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Background: Understanding clot composition may allow for better technical planning and improved outcomes in mechanical thrombectomy (MT). We sought to correlate clot composition with reperfusion outcomes in MT. Methods: Clinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin and eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of First-Pass Effect (mTICI2c/3, FPE) and the number of device passes. Results: A total of 1430 patients (mean age, 68.4±13.5years; median [IQR] baseline NIHSS,17.2 [10.5-23]; IV-tPA use, 36%; Stent-Retrievers [SR], 27%; Contact Aspiration [CA], 27%; Combined SR + CA, 43%) were included. The median [IQR] number of passes was 1 [1-2]. FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for RBC-rich (P Conclusion: Despite the lack of correlation between clot histology and FPE in the overall population, our study adds to the growing body of evidence supporting the notion that clot composition influences reperfusion treatment strategy outcomes. Additional studies are needed.

Background: Plasma protein biomarkers measured in the hyperacute setting that are associated with stroke diagnosis or with clinical neurological severity, can be diagnostically and prognostically meaningful in patient care. We hypothesized that high-throughput proteomics can identify panels of plasma proteins that can differentiate stroke mimics from ischemic and hemorrhagic stroke, and are associated with neurological severity. Methods: From a clinically-characterized biorepository of 320 plasma samples collected at time of patient presentation to the Emergency Room at Grady Memorial Hospital (Atlanta), 40 samples (10 stroke mimics, 10 intracerebral hemorrhage [ICH], 20 acute ischemic stroke [AIS]) were included (Fig A). 7,000 proteins were measured per sample using aptamer-based proteomics (SomaLogic). A combination of differential-expression and variance partitioning analyses (VPA) identified proteins associated with diagnosis (mimic vs ICH vs AIS), neurological severity (NIHSS), age and sex. Results: Cohort characteristics are shown (Fig B). VPA identified top proteins that accounted for majority of variance in several traits (Fig C). One-way ANOVA identified >400 proteins showing group-wise differences, of which a panel of 56 proteins collectively distinguished mimics from both AIS and ICH, ICH from both mimics and AIS, as well as distinguished between AIS based on NIHSS (Fig D). The pattern of expression of these 56 plasma proteins across diagnostic groups is shown in Fig E. We also identified plasma biomarkers associated with increasing age, indicative of age-related vascular dysfunction. Conclusions: This pilot study of AIS, ICH and stroke mimics demonstrates the applicability of aptamer-based proteomics as a promising approach for plasma protein biomarker discovery in stroke. We identified acute plasma protein biomarkers of neurological severity, diagnostic group and age-related vascular dysfunction that need further validation.

Introduction: Over 10% of stroke survivors have a recurrent stroke, and studies indicate that Black people have a higher risk of stroke recurrence. Social Determinants of Health (SDoH) are associated with a high incidence of stroke, and there is emerging data on recurrence. Grady Memorial Hospital serves this vulnerable urban population at high risk of first and recurrent stroke. We sought to determine the prevalence of SDoH in our clinic population and address these unmet needs to reduce disparities. Methods: We implemented SDoH screening in the stroke clinic by training two medical assistants to fill out the SDoH questionnaire during patient check-in. Screening results were checked by the fellows/attending during the clinic visit. Social worker consultation was sought for unmet social needs. Data was collected in a prospectively maintained stroke clinic registry. Results: There were 131 patients seen between October 2021 and February 2022 in the stroke clinic. Of those, 108 patients (82%) were screened for unmet SDoH needs (financial, transportation, and food insecurity). Of the screened, 81% were black, the mean age was 55 years, 51% were male, and 59% were from economically at-risk or distressed communities. The mean duration from stroke onset to clinic visit was 12 months. Fifty-eight of the screened patients had at least one unmet need (54%), 30 had none (28%), and 20 were unknown (19%). Eighty-one percent (47/58) of patients with unmet needs had BP ≥130/80 (Odds ratio 2.47 CI 0.91-6.66, p =0.07). Most patients had financial insecurity (74%), followed by transportation needs (55%) and food insecurity (50%). Of the patients with unmet needs, 59% (n=34/58) reside in economically at-risk or distressed communities. 55% (32/58) of patients received resources to address these needs during the clinic visit. Conclusions: We found a high prevalence of unmet social needs in our stroke population, and the needs persisted for at least a year post-stroke. Screening and addressing unmet social needs should be incorporated as a routine follow-up post-stroke care. Systematic ways of assessing SDoH to address their effects on stroke recurrence and recovery should be done in larger studies.

Introduction: Over 10% of stroke survivors have a recurrent stroke, and studies indicate that Black people have a higher risk of stroke recurrence. Social Determinants of Health (SDoH) are associated with a high incidence of stroke, and there is emerging data on recurrence. Grady Memorial Hospital serves this vulnerable urban population at high risk of first and recurrent stroke. We sought to determine the prevalence of SDoH in our clinic population and address these unmet needs to reduce disparities. Methods: We implemented SDoH screening in the stroke clinic by training two medical assistants to fill out the SDoH questionnaire during patient check-in. Screening results were checked by the fellows/attending during the clinic visit. Social worker consultation was sought for unmet social needs. Data was collected in a prospectively maintained stroke clinic registry. Results: There were 131 patients seen between October 2021 and February 2022 in the stroke clinic. Of those, 108 patients (82%) were screened for unmet SDoH needs (financial, transportation, and food insecurity). Of the screened, 81% were black, mean age was 55 years, 51% were male, and 59% were from economically at-risk or distressed communities. The mean duration from stroke onset to clinic visit was 12 months. Fifty-eight of the screened patients had at least one unmet need (54%), 30 had none (28%), and 20 were unknown (19%). Eighty-one percent (47/58) of patients with unmet needs had BP ≥130/80 (Odds ratio 2.47 CI 0.91-6.66, p =0.07). Most patients had financial insecurity (74%), followed by transportation needs (55%) and food insecurity (50%). Of the patients with unmet needs, 59% (n=34/58) reside in economically at-risk or distressed communities. 55% (32/58) of patients received resources to address these needs during the clinic visit. Conclusions: We found a high prevalence of unmet social needs in our stroke population, and the needs persisted for at least a year post-stroke. Screening and addressing unmet social needs should be incorporated as a routine follow-up post-stroke care. Systematic ways of assessing SDoH to address their effects on stroke recurrence and recovery should be done in larger studies.

BackgroundProper identification of infarct extent is crucial for thrombectomy and prognostication. We sought to study the frequency and topographic aspects of those cases in which CT perfusion (CTP) misses a core lesion that is present on initial non-contrast CT (NCCT).MethodsA review was carried out of a prospectively collected database of endovascular patients with anterior circulation large vessel occlusion strokes from January 2014 to November 2018. Patients with an e-ASPECTS ResultsIn total, 629 patients were analyzed of which 161 (25.6%) had a TMC. On univariate analysis, TMC was associated with isolated deep middle cerebral artery (MCA) strokes (77.6% vs 56.6%, pConclusionsCTP may completely fail to detect ischemic core in as many as 25% of cases, especially in isolated deep MCA strokes. Technical refinements of the post-processing algorithms are therefore warranted. TMC infarcts may have a lower risk of reperfusion hemorrhage, potentially due to greater preservation of the neurovascular unit structure in face of delayed recovery of cerebral blood flow.

Background Basal ganglia infarcts are thought to carry worse clinical outcomes compared with other infarct patterns. We aimed to investigate whether pretreatment topographic infarct patterns including complete basal ganglia involvement versus other infarct patterns help predict mechanical thrombectomy outcomes. Methods This was a review of a prospectively collected database of consecutive mechanical thrombectomy patients with anterior circulation large vessel occlusion strokes between January 2014 and November 2018. Patients were categorized into the following 2 groups: (1) total basal ganglia (TBG) strokes defined as infarcts affecting both the caudate and lentiform nuclei regardless of cortical involvement and (2) other infarct patterns. Infarct location was assessed on preprocedure noncontrast computed tomography using an automated software (e‐ASPECTS). Baseline characteristics and outcome measures were compared. Results A total of 1011 patients were analyzed of which 234 (23.12%) had TBG strokes. Patients with TBG strokes were younger ( P =0.01); had higher National Institutes of Health Stroke Scale (NIHSS) ( P =0.006), lower e‐ASPECTS ( P P =0.024); and had diabetes less often ( P =0.01). Baseline characteristics were otherwise comparable between groups. Involvement of the caudate or lentiform nucleus alone was observed in 237 (30.5%) and 21 (2.7%) patients, respectively, in the other infarct patterns group. No internal capsule involvement was detected in either group. There were no differences in terms of 90‐day functional outcomes whether dichotomized (modified Rankin Scale score≤2: TBG=44.6% versus other=50.1%; P =0.14) or looking at the entire spectrum of the scale (shift analysis; P =0.74). However, TBG strokes had significantly higher rates of any parenchymal hematomas (15.4% versus 8.2%; P =0.001), an association that held true in multivariable analysis (adjusted odds ratio, 2.57 [95% CI, 1.41–4.62]; P =0.002). Conclusions Despite increased rates of hemorrhagic transformation, ganglionic infarcts carry similar functional outcomes after mechanical thrombectomy compared with other stroke patterns.

BackgroundPatients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis.ObjectiveTo compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes.MethodsReview of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0–5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups.Results1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS.ConclusionsOutcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.

Background and Purpose Infarct growth rate (IGR) in acute ischemic stroke is highly variable. We sought to evaluate impact of symptom-reperfusion time on outcomes in patients undergoing mechanical thrombectomy (MT). Methods A prospectively maintained database from January,2012-August,2020 was reviewed. All patients with isolated MCA-M1 occlusion who achieved complete reperfusion(mTICI2C-3), had a witnessed symptom onset and follow-up MRI were included. IGR was calculated as final infarct volume (FIV)(ml)/symptom onset to reperfusion time(hours) and was dichotomized according to the median value into slow-(SP) versus fast-progressors (FP). The primary analysis aimed to evaluate the impact of symptom-reperfusion time on 90-day mRS in SP and FP. Secondary analysis was performed to identify predictors of IGR. Results A total of 137 patients were eligible for analysis. Mean age was 63 ± 15.4 years and median IGR was 5.13ml/hour. SP(n = 69) had higher median ASPECTS, lower median rCBFConclusions The impact of symptom-reperfusion time on outcomes significantly varies across slow-versus fast-progressors. ASPECTS, collateral score, rCBF

Introduction: Heart failure with reduced Ejection Fraction (HFrEF) is an important risk factor for ischemic stroke and has been shown to carry higher mortality among stroke survivors. However, data among patients with large vessel occlusion strokes (LVOS) undergoing mechanical thrombectomy (MT) is lacking. We aimed to investigate the impact of HFrEF on procedural and functional outcomes after MT. Methods: We conducted a retrospective analysis of a prospectively collected MT database of all consecutive anterior circulation LVOS (Intracranial ICA, MCA-M1, M2) patients undergoing MT at a large urban comprehensive stroke center from Jan,2015-Dec,2020. HFrEF was defined as LVEF ≤40% on transthoracic or transesophageal echocardiograms obtained during the same admission. Uni-multivariable analyses were performed to evaluate the predictors of first pass effect (FPE), mRS0-2 and mortality at 90 days. Results: Of 1466 patients included in the analysis, 293 had HFrEF. The HFrEF group had fewer females, higher median baseline NIHSS, higher rates of Atrial fibrillation (p Conclusion: Our single-center study showed that HFrEF was associated with better procedural outcomes but did not impact functional outcomes at 90-day. Large multi-center studies are warranted.

BackgroundGiven the relative strength of prior mechanical thrombectomy (MT) data in face of the perceived poor natural history of emergent large vessel occlusion strokes, randomization to medical therapy during the recent clinical MT trials raised ethical challenges at individual and institutional levels despite overall clinical equipoise.MethodsIn a thrombectomy stroke registry, we compared treatment rates preceding and following the SWIFT-PRIME and DAWN trials. Based on effect sizes of treatment in both trials, we estimated missed opportunities due to randomization to medical therapy and estimated the societal benefit resulting from additional patients who benefited as a result of these studies.ResultsThe average monthly thrombectomy rate in the SWIFT-PRIME time window increased from 14.1±4 patients-per-month (ppm) to 23.8±6 ppm (pConclusionCompletion of recent trials resulted in observable increases in rates of thrombectomy, translating to functional benefits that rapidly offset any missed opportunities due to randomization to medical therapy arms.

BackgroundCarotid webs (CaW) are now recognized as a cause of ischemic stroke in young patients. The thromboembolic potential appears related to the CaW’s morphology and consequent impact on local flow dynamics. We aim to evaluate the reliability of different measurement methods for the quantification of CaW and their relationship to symptomatic status, presence of large vessel occlusion stroke (LVOS), clot burden and final infarct volume.MethodsThis was a retrospective analysis of the local comprehensive stroke center CaW database (September 2014–July 2019). CT angiograms (CTAs) were reviewed independently by two raters, blinded to the clinical information and laterality of the stroke/transient ischemic attack. CaW were quantified with 1-D (length), 2-D (area) and 3-D (volume) measurements via Osirix software. Final infarct volume was calculated on MRI. Patients with superimposed CaW thrombus and no repeat imaging were excluded.ResultsForty-eight CaW (37 symptomatic and 11 contralateral/asymptomatic) in 38 patients were included. Mean age (±SD) was 48.7 (±8.5) years, 78.9% were women and 77.1% were black. Inter-rater agreement was 0.921 (p2(p=0.35) and median volume was 15.0 versus 10.6 mm3(pConclusionCaW dimension quantification (1-D, 2-D and 3-D) is highly reproducible. Linear and volumetric measurements were more strongly associated with symptoms. The impact of CaW size on the presence of LVOS, clot burden and final infarct volume is unclear.

Background: The degree to which the COVID-19 pandemic has affected systems of care, in particular those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence (AI) platform. Methods: Data were derived from the Viz Platform, an AI application designed to optimize the workflow of acute stroke patients. Neuroimaging data on suspected stroke patients across 97 hospitals in 20 US states were collected in real-time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of CTA, CTP, Large vessel occlusions (LVOs) (defined according to the automated software detection), and severe strokes on CTP (defined as those with hypoperfusion volumes>70mL) normalized as number of patients per day per hospital. Data from the pre-pandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23,223 patients were included. The incidence of LVO on CTA and severe strokes on CTP were 11.2%(n=2,602) and 14.7%(n=1,229/8,328), respectively. There were significant declines in the overall number of CTAs (-22.8%;1.39 to 1.07 patients/day/hospital,p Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This underscores the broader application of AI neuroimaging platforms for the real-time monitoring of stroke systems of care.

Background and Purpose: The e-Stroke Suite software (Brainomix, Oxford, United Kingdom) is a tool designed for the automated quantification of The Alberta Stroke Program Early CT Score and ischemic core volumes on noncontrast computed tomography (NCCT). We sought to compare the prediction of postreperfusion infarct volumes and the clinical outcomes across NCCT e-Stroke software versus RAPID (IschemaView, Menlo Park, CA) computed tomography perfusion measurements. Methods: All consecutive patients with anterior circulation large vessel occlusion stroke presenting at a tertiary care center between September 2010 and November 2018 who had available baseline infarct volumes on both NCCT e-Stroke Suite software and RAPID CTP as well as final infarct volume (FIV) measurements and achieved complete reperfusion (modified Thrombolysis in Cerebral Infarction scale 2c-3) post-thrombectomy were included. The associations between estimated baseline ischemic core volumes and FIV as well as 90-day functional outcomes were assessed. Results: Four hundred seventy-nine patients met inclusion criteria. Median age was 64 years (55–75), median e-Stroke and computed tomography perfusion ischemic core volumes were 38.4 (21.8–58) and 5 (0–17.7) mL, respectively, whereas median FIV was 22.2 (9.1–56.2) mL. The correlation between e-Stroke and CTP ischemic core volumes was moderate (R=0.44; P P P 6 hours) treatment windows. Multivariate analysis showed that both e-Stroke software NCCT baseline ischemic core volume (adjusted odds ratio, 0.98 [95% CI, 0.97–0.99]) and RAPID CTP ischemic core volume (adjusted odds ratio, 0.98 [95% CI, 0.97–0.99]) were independently and comparably associated with good outcome (modified Rankin Scale score of 0–2) at 90 days. Conclusions: NCCT e-Stroke Suite software performed similarly to RAPID CTP in assessing postreperfusion FIV and functional outcomes for both early- and late-presenting patients. NCCT e-Stroke volumes seems to represent a viable alternative in centers where access to advanced imaging is limited. Moreover, the future development of fusion maps of NCCT and CTP ischemic core estimates may improve upon the current performance of these tools as applied in isolation.

BackgroundAge and infarct volume are among the most powerful predictors of outcome after large vessel occlusion acute strokes (LVOS).ObjectiveTo study the impact of age-adjusted final infarct volume (FIV) on functional outcomes.MethodsReview of a prospectively collected thrombectomy database at a tertiary care center between September 2010 and February 2018. Consecutive patients with anterior circulation LVOS who achieved full reperfusion (modified Thrombolysis in Cerebral Infarction 3) were categorized into four age groups: (G1) Results516 patients were analyzed (G1: n=171, G2: n=130, G3: n=103, G4: n=112). Patients with poor outcome had a larger FIV in each group (pIn multivariate analysis, adjusting for confounders including age and FIV, achieving a FIV less than the age-adjusted threshold was an independent predictor of good outcome (aOR=2.72, 95% CI 1.41 to 5.24, pConclusionsAge-adjusted infarct volume represents a strong outcome discriminator beyond age and infarct volume in isolation and might help to refine patient selection and improve outcome prognostication in stroke thrombectomy.

Background and Purpose: The hypoperfusion intensity ratio (HIR) is a perfusion-weighted imaging parameter defined as the ratio of Tmax>10 seconds : Tmax>6 seconds volume and is believed to be reflective of collateral strength and consequently influence infarct growth. We sought to assess the utility of the HIR in predicting infarct growth in patients undergoing thrombectomy at a comprehensive stroke center (CSC). Methods: Consecutive acute ischemic stroke patients transferred to our CSC from 09/2010-11/2018 were identified and included if the following criteria were met: 1)computed tomography perfusion (CTP) imaging enabling assessment of baseline ischemic core volume and HIR 2) follow-up neuroimaging for assessment of final infarct volumes and 3)modified Thrombolysis In Cerebral Infarction scale (mTICI) 2c status or greater post-thrombectomy. Infarct growth rate (IGR) was calculated as the difference between infarct volume on follow-up imaging and the acute DWI lesion volume, divided by time from CTP to reperfusion in hours. Results: 461 patients (median age, 64 [55-75] years, median baseline NIHSS, 16 [12-21]) were eligible for this analysis. HIR poorly correlated with IGR (Spearman’s rho=0.001, p=0.89). An HIR cut-off of 0.5 was not able to discriminate ‘fast progressors’ (IGR>5 mL/hr) (AUC 0.42, sensitivity 40%, specificity 51%), or IGR at thresholds of either 2.5 or 10 mL/hr (AUC 0.44 and 0.49 respectively, with 95% confidence intervals [0.35-0.52] and [0.41-0.57], respectively). Similarly, an HIR of 0.5 only weakly distinguished ‘fast progression’ in patients reperfused beyond 120 min from imaging and patients with early CTP (last known well to CTP2 =0.13) but was predictive of ‘fast progression’ (OR 0.22, 95% CI [0.09-0.60], p=0.003, pseudo-R 2 =0.16). Conclusions: Though predictive of fast progression, the HIR is a poor discriminator of infarct growth in successfully reperfused thrombectomy patients who undergo perfusion imaging at a CSC, and thus should not be factored into treatment decision-making.

BackgroundThe pilot use of a smartphone platform for electronic informed consent (e-Consent) in large vessel occlusion acute stroke (LVOS) trials has recently been reported. The degree of satisfaction from Legal Authorized Representatives (LARs) with regard to this process remains to be established.MethodsA single-center study evaluating the experience of LARs with the use of e-Consent in a LVOS randomized trial of an investigational drug administered within 12 hours of last known normal was carried out. A structured survey was used to evaluate the experience of the LARs with the e-consenting process.ResultsFrom February to November 2018, 60 consecutive patients were e-Consented. Of these, 53 LARs completed the survey. The median (IQR) age of the patients was 63 (53–70) years, baseline/discharge National Institutes of Health Stroke Scale score was 17 (12–20)/3(1–12), and 45% were independent at discharge. The survey was applied in person in 43% of cases and via telephone in 57%. Median LAR age was 48 (39–59) years, 64% were female, and a multi-ethnic composition was observed. Forty percent of LARs had less than tertiary level of education (high-school or less). Regarding the e-Consent, 98% of LARs reported to be ‘clear’ and 83% felt ‘very comfortable’ in signing. The overall experience was ‘excellent/good’ in 91%. Despite the positive general impression regarding the use of e-Consent, 12 LARs (22%) would have preferred paper consent. Multivariable regression indicated that lower educational status (tertiary education or less: OR 5.09, 95% CI 1.02 to 25.48; p=0.04) and lower baseline ASPECTS score (OR 0.63, 95% CI 0.41 to 0.96; p=0.03) were independently associated with preference for paper consent.Conclusionse-Consent was overall very well perceived by LARs in a randomized clinical trial of LVOS. A minority of proxies, who were more commonly less formally educated, would have preferred paper consenting.

Background and Purpose- It remains unclear how experience influences outcomes after the advent of stent retriever technology. We studied the relationship between site experience and outcomes in the Trevo Acute Ischemic Stroke multicenter registry. Methods- The 24 sites that enrolled patients in the Trevo Acute Ischemic Stroke registry were trichotomized into low-volume (2 cases/month), medium-volume (2-4 cases/month), and high-volume centers (4 cases/month). Baseline features, imaging, and clinical outcomes were compared across the 3 volume strata. A multivariable analysis was performed to assess whether outcomes were influenced by site volumes. Results- A total of 624 patients were included and distributed as low- (n=188 patients, 30.1%), medium- (n=175, 28.1%), and high-volume (n=261, 41.8%) centers. There were no significant differences in terms of age (mean, 66±16 versus 67±14 versus 65±15; P=0.2), baseline National Institutes of Health Stroke Scale (mean, 17.6±6.5 versus 16.8±6.5 versus 17.6±6.9; P=0.43), or occlusion site across the 3 groups. Median (interquartile range) times from stroke onset to groin puncture were 266 (181.8-442.5), 239 (175-389), and 336.5 (221.3-466.5) minutes in low-, medium-, and high-volume centers, respectively (P=0.004). Higher efficiency and better outcomes were seen in higher volume sites as demonstrated by shorter procedural times (median, 97 versus 67 versus 69 minutes; P0.001), higher balloon guide catheter use (40% versus 36% versus 59%; P≤0.0001), and higher rates of good outcome (90-day modified Rankin Scale [mRS], ≤2; 39% versus 50% versus 53.4%; P=0.02). There were no appreciable differences in symptomatic intracranial hemorrhage or 90-day mortality. After adjustments in the multivariable analysis, there were significantly higher chances of achieving a good outcome in high- versus low-volume (odds ratio, 1.67; 95% CI, 1.03-2.7; P=0.04) and medium- versus low-volume (odds ratio, 1.75; 95% CI, 1.1-2.9; P=0.03) centers, but there were no significant differences between high- and medium-volume centers (P=0.86). Conclusions- Stroke center volumes significantly influence efficiency and outcomes in mechanical thrombectomy.

Background and Purpose: Different imaging paradigms have been used to select patients for endovascular therapy (ET) in large vessel occlusion stroke (LVOS). We sought to determine whether CT perfusion (CTP) selection improves ET outcomes as compared to non-contrast CT (NCCT) alone. Methods: Review of a prospective single-center interventional database of consecutive patients between September 2010 and March 2016. Patients with anterior circulation strokes undergoing stent-retriever thrombectomy were categorized according to imaging selection: (1) CTP and (2) NCCT alone. Two separate analyses were performed: (1) Uni- and Multivariate analyses of the overall cohort and (2) Matched analysis based on age, baseline NIHSS, and glucose levels. Results: A total of 602 patients were included. CTP-selected patients (n=365; 61%) were younger (p=0.02) and had less comorbidities. On univariate analysis, CTP-selection was associated with higher rates of full reperfusion (mTICI-3, p Conclusion: CTP-based selection is associated with a favorable shift in functional outcomes in patients undergoing stent-retriever thrombectomy. Future prospective studies are warranted.

Introduction: Previously reported stroke screening tools used to identify large vessel occlusion (LVO) have been developed based on retrospective analyses or cohorts enrolled in a clinical trial. Hypothesis: Stroke screening tools may have lower specificity for detection of LVO when tested in a prospective cohort study of patients identified by emergency medical services (EMS) to have stroke signs and symptoms. Methods: Consecutive patients presenting to a stroke center with stroke symptoms or a positive FAST screen by EMS within 6 hours from stroke onset or wakeup were included in this prospective analysis. All patients were initially evaluated by a neurology attending or resident and underwent non-contrast CT (NCCT). Patients identified to have a stroke mimic on initial assessment or hemorrhagic stroke on NCCT did not undergo intracranial large artery imaging (iLAI); all remaining patients underwent iLAI. Sensitivity and specificity for LVO with the following screens were assessed: NIHSS ≥ 15, LAMS ≥ 4, RACE ≥ 5 and CPSSS ≥2. Results: Of 92 patients (mean age 69±17 years, mean NIHSS 8) evaluated over the 3 month study period, 41 (45%) were identified to have a stroke mimic and 9 (10%) had a hemorrhagic stroke on NCCT; 19 (21%) patients had LVO. The remaining 42 patients underwent iLAI within Conclusion: Previously published stroke screening tools have high specificity for detection of LVO when tested in a prospective cohort study of patients identified by EMS to have stroke signs and symptoms.

Objective Circadian pattern for the onset of acute ischemic stroke has been described; however, data assessing an association between thrombolytic therapy efficacy and circadian rhythm are limited. We assessed the relationship between the time of stroke onset and neurologic outcomes after thrombolytic therapy for acute ischemic stroke in the National Institute of Neurological Disorders and Stroke (NINDS) Recombinant Tissue Plasminogen Activator (rt-PA) Stroke Trial. Methods We conducted exploratory, post hoc analysis of 624 patients in the NINDS rt-PA Stroke Trial. Variables assessed included presenting time of day (4- and 6-hour time blocks), outcome variables, stroke subtypes, treatment assignment, and biological markers. Outcome variables included 3-month mortality, clinical outcome at 3 months, intracranial hemorrhage (ICH), computed tomography lesion volume at 3 months, and deterioration at 24 hours. Results The distribution of patients in the time blocks was balanced between the rt-PA and placebo groups. There was not a clear circadian variation in the stroke onset time. There were no associations detected between stroke onset time and clinical outcome, computed tomography lesion volume, and asymptomatic hemorrhage. Patients treated with rt-PA whose stroke onset was between 0401 and 0800 hours had less symptomatic ICH, whereas those who received rt-PA between 0000 and 0400 hours had a 43% incidence of symptomatic ICH. Patients in the placebo group who had stroke onset between 1801 and 2400 hours had lower chances for neurologic deterioration. Patients who had a stroke between 0001 and 0400 hours had the highest fibrinogen concentrations. Conclusions We did not find a circadian pattern to time of day of stroke onset in the patients included in the NINDS rt-PA Stroke Trial. The effect of rt-PA treatment on favorable outcome was independent of time of day of stroke onset. Patients who received rt-PA between 4 and 8 am were less likely to develop symptomatic ICH.

Background and Purpose: Time to reperfusion is an essential factor in determination of outcomes in (AIS). We sought to establish the effect of the procedural time on the clinical and radiographic outcomes of AIS patients undergoing intra-arterial therapy. Methods: Retrospective review of a prospectively collected database of endovascularly treated large vessel AIS in a large academic center. Data from all consecutive patients who underwent mechanical thrombectomy from September 2010 to July 2012 were analyzed. The variable of interest was procedural time (defined as time from groin puncture to end of procedure). Outcome measures included the rates of symptomatic intracebral hemorrhage (sICH, defined as any parenchymal hematoma e.g. PH-1/PH-2), final infarct volume, 90-day mortality, and independent functional outcomes (modified Rankin Scale, mRS 0-2) at 90 days. Results: The entire cohort included 242 patients with a mean age of 65.5+/- 14.2 and median baseline NIHSS 20. Of the patients 49.38% were females. The median ASPECTS score was 8. The mean procedure time was significantly shorter in patients with good outcome (86.73 vs. 73.13 respectively, P-value: 0.0228). However, after controlling for ASPECTS score, type of retrieval device, TICI score, volume of infarct, interval from symptoms onset to puncture, and co-morbidities, this association did not prove to be significant (P-value = 0.7101). Patients with SICH had significantly higher mean procedure time than patients without SICH (79.65 vs. 104.5 respectively; P-value: 0.0319) which remained significant when controlling to the previous factors (OR = 0.974 with a 95 % CI of (0.957, 0.991). There was no correlation between the volume of infarction and the procedure time (r = 0.10996, P-value: 0.0984). There was no association between procedure time and 90-day mortality (77.8 vs. 88.2 minutes in survivals vs. deaths respectively; P-value: 0.0958). Conclusion: Our data support an association between the risk of SICH and a longer procedure time while no definite association between procedural times and the final infarction volume or long-term functional outcomes was found after adjustment for multiple imbalances.

Background: We previously reported that persons living in the Stroke Belt were more likely than non-Belt persons to consume ≥2 weekly servings of fried fish but less likely to meet the AHA recommendation of ≥2 weekly servings of nonfried fish. The objective of this report was to evaluate whether the differential consumption of fish contributes to the geographic and racial disparities in stroke. Methods: REGARDS is a national cohort study that recruited 30,239 participants (2003-2007) ≥45 years with oversampling from the southeastern Stroke Belt and African Americans (AAs). Centralized phone interviewers obtained medical histories and in-home examiners obtained physical measures. Dietary data were collected using the self-administered Block98 Food Frequency Questionnaire (FFQ). After excluding the top and bottom 1% of total energy intake, individuals who did not answer 85% or more of the FFQ, and those with a history of stroke or TIA at baseline, the analysis cohort included 20,480 participants. Incident stroke was defined as first stroke occurrence over 5.0 years of follow-up. Results: There were 549 incident strokes including 501 ischemic strokes. After excluding hemorrhagic strokes and stratifying by race, white participants eating ≥2 servings per week (vs Conclusions: Fried fish intake of ≥2 servings (vs

Introduction: Guidelines recommend specific classes of medications for secondary stroke prevention. In this analysis we are interested in whether the use of antiplatelet, anticoagulant, anti-hypertensive, and lipid lowering medications differs by race and region among participants who self-reported stroke or TIA in a national, general population sample. Methods: Data were derived from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a national cohort study of 30,239 black and white participants aged 45+ enrolled between 2003 and 2007 from the 48 contiguous states, with over-sampling in the southeast region known as the stroke belt and buckle.A centralized phone interview was used for medical history and in-home evaluation for medication inventory. All medications used in the previous two weeks were recorded and subsequently coded into drug classes. The dataset was restricted to those with self-reported stroke (1930) or TIA (1114) at baseline. Chi-square tests were used to determine racial and regional (non-belt, belt, buckle) differences in the use of each medication classification, though indication or contraindication for treatment is unknown. Separate univariate logistic regression models were fit to assess the association between each medication class and race and region. Incremental models (demographics, SES factors, health behaviors, and co-morbidities) were then fitted to determine the impact of adding groups of covariates on the associations. Odds ratios and 95% confidence intervals (CI) for the association between each of race and region, and each medication class, were computed. Results: The results from the univariate and fully-adjusted models are presented in Table 1. After multivariable adjustment, blacks were less likely than whites to report using antiplatelet and lipid-lowering medications, while the belt and buckle residents were more likely than non-belt residents to report antiplatelets. Table 1: Association between Medications and Race and Region, univariate and adjustment. (95% CI) Adjusted model includes demographics, SES, health behavior, and co-morbidities. Whites and non-belt region serve as reference for logistic regression models of race and region, respectively. Conclusions: These data indicate differential use of antiplatelet therapy by race and region, and lipid lowering therapy by race, in those self-reporting stroke/TIA, with differences in use of anticoagulant and antihypertensive medications accounted for by covariant adjustment. This suggests targeted interventions are needed following stroke/TIA.

Background and Purpose —Little is known in regard to cerebral arterial reocclusion after successful thrombolysis. In the absence of arteriographic information, the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Trial investigators prospectively identified clinical deterioration following improvement (DFI) as a possible surrogate marker of cerebral arterial reocclusion after rt-PA–induced recanalization. Also, we identified any significant clinical deterioration (CD) even if not preceded by improvement. This observational analysis was designed to determine the incidence of DFI and CD in each treatment group, to identify baseline or posttreatment variables predictive of DFI or CD, and to determine any relationship between DFI, CD, and clinical outcome. Methods —DFI was defined as any 2-point deterioration on the NIH Stroke Scale after an initial 2-point improvement after treatment. CD was defined as any 4-point worsening after treatment compared with baseline. All data were collected prospectively by investigators blinded to treatment allocation. A noncontrast brain CT was mandated when a 2-point deterioration occurred. All cases were validated by a central review committee. Results —DFI was identified in 81 of the 624 patients (13%); 44 were treated with rt-PA and 37 were treated with placebo ( P =0.48). DFI occurred more often in patients with a higher baseline NIH Stroke Scale score. CD within the first 24 hours occurred in 98 patients (16% of all patients); 43 were given rt-PA and 55 were given placebo ( P =0.19). Baseline variables associated with CD included a less frequent use of prestroke aspirin and a higher incidence of early CT changes of edema or mass effect or dense middle cerebral artery sign. Patients with CD had higher rates of increased serum glucose and fibrin degradation products, and they also had higher rates of symptomatic intracranial hemorrhage and death. Patients who experienced either DFI or CD were less likely to have a 3-month favorable outcome. Conclusions —We found no association between DFI, CD, and rt-PA treatment, and no clinical evidence to suggest reocclusion. Deterioration was strongly associated with stroke severity and poor outcome and was less frequent in patients whose stroke occurred while they were on aspirin.