Abstract 014: Beveled‐Tip Aspiration Catheters Reduce Stoke Procedure Time And Cost For Large And Medium Vessel Occlusions

Introduction Thrombectomy catheters with a unique angled‐tip design (ZoomTM Aspiration Catheters, Imperative Care Inc., Campbell, CA) have recently emerged as promising devices for treating acute ischemic stroke. The angled‐tip configuration is engineered to enhance device trackability and optimize clot engagement. Following promising initial results observed during our catheter evaluation, we integrated these novel catheters into the majority of thrombectomy procedures at our institution. In this study, we aimed to determine whether the utilization of angled‐tip catheters could lead to reduced procedural expenses and shorter time to reperfusion in our patient population. Methods We conducted a retrospective single‐center cohort study involving consecutive patients with acute ischemic stroke due to large and medium vessel occlusions. All patients were treated by a single operator between January 2020 and March 2023. Patients treated within the 18‐month period preceding the introduction of the Zoom aspiration catheters using traditional straight‐tip catheters were assigned to the straight‐tip group, while those treated with the Zoom aspiration catheters were assigned to the angled‐tip group. Our primary analysis was a cost comparison between the angled‐tip and straight‐tip groups using the list prices associated with each device employed in the procedures. The secondary analysis was focused on safety and procedural outcomes including self‐adjudicated modified Thrombolysis in Cerebral Infarction (mTICI) reperfusion scores and time from puncture to reperfusion. Frequencies were compared using the Fisher’s exact test and means were compared using a two‐sample t‐test. P‐values <0.05 were considered significant. Results A total of 163 patients were included, with 68 (41.7%) in the straight‐tip group and 95 (58.3%) in the angled‐tip group. There were no significant difference in age, sex, comorbidities, initial National Institutes of Health Stroke Scale score, access site, or procedure type between the two groups. However, utilization of the ADAPT thrombectomy technique was significantly higher in the angled‐tip group (55.9%, 38/68) compared to the straight‐tip group (13.7%, 13/95) which primarily used the Solumbra technique, p<0.001. Overall, the angled‐tip group demonstrated a significant decrease in mean procedure cost ($9,728 vs$12,127; p=0.002). Sub‐group analyses based on the procedure type showed that the angled‐tip group was associated with a numeric decrease in cost; however, due to the lower sample size statistical significance was not achieved (Table). The angled‐tip group was also associated with significantly shorter times to achieve mTICI ≥2B reperfusion (38.30 min vs 53.26 min; p=0.018), mTICI ≥2C reperfusion (45.09 min vs 58.74 min; p=0.042), and procedure completion (46.42 min vs 62.38 min; p=0.022). There were no significant differences in the overall rate of hemorrhage between the angled‐tip (17.9%) and straight‐tip groups (20.6%), p=0.690, though we did observe a numerical decrease in the rate of larger hemorrhages (HI2 and PH2) in the angled‐tip group (Table). Both groups achieve similar rates of mTICI ≥2B reperfusion. Conclusion The angled‐tip catheters were associated with a lower procedure cost and shorter time to achieve reperfusion. Similar rates of reperfusion and intracranial hemorrhages were observed in both groups

Abstract Number ‐ 188: Rescue Stenting for Intracranial Stenosis In ELVO patients Using Neuroform Atlas Stent Through Gateway Balloon

Introduction Management of acute large vessel occlusion due to intracranial stenosis remains challenging with high complication and poor recanalization rates. Morbidity is also related to the intracranial exchange that is required for stent placement after the rescue angioplasty. We aim to present our initial experience of deployment of Neuroform Atlas stent through the lumen of a Gateway angioplasty balloon to avoid microcatheter exchange. Methods Patients were identified from prospectively collected mechanical thrombectomy stroke database from Feb 2019 to July 2021. Demographic and clinical information was collected. Primary outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale (mRS) score of 0–3), and the rate of intracranial hemorrhage (ICH). Good angiographic recanalization (TICI ≥ 2b), and mortality at 30 days were other outcomes. Results We identified 5 patients treated with this approach [mean age 54 ± 14 years, all were men] who presented with large vessel occlusion of middle cerebral artery. Initial median NIHSS was 8 (range 6–16) with one patient received IV t‐PA. Patient initially underwent mechanical thrombectomy using the Solumbra technique. Due to reocclusion or impending occlusion with evidence of atherosclerotic plaque, rescue angioplasty with stent placement was performed. Patients were loaded with 650 mg of aspirin and 180 mg of ticagrelor through nasogastric tube prior. Balloon angioplasty was performed using the gateway balloon size ranging from 1.5 to 3 mm which was inflated to subnominal pressures over 1 minutes. This was followed by placing Neuroform atlas stent through the gateway balloon with size ranging from 3 to 4 mm diameter and length ranges from 21–24 mm. TICI ≥ 2b was achieved in 4 patients. Mean time from symptoms onset to revascularization was (336 ± 90) minutes. One patient had asymptomatic ICH. 2 patients had mRs 0–3 at the time of discharge and one patient was dead at 1 month Conclusions Our preliminary experience showed lower risk of guidewire perforation as well as potentially decreased operative time and early reperfusion by deploying the Neuroform stent through a compatible gateway balloon microcatheter. This should be investigated further in a large multicenter stud

Abstract 040: Hemorrhagic Conversion Patterns After Transition of Stroke Thrombolysis from Alteplase to Tenecteplase; Real‐World Experience

Introduction Importance:Tenecteplase (TNK) use is more prevalent as the thrombolytic drug of choice for acute ischemic stroke (AIS), given its ease of use with results from randomized trials showing non‐ inferiority and comparable safety to Alteplase (tPA). However, there is conflicting data in terms of intracranial hemorrhage risk. Objective: We are reporting the rate of symptomatic intracranial hemorrhage(sICH) in TNK and tPA treated stroke populations across two large hospital systems. Methods Design: Retrospective cohort observational study. Data was collected from April 1, 2022 through March 29, 2023. Setting: Data was collected from 15 stroke centers: 10 primary and 5 comprehensive stroke centers in Texas. Participants: Inclusion criteria: 18 years or older, suspected to have an AIS were eligible to receive thrombolytic therapy, and received either IV TNK or tPA at the standard dose. A total of 431 patients were included. 216 patients received alteplase and 215 patients received tenecteplase. Exposure: Data was collected 90 days before and 90 days after the stroke center changed from tPA to TNK. Main Outcomes: The primary endpoint was to compare the incidence of sICH according to SITS‐MOST/ECASS‐3 criteria in the tPA and TNK groups. Secondary endpoints included the radiographic pattern of hemorrhagic conversion according to the Heidelberg bleeding classification (HBc). Results A total of 431 patients; half of them had been administered Alteplase (n=216) and the other half had Tenecteplase (n=215). Approximately half of them were females 110 (51%) for alteplase and 117 (54%) for Tenecteplase. Almost 2/3 of the study population never smoked; 66% for alteplase 64% for Tenecteplase. Majority of the patient population got thrombolytic therapy within 3 hours 174 (81%) for alteplase versus 176 (82%) for Tenecteplase. 34 patients (15%) in the alteplase group as compared to 26 patients (12%) in the Tenecteplase group had endovascular thrombectomy attempted. 7 patients in the tPA group (3.2%) and 14 patients (6.5%) in the TNK group had sICH. An increase in the NIHSS on arrival (p=0.048) was a statistically significant predictor of sICH. A two sample proportion test on TNK produced a statistically significant increase in Heidelberg Bleed class 3 (HBc3) (p=0.040) over tPA. Conclusion We observed increased cases of bleeding associated with TNK administration with statistically significant increase in the HBc3 when compared to patients who received tPA. Suggested mechanisms of bleeding are hemorrhagic conversion in clinically silent infarcts, and contusions underlying the lesions. These findings suggest a potential need to reevaluate the criteria for administering TNK to patients. Larger studies are required to confirm this data

Systolic blood pressure measurements are unreliable for the management of acute spontaneous intracerebral hemorrhage

Purpose: Whether systolic blood pressure (SBP) is reliable in acute spontaneous intracerebral (sICH) by assessing agreement between simultaneous BP measurements obtained from cuff non-invasive blood pressure (NIBP) and radial arterial invasive blood pressure (AIBP) devices. Material and methods: Among 766 prospectively screened sICH subjects, 303 (39.5%) had NIBP and AIBP measurements. During the first 24 h, 2157 simultaneous paired measurement readings were abstracted. Paired NIBP/AIBP measurements were included in a Bland-Altman technique with 95% agreement limits and coefficients from regression analysis derived from a bootstrap procedure. Results: Variance for SBP was 66.1 mmHg, which was larger than the 44.3 mg Hg for diastolic blood pressure (DBP) or the 46.1 mmHg for mean arterial pressure (MAP). Pairwise comparison of mean biases showed a significant difference between SBP when compared to DBP (p \u3c 0.0001) or MAP (p \u3c 0.0001). The mean bias between DBP and MAP was not different (p = 0.68). Regression-based Bland Altman analysis found significant bias (slope -0.16, 95% CI -0.23, -0.09, p \u3c 0.05) over the range of mean SBP. Bias over the range of mean DBP or MAP was not significant. Conclusions: We concluded that SBP is an unreliable blood pressure measurement in patients with sICH

Systolic blood pressure measurements are unreliable for the management of acute spontaneous intracerebral hemorrhage.

PURPOSE: Whether systolic blood pressure (SBP) is reliable in acute spontaneous intracerebral (sICH) by assessing agreement between simultaneous BP measurements obtained from cuff non-invasive blood pressure (NIBP) and radial arterial invasive blood pressure (AIBP) devices. MATERIAL AND METHODS: Among 766 prospectively screened sICH subjects, 303 (39.5%) had NIBP and AIBP measurements. During the first 24 h, 2157 simultaneous paired measurement readings were abstracted. Paired NIBP/AIBP measurements were included in a Bland-Altman technique with 95% agreement limits and coefficients from regression analysis derived from a bootstrap procedure. RESULTS: Variance for SBP was 66.1 mmHg, which was larger than the 44.3 mg Hg for diastolic blood pressure (DBP) or the 46.1 mmHg for mean arterial pressure (MAP). Pairwise comparison of mean biases showed a significant difference between SBP when compared to DBP (p \u3c 0.0001) or MAP (p \u3c 0.0001). The mean bias between DBP and MAP was not different (p = 0.68). Regression-based Bland Altman analysis found significant bias (slope -0.16, 95% CI -0.23, -0.09, p \u3c 0.05) over the range of mean SBP. Bias over the range of mean DBP or MAP was not significant. CONCLUSIONS: We concluded that SBP is an unreliable blood pressure measurement in patients with sICH

RESCUE‐ICAS: Rationale and Study Design

BACKGROUND Mechanical thrombectomy (MT) failure occurs in ≈10% to 20% of MTs. Among the common causes of failed MT is residual underlying intracranial stenosis (ICAS), typically attributable to atherosclerotic disease. ICAS large‐vessel occlusion (ICAS‐LVO) remains poorly understood, and management of ICAS‐LVO is unclear. The RESCUE‐ICAS (Registry of Emergent Large Vessel Occlusion Due to Intracranial Stenosis) aims at providing better understanding of the prevalence of ICAS‐LVO, and the overall safety and efficacy of various rescue therapies. METHODS RESCUE‐ICAS is a multicenter, international, prospective registry that is currently enrolling patients with ICAS‐LVO who underwent MT. All sites are required to report monthly MT cases that meet inclusion criteria. The decision of whether to use rescue therapy is up to the interventionist. RESULTS We will collect patients’ demographic, clinical, and radiographic data at baseline. Also, we will capture variables related to the MT procedure and rescue therapy (if performed), and postprocedural clinical and imaging variables. Outcomes include the rate of successful recanalization, defined by modified Thrombolysis in Cerebral Infarction score of ≥2b, the rate of symptomatic intracranial hemorrhage, the 90‐day modified Rankin scale score, and mortality. CONCLUSIONS No strong evidence is currently available to support an optimal treatment strategy for patients with ICAS‐LVO undergoing MT. RESCUE‐ICAS is a prospective cohort study that will provide important data to help design randomized controlled trials

Endovascular Thrombectomy With and Without Preceding Thrombolysis in Posterior Circulation Stroke—Insights From STAR

BACKGROUND Multiple randomized trials could not establish the noninferiority of endovascular thrombectomy (EVT) alone without preceding intravenous thrombolysis (IVT) or superiority of IVT followed by EVT in anterior circulation large‐vessel occlusion stroke. The role of prior IVT in posterior circulation large‐vessel occlusion remains controversial. METHODS In this multicenter, retrospective study, patients with stroke with large‐vessel occlusion in the posterior circulation who received EVT alone or with IVT were selected from the stroke thrombectomy and aneurysm registry between 2013 and 2022. Effects of IVT followed by thrombectomy on favorable functional outcome (defined as modified Rankin scale≤3 at 90 days) and safety were investigated using multivariable logistic and linear regression models. RESULTS Of the 588 included patients, 67% (n = 394) were treated with EVT alone and 29% (n = 170) with EVT after IVT, and 4% (n = 24) have missing values on this variable. Controlling for multiple confounding factors, IVT was not associated with a higher likelihood of favorable functional outcome at 90 days (odds ratio, 1.04 [95% CI, 0.52–2.09; P = 0.901). Thrombectomy alone did not show any safety advantages compared with those receiving IVT. CONCLUSION Similar functional outcomes and complication rates were seen in patients with posterior circulation large‐vessel occlusion treated with EVT alone versus EVT after IVT. Further prospective studies are required to determine the utility of IVT in posterior circulation stroke, especially in patients being directly admitted to thrombectomy centers

Abstract WP192: Impact of Second Line Thrombectomy Technique Following Failed First Pass Thrombectomy for Anterior Circulation Stroke: To Switch or Not to Switch?

Abstract only Introduction: Despite comparable outcomes for different frontline techniques in mechanical thrombectomy (MT) for acute ischemic stroke (AIS), there are sparse data regarding if and when to switch techniques if the first pass is unsuccessful. We aimed to investigate the impact of converting from one MT technique to another on the second MT attempt for AIS among patients with large vessel occlusion (LVO). Methods: This was a retrospective observational study using data from the large multicenter international Stroke Thrombectomy and Aneurysm Registry (STAR). Data from 29 stroke centers for 10,229 AIS patients treated with MT for LVO between January 2010 and December 2022 was investigated. The primary outcome measure was successful recanalization defined as modified Thrombolysis in Cerebral Ischemia (mTICI) score of 2b or higher. 90-day modified Rankin score (mRS) 0-2, mortality and symptomatic hemorrhage were used as secondary outcomes. Clinical and technical outcomes after the second MT attempt were compared between those with or without technique conversion. Results: Among 10,229 AIS patients, 1,797 AIS patients with LVO failed first pass recanalization and were included in this retrospective analysis. 927 patients were female (52%) and median (interquartile range) age was 72 (61-81) years. Converting to alternative techniques following a first failed attempt was more likely to be associated with successful recanalization at the second attempt (adjusted odds ratio 2.30, 95% CI: 1.37-3.86, P = 0.002) and 90-day good clinical outcome (adjusted odds ratio 2.10, 95% CI: 1.15-3.85, P = 0.02) after multivariate adjustment. Conclusions: This study demonstrates better clinical and technical outcomes with conversion of MT technique for the second attempt in AIS patients with LVO who failed first pass recanalization

Abstract WP205: Development and Validation of a Prediction Model for Outcome in Mechanical Thrombectomy for Large-Vessel Occlusion Anterior Circulation Stroke With Low ASPECTS

Abstract only Introduction: Recent randomized control trials suggested that mechanical thrombectomy (MT) was associated with good functional outcomes after acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in patients presenting with low Alberta Stroke Program Early CT Score (ASPECTS) (defined as ASPECTS 2-5). The aim of this study is to develop and validate a stroke prediction tool for outcome in MT for AIS patients with low ASPECTS using data from an ongoing international multicenter registry, the Stroke Thrombectomy and Aneurysm Registry (STAR). Methods: 236 AIS patients with low ASPECTS caused by LVO who undertook MT between January 2010 and December 2022 were retrospectively investigated. Univariate and multivariate logistic regression results were used to screen model predictors and construct nomograms of 90-day modified Rankin Scale scores (mRS) 0-3. The performance of the model was detected by using receiver operating characteristic analysis. The bootstrap resampling method was considered internal validation of the model. Results: Age (< 70 years), premorbid status (mRS 0), National Institutes of Health Stroke Scale (NIHSS) (< 20), and recanalization status after the MT (modified Thrombolysis in Cerebral Ischemia [mTICU] ≥2b) were related to 90-day mRS 0-3. Predictive score was calculated by adding 1 point for age (< 70 years), premorbid status (mRS 0), and NIHSS < 20 and 3 points for a mTICI ≥2b (ranging 0-6). 90-day mRS 0-3 was observed in 0% of patients with a score of 0 or 1, 6.3% with a score of 2, 17.7% with a score of 3, 22.2% with a score of 4, 45.7% with a score of 5, and 73.7% with a score of 6. The score showed relatively high performance in predicting 90-day mRS0-3 (area under the curve: 0.79 [95% CI 0.73-0.79] and 0.78 [95% CI 0.78-0.78] for derivation and validation cohorts, respectively). Conclusions: This study indicates the STAR score can be calculated with baseline and periprocedural characteristics to predict the 90-day outcome after MT in AIS patients with low ASPECTS

Clinical and radiographic outcomes after mechanical thrombectomy in medium-vessel posterior cerebral artery occlusions: Subgroup analysis from STAR

Whereas mechanical thrombectomy (MT) has become standard-of-care treatment for patients with salvageable brain tissue after acute stroke caused by large-vessel occlusions, the results of MT in patients with medium-vessel occlusions (MEVOs), particularly in the posterior cerebral artery (PCA), are not well known.BACKGROUNDWhereas mechanical thrombectomy (MT) has become standard-of-care treatment for patients with salvageable brain tissue after acute stroke caused by large-vessel occlusions, the results of MT in patients with medium-vessel occlusions (MEVOs), particularly in the posterior cerebral artery (PCA), are not well known.Using data from the international Stroke Thrombectomy and Aneurysm Registry (STAR), we assessed presenting characteristics and clinical outcomes for patients who underwent MT for primary occlusions in the P2 PCA segment. As a subanalysis, we compared the PCA MeVO outcomes with STAR's anterior circulation MeVO outcomes, namely middle cerebral artery (MCA) M2 and M3 segments.METHODSUsing data from the international Stroke Thrombectomy and Aneurysm Registry (STAR), we assessed presenting characteristics and clinical outcomes for patients who underwent MT for primary occlusions in the P2 PCA segment. As a subanalysis, we compared the PCA MeVO outcomes with STAR's anterior circulation MeVO outcomes, namely middle cerebral artery (MCA) M2 and M3 segments.Of the 9812 patients in STAR, 43 underwent MT for isolated PCA MeVOs. The patients' median age was 69 years (interquartile range 61-79), and 48.8% were female. The median NIH Stroke Scale score was 9 (range 6-17). After recanalization, 67.4% of patients achieved successful recanalization (modified treatment in cerebral infarction score [mTICI] ≥ 2b), with a first-pass success rate of 44.2%, and 39.6% achieved a modified Rankin score of 0-2 at 90 days. Nine patients (20.9%) had died by the 90-day follow-up. In comparison with M2 and M3 MeVOs, there were no differences in presenting characteristics among the three groups. Patients with PCA MeVOs were less likely to undergo intra-arterial thrombolysis (4.7% PCA vs. 10.1% M2 vs. 16.2% M3, p = 0.046) or to achieve successful recanalization (mTICI ≥ 2b, 67.4%, 86.7%, 82.3%, respectively, p < 0.001); however, there were no differences in the rates of successful first-pass recanalization (44.2%, 49.8%, 52.3%, respectively, p = 0.65).RESULTSOf the 9812 patients in STAR, 43 underwent MT for isolated PCA MeVOs. The patients' median age was 69 years (interquartile range 61-79), and 48.8% were female. The median NIH Stroke Scale score was 9 (range 6-17). After recanalization, 67.4% of patients achieved successful recanalization (modified treatment in cerebral infarction score [mTICI] ≥ 2b), with a first-pass success rate of 44.2%, and 39.6% achieved a modified Rankin score of 0-2 at 90 days. Nine patients (20.9%) had died by the 90-day follow-up. In comparison with M2 and M3 MeVOs, there were no differences in presenting characteristics among the three groups. Patients with PCA MeVOs were less likely to undergo intra-arterial thrombolysis (4.7% PCA vs. 10.1% M2 vs. 16.2% M3, p = 0.046) or to achieve successful recanalization (mTICI ≥ 2b, 67.4%, 86.7%, 82.3%, respectively, p < 0.001); however, there were no differences in the rates of successful first-pass recanalization (44.2%, 49.8%, 52.3%, respectively, p = 0.65).We describe the STAR experience performing MT in patients with PCA MeVOs. Our analysis supports that successful first-pass recanalization can be achieved in PCA MEVOs at a rate similar to that in MCA MeVOs, although further study and possible innovation may be necessary to improve successful PCA MeVO recanalization rates.CONCLUSIONSWe describe the STAR experience performing MT in patients with PCA MeVOs. Our analysis supports that successful first-pass recanalization can be achieved in PCA MEVOs at a rate similar to that in MCA MeVOs, although further study and possible innovation may be necessary to improve successful PCA MeVO recanalization rates