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Introduction Endovascular therapy has shown to be safe and effective for the treatment of cerebral dural arteriovenous fistulas; however, recurrence after complete occlusion is not uncommon, and the timing of recurrence remains unknown. Methods A retrospective single-center cohort study was conducted from January 2005 to December 2020. Patients with high-grade (≥Borden II–Cognard IIB) dural arteriovenous fistulas treated with endovascular therapy were included in this study. Clinical and angiographic characteristics were collected for hospitalization and at follow-up. Results A total of 51 patients with a median age of 61 years were studied; 57% were female. High-flow symptoms related to the high-flow fistula were the most common presentation (67%), and 24% presented with intracranial hemorrhage. Transverse-sigmoid (26%) and cavernous (26%) sinuses were the most common dural arteriovenous fistula locations. A total of 40 patients (70%) had middle meningeal arterial feeders and 4 (7%) had deep cerebral venous drainage. The mean number of embolization procedures per patient was 1.4. Transarterial access was the most frequent approach (61%). Onyx alone was the most common embolic agent (26%). Complete occlusion rate was achieved in 46 patients (80.1%). Last mean radiographic follow-up time was 26.7 months for all 57 dural arteriovenous fistulas. Dural arteriovenous fistula recurrence after radiographic resolution at last treatment was seen in six cases (6/46, 13.1%). Mean time for recurrence was 15.8 months. Mean time of last clinical follow-up was 46.1 months for the 51 patients (100%). A total of 10 (20%) experienced any procedural complications, among which two (4%) became major thromboembolic events. Conclusion Endovascular therapy is safe and effective for the treatment of high-grade dural arteriovenous fistulas. Given the significant recurrence rate of embolized dural arteriovenous fistulas even after 2 years, long-term angiographic follow-up might be needed.

The availability of cone-beam CT perfusion (CBCTP) in angiography suites may improve large-vessel occlusion (LVO) triage and reduce reperfusion times for patients presenting during extended time window. We aim to evaluate the perfusion maps correlation and agreement between multidetector CT perfusion (MDCTP) and CBCTP when obtained sequentially in patients undergoing endovascular therapy.This is a prospective, pilot, single-arm interventional cohort study of consecutive patients with anterior circulation LVO. All patients underwent MDCTP and CBCTP prior to endovascular therapy, generating cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum/time to peak contrast concentration maps. We compared the two imaging modalities using three different methods: (1) six regions of interest (ROIs) placed in the anterior circulation territory; (2) ROIs placed in all 10 Alberta Stroke Program Early CT Score regions; and (3) ROI drawn around the entire ischemic area. ROI ratios (unaffected/affected area) were compared for all sequences in each method. We used the intraclass correlation coefficient to calculate the correlation between the studies. Bland-Altman plots were also created to measure the degree of agreement. Finally, a sensitivity analysis was done comparing both modalities in patients with low infarct growth rate.Fourteen patients were included (median age 81 years [74-87], 50% males, median National Institutes of Health Stroke Scale 19 [14-22]). Median time between studies was 42 minutes (interquartile range 29-61). Independently of the method used, we found moderate to excellent correlation in CBF, CBV, and MTT between modalities. CBF correlation further improved in patients with low infarct growth.These results demonstrate promising accuracy of CBCTP in evaluating ischemic tissue in patients presenting with LVO ischemic stroke.

ImportanceApproximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear.ObjectiveTo evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs.Design, Setting, and ParticipantsThis cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography.ExposuresPatients with TLs were divided into CAS vs nonstenting groups.Main Outcomes and MeasuresPrimary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days.ResultsOf 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups.Conclusions and RelevanceIn this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

Background and PurposeWe aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions (TLs) and whether using intraprocedural antiplatelet therapy (APT) influences MT’s safety with IVT treatment.MethodsThis is a sub-analysis of a pooled, international multicenter cohort of patients with acute anterior circulation TLs treated with MT. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2). Additional outcomes included hemorrhagic transformation (HT), successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3), complete reperfusion (mTICI 3), favorable functional outcome (90-day modified Rankin score [mRS] 0-2), excellent functional outcome (90-day mRS 0-1), in-hospital mortality, and 90-days mortality.ResultsOf 691 patients, 599 were included (255 underwent IVT+MT and 344 MT alone). There was no difference in the risk of sICH (aOR=1.43; 95%CI:0.72–2.87;p=0.308), PH2 (aOR=1.14; 95%CI:0.57– 2.28;p=0.705), and HT (aOR=0.92; 95%CI:0.54–1.57;p=0.751) between the IVT+MT and MT alone groups after adjusting for confounders. There was an IVT-by-intraprocedural APT interaction for sICH (pinteraction=0.031). Administration of IVT was associated with an increased risk of sICH in patients who received IV-APT (aOR=3.58; 95%CI:1.17–10.89;p=0.025). The IVT+MT group had higher odds of 90-days mRS 0-2 (aOR=1.76; 95%CI:1.05–2.94;p=0.030). The odds of successful reperfusion, complete reperfusion, 90-days mRS 0-1, in-hospital mortality, or 90-days mortality did not differ between the IVT+MT vs. MT alone groups.ConclusionOur study showed that the combination of IVT with MT for TL did not increase the overall risk of sICH, PH2, or overall HT independently of the cervical revascularization technique used. However, intraprocedural IV-ATP during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT prior to MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcome at 90 days.

Despite successful endovascular therapy, a proportion of stroke patients exhibit long-term functional decline, regardless of the cortical reperfusion. Our objective was to evaluate the early activation of the adaptive immune response and its impact on neurological recovery in patients with large vessel occlusion (LVO).Nineteen (13 females, 6 males) patients with acute LVO were enrolled in a single-arm prospective cohort study. During endovascular therapy (EVT), blood samples were collected from pre and post-occlusion, distal femoral artery, and median cubital vein (controls). Cytokines, chemokines, cellular and functional profiles were evaluated with immediate and follow-up clinical and radiographic parameters, including cognitive performance and functional recovery.In the hyperacute phase (within hours), adaptive immune activation was observed in the post-occlusion intra-arterial environment (post). Ischemic vascular tissue had a significant increase in T-cell-related cytokines, including IFN-γ and MMP-9, while GM-CSF, IL-17, TNF-α, IL-6, MIP-1a, and MIP-1b were decreased. Cellularity analysis revealed an increase in inflammatory IL-17+ and GM-CSF+ helper T-cells, while natural killer (NK), monocytes and B-cells were decreased. A correlation was observed between hypoperfused tissue, infarct volume, inflammatory helper, and cytotoxic T-cells. Moreover, helper and cytotoxic T-cells were also significantly increased in patients with improved motor function at 3 months.We provide evidence of the activation of the inflammatory adaptive immune response during the hyperacute phase and the association of pro-inflammatory cytokines with greater ischemic tissue and worsening recovery after successful reperfusion. Further characterization of these immune pathways is warranted to test selective immunomodulators during the early stages of stroke rehabilitation.

INTRODUCTION: We have demonstrated in a multicenter cohort that the COVID-19 pandemic has led to a delay in intravenous thrombolysis (IVT) among stroke patients. Whether this delay contributes to meaningful short-term outcome differences in these patients warranted further exploration. METHODS: We conducted a nested observational cohort study of adult acute ischemic stroke patients receiving IVT from 9 comprehensive stroke centers across 7 U.S states. Patients admitted prior to the COVID-19 pandemic (1/1/2019-02/29/2020) were compared to patients admitted during the early pandemic (3/1/2020-7/31/2020). Multivariable logistic regression was used to estimate the effect of IVT delay on discharge to hospice or death, with treatment delay on admission during COVID-19 included as an interaction term. RESULTS: Of the 676 thrombolysed patients, the median age was 70 (IQR 58-81) years, 313 were female (46.3%), and the median NIHSS was 8 (IQR 4-16). Longer treatment delays were observed during COVID-19 (median 46 vs 38 min, p = 0.01) and were associated with higher in-hospital death/hospice discharge irrespective of admission period (OR per hour 1.08, 95% CI 1.01-1.17, p = 0.03). This effect was strengthened after multivariable adjustment (aOR 1.15, 95% CI 1.07-1.24, p < 0.001). There was no interaction of treatment delay on admission during COVID-19 (pinteraction = 0.65). Every one-hour delay in IVT was also associated with 7% lower odds of being discharged to home or acute inpatient rehabilitation facility (aOR 0.93, 95% CI 0.89-0.97, p < 0.001). CONCLUSION: Treatment delays observed during the COVID-19 pandemic led to greater early mortality and hospice care, with a lower probability of discharge to home/rehabilitation facility. There was no effect modification of treatment delay on admission during the pandemic, indicating that treatment delay at any time contributes similarly to these short-term outcomes.

Despite advancement in mechanical thrombectomy (MT) techniques, 10–30% of MT for large vessel occlusions (LVO) are unsuccessful. Current prediction models fail to address the association between patient-specific factors and reperfusion. We aimed to evaluate objective, easily reproducible, admission clinical and radiological biomarkers that predict unsuccessful MT. We analyzed consecutive anterior LVO MT patients at two comprehensive stroke centers. The primary outcome was unsuccessful reperfusion defined by a modified thrombolysis in cerebral infarction (mTICI) score of 0–2a. We quantitatively assessed the hyperdense vessel sign by measuring Hounsfield units (HU) on admission computed tomography (CT). Receiver operating characteristic (ROC) curves were plotted to estimate the predictive value of quantitative hyperdense middle cerebral artery (MCA) measurements (delta and ratio) and of the final model for mTICI scores. We performed multivariable logistic regression to analyze associations with outcomes. Out of 348 patients 87 had unsuccessful MT. Smoking, difficult arch, vessel tortuosity, vessel calcification, diminutive vessels, truncal M1 occlusion, delta HU and HU ratio were significantly associated with unsuccessful MT in the univariate analysis. When we fitted two separate multivariate models including all significant variables and a HU measurement; delta HU

BackgroundWhile mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT.MethodsWe distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups.ResultsWe received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial.ConclusionsThe PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.

Introduction Carotid artery stenting (CAS) has increasingly emerged as an alternative strategy to carotid endarterectomy in the treatment of patients with symptomatic carotid stenosis. Optimal timing for CAS after symptoms onset remains unclear. We aimed to evaluate the safety and efficacy of CAS when performed in an emergency setting. Patients and methods We performed a retrospective analysis of CAS patients admitted to our CSC with symptomatic extracranial carotid occlusion or significant stenosis from January 2014-September 2019. Emergency CAS was defined as CAS performed during the same hospitalization from TIA/stroke onset, whereas elective CAS as CAS performed on a subsequent admission. The primary outcome was defined as the occurrence of any stroke, myocardial infarction, or death related to the procedure at 3 months of follow-up. Secondary outcomes included periprocedural complications and the rate of restenosis/occlusion at follow-up. Logistic regression and survival analyses were used to compare outcomes and restenosis at follow-up. Results We identified 75 emergency and 104 elective CAS patients. Emergency CAS patients had significantly higher rates of ipsilateral carotid occlusion (17% vs. 2%, p Conclusion In our study, emergency CAS in symptomatic patients might have a similar safety and efficacy profile to elective CAS at 3 months and long-term follow-up.

Introduction: Observational studies have found an increased risk of hemorrhagic transformation and worse functional outcomes in patients with higher systolic blood pressure variability (BPV). However, the time-varying behavior of BPV after endovascular thrombectomy (EVT) and its effects on functional outcome have not been well characterized. Patients and methods: We analyzed data from an international cohort of patients with large-vessel occlusion stroke who underwent EVT at 11 centers across North America, Europe, and Asia. Repeated time-stamped blood pressure data were recorded for the first 72 h after thrombectomy. Parameters of BPV were calculated in 12-h epochs using five established methodologies. Systolic BPV trajectories were generated using group-based trajectory modeling, which separates heterogeneous longitudinal data into groups with similar patterns. Results: Of the 2041 patients (age 69 ± 14, 51.4% male, NIHSS 15 ± 7, mean number of BP measurements 50 ± 28) included in our analysis, 1293 (63.4%) had a poor 90-day outcome (mRS ⩾ 3) or a poor discharge outcome (mRS ⩾ 3). We identified three distinct SBP trajectories: low (25%), moderate (64%), and high (11%). Compared to patients with low BPV, those in the highest trajectory group had a significantly greater risk of a poor functional outcome after adjusting for relevant confounders (OR 2.2; 95% CI 1.2–3.9; p = 0.008). In addition, patients with poor outcomes had significantly higher systolic BPV during the epochs that define the first 24 h after EVT ( p Discussion and conclusions: Acute ischemic stroke patients demonstrate three unique systolic BPV trajectories that differ in their association with functional outcome. Further research is needed to rapidly identify individuals with high-risk BPV trajectories and to develop treatment strategies for targeting high BPV.

Background: Studies have reported an association between lower socioeconomic status (SES) and an elevated risk of ischemic stroke. It is unclear whether low SES is correlated with a specific etiology of ischemic stroke. Few studies have investigated the relationship in LMIC nations with wide disparities in SES. We analyzed data from a hospital-based stroke registry in Lima, Peru to determine the association between level of education as an indicator of SES and ischemic stroke etiology. Methods: All patients hospitalized with ischemic stroke at the National Institute of Neurologic Sciences from 2015-2018 were prospectively collected in a registry including demographics, risk factors, highest attained level of education, and diagnosed etiology of stroke by TOAST criteria. Association between ordinal level of education and stroke etiology was assessed after adjusting for differences in demographics and comorbidities by a multinomial multivariate logistic regression model. Results: A total of 461 cases of ischemic stroke were ascertained with 38.4% female and a mean age of 66.2 (SD 13.0). Stroke etiology was composed of 7.5% atherosclerotic, 29.7% cardioembolic, 14.2% small vessel disease, 24.7% cryptogenic, and 24.0% with incomplete evaluation. Higher education level strata had more men, younger mean age, and lower rates of hypertension. After multivariate adjustment, lower level of education was associated with an increased odds of large artery atherosclerosis compared to all non-cardioembolic etiologies (OR=2.27; 95% CI, 1.12-4.55). There was no significant association with level of education and odds of cardioembolic stroke after multivariate adjustment. Conclusion: Lower SES is associated with an increased odds of atherosclerotic etiology in patients with non-cardioembolic ischemic stroke. The associated between SES and stroke may be attributed to a higher burden of atherosclerotic disease in lower SES.

Background: Impairment of cerebral autoregulation after subarachnoid hemorrhage (SAH) makes patients vulnerable to changes in blood pressure (BP). While oral nimodipine is recommended for improving neurological outcomes, its administration is frequently associated with reductions in BP. In this observational study, we examined the effect of nimodipine-induced BP reductions below personalized limits of autoregulation on outcome after aneurysmal SAH. Methods: Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy-derived tissue oxygenation (a cerebral blood flow surrogate) in response to changes in mean arterial pressure (MAP). The resulting autoregulatory index was used for trending the BP range at which autoregulation was most preserved. Cerebral hypoperfusion was defined as episodes with at least 30 minutes of MAP reductions below the lower limit of autoregulation (LLA) following nimodipine administration (Fig. 1). Functional outcome was measured with the modified Rankin Scale at 90 days. Results: We identified 593 occurrences of nimodipine administration with simultaneous recording of continuous physiologic data for 60 minutes before and after the intervention among 26 SAH patients (mean age 57 + 14, 21 F). Following nimodipine administration, the mean MAP decreased from 103 to 98 mmHg (p Conclusions: Nimodipine-induced BP reductions below the LLA may increase the risk of secondary brain injury and poor functional outcomes. A more personalized treatment approach accounting for cerebral autoregulation status could help identify vulnerable patients and maximize the benefit from current clinical interventions.

Introduction: The precise interactions between collateral perfusion, hemodynamics, and infarct growth after large vessel occlusion (LVO) require further definition. This study examined whether patients with poor collateral circulation and rapid early infarct progression are more vulnerable to reductions in blood pressure (BP). Methods: We prospectively enrolled patients with LVO stroke who underwent thrombectomy. Volumes of arterial tissue delay and relative cerebral blood flow (CBF) were estimated with RAPID software; a poor collateral profile was defined by a hypoperfusion intensity ratio >0.4. Early infarct growth rate (EIGR) was defined as ischemic core volume (CBF10 mL/h. The final infarct growth rate (FIGR) was the quotient of final infarct volume (FIV) and time from symptom onset to reperfusion. BP reduction was measured as the difference between admission mean arterial pressure (MAP) and lowest MAP before reperfusion. Results: Fifty-five patients (mean age 69 + 15, mean NIHSS 13) with successful reperfusion (TICI 2B/3) were included in the analysis. The median MAP reduction was 17 (IQR 9, 32). Poor collateral perfusion and EIGR were independent predictors of FIV after adjusting for age and admission NIHSS (mean FIV 70 vs. 31 mL, p=0.012 and 60 vs. 29 mL, p=0.01, respectively). A significant interaction was found between MAP reduction and both collateral status (p=0.04) and progressor profile (p=0.01). For every 10 mmHg MAP reduction, patients with poor collaterals experienced an average increase in FIGR of 3.6 mL/h (Fig. 1A). Above a critical MAP reduction threshold of 30 mmHg, mean FIV was significantly larger in patients with rapidly progressing infarcts (p Conclusions: Patients with poor collaterals and rapid early infarct growth are at higher risk of accelerated infarct growth and larger FIV related to BP reductions.

Introduction: High blood pressure variability (BPV) after endovascular thrombectomy is associated with post-stroke complications and poor neurological outcomes. However, whether BPV is an epiphenomenon of the stroke itself or causally related to the outcome remains unknown. Objective: In this study we aimed to evaluate if a relationship exists between pre-and post-stroke BPV in patients with large vessel occlusions (LVO). Methods: From our prospective stroke registry, we identified patients who had an anterior circulation LVO, underwent EVT, and had at least three blood pressure measurements recorded in the electronic medical record in the six months prior to their stroke admission. All patients had repeated time-stamped blood pressure data recorded for the first 72 hours after thrombectomy. Using the standard deviation of systolic BP, we calculated BPV for each patient and separated patients into tertiles based on their post-EVT BPV. The relationship between pre-stroke BPV and post-EVT BPV was analyzed using an ordinal logistic regression and Spearman’s rank correlation analysis. Results: Two hundred fifty-two patients were included in our analysis (mean age 70±16.2 years, mean admission NIHSS 15±7, median pre-stroke BP measurements 14.5 (IQR 5.0-55.8)). Pre-stroke BPV gradually increased for patients with higher post-EVT BPV tertiles (tertile 1 = 13.2(±5.2) mmHg, tertile 2 = 15.0(±5.5) mmHg, tertile 3 = 16.7(±7.0) mmHg, p=0.001). A positive correlation was observed between pre-stroke BPV and post-EVT BPV (p Conclusion: High pre-stroke BPV is correlated with high post-EVT BPV. Although larger, prospective studies are needed to provide definitive evidence of this relationship, our work suggests that high post-EVT BPV may be related to an underlying biological phenomenon and not merely a consequence of the stroke itself. Individuals with high BPV may benefit from more intensive blood pressure management in the acute phase after EVT.

Introduction: Infarct evolution is a highly dynamic process that varies among individuals. This study aimed to identify clinical and radiological features associated with an exponential infarct growth rate (IGR) pattern in stroke patients with large vessel occlusion (LVO). Methods: This is a retrospective cohort study of anterior LVO stroke patients who underwent mechanical thrombectomy (MT) and achieved complete recanalization (mTICI 2c-3). Infarct volumes were calculated at two time points, pre-MT: CT perfusion (CTP) using Rapid software to estimate the CBF Results: Of the 159 patients (median age 71 [6-82], 45% male, median NIHSS 14 [9-18]) included in the analysis, 91 (57%) patients had an exponential IGR pattern. These patients had higher CT ASPECTS (9[7-10] vs 8[7-9], p=0.038), higher glucose levels (126[114-150] vs 117[106-135], p=0.022), lower Tmax Conclusions: Parameters associated with exponential infarct growth might help to stratify the most time sensitive vulnerable LVO population in which newer therapeutic and triage strategies should be prioritized. Fig. Infarct Growth Rate Plots and Collateral Status . A shows IGR with an exponential pattern . B shows IGR with a non-exponential pattern.

[Figure: see text].

Carotid web (CW) is an atypical form of intimal fibromuscular dysplasia that occurs at the level of the carotid bulb. It is associated with ischemic strokes. The first report of this association was in 1967 and it is currently known to represent a significant percentage of cryptogenic stroke. We report the case of a young female patient with a history of transient ischemic attack who presented a cerebral infarction of the territory of the left middle cerebral artery. The diagnosis of CW was suggested by the findings of the ultrasound carotid duplex and was confirmed by digital subtraction angiography. Likewise, brain magnetic resonance angiography showed an incipient alteration in the morphology of the wall of the left internal carotid artery in its intracranial segment. Aspirin treatment was started and there was no recurrence up to two years of follow-up. CW represents a diagnostic challenge; it should be suspected in young adults with ischemic stroke. In them, studies of the supra-aortic vessels should be performed. Ultrasound carotid duplex can be a useful diagnostic tool.

Background and Purpose: Patient selection for thrombectomy of acute ischemic stroke caused by large vessel occlusion in the delayed time window (>6 hours) is dependent on delineation of clinical-core mismatch or radiological target mismatch using perfusion imaging. Selection paradigms not involving advanced imaging and software processing may reduce time to treatment and broaden eligibility. We aim to develop a conversion factor to approximately determine the volume of hypoperfused tissue using the National Institutes of Health Stroke Scale (NIHSS) score (clinically approximated hypoperfused tissue [CAT] volume) and explore its ability to identify patients eligible for thrombectomy in the late-time window. Methods: We performed a retrospective analysis of anterior circulation large vessel occlusion strokes at 3 comprehensive stroke centers. Demographic, clinical, and imaging (computed tomography perfusion processed using RAPID, IschemaView) information was analyzed. A conversion factor, which is a multiple of the NIHSS score (for NIHSS score 6 seconds volume) was tested using DEFUSE-3 criteria (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) eligibility as a gold standard in an independent cohort. Results: Of the 309 large vessel occlusion strokes (age, 70±14, 46% male, median NIHSS 16 [12–20]) included in this study, 38% of patients arrived beyond 6 hours of time from last known well. Conversion factors derived (derivation cohort-center A: 187) based on median values of Tmax>6 second volume for NIHSS score Conclusions: Clinical severity of stroke (NIHSS score) may be used to calculate the volume of hypoperfused tissue during large vessel occlusion stroke. CAT volumes for NIHSS score

Background and Purpose: Mechanical thrombectomy (MT) is now the standard of care for large vessel occlusion (LVO) stroke. However, little is known about the frequency and outcomes of repeat MT (rMT) for patients with recurrent LVO. Methods: This is a retrospective multicenter cohort of patients who underwent rMT at 6 tertiary institutions in the United States between March 2016 and March 2020. Procedural, imaging, and outcome data were evaluated. Outcome at discharge was evaluated using the modified Rankin Scale. Results: Of 3059 patients treated with MT during the study period, 56 (1.8%) underwent at least 1 rMT. Fifty-four (96%) patients were analyzed; median age was 64 years. The median time interval between index MT and rMT was 2 days; 35 of 54 patients (65%) experienced recurrent LVO during the index hospitalization. The mechanism of stroke was cardioembolism in 30 patients (56%), intracranial atherosclerosis in 4 patients (7%), extracranial atherosclerosis in 2 patients (4%), and other causes in 18 patients (33%). A final TICI recanalization score of 2b or 3 was achieved in all 54 patients during index MT (100%) and in 51 of 54 patients (94%) during rMT. Thirty-two of 54 patients (59%) experienced recurrent LVO of a previously treated artery, mostly the pretreated left MCA (23 patients, 73%). Fifty of the 54 patients (93%) had a documented discharge modified Rankin Scale after rMT: 15 (30%) had minimal or no disability (modified Rankin Scale score ≤2), 25 (50%) had moderate to severe disability (modified Rankin Scale score 3–5), and 10 (20%) died. Conclusions: Almost 2% of patients treated with MT experience recurrent LVO, usually of a previously treated artery during the same hospitalization. Repeat MT seems to be safe and effective for attaining vessel recanalization, and good outcome can be expected in 30% of patients.

Introduction: Infarct growth is affected by the collateral blood supply and ischemic tolerance and thus unlikely linear. This study aimed to better characterize infarct growth rates (IGR) after large-vessel occlusion (LVO) stroke. Methods: We retrospectively identified patients with anterior LVO stroke who underwent mechanical thrombectomy (MT) at two comprehensive stroke centers. Core infarct volumes at presentation (CBF Results: Of the 361 patients (age 68 ± 15, 55% female, NIHSS 14 ± 6) included in the analysis, 282 (78.1%) had successful reperfusion, and 150 (41.6%) achieved a good outcome (mRS ≤2). IGR showed an exponential growth pattern (Figure 1). There was no significant difference in the median IGR 1 between the poor and good outcome groups (2.3 vs. 1 ml, p=0.061). The median IGR 2 in patients with poor outcome was significantly higher when compared to those in the good outcome group (IGR 14.1ml/h vs. 4.62ml/h, p Conclusions: We identified an exponential infarct growth pattern after LVO stroke that differs in relation to outcome. High IGR in the interval from CTP to reperfusion is associated with worse outcomes, emphasizing the importance of future research into therapeutic approaches to slow down infarct progression.

Introduction: Safety of emergent carotid artery stenting (CAS) during endovascular thrombectomy (EVT) for acute strokes with intracranial large vessel and cervical internal carotid artery tandem occlusion is still unclear. Given the potential risk of symptomatic intracranial hemorrhage (ICH) with anti-thrombotic medications required in the setting of CAS, the decision between CAS versus carotid artery angioplasty (CAA) alone remains controversial. In this study, we aimed to identify the optimal endovascular carotid revascularization approach in this patient population, using a large, nationally representative dataset. Methods: We utilized the Nationwide Readmissions Database 2016-2017 to identify patients admitted due to acute ischemic stroke who underwent anterior circulation EVT as well as CAS or CAA on the same day. Survey design methods were used to generate national estimates. Logistic regression analysis was used to compare the in-hospital outcomes between patients who underwent CAS versus CAA. Survival analysis was used to estimate the 30-day readmissions. Results: We identified 2,042 hospitalizations meeting the study inclusion criteria (mean±SD age: 66.0±12.5 years, female 31.3%). Of these, 1,391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar except patients with CAS were more likely to be on anti-thrombotics and were less likely to have received intravenous thrombolysis (tPA) as compared to those with CAA. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, and hospital charges between the two groups in unadjusted analysis and after adjustment for the demographics and tPA use. All-cause 30-day readmission rate was similar between the two groups [hazards ratio (HR) 0.98, 95% confidence interval (CI) 0.64-1.51, p-value 0.924]. Patients with CAS had more readmissions due to ICH (HR 2.72, 95% CI 0.30-24.74) and less readmissions due to ischemic events (HR 0.78, 95% CI 0.12-5.08), although the difference was not statistically significant. Conclusion: Emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.

Introduction: Acute Ischemic Stroke (AIS) is one of the leading causes of disability and death in US. Although Endovascular Therapy (EVT) remains the mainstay therapy during acute phase for large vessel occlusions (LVOs), functional outcome varies among the treated patients. This ischemic injury results in an inflammatory response which plays an important role in the functional and neurological outcomes. We hypothesize that the early changes in the inflammatory response near the site of occlusion can be used as predictor of long-term neurofunctional decline Methods: AIS-LVO patients presenting to an academic comprehensive stroke center (CSC) within 24 hours from their last known well and undergoing EVT were included. Blood was collected proximal and distal to the thrombus during thrombectomy. Control samples were collected from the femoral artery and median cubital vein. Cytokine analysis and deep immune profiling was performed using a 20-parameter bead array and 13-parameter flow cytometer. Least Absolute Shrinkage and Selection Operator (LASSO) models were used for cell selection and correlation was evaluated for outcomes including mRS, NIHSS, MOCA and mortality, using R-software. Results: With 19 patients meeting the inclusion criteria, cytokine analysis revealed a significant increase in MMP and IFN-g, and decrease in GM-CSF, IL17, TNF-α, IL6, MIP-1a, and MIP-1b distal to clot. Flow cytometry analysis revealed a significant decrease in NK-T-cells, and CD8 T-cells counts and a relative increase in GM-CSF+ and IL17+ CD4 T-cells distal to clot. Immunological and neurological analysis revealed a correlation with CD4 + IFN-γ - IL10 + (r=0.7) & CD8 + IFN-γ - GMCSF + (0.6) with mRS, and CD4 + IFN-γ - IL10 + (r=0.7), CD4+ IFN-γ - IL17 + (r= -0.6), & CD8 + IFN-γ + IL17 + (r=0.7) cells with mortality. Conclusion: Our results indicate that local ischemia results in a hyperacute adaptive immune response at the site of occlusion. This immune response is predictive of functional outcome among AIS patients and is impactful in multiple ways, including the use of supportive therapy for patients with a poor functional trajectory and the use of immune-modulators at the site of ischemic injury.

Introduction: Acute ischemic strokes with intracranial large vessel occlusion (LVO) and cervical internal carotid artery (ICA) tandem occlusion have traditionally been known to have a poor prognosis. Recent evidence suggests favorable functional outcomes in patients undergoing emergent carotid artery stenting (CAS) following intracranial mechanical thrombectomy (MT). We aimed to evaluate the outcomes of endovascular carotid revascularization (CR) performed acutely after emergent intracranial MT. Methods: We used the Nationwide Readmissions Database 2016-2017 to identify patients admitted with anterior circulation LVO treated with MT. Patients who underwent CAS or carotid artery angioplasty (CAA) during the same hospitalization were also identified. Propensity scores were used to match patients with and without CR in a 1:1 ratio by demographics, comorbidities, use of intravenous thrombolysis and hospital-level characteristics. Logistic regression and survival analyses were used to compare the outcomes. Results: We identified 15,137 hospitalizations meeting the study inclusion criteria (mean±SD age:70.1±14.6, female 51.1%). Of these, 1,214 (8.0%) underwent CAS or CAA during the same hospitalization. After propensity score matching, we obtained 1,063 well matched pairs of patients with and without CR. In the matched cohort, patients who underwent CR had higher odds of hemorrhagic transformation (OR 1.34, 95% CI 1.07-1.69, p 0.011) and higher total hospital cost (mean difference $6,232, 95% CI 3,606-8,858, p 0.001) but other clinical outcomes including gastrostomy tube placement, decompressive craniectomy, prolonged mechanical ventilation, in-hospital mortality, length of stay, and discharge disposition did not differ between the two groups. Patients with CR were less likely to have an unplanned 30-day readmission (HR 0.67, 95% CI 0.51-0.87, p 0.004). Further, they had more readmissions due to ICH (HR 1.06, 95% CI 0.41-2.71) and less readmissions due to ischemic events (HR 0.39, 95% CI 0.14-1.08), although the difference was not statistically significant. Conclusion: If indicated, early endovascular CR for anterior circulation tandem occlusions seems to be safe with clinical outcomes comparable to patients undergoing MT alone.

Introduction: Despite treatment with mechanical thrombectomy (MT), some patients fail to regain functional independence at 90 days. The growth of the ischemic core varies across patients, and likely reflects differences in collateral flow and ischemic tolerance. In this study, we sought establish the optimal infarct growth rate (IGR) threshold to differentiate between slow and fast progressors and assess its ability to predict poor outcome. Methods: We retrospectively identified patients with anterior large-vessel occlusion (LVO) stroke with successful MT (mTICI ≥ 2b) at two comprehensive stroke centers. Final infarct volume (FIV) was calculated from post-MT Diffusion-weighted MRI. Assuming relative stability of the FIV after successful reperfusion, we defined IGR as [FIV (ml)] / [Time from stroke onset to reperfusion (hours)]. Good clinical outcome was defined as a modified Rankin scale score (mRS) ≤2. We used Receiver Operating Characteristics (ROC) analysis to calculate the optimal IGR threshold with high specificity for predicting a poor outcome. Multivariate logistic regression analysis was performed to evaluate the association of fast progressors (IGR ≥ 7.14 ml/h) on the poor functional outcome and mortality. Results: Of the 212 patients (age 68 ± 15, 51% female, NIHSS 15 ± 7) included, 110 (51.8%) patients had a poor outcome. The median IGR was significantly higher in patients with poor compared to good outcome (7 ml/h vs. 3.1 ml/h, p Conclusions: IGR is an independent predictor of poor outcome and mortality in patients with successful MT. Early identification of this population might help to institute therapeutic strategies of accelerating reperfusion and slowing the IGR.

Introduction: Decreases in blood pressure (BP) during thrombectomy are associated with infarct progression and worse outcomes. Many patients present first to a primary stroke center (PSC) and are later transferred to a comprehensive stroke center (CSC) to undergo thrombectomy. During this period, important BP variations might occur. We evaluated the association of BP reductions with neurological worsening and functional outcomes. Methods: We prospectively collected hemodynamic, clinical, and radiographic data on consecutive patients with LVO ischemic stroke who were transferred from a PSC for possible thrombectomy between 2018 and 2020. We assessed systolic BP (SBP) and mean arterial pressure (MAP) at five time points: earliest recorded, average pre-PSC, PSC admission, average PSC, and CSC admission. We measured neurologic worsening as a change in NIHSS (ΔNIHSS) from PSC to CSC >3 and functional outcome using the modified Rankin Scale (mRS) at discharge and 90 days. Relationships between variables of interest were evaluated using linear regression. Results: Of 91 patients (mean age 70±16 years, mean NIHSS 12) included, 13 (14%) experienced early neurologic deterioration (ΔNIHSS>3), and 34 (37%) achieved a good outcome at discharge (mRS Conclusions: Patients with poor outcomes have higher BP throughout the pre-CSC period, possibly reflecting an augmented hypertensive response. Reductions in SBP and MAP before arrival at the CSC are associated with neurologic worsening. These results suggest that BP management strategies in the pre-CSC period to avoid large reductions in BP may improve outcomes in patients affected by LVO stroke.

Introduction: To evaluate overall ischemic stroke rates, specific subtypes, and clinical presentation during the COVID-19 pandemic in a multicenter observational study from eight states across US. Methods: We compared all ischemic strokes admitted between January 2019 and May 2020, grouped as; March-May 2020 (COVID-19 period), March-May 2019 (seasonal pre-COVID period) and November 2019-January 2020 (immediate pre-COVID-19 period). Primary outcome was stroke severity at admission measured by NIHSS stratified as mild (0-7), moderate (8-14), and severe (>14) symptoms. Secondary outcomes were number of large vessel occlusions (LVOs), stroke etiology, IV-tPA rates, and disposition. Results: Of the 7,969 patients diagnosed with acute stroke during the study period, 933 (12%) presented in the COVID-19 period, 1319 (17%), and 1254 (16%) presented in the seasonal pre-COVID-19 and immediate pre-COVID-19 periods, respectively. Significant decline was observed in the weekly mean volume of newly diagnosed strokes (98±7.3 vs 50±20, p Conclusions: We observed a decrease in newly diagnosed stroke cases and rates of IV-tPA administration, while the LVO frequency remained unchanged during the COVID-19 pandemic. Additionally, these stroke patients had more severe presentations.