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Background: Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Methods: Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. Results: We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70–11.74). MTA was Conclusions: Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country’s per capita gross national income, prehospital LVO triage policy, and MT operator and center availability.

Introductions: Clinical trials have shown that aspiration thrombectomy is as safe and effective as stent-retriever thrombectomy. Multiple improvements have been made to the aspiration technique over the last few years. In this study, we aim to assess the effect of aspiration catheter bore size on the outcomes of A direct aspiration first pass technique (ADAPT) thrombectomy. Methods: We included patients who underwent ADAPT thrombectomy for M1 or internal carotid artery terminus (ICA-T) occlusions in the Stroke Thrombectomy and Aneurysm (STAR) database. Patients included between July 2016 and July 2022. We compared baseline characteristics, procedural metrics and outcomes between patients who underwent thrombectomy using small bore (0.035”-0.060”), medium bore (0.062”-0.068”) and large bore (0.070”-0.074”) catheters. Results: A total of 1158 patients were included; 576 (49.7%) females, 645 (70%) White, and 464 (40.6%) received IV-tPA. No difference was noticed in age, sex, and vascular risk factors between the 3 different groups. There was higher rate of IV-tPA in the small-bore catheter group (48.8%) compared to the medium and large bore catheter groups (38.4% and 36.7%, respectively) (P=0.03). Procedure duration was shorter when using medium (20 min) and large (18 min) compared to small bore catheters (30 min) (P=0.01). Both medium and large bore catheters were associated with higher rate of successful recanalization (88.9% and 87.9%, respectively) compared to small bore catheters (81.6%) (P=0.010). However, the difference in successful recanalization or procedure duration between medium and large bore catheters was not significant. No difference was noted in the rate of symptomatic hemorrhagic transformation (sICH) (4.7%, 5.3%, and 7.1%; P=0.345), 90-day favorable outcome (modified Rankin Scale 0-2) (41.8%, 39.3%, 40.8%; P=0.766) or 90-day mortality (18.1%, 23.5%, 24.4%; P=0.111) between the groups. Conclusions: Higher rate of successful recanalization and shorter procedure duration were observed when using medium and large bore aspiration catheters compared with small bore catheters in ADAPT technique. However, these procedural benefits were not observed when comparing large bore to medium bore catheters.

Introduction: Management of anterior circulation emergent large vessel occlusion with tandem carotid occlusion (TCO) remains a challenge during mechanical thrombectomy (MT). To day, there is no consensus regarding emergent carotid stenting (ECS) in the setting of MT with TCO. We aimed to compare the outcomes of ECS versus conservative management (MT alone) among patients with TCO. Methods: Data from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 was interrogated. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the ICA or MCA were included in the analyses. We compared baseline, procedural charecteristics, successful reperfusion (mTICI 2b-3), favorable 90-day good outcomes (mRS 0-2), intravenous tPA administration and symptomatic ICH between patients who did or did not undergo ECS. Multivariate regression was performed adjusting for variables of clinical importance. Propensity score matching for IV tPA use was performed to explore its safety with stenting. Results: Among 9812 thrombectomy patients, 688 patients had TCO; 132 underwent emergent stenting and 444 had MT alone. Patients who did not undergo ECS had a higher prevalence of atrial fibrillation (33.9% Vs 9.2%, P Conclusion: ECS during MT for TCO appears to be safe and is associated with better clinical and angiographic outcomes compared to conservative management.

Background: While mechanical thrombectomy (MT) has become the standard of care for acute stroke patients presenting with large vessel occlusion (LVO) and salvageable brain tissue, limited data is currently available regarding the benefits of MT in patents with medium vessel occlusions (MeVO) especially in the posterior circulation (P2 occlusions). Methods: We used the Stroke Thrombectomy and Aneurysm registry (STAR) which included data from 35 stroke centers in North America, Europe, Asia, and South America. We included patients who presented with MeVO in the M2, M3 or P2 segments and underwent MT. We used a Generalized Linear Model to assess the relationship between location of occlusion and outcomes. Results: 9812 patients were included in STAR at the time of this analysis; 43 underwent MT for P2 occlusion, 130 underwent MT for M3 occlusion; and 1273 underwent MT for M2 occlusion. There was no difference in age, sex, race, rate of IV-tPA and stroke severity between patients in all 3 groups (Table 1). There was a trend toward lower rate of atrial fibrillation in patients with P2 and M3 occlusions. Patients with P2 occlusions were less likely to achieve successful recanalization (modified treatment in cerebral infarction score≥2b); intraarterial thrombolysis was used less in P2 occlusions (4.7% compared to 16.2% in M3 occlusions and 10.1% in M2 occlusions). However, there was no difference in the rate of successful first pass. On multivariable analysis, P2 occlusions were not associated with hemorrhagic transformation (OR 2.0, 95% CI 0.7-5.7, P 0.186), 90-day mortality (OR 0.5, 95% CI 0.2-1.4, P 0.183), or 90-day favorable outcome (OR 2.0, 95% CI 0.9-4.4, P 0.084). Conclusions: In this multicenter study, there was no significant difference in safety and efficacy of MT in patients with MeVOs in posterior circulation (P2 occlusions) compared to M2 and M3 occlusions. Improved techniques for successful recanalization are needed for posterior circulation MeVOs.

Background: Mechanical thrombectomy is standard of care for acute ischemic stroke secondary to LVO however MT failure (MTF) occurs in approximately 15% of cases. Objective: Investigate patient and procedural characteristics that predict MTF. Methods: Retrospective review of prospectively collected, Stroke Thrombectomy and Aneurysm Registry. Patients who underwent MT for LVO were included and categorized by MT Success (MTS) or MTF, defined as mTICI≥2b or Results: A total of 8452 patients were analyzed, and 1301(15.4%) experienced MTF.MTF patients were older(73 vs.71, p=0.008)had higher poor premorbid mRS(10.8% vs 8.4%, p=0.17).Onset to puncture was greater in MTF group(442 vs.411 min, p=0.006).There were more ICA occlusions(15.6% vs. 13.5%)and basilar occlusions(7.8% vs.6.2%)in the MTF group and more M1 occlusions(42.2%vs.37.5%)in the MTS group (p Conclusion: MTF is associated with more complications and worse outcome. Final use of aspiration and rescue intracranial stenting may increase chances of recanalization.

BackgroundEndovascular thrombectomy (EVT) has become the mainstay treatment for large vessel occlusion, with favorable safety and efficacy profile. However, the safety and efficacy of EVT in concurrent multi-territory occlusions (MTVOs) remains unclear.ObjectiveTo investigate the prevalence, clinical and technical outcomes of concurrent EVT for MTVOs.MethodsData were included from the Stroke Thrombectomy and Aneurysm Registry (STAR) with 32 stroke centers for EVT performed to treat bilateral anterior or concurrent anterior and posterior circulation occlusions between 2017 and 2021. Patients with MTVO were identified, and propensity score matching was used to compare this group with patients with occlusion in a single arterial territory.ResultsOf a total of 7723 patients who underwent EVT for acute ischemic stroke, 54 (0.7%) underwent EVT for MTVOs (mean age 69±12.5; female 50%). 28% had bilateral and 72% had anterior and posterior circulations occlusions. The rate of successful recanalization (Thrombolysis in Cerebral Infarction 2b/3), complications, modified Rankin score at 90 days, and mortality was not significantly different between the matched cohorts. Multivariate analysis confirmed that MTVOs were not associated with poor functional outcome, symptomatic intracranial hemorrhage, or longer procedure time.ConclusionCompared with EVT for single vessel occlusions, EVT in appropriately selected patients with MTVOs has a similar efficacy and safety profile.

BackgroundThe safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone.MethodsThis is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups.ResultsA total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0–2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes.ConclusionPretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.

BackgroundEndovascular thrombectomy (EVT) is the standard-of-care for proximal large vessel occlusion (LVO) stroke. Data on technical and clinical outcomes in distal vessel occlusions (DVOs) remain limited.MethodsThis was a retrospective study of patients undergoing EVT for stroke at 32 international centers. Patients were divided into LVOs (internal carotid artery/M1/vertebrobasilar), medium vessel occlusions (M2/A1/P1) and isolated DVOs (M3/M4/A2/A3/P2/P3) and categorized by thrombectomy technique. Primary outcome was a good functional outcome (modified Rankin Scale ≤2) at 90 days. Secondary outcomes included recanalization, procedure-time, thrombectomy attempts, hemorrhage, and mortality. Multivariate logistic regressions were used to evaluate the impact of technical variables. Propensity score matching was used to compare outcome in patients with DVO treated with aspiration versus stent retrieverResultsWe included 7477 patients including 213 DVOs. Distal location did not independently predict good functional outcome at 90 days compared with proximal (p=0.467). In distal occlusions, successful recanalization was an independent predictor of good outcome (adjusted odds ratio (aOR) 5.11, pConclusionsOutcomes following EVT for DVO are comparable to LVO with similar results between techniques. Techniques may exhibit different futility metrics; stent retriever thrombectomy was influenced by attempts whereas aspiration was more dependent on procedure time.

BackgroundReducing intracranial hemorrhage (ICH) can improve patient outcome in acute ischemic stroke (AIS) intervention. We sought to identify ICH risk factors after AIS thrombectomy.MethodsThis is a retrospective review of the Stroke Thrombectomy and Aneurysm Registry (STAR) database. All patients who underwent AIS thrombectomy with available ICH data were included. Multivariable regression models were developed to identify predictors of ICH after thrombectomy. Subgroup analyses were performed stratified by symptom status and European Cooperative Acute Stroke Study (ECASS) grade.ResultsThe study cohort comprised 6860 patients. Any ICH and symptomatic ICH (sICH) occurred in 25% and 7% of patients, respectively. Hemorrhagic infarction 1 (HI1) occurred in 36%, HI2 in 24%, parenchymal hemorrhage 1 (PH1) in 22%, and PH2 in 17% of patients classified by ECASS grade. Intraprocedural complications independently predicted any ICH (OR 3.8083, PConclusionsThis study identified ICH risk factors after AIS thrombectomy using real-world data. There was a propensity towards a reduced sICH risk with direct aspiration. Procedural complications and ethnicity were predictors congruent between categories of any ICH, sICH, PH1, and PH2. Further investigation of technique and ethnicity effects on ICH and outcomes after AIS thrombectomy is warranted.

Background Endovascular thrombectomy(EVT) is the standard of care for large vessel occlusion(LVO) stroke. Data on technical and clinical outcome in proximal medium vessel occlusions(pMeVOs) comparing frontline techniques remain limited. Methods We report an international multicenter retrospective study of patients undergoing EVT for stroke at 32 centers between 2015–2021. Patients were divided into LVOs(ICA/M1/Vertebrobasilar) or pMeVOs(M2/A1/P1) and categorized by thrombectomy technique. Primary outcome was 90-day good functional outcome(mRS ≤ 2). Multivariate logistic regressions were used to evaluate the impact of technical variables on clinical outcomes. Propensity score matching was used to compare outcome in patients with pMeVO treated with aspiration versus stent-retriever. Results In the cohort of 5977 LVO and 1287 pMeVO patients, pMeVO did not independently predict good-outcome(p = 0.55). In pMeVO patients, successful recanalization irrespective of frontline technique(aOR = 3.2,p Conclusions Clinical outcomes following EVT for pMeVO are comparable to those in LVOs. The golden hour or 3-pass rules in LVO thrombectomy still apply to pMeVO thrombectomy. Different techniques may exhibit different futility metrics; SR thrombectomy was more influenced by attempts whereas aspiration was more dependent on procedure time.

ImportanceThere is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy.ObjectiveTo assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI).Design, Setting, and ParticipantsIn this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022.ExposuresSelection by NCCT, CTP, or DWI.Main Outcomes and MeasuresPrimary outcome was functional independence (modified Rankin scale 0-2) at 90 days.ResultsAmong 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups.Conclusions and RelevanceIn this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.

Introduction: Mechanical thrombectomy (MT) for acute stroke is the current standard of care treatment. Level 1 evidence for efficacy of thrombectomy has been established in multiple randomized controlled trials on selective patient populations; however, the high effect size of MT had led multiple centers in the US and globally to expand their patient selection to include populations that were not studied in major trials. To provide ongoing data on MT outcomes in different patient populations from the real-world, we have initiated an international multicenter initiative, STAR (Stroke Thrombectomy and Aneurysm Registry). Methods: STAR is a multicenter and international platform to curate patient outcome data after MT for acute ischemic stroke at comprehensive stroke centers. STAR includes all patients who underwent MT for acute ischemic stroke irrespective of age, time from onset, ASPECT score, and NIHSS. Patients were curated from 01/2015 to date and is prospectively maintained. Patient charts are reviewed for demographics, baseline functioning, and admission deficits. Procedure notes are reviewed for technical variables and technical outcomes. Clinical outcomes were collected at 90-day follow-up by stroke neurologist. Results: A total of 24 centers globally have enrolled in STAR. By December 2018, the total number of enrolled and verified patients in STAR was 3,850 (mean age 69±14, 51% females). Anterior circulation strokes were treated in 89% of cases, average NIHSS on admission was 15.5±7, and 73% had pre-stroke mRS below 2. Around 51% of patients received IV-tPA. Mechanical thrombectomy was performed using aspiration (45%), stent retriever (28%), primary combined approach (24%) or intracranial stenting (3%). Successful recanalization was achieved in 84% of cases, the rate of favorable outcome (mRS 0-2) was 41%, and mortality was 25%. Complication rate was 6% and rate of symptomatic post-procedural hemorrhage was 6%. Conclusions: STAR represent a large real-world international registry for outcomes after MT, and constitutes a statistically robust platform to study real-world practice outcome in patient sub-populations that are under-represented in randomized trials. Link: https://medicine.musc.edu/departments/neurosurgery/star

Key Points Question What is the 90-day outcome for patients with stroke presenting with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5 who underwent mechanical thrombectomy? Findings In this multicenter cohort study of 2345 patients presenting with an intracranial internal carotid artery or M1 occlusion who underwent mechanical thrombectomy, 213 [9.1%] had an ASPECTS of 2 to 5, and 22% of these patients achieved favorable 90-day outcomes (modified Rankin scale score of 0-2). Patients who achieved successful recanalization were nearly 5 times more likely to achieve favorable outcomes compared with patients who had unsuccessful recanalization. Meaning This study suggests that patients with a low ASPECTS on presentation may achieve 90-day functional independence after mechanical thrombectomy if they achieve successful recanalization., Importance Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. Objective To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. Design, Setting, and Participants This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score. Exposure All patients underwent MT in one of the included centers. Main Outcomes and Measures A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset). Results A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64). Conclusions and Relevance In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window., This cohort study uses data from the Stroke Thrombectomy and Aneurysm Registry to investigate the safety and effectiveness of mechanical thrombectomy for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score of 2 to 5.

Background: Time to reperfusion following endovascular treatment (ET) strongly predicts outcomes after acute ischemic stroke (AIS). However, the impact of time may vary depending on the grade of reperfusion. We sought to assess time-outcome relationship within grades of reperfusion in the North American Solitaire Acute Stroke (NASA) registry. Methods: The investigator-initiated NASA registry recruited 24 clinical sites within North America to submit demographic, clinical, site-adjudicated angiographic, and clinical outcome data on consecutive patients treated with the Solitaire Flow Restoration device. We identified patients treated with anterior circulation ischemic stroke treated within 8 hours. The modified Thrombolysis in Cerebral Ischemia (TICI) was used wherein TICI 2 was divided in TICI 2a (< 50% reperfusion) and TICI 2b (> 50% reperfusion). We assessed the impact of time to reperfusion (onset to procedure completion time) on good outcome (modified Rankin Scale 0-2 at 3 months) in those who achieved at least TICI 2a reperfusion, independent of other relevant covariates using logistic regression analysis. We further assessed this relationship within strata of reperfusion grade. Results: Among 265 eligible patients, 209 (78.9%) had complete data (mean age 68.4 years, median NIHSS score 18). Reperfusion grade was as follows: TICI 3: 35.4%; TICI 2b: 39.7%, TICI 2a: 14.8%; TICI 0-1: 10.0%. Independent predictors of outcome at 3 months among those achieving TICI 2-3 reperfusion were: initial NIHSS score, intravenous tissue plasminogen activator use, symptomatic hemorrhage, and time to reperfusion. For each 30 minutes, the adjusted OR for time to reperfusion was 0.874 (95% CI 0.797-958). There was a significant interaction between final TICI grade and 30-minute time to reperfusion intervals (P=0.001) such that the effect of time was strongest in TICI 2a patients. Conclusions: Time to reperfusion is a strong predictor of outcome following ET for AIS with 13% decreased odds of good outcome per 30-minute delay in achieving TICI 2-3 reperfusion. However, the effect varied by TICI grade such that its greatest effect was in those achieving TICI 2a reperfusion.

To establish outcome rates for patients receiving intravenous thrombolysis based on vascular occlusion site.This is a retrospective analysis of 225 patients who had received intravenous-rt-PA for anterior circulation strokes. The occlusion-site was prospectively determined on the admission computed tomographic angiography (CTA) and divided into: large vessel occlusion (LVO) including patients with an internal carotid artery terminus or middle cerebral artery (M1/proximal M2) occlusions and no large vessel occlusion (No-LVO; distal M2/M3/ACA) including patients with either distal or no occlusions. The primary outcome was the modified Rankin score (mRS) at 90-days with a good outcome defined by mRS of 0-2.000.There were 114 (50.7%) patients in the LVO and 111 (49.3%) in the No-LVO group. A good outcome was seen in 28 (24.6%) patients in the LVO and 77 (69.4%) patients in the No-LVO group (OR .14; 95% CI: .08-.26; P.0001). Mortality was observed in 13 (11.7%) patients in the No-LVO group and 48 (42.1%) patients in the LVO group (OR .18; 95% CI: .09-.36; P.0001). Significant hemorrhage was seen in 14 (12.5%) patients in the LVO and 0 (0%) patients in the No-LVO group (P.0001). Older age (OR .96; 95% CI: .93-.98; P = .002) and presence of LVO (OR .29; 95% CI: .12-.68; P = .004) were significant independent predictors of poor outcome.CTA identification of proximal occlusions is associated with significantly poor outcomes in patients receiving intravenous stroke thrombolysis.

Background and Purpose: Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy. Methods: Retrospective analysis of consecutive patients presenting to 13 high-volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 hours from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PH) as well as 90-day poor outcome (mRS≥3), and mortality. Results: A total of 1122 patients (mean age, 67±15 years; median NIHSS, 17 [IQR13-20]) were studied. Independent predictors for HI included diabetes mellitus (OR 2.27, 95%CI [1.58-3.26], p Conclusions: In AIS patients undergoing endovascular therapy, diabetes mellitus, longer time to treatment, and Merci thrombectomy appear to be associated with a higher risk for HI while atrial fibrillation appears to result in a higher risk for PH. While both HI and PH are associated with poor outcomes only PH is associated with higher mortality.

Cerebral revascularization with extracranial-to-intracranial bypass is often required during the surgical treatment of complex intracranial aneurysms. This report is the first in which a vertebral artery (VA)-to-middle cerebral artery (MCA) bypass in conjunction with endovascular coil embolization is used in the successful treatment of a giant intracranial aneurysm.A 68-year-old man previously diagnosed with a 6-cm internal carotid artery (ICA) aneurysm presented complaining of progressing left hemiparesis and mental status changes. His aneurysm had been treated previously by common carotid artery occlusion 20 years earlier. Arteriography defined the partially thrombosed, right supraclinoid ICA aneurysm arising at the junction of the posterior communicating artery and the supraclinoid ICA.Because of the patient's worsening symptomatology, endovascular coiling with placement of a superficial temporal artery-to-MCA bypass was performed. The patient tolerated this procedure well, and his symptoms resolved. However, they recurred several months later, and imaging suggested poor right hemispheric perfusion despite a patent bypass. A VA-MCA bypass using a saphenous vein graft was then performed using the distal right VA at the level of cervical vertebra 1 (C1) as the donor vessel with a distal anastomotic site on the right MCA. Coil embolization of the aneurysm was repeated, and the feeding posterior communicating artery was sacrificed. The patient is currently asymptomatic more than 1 year after the second bypass and coil embolization.This report describes a safe and definitive treatment option for a giant intracranial ICA aneurysm using a posterior-to-anterior circulation (VA-MCA) bypass, followed by endovascular coil embolization in a patient with previous ligation of the common carotid artery. VA-MCA high-flow saphenous vein bypass followed by coil embolization is a useful technique that is especially valuable in the subset of giant aneurysm patients who have previously been treated by carotid ligation.