities for the detection of carotid webs. Methods Using an institutional neurovascular database, we retrospectively identified consecutive patients diagnosed with carotid web and internal carotid artery atherosclerosis. Multimodality imaging including at minimum neck CT angiography (CTA) at baseline plus either Digital Subtraction Angiography (DSA) and/or carotid Ultrasound (US) was mandatory. CTA images were evaluated by two readers (neurointerventionist#1 and diagnostic neuroradiologist) in a consensus read for confirmation of diagnosis, and degree of stenosis based on NASCET criteria. DSA studies were evaluated by two blinded readers (neurointerventionists #2 and #3) to categorize the presence or absence of carotid web or atherosclerotic plaque in individual carotid arteries. US studies were evaluated by two blinded readers (two neurosonology-credentialed stroke neurologists) to characterize diagnosis (carotid web vs atherosclerosis vs normal), degree of certainty, and the degree of stenosis. In the setting of discrepancies, consensus read was obtained. The performance of DSA and of US was compared to CTA. Results Median age of the cohort was 57 years (IQR 46–61 years) with 36.4% (12/33) male gender. Overall comorbidities included 60.6% (20/33) hypertension, 33.3% (11/33) hyperlipidemia, 21.2% (7/33) diabetes mellitus, and 27.3% (9/33) smoking. Multimodal imaging was available for 33 carotid arteries. Twenty-eight carotids had CTA and DSA available for review. DSA readers identified correctly all normal vessels, but diagnosed carotid webs less frequently (43%, 12/28; DSA group vs 50%, 14/28; CTA group) and atherosclerosis more frequently (43%, 12/28; DSA group vs 36%, 10/28; CTA group) when compared to CTA. Inter-rater correlation for the two DSA readers (κ=0.86, p Conclusion CTA and DSA should be preferred imaging modalities to diagnose and characterize carotid webs. Disclosures T. Madaelil: None. R. Nogueira: None. J. Grossberg: None. A. Anderson: None. C. Barreira: None. D. Haussen: None.

Background: Hyperglycemia on admission is known to be associated with poor outcome after intravenous or intra-arterial thrombolysis treatment in patient with acute ischemic stroke. However, its effect on mechanical thrombectomy outcomes remains elusive. We investigated whether clinical and procedural outcomes differ between normoglycemic and hyperglycemic patients with large vessel occlusion stroke after endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between 9/2010-12/2016. Hyperglycemia was defined as admission serum glucose >140mg/dl. All patients that underwent ET for anterior circulation large vessel occlusion acute ischemic stroke were included and categorized into two groups according to their glycemic status. Baseline and procedural characteristics, as well as outcome parameters were compared. Results: A total of 931 patients qualified for the study of which 289 (31%) had hyperglycemia on admission. Those with hyperglycemia were older (p=0.001), had more comorbidities and more severe strokes as assessed by the NIHSS (19[15-23] vs 17[13-21], p=0.01). In univariate analysis, Hyperglycemic patients had lower rates of successful reperfusion (mTICI2b-3, 85.4% vs 90.6%,, p=0.02) and 90-day good outcomes (mRS 0-2, 32.7% vs 52.3%, p Conclusions: Our study confirms that hyperglycemia is associated with poorer procedural and clinical outcomes in patients undergoing mechanical thrombectomy for large vessel occlusion strokes.

Background: The impact of oversized stent-retrievers in reperfusion rates during thrombectomy is unclear. Devices matching the vessel diameter may lead to proportionally larger cells and facilitate device-clot integration. We aim to evaluate if the device diameter may impact reperfusion rates in stroke thrombectomy. Methods: This is a retrospective analysis of a prospectively collected database from a single comprehensive stroke center. We included patients with intracranial carotid occlusions in which stent-retrievers (Trevo or Solitaire devices) were used as the first strategy, from September 2010-March 2017, and compared the 4mm vs 6mm diameter groups. 3mm devices and other retriever-like devices were excluded. Primary outcome was first pass reperfusion (modified TICI2b-3 with the first device pass). Results: Of the 1204 thrombectomies performed within the study period, 150 met inclusion criteria (Trevo: 64/Solitaire: 86/6mm device:67 /4mm: 83). Age, gender, comorbidities and the use of IV tPA were comparable between groups. NIHSS was similar between the 4mm vs 6mm devices (19[14-22] vs 18.5[14-22];p=0.64), as well as time from last normal to puncture (403[260-626] minutes vs 344 [209-816];p=0.54), and ASPECTS (7[6-9] vs 8[7-9];p=0.25), respectively. Patients with 4mm devices had less tandem disease (11% vs 28%,p=0.01). The use of local aspiration was similar between groups (7vs9%p=0.76) for the 4mm and 6mm devices. First-pass mTICI2b-3/mTICI3 reperfusion was achieved in similar proportion between the 4mm vs 6mm groups: 52%vs.56%;p=0.62 / 32%vs22%;p=0.20, respectively. Parenchymal hematomas (16% vs 9%;p=0.22) and subarachnoid hemorrhage (5% vs 7%;p=0.74) were similar between the 4mm and 6mm arms. Independent outcome at 3months was more common in the 4mm vs 6mm groups (28%vs50%;p=0.03). Multivariable analysis indicated mRS0-2 at 90-days independently associated with first-pass reperfusion and demonstrated no impact of device diameter on first-pass reperfusion. Conclusions: The use of 6mm stent retrievers for intracranial carotid occlusions had demonstrated benefit over 4mm devices for chances of first pass reperfusion.

Background and Purpose: Smoking is a well-established risk factor for stroke. However, several studies have shown that smokers with stroke have better outcomes after thrombolysis, a phenomenon commonly known as the smoking-thrombolysis paradox. We investigated whether clinical and procedural outcomes differ between smokers and non-smokers with large vessel occlusion stroke after endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients that underwent endovascular therapy for anterior circulation large vessel occlusion acute ischemic stroke were included and categorized into two groups: (1) current smokers and (2) non-smokers. The 2 groups were then matched for age, baseline NIHSS and glucose levels using a weighted Euclidian distance method. Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results: A total of 326 (163 matched pairs) qualified for the study. Smokers had higher rates of dyslipidemia (48.5% vs 28.8%, p Conclusion: Our data shows that smoking is not associated with outcomes in patients with large vessel occlusion stroke treated with mechanical thrombectomy.

Background: Little is known on the outcomes of nonagenarians treated with endovascular therapy for acute large vessel occlusion stroke. It is unclear whether they have worse clinical outcomes than octogenarians. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients older than 80 years that underwent endovascular therapy for large vessel occlusion acute ischemic stroke were included and categorized into two groups: 80-89 years (octogenarians), and 90-99 years (nonagenarians). Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results: Thirty-one nonagenarians and 181 octogenarians were treated over the 6-year study period. When compared with octogenarians, nonagenarians had lower glucose levels (121±26 vs 138±46, p Conclusions: Our study shows that there is no significant difference in procedural and clinical outcomes between nonagenarians and octogenarians treated with endovascular therapy. Baseline stroke severity and successful reperfusion are the main drivers of favorable functional outcome in patients ≥80years old.

To determine the impact of different aortic clamping strategies on the incidence of cerebral embolic events during coronary artery bypass grafting (CABG).Between 2012 and 2015, 142 patients with low-grade aortic disease (epiaortic ultrasound grade I/II) undergoing primary isolated CABG were studied. Those undergoing off-pump CABG were randomized to a partial clamp (n = 36) or clampless facilitating device (CFD; n = 36) strategy. Those undergoing on-pump CABG were randomized to a single-clamp (n = 34) or double-clamp (n = 36) strategy. Transcranial Doppler ultrasonography (TCD) was performed to identify high-intensity transient signals (HITS) in the middle cerebral arteries during periods of aortic manipulation. Neurocognitive testing was performed at baseline and 30-days postoperatively. The primary endpoint was total number of HITS detected by TCD. Groups were compared using the Mann-Whitney U test.In the off-pump group, the median number of total HITS were higher in the CFD subgroup (30.0; interquartile range [IQR], 22-43) compared with the partial clamp subgroup (7.0; IQR, 0-16; P .0001). In the CFD subgroup, the median number of total HITS was significantly lower for patients with 1 CFD compared with patients with1 CFD (12.5 [IQR, 4-19] vs 36.0 [IQR, 25-47]; P = .001). In the on-pump group, the median number of total HITS was 10.0 (IQR, 3-17) in the single-clamp group, compared with 16.0 (IQR, 4-49) in the double-clamp group (P = .10). There were no differences in neurocognitive outcomes across the groups.For patients with low-grade aortic disease, the use of CFDs was associated with an increased rate of cerebral embolic events compared with partial clamping during off-pump CABG. A single-clamp strategy during on-pump CABG did not significantly reduce embolic events compared with a double-clamp strategy.

Background and Purpose: The objective of our study was to evaluate magnetic resonance imaging (MRI) and echocardiographic characteristics that would identify patients with cryptogenic ischemic stroke (IS) and transient ischemic attack (TIA) who subsequently developed paroxysmal atrial fibrillation (PAF) on mobile cardiac outpatient telemetry (MCOT). Methods: All patients with cryptogenic IS or TIA seen at the Emory University Hospital and Emory University Hospital Midtown from January 1, 2009, to June 30, 2013, who underwent MCOT were included in this analysis. Location (cortical, high subcortical, or neither) of current and prior strokes on MRI and left atrial (LA) functional and anatomical echocardiographic parameters were evaluated to determine their association with subsequent detection of PAF. Results: Of 132 patients, 17 (13%) had evidence of newly diagnosed PAF on MCOT (mean duration of monitoring = 25 days). The presence (vs absence) of ≥1 cortical infarct on baseline MRI was a significant predictor of identifying PAF (odds ratio: 5.2, 95% confidence interval: 1.3-19; P = .01). On baseline echocardiography, patients who had PAF (vs non-PAF) had significantly higher mean LA diameters (4.2 vs 3.7 cm, P = .03) and lower tissue Doppler velocity (a’; 5.5 vs 13.5 cm/s, P = .03). In receiver operating characteristic analysis, the ratio of LA volume index to the septal Doppler velocity (LAVI/a’) of >4.6 was associated with a higher likelihood of PAF. Combining MRI with echocardiographic variables did not improve the predictive ability beyond echocardiography alone. Conclusion: Although the presence of cortical-based infarcts on MRI in patients with cryptogenic IS or TIA increases the likelihood of detecting PAF on MCOT, LA functional and anatomic parameters alone best predicted which patients subsequently had PAF.

Background: The ethnic disparities in stroke outcomes have been well described. Stroke is twice more common and leads to higher mortality rates among blacks as compared to whites. We compared the outcomes of patients undergoing endovascular stroke therapy (ET) in a high-volume center according to their racial profile after age adjustment. Methods: Retrospective analysis of a prospectively collected ET database between September/2010-September/2015. The baseline characteristics of African-American vs. Caucasian patients were compared. Given the impact of age on stroke outcomes additional analyses were performed dichotomizing patients using the median age of the overall cohort. Primary and secondary efficacy outcomes included the rates of good outcome (90-day mRS 0-2) and successful reperfusion (mTICI 2b-3), respectively. Safety outcome was accessed by rates of any parenchymal hematoma (PH-1 and PH-2) and 90-day mortality. Results: 781 patients fit the inclusion criteria and were included in the analysis; 440 were included in the Caucasian group (56% overall cohort) and 341 in the African-American group (44%). Caucasian patients were significantly older (69±13 vs. 60±14 years-old, p Conclusion: Aggressive treatment of acute ischemic stroke with endovascular therapy leads to similar outcomes across African-American and Caucasian patients. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.

Background: The minimal stroke severity justifying endovascular intervention remains elusive; however, a significant proportion of patients presenting with large vessel occlusions and mild symptoms subsequently decline and have poor outcomes. We evaluated clinical outcomes of patients presenting with mild symptoms (NIHSS≤8) undergoing endovascular therapy. Methods: Retrospective analysis of a prospectively collected ET database between September/2010-March/2016. Patients with mild symptoms (baseline NIHSS≤8) were included in the analysis. Primary and secondary efficacy outcomes were defined as the rates of good outcome (90-day mRS 0-2) and successful reperfusion (mTICI 2b-3), respectively. Safety outcome was accessed by rates of any parenchymal hematoma (PH-1 and PH-2) and 90-day mortality. Results: 72 patients with baseline NIHSS≤8 we included in the analysis. Mean age in the overall cohort was 63.3 years (range, 56-69) and 39 patients were men (54%). The mean baseline NIHSS, CTP core volumes, and ASPECTS were 6.3±1.5, 7.5±16.1cc, and 8.5±1.3 respectively. A total of 28 patients (38%) received intravenous tPA. The occlusions were located as follows: proximal MCA-M1 in 29 (40%), MCA-M2 in 20 (27%), ICA terminus in 6 (8%) and vertebrobasilar in 9 patients (12%). Tandem occlusion was documented in 7 patients (9%). Successful reperfusion (TICI 2b-3) was achieved in 67 patients (93%) and 90-day good outcome in 52 (72%). The mean final infarct volume was 32.2±59.9 cc. Any parenchymal hematoma occurred in 4 patients (5%). The 90-day mortality was 9% (n=7). Logistic regression showed that only successful reperfusion (OR 27.7; 95%CI [1.1-655.5]; p=0.04) was an independent predictor of good outcomes. Conclusion: Our findings demonstrate a good safety profile for endovascular therapy in patients presenting with low NIHSS and proximal arterial occlusions. Future prospective controlled studies are warranted.

Background and Purpose: The smoking-thrombolysis paradox has been well described in myocardial infarction. However, its existence in the stroke population remains elusive. In the past decade, several studies have investigated the phenomenon with mixed results. We sought to determine whether clinical outcomes differ between smokers and non-smokers with acute ischemic stroke undergoing endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients who underwent endovascular therapy for acute large vessel occlusion acute ischemic stroke were categorized into current smokers and non-smokers. Baseline characteristics, procedural radiological as well as outcome parameters where compared. Results: A total of 968 patients qualified for the study of which 189 (19.5%) were current smokers. Smokers were younger (60.78±11.95 vs. 66.41±15.05 years, p Conclusion: In stroke patients treated with mechanical thrombectomy, smoking does not seem to be associated with outcomes regardless of stroke subtype or location.

Background: The role of anticoagulation in patients with embolic strokes of unknown source (ESUS) remains controversial. Left atrial (LA) structural and functional parameters on transthoracic echocardiography (TTE) may predict ESUS patients who are likely to develop subsequent paroxysmal atrial fibrillation (PAF). Hypothesis: LA parameters in ESUS patients will be similar to cardioembolic (CE) stroke patients and different from patients with strokes due to other determined cause (ODC). Methods: Patients admitted to a stroke center from June 1 to November 30, 2015 with acute ischemic stroke were included in this analysis. Baseline characteristics and results of inpatient diagnostic workup including neuroimaging, echocardiography, and cardiac telemetry were reviewed retrospectively to classify patients into three subtypes: CE, ODC or ESUS. LA diameter, LA volume index (LAVI), mitral valve early (MV E) and late filling peak (MV Peak A) velocities were compared between the 3 subtypes. Results: Of 131 patients (mean age 67 ± 16, 47% female, 45% white), 35 (27%) were classified as CE, 62 (47%) ODC and 34 (26%) ESUS. Baseline characteristics were similar between groups except that ODC patients were less likely to be female than CE and ESUS patients (p=0.05). LAVI, MV E and MV Peak A were all significantly different in CE compared with ODC and ESUS patients (p Conclusions: LA structural and functional parameters among CE patients in our cohort were significantly different from those of ESUS and ODC patients, suggesting that ESUS patients may have lower risk of AF (and therefore lower likelihood of benefit from preemptive anticoagulation). Our study suggests that ESUS patients may benefit from long-term cardiac monitoring prior to initiation of anticoagulation therapy.

Background: Consequences of stroke can be devastating and long-term, impacting physical and mental functioning, quality of life, and other activities of daily living. Based on fear appeal research, perceived harm from having a stroke can be used to motivate people to engage in self-protective behaviors. Methods: REGARDS is a national, population-based, longitudinal study of 30,239 blacks and whites ≥ 45 years. The study used a centralized telephone interview and an in-home evaluation for baseline risk assessment with telephone follow-up every six months. Ten years after enrollment, participants underwent a 2 nd risk factor assessment. As part of a Risk Behavior Diagnosis Scale, participants were asked their level of agreement with the statement “I believe that stroke is extremely harmful.” Data from the 10-year assessment were available on 15,312 participants. Logistic regression was used to examine the association of agreement with the statement by demographics, region, socioeconomic (SES) factors, previous stroke and hypertension. Results: Almost 500 (3%; 446/15,312) participants did not agree with the statement that stroke is extremely harmful. In the multivariable model (see table), the odds of blacks agreeing that stroke was harmful was only one-third that of whites. Older participants, those with previous stroke, and those with lower income or education were also much less likely to agree stroke was harmful. There was no significant association by sex, region, or hypertension. Conclusions: Despite public health campaigns and active participation in a long term observational study of stroke risk factors, the harmful repercussions from stroke are not perceived similarly for blacks and whites, across SES and age groups, and even in persons who have experienced a stroke compared to those who have not. Fear-based messaging intended to motivate stroke prevention behaviors may not be as effective in these subgroups.

Background and Purpose— Sulcal effacement with preserved underlying gray–white matter junction (isolated sulcal effacement [ISE]) in acute ischemic stroke may not represent irreversible parenchymal injury. We aimed to evaluate the frequency and significance of ISE in patients with large vessel occlusion acute ischemic stroke. Methods— Consecutive acute ischemic stroke patients with middle cerebral artery M1 or internal carotid artery terminus occlusions who underwent computed tomography angiogram/perfusion followed by intra-arterial therapy were screened for ISE. Results— Out of the 568 patients who underwent intra-arterial therapy between March 2011 and September 2014, 108 fulfilled inclusion criteria. ISE was present in 8 (7.4%) patients (age 55.7±10.5 years, 6 female, baseline National Institutes of Health Stroke Scale 16.1±3.8, 5 middle cerebral artery-M1, and 3 internal carotid artery terminus occlusions). Computed tomography angiogram revealed engorged/dilated leptomeningeal vessels obliterating the sulci within the areas of effacement, whereas computed tomography perfusion indicated normal-to-increased cerebral blood volume and prolonged T max in all patients. Modified treatment in cerebral ischemia (mTICI) 2b-3 reperfusion was achieved in all patients. Follow-up imaging confirmed no infarct in the ISE area in all patients, and 5 (62%) had modified Rankin Scale 0 to 2 at 3 months. Conclusions— Sulcal effacement with preserved gray–white delineation is occasionally visualized in patients with proximal occlusion strokes, relates to robust leptomeningeal collaterals, and indicates preserved underlying parenchyma. ISE should not be used to exclude patients from thrombectomy.

Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P 7: 50% versus 76%; P P =0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P =0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

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: Treatment with IV tPA in acute stroke has restricted applicability due to its many contraindications. Indeed, the recent AHA guidelines provide only limited support to endovascular therapy (ET) in non IV-tPA patients as only few of these patients were included in the recent randomized ET trials. Our study aims to access the safety and efficacy of ET within 6 hours of stroke onset in patients ineligible to IV-tPA. Methods: Retrospective analysis of a prospectively collected ET database between September/2010-April/2015 for patients presenting within 6 hours of symptom onset. Patients who underwent ET alone due to IV-tPA ineligibility were compared to those who underwent IV-tPA + ET. Primary and secondary efficacy outcome included the rates of good outcome (90-day mRS 0-2) and successful reperfusion (mTICI 2b-3), respectively. Safety outcome was accessed by rates of any parenchymal hematoma (PH-1 and PH-2) and 90-day mortality. Results: 422 patients were included in the analysis, 253 received combined IV-tPA + ET (59% overall cohort) and 169 were treated with ET alone (41%). Patients in the ET alone group were slightly older (65±16 vs. 68±15 years-old, p=0.05) and more frequently had basilar occlusions (3% vs. 8%, p=0.02) but the remaining baseline characteristics were otherwise well balanced including NIHSS (19±5 vs. 18±6, p=0.85), ASPECTS (7.7±1.6 vs. 7.9±1.5, p=0.24), time stroke onset to puncture (235±70 vs. 240±81 min, p=0.27), and glucose levels (135±50 vs. 143±60 mg/dL, p=0.13). There were no differences in the rates of 90-day mRS≤2 (45% vs. 38%, p=0.21), mTICI 2b-3 (83% vs. 80%, p=0.52), or any PH (3% vs. 5%, p=0.21) across the combined therapy and ET alone groups. The 90-day mortality was higher in patients in the ET alone (e.g. IV t-PA ineligible) patients (21% vs. 34%, p Conclusion: Our data supports aggressive treatment with ET in IV tPA ineligible patients within 6 hours of stroke onset as these patients appear to have similar outcomes to IV tPA eligible patients and are known to have a poor natural history in the absence of reperfusion.

Introduction and Objectives: The best imaging method for selecting patients for thrombectomy remains unknown. We aim to evaluate the correlation between ASPECTS and RAPID automated CT perfusion (CTP) ischemic core volumes. Methods: This was a retrospective review of a prospectively collected interventional database. We included patients from January 2011-February 2015 with MCA-M1, MCA-M2 or ICA-terminus occlusions that underwent good quality RAPID CTP. The correlation between ASPECTS and CTP-derived ischemic core volumes (CBF Results: A total of 188 were included. Mean age was 62.4±14.8, 51% were males, 71% had hypertension, 34% dyslipidemia, 33% atrial fibrillation, 21% diabetes, and 37% received IV-tPA. Mean baseline NIHSS was 17.1±5.4 and ASPECTS 7.7±1.5. Time from last-known-normal to groin puncture was 6.9±4.3 hours. Sixty-one percent had MCA-M1, 21% MCA-M2, and 18% ICA-terminus occlusions. Seventy-two percent were treated with stent-retrievers, leading to 82% mTICI 2b-3 reperfusion, 9% parenchymal hemorrhages, 54% mRS0-2 and 11% mortality at 90 days. The correlation between ASPECTS and CTP-derived ischemic core was weak (rho 0.27; p Conclusion: There is wide variability of CTP-derived ischemic core volumes within specific ASPECTS. Patient selection may significantly be affected by the imaging selection method.

Technological advances have helped to improve the efficiency of treating patients with large vessel occlusion in acute ischemic stroke. Unfortunately, the sequence of events prior to reperfusion may lead to significant treatment delays. This study sought to determine if high-volume (HV) centers were efficient at delivery of endovascular treatment approaches.A retrospective review was performed of nine centers to assess a series of time points from obtaining a CT scan to the end of the endovascular procedure. Demographic, radiographic and angiographic variables were assessed by multivariate analysis to determine if HV centers were more efficient at delivery of care.A total of 442 consecutive patients of mean age 66 ± 14 years and median NIH Stroke Scale score of 18 were studied. HV centers were more likely to treat patients after intravenous administration of tissue plasminogen activator and those transferred from outside hospitals. After adjusting for appropriate variables, HV centers had significantly lower times from CT acquisition to groin puncture (OR 0.991, 95% CI 0.989 to 0.997, p=0.001) and total procedure times (OR 0.991, 95% CI 0.986 to 0.996, p=0.001). Additionally, patients treated at HV centers were more likely to have a good clinical outcome (OR 1.86, 95% CI 1.11 to 3.10, p0.018) and successful reperfusion (OR 1.82, 95% CI 1.16 to 2.86, p0.008).Significant delays occur in treating patients with endovascular therapy in acute ischemic stroke, offering opportunities for improvements in systems of care. Ongoing prospective clinical trials can help to assess if HV centers are achieving better clinical outcomes and higher reperfusion rates.

Background and Purpose— Intra-arterial (IA) rescue procedures are increasingly used to treat acute ischemic stroke. We implemented continuous transcranial Doppler (TCD) monitoring during these procedures to detect any potentially harmful flow changes. Here, we report diagnostic criteria and yield of TCD monitoring. Methods— We studied consecutive acute stroke patients who underwent IA reperfusion procedures. TCD flow signatures during these procedures were analyzed and any abnormal findings were documented. Results— Patients were included only if there was successful insonation through the skull; of 56 eligible patients, 51 were included. IA procedures included IA tissue plasminogen activator, use of the Merci retriever, the Penumbra system, balloon angioplasty, and stenting. On TCD monitoring, contrast injections produced high-intensity signals and increased the mean flow velocity (MFV). Deployment of the Merci device appeared as high-intensity, short-duration signals with a transient MFV decrease of 11.5%. The Penumbra system produced lower-intensity signals with a greater transient decrease in MFV during aspiration. IA tissue plasminogen activator significantly increased MFV by 7.5% over Merci and Penumbra flow velocity changes. Power motion Doppler–TCD detected reocclusion in 13 patients, artery-to-artery embolization in 2 patients, air embolism in 2 patients, and hyperperfusion in 6 patients. Overall, the yield of TCD monitoring was positive in 23 (49%) patients who received IA reperfusion procedures. Conclusions— Our velocity, intensity, and flow signatures criteria for TCD monitoring of IA reperfusion procedures detect reocclusion, hyperperfusion, or thromboembolism and air embolism in nearly half of all procedures. This hemodynamic information can be particularly helpful when neurological assessment is limited or delayed.

Introduction: Intra-arterial therapy (IAT) for large vessel occlusion strokes (LVOS) has been increasingly utilized. The benefit of IAT in patients with midrange Alberta Stroke Program Early Computed Tomography Score (ASPECTS) remains to be established. Materials and Methods: This was a retrospective analysis of LVOS with ASPECTS 5-7 treated with IAT (n = 86) or medical therapy alone (intravenous tissue plasminogen activator; n = 15) at two centers from 2009 to 2012. Definitions were as follows: symptomatic intracranial hemorrhage = any parenchymal hematoma; successful reperfusion = mTICI ≥2b; good and acceptable outcomes = 90-day mRS 0-2 and 0-3, respectively. Final infarct volumes (FIV) were calculated based on 24-hour CT/MRI scans. Results: Mean age (67 ± 14 vs. 67 ± 19 years) and baseline NIHSS (20 ± 5 vs. 20 ± 6) were similar in the two groups. Successful reperfusion was achieved in 58 (67%) IAT patients. Symptomatic and asymptomatic intracranial hemorrhage occurred in 9 (10%) and 31 (36%) IAT patients, respectively. The proportion of 90-day good and acceptable outcomes was 20 (17/86) and 33% (28/86), respectively. Successful IAT reperfusion was associated with smaller FIV (p = 0.015) and higher rates of good (p = 0.01) and acceptable (p = 0.014) outcomes. There was a strong trend towards a higher hemicraniectomy requirement in medically as compared to endovascularly treated patients (20 vs. 6%; p = 0.06) despite similar in-hospital mortality. The median FIV was significantly lower with IAT versus medical therapy [80 ml (interquartile range, 38-122) vs. 190 ml (121-267); p = 0.015]. Conclusions: Despite a relatively low probability of achieving functional independence, IAT in LVOS patients with ASPECTS 5-7 appears to result in lower degrees of disability and may lessen the need for hemicraniectomy. Therefore, it may be a reasonable option for patients and families who favor a shift from severe to moderate disability.

Background and Purpose— Oral anticoagulation (OAC) plays a major role in atrial fibrillation stroke prevention but represents a contraindication to intravenous tissue-type plasminogen activator. Intra-arterial therapy remains a potential reperfusion strategy in these patients; however, supporting data are scarce. Methods— Retrospective analysis of prospectively collected consecutive intra-arterial therapies from October 2010 to March 2015 comparing OAC (vitamin-K antagonists and novel oral anticoagulants) versus normal hemostasis versus intravenous tissue-type plasminogen activator patients. Primary safety end point is parenchymal hematoma. Secondary safety end point is 90-day mortality. Efficacy end points are successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b-3) and good outcome (90-day modified Rankin Scale score of 0–2). Logistic regression for predictors of parenchymal hematoma was performed. Results— A total of 604 patients were qualified for the study. Baseline and outcomes variables were overall similar for vitamin-K antagonists (n=29) and novel oral anticoagulants (n=17) patients. When compared with normal hemostasis (n=265) and intravenous tissue-type plasminogen activator (n=297), OAC (n=46) patients were older and had more comorbidities. There were no statistically significant differences in the rates of parenchymal hematoma (8% versus 5%; P =0.42), 90-day modified Rankin Scale score of 0 to 2 (30% versus 40%; P =0.26), and 90-day mortality (32% versus 26%; P =0.46) among OAC and normal hemostasis patients. Similarly, there were no significant differences between OAC and intravenous tissue-type plasminogen activator patients in terms of parenchymal hematoma (8% versus 4%; P =0.16), 90-day modified Rankin Scale score of 0 to 2 (30% versus 43%; P =0.13), and 90-day mortality (32% versus 22%; P =0.18). The use of OAC was not associated with the occurrence of parenchymal hematoma on multivariate logistic regression analysis. Conclusions— Intra-arterial therapy seems to be safe in patients taking OACs; however, our study showed a nonsignificant increase in hemorrhage and mortality with a nonsignificant decrease in good outcomes in comparison with non-OAC patients. Although these nominal differences may have been related to older age and more comorbidities in the OAC group, larger studies are needed to confirm our findings given our limited sample size.

Background and Purpose Antithrombotic medications are effective for ischemic stroke prevention, but stoppage of these medications is associated with an increased risk of thromboembolism. The frequency of antithrombotic withdrawal in the general population is unknown. Methods We conducted a random phone sample of 2036 households in the Greater Cincinnati metropolitan area, representative of the stroke population by age, sex, and race, to determine the frequency of antithrombotic medication use and stoppage by physicians for medically indicated procedures. Results Sixty-two percent of survey respondents reported that they were on an antithrombotic medication. Ten percent of participants reported that they had stopped taking their medication within the past 60 days for a medically indicated intervention. Of those who stopped taking the medication, it was more common for persons taking an anticoagulant to stop their medication (20%) than those taking an antiplatelet agent (9%). Colonoscopies and orthopedic surgeries were the most common reasons for withdrawal of antiplatelet agents, whereas orthopedic and vascular surgeries were the most common reason for withdrawal of anticoagulants. Conclusions Recommended discontinuation of antithrombotic medication for surgical or diagnostic procedures is common practice for persons in the community representative of a stroke population. Because stoppage of these medications is associated with an increased risk of thromboembolic stroke, further clinical trials are needed to determine best management practices in this setting.

Background and Purpose: Secondary stroke prevention medications (SSPs) have been shown to prevent recurrent stroke, but few national reports of prescribing SSPs are available from hospitals regardless of their participation in national quality improvement programs. We examined SSP prescribing at discharge following hospitalization for adjudicated incident ischemic stroke (IS) in a large national cohort and unselected hospitals. Methods: We performed a retrospective review of incident IS admissions within the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort; admissions were to unselected hospitals. Exclusions were history of stroke, hospital death, missing data, and prevalent use of the medication of interest. Race, sex, age, rurality of residence (as defined by Rural Urban Commuting Area codes) were obtained at REGARDS baseline. Admission and discharge medications were obtained from hospital records. Associations between characteristics and discharge SSP prescriptions were examined using logistic regression adjusting for race, age, sex, and rurality. Results: From 2003-2011, of 657 IS, 429 met inclusion criteria. Mean age of participants was 73 (42% Black, 49% female, 27% non-urban). Antithrombotic therapy (antiplatelet/anticoagulant) was prescribed for 87%, statins 36% (10% 80mg), and ACE-I/ARB for 16%. We observed no statistically significant differences in prescribing antithrombotics or statins by race, sex, age, or rurality. Participants in non-urban areas had lower odds of ACE-I/ARB at discharge (OR 0.38, 0.15-0.98), with no differences by race, sex, or age. Conclusions: The majority of participants with incident IS within REGARDS were newly prescribed antithrombotics at discharge but alarmingly few were newly prescribed statins or ACE-I/ARBs. Our findings among incident SSP users differ from previous reports among prevalent users within hospitals participating in a national quality improvement program. More studies of quality of care after IS at unselected hospitals are needed.

Introduction: Data related to the treatment of patients with acute ischemic stroke caused by carotid artery dissection is scarce. Methods: We retrospectively reviewed our interventional stroke database Sep 2010 - Jan 2014 to investigate the clinical and radiological characteristics of patients presenting with tandem cervical and intracranial occlusions due to cervical carotid dissection. Results: Out of 504 consecutive patients treated with endovascular therapy for acute ischemic stroke during the study period, 12 (2.5%) patients were observed to have cervical carotid artery dissection as the underlying etiology. Mean age was 56±13 years, 75% were male, 50% received IV t-PA, mean NIHSS was 20±5, 75% had CT ASPECTS≥7, and mean time from last known normal to groin puncture was 6±3 hours. There were 4 MCA M1, 1 MCA M2 and 7 ICA-T occlusions. Extracranial carotid stent was used in 58% and angioplasty in 8% of cases. In 33% of the cases, the carotid dissection was not stented due to the fear of hemorrhagic transformation in cases of IV thrombolysis (presumably increased risk if dual antithrombotics used). IA tPA was used in 41% of cases, while Merci in 16%, Penumbra in 58%, and stentretrivers in 50%. Intracranial TICI 2b-3 reperfusion was achieved in 91% of patients, with PH2 hemorrhage in 8% and mRS at 90 days in 45% of cases. Conclusions: Carotid dissections with associated intracranial occlusions are often refractory to IV tPA and present with a high stroke severity. These lesions are amenable to endovascular therapy resulting in high rates of reperfusion with an acceptable safety profile.

Introduction: Intra-arterial therapy (IAT) for large vessel occlusions strokes (LVOS) has been increasingly utilized. The benefit of endovascular reperfusion in patients with mid-range ASPECTS remains to be established. Materials and methods: Retrospective analysis of LVOS patients with ASPECTS 5-7 treated with IAT (n=86) or medical therapy alone (±IV t-PA; n=15) at two academic centers from 2009-2012. Definitions employed: Symptomatic ICH: any parenchymal hematoma; Successful reperfusion: modified TICI≥2B; Good and acceptable clinical outcomes: 90-day mRS 0-2 and 0-3, respectively. Final infarct volumes were calculated based on 24-hour post-procedure CT or MRI scans. Results: Mean age (67±14 vs. 67±19 years) and baseline NIHSS (20±5 vs. 20±6) were similar in the IAT and medical treatment groups. Successful reperfusion was achieved in 58 (67%) IAT patients. Symptomatic and asymptomatic ICH occurred in 9 (10%) and 31 (36%) IAT patients, respectively. The IAT rates of 90-day good and acceptable outcomes were 20% (17/86) and 33% (28/86), respectively. Successful reperfusion in IAT patients was associated with smaller FIV (p=0.015) and higher rates of good (p=0.02) and acceptable (p=0.03) outcomes. The median final infarct volume was significant lower with IAT vs. medical therapy (80ml [IQR, 38-122] vs. 190ml [121-267], p=0.015). There was a strong trend towards a higher hemicraniectomy requirement in medically vs. endovascularly treated patients (20% versus 6%, p=0.06) despite similar in-hospital mortality (20% versus 26.7 %, p=0.75). Conclusions: Despite a low probability of achieving functional independence, IAT in LVOS patients with ASPECTS 5-7 appears to result in smaller final infarct volumes leading to a reduction in the need for hemicraniectomy and decreasing the degree of overall disability. Therefore, it may be a reasonable option for patients and families who favor a shift from severe to moderate disability. Prospective studies utilizing shift in outcome measures are warranted to confirm these results.

Background Blood pressure control is a paramount goal in secondary stroke prevention; however, high prevalence of uncontrolled blood pressure and use of multiple antihypertensive medication classes in stroke patients suggest this goal is not being met. We determined the prevalence and factors associated with apparent treatment-resistant hypertension in persons with/without stroke or transient ischemic attack. Methods Data came from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national, population-based cohort of 30,239 black and white adults aged ≥45 years, enrolled 2003-2007, restricted to 11,719 participants with treated hypertension. Apparent treatment-resistant hypertension was defined as (1) uncontrolled blood pressure (systolic ≥140 mm Hg or diastolic ≥90 mm Hg) with ≥3 antihypertensive medication classes, or (2) use of ≥4 antihypertensive medication classes, regardless of blood pressure level. Poisson regression was used to calculate characteristics associated with apparent treatment-resistant hypertension. Results Among hypertensive participants, prevalence of apparent treatment-resistant hypertension was 24.9% (422 of 1694) and 17.0% (1708 of 10,025) in individuals with and without history of stroke or transient ischemic attack, respectively. After adjustment for cardiovascular risk factors, the prevalence ratio for apparent treatment-resistant hypertension for those with versus without stroke or transient ischemic attack was 1.14 (95% confidence interval, 1.03-1.27). Among hypertensive participants with stroke or transient attack, male sex, black race, larger waist circumference, longer duration of hypertension, and reduced kidney function were associated with apparent treatment-resistant hypertension. Conclusions The high prevalence of apparent treatment-resistant hypertension among hypertensive persons with history of stroke or transient ischemic attack suggests the need for more individualized blood pressure monitoring and management.

Background and purpose Higher reperfusion rates have been established with endovascular treatment of acute ischemic stroke (AIS). There are limited data on the comparative performance of mechanical thrombectomy devices. Methods A retrospective single-center analysis was undertaken of all consecutive patients who underwent thrombectomy using Merci, Penumbra or stent retrievers (SR) from September 2010 to November 2012. Baseline characteristics, rates of successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) score 2b–3), symptomatic intracerebral hemorrhage (sICH), final infarct volume, 90-day mortality and independent functional outcomes at 90 days were compared across the three devices. Results Our cohort included 287 patients. There were mild imbalances in baseline characteristics with trends towards higher National Institutes of Health Stroke Scale (NIHSS) score in patients in the Merci group (SR=18 vs Merci=21 vs Penumbra=19, p=0.06) and lower Alberta Stroke Program Early CT Score (ASPECTS) in patients in the SR group (>7: SR=51% vs Merci=61% vs Penumbra=62%, p=0.12). On univariate analysis there were no differences in the rate of sICH (SR=7% vs Merci=7% vs Penumbra=6%, p=0.921) and infarct volume (SR=61.5 mL vs Merci=69.5 mL vs Penumbra=59.2 mL, p=0.621). Trends towards better functional outcomes were found with Penumbra and SR vs Merci (41% vs 36% vs 25%, respectively, p=0.079). Complete or near complete reperfusion (mTICI 2b–3) was higher in the SR and Penumbra groups than in the Merci group (86% vs 78% vs 70%, respectively, p=0.027). Binary logistic regression showed that SR was an independent predictor of good functional outcome (OR 2.27, 95% CI 1.018 to 5.048; p=0.045). Conclusions Although our initial data confirm the superiority of SR technology over the Merci device, there was no significant difference in near complete/complete reperfusion, final infarct volumes or clinical outcomes between SR and Penumbra thromboaspiration.

Introduction: Rapid evaluation and treatment with rt-PA is the hallmark of acute stroke care, yet only a fraction of ischemic stroke patients arrive within the time window for treatment. National stroke awareness campaigns have attempted to increase community awareness of stroke with action plans to call 911. We sought to compare the use of emergency medical services (EMS) by stroke patients between 2005 and 2010. Methods: Stroke and TIA patients were identified in a population of 1.3 million in the Greater Cincinnati area in 2005 and 2010. Patient charts were abstracted by research nurses and reviewed by study physicians. For this analysis, patients must have resided at home and presented to a local ED. Proportion of EMS users was computed. Logistic regression was used to test for associations of EMS use with age, race, sex, prior stroke, stroke type and severity, and setting (home, work, other) where stroke occurred. Results: There were 2546 stroke cases identified in 2005 and 2704 in 2010 which met criteria for analysis. The mean age was 68 years (SD 15), 54% female, and 20% black in both study periods. EMS use did not change between study periods, 52.7% in 2005 and 52.0% in 2010 (p=.64). In both study years, increasing age, increasing stroke severity, and hemorrhagic stroke were associated with EMS use. History of prior stroke was associated with increased EMS use in 2005, but this association was not seen in 2010. Sex, race, and the setting where stroke occurred were not associated with EMS use. Discussion: Rates of EMS use in our population-based study are still only about 52% and did not increase between 2005 and 2010. Community stroke awareness campaigns should include an action plan containing the urgency of calling 911 as soon as any stroke symptoms occur.

Objective We explore the impact of discharge disposition (independent rehabilitation facility (IRF) vs skilled nursing facility (SNF)) on 90 day outcomes in persons with stroke who received acute endovascular treatment. Methods Using a database from a single primary care stroke center, discharge disposition, National Institutes of Health Stroke Scale (NIHSS), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-Arterial Therapy 2 (HIAT-2), and Acute Physiology and Chronic Health Evaluation (APACHE II) scores, and successful reperfusion were obtained. Univariate analysis was performed to assess predictors of good clinical outcome, as defined by 90 day modified Rankin Scale (mRS) scores ≤2. A binary logistic regression model was used to determine the impact of placement to an IRF versus an SNF on clinical outcomes. Results 147 subjects were included in the analysis with a mean age of63±14 years and median NIHSS of 18 (IQR 14–21). Final infarct volumes, and modified APACHE II, THRIVE, and HIAT-2 scores were similar between those discharged to an IRF and those discharged to an SNF.However, their 90 day outcomes were significantly different, with far fewer patients at SNFs achieving good clinical outcomes (25% vs 46%; p=0.023). Disposition to SNF was significantly associated with a lower probability of achieving an mRS score of 0–2 at 90 days (OR = 0.337 (95% CI 0.12 to 0.94); p Conclusions Subjects discharged to SNFs and IRFs after thrombectomy have similar medical and neurological severity at admission and similar final infarct volumes at discharge. Despite these similarities, patients discharged to an SNF had a significantly lower probability of achieving a good neurological outcome. These results have implications for future acute stroke trial design.

Pretreatment Alberta Stroke Program Early CT Scores (ASPECTS) is associated with clinical outcomes. The rate of decline between subsequent images, however, may be more predictive of outcomes as it integrates time and physiology.A cohort of patients transferred from six primary stroke centers and treated with intra-arterial therapy (IAT) was retrospectively studied. Absolute ASPECTS decay was defined as ((ASPECTS First CT-ASPECTS Second CT)/hours elapsed between images). A logistic regression model was performed to determine if the rate of ASPECTS decay predicted good outcomes at 90 days (modified Rankin Scale score of 0-2).106 patients with a mean age of 66±14 years and a median National Institutes of Health Stroke Scale score of 19 (IQR 15-23) were analyzed. Median time between initial CT at the outside hospital to repeat CT at our facility was 2.7 h (IQR 2.0-3.6). Patients with good outcomes had lower rates of absolute ASPECTS decay compared with those who did not (0.14±0.23 score/h vs 0.49±0.39 score/h; p0.001). In multivariable modeling, the absolute rate of ASPECTS decay (OR 0.043; 95% CI 0.004 to 0.471; p=0.01) was a stronger predictor of good patient outcome than static pretreatment ASPECTS obtained before IAT (OR 0.64; 95% CI 0.38 to 1.04; p=0.075). In practical terms, every 1 unit increase in ASPECTS decline per hour correlates with a 23-fold lower probability of a good outcome.Patients with faster rates of ASPECTS decay during inter-facility transfers are associated with worse clinical outcomes. This value may reflect the rate of physiological infarct expansion and thus serve as a tool in patient selection for IAT.