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Background and Purpose— Mechanical thrombectomy (MT) devices have led to improved reperfusion and clinical outcomes in acute ischemic stroke patients with emergent large vessel occlusions; however, less than one-third of patients achieve complete reperfusion. Use of intraarterial thrombolysis in the context of MT may provide an opportunity to enhance these results. Here, we evaluate the use of intraarterial rtPA (recombinant tissue-type plasminogen activator) as rescue therapy (RT) after failed MT in the North American Solitaire Stent-Retriever Acute Stroke registry. Methods— The North American Solitaire Stent-Retriever Acute Stroke registry recruited sites within North America to submit data on acute ischemic stroke patients treated with the Solitaire device. After restricting the population of 354 patients to use of RT and anterior emergent large vessel occlusions, we compared patients who were treated with and without intraarterial rtPA after failed MT. Results— A total of 37 and 44 patients was in the intraarterial rtPA RT and the no intraarterial rtPA RT groups, respectively. Revascularization success (modified Thrombolysis in Cerebral Infarction ≥2b) was achieved in more intraarterial rtPA RT patients (61.2% versus 46.6%; P =0.13) with faster times to recanalization (100±85 versus 164±235 minutes; P =0.36) but was not statistically significant. The rate of symptomatic intracranial hemorrhage (13.9% versus 6.8%; P =0.29) and mortality (42.9% versus 44.7%; P =0.87) were similar between the groups. Good functional outcome (modified Rankin Scale score of ≤2) was numerically higher in intraarterial rtPA patients (22.9% versus 18.4%; P =0.64). Further restriction of the RT population to M1 occlusions only and time of onset to groin puncture ≤8 hours, resulted in significantly higher successful revascularization rates in the intraarterial rtPA RT cohort (77.8% versus 38.9%; P =0.02). Conclusions— Intraarterial rtPA as RT demonstrated a similar safety and clinical outcome profile, with higher reperfusion rates achieved in patients with M1 occlusions. Prospective studies are needed to delineate the role of intraarterial thrombolysis in MT.

Background and Purpose— In acute ischemic stroke, fast and complete recanalization of the occluded vessel is associated with improved outcomes. We describe a novel measure for newer generation devices: the first pass effect (FPE). FPE is defined as achieving a complete recanalization with a single thrombectomy device pass. Methods— The North American Solitaire Acute Stroke Registry database was used to identify a FPE subgroup. Their baseline features and clinical outcomes were compared with non-FPE patients. Clinical outcome measures included 90-days modified Rankin Scale score, National Institutes of Health Stroke Scale score, mortality, and symptomatic intracranial hemorrhage. Multivariate analyses were performed to determine whether FPE independently resulted in improved outcomes and to identify predictors of FPE. Results— A total of 354 acute ischemic stroke patients underwent thrombectomy in the North American Solitaire Acute Stroke registry. FPE was achieved in 89 out of 354 (25.1%). More middle cerebral artery occlusions (64% versus 52.5%) and fewer internal carotid artery occlusions (10.1% versus 27.7%) were present in the FPE group. Balloon guide catheters were used more frequently with FPE (64.0% versus 34.7%). Median time to revascularization was significantly faster in the FPE group (median 34 versus 60 minutes; P =0.0003). FPE was an independent predictor of good clinical outcome (modified Rankin Scale score ≤2 was seen in 61.3% in FPE versus 35.3% in non-FPE cohort; P =0.013; odds ratio, 1.7; 95% confidence interval, 1.1–2.7). The independent predictors of achieving FPE were use of balloon guide catheters and non-internal carotid artery terminus occlusion. Conclusions— The achievement of complete revascularization from a single Solitaire thrombectomy device pass (FPE) is associated with significantly higher rates of good clinical outcome. The FPE is more frequently associated with the use of balloon guide catheters and less likely to be achieved with internal carotid artery terminus occlusion.

Introduction/Purpose Since 2012, our team of neurointerventional physicians have performed over 600 intracranial arterial thrombectomies with stent-retrievers. Thrombectomy in the ICA and M1 segments has been shown in randomized trials to reduce permanent disability and is now the standard of care. The time window has continued to expand. However, less is known about outcomes for thrombectomy performed in distal branches, such as near the M2–3 junction or within the M3 segments. Current guidelines state that thrombectomy in these locations may be performed in carefully selected patients, however data is limited. Materials and methods A retrospective review of our stroke database from 2012–2018 was undertaken to find cases of MCA interventions involving the distal third of the M2 insular segment or the M3 opercular segment. Isolated ICA, M1 and proximal M2 branch occlusions, as well as proximal occlusions that resulted in distal emboli post-thrombectomy, were excluded. Patients were selected for intervention based on noncontrast CT head, CTA, CT perfusion results; onset time; and clinical exam. Distal vessel thrombectomies were performed with the use of a stent-retriever device. Pre-intervention scans were compared to post-intervention scans to evaluate degree of infarct. The baseline and discharge National Institute of Health Stroke Scale, and the modified Rankin Scale at 90 days were used to evaluate the degree of residual deficits. Results A total of 43 patients met the inclusion criteria. Mean age was 69.4 (IQR 60.5–82). 23 (53.5%) were female. Thrombus was categorized as being located completely within the M3 segment in 21 cases (48.8%) and spanning the M2-M3 junction in 22 cases. 6 patients (14.0%) presented with tandem vessel occlusions involving the ICA or a proximal MCA segment, or proximal occlusion that had moved distally between CTA and angiography. 18 patients received intravenous tPA (41.9%). 42 cases were treated with a stent-retriever, and 1 case was treated with intra-arterial tPA. Multiple devices were used, however all were 3–4 mm in diameter, and 39 were 15–20 mm in length. 3 cases used a 4x40 mm device. The mean number of passes with a device was 1.2 (range 1–3). Near or complete reperfusion (mTICI score 2b or greater) was achieved in 40 cases (93.0%). Median initial NIHSS on presentation was 10.5 (IQR 7.8–18). Median discharge NIHSS was 2 (IQR 1–5.3). Initial and discharge NIHSS was not available in 3 patients. 90-day mRS was 0–2 in 17 patients (48.6% of those available) and 3–6 in 18 patients (51.4% of those available). 90-day mRS was not available in 9 patients (18.6% of total), mostly in the earliest cases found in the database. 3 cases of intraparenchymal hemorrhage occurred (7.0%), 2 of which were symptomatic including 1 resultant death. Conclusion Distal middle cerebral artery thrombectomy with stent-retriever devices is achievable and can be safe and technically effective. Randomized controlled trials have not been performed to determine if thrombectomy in or distal to the M2-3 junction is more beneficial than other techniques, such as aspiration thrombectomy, intravenous thrombolysis, or maximum medical therapy. Disclosures B. Donegan: None. J. Loeb: None. C. Martin: None. W. Holloway: None. J. Halpin: None. N. Akhtar: None.

Background and Purpose- Mechanical thrombectomy (MT) devices have led to improved reperfusion and clinical outcomes in acute ischemic stroke patients with emergent large vessel occlusions; however, less than one-third of patients achieve complete reperfusion. Use of intraarterial thrombolysis in the context of MT may provide an opportunity to enhance these results. Here, we evaluate the use of intraarterial rtPA (recombinant tissue-type plasminogen activator) as rescue therapy (RT) after failed MT in the North American Solitaire Stent-Retriever Acute Stroke registry. Methods- The North American Solitaire Stent-Retriever Acute Stroke registry recruited sites within North America to submit data on acute ischemic stroke patients treated with the Solitaire device. After restricting the population of 354 patients to use of RT and anterior emergent large vessel occlusions, we compared patients who were treated with and without intraarterial rtPA after failed MT. Results- A total of 37 and 44 patients was in the intraarterial rtPA RT and the no intraarterial rtPA RT groups, respectively. Revascularization success (modified Thrombolysis in Cerebral Infarction ≥2b) was achieved in more intraarterial rtPA RT patients (61.2% versus 46.6%; P=0.13) with faster times to recanalization (100±85 versus 164±235 minutes; P=0.36) but was not statistically significant. The rate of symptomatic intracranial hemorrhage (13.9% versus 6.8%; P=0.29) and mortality (42.9% versus 44.7%; P=0.87) were similar between the groups. Good functional outcome (modified Rankin Scale score of ≤2) was numerically higher in intraarterial rtPA patients (22.9% versus 18.4%; P=0.64). Further restriction of the RT population to M1 occlusions only and time of onset to groin puncture ≤8 hours, resulted in significantly higher successful revascularization rates in the intraarterial rtPA RT cohort (77.8% versus 38.9%; P=0.02). Conclusions- Intraarterial rtPA as RT demonstrated a similar safety and clinical outcome profile, with higher reperfusion rates achieved in patients with M1 occlusions. Prospective studies are needed to delineate the role of intraarterial thrombolysis in MT.

Background: Basilar artery occlusion (BAO) remains a devastating ischemic stroke subtype leading to high mortality rates and poor outcomes. Recently, mechanical retrieval therapy (MER) became a standard of care and a influential predictor of favorable outcomes in anterior circulation stroke patients. However, the use of MER in AIS patients with BAO is not established. Purpose: Our hospital sees over 1600 stroke patients a year with over 18% of stroke patients receiving MER therapy compared to the national average of 4.3%. We sought to evaluate our BAO patients who received MER therapy for efficacy and outcomes. Methods: Patients presenting to our facility between January 1, 2015 and June 30, 2018 were studied in a retrospective chart review. AIS patients who had BAO were evaluated for types of treatment, age, outcomes, recanalization rate TICI score of >2b, and disability or mortality after stroke. Of the 4,212 stroke patients presenting at our facility in the timeframe, 441 underwent MER therapy with 20 patients having a primary occlusion of basilar artery. Data was analyzed and compared to meta-analysis data. Results: Our patients with BAO had a (mRS) modified Rankin Score (0-2) of 81.8% (95% CI 7.8%, 96.8%) compared to the national average of 42.0% (95% CI 36%, 48%). Reperfusion scores (TICI >2b) in our patients was 90.9 % (95% CI 57.1%, 99.5%), while the reperfusion scores (TICI >2b) in the comparison group as 81% (95% CI 73%, 87%). Our sICH rate was 0.0% (95% CI 0.0%, 31.1%) while the comparison group was 4% (95% CI 2.0%, 8.0%). Our overall mortality rate of our BAO patients was 5.1%, with the comparison group’s mortality rate at 30.1%. There was no significance noted in patients’ ages or in the use of thrombolytics between the two groups. Conclusion: Patients presenting with stroke caused by BAO who receive MER at our facility have more favorable outcomes than those in the systematic review. Potential reasons include shorter time to recanalization, improved catheters and technology, experienced staff and strict attention to seamless transitions of care. MER therapy can be a safe treatment modality for patients with BAO. Further clinical trials are needed to show MER efficacy in patients experiencing a BAO.

Introduction Carotid artery occlusion in the setting of acute stroke with concurrent intracranial involvement is a serious and deadly combination, and can prove to be a challenging endeavor when encountered. The stroke is usually more severe due to poor collaterals and successful revascularization is difficult to achieve, resulting in a higher morbidity and mortality. We aim to assess the revascularization rates and clinical outcomes in this subset of patients treated with endovascular therapy. Materials and methods An IRB approved retrospective chart review of cases presenting with acute ischemic stroke with carotid occlusions and concurrent intracranial involvement treated with endovascular therapy over a 4 year period was conducted. Of these reviewed cases, 75 patients had carotid occlusions with intracranial involvement. The carotid T occlusions and critical ICA stenosis with intracranial flow were excluded from the study. Based on the CT and catheter angiogram findings, the 75 patients fell into two groups: Group A (n=35): Carotid occlusion with underlying atherosclerotic disease/dissection resulting in occlusion and were treated with angioplasty and stenting followed by thrombus retrieval. Group B (n=40): No underlying pathology was found and ICA was occluded due to a large embolus to the ICA with no anterograde flow in the ICA. This group was treated with thrombus retrieval alone. Results Our data shows that the presence of a stent in the ICA does not adversely affect the intracranial recanalization rate (91.4% TICI ≥2 b). There was also no significant increase in hemorrhage rate with revascularization and antiplatelet therapy (2.9%). This finding was especially significant due to the large amount of wake up strokes in our study that were treated with intervention (17.3%). The successful reperfusion rate (TICI ≥2 b) overall in both groups was 82.7%. In the successfully recanalized group, the mortality was 16% compared to the mortality in the unsuccessfully recanalized group (69.2%). Conclusion Our study results show that it is possible to achieve a high success rate of revascularization and clinical outcomes with an endovascular approach to managing carotid occlusion with intracranial involvement. Disclosures B. Donegan: None. I. Akhtar: None. C. Boutwell: None. J. Halpin: None. C. Martin: None. W. Holloway: None. N. Akhtar: None.

Introduction and purpose Time and again we come across cases of acute intraluminal thrombus in the proximal carotid and vertebral arteries without intracranial involvement. They are particularly challenging as the risk of dislodging the thrombus with intervention is high and can result in a potentially worse stroke. We present our experience of seven patients with an acute thrombus in their cervical arteries. The aim of this presentation is to demonstrate the diversity of managements in these patients. Materials and methods We retrospectively reviewed cerebral angiography reports spanning 8 years at our institution retaining cases showing thrombus in carotid or vertebral arteries. With identified cases, medical records were reviewed for stroke presentation, severity, and management. A total of 7 cases were identified. There were four patients with a thrombus in the proximal internal carotid artery and three patients with a thrombus in the proximal vertebral arteries. In all of these cases, the thrombus was due to underlying severe stenosis of the ICA/vertebral origins and was seen on catheter angiogram and CT angiogram as filling defects within the lumen of these vessels. Results 3 patients (2 carotid, 1 vertebral) were treated medically–2 with anticoagulant therapy (heparin/coumadin) in 1 with Aspirin/Clopidogrel. All 3 were admitted to the Intensive Care Unit and closely monitored until there was complete resolution of the acute clot on follow up imaging. Of these 3 patients, 2 patients underwent angioplasty/stenting and 1 patient underwent endarterectomy electively for underlying critical stenoses. 2 patients with an ICA thrombus showed changes of acute/subacute strokes on presenting CT and were considered to be unsuitable for anticoagulation. They were treated with angioplasty and stenting with distal embolic protection. In one patient, the thrombus was successfully trapped within the stent while in the other patient, part of the thrombus embolized to the middle cerebral artery and was subsequently retrieved with a stent retriever. In one patient with a vertebral thrombus, anticoagulation was started but the patient showed evidence of intracranial embolization with new strokes on MRI within the first 24 hours and angioplasty and stenting was performed acutely with no complications. In one patient with vertebral thrombus, anticoagulant therapy was started but the clot embolized into the basilar artery within 1 hour of the start of treatment with significant neurological worsening. No further treatment was performed per family request and the patient died in 48 hours. Conclusion The treatment for acute intraluminal thrombus in the major vessels is very challenging, as the situation is very fluid and can change for worse if the clot embolizes. These patients should be closely observed and the treatment should be customized according to the clinical situation. Disclosures B. Donegan: None. I. Akhtar: None. J. Halpin: None. C. Martin: None. W. Holloway: None. N. Akhtar: None.

Background: Various techniques are used to enhance the results of mechanical thrombectomy with stent-retrievers, including proximal arrest with balloon guide catheter (BGC), conventional large bore proximal catheter (CGC), or in combination with local aspiration through a large-bore catheter positioned at the clot interface (Aspiration-Retriever Technique for Stroke [ARTS]). We evaluated the impact of ARTS in the North American Solitaire Acute Stroke (NASA) registry. Summary: Data on the use of the aspiration technique were available for 285 anterior circulation patients, of which 29 underwent ARTS technique, 131 CGC, and 125 BGC. Baseline demographics were comparable, except that ARTS patients are less likely to have hypertension or atrial fibrillation. The ARTS group had more ICA occlusions (41.4 vs. 22% in the BGC, p = 0.04 and 26% in CGC, p = 0.1) and less MCA/M1 occlusions (44.8 vs. 68% in BGC and 62% in CGC). Time from arterial puncture to reperfusion or end of procedure with ARTS was shorter than with CGC (54 vs. 91 min, p = 0.001) and was comparable to the BGC time (54 vs. 67, p = 0.11). Final degree of reperfusion was comparable among the groups (TICI [modified Thrombolysis in Cerebral Infarction] score 2b or higher was 72 vs. 70% for CGC vs. 78% for BGC). Procedural complications, mortality, and good clinical outcome at 90 days were similar between the groups. Key Messages: The ARTS mechanical thrombectomy in acute ischemic stroke patients appears to yield better results as compared to the use of CGCs with no significant difference when compared to BGC. This early ARTS technique NASA registry data are limited by the earlier generation distal large bore catheters and small sample size. Future studies should focus on the comparison of ARTS and BGC techniques.

Background and Purpose— Failure to recanalize predicts mortality in acute ischemic stroke. In the North American Solitaire Acute Stroke registry, we investigated parameters associated with mortality in successfully recanalized patients. Methods— Logistic regression was used to evaluate baseline characteristics and recanalization parameters for association with 90-day mortality. A multivariable model was developed based on backward selection with retention criteria of P P ≤0.10), then refit to minimize the number of excluded cases (missing data). Results— Successfully recanalized patients had lower mortality (25.2% [59/234] versus 46.9% [38/81] P P =0.205). However, mortality was significantly higher in patients with symptomatic intracranial hemorrhage (72% [23/32] versus 26% [73/281]; P P P c index=0.72), proximal occlusion, initial National Institutes of Health Stroke Scale≥18, and use of rescue therapy remained significant independent predictors of 90-day mortality. Conclusions— Failure to recanalize and presence of symptomatic intracranial hemorrhage resulted in increased mortality. Despite successful recanalization, proximal occlusion, high National Institutes of Health Stroke Scale, and need for rescue therapy were predictors of mortality.

Introduction: Carotid artery occlusion in the setting of acute stroke with concurrent intracranial involvement is a serious and deadly combination, and can prove to be a challenging endeavor when encountered. The stroke is usually more severe due to poor collaterals and successful revascularization is difficult to achieve, resulting in a higher morbidity and mortality. We aim to assess the revascularization rates and clinical outcomes in this subset of patients treated with endovascular therapy. Methods: An IRB approved retrospective chart review of cases presenting with acute ischemic stroke with carotid occlusions and concurrent intracranial involvement treated with endovascular therapy over a 4-year period was conducted. Of these reviewed cases, 75 patients had carotid occlusions with intracranial involvement. The carotid T occlusions and critical ICA stenosis with intracranial flow were excluded from the study. Based on the CT and catheter angiogram findings, the 75 patients fell into two groups: 1) Group A (n=35): Carotid occlusion with underlying atherosclerotic disease/dissection resulting in occlusion and were treated with angioplasty and stenting followed by thrombus retrieval. 2) Group B (n=40): No underlying pathology was found and ICA was occluded due to a large embolus to the ICA with no anterograde flow in the ICA. This group was treated with thrombus retrieval alone. Results: Our data shows that the presence of a stent in the ICA does not adversely affect the intracranial recanalization rate (91.4% TICI ≥ 2b). There was also no significant increase in hemorrhage rate with revascularization and antiplatelet therapy (2.9%). This finding was especially significant due to the large amount of wake up strokes in our study that were treated with intervention (17.3%). The successful reperfusion rate (TICI ≥2b) overall in both groups was 82.7%. In the successfully recanalized group, the mortality was 16% compared to the mortality in the unsuccessfully recanalized group (69.2%). Conclusions: Our study results show that it is possible to achieve a high success rate of revascularization and clinical outcomes with an endovascular approach to managing carotid occlusion with intracranial involvement.

Mechanical thrombectomy using retrievable stents or stent retriever devices has become the mainstay of intra-arterial therapy for acute ischemic stroke. The recent publication of a series of positive trials supporting intra-arterial therapy as standard of care for the treatment of large vessel occlusion will likely further increase stent retriever use. Rarely, premature stent detachment during thrombectomy may be encountered. In our multicenter case series, we found a rate of detachment of less than 1% (n = 7/1,067), and all were first-generation Solitaire FR devices. A review of the US Food and Drug Administration database of device experience yielded 90 individual adverse reports of detachment. There were 82, 1 and 7 detachments of Solitaire FR (first generation), Solitaire FR2 (second generation) and Trevo devices, respectively. We conclude with a brief overview of the technical and procedural considerations which may be helpful in avoiding this rare complication.

Background and Purpose— The Solitaire With the Intention for Thrombectomy (SWIFT) and thrombectomy revascularization of large vessel occlusions in acute ischemic stroke (TREVO 2) trial results demonstrated improved recanalization rates with mechanical thrombectomy; however, outcomes in the elderly population remain poorly understood. Here, we report the effect of age on clinical and angiographic outcome within the North American Solitaire-FR Stent-Retriever Acute Stroke (NASA) Registry. Methods— The NASA Registry recruited sites to submit data on consecutive patients treated with Solitaire-FR. Influence of age on clinical and angiographic outcomes was assessed by dichotomizing the cohort into ≤80 and >80 years of age. Results— Three hundred fifty-four patients underwent treatment in 24 centers; 276 patients were ≤80 years and 78 were >80 years of age. Mean age in the ≤80 and >80 cohorts was 62.2±13.2 and 85.2±3.8 years, respectively. Of patients >80 years, 27.3% had a 90-day modified Rankin Score ≤2 versus 45.4% ≤80 years ( P =0.02). Mortality was 43.9% and 27.3% in the >80 and ≤80 years cohorts, respectively ( P =0.01). There was no significant difference in time to revascularization, revascularization success, or symptomatic intracranial hemorrhage between the groups. Multivariate analysis showed age >80 years as an independent predictor of poor clinical outcome and mortality. Within the >80 cohort, National Institutes of Health Stroke Scale (NIHSS), revascularization rate, rescue therapy use, and symptomatic intracranial hemorrhage were independent predictors of mortality. Conclusion— Greater than 80 years of age is predictive of poor clinical outcome and increased mortality compared with younger patients in the NASA registry. However, intravenous tissue-type plasminogen activator use, lower NIHSS, and shorter revascularization time are associated with better outcomes. Further studies are needed to understand the endovascular therapy role in this cohort compared with medical therapy.

Background and Purpose— Previous work that predated the availability of the safer stent-retriever devices has suggested that general anesthesia (GA) may have a negative impact on outcomes in patients with acute ischemic stroke undergoing endovascular therapy. Methods— We reviewed demographic, clinical, procedural (GA versus local anesthesia [LA], etc), and site-adjudicated angiographic and clinical outcomes data from consecutive patients treated with the Solitaire FR device in the investigator-initiated North American SOLITAIRE Stent-Retriever Acute Stroke (NASA) Registry. The primary outcomes were 90-day modified Rankin Scale, mortality, and symptomatic intracranial hemorrhage. Results— A total of 281 patients from 18 centers were enrolled. GA was used in 69.8% (196/281) of patients. Baseline demographic and procedural factors were comparable between the LA and GA groups, except the former demonstrated longer time-to-groin puncture (395.4±254 versus 337.4±208 min; P =0.04), lower National Institutes of Health Stroke Scale (NIHSS; 16.2±5.8 versus 18.8±6.9; P =0.002), lower balloon-guide catheter usage (22.4% versus 49.2%; P =0.0001), and longer fluoroscopy times (39.5±33 versus 28±22.8 min; P =0.008). Recanalization (thrombolysis in cerebral infarction ≥2b; 72.94% versus 73.6%; P =0.9) and rate of symptomatic intracranial hemorrhage (7.1% versus 11.2%; P =0.4) were similar but modified Rankin Scale ≤2 was achieved in more LA patients, 52.6% versus 35.6% (odds ratio, 1.4 [1.1–1.8]; P =0.01). In multivariate analysis, hypertension, NIHSS, unsuccessful revascularization, and GA use (odds ratio, 3.3 [1.6–7.1]; P =0.001) were associated with death. When only anterior circulation and elective GA patients were included, there was a persistent difference in good outcomes in favor of LA patients (50.7% versus 35.5%; odds ratio, 1.3 [1.01–1.6]; P =0.04). Conclusions— The NASA Registry has demonstrated that clinical outcomes and survival are significantly better in patients treated with LA, without increased symptomatic intracranial hemorrhage risk. Future trials should prospectively evaluate the effect of GA on outcomes.

BackgroundThe increasing utilization of balloon guide catheters (BGCs) in thrombectomy therapy for ischemic stroke has led to concerns about large-bore sheaths causing vascular groin complications.Objective To retrospectively assess the impact of large large-bore sheaths and vascular closure devices on groin complication rates at a comprehensive stroke center over a 10-year period.MethodsRadiological and clinical records of patients with acute ischemic stroke who underwent mechanical endovascular therapy with an 8Fr or larger sheaths were reviewed. A groin complication was defined as the formation of a groin hematoma, retroperitoneal hematoma, femoral artery pseudoaneurysm, or the need for surgical repair. Information collected included size of sheath, type of hemostatic device, and anticoagulation status of the patient. Blood bank records were also analyzed to identify patients who may have had an undocumented blood transfusion for a groin hematoma.ResultsA total of 472 patients with acute ischemic stroke who underwent mechanical thrombectomy with a sheath and BGC sized 8Fr or larger were identified. 260 patients (55.1%) had tissue Plasminogen Activator (tPA) administered as part of stroke treatment. Vascular closure devices were used in 97.9% of cases (n=462). Two patients were identified who had definite groin complications and a further two were included as having possible complications. There was a very low rate of clinically significant groin complications (0.4–0.8%) associated with the use of large-bore sheaths.ConclusionsThese findings suggest that concerns for groin complications should not preclude the use of BGCs and large-bore sheaths in mechanical thrombectomy for acute ischemic stroke.

Background: Time critical care in the Emergency Department is important for a patient’s survival and recovery. Reductions in disability are attributed to rapid triage and treatment for patients with both small and large vessel strokes. Current guidelines provide recommendations in clinical practice but do not delineate which type of stroke patients should receive heightened levels of triage when they arrive in the ED simultaneously. Purpose: To decrease unintentional care delays by classifying patients who are in need of intravenous tPA, endovascular therapy, or patients receiving no therapy in the initial assessment. Additionally, the number of activations of over 4,000 since 2014 was leading to stroke fatigue and we sought to decrease this fatigue with a tiered triage approach. Methods: Performance improvement initiatives were used to eliminate under used resources while also accounting for overburden of multiple patients in a very busy stroke center. The project prioritized code stroke activations based on acuity into RED, YELLOW and GREEN stroke alerts. RED signified a patient as a possible candidate for IV tPA, YELLOW prioritized the patient as possible endovascular candidate, and GREEN prioritized the patient as having a longer symptom onset initially. Results: The ultimate goal was to improve stroke treatment times while also decreasing activation fatigue. In the RED activations, the door to needle (DTN) time decreased from a mean of 46 minutes in 2014 to a mean of 34 minutes in 2016. In the YELLOW activations, the door to groin puncture mean decreased from 155 minutes to 72 minutes in the same time period. Prioritizing stroke based on acuity has demonstrated efficiency in team members’ time and improved stroke treatment times and treatment rates. Conclusions: Despite the increased influx of stroke patients into comprehensive stroke for endovascular consideration, the patients who were candidates for tPA could be prioritized to minimize delays in tPA treatment. Furthermore, patients with potential treatment for endovascular could be further prioritized and treatment times could also improve. Decreasing activation fatigue and fine tuning flow process helped manage multiple stroke patients at one time and favored improved patient outcomes.

Background: Five recently published randomized trials of endovascular therapy versus medical management, including intravenous thrombolysis, demonstrated strong positive data in support endovascular thrombectomy procedures. The American Heart Association/American Stroke Association released a focused update to specifically incorporate the findings of these trials. Implementing the care these studies show as beneficial requires a mechanism to rapidly transfer large vessel occlusion patients from primary stroke centers to those offering thrombectomy. Purpose: The purpose of the project was to streamline stroke work-up across the various levels of stroke hospitals and to apply rapid routing practices when transferring stroke patients between facilities. We evaluated the changes in stroke systems of care, with an emphasis on the role of pre-hospital stroke triage, inter-hospital transfer, and the two main levels of stroke center certification (primary and comprehensive). Methods: The system stroke steering team, defined four primary processes to reduce transfer times. These included 1) benchmarks for hospital door in to door out times of transferring centers 2) scripted transfer verbiage to designated time critical patients 3) large vessel stroke criteria definitions 4) pre-notification of the endovascular team to treat potential patients presenting with stroke. A reduction in time between initial patient contact and arterial puncture times and measures of patient outcomes were used as indicators of effectiveness. Results: The implementation of four process improvements for large vessel stroke patients was associated with improved treatment times. Mean door to recanalization times decreased from 224 minutes in 2014 to 112 minutes, thus far in 2016. Stroke treatment rates for tPA increased from 19.8% in 2013 to 22.7% in 2016, and endovascular treatment rates of 14.6% to 18.1% in the same time period. Conversely, complication rates from stroke treatment declined within the same period from 7.4% to 3.8%. Conclusion: Within a metropolitan health system, using the above multimodal approach to streamline the transfer of patients from primary to comprehensive centers decreases latency to treatment and is associated with improved outcomes.

Background: The Interventional Management of Stroke III (IMS-III) trial demonstrated no benefit for intravenous recombinant tissue plasminogen activator (IV rt-PA) followed by endovascular therapy versus IV rt-PA alone. However, IMS-III mostly included earlier generation devices. The recent thrombectomy trials have incorporated the stent-retriever technology, but their generalizability remains unknown. Methods: The North American Solitaire Acute Stroke (NASA) registry recruited patients treated with the Solitaire FR™ device between March 2012 and February 2013. The NASA-IMS-III-Like Group (NILG baseline NIHSS score ≥10 who received IV rt-PA) was compared to the IV rt-PA and IV + intra-arterial (IA)-IMS-III groups and the MR CLEAN, ESCAPE, SWIFT Prime, and REVASCAT trial controls to assess the stent-retriever treatment in the ‘real-world' setting. The NILG was also compared to non-IV rt-PA NASA patients to evaluate the impact of IV rt-PA on thrombectomy. Results: A total of 136 of the 354 NASA patients fulfilled criteria for the NILG. Baseline characteristics were well balanced across groups. Time from onset to puncture was higher in NILG than IV+IA-IMS-III patients (274 ± 112 vs. 208 ± 47 min, p < 0.0001). Occlusions involving the intracranial ICA, MCA-M1, or basilar arteries were more common in NILG than IV+IA-IMS-III patients (91.2 vs. 47.2%, p < 0.00001). Modified thrombolysis in cerebral infarction ≥2b reperfusion was higher in NILG than IV+IA-IMS-III patients (74.3 vs. 39.6%, p < 0.00001). A 90-day modified Rankin Scale score ≤2 was more frequent in the NILG than IV+IA-IMS-III patients (51.9 vs. 40.8%, p = 0.03) and MR CLEAN (51.9 vs. 19.1%, p < 0.00001), ESCAPE (51.9 vs. 29.3%, p = 0.0002), SWIFT Prime (51.9 vs. 35.5%, p = 0.02), and REVASCAT (51.9 vs. 28.2%, p = 0.0003) controls. Symptomatic intracranial hemorrhage definitions varied across the different studies with rates ranging from 2.7% (ESCAPE) to 11.9% (NILG). The NILG 90-day mortality (24.4%) was higher than in SWIFT Prime but comparable to all other groups. IV rt-PA was an independent predictor of good outcome in NASA (OR = 2.3, 95% CI 1.2-4.7). Conclusion: Our results support the ‘real-world' applicability of the recent thrombectomy trials.

BackgroundTime to reperfusion following endovascular treatment (ET) predicts outcomes after acute ischemic stroke (AIS).ObjectiveTo assess the time–outcome relationship within reperfusion grades in the North American Solitaire Acute Stroke registry.MethodsWe identified patients given ET for anterior circulation ischemic stroke within 8 h from onset and in whom reperfusion was achieved. Together with clinical and outcome data, site-adjudicated modified Thrombolysis in Cerebral Ischemia (TICI) was recorded. We assessed the impact of time to reperfusion (onset to procedure completion time) on good outcome (modified Rankin Scale 0–2 at 3 months) in patients who achieved TICI 2 or higher reperfusion in multivariable models. We further assessed this relationship within strata of reperfusion grades. A pResultsIndependent predictors of good outcome at 3 months among those achieving TICI ≥2a reperfusion (n=188) were initial National Institutes of Health Stroke Scale score (adjusted OR=0.90, 95% CI 0.85 to 0.95), symptomatic hemorrhage (adj. OR=0.16, 95% CI 0.05 to 0.60), TICI grade (TICI 3: adj. OR=11.52, 95% CI 3.34 to 39.77; TICI 2b: adj. OR=5.14, 95% CI 1.61 to 16.39), and time to reperfusion per 30 min interval (adj. OR=0.91, 95% CI 0.82 to 0.99). There was an interaction between final TICI grade and 30 min time to reperfusion intervals (p=0.001) such that the effect of time was strongest in TICI 2a patients.ConclusionsTime to reperfusion was a strong predictor of outcome following ET for AIS. However, the effect varied by TICI grade such that its greatest effect was in those achieving TICI 2a reperfusion.

Background and Purpose: Time has consistently been cited as a fundamental variable to improve clinical outcomes in stroke. We identified potential to reduce ‘Door to Imaging’ and ‘Door to Groin Puncture’ times at our institution by streamlining the flow process for acute stroke management by the multidisciplinary team. Methods: Retrospective analysis was performed over a 3-month period on all patients who underwent mechanical thrombectomy for symptomatic stroke. Time-interval metrics collected included time from patient arrival to the start of imaging, start of groin puncture and start of revascularization. We then identified weak links in the pathway of stroke care and implemented strategies for change, including early notification of the interventionist by stroke neurologists or the ‘Code Neuro’ stroke nurse, the patient being taken directly to CT on arrival to the Emergency Department if hemodynamically stable and point of care processing of blood tests. Other interventions included enhancement of pre-hospital work-up by Emergency Medical Services and a unified paging system. Following these interventions, another analysis of time-interval metrics was undertaken on a second population of patients, also over a 3-month period. Results: Data on a total of 20 patients prior to change implementation and 22 patients after change were analyzed. The results obtained are tabulated as shown: Conclusion: This quality improvement project was able to successfully demonstrate a reduction in various time-interval metrics following a targeted, and ongoing, initiative to optimize specific response mechanisms in the acute stroke process pathway.

BackgroundMechanical thrombectomy with stent-retrievers results in higher recanalization rates compared with previous devices. Despite successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b) of 70–83%, good outcomes by 90-day modified Rankin Scale (mRS) score ≤2 are achieved in only 40–55% of patients. We evaluated predictors of poor outcomes (mRS >2) despite successful recanalization (TICI ≥2b) in the North American Solitaire Stent Retriever Acute Stroke (NASA) registry.MethodsLogistic regression was used to evaluate baseline characteristics and recanalization outcomes for association with 90-day mRS score of 0–2 (good outcome) vs 3–6 (poor outcome). Univariate tests were carried out for all factors. A multivariable model was developed based on backwards selection from the factors with at least marginal significance (p≤0.10) on univariate analysis with the retention criterion set at p≤0.05. The model was refit to minimize the number of cases excluded because of missing covariate values; the c-statistic was a measure of predictive power.ResultsOf 354 patients, 256 (72.3%) were recanalized successfully. Based on 234 recanalized patients evaluated for 90-day mRS score, 116 (49.6%) had poor outcomes. Univariate analysis identified an increased risk of poor outcome for age ≥80 years, occlusion site of internal carotid artery (ICA)/basilar artery, National Institute of Health Stroke Scale (NIHSS) score ≥18, history of diabetes mellitus, TICI 2b, use of rescue therapy, not using a balloon-guided catheter or intravenous tissue plasminogen activator (IV t-PA), and >30 min to recanalization (p≤0.05). In multivariable analysis, age ≥80 years, occlusion site ICA/basilar, initial NIHSS score ≥18, diabetes, absence of IV t-PA, ≥3 passes, and use of rescue therapy were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index=0.80).ConclusionsAge, occlusion site, high NIHSS, diabetes, no IV t-PA, ≥3 passes, and use of rescue therapy are associated with poor 90-day outcome despite successful recanalization.

Background and Purpose— Efficient and timely recanalization is an important goal in acute stroke endovascular therapy. Several studies demonstrated improved recanalization and clinical outcomes with the stent retriever devices compared with the Merci device. The goal of this study was to evaluate the role of the balloon guide catheter (BGC) and recanalization success in a substudy of the North American Solitaire Acute Stroke (NASA) registry. Methods— The investigator-initiated NASA registry recruited 24 clinical sites within North America to submit demographic, clinical, site-adjudicated angiographic, and clinical outcome data on consecutive patients treated with the Solitaire Flow Restoration device. BGC use was at the discretion of the treating physicians. Results— There were 354 patients included in the NASA registry. BGC data were reported in 338 of 354 patients in this subanalysis, of which 149 (44%) had placement of a BGC. Mean age was 67.3±15.2 years, and median National Institutes of Health Stroke Scale score was 18. Patients with BGC had more hypertension (82.4% versus 72.5%; P =0.05), atrial fibrillation (50.3% versus 32.8%; P =0.001), and were more commonly administered tissue plasminogen activator (51.6% versus 38.8%; P =0.02) compared with patients without BGC. Time from symptom onset to groin puncture and number of passes were similar between the 2 groups. Procedure time was shorter in patients with BGC (120±28.5 versus 161±35.6 minutes; P =0.02), and less adjunctive therapy was used in patients with BGC (20% versus 28.6%; P =0.05). Thrombolysis in cerebral infarction 3 reperfusion scores were higher in patients with BGC (53.7% versus 32.5%; P P =0.002) and good clinical outcome at 3 months were superior in patients with BGC compared with patients without (51.6% versus 35.8%; P =0.02). Multivariate analysis demonstrated that the use of BGC was an independent predictor of good clinical outcome (odds ratio, 2.5; 95% confidence interval, 1.2–4.9). Conclusions— Use of a BGC with the Solitaire Flow Restoration device resulted in superior revascularization results, faster procedure times, decreased need for adjunctive therapy, and improved clinical outcome.

BackgroundLimited post-marketing data exist on the use of the Solitaire FR device in clinical practice. The North American Solitaire Stent Retriever Acute Stroke (NASA) registry aimed to assess the real world performance of the Solitaire FR device in contrast with the results from the SWIFT (Solitaire with the Intention for Thrombectomy) and TREVO 2 (Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischemic stroke) trials.MethodsThe investigator initiated NASA registry recruited North American sites to submit retrospective angiographic and clinical outcome data on consecutive acute ischemic stroke (AIS) patients treated with the Solitaire FR between March 2012 and February 2013. The primary outcome was a Thrombolysis in Myocardial Ischemia (TIMI) score of ≥2 or a Treatment in Cerebral Infarction (TICI) score of ≥2a. Secondary outcomes were 90 day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage.Results354 patients underwent treatment for AIS using the Solitaire FR device in 24 centers. Mean time from onset to groin puncture was 363.4±239 min, mean fluoroscopy time was 32.9±25.7 min, and mean procedure time was 100.9±57.8 min. Recanalization outcome: TIMI ≥2 rate of 83.3% (315/354) and TICI ≥2a rate of 87.5% (310/354) compared with the operator reported TIMI ≥2 rate of 83% in SWIFT and TICI ≥2a rate of 85% in TREVO 2. Clinical outcome: 42% (132/315) of NASA patients demonstrated a 90 day mRS ≤2 compared with 37% (SWIFT) and 40% (TREVO 2). 90 day mortality was 30.2% (95/315) versus 17.2% (SWIFT) and 29% (TREVO 2).ConclusionsThe NASA registry demonstrated that the Solitaire FR device performance in clinical practice is comparable with the SWIFT and TREVO 2 trial results.

Introduction/purpose Posterior circulation strokes with basilar occlusions have the worse clinical outcomes of all strokes. The outcome data utilizing new generation stent retrievers is sparse as most of the clinical trials evaluating stent retrievers exclude posterior circulation strokes. This retrospective review was undertaken to report our experience with stent retrievers in acute basilar occlusions. Materials/methods From March 2012 to March 2016, we performed thrombus retrieval in 337 patients. Retrospective review revealed 23 patients (7%) with basilar occlusions were treated with stent retrieval and adjuvant therapy. • Patient demographic: ○ 23 patients: 16 males, 7 females ○ Age ranged from 29–87 years (mean: 60.4, median: 63) • Presentation time from symptom onset: ○ 0–3 hours: 4 patients ○ 3–8 hours: 6 patients ○ Time unknown: 13 patients. 9/13 patients: wake up strokes ○ Intravenous TPA was administered in 4/23 patients (17%) ○ Initial non contrast CT scan findings: ○ Negative: 17 patients ○ Positive for patchy strokes: 6 patients ○ Dense basilar artery on CT: 9 patients • Thrombectomy device utilized: ○ Solitaire 4x20mm in 7, 4x40mm in 4, 6x30mm in 9, 6x20mm in 1 patient ○ In one patient solitaire could not be deployed ○ In one patient: Trevo was utilized ○ Balloon guide catheters were used in 10 patients with balloon dilated in the Subclavian artery. In 9 patients, local suction with stent retrievers was applied.o 6/23 patients required stent placement for underlying stenosis Results • NIHSS ○ NIHSS at presentation range from 2–38 (mean: 24, median: 22.5) ○ NIHSS 24 hour post intervention range from 0–38 (mean: 17, median: 13.5) • Number of passes: ○ Pass attempts range from 1–5. Successful 1 st pass achieved in 10 patients (mean number of passes: 2/patient) • TICI scores: ○ Initial TICI pre procedure: TICI 0: 19 patients, TICI 1/2a: 4 patients ○ Final TICI score post procedure: TICI 3: 11, TICI 2c: 2, TICI 2b: 5, TICI 1: 2, and TICI 0: 3 patients. Successful reperfusion (TICI 2b or higher) was achieved in 18/23 patients (78.3%). • Outcome: ○ Modified Rankin Score (MRS) at discharge/90 days: Death (6): 10 patients MRS 0–2 (good clinical outcome group): 7/23 (30%) MRS 3–5: 5 patients 1 patient declined follow up Good clinical outcome group 5/7 patients presented within 6 hours of symptom onset while 2/7 patients presented as wake up strokes. Initial CT findings were negative in all 7 patients. Conclusion Although the successful recanalization rate (TICI 2 b or higher) in basilar occlusions is high (18/23 (78.3%)), the mortality (10/23 (43%)) and morbidity with MRS ≥ 3 (5/23 (22%)) remains disappointingly high. In our study, good clinical outcome (MRS 0–2) was achieved in 30% (7/23) of patients, better than the natural course in basilar occlusions, which is encouraging. This group highlights the value of early presentation and a negative CT as strong predictors of a good outcome. The prognosis in patients with basilar occlusions with positive CT findings and unknown time of onset remain guarded. Disclosures I. Akhtar: None. J. Halpin: None. W. Holloway: None. C. Martin: None. N. Akhtar: None.

Introduction/purpose Stents for the intracranial circulation are approved for stent assisted coiling of brain aneurysms, flow diversion of brain aneurysms and atherosclerotic occlusive disease. These stents are deliverable and approved for intracranial placement of cerebral arteries ranging in size from 2.5 to 4.5 mm. The relatively small stents are unsuitable for skull based internal carotid artery for dissection and venous sinus deployment due to the large diameter of these vessels. Self-expandable cobalt chromium carotid stents are properly sized to these circulations but do not track the curvatures of the intracranial arterial and venous circulations. These self-expanding cobalt chromium carotid stents are available in 6 and 8 mm diameter sizes and, due to the braided design, these implants will track curves when partially deployed. We report a technique of partially deploying a cobalt chromium stent within a 072 intracranial support catheter which has already been positioned distal to the target. This allows the stent to be advanced around curves and unsheathed directly from the catheter thus allowing intracranial stenting of larger vessels. Materials and methods This is a retrospective review of 11 cases in which cobalt chromium stents were placed in the intracranial circulation at our facility over a two year period. These stents were placed with an 072 intracranial support catheter positioned distal to the target. Three stents were placed in distal cervical ICA transitioning into the horizontal petrous ICA. Eight stents were placed in the venous circulation (1 straight sinus to transverse sinus, 5 transverse sinus, 1 transverse-sigmoid junction, 1 sigmoid-jugular junction). In two venous cases, the stents were used to support coil masses. Results All cases in which the cobalt chromium stents were deployed were successful. No neurological sequelae were observed post procedure. Conclusion This technique allows for a wider range of stent sizes to access the tortuous intracranial circulation and provides an additional tool to the neurointerventional surgeon. Disclosures C. Martin: None. I. Akhtar: None. J. Halpin: None. W. Holloway: None. N. Akhtar: None.

Introduction/purpose Endovascular treatment using stent retrievers are now the standard of care in patients with acute ischemic stroke due to proximal middle cerebral artery occlusion. Recent randomized clinical trials have shown stent retriever recanalization rates (TICI 2 b or higher) surpassing 80%. The Solitaire stent retriever is available in different diameters and lengths. More recently, in August 2014, a 4 × 40 device was made available for thrombus retrieval in the US. While there have been many studies comparing the Solitaire to the other mechanical thrombectomy devices, at present, there have been little to no human data comparing the relatively new 4 × 40 Solitaire device with the older 4 × 20 and 4 × 15 devices. In our presentation we will be looking at the cases in which the 4 × 40 device was deployed and compare the recanalization rates to those achieved with cases treated with the 4 × 20 and 4 × 15 in patients with acute stroke. Materials and methods Materials used were the Solitaire Revascularization device in the sizes 4 × 40 mm, 4 × 20 mm, and 4 × 15 mm. All devices are identical in diameter but differ in the working length. Methods This is a retrospective study of 247 stroke patients who underwent clot retrieval using a 4 mm diameter Solitaire device as the first device deployed in a case at Saint Luke’s Hospital of Kansas City from 2012 till January 2016. Of the 247 total patients, 34 had undergone initial endovascular treatment with the Solitaire 4 × 40 device. The remainder were either treated with the 4 × 20 or the 4 × 15 Solitaire devices. Successful recanalization was determined as having a final TICI score of 2b or higher (>50% recanalization). Almost every case was performed with a balloon guide catheter inflated in the neck vasculature with aspiration on the guide catheter during Solitaire retrieval. Results The following Table 1 shows the recanalization rate with the different Solitaire devices. Conclusions The Solitaire 4 × 40 device showed a statistical trend for achieving better recanalization compared to the shorter devices. However due to our small sample size of patients undergoing treatment with the 4 × 40, further investigation is warranted to determine whether this result is maintained in larger sample size such as the STRATUS registry. Disclosures W. Holloway: None. I. Akhtar: None. J. Halpin: None. C. Martin: None. N. Akhtar: None.

Background Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates and better outcomes compared to previous devices. However, despite successful recanalization rates (Treatment in Cerebral Infarction, TICI, score ≥ 2b) between 70 and 90%, good clinical outcomes assessed by modified Rankin Scale (mRS ≥ 2 is present in 40–50% of patients. We aimed to evaluate predictors of poor outcomes (mRS ≥ 2) despite successful recanalization (TICI ≥ 2b) in the acute stroke patients treated with the Solitaire device of the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. Methods The NASA registry is a multicenter, non-sponsored, physician-conducted, post-marketing registry on the use of SOLITAIRE FR device in 354 acute, large vessels, ischemic stroke patients. Logistic regression was used to evaluate patient characteristics and treatment parameters for association with 90-day mRS score of 0–2 (good outcome) versus 3–6 (poor outcome) within patients who were recanalised successfully (Thrombolysis in Cerebral Infarction or TICI score 2b-3). Univariate tests were followed by development of a multivariable model based on stepwise selection with entry and retention criteria of p Results Out of 354 patients, 256 (72.3%) were successfully recanalised (TICI ≥ 2b). Based on 90-day mRS score for 234 of these patients, there were 116 (49.6%) with mRS ≥2. Univariate analysis identified increased risk of mRS ≥2 for each of the following: age ≥ 80 years (upper quartile of data), occlusion site other than M1/M2, NIH Stroke Scale (NIHSS) score ≥ 18 (median), history of diabetes mellitus (DM), TICI = 2b, use of rescue therapy, not using a balloon-guided catheter (BCG) or intravenous tissue plasminogen activator (IV t-PA), and time to recanalization > 30 min (all p ≤ 0.05). Three or more passes was marginally significant (p = 0.097). In multivariable analysis, age ≥80 years, site other than M1/M2, initial NIHSS ≥18, DM, absence of IVtPA, use of rescue therapy and three or more passes were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index = 0.80). Conclusions Age, occlusion site, high NIHSS, diabetes, not receiving IVtPA, use of rescue therapy and three or more passes, were associated with poor 90-day outcome despite successful recanalization. Disclosures I. Linfante: None. G. Dabus: None. A. Starosciak: None. A. Castonguay: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. T. Malisch: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. R. Novakovic: None. A. Yoo: None. O. Zaidat: None.

A 49-year-old woman was admitted with Hunt and Hess grade 1 subarachnoid haemorrhage. A cerebral aneurysm of the intracranial left vertebral artery (VA) distal to the left posterior inferior cerebellar artery (PICA) was found and treated using parent vessel occlusion with coils. The PICA was preserved. Angiography at three time points during her hospitalisation showed a normal right VA. Eight months later, angiography demonstrated a new 14 mm right VA dissecting aneurysm with 90% outflow stenosis and recurrence of the left VA aneurysm distal to the coils. A Marksman microcatheter would not traverse the stenosis despite the use of two intraluminal wires. Following Gateway balloon (1.5 mm × 9 mm) angioplasty, the Marksman passed easily. The pipeline embolisation device (PED) was successfully deployed across the aneurysm and 11 coils placed through a trapped microcatheter. The patient was discharged home 2 days later. Eighteen-month follow-up has revealed complete resolution of both aneurysms.

Background Advances in acute ischemic stroke mechanical thrombectomy devices have led to increased expectations of their safety and efficacy results. Objective To describe a new measure for the newer generation stroke thrombectomy devices, the First Pass Effect (FPE), defined as achieving thrombolysis in cerebral ischemia (TICI) score of 3 from the first pass, without the use of rescue therapy. In addition, a second objective was to assess if achieving TICI2b only with FP (FPE-TICI2b only) yielded similar results as FPE-TICI3 or non-FPE-TICI3 or non-FPE-TICI2b. The influence of FPE on clinical outcome, and its frequency and predictors was evaluated in the North American Solitaire Acute stroke (NASA) registry. Methods The FPE group was identified from the NASA multicenter registry database. Baseline features and clinical outcomeswere compared between the FPE group and the rest of the cohort. Subsequently, two multivariate analyzes were performed to identify if FPE is an independent predictor of clinical outcome and to identify the predictors of FPE. Furthermore, we assessed the difference between FPE and achieving other revascularization grades such as non-FPE-TICI3, FPE-TICI2b, and non-FPE-TICI2b scores. Clinical outcomes were mRS0–2 at 90 days, NIH stroke severity scale, mortality, and symptomatic intracranial hemorrhage (sICH). Results A total of 354 patients from 24 US centers were included in the NASA registry. The FPE was achieved in 89/354 (25.1%). Baseline demographics were comparable between FPE and the rest of the cohort, except that the FPE population had less octogenarians (34.6% vs. 65.4%), more woman (60.7% vs. 47.2%), and more Caucasians (83% vs. 71.2%). Baseline NIHSS and time from onset to groin puncture did not differ among the two groups. Angiographic features demonstrated more MCA occlusion (64% vs. 52.7%) and less ICA occlusion (10.1% vs. 27.7%) in the FPE group. Technical factors associated with FPE were limited to BGC use (64.8% vs. 36.8%), with no difference with use of IV-tPA, IA-tPA, or General Anesthesia. Multivariate analysis demonstrated use of BGC, no ICA occlusion, MCA occlusion, female gender, and white race as independent predictors of FPE. Clinical outcome measured with mRS 0–2 at 90 days was seen in 61.3%, 52.4%, 44.7%, and 39.1% with FPE-TICI3, FPE-TICI 2b, non-FPE-TICI3, and non-FPE-TICI2b, respectively. sICH was seen less frequently in FPE (5.6%,11.6%, 9.6%, and 12.9% in FPE-TICI3, FPE-TICI2b, non-FPE-TICI3,and non-FPE-TICI2b, respectively). Ninety days mortality was 16.3%, 31.0%, 27.7%, and 29.7% with FPE-TICI3, FPE-TICI2b, non-FPE-TICI3, and non-FPE-TICI2b, respectively. Conclusions The First Pass Effect was seen in 25.1% of NASA post-marketing registry patients and is the most powerful predictor of clinical outcome with best safety results. FPE is more commonly seen in white patients, MCA occlusion, and balloon guide catheter use; however, ICA terminus occlusion seems to be resistant to FPE. The FPE may also be related to gender, race, and age. Further research is needed to better understand the FPE and to guide future technical advances. Disclosures O. Zaidat: 1; C; Covidien, Stryker. 2; C; Covidien, Stryker. A. Castonguay: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. I. Linfante: None. G. Dabus: None. T. Malisch: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. R. Novakovic: None. A. Yoo: None. A. Abou-Chebl: None. P. Chen: None. G. Britz: None. R. Kaushal: None. A. Nanda: None. R. Nogueira: None.

Introduction The relationship between the two angiographic parameters, recanalization and reperfusion, as they relate to clinical outcome of acute stroke patients undergoing endovascular intervention is not well defined. We sought to determine the relationship of recanalization of the primary arterial occlusive lesion (AOL) and global reperfusion of the distal vascular bed in patients treated with endovascular stroke rescue at our institution. Hypothesis We assessed the hypothesis that recanalization and reperfusion scores would comparably predict outcome. Methods 96 angiograms were reanalyzed using recanalization and reperfusion scores by neurointerventionalists blinded to clinical outcome. The AOL score was defined as follows: 0=no recanalization of the primary occlusion; I=incomplete or partial recanalization of the primary occlusion with no distal flow; II=incomplete or partial recanalization of the primary occlusion with distal flow; or III=complete recanalization of the primary occlusion with distal flow. The Thrombolysis in Cerebral Infarction (TICI) Score was defined as follows: 0=no perfusion; 1= penetration, but no distal branch filling; 2a= perfusion with incomplete ( 50%) distal branch filling; and 3=full perfusion with filling of all distal branches. We compared these methods of assessment to one another and with good clinical outcome (modified Rankin Score 0 to 2). Results AOL and TICI scores showed moderate to substantial agreement (κ=0.660, 95% CI (0.518 to 0.801). Good clinical outcome was seen in 60% of patients with AOL II/III scores (p=0.462) and in 71% with TICI 2/3 scores (p=0.854). The two methods did not significantly differ in predicting outcome (p=0.52). Conclusion In conclusion, TICI reperfusion scores and AOL recanalization scores comparably predicted clinical outcome in our patient population. However, further investigation should be performed, possibly with the aid of other imaging modalities, to further differentiate between these parameters and their relationship to clinical outcome.

Background In light of the negative results of three randomised trials for endovascular acute ischemic stroke therapy, proper patient selection has become a critical area of focus for endovascular therapy. The Stroke Prognostication using Age and NIH Stroke Scale (SPAN) index, a score that combines age and NIHSS, demonstrated that SPAN-100 positive patients did not benefit from IV-tPA. Here, we sought to evaluate the predictive value of SPAN index in a real-life cohort of patients undergoing endovascular therapy. Method Using data from the investigator-initiated, multicenter North American Solitaire Stent-Retriever Acute Stroke (NASA) Registry, the SPAN index was calculated for each patient (age plus NIHSS). A cohort of SPAN-100 positive (SPAN ≥ 100) patients was identified and compared to SPAN-100 negative (SPAN Results Of 354 patients in the NASA Registry, 308 had available baseline NIHSS scores and 90-day mRS scores. 68/354 (22.1%) patients were SPAN-100 positive. Mean age of patients that were SPAN-100 positive was 83.9 ± 5.6 years vs. 62.8 ± 13.3 years in the SPAN-100 negative cohort (p = Conclusion Analysis of the NASA Registry demonstrated that SPAN-100 positive is significantly associated with worse clinical outcome and higher mortality rate at 90 days compared to SPAN-100 negative patients. SPAN-100 was shown as an independent predictor of clinical outcome and may be useful tool in the selection of patients for endovascular therapy. Disclosures A. Castonguay: None. O. Zaidat: 1; C; Stryker Neurovascular, Covidien Neurovascular. 2; C; Covidien Neurovascular. R. Novakovic: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. I. Linfante: None. G. Dabus: None. T. Malisch: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. A. Yoo: None. A. Abou-Chebl: None.

Introduction Efficient and timely recanalisation is an important goal in acute stroke endovascular therapy. Several studies have shown improved recanalisation and clinical outcomes with the Stentriever devices compared to the MERCI device. The goal of this study was to evaluate the role of the balloon guide catheter and recanalisation success in a sub-study of the North American Solitaire Stent-Retriever Acute Stroke Registry (NASA). Methods The investigator-initiated NASA Registry recruited 24 clinical sites in North America to submit demographic, clinical, site-adjudicated angiographic and clinical outcome data on consecutive patients treated with the Solitaire FR device (Covidien). Balloon guide catheter was used at the discretion of the treating physicians. Results There were 354 patients included in this study. Data of BGC use was not reported in 16 patients, leaving 338 patients in this sub-analysis, of which 149 (44%) had placement of the BGC. Mean age was 67.3+15.2 years and median NIHSS was 18. Patients with BGC had more hypertension (82% vs 73%; p=0.05), atrial fibrillation (51% vs 33%; p=0.001) and were more commonly administered tPA (51% vs 39%; p=0.02) compared to patients without BGC. Time from symptom onset to groin puncture and number of passes were similar between the two groups. Procedure time was shorter in patients with BGC (120 vs 161 minutes, p=0.02) and less rescue therapy was used in patients with BGC (20% vs 28.6%, p=0.05). TICI 2b/3, TICI 3 recanalisation was higher in patients with BGC compared to patients without (TICI 2b/3: 75% vs 70%; TICI 3 53% vs 32.5% p>0.001). Distal emboli and emboli in new territory were similar between the two groups. Discharge NIHSS (mean 12 vs 17.5; p=0.002) and good clinical outcome at 3 months were superior in patients with BGC compared to patients without (51.6% vs 35.8%; p=0.02). In multivariate analysis, initial NIHSS, use of general anaesthesia and BGC were independent predictors of good clinical outcome. Conclusion Use of a balloon guide catheter with the Solitaire Stent retriever in acute ischaemic stroke results in superior recanalisation results, faster procedure time, decreased need for rescue therapy, and improved clinical outcome. Disclosures T. Nguyen: 2; C; Penumbra, THERAPY Trial DSMB/ CEC. T. Malisch: None. A. Castonguay: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. I. Linfante: None. G. Dabus: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. A. Badruddin: None. M. Taqi: None. M. Abraham: None. H. Shaltoni: None. V. Janardhan: None. A. Abou Chebl: None. P. Chen: None. A. Yoo: None. R. Nogueira: None. A. Norbash: None. O. Zaidat: None.

Introduction/Purpose The recent results of the SWIFT and TREVO-2 trials demonstrated better recanalisation and efficacy rates with mechanical thrombectomy; however, its efficacy in the elderly population is poorly understood. Here, we report the effect of age on clinical and angiographic outcome within the North American SOLITAIRE-FR Stent-Retriever Acute Stroke (NASA) Registry. Methods The investigator-initiated NASA Registry recruited sites within North America to submit data on consecutive patients treated with Solitaire-FR. Good clinical outcome was defined as a 90-day mRS ≤2. Successful recanalisation was defined as TIMI ≥2. SICH was defined as any parenchymal haematoma, SAH, or IVH associated with a worsening of the NIHSS score by 4 or more within 24 hours. Age influence on outcomes was assessed by comparing the means between outcomes and dichotomising the age into ≤80 or ≥80 years of age. A standard medical care cohort was not available for comparison in this study. Results 343 patients underwent treatment using the SOLITAIRE-FR device in 24 centres. The mean age for those with good clinical outcome at 90 days was 64.9 ± 15 versus 69.2 ± 14.4 years (P=0.02). Only 26.6% (17/64) of patients >80 years of age had a 90-day mRS ≤ 2 versus 45.3% (111/245) of those ≤80 years of age (p=0.007, OR 1.34, 95%CI 1.2-1.6). Mortality was 42.2% (27/64) and 27.4% (67/245) in the >80 and ≤80 age groups, respectively. No difference in good outcome or mortality between female and males was observed in this population (90-day mRS≤ 2 was 41.3% (62/150) with mortality of 28% (42/150) versus 42.1% (69/164) with mortality of 32.3% (53/164) in females and males, respectively). Multivariate logistic regression analysis (adjusting for age, sex, race, baseline-NIHSS, occlusion site, initial BP, time from symptoms onset to groin puncture, and revascularisation), showed age, baseline-NIHSS, initial systolic blood pressure and revascularisation status as an independent predictors of both good outcome and mortality. Conclusions In the NASA registry, patients >80 years of age who were treated with the Solitaire-FR device demonstrated a significantly lower rate of good clinical outcome and increased mortality at 90-days, compared to the those in the ≤ 80 years of age group. Disclosures A. Castonguay: None. R. Gupta: None. R. Nogueira: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. T. Malisch: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. A. Badruddin: None. M. Taqi: None. I. Linfante: None. G. Dabus: None. M. Abraham: None. H. Shaltoni: None. V. Janardhan: None. T. Nguyen: None. A. Abou-Chebl: None. P. Chen: None. A. Yoo: None. G. Britz: None. A. Nanda: None. O. Zaidat: None.

Introduction/Purpose IMS3 demonstrated no significant difference between treatment with IV-rtPA alone or IV-rtPA plus IA therapy. However, the trial included only earlier generations of thrombectomy devices and did not evaluate the efficacy of newer devices. Here, we present data on an “IMS-III-Like group” from The North American SOLITAIRE Acute Stroke (NASA) Registry, a repository database of the newer generation Solitaire Stent-retriever. An exploratory analysis was performed to compare these results to the IMS3 IV and IV/IA groups. Materials and Methods The investigator-initiated NASA Registry recruited sites to submit data on consecutive patients treated with Solitaire-FR. A cohort similar to the IMS-III IV-rtPA+Solitaire-FR population (NASA-IMS3 Matched Group (NIMG)) was identified and compared to the recently published results of the IMS3 IV and IV/IA groups. Good clinical outcome was defined as a 90-day mRS ≤2. Successful recanalisation was defined as TIMI ≥2. SICH was defined as any parenchymal haematoma, SAH, or IVH associated with a worsening of the NIHSS score by 4 or more within 24 hours. Results 354 acute ischaemic stroke patients were enrolled in the NASA Registry from 24 centres. The cohorts were comprised of: 156 NIMG versus 434 and 222 in the IMS3 IV/IA and IV only groups, respectively. Baseline demographics were similar between cohorts: Median age 70 (NIMG); 69 (IMS3 IV/IA); 70 (IMS3 IV). Initial median NIHSS was higher in NIMG (19) compared to the IMS3 IV/IA (17) and IMS3 IV groups (18). mTICI > 2b rate was 69.9% in NIMG versus 39.6% in the IMS III IV/IA. Interestingly, mTICI 3 rate was 41% in NIMG vs 2.2% in the IMS III IV/IA group. The 90-day mRS outcome was available in 88.5% (138/156) of NIMG patients. A good outcome of mRS?2 was demonstrated in 51.5% (71/138), compared to 40.8% (169/415) in IMS3 IV/IA and 38.7% (83/215) in IM3 IV alone groups. 90-day mortality was 24.6% in NIMG versus 19.1% and 21.6% in IMS3 IV/IA and IV alone groups, respectively. Conclusion In the NASA registry, the NASA-IMS3 Matched Group (NIMG) demonstrated a higher rate of good clinical outcome (51.5%) compared to the IMS3 IV/IA (40.8%) and IV alone (34.6%) groups. Disclosures R. Nogueira: None. A. Castonguay: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. I. Linfante: None. G. Dabus: None. T. Malisch: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. A. Yoo: None. A. Abou-Chebl: None. P. Chen: None. O. Zaidat: None.