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Background: There is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT)., Methods: This was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration., Results: In the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0-2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0)., Conclusions: Prior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO., Competing Interests: Competing interests: MM: Grant NIH R21NS109575. Consultant: Medtronic, Cerenovus. Stock options: Brain Q, Endostream Serenity Medical, Synchron. Assistant Editor for JNIS. MW: None. JTF: Consultant: Stryker, Penumbra, Microvention. Stocks: Cerebrotech, The Stroke Project. RDL: Consultant: Cerenovus, Stryker, Penumbra, Imperative Care, Siemens. Stock options: Synchron, Endostream, Q’Apel. Social Media Editor for JNIS. DF: Consultant: Balt USA, Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical, Marbelhead, Medtronic, MENTICE, Neuorogami, RAPID AI, Rapid Medical, Phenox. Associate Editor for JNIS. EIL: Consultant: Penumbra, NextGen Biologics, Rapid Medical, Cognition Medical, Three Rivers Medical, Stryker, MedX, Endostream Medical. KS: Consultant: Penumbra, Canon Medical Systems, Medtronic, Jacobs Institute, Neurovascular Diagnostics. RAH: Consultant: Penumbra, Endostream, Cerebrotech, Synchron, InNeuroCo, Medtronic, Microvention, Stryker, Cerenovus; Elum, Three Rivers. KW: Consultant: Penumbra. IC: Consultant: Medtronic, Microvention, Penumbra. Stocks: Cerenovus, Serenity Medical, Cerebrotech, Three Rivers Medical, Q’apel. ATR: Consultant: Penumbra, Microvention, Stryker. DF: Consultant: Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical, Siemens. JEDA: Consultant: Penumbra, Medtronic. MK: Consultant: Penumbra, Medtronic, Endostream. ASA: Consultant: Cerenovus, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker. Stocks: Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad, Vascular Simulations. BWB: Consultant: Penumbra, Medtronic, Stryker, Cerenovus, Viz.ai, 880 Medical, Route 92, Artio Medical. JE: Consultant: Penumbra, Medtronic, Stryker, Route 92 Medical. IL: Consultant: Penumbra, Medtronic, Stryker, Microvention, InNeuroCo, Three Rivers. KMF: Associate Editor for JNIS. AT: Consultant: Cardinal Consulting, Cerenovus, Corindus, Medtronic, Siemens, 880 Medical. Stock: Cerebrotech, Endostream. Imperative Care, Three Rivers Medical, Vastrax, Shape Memory, Synchron, Serenity Medical, Blink TBI, Echovate, RIST, Apama, Q’Apel, VizAi, Early Bird Medical, Rapid Medical, Spinnaker Medical. AHS: Stocks: Adona Medical, Inc., Amnis Therapeutics, Bend IT Technologies, Ltd, BlinkTBI, Inc., Buffalo Technology Partners, Inc., Cardinal Consultants, LLC, Cerebrotech Medical Systems, Inc., Cerevatech Medical, Inc., Cognition Medical, CVAID Ltd, Endostream Medical, Ltd, Imperative Care, Inc., Instylla, Inc., International Medical Distribution Partners, Launch NY, Inc., NeuroRadial Technologies, Inc., Neurotechnology Investors, Neurovascular Diagnostics, Inc., PerFlow Medical, Ltd, Q’Apel Medical, Inc., QAS.ai, Inc., Radical Catheter Technologies, Inc., Rebound Therapeutics Corp. (purchased 2019 by Integra Lifesciences, Corp.), Rist Neurovascular, Inc. (purchased 2020 by Medtronic), Sense Diagnostics, Inc., Serenity Medical, Inc., Silk Road Medical, SongBird Therapy, Spinnaker Medical, Inc., StimMed, LLC, Synchron, Inc., Three Rivers Medical, Inc., Truvic Medical, Inc., Tulavi Therapeutics, Inc., Vastrax, LLC, VICIS, Inc., Viseon, Inc. Consultant/Advisory Board: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc., Cordis, Corindus, Inc., Endostream Medical, Ltd, Imperative Care, Integra, IRRAS AB, Medtronic, MicroVention, Minnetronix Neuro, Inc., Penumbra, Q’Apel Medical, Inc., Rapid Medical, Rebound Therapeutics Corp., Serenity Medical, Inc., Silk Road Medical, StimMed, LLC, Stryker Neurovascular, Three Rivers Medical, Inc., VasSol, Viz.ai, Inc., W.L. Gore & Associates. JM: Stock options: Cerebrotech, Imperative Care, Endostream, Viseon, BlinkTBI, Serenity, Cardinal Consulting, NTI, RIST, Viz.ai, Synchron. Consultant: Imperative Care, Cerebrotech, VIseon, Endostream, Vastrax, RIST, Synchron, Viz.ai, Perflow, CVAid. Associate Editor for JNIS., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Clot density (Hounsfield units, HU) and perviousness (post-contrast increase in the HU of clot) are thought to be associated with clot composition. We evaluate whether these imaging characteristics were associated with angiographic outcomes of aspiration and stent retriever thrombectomy in COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion., Methods: Clot density and perviousness were measured by two independent operators who were blind to all the final angiographic and clinical outcomes. The association of clot density and perviousness with the Thrombolysis In Cerebral Infarction (TICI) scale after first pass was assessed using univariate and multivariate analysis., Results: Among all patients enrolled in COMPASS, 165 were eligible for the post-hoc analysis (81 patients in the aspiration first and 84 in the stent retriever first groups). Overall mean perviousness of clot was significantly higher in patient with mTICI 2b-3 after first pass (28.6±22.9 vs 20.3±19.2, p=0.017). Mean perviousness among patients who achieved TICI 2c/3 versus TICI 2b versus TICI 0-2a in the aspiration first group varied significantly (32.6±26.1, 35.3±24.4, and 17.7±13.1, p=0.013). The association of perviousness with first pass success was not significant in the stent retriever group. Using multivariate analysis, high perviousness (defined as cut-off >27.6) was an independent predictor of TICI 2b-3 (OR 3.82, 95% CI 1.10 to 13.19; p=0.034)., Conclusions: Clot perviousness is associated with first pass angiographic success in patients treated with the aspiration first approach for thrombectomy., Competing Interests: Competing interests: MM: Grant NIH R21NS109575. Consultant; Medtronic, Canon medical, Cerenovus. Stock options: Serenity medical, Synchron, VICIS, Endostream. MW: None. JF: Consultant: Stryker, Penumbra, Microvention. Stock: Cerebrotech, The Stroke Project. RDL: Consultant: Penumbra, Cerenovus, Siemens. DF: Consultant: Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical. EIL: 6; Consultant: Penumbra, NextGen Biologics, Rapid Medical, Cognition Medical, Three Rivers Medical, Stryker, MedX, Endostream Medical. KS Consultant: Penumbra, Canon Medical Systems, Medtronic, Jacobs Institute, Neurovascular Diagnostics. RH: Consultant: Penumbra, Endostream, Cerebrotech, Synchron, InNeuroCo, Medtronic, Microvention, Stryker, Cerenovus; Elum, Three Rivers. KW: Consultant: Penumbra. IC: Consultant: Medtronic, Microvention, Penumbra. Stock: Cerenovus, Serenity Medical, Cerebrotech, Three Rivers Medical, Q’apel. ATR: Consultant: Penumbra, Microvention, Stryker. DF: Consultant: Penumbra, Cerenovus, Stryker, Genentech, Shape Memory Medical, Siemens. JEDA: Consultant: Penumbra, Medtronic. MK: Consultant: Penumbra, Medtronic, Endostream. ASA: Consultant: Cerenovus, Medtronic, Microvention, Penumbra, Scientia, Siemens, Stryker. Stock: Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad, Vascular Simulations. BWB: Consultant: Penumbra, Medtronic, Stryker, Cerenovus, Viz.ai, 880 medical, Route 92, Artio Medical. JE: Consultant: Penumbra, Medtronic, Stryker, Route 92 Medical. IL: Consultant: Penumbra, Medtronic, Stryker, Microvention, InNeuroCo, Three Rivers. KF: None. AT: Consultant: Cardinal Consulting, Cerenovus, Corindus, Medtronic, Siemens, 880 Medical. Stocks: Cerebrotech, Endostream. Imperative Care, Three Rivers Medical, Vastrax, Shape Memory, Synchron, Serenity Medical, Blink TBI, Echovate, RIST, Apama, Q’Apel, VizAi, Early Bird Medical, Rapid Medical, Spinnaker Medical. AHS: Stocks: Amnis Therapeutics, Apama Medical, BlinkTBI, Inc, Buffalo Technology Partners, Inc, Cardinal Health, Cerebrotech Medical Systems, Inc, Claret Medical, Cognition Medical, Endostream Medical, Ltd, Imperative Care, International Medical Distribution Partners, Rebound Therapeutics Corp, Silk Road Medical, StimMed, Synchron, Three Rivers Medical, Inc, Viseon Spine, Inc. Consultant/Advisory Board: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA, Cerebrotech Medical Systems, Inc, Cerenovus, Claret Medical, Corindus, Endostream Medical, Ltd, Guidepoint Global Consulting, Imperative Care, Integra, Medtronic, MicroVention. JM: Stock options: Cerebrotech, Imperative Care, Endostream, Viseon, BlinkTBI, Serenity, Cardinal Consulting, NTI, RIST, Viz.ai, Synchron. Consultant: Imperative Care, Cerebrotech, VIseon, Endostream, Vastrax, RIST, Synchron, Viz.ai, Perflow, CVAid., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Thrombectomy is an efficacious treatment for acute ischemic stroke (AIS). However, relatively few studies to date have specifically examined the impact and clinical implications of age on outcomes for thrombectomy in anterior AIS., Objective: To provide a snapshot of patient metrics and outcomes with respect to age following thrombectomy for anterior AIS to supplement the current body of data for predictors of clinical outcomes in a real-world setting., Methods: Data were collected for 20 consecutive patients with AIS treated with thrombectomy at 15 high-volume stroke centers across North America between 2015 and 2016. Patients with anterior occlusions were dichotomized based on whether they were older or younger than 80 years. Ordinal logistic regression analyzed how clinical variables impacted disability using 90-day modified Rankin Scale (mRS) scores., Results: Adequate revascularization (TICI ≥2B) was achieved in 92.3% of patients aged <80 years with an average 1.7±0.1 passes taken with the primary technique and in 88.0% of patients aged ≥80 years with an average 1.7±0.2 passes. Despite similar baseline characteristics, mRS scores were significantly higher in older patients postoperatively and at 90 days after intervention. Age was a significant predictor of 90-day mRS across the study population., Conclusion: This analysis affirms age is a significant determinant of 90-day mRS scores following thrombectomy for large vessel anterior AIS. Further investigation into risks faced by elderly patients during thrombectomy may provide actionable information to help refine patient selection and improve outcomes., Competing Interests: Competing interests: AHS: Financial Interest/Investor/Stock Options/Ownership: Imperative Care, Q’Apel Medical; Consultant/Advisory Board: Cerenovus, Imperative Care, Medtronic, MicroVention, Penumbra, Q’Apel Medical, Stryker. JE: Consultant: Stryker Neurovascular, Medtronic. AT: Consultant: BALT/Blockade, Cerenovus, Medtronic, Microvention-Terumo, Penumbra, Imperative Care, Stryker. KW: Consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker. AR: Consultant: Stryker, Cerenovus, Microvention. BB: Consultant: Penumbra, Medtronic, Stryker; Shareholder: Penumbra. RH: Grant/Research Support: Medtronic, Stryker, Microvention; Consultant: Medtronic, Stryker, Cerenovus, Microvention, Balt. JEDA: Consultant: Penumbra, Medtronic, Microvention. ASA: Consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; Research Support: Microvention, Cerenovus, Penumbra. DFi: Consultant: Medtronic, Microvention, Penumbra, Balt, Cerenovus, Stryker; Research Support: Siemens, Microvention, Penumbra, Cerenovus. MK: Consultant: Penumbra, Medtronic. LP: Consultant: Medtronic. DFr: Consultant/Speakers Bureau: Penumbra, Stryker, Research support: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; Stock ownership: Penumbra. IL: Consultant: Medtronic, Stryker, Cerenovus. RDL: Consultant: Cerenovus, Penumbra, Q’Apel Medical, Imperative Care, Mivi Neuroscience; Research support: Medtronic, Asahi Intec. JM: Consultant: Cerebrotech, Rebound Therapeutics, TSP, Lazarus Effect, Medina, Pulsar Vascular; Investor: Blockade, Medina, Lazarus Effect, TSP; Research support: Penumbra., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Thrombectomy for anterior large vessel occlusion less than 24 hours since last known well is now standard of care. Certain aspects of clinical trials may limit generalizability to 'real-world' practice., Objective: To compare revascularization rates and outcomes for direct aspiration (ADAPT) and stent retriever thrombectomy following anterior acute ischemic stroke (AIS) in a real-life setting., Methods: Data from the most recent 20 consecutive patients with AIS treated with mechanical thrombectomy between 2015 and 2016 were collected from 15 high-volume stroke centers across North America for a total of 300 cases. Patients with proximal anterior large vessel occlusions were dichotomized by primary treatment technique. Ordinal logistic regression assessed the effects of clinical variables on patient disability using 90-day modified Rankin Scale (mRS) scores., Results: Adequate revascularization (Thrombolysis in Cerebral Infarction ≥2b) was ultimately achieved in 91.2% of first-line direct aspiration (ADAPT) cases with an average of 1.9±1.9 passes and in 87.5% of stent retriever cases with an average of 1.7±1.0 passes. Time from groin puncture to revascularization was shorter for ADAPT cases. The mean 90-day mRS score for both groups was 3.0±2.4. Number of passes using primary technique, and postintervention intracranial hemorrhage, were significant predictors of 90-day mRS scores after ADAPT, while age and preprocedure mRS score were predictive of outcomes following first-line stent retriever., Conclusions: Our data show similar adequate revascularization rates and 90-day functional outcomes for first-line direct aspiration and stent retrievers for anterior large vessel occlusion in a real-world setting. These results support the findings of other prospective trials evaluating the two techniques., Competing Interests: Competing interests: AHS: financial interest/investor/stock options/ownership: Imperative Care, Q’Apel Medical, Inc; consultant/advisory board: Cerenovus, Imperative Care, Medtronic, MicroVention, Penumbra, Q’Apel Medical, Inc, Stryker. JE: consultant: Stryker Neurovascular, Medtronic. AT: consultant: BALT/Blockade, Cerenovus, Medtronic, Microvention-Terumo, Penumbra, Imperative Care, Stryker. KW0: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker. AR: consultant: Stryker, Cerenovus, Microvention. BB: consultant: Penumbra, Medtronic, Stryker; shareholder: Penumbra. RH: grant/research support: Medtronic, Stryker, Microvention; consultant: Medtronic, Stryker, Cerenovous, Microvention, Balt. JEDA: consultant: Penumbra, Medtronic, Microvention. ASA: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; research support: Microvention, Cerenovus, Penumbra. AA: consultant: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; research support: Microvention, Cerenovus, Penumbra. MK: consultant: Penumbra, Medtronic. LP: consultant: Medtronic. DF: consultant/speakers bureau: Penumbra; Stryker; research support: Cerenovus, Medtronic, Microvention, Penumbra, Stryker; stock ownership: Penumbra. IL: consultant: Medtronic, Stryker, Cerenovus. RDL: consultant: Cerenovus, Penumbra, Q’Apel Medical Inc, Imperative Care, Mivi Neuroscience; research support: Medtronic, Asahi Intec. JM: consultant: Cerebrotech, Rebound Therapeutics, TSP Inc, Lazarus Effect, Medina, Pulsar Vascular; investor: Blockade, Medina, Lazarus Effect, TSP Inc; research support: Penumbra, (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Efficacy of thrombectomy treatment in acute ischemic stroke large vessel occlusion (AIS-LVO) patients is time dependent. Direct admission to thrombectomy centers (vs. interhospital transfer) may reduce time to treatment and improve outcomes. In this subset analysis of the COMPLETE registry, we compared outcomes between direct to thrombectomy center (Direct) vs. transfer from another hospital to thrombectomy center (Transfer) in AIS-LVO patients treated with aspiration thrombectomy. Methods: COMPLETE was a prospective, international registry that enrolled patients from July 2018 to October 2019, with a 90-day follow-up period that was completed in January 2020. Imaging findings and safety events were adjudicated by core lab and independent medical reviewers, respectively. Pre-defined primary endpoints included post-procedure angiographic revascularization (mTICI ≥2b), 90-day functional outcome (mRS 0-2), and 90-day all-causemortality. Planned collections of procedural timemetrics and outcomes were used in the present post-hoc analysis to compare outcomes between transfer and direct patient cohorts. Results: Of 650 patients enrolled, 343 were transfer [52.8% female; mean (SD) age, 68.2 (13.9) years], and 307 were direct [55.4% female; 68.5 (14.5) years] admit. Median onset-to-puncture time took longer in the transfer vs. direct cohort (5.65 vs. 3.18 h: 2.33 h difference, respectively; p < 0.001). There was no significant difference in successful revascularization rate, mTICI ≥2b (88.3 and 87.3%), sICH at 24 h (3.8 and 3.9%), median length of hospital stay (7 and 6 days), and 90-day mortality (16.9 and 14.0%) between transfer vs. direct patients, respectively. However, achieving 90-day functional independence was less likely in transfer compared with direct patients (mRS 0-2 was 50.3 vs. 61.7%, p = 0.0056). Conclusions: In the COMPLETE registry, direct to thrombectomy center was associated with significantly shorter onset-to-puncture times, and higher rates of good clinical outcome across different geographies. Additional research should focus on AIS-LVO detection to facilitate direct routing of patients to appropriate treatment centers. [ABSTRACT FROM AUTHOR]