XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Background and Purpose—The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audienc...

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Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Methods We randomly assigned eligible patients to either intraarterial treatment plus usual care or usual care alone. Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intraarterially within 6 hours after symptom onset. The primary outcome was the modified Rankin scale score at 90 days; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death). The treatment effect was estimated with ordinal logistic regression as a common odds ratio, adjusted for prespecified prognostic factors. The adjusted common odds ratio measured the likelihood that intraarterial treatment would lead to lower modified Rankin scores, as compared with usual care alone (shift analysis). Results We enrolled 500 patients at 16 medical centers in the Netherlands (233 assigned to intraarterial treatment and 267 to usual care alone). The mean age was 65 years (range, 23 to 96), and 445 patients (89.0%) were treated with intravenous alteplase before randomization. Retrievable stents were used in 190 of the 233 patients (81.5%) assigned to intraarterial treatment. The adjusted common odds ratio was 1.67 (95% confidence interval [CI], 1.21 to 2.30). There was an absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate of functional independence (modified Rankin score, 0 to 2) in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage. Conclusions In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation, intraarterial treatment administered within 6 hours after stroke onset was effective and safe. (Funded by the Dutch Heart Foundation and others; MR CLEAN Netherlands Trial Registry number, NTR1804, and Current Controlled Trials number, ISRCTN10888758.)

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A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)00163-X.pdf

Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials

The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

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Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

Preoperative Embolization of Meningiomas

<h3>Objectives</h3> This is the first FDA approved IDE study for mechanical thrombectomy to treat distal occlusions. DISTALS is a randomized study planned to evaluate the safety and effectiveness of the TIGERTRIEVER 13 Revascularization Device in restoring blood flow in the neurovasculature by removing thrombus in subjects presenting within 24 hours of onset with an ischemic stroke with disabling neurological deficits due to a primary distal vessel occlusion (DVO), as compared to medical management. <h3>Methods</h3> 118 patients of age 18–85 will be randomized in 1:1 ratio in USA and outside USA clinical centers. The primary endpoint will be successful reperfusion at 24 ± 6 hours post randomization, measured either by CTP or MR PWI. The secondary endpoints will include 90 days mRS shift, delta NIHSS at discharge compared to baseline, Quality of life measured by EQ-5D and cognitive assessment measured by MoCA at 90 days. Safety endpoints will include symptomatic and asymptomatic intracranial hemorrhages. Key inclusion criteria will be disabling presenting deficits that localize to the territory of the distal vessel occlusion; NIHSS 4–24, or NIHSS 2–24 for patients with aphasia and/or hemianopia, CTP or MR PWI confirmed lesions non-dominant or co-dominant M2, M3, PCA or ACA; 24 hours since last known well. Patients with excessive tortuosity, treated with IV thrombolysis therapy, intracranial hemorrhage, bilateral stroke or stroke in multiple territories will be excluded. CT, MRI and Radiographic Images will be analyzed by an independent core lab (UCLA). <h3>Results</h3> Technical aspects of the TIGERTIEVER 13 device, will be presented as well as summary of the European experience with the device. More study details and the study status will be discussed. <h3>Conclusion</h3> The TIGERTRIEVER 13 device with operator controllability and high fluoroscopy visibility and its small size can potentially provide a safe and effective clot removal in patients with distal vessels occlusion. <h3>Disclosures</h3> <b>D. Fiorella:</b> 1; C; Rapid Medical. <b>R. Gupta:</b> None. <b>R. Chapot:</b> None. <b>J. Saver:</b> None. 

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O-020 The tigertriever 13 distals study: distal ischemic stroke treatment with adjustable low-profile stentriever

Introduction Treatment of wide necked bifurcation aneurysms often poses procedural and long-term outcome challenges. We describe the initial preclinical experience with the Pulsar Vascular Aneurysm Neck Reconstruction Device (PVANRD) in a canine bifurcation model. Methods Experimental bifurcation vein pouch aneurysms were surgically created in the carotid arteries of eight canines. Endovascular coiling of the aneurysms with assistance of the PVANRD was performed in all cases with acute performance compared to Y-stenting. Results 12 devices were deployed in the eight cases. Device deployment was straightforward and successfully protected the parent artery and maintained patency of the bifurcation in all cases, despite the use of oversized coils. Conclusion The PVANRD is a novel bifurcation stent that facilitates treatment of wide necked bifurcation aneurysms compared with currently available adjunctive devices. Competing interests A Turk: Pulsar Vascular. S Tateshima: None. M Chaudry: None. D Fiorella: None. R Turner: None. M Kelly: None.Abstract E-019 Figure 1

E-019 Novel aneurysm neck reconstruction device: initial experience in an experimental pre-clinical bifurcation aneurysm model: Abstract E-019 Figure 1

Introduction Several methods of extracting arterial blood flow rates from angiography have been attempted over the past decades.1 2 However, catheter-based contrast injections in arteries can cause substantial disturbances to the baseline blood flow,3 which has limited the utilization of these methods in the clinical setting. Contrast reflux, which is the movement of contrast proximal to the catheter tip is frequently observed during antegrade angiography. The goal of this study was to evaluate the relationship between baseline hemodynamics and contrast reflux. Methods A silicone replica of a complete circle of Willis was connected to a pulsatile flow pump (Vascular Simulations, Stony Brook, NY). Contrast injections (n=144) were performed in both the right carotid and right vertebral arteries under varying blood flow and injection conditions with high-speed (15 FPS) image acquisition. Reflux length was measured as the distance from the tip of the catheter to the most proximal point of contrast reflux. The reflux length was normalized by the vessel diameter at the catheter tip location and plotted against the ratio of the Reynolds number (a common fluid dynamics parameter) of blood flow to Reynolds number of contrast injection (figure 1). An appropriate equation was chosen to fit the data and the estimated mean blood flow from curve-fitting was compared to the true, measured blood flow. Mean blood flow was also estimated using the conventional Transit-Time method1 and the flow estimation errors between the new and conventional methods were statistically compared. Results The relationship between the Reynolds number ratio and reflux length could be described by a sigmoidal equation (figure 1, R­2=0.64). The Reflux method showed a lower error (22.8 ± 20.4%) as compared to the conventional Transit-Time method (31.7 ± 39.7%), but without statistical significance (p=0.27). Conclusion The novel Reflux method presented in this study may have better accuracy and precision than conventional transit-time methods for estimating blood flow. Contrast reflux at the catheter tip is essentially an output of hemodynamic disturbances caused by catheter injections with baseline flow and injection parameters as input. Thus, as opposed to traditional methods, the Reflux method inherently relies on, and is robust against, these hemodynamic disturbances. Refinement of the technique is needed to improve the accuracy and precision for clinical use. References Shpilfoygel S, et al. Med. Phys 2000;27(9):2008–2023. Shaughnessy G, et al. Med Phys 2018;45(10):4510–4518. Kovarovic B, et al. Cardiovasc Eng Technol 2018;9(2):226–239. Disclosures S. Marfoglio: 5; C; Vascular Simulations, Inc. 6; C; Vascular Simulations Inc. B. Kovarovic: None. D. Fiorella: 4; C; Vascular Simulations Inc. C. Sadasivan: 2; C; Vascular Simulations Inc. 4; C; Vascular Simulations Inc. 6; C; Vascular Simulations Inc.

https://jnis.bmj.com/content/neurintsurg/12/Suppl_1/A116.full.pdf

E-161 A novel angiographic method to measure arterial blood flow rates using contrast reflux

Background: A previous SAMMPRIS analysis of patients randomized to stenting showed that peri-procedural ischemic infarcts were significantly associated with diabetes, basilar stenosis, age, and smoking status with never smokers having a higher risk (odds ratio = 8.8, p Method: Baseline features in 213 patients undergoing stenting in SAMMPRIS were compared between never smokers vs. former and current smokers in univariate and multivariate analyses. Logistic regression was used to determine the effect of smoking on peri-procedural ischemic infarcts after adjusting for factors related to smoking. Data: Univariate results are shown in Table 1. Never smokers were significantly (P Conclusion: While never smokers had significantly higher rates of some risk factors compared to active or previous smokers, these risk factors do not explain all the increased risk of early stroke in never smokers after stenting in SAMMPRIS. Another contributory factor may be that smoking accelerates the conversion of clopidogrel to its active form.

David Fiorella

Papers

Preoperative Embolization of Meningiomas

O-020 The tigertriever 13 distals study: distal ischemic stroke treatment with adjustable low-profile stentriever

E-019 Novel aneurysm neck reconstruction device: initial experience in an experimental pre-clinical bifurcation aneurysm model: Abstract E-019 Figure 1

E-161 A novel angiographic method to measure arterial blood flow rates using contrast reflux

Abstract WP164: Role of Risk Factors in the Paradoxical Effect of Smoking on Peri-procedural Stroke in SAMMPRIS