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Background: Acute ischemic stroke with large or medium-vessel occlusion associated with intracranial artery calcification (IAC) is an infrequent phenomenon presumably associated with intracranial atherosclerotic disease. We aimed to characterize IAC and its impact on endovascular treatment outcomes. Methods: We performed a retrospective cross-sectional study of consecutive patients with stroke treated with thrombectomy from January 2020 to July 2021 in our institution. We described IAC findings (length, density, and location pattern) on baseline noncontrast computed tomography. Patients were divided into 3 groups: IAC related to the occlusion location (symptomatic-IAC group), unrelated to the occlusion (asymptomatic-IAC group), and absence of any IAC (non-IAC group). We analyzed the association between the IAC profile and outcomes using logistic regression models. Intracranial angioplasty and stenting were considered rescue treatments. Results: Of the 393 patients included, 26 (6.6%) patients presented a symptomatic-IAC, 77 (19.6%) patients an asymptomatic-IAC, and in 290 (73.8%) patients no IAC was observed. The rate of failed recanalization (expanded Thrombolysis in Cerebral Infarction 0-2a) before rescue treatment was higher in symptomatic-IAC (65.4%) than in asymptomatic-IAC (15.6%; P P P P P P =0.004), and poor functional outcome (90-day modified Rankin Scale score ≥3; odds ratio, 3.51 [95% CI, 1.02–12.00]; P =0.046). Conclusions: The presence of IAC related to the occlusion location is associated with worse angiographic and functional outcomes. Therefore, identification of symptomatic-IAC on baseline imaging may guide optimal endovascular treatment strategy, predicting the need for intracranial stenting and angioplasty.

Mechanical thrombectomy; New device; Stroke Trombectomia mecànica; Nou dispositiu; Ictus Trombectomía mecánica; Nuevo dispositivo; Ictus Introduction The ANA™ (Anaconda Biomed) thrombectomy system is a novel stroke thrombectomy device comprising a self-expanding funnel designed to reduce clot fragmentation by locally restricting flow while becoming as wide as the lodging artery. Once deployed, ANA allows distal aspiration in combination with a stentretriever (SR) to mobilize the clot into the funnel where it remains copped during extraction. We investigate safety and efficacy of ANA™ in a first-in-man study. Methods Prospective data was collected on 35 consecutive patients treated as first line with ANA™ at a single centre. Outcome measures included per-pass reperfusion scores, symptomatic intracerebral hemorrhage (sICH), NIHSS at day 5, and mRS at 90 days. Results Median NIHSS was 12(9−18). Sites of primary occlusion were: 5 ICA, 15 M1-MCA, 15 M2-MCA. Primary performance endpoint, mTICI 2b-3 within 3 passes without rescue therapy was achieved in 91.4% (n = 32) of patients; rate of complete recanalization (mTICI 2c-3) was 65.7%. First pass complete recanalization rate was 42.9%, and median number of ANA passes 1(IQR: 1−2). In 17.1% (n = 6) rescue treatment was used; median number of rescue passes was 2(1–7), leading to a final mTICI2b-3rate of 94.3% (n = 33). There were no device related serious adverse events, and rate of sICH was 5.7% (n = 2). At 5 days median NIHSS was 1 (IQR 1−6) and 90 days mRS 0−2 was achieved in 60% of patients. Conclusions In this initial clinical experience, the ANA™ device achieved a high rate of complete recanalization with a good safety profile and favourable 90 days clinical outcomes. The study was funded by Anaconda Biomed S.L.

Background and Purpose: Mechanical thrombectomy (MT) in ischemic stroke patients with poor prestroke conditions remains controversial. We aimed to analyze the frequency of previously disabled patients treated with MT in clinical practice, the safety and clinical response to MT of patients with preexisting disability, and the disabled patient characteristics associated with a better response to MT. Methods: We studied all consecutive patients with anterior circulation occlusion treated with MT from January 2017 to December 2019 included in the Codi Ictus Catalunya registry—a government-mandated, prospective, hospital-based data set. Prestroke disability was defined as modified Rankin Scale score 2 or 3. Functional outcome at 90 days was centrally assessed by a blinded evaluator of the Catalan Stroke Program. Favorable outcome (to return at least to prestroke modified Rankin Scale at 90 days) and safety and secondary outcomes were compared with patients without previous disability. Logistic regression analysis was used to assess the association between prestroke disability and outcomes and to identify a disabled patient profile with favorable outcome after MT. Results: Of 2487 patients included in the study, 409 (17.1%) had prestroke disability (313 modified Rankin Scale score 2 and 96 modified Rankin Scale score 3). After adjustment for covariates, prestroke disability was not associated with a lower chance of achieving favorable outcome at 90 days (24% versus 30%; odds ratio, 0.79 [0.57–1.08]), whereas it was independently associated with a higher risk of symptomatic intracranial hemorrhage (5% versus 3%; odds ratio, 2.04 [1.11–3.72]) and long-term mortality (31% versus 18%; odds ratio, 1.74 [1.27–2.39]) compared with patients without disability. Prestroke disabled patients without diabetes, Alberta Stroke Program Early CT Score >8 and National Institutes of Health Stroke Scale score Conclusions: Despite a higher mortality and risk of symptomatic intracranial hemorrhage, prestroke-disabled patients return as often as independent patients to their prestroke level of function, especially those nondiabetic patients with favorable early ischemic signs profile. These data support a potential benefit of MT in patients with previous mild or moderate disability after large anterior vessel occlusion stroke.

Resumen Objetivo El objetivo es informar de nuestro estudio multicentrico de seguridad y eficacia acerca de la angioplastia con stent recuperable en el vasoespasmo secundario a la hemorragia subaracnoidea por aneurisma (HSAa). Metodos Realizamos un analisis retrospectivo de una base de datos prospectiva de pacientes consecutivos sometidos a tratamiento endovascular mediante angioplastia con stent recuperable para el vasoespasmo relacionado con la HSAa en cuatro departamentos de neurorradiologia intervencionista, entre enero de 2018 y julio de 2019. Incluimos a pacientes consecutivos mayores de 18 anos con vasoespasmo mayor del 50% de la arteria carotida interna (ACI), la arteria cerebral anterior (ACA) y/o las arterias cerebrales medias (ACM) secundario a HSAa, tratado endovascularmente mediante angioplastia con stent recuperable. Las complicaciones del procedimiento y las complicaciones clinicas se registraron como variables de seguridad. Las variables de eficacia radiologica del procedimiento se definieron como la mejora en el porcentaje de estenosis despues del tratamiento endovascular y la mejora o normalizacion del tiempo de circulacion cerebral (TCC). Resultados Incluimos 16 procedimientos de angioplastia con stent recuperable en 13 pacientes, con 33 segmentos arteriales tratados (10 ACI, 15 ACM y 8 ACA). No encontramos complicaciones de procedimiento en ningun paciente, ni complicaciones clinicas en pacientes no intubados. Todos los pacientes con TCC retrasado al principio del procedimiento, excepto uno, mostraron una mejora en el TCC. La mejora en el porcentaje de estenosis en la ACI fue de 18 ± 11,65 (media ± DE), 30,67 ± 18,45 en la ACM y 28,38 ± 15,49 en la ACA. No encontramos ninguna asociacion estadisticamente significativa entre las variables de tratamiento endovascular y la mejora en el porcentaje de estenosis. Conclusion La angioplastia con stent recuperable como tratamiento del vasoespasmo secundario a la HSAa es un procedimiento seguro y eficaz que mejora el TCC y la estenosis del vaso despues del tratamiento.

BackgroundIn patients with stroke, current guidelines recommend non-invasive vascular imaging to identify intracranial vessel occlusions (VO) that may benefit from endovascular treatment (EVT). However, VO can be missed in CT angiography (CTA) readings. We aim to evaluate the impact of consistently including CT perfusion (CTP) in admission stroke imaging protocols.MethodsFrom April to October 2020 all patients admitted with a suspected acute ischemic stroke underwent urgent non-contrast CT, CTA and CTP and were treated accordingly. Hypoperfusion areas defined by time-to-maximum of the tissue residue function (Tmax) >6 s, congruent with the clinical symptoms and a vascular territory, were considered VO (CTP-VO). In addition, two experienced neuroradiologists blinded to CTP but not to clinical symptoms retrospectively evaluated non-contrast CT and CTA to identify intracranial VO (CTA-VO).ResultsOf the 338 patients included in the analysis, 157 (46.5%) presented with CTP-VO (median Tmax >6s: 73 (29–127) mL). CTA-VO was identified in 83 (24.5%) of the cases. Overall CTA-VO sensitivity for the detection of CTP-VO was 50.3% and specificity was 97.8%. Higher hypoperfusion volume was associated with increased CTA-VO detection (OR 1.03; 95% CI 1.02 to 1.04). EVT was performed in 103 patients (30.5%; Tmax >6s: 102 (63–160) mL), representing 65.6% of all CTP-VO. Overall CTA-VO sensitivity for the detection of EVT-VO was 69.9% and specificity was 95.3%. Among patients who received EVT, the rate of false negative CTA-VO was 30.1% (Tmax >6s: 69 (46–99.5) mL).ConclusionSystematically including CTP in acute stroke admission imaging protocols may increase the diagnosis of VO and rate of EVT.

Background: Increasing efficacy of endovascular thrombectomy for ischemic stroke entails a rising demand for intervention outside Comprehensive Stroke Centers (CSC), in regions where time to treatment and transfer delays result in worse outcomes. We explore the use of a remote teleproctoring system to support vascular interventionists in a remote Local Stroke Center (LSC) to safely perform mechanical thrombectomy (MT) in patients with acute ischemic stroke. Methods: Since November 2020, a Tegus Medical Teleproctoring System was installed in a LSC (Arnau de Vilanova Hospital, Lleida) where the potential MT population could be 80-100 procedures/year, however only half that figure is currently being treated, with most patients transferred to the CSC (Vall d’Hebron Hospital, Barcelona) 160 kms away. Since the implementation of this technology, thrombectomy procedures have been performed by vascular interventionists with moderate neurovascular experience at the LSC, remotely assisted by expert neurointerventionists from the CSC. We retrospectively analyzed the safety and effectiveness of MT with the aid of this proctoring System, comparing with procedures performed in the CSC. Results: Ten MT were performed in the LSC, comprising 50% of the acute stroke cases taken to the angiosuite in one year. The thrombectomy technique was combined distal aspiration with stent-retriever in all cases. Seven thrombectomies resulted successful after the first pass (70%), achieving complete/near complete recanalization (TICI 2c/3) in 80% of the cases. Comparing with CSC, median puncture to recanalization time was 31 (26-62) vs 42 (27-67) and the rate of final succesful reperfusion (90% in LSC vs 86.5% in CSC) was similar. No technical or procedural complications were reported. At 90 days, 40% of the patients had a mRS 0-2. A survey exploring the personal experience showed that communication was considered optimal and confidence in decision making was considered high at both ends of the system. Conclusion: Tegus system seems a valuable tool to support vascular interventionists facing a rise in thrombectomy demands in distant LSCs maintaining enough safety, effectiveness and confidence during the procedures. These data should be challenged by prospective studies.

Introduction: Endovascular treatment with a covered heparin-bonded stent graft has been shown to be feasible and safe for treatment of peripheral artery disease, but its role in carotid disease remains unclear. The purpose of this study was to determine the feasibility and safety of a covered stent graft in treating cervical carotid artery disease in a consecutive series of patients with acute ischemic stroke (AIS) due to tandem lesion in a single high-volume Comprehensive Stroke Center. Methods: A retrospective review of all patients that underwent carotid endovascular interventions during mechanical thrombectomy for AIS using a self-expanding covered stent graft at Vall d'Hebron University Hospital between 2016 and 2018 was conducted. Patient clinical and angiographical characteristics as well as postoperative outcome and follow-up were recorded. Results: A total of eight patients were treated with the covered stents, and we observed significant improvement in stroke severity at 24 h in 5/8 patients (mean NIHSS 18 ± 5 vs 12 ± 8, p = 0.02). Successful recanalization (TICI 2b-3) after thrombectomy was achieved in 5/8 (62.5%) patients. One stent occluded during the procedure. At 3-month follow-up, stents were patent in three (37.5%) patients (two with mRS 3 and one with mRS 1). The stents of the remaining four patients (62.5%) were occluded (one with mRS 2 and three with mRS 4), although the patients did not show signs of stroke recurrence. Conclusion: The preliminary results of our study show that the self-expanding covered stent graft did not achieve satisfactory patency at 90-days among patients with AIS and tandem lesions, suggesting that its use in the carotid circulation may not be recommended in the context of AIS.

Background and Purpose: Different studies have pointed that CT perfusion (CTP) could overestimate ischemic core in early time window. We aim to evaluate the influence of time and collateral status on ischemic core overestimation. Methods: Retrospective single-center study including patients with anterior circulation large-vessel stroke that achieved reperfusion after endovascular treatment. Ischemic core and collateral status were automatically estimated on baseline CTP using commercially available software. CTP-derived core was considered as tissue with a relative reduction of cerebral blood flow 6 seconds with time to maximum of tissue residue function >10 seconds). Final infarct volume was measured on 24 to 48 hours noncontrast CT. Ischemic core overestimation was considered when CTP-derived core was larger than final infarct. Results: Four hundred and seven patients were included in the analysis. Median CTP-derived core and final infarct volume were 7 mL (interquartile range, 0–27) and 20 mL (interquartile range, 5–55), respectively. Median hypoperfusion intensity ratio was 0.46 (interquartile range, 0.23–0.59). Eighty-three patients (20%) presented ischemic core overestimation (median overestimation, 12 mL [interquartile range, 41–5]). Multivariable logistic regression analysis adjusted by CTP-derived core and confounding variables showed that poor collateral status (per 0.1 hypoperfusion intensity ratio increase; adjusted odds ratio, 1.41 [95% CI, 1.20–1.65]) and earlier onset to imaging time (per 60 minutes earlier; adjusted odds ratio, 1.14 [CI, 1.04–1.25]) were independently associated with core overestimation. No significant association was found with imaging to reperfusion time (per 30 minutes earlier; adjusted odds ratio, 1.17 [CI, 0.96–1.44]). Poor collateral status influence on core overestimation differed according to onset to imaging time, with a stronger size of effect on early imaging patients( P interaction Conclusions: In patients with large-vessel stroke that achieve reperfusion after endovascular therapy, poor collateral status might induce higher rates of ischemic core overestimation on CTP, especially in patients in earlier window time. CTP reflects a hemodynamic state rather than tissue fate; collateral status and onset to imaging time are important factors to consider when estimating core on CTP.

BackgroundFlow diverters have emerged in recent years as a safe and effective treatment for intracranial aneurysms, with expanding indications. The Derivo embolization device (DED) is a second-generation flow diverter with a surface finish that may reduce thrombogenicity. We report our multicenter experience evaluating its safety and efficacy.MethodsWe retrospectively analyzed all patients treated with the DED in eight centers in Spain between 2016 and 2020. Demographics, clinical data, procedural complications, morbidity and aneurysm occlusion rates were collected.ResultsA total of 209 patients with 250 aneurysms were treated (77.5% women). The majority of aneurysms were located in the internal carotid artery (86.8%) and most (69.2%) were small (ConclusionThe DED is a second-generation surface-modified flow diverter that presents an option for treatment of intracranial aneurysms with comparable safety and efficacy to other available flow diverter devices. Nonetheless, risks are not negligible, and must be balanced against the natural history risk of cerebral aneurysms, considering the tendency to widen indications for treatment of smaller and less complex lesions in day-to-day use.

Background and Purpose— Despite recanalization, almost 50% of patients undergoing endovascular treatment (EVT) experience poor outcome. We aim to evaluate the value of computed tomography perfusion as immediate outcome predictor postendovascular treatment. Methods— Consecutive patients receiving endovascular treatment who achieved recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI] 2a-3) underwent computed tomography perfusion within 30 minutes from recanalization (CTPpost). Hypoperfusion was defined as the Tmax>6 second volume; hyperperfusion as visually increased cerebral blood flow/cerebral blood volume with reduced Tmax compared with unaffected hemisphere. Dramatic clinical recovery (DCR) was defined as 24-hour National Institutes of Health Stroke Scale score ≤2 or ≥8 points drop. Delayed recovery was defined as no-DCR with favorable outcome (modified Rankin Scale score 0–2) at 3 months. Results— We included 151 patients: median National Institutes of Health Stroke Scale score 16 (interquartile range, 10–21), median admission ASPECTS 9 (interquartile range, 8–10). Final recanalization was the following: mTICI2a 11 (7.3%), mTICI2b 46 (30.5%), and mTICI3 94 (62.3%). On CTPpost, 80 (52.9%) patients showed hypoperfusion (median Tmax>6 seconds: 4 cc [0–25]) and 32 (21.2%) hyperperfusion. There was an association between final TICI and CTPpost hypoperfusion(median Tmax>6: 91 [56–117], 15 [0–37.5], and 0 [0–7] cc, for mTICI 2a, 2b, and 3, respectively, P P P P P Conclusions— Hypoperfusion on CTPpost constitutes an immediate accurate surrogate marker of success after endovascular treatment and identifies those patients with delayed recovery and favorable outcome.

The number of stentriever passes during endovascular thrombectomy impacts clinical outcomes in acute ischemic stroke. Previous studies suggest that the simultaneous double stent retriever technique (DSRT) could improve the efficacy and reduce the number of passes. We aim to analyze the degree of vessel wall injury according to the number of passes and technique (single vs. simultaneous devices). Histological changes were evaluated in renal arteries (RAs) of swine models after thrombectomy (1, 2, or 3 passes) with single stent (SSRT) and DSRT. Thrombectomy passes were performed in 12 RA: 3 samples from each artery were studied by optical microscopy to assess a vascular damage score. All thirty-six samples showed endothelial denudation and different degrees of damage in the deepest layers of the arterial wall; however, all arteries remained patent by the time of assessment. In all cases, the degree of vascular injury increased with the number of passes. Compared with a SSRT, DSRT showed a higher severity of histological damage corresponding to the damage caused by 1.4 SSRT passes. However, in distal arteries, vascular damage was relatively similar when comparing SSRT with multiple passes and DSRT with one pass. The degree of vessel injury increases with the number of passes. Even though histological damage per pass was 1.4 higher with DSRT than SSRT, short-term vessel patency was not compromised after up to 3 DSRT passes. Further studies are needed to characterize the risk-benefit ratio of the DSRT in routine clinical practice.

Introduction: Endovascular treatment (EVT) for acute ischemic stroke (AIS) between 6 and 24 h is established as a standard of care among patients selected by multiparametric neuroimaging. We aimed to explore neuroimaging parameters in late-window large vessel occlusion (LVO) patients and its association with non-contrast computed tomography (NCCT) findings. Methods: We included consecutive AIS patients within 6–24 h from the symptoms onset with LVO. We described multiparametric imaging findings, the rate of patients who fulfilled imaging perfusion criteria according to the DAWN and DEFUSE-3 trials that define the computed tomography perfusion mismatch (CTP-MM) group and its association with NCCT focused on Alberta Stroke Program Early CT Score (ASPECTS). We also analyzed the association between neuroimaging parameters and the clinical outcome determined by the 90-day modified Rankin scale (mRS). Results: We included 206 patients, of them, 176 (85.4%) presented CTP-MM and 184 (89.3%) presented an ASPECTS ≥6 on admission. The rate of CTP-MM was 90.8% in patients with ASPECTS ≥6, compared with 40.9% in those with low ASPECTS. ASPECTS was moderately correlated with ischemic core determined by cerebral blood flow p < 0.001). In EVT-treated patients (185, 89.8%), after adjusting for identifiable confounders, the presence of CTP-MM was a predictor of 90-day functional independence (OR: 3.38; 95% CI: 1.01–11.29; p = 0.048). We did not find an association between CTP-MM and 90-day functional disability (ordinal mRS shift, aOR: 1.39; 95% CI: 0.58–3.34; p = 0.459). Conclusions: A great majority of patients who presented a LVO in the late window fulfilled guidelines imaging criteria to undergo EVT, especially those with high ASPECTS (≥6). Our data suggest that NCCT with CT angiography could be a reasonable approach for AIS treatment selection also in the late window.

Background: Endovascular treatment (EVT) for acute ischemic stroke (AIS) between 6 to 24 hours is established as a standard of care among patients selected by multiparametric neuroimaging. Therefore, we aimed to explore neuroimaging parameters in late window AIS large vessel occlusion (LVO) patients and the association between findings in non-contrast computed tomography (NCCT) and multiparametric CT. Methods: We included consecutive AIS patients within 6-24 hours from symptoms onset with CTA-LVO. We studied potential associations between computed tomography mismatch defined by DAWN and/or DEFUSE-3 neuroimaging criteria (CTP-MM), infarct volume on CTP, and ASPECTS on NCCT. We also analyzed the association between neuroimaging parameters and outcome determined by 90-day mRS. Results: We included 206 patients, of which 176 (85.4%) presented CTP-MM and 184 (89.3%) presented with an ASPECTS ≥ 6 on admission. The rate of CTP-MM was 90.8% in patients with ASPECTS ≥ 6, as compared with 40.9% in those with low ASPECTS [Figure 1A] . The ASPECTS correlated with infarct core, determined by Cerebral Blood Flow [Figure 1B] . Conclusions: A great majority of patients who presented a LVO in late window fulfilled guidelines imaging criteria to undergo EVT, especially those with high ASPECTS (≥ 6). Our data suggest that NCCT with CT angiography is a reasonable approach for acute ischemic stroke treatment selection also in the late window.

Aim: We performed a histological and immune analysis of the clot in acute stroke patients to detect surrogates of stroke etiology. Methods: We conducted a prospective observational study of consecutive patients with acute stroke who underwent thrombectomy that obtained extracted thrombus (ITACAT study). Several staining were performed to evaluate red blood cells/fibrin (hematoxylin/eosin), platelets (CD61) and leucocytes (CD4, CD8 and CD20). All patients received CT angio to detect extra/intracranial vascular stenosis and 30-day cardiac monitoring to diagnose AF. According to TOAST classification the thrombi were classified in cardioembolic etiology CE (T-CE), due to symptomatic atherosclerosis (T-AT) and without any cause (T-CRYP). We excluded strokes due to double cause or incomplete workup. Results: Of the 117 patients: 30 were T-AT, 55 were T-CE and 32 were T-CRYP. T-AT patients were younger: T-AT 68 years (60-77) Vs. T-CE 75 years (68-80) Vs. T-CRYP 72 years (55-81) (p=0.034). T-AT group had higher percentage of CD4: T-AT 6.52% (4-13) Vs. T-CE (3.31% (12.9) Vs .T-CRYP 3.72% (1.5-12) (p=0.015) and lower percentage of CD61: T-AT 51.18% (34-68) Vs. CE 64.70% (19.56) Vs. CRYP 70.3% (19) (p=0.001). There were no correlation between CD4 and platelets. Both CD4 OR 1.05 (1-1.10) (p=0.020) and CD61 (OR 0.96 (0.94-0.98) (p=0.01) independently predicted T-AT from the age. Final analysis (n=400 cases) will be ended in September 2021. Conclusions: Patients with high percentage of CD4 and low percentage of CD61 are related to atherosclerosis etiology.

Artificial Intelligence (AI) can assist in vessel occlusion (VO) identification in acute stroke patients. We aim to investigate the impact of using an AI-based software for automated VO detection on non-contrast CT (AI-VO) as compared to CT-Aangiograpphy (CTA). Methods: From April to October 2020 all patients admitted with a suspected acute ischemic stroke underwent urgent non-contrast CT / CTA / CTP and were treated accordingly. Hypoperfusion areas defined as Tmax>6s on CTP (RAPID software), congruent with the clinical symptoms and a vascular territory, were considered VO (CTP-VO: ground truth). In addition, two experienced neuroradiologists blinded to CTP but not to clinical symptoms retrospectively evaluated CT and CTA to identify intracranial VO (CTA-VO). AI-VO was automatically determined by an AI-based software (Methinks). Results: Of the 338 patients included, 157 (46.5%) showed a CTP-VO (median Tmax>6s: 73[29-127]ml). Overall sensitivity to detect CTP-VO was 50.3% for CTA-VO and 66.9% for AI-VO; specificity was 97.8% for CTA-VO and 86.2% for AI-VO. EVT was performed in 103 patients (EVT-VO: 65.6% of CTP-VO; Tmax>6s: 102[63-160]ml); sensitivity to detect EVT-VO was 69% for CTA-VO and 79.6% for AI-VO; specificity was 95.3% for CTA-VO and 79.6% for AI-VO. The probability to detect a CTP-VO was higher with AI than with CTA for distal occlusions (figure). Accordingly, AI-VO sensitivity was higher than CTA-VO for angiographically confirmed M2/M3-MCA occlusions (80.7% vs 34.6%; p=0.002) but not for M1-MCA/ICA occlusions (82.1% Vs 88.1%;p=0.467). Conclusion: AI-assisted vessel occlusion identification on non-contrast CT may be a useful tool in acute stroke evaluation, especially for distal VO identification, potentially increasing endovascular treatment in these cases.

Introduction: Our objective is to identify thrombus composition associated with first pass recanalization (FPR) in mechanical thrombectomy (MT). Methods: Intracranial thrombi obtained in MT were divided in two equal parts. One part was analyzed with anatomopathological studies to quantify fibrin, red-blood cell( Hematoxilin & Eosin) and platelets( cd61 Immunohistochemical staining ) , the other part was analyzed by flow cytometry to quantify leukocyte populations (granulocytes, lymphocytes and monocytes) and their relative proportions . FPR were defined as ≥ mTICI 2b after first pass in MT. Thrombi composition, baseline variables (demographics, previos use of antiplatelets or anticoagulants, blood pressure and blood glucose at hospital arrival ) etiology, intravenous fibrinolysis, ASPECTS score and first attempt thrombectomy devices: direct aspiration, stent retriever or combinations were compared between FPR and Non-FPR groups. Results: Fifty percent (38/76) of the cases analyzed obtained FPR. There were no differences in baseline variables , etiology, Aspects score, previous use of fibrinolysis or type of device used for MT. The thrombi obtained with FPR presented higher proportion of red blood cells (33.64% vs 18.16% p = 0.048) and lymphocytes (10.07% vs 4.43% p = 0.042) and lower proportion of platelets (61, 48% vs 67.26% p = 0.042) in comparison to non-FPR group. The proportion of platelets was an independent marker of FPR (OR 0.97; CI 0.95-0.99). There was an inverse correlation between the proportion of platelets and lymphocytes (rho -0.44, p Conclusion: Platelets proportion in intracranial thrombus is an independent marker of first pass recanalization. Inverse relationship between lymphocytes and platelets may be a target for future reperfusion treatments

OBJECTIVEThe goal of this study was to evaluate the effectiveness and safety of a new noncompletely occlusive net-assisted remodeling technique in which the Cascade net device is used for temporary bridging of intracranial aneurysms.METHODSBetween July 2018 and May 2019, patients underwent coil embolization with the Cascade net device within 4 centers in Europe. Analysis of angiographic (modified Raymond-Roy classification [MRRC]) and clinical outcomes data was conducted immediately following treatment and at the 6-month follow-up.RESULTSFifteen patients were included in the study (mean age 58 ± 13 years, 11/15 [73.3%] female). Ten patients had unruptured aneurysms, and 5 presented with ruptured aneurysms with acute subarachnoid hemorrhage. The mean aneurysm dome length was 6.27 ± 2.33 mm and the mean neck width was 3.64 ± 1.19 mm. Immediately postprocedure, MRRC type I (complete obliteration) was achieved in 11 patients (73.3%), whereas a type II (residual neck) was achieved in 4 patients (26.7%). Follow-up examination was performed in 7/15 patients and showed stabilization of aneurysm closure with no thromboembolic complications and only 1 patient with an increased MRRC score (from I to II) due to coil compression.CONCLUSIONSInitial experience shows that the use of a new noncompletely occlusive net-assisted remodeling technique with the Cascade net device may be safe and effective for endovascular coil embolization of intracranial aneurysms.

Introduction: Different studies have pointed that CT perfusion(CTP) could overestimate ischemic core in early time window. We aim to evaluate the influence of time and collateral status on ischemic core overestimation. Methods: Retrospective single-center study including patients with anterior circulation large-vessel stroke that achieved reperfusion after endovascular treatment. Ischemic core and collateral status were automatically estimated on baseline CTP using available software. CTP-derived core was considered as tissue with a relative reduction of cerebral blood flow 6 seconds with Tmax>10 seconds, HIR). Final infarct was measured on 24-48 hours non-contrast CT. Ischemic core overestimation was considered when CTP-derived core was larger than final infarct. Results: Four-hundred and seven patients were included in the analysis. Median CTP-derived core and final infarct were 7mL(IQR 0-27) and 20mL(IQR 5-55), respectively. Median HIR was 0.46(IQR 0.23-0.59). 83 patients(21%) presented ischemic core overestimation(median overestimation, 12mL(IQR 5-41)). Multivariable logistic regression analysis adjusted by CTP-derived core and confounding variables showed that poor collateral status (per 0.1 HIR increase, adjusted odds ratio(aOR) 1.41, 95% confidence interval(CI)1.20-1.65) and earlier onset to imaging time(per 60 minutes earlier, aOR 1.14, CI1.04-1.25) were independently associated with ischemic core overestimation. No significant association was found with imaging to reperfusion time(per 30 minutes earlier, aOR 1.17 CI0.96-1.44). Poor collateral status influence on ischemic core overestimation differed according to onset to imaging time, with a stronger size of effect on early imaging patients(pinteraction Conclusion: In patients with large vessel stroke that achieve reperfusion after endovascular therapy, poor collateral status might induce higher rates of ischemic core overestimation on CTP, especially in patients in earlier window time. CTP reflects a hemodynamic state rather than tissue fate; collateral status and onset to imaging time are important factors to estimate ischemic core on CTP.

Background and Purpose: We aim to evaluate if good collateral flow (CF) modifies endovascular therapy (EVT) efficacy on large-vessel stroke. To do that, we used final degree of reperfusion and number of device-passes performed, factors previously associated with better functional outcome, as main outcome measures. Methods: Single-center retrospective study including consecutive stroke patients receiving EVT for anterior circulation large-vessel stroke. CF degree was assessed on CT angiography before EVT using a previously validated 4-grade score. Final degree of reperfusion, using modified Thrombolysis in Cerebral Ischemia (mTICI), and number of device-passes performed were prospectively collected. Multivariable analysis was performed to evaluate the influence of collateral flow degree on final degree of reperfusion and number of device-passes performed. Results: Six hundred twenty-six patients were included in the study; 369 patients (59%) presented good collateral flow on CT angiography. Five hundred twenty-two patients (84%) achieved successful reperfusion (mTICI 2B-3) after EVT, 304 (48%) of them with a final mTICI 2C-3. Median number of device-passes was 2 (interquartile range, 1–3). Good CF was independently associated with better final degree of reperfusion (shift analysis for mTICI0-2A/2B/2C-3%, poor CF 19/38/43 versus good CF 15/32/53, adjusted odds ratio, 1.51 [95% CI, 1.08–2.11]). Poor CF was independently associated with higher number of device-passes performed to achieve successful reperfusion (mTICI2B-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.59, [95% CI, 1.09–2.31]) and complete reperfusion (mTICI2C-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.70 [95% CI, 1.04–2.90]). Conclusions: Patients with good CF treated with EVT experience higher rates of successful reperfusion with lower number of device-passes. CF may facilitate thrombus retrieval and prevent distal embolization of clot fragments, improving device-passes efficacy.

The aim of the study was to find markers of high-risk cardioembolic etiology (HRCE) in patients with cryptogenic strokes (CS) through the analysis of intracranial clot by flow cytometry (FC). A prospective single-center study was designed including patients with large vessel occlusion strokes. The percentage of granulocytes, monocytes, lymphocytes, and monocyte-to-lymphocyte ratio (MLr) were analyzed in clots extracted after endovascular treatment (EVT) and in peripheral blood. Large arterial atherosclerosis (LAA) strokes and high-risk cardioembolic (HRCE) strokes were matched by demographics and acute reperfusion treatment data to obtain FC predictors for HRCE. Multilevel decision tree with boosting random forest classifiers was performed with each feature importance for HRCE diagnosis among CS. We tested the validity of the best FC predictor in a cohort of CS that underwent extensive diagnostic workup. Among 211 patients, 178 cases underwent per-protocol workup. The percentage of monocytes (OR 1.06, 95% CI 1.01-1.11) and MLr (OR 1.83, 95% CI 1.12-2.98) independently predicted HRCE diagnosis when LAA clots (n = 28) were matched with HRCE clots (n = 28). Among CS (n = 82), MLr was the feature with the highest weighted importance in the multilevel decision tree as a predictor for HRCE. MLr cutoff point of 1.59 yield sensitivity of 91.23%, specificity of 44%, positive predictive value of 78.79%, and negative predictive value of 68.75 for HRCE diagnosis among CS. MLr >= 1.6 in clot analysis predicted HRCE diagnosis (OR, 6.63, 95% CI 1.85-23.71) in a multivariate model adjusted for age. Clot analysis by FC revealed high levels of monocyte-to-lymphocyte ratio as an independent marker of cardioembolic etiology in cryptogenic strokes.

Background An increased rate of thrombotic events has been associated to Coronavirus Disease 19 (COVID-19) with a variable rate of acute stroke. Our aim is to uncover the rate of acute stroke in COVID-19 patients and identify those cases in which a possible causative relationship could exist. Methods We performed a single-center analysis of a prospective mandatory database. We studied all patients with confirmed COVID-19 and stroke diagnoses from March 2nd to April 30th. Demographic, clinical, and imaging data were prospectively collected. Final diagnosis was determined after full diagnostic work-up unless impossible due to death. Results Of 2050 patients with confirmed SARS-CoV-2 infection, 21 (1.02%) presented an acute ischemic stroke 21 and 4 (0.2%) suffered an intracranial hemorrhage. After the diagnostic work-up, in 60.0% ischemic and all hemorrhagic strokes patients an etiology non-related with COVID-19 was identified. Only in 6 patients the stroke cause was considered possibly related to COVID-19, all of them required mechanical ventilation before stroke onset. Ten patients underwent endovascular treatment; compared with patients who underwent EVT in the same period, COVID-19 was an independent predictor of in-hospital mortality (50% versus 15%; Odds Ratio, 6.67; 95% CI, 1.1-40.4; p 0.04). Conclusions The presence of acute stroke in patients with COVID-19 was below 2% and most of them previously presented established stroke risk factors. Without other potential cause, stroke was an uncommon complication and exclusive of patients with a severe pulmonary injury. The presence of COVID-19 in patients who underwent EVT was an independent predictor of in-hospital mortality.

Introduction Direct transfer to angiosuite (DTAS) has consistently shown to be effective and safe shortening in-hospital workflows and encouraging long-term outcome benefits. In order to generalize DTAS an organizational and manpower effort is necessary. We aim to perform a cost-effective analysis of the implementation of a new angiography suite primarily dedicated to DTAS of stroke patients that will allow generalization of this pathway. Material and Methods 61 patients who underwent endovascular treatment (EVT) following DTAS were matched for baseline variables to 117 patients who underwent conventional imaging protocol before EVT. An economic model based on current data was developed to assess the short and long term clinical and economic implications. The DTAS development scenario estimates a gradual 20% increase of DTAS rate for 4 years followed by a stable 80% rate of DTAS. Initial investment and additional organizational costs were included: 4M €. A cost-effective study compared the DTAS development scenario (SC1) to a scenario with no organizational changes (SC2) over 10 years. Results The 10 year model included 1775 EVT patients in each scenario: SC1 68% DTAS Vs SC2 0% DTAS. SC1 would be associated with better functional independence rates (mRS 0–2: 45.8% versus 40.2% p=0.04) and a quality-adjusted life-years gain of 0.12 per patient. Despite the additional investment, SC1 development was associated with an estimated 15.1% reduction (26.25M €) of total costs (173.749M €). Cost saving was mainly due to long-term associated costs related with patient disability (€ 26.4 million). Conclusions Our economic model predicts that the development of a DTAS program is cost effective. Disclosures M. Requena: None. V. Seguel: None. M. Olive-Gadea: None. A. Garcia-Tornel: None. A. Vilaseca: None. N. Rodriguez-Villatoro: None. M. Deck: None. J. Juega: None. S. Boned: None. M. Muchada: None. C. Pinana: None. J. Pagola: None. D. Rodriguez-Luna: None. D. Hernandez: None. M. Rubiera: None. C. Molina: None. A. Tomasello: None. M. Ribo: 2; C; Medtronic, Stryker, Johnson and Johnson, Anaconda Biomed, Apta Targets.

Background and Purpose— Direct transfer to angiography-suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The magnitude of the improvement of good outcome rates in function of time depends of several factors. We aim to analyze the benefit of DTAS according to time from symptom onset. Methods— Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to computed tomography (directly transferred to computed tomography) from February 2016 to June 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline National Institutes of Health Stroke Scale score (±2 points), and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (modified Rankin Scale score, 0–2) and safety variables stratified in less or more than 3 hours from onset to arrive. Results— There were no significant differences regarding age, sex, or baseline National Institutes of Health Stroke Scale score. Median door-to-groin time was shorter in the DTAS patients (16 [3–21] minutes versus 70 [41.5–98.5]; P P =0.01) and a lower rate of symptomatic hemorrhagic transformation (4.6% versus 10.9%, P P =0.01). Better outcome in DTAS was observed in patients admitted in the 0 to 3 hours form onset window (n=156, odds ratio 2.63 [95% CI, 1.31–5.28]; P P =0.2). Conclusions— DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.

Introduction Mechanical thrombectomy (MT) with combined treatment including both a stent retriever and distal aspiration catheter may improve recanalization rates in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Here, we evaluated the effectiveness and safety of the REACT aspiration catheter used with a stent retriever. Methods This prospective study included consecutive adult patients who underwent MT with a combined technique using REACT 68 and/or 71 between June 2020 and July 2021. The primary endpoints were final and first pass mTICI 2b-3 and mTICI 2c-3 recanalization. Analysis was performed after first pass and after each attempt. Secondary safety outcomes included procedural complications, symptomatic intracranial hemorrhage (sICH) at 24 h, in-hospital mortality, and 90-day functional independence (modified Rankin Scale [mRS] 0–2). Results A total of 102 patients were included (median age 78; IQR: 73–87; 50.0% female). At baseline, median NIHSS score was 19 (IQR: 11–21), and ASPECTS was 9 (IQR: 8–10). Final mTICI 2b-3 recanalization was achieved in 91 (89.2%) patients and mTICI 2c-3 was achieved in 66 (64.7%). At first pass, mTICI 2b-3 was achieved in 55 (53.9%) patients, and mTICI 2c-3 in 37 (36.3%). The rate of procedural complications was 3.9% (4/102), sICH was 6.8% (7/102), in-hospital mortality was 12.7% (13/102), and 90-day functional independence was 35.6% (36/102). Conclusion A combined MT technique using a stent retriever and REACT catheter resulted in a high rate of successful recanalization and first pass recanalization in a sample of consecutive patients with AIS due to LVO in clinical use.

IMPORTANCE: Direct transfer to angiography suite (DTAS) for patients with suspected large vessel occlusion (LVO) stroke has been described as an effective and safe measure to reduce workflow time in endovascular treatment (EVT). However, it is unknown whether DTAS improves long-term functional outcomes. OBJECTIVE: To explore the effect of DTAS on clinical outcomes among patients with LVO stroke in a randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS: The study was an investigator-initiated, single-center, evaluator-blinded randomized clinical trial. Of 466 consecutive patients with acute stroke screened, 174 with suspected LVO acute stroke within 6 hours of symptom onset were included. Enrollment took place from September 2018 to November 2020 and was stopped after a preplanned interim analysis. Final follow-up was in February 2021. INTERVENTIONS: Patients were randomly assigned (1:1) to follow either DTAS (89 patients) or conventional workflow (85 patients received direct transfer to computed tomographic imaging, with usual imaging performed and EVT indication decided) to assess the indication of EVT. Patients were stratified according to their having been transferred from a primary center vs having a direct admission. MAIN OUTCOMES AND MEASURES: The primary outcome was a shift analysis assessing the distribution of the 90-day 7-category (from 0 [no symptoms] to 6 [death]) modified Rankin Scale (mRS) score among patients with LVO whether or not they received EVT (modified intention-to-treat population) assessed by blinded external evaluators. Secondary outcomes included rate of EVT and door-to-arterial puncture time. Safety outcomes included 90-day mortality and rates of symptomatic intracranial hemorrhage. RESULTS: In total, 174 patients were included, with a mean (SD) age of 73.4 (12.6) years (range, 19-95 years), and 78 patients (44.8%) were women. Their mean (SD) onset-to-door time was 228.0 (117.9) minutes, and their median admission National Institutes of Health Stroke Scale score was 18 (interquartile range [IQR], 14-21). In the modified intention-to-treat population, EVT was performed for all 74 patients in the DTAS group and for 64 patients (87.7%) in the conventional workflow group (P = .002). The DTAS protocol decreased the median door–to–arterial puncture time (18 minutes [IQR, 15-24 minutes] vs 42 minutes [IQR, 35-51 minutes]; P

Background and Purpose— First pass (FP) recanalization has been shown to be a predictor of favorable outcome in endovascular treatment of stroke. The reasons why FP recanalization leads to better outcome as compared with multiple passes (MP) are unknown. We aim to investigate the recanalization pattern and its relationship with outcome. Methods— Six hundred nine consecutive patients underwent endovascular treatment. Recanalization was defined as modified Thrombolysis in Cerebral Infarction score 2B-3. Favorable outcome was defined as modified Rankin Scale score of 0 to 2 at 90 days. Sudden recanalization (SR) was considered when modified Thrombolysis in Cerebral Infarction score varied from 0-1 to 2B-3 in a single pass. Progressive recanalization (PR) was considered if modified Thrombolysis in Cerebral Infarction score 2A was achieved at an interim pass before achieving recanalization. Patients were also categorized as recanalizers at FP, MP, or nonrecanalizers. Results— Five hundred nine (83.9%) patients achieved recanalization. SR was achieved in 378 (62.1%) patients; 280 (46%) were FP-SR, and 98 (16.1%) were MP-SR. MP-PR was achieved in 131 (21.5%) patients. Rates of favorable outcome were similar between patients with FP-SR (57.5%) and MP-SR (57.1%; odds ratio [OR], 0.9 [CI, 0.53–1.54]; P =0.7) but lower in MP-PR (29.8%; OR, 3.33 [CI, 1.71–5.63]; P P P P P P P =0.937). Conclusions— SR strongly predicts favorable outcome in patients undergoing endovascular treatment, even after previous unsuccessful attempts. PR may reflect clot fragmentation and embolization due to more friable composition, leading to worse outcomes. Prospective studies with independent assessment of recanalization pattern should validate these results.

Introduction: Perfusion imaging has emerged as an imaging tool to select patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) for endovascular treatment (EVT). We aim to compare an automated method to assess the infarct ischemic core (IC) in Non-Contrast Computed Tomography (NCCT) with Computed Tomography Perfusion (CTP) imaging and its ability to predict functional outcome and final infarct volume (FIV). Methods: 494 patients with anterior circulation stroke treated with EVT were included. Volumetric assessment of IC in NCCT (eA-IC) was calculated using eASPECTS™ (Brainomix, Oxford). CTP was processed using availaible software considering CTP-IC as volume of Cerebral Blood Flow (CBF) Results: Median eA-IC and CTP-IC were 16 (IQR 7-31) and 8 (IQR 0-28), respectively. 419 patients (85%) achieved complete recanalization, and their median FIV was 17.5cc (IQR 5-52). Good functional outcome was achieved in 230 patients (47%). EA-IC and CTP-IC had moderate correlation between them (r=0.52, p40cc, OR 1.5, IC1.3-1.8, p Conclusion: Automated volumetric assessment of infarct core in NCCT has similar performance predicting prognosis and final infarct volume than CTP. Prospective studies should evaluate a NCCT-core / vessel occlusion penumbra missmatch as an alternative method to select patients for EVT.

Background and Purpose: Extracranial internal carotid artery (ICA) lesion in the setting of tandem occlusions is a therapeutic challenge, and hemorrhagic transformation (HT) is one of the leading causes of poor clinical outcome. We aimed to determine determinants of HT for tandem occlusions undergoing emergent extracranial ICA stenting during endovascular treatment (EVT). Methods: We performed a prospective, observational cohort study of consecutive patients with non-cardioembolic ischemic stroke due to tandem occlusion who underwent EVT with extracranial ICA stent placement during the procedure from April 2013 to June 2019 in a single stroke center. We compared clinical (vascular risk factors, previous antiplatelet treatment, and IV rtPA), radiological (ASPECTS at admission and in-stent thrombosis at 24 hours) and serological (platelet count, fibrinogen, total cholesterol, HDL-cholesterol, and LDL-cholesterol) parameters according to the presence of HT in 24 hours CT-scan. Results: One-hundred and eight patients were included: 78.7% were men, mean age 68.5±14.3 years, median time from symptoms onset to treatment was 220 (150-337.5) minutes, median ASPECTS at admission was 9 (8-10). Eighty-six (79.6%) patients presented an extracranial ICA occlusion, and 22 (20.4%) a high-grade (>50%) stenosis. In 88 (81.5%) patients the etiology of extracranial ICA lesion was ateroma, and in 20 (18.5%) was a dissection. Intravenous rtPA was administered in 47 (43.5%) patients. Successful recanalization (mTICI ≥2b) was achieved in 83 (76.9%) patients, and extracranial ICA recanalization in 108 (100%) patients. Type 2 diabetes (OR 1.5, 95% CI 1.1-3.5), higher fibrinogen levels (OR 4.6, 95% CI 1.6-12.9), and ASPECTS Conclusions: Patients with a non-cardioembolic ischemic stroke due to tandem occlusion who present type 2 diabetes, higher fibrinogen levels, or ASPECTS

Introduction: First pass recanalization (FPR) is known to be a strong predictor of good outcome in endovascular treatment (EVT) of stroke. The reasons why FPR leads to better outcome than if achieved in multiple-passes (MP) are unknown. We aim to investigate the recanalization pattern and its relation with good outcome. Methods: 609 consecutive patients underwent EVT in the anterior circulation at a single stroke center. Demographic and imaging characteristics, number of passes and recanalization pattern were recorded. Complete recanalization was defined as mTICI2b-3 at the end of EVT. Good functional outcome was defined as modified Rankin scale (mRs) 0-2 at 90 days. Sudden recanalization(SR) was considered when mTICI score varied from 0-1 to 2B-3 in a single pass. Progressive recanalization (PR) was considered if mTICI 2a was achieved at an interim pass before achieving complete recanalization. Patients were categorized as recanalizers at first-pass (FP) and multiple-passes (MP) or non-recanalizers (NR). 70 (10.3%) patients in MP group were excluded due to missing procedural data. Results: 509 (83.9%) patients achieved complete recanalization. SR was achieved in 378 (62.1%) patients; 280 (46%) were FP-SR and 98 (16.1%) were MP-SR. MP-PR was achieved in 131 (21.5%) patients. Rates of good functional outcome depending on recanalization pattern were: FP-SR 57.5%, MP-SR 57.1% (FP-SR vs MP-SR, OR 0.9 CI 0.53-1.54, p=0.7), MP-PR 29.8% (MP-SR vs MP-PR, OR 3.06 CI 1.66-5.62, p Conclusions: Sudden recanalization is a strong predictor of good functional outcome in patients undergoing EVT, even after previous unsuccessful attempts. Progressive recanalization may reflect clot fragmentation and embolization due to more friable composition, leading to worse outcomes. Benefits of first pass effect are driven by sudden recanalization.

Approximately 30% of strokes are cryptogenic despite an exhaustive in-hospital work-up Analysis of clot composition following endovascular treatment could provide insight into stroke etiology. Objective: To evaluate different population of lymphocytes in the clot analyses obtained in the hyper acute phase of stroke, as an early marker of etiology of ischemic stroke. Material and Methods: Consecutively, intracranial clots were obtained in the hyper acute phase of stroke in endovascular treatment with solitaire device and analyzed by flow cytometry quantifying the relative proportion ( RP ) of main leukocyte, monocyte, granulocyte and total lymphocyte populations and lymphocyte sub populations of B line (CD19), T line (CD3, CD4, CD8), Cytotoxic and Natural Killer. The results were expressed as percentages (%). All patients included were studied with complete diagnostic work up that included at least complete arteriography , aortic Angio CT , complete cardiac holter monitoring until one month form hospital discharge and transthoracic echocardiography , The etiology of stroke was categorized: cardiomebolic ( major structural heart disease and Atrial Fibrillation) atherosclerotic ( AT) (severe symptomatic arterial stenosis or complicated aortic atheromatosis ulceration confirmed by trans esophageal echocardiography ) ,infrequent causes or unknown etiology . Results: 80 patients were included. 22, 5% AT (n = 18) strokes were associated with higher RP lymphocytes PR (16.55 % vs. 5. 37 % p < 0,001), CD4 RP (5.74% vs. 2.03 % p = 0.001) and RP CD 19 (2.26 % vs. 0.37 % p< 0,001) in clot cytometry Analysis than rest of of strokes etiologies (n= 72). Multivariate logistic regression analysis showed that RP CD 19 (OR 3.51; 95% CI, 1, 81-6.81) was an independent predictor of atherosclerotic stroke .The ROC curve showed AUC (0.83) (95% CI, 0.72-0.95) for RP CD 19 for diagnosis of atherosclerotic strokes with flow cytometry of the clot ,obtained in emergent endovascular treatment. Conclusion: High expression of lymphocytes B in intracranial thrombi is a marker of atherosclerotic etiology.