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Background and Purpose: There is a robust relationship between the duration of ischemia and functional outcomes after mechanical thrombectomy. Higher number of mechanical thrombectomy passes strongly correlate with lower chances of favorable outcomes. Indeed, previous studies have suggested that after multiple passes the procedure may be futile. However, using uncontrolled thresholds to define thrombectomy futility might be misleading. We aim to compare the outcome of successful reperfusion after 4 to 5 passes and ≥6 passes with those of failed reperfusion., Methods: A prospectively acquired mechanical thrombectomy database from January 2012 to October 2019 was reviewed. Patients were included if they had intracranial internal carotid artery or middle cerebral artery-M1/M2 occlusions and either achieved successful reperfusion after ≥4 passes or failed reperfusion. Reperfused patients (mTICI2b-3) were divided into 2 subgroups; (1) 4 to 5 passes and (2) ≥6 passes. Each subgroup was compared with a matched group of mechanical thrombectomy failure (mTICI0-2a). The primary outcome was the shift in the degree of disability at 90-day as measured by the modified Rankin Scale., Results: A total of 273 patients were included. As compared with matched failed reperfusion patients (n=62), those reperfused after 4 to 5 passes (n=62) had a favorable shift in the overall modified Rankin Scale score distribution (adjusted odds ratio, 3.992 [95% CI, 1.807–8.512], P=0.001] and higher rates of functional independence (31% versus 8.9%, P=0.004, adjusted odds ratio; 9.860 [95% CI, 2.323–41.845], P=0.002) at 90 days. Similarly, when compared with a matched group of failed reperfusion (n=42), patients reperfused after ≥6 passes (n=42) demonstrated a favorable shift in the overall modified Rankin Scale score distribution (adjusted odds ratio, 2.640 [95% CI, 1.073–6.686], P=0.037) and had higher rates of functional independence (36.8% vs 11.1%, P=0.004, adjusted odds ratio, 5.392 [95% CI, 1.185–24.530], P=0.029) at 90 day. Rates of parenchymal hematoma type-2 and 90-day mortality were comparable in the reperfused and nonreperfused groups., Conclusions: Achieving reperfusion despite multiple passes leads to improved outcomes compared with failed procedures. Arbitrary uncontrolled thresholds for a maximum number of passes to predict futile recanalization may lead to inappropriate early termination of procedures.

Background: Longer stent retrievers have recently become available and have theoretical advantages over their shorter counterparts. We aim to evaluate whether stent retriever length impacts reperfusion rates in stroke thrombectomy., Methods: This was a retrospective analysis of a prospectively collected thrombectomy database in which equal diameter (4 mm) stent retrievers were used as the first-line strategy for intracranial internal carotid or middle cerebral artery M1 or M2 occlusions along with a balloon guide catheter from June 2011 to March 2017. The population was dichotomized into long (Trevo 4×30 mm/Solitaire 4×40 mm) or short (Trevo 4×20 mm/Solitaire 4×20 mm) retrievers. The primary outcome was first-pass modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 reperfusion., Results: Of 1126 thrombectomies performed within the study period, 420 were included. Age, gender, National Institutes of Health Stroke Scale, ASPECTS, IV tissue plasminogen activator use, stroke etiology, occlusion site, time from last-known-normal to puncture, distribution of Trevo and Solitaire, and the use of newer generation local thromboaspiration devices were comparable between the long and short retrievers. The short retriever group had more frequent hypertension, dyslipidemia, and atrial fibrillation. First-pass mTICI 2b/3 reperfusion was more common in the long retriever group (62% vs 50%; P=0.01). Parenchymal hematomas type 2, subarachnoid hemorrhage, 90-day modified Rankin Scale score 0-2, and mortality were comparable. Multivariable analysis indicated that long retriever (OR 2.2; 95% CI 1.3 to 3.6; P=0.001), radiopaque device (OR 2.1; 95% CI 1.2 to 3.4; P=0.003), and adjuvant local aspiration (OR 2.4; 95% CI 1.3 to 4.3; P=0.003) were independently associated with first-pass reperfusion., Conclusions: The use of longer stent retrievers is an independent predictor of first-pass mTICI 2b/3 reperfusion. First-pass reperfusion was also associated with the use of radiopaque devices and adjuvant local aspiration., Competing Interests: Competing interests: RGN: Stryker-Neurovacular (Trevo-2 and DAWN/Trial PI), Covidien (SWIFT and SWIFT-PRIME/Steering- Committee, STAR Trial/Core-Lab), Penumbra (3-D Separator Trial/Executive-Committee)., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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 of 63±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<0.04)., 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., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: The efficacy of hypothermia as a neuroprotectant has yet to be demonstrated in acute ischemic stroke. We conducted a phase I pilot study to assess the feasibility and safety of performing intravascular hypothermia after definitive intra-arterial reperfusion therapy (IAT)., Methods: ReCCLAIM (Reperfusion and Cooling in Cerebral Acute Ischemia) is a prospective single-arm open-label clinical trial conducted between May and August 2012 at Grady Memorial Hospital. Twenty patients with Alberta Stroke Program Early CT Score (ASPECTS) 5-7 and NIH Stroke Scale (NIHSS) score > 13 were enrolled and treated with intravascular cooling immediately after IAT. The incidence of pneumonia, deep vein thrombosis, cardiac arrhythmias and postoperative hemorrhages was documented for the entire length of stay. Secondary outcomes included blood-brain barrier (BBB) breakdown on gadolinium-enhanced MRIs and 90-day modified Rankin scores (mRS)., Results: The mean age, median NIHSS score and median final infarct volume were 59.7 ± 14.6 years, 19 (IQR16-22) and 78 cm(3) (IQR 16-107), respectively. The average time to the target temperature (33 °C) was 64 ± 50 min. Intracranial hemorrhages were found in three patients, of which one was symptomatic. Evidence of BBB breakdown was observed on 3 of 14 MRIs (21%). Six patients died due to withdrawal of care, whereas six patients (30%) achieved mRS of 0-2 at 90 days. In a binary logistical regression model comparing ReCCLAIM patients with 68 historical controls at our institution, hypothermia was protective against intracerebral hemorrhages (OR 0.09, 95% CI 0.02 to 0.56; p<0.01)., Conclusions: Hypothermia can be safely performed after definitive IAT in patients with large pretreatment core infarcts. A phase II study randomizing patients to hypothermia or normothermia is needed to properly assess the efficacy of hypothermia as a neuroprotectant for reperfusion injury., Trial Registration Number: NCT01585597.

Background and Purpose: 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., Methods: 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., Results: 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, p<0.018) and successful reperfusion (OR 1.82, 95% CI 1.16 to 2.86, p<0.008)., Conclusions: 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: 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<0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P<0.001) and significantly worse clinical outcomes (29% versus 51%; 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.

Objective: We aimed to assess the impact of time to endovascular thrombectomy (EVT) on clinical outcomes in the DAWN trial, while also exploring the potential effect modification of mode of stroke onset on this relationship. Methods: The association between every 1‐h treatment delay with 90‐day functional independence (modified Rankin Scale [mRS] score 0–2), symptomatic intracranial hemorrhage, and 90‐day mortality was explored in the overall population and in three modes of onset subgroups (wake‐up vs. witnessed vs. unwitnessed). Results: Out of the 205 patients, 98 (47.8%) and 107 (52.2%) presented in the 6 to 12 hours and 12 to 24 hours time window, respectively. Considering all three modes of onset together, there was no statistically significant association between time last seen well to randomization with either functional independence or mortality at 90 days in either the endovascular thrombectomy (mRS 0–2 1‐hour delay OR 1.07; 95% CI 0.93–1.24; mRS 6 OR 0.84; 95% CI 0.65–1.03) or medical management (mRS 0–2 1‐hour delay OR 0.98; 95% CI 0.80–1.14; mRS 6 1‐hour delay OR 0.94; 95% CI 0.79–1.09) groups. Moreover, there was no significant interaction between treatment effect and time (p = 0.439 and p = 0.421 for mRS 0–2 and 6, respectively). However, within the thrombectomy group, the models that tested the association between time last seen well to successful reperfusion (modified Treatment in Cerebral Infarction ≥2b) and 90‐day functional independence showed a significant interaction with mode of presentation (p = 0.013). This appeared to be driven by a nominally positive slope for both witnessed and unwitnessed strokes versus a significantly (p = 0.018) negative slope in wake‐up patients. There was no association between treatment times and symptomatic intracranial hemorrhage. Interpretation: Mode of onset modifies the effect of time to reperfusion on thrombectomy outcomes, and should be considered when exploring different treatment paradigms in the extended window. ANN NEUROL 2024;96:356–364 [ABSTRACT FROM AUTHOR]

Background: Computed tomography perfusion (CTP) has been increasingly used for patient selection in mechanical thrombectomy for stroke. However, previous studies suggested that CTP might overestimate the infarct size. The term ghost infarct core (GIC) has been used to describe an overestimation of the final infarct volumes by pre-treatment CTP of >10 ml. Aim: We sought to study the frequency and predictors of GIC. Methods: A prospectively collected mechanical thrombectomy database at a comprehensive stroke center between September 2010 and August 2020 was reviewed. Patients were included if they had a successful reperfusion (mTICI2b-3), a pre-procedure CTP, and final infarct volume measured on follow-up magnetic resonance imaging. Uni- and multivariable analyses were performed to identify predictors of GIC. Results: Among 923 eligible patients (median [IQR] age, 64 [55–75] years; NIHSS, 16 [11–21]; onset to reperfusion time, 436.5 [286–744.5] min), GIC was identified in 77 (8.3%) of the overall patients and in 14% (47/335) of those reperfused within 6 h of symptom onset. The median overestimation volume was 23.2 [16.4–38.3] mL. GIC was associated with higher NIHSS score, larger areas of infarct core and tissue at risk on CTP, unfavorable collateral scores, and shorter times from onset to image acquisition and to reperfusion as compared to non-GIC. Patients with GIC had smaller median final infarct volumes (10.7 vs. 27.1 ml, p < 0.001), higher chances of functional independence (76.2% vs. 55.5%, adjusted odds ratio (aOR) 3.829, 95% CI [1.505–9.737], p = 0.005), lower disability (one-point-mRS improvement, aOR 1.761, 95% CI [1.044–2.981], p = 0.03), and lower mortality (6.3% vs. 15%, aOR 0.119, 95% CI [0.014–0.984], p = 0.048) at 90 days. On multivariable analysis, time from onset to reperfusion ≤6 h (OR 3.184, 95% CI [1.743–5.815], p < 0.001), poor collaterals (OR 2.688, 95% CI [1.466–4.931], p = 0.001), and higher NIHSS score (OR 1.060, 95% CI [1.010–1.113], p = 0.018) were independent predictors of GIC. Conclusion: GIC is a relatively common entity, particularly in patients with poor collateral status, higher baseline NIHSS score, and early presentation, and is associated with more favorable outcomes. Patients should not be excluded from reperfusion therapies on the sole basis of CTP findings, especially in the early window. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Age and infarct volume are among the most powerful predictors of outcome after large vessel occlusion acute strokes (LVOS). Objective To study the impact of age- adjusted final infarct volume (FIV) on functional outcomes. Methods Review of a prospectively collected thrombectomy database at a tertiary care center between September 2010 and February 2018. Consecutive patients with anterior circulation LVOS who achieved full reperfusion (modified Thrombolysis in Cerebral Infarction 3) were categorized into four age groups: (G1) <60 years, (G2) 60-69, (G3) 70-79, (G4) ≥80 years. The Youden Index was used to identify the optimal FIV cut- off point for good outcome (modified Rankin Scale score 0--2) discrimination in each group and the overall population. The predictive ability of these specific thresholds was evaluated using binary logistic regressions and compared with the non- age- adjusted cut- off point. Results 516 patients were analyzed (G1: n=171, G2: n=130, G3: n=103, G4: n=112). Patients with poor outcome had a larger FIV in each group (p<0.01 for all). The target FIV cut- off point decreased with increased age: G1: 45.7 mL (sensitivity 56%, specificity 80%); G2: 30.4 mL (sensitivity 63%, specificity 75%); G3: 20.2 mL (sensitivity 76%, specificity 65%); G4: 16.9 mL (sensitivity 68%, specificity 70%). The non- age- adjusted cut- off point was 19.2 mL (sensitivity 70%, specificity 59%). In multivariate analysis, adjusting for confounders including age and FIV, achieving a FIV less than the age- adjusted threshold was an independent predictor of good outcome (aOR=2.72, 95% CI 1.41 to 5.24, p<0.001). In contrast, a similar model including the non- age- adjusted target cut- off point failed to reveal an association with good outcome (aOR=1.72, 95% CI 0.93 to 3.19, p<0.085). Furthermore, the latter model had a weaker outcome predictive ability as assessed by the Akaike information criterion (409 vs 403). Conclusions Age- adjusted infarct volume represents a strong outcome discriminator beyond age and infarct volume in isolation and might help to refine patient selection and improve outcome prognostication in stroke thrombectomy. [ABSTRACT FROM AUTHOR]

Background Patients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis. Objective To compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes. Methods Review of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0-5) and high ASPECTS (6- 10) and subsequently into limited and large CTP- core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90- day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups. Results 1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90- day modified Rankin Scale (mRS) score 0- 2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS. Conclusions Outcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS -5 but baseline infarct volumes -70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment. [ABSTRACT FROM AUTHOR]

Background and purpose: Thromboaspiration technology continues to evolve at an accelerated pace with increasing availability of larger and more navigable devices. Herein, we provide our initial experience with the intracranial navigation of a large-bore (.088" inner diameter) catheters during mechanical thrombectomy (MT). Methods: Retrospective review of consecutive large vessel occlusion stroke patients in whom a TracStar™ or Zoom 88™ (Imperative Care, Campbell, CA) large-bore catheters were utilized in MT. The primary outcome was successful reperfusion (eTICI2b-3) at the end of the procedure. Safety measures included procedural complications and rates of symptomatic intracranial hemorrhage. Results: Five patients (age,∼50–85 years; baseline NIHSS,17-23) were treated. The.088" catheters were used as the primary tool for contact aspiration in two patients (distal basilar artery and proximal MCA occlusions) with complete thrombus ingestion (eTICI3) during the first pass. In two patients, the.088" catheter was used for flow control where it was placed in the distal M1-segment of a patient with M2 occlusion treated with a combination of stent-retriever and.070" aspiration catheter and in the proximal M1 in a patient with distal M1 occlusion treated with.071" aspiration catheter resulting in eTICI3 reperfusion in both cases. In the fifth patient, the.088" catheter was navigated into the cavernous ICA to support.071" aspiration catheter treatment of an M2 occlusion resulting in eTCI2b67 reperfusion. Procedural duration ranged between 14 and 33 minutes. There were no adverse events. Conclusion: Intracranial navigation of.088" large-bore catheters in MT appears technically feasible and safe. Larger prospective studies are warranted. [ABSTRACT FROM AUTHOR]

background First 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. Methods A 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 <0.3 versus ≥0.3. Univariable and multivariable analyses were performed to establish the predictors of 90- day functional independence (modified Rankin Scale (mRS) ≤2) in each subgroup. results A 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 <0.3 (62.9% vs 52.8%, adjusted OR 1.524; 95% CI 0.592 to 3.920, p=0.38). Conclusions The 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. [ABSTRACT FROM AUTHOR]

Introduction Technical improvements to enhance distal occlusion thrombectomy are desirable. We describe the blind catheter exchange technique and report the pinning technique with small devices ('mini-pinning') for distal occlusions. Methods A retrospective review of a prospective database from January 2015 to August 2018 was performed for cases of distal occlusion in which the 'blind exchange/mini-pinning' (BEMP) techniques were used. The technique involves the deployment of a 3 mm Trevo retriever followed by microcatheter removal and blind advancement of a 3MAX aspiration catheter over the bare retriever delivery wire ('blind exchange') until clot contact under aspiration. The retriever is subsequently partially recaptured in order to 'cork' the thrombus ('mini-pinning') and the system pulled as a unit. Patients with distal occlusions treated with BEMP and standard techniques (either 3 mm Trevo or 3MAX) were compared. Results Twenty-five vessels were treated in 22 patients. The majority of patients had isolated distal occlusions predominantly in the distal middle cerebral artery (MCA) segments, half of which involved the superior division. The comparison between BEMP (n=25 vessels) and standard techniques (n=144 vessels) revealed balanced groups. One of the highlighted differences was the more distal MCA occlusions among those who underwent BEMP (M3 occlusions 52% vs 22%; p=0.001). Otherwise, the vessel, segments, divisions and luminal diameter were comparable. There was a higher rate of first-pass modified Thrombolysis in Cerebral Infarction 2b-3 (80% vs 56%; p=0.03) and a trend towards higher rates of first-pass full reperfusion (60% vs 40%; p=0.07) with BEMP compared with standard techniques. Final reperfusion and clinical outcomes were comparable. Conclusion BEMP appears to be a safe and effective technique for the treatment of distal occlusions. Additional studies are warranted. [ABSTRACT FROM AUTHOR]

Background Although aspiration and stent retriever thrombectomy perform similarly in proximal occlusions, no comparative series are available in distal occlusions. We aimed to compare the 3 mm Trevo Retriever against the 3MAX thromboaspiration catheter in distal arterial occlusions. Methods A single-center retrospective review of a prospectively maintained databank for patients treated with the 3 mm Trevo stent retriever or 3MAX thromboaspiration as the upfront approach for distal occlusions (middle cerebral artery mid/distal M2/M3, anterior cerebral artery A1/A2/A3 or posterior cerebral artery P1/P2) from January 2014 to July 2018 was performed. The primary outcome was the rate of distal occlusion first-pass reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3). Results Of 1100 patients treated within the study period, 137 patients/144 different arteries were treated with the 3 mm Trevo (n=92) or 3MAX device (n=52). The groups had comparable demographics and baseline characteristics. There was a higher rate of first-pass mTICI 2b-3 reperfusion (62% vs 44%; p=0.03), a trend towards a higher rate of final mTICI 2b-3 reperfusion (84% vs 69%; p=0.05), and lower use of adjuvant therapy (15% vs 31%; p=0.03) with the 3 mm Trevo compared with the 3MAX. The median number of passes (p=0.46), frequency of arterial spasm (p=1.00), rates of parenchymal hematomas (p=0.22)/subarachnoid hemorrhage (p=0.37) in the territory of the approached vessel were similar across the two groups. The 90-day rate of good outcomes (45% vs 46% in the 3 mm Trevo and 3MAX groups, respectively; p=0.84) was comparable. Multivariable regression identified baseline NIH Stroke Scale (NIHSS) score (OR 0.9; 95% CI 0.8 to 0.97; p<0.01) and use of 3 mm Trevo (OR 2.2; 95% CI 1.1 to 4.6; p=0.02) independently associated with first-pass mTICI 2b-3 reperfusion. Conclusions In the setting of distal arterial occlusions, the 3 mm Trevo may lead to higher rates of first-pass reperfusion than direct 3MAX thromboaspiration. Lower NIHSS was found to be associated with improved reperfusion rates as observed in more proximal lesions. Further studies are warranted. [ABSTRACT FROM AUTHOR]

Background 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. Methods 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). Results 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; p<0.001). 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. Conclusions 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. [ABSTRACT FROM AUTHOR]

The article presents a study on the acute ischemic stroke patients who underwent endovascular reperfusion. It mentions that retrospective approach was used in the study to evaluate stroke patients who were treated by endovascular therapy from November 2010 to July 2012. The study found that picture-to-puncture time delays during interhospital transfers can reduce the probable good outcome of those treated patients. INSET: CLINICAL PERSPECTIVE.