Showing papers by "Pooja Khatri published in 2020"

Preserving stroke care during the COVID-19 pandemic: Potential issues and solutions.

Abstract: The coronavirus 2019 (COVID-19) pandemic requires drastic changes in allocation of resources, which can affect the delivery of stroke care, and many providers are seeking guidance. As caregivers, we are guided by 3 distinct principles that will occasionally conflict during the pandemic: (1) we must ensure the best care for those stricken with COVID-19, (2) we must provide excellent care and advocacy for patients with cerebrovascular disease and their families, and (3) we must advocate for the safety of health care personnel managing patients with stroke, with particular attention to those most vulnerable, including trainees. This descriptive review by a diverse group of experts in stroke care aims to provide advice by specifically addressing the potential impact of this pandemic on (1) the quality of the stroke care delivered, (2) ethical considerations in stroke care, (3) safety and logistic issues for providers of patients with stroke, and (4) stroke research. Our recommendations on these issues represent our best opinions given the available information, but are subject to revision as the situation related to the COVID-19 pandemic continues to evolve. We expect that ongoing emergent research will offer additional insights that will provide evidence that could prompt the modification or removal of some of these recommendations.

Temporal Trends in Stroke Incidence Over Time by Sex and Age in the GCNKSS

Abstract: Background and Purpose— Sex differences in stroke incidence over time were previously reported from the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study). We aimed to determine whether the...

Association of Blood Pressure With Outcomes in Acute Stroke Thrombectomy.

Abstract: Limited data exist evaluating the effect of blood pressure (BP) on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with mechanical thrombectomy (MT)....

Blood Pressure Variability and Neurologic Outcome After Endovascular Thrombectomy: A Secondary Analysis of the BEST Study.

Abstract: Background and Purpose- Although higher blood pressure variability (BPV) is associated with worse functional outcome after stroke, this association is not as well established in large vessel occlusion strokes treated with endovascular treatment (EVT). Methods- In this post hoc analysis of BEST (Blood Pressure after Endovascular Therapy for Ischemic Stroke), a prospective, multicenter cohort study of anterior circulation acute ischemic stroke patients undergoing EVT, we determined the association of BPV with poor outcome or death (90-day modified Rankin Scale, 3-6). We calculated BPV during the first 24 hours after EVT for systolic and diastolic BP using 5 methodologies, then divided BPV into tertiles and compared the highest to lowest tertile using logistic regression. Results- Of the 443 patients included in our analysis, 259 (58.5%) had a poor outcome, and 79 (17.8%) died. All measures of BPV were significantly higher in patients with poor outcome or death, but the difference was more pronounced for systolic than diastolic BPV. In the logistic regression, the highest tertile of systolic BPV consistently predicted poor outcome (odds ratio, 1.8-3.5, all P<0.05). The rate of death within 90 days was 10.1% in the tertile with the lowest systolic BPV versus 25.2% in the tertile with the highest BPV (P<0.001). Conclusions- In EVT-treated stroke patients, higher BPV in the first 24 hours is associated with worse 90-day outcome. This association was more robust for systolic BPV. The mechanism by which BPV may exert a negative influence on neurological outcome remains unknown, but the consistency of this association warrants further investigation and potentially intervention.

Endovascular Therapy for Patients With Acute Ischemic Stroke During the COVID-19 Pandemic: A Proposed Algorithm.

Abstract: As of this writing, the growing coronavirus disease 2019 (COVID-19) pandemic has suspended international travel, has injected instability in global financial markets, and has led to widespread school and business closures. There are increased calls for social distancing, avoidance of unnecessary physical contacts/interactions, and even mandatory isolation in some countries. These restrictions are leading hospitals and healthcare systems to suspend elective procedures and limit staff interactions with patients to essential personnel only. The currently reported overall case fatality rate of COVID19 is 2.3% in the general population, and is higher (14.8%) in patients >80 years of age. Further, patients with COVID-19 requiring hospitalization suffer a number of cardiovascular complications including arrhythmias (16.7% of patients) and heart failure (23% of patients), raising the risk for acute ischemic stroke (AIS). Indeed, cerebrovascular complications have been reported in 5% to 6% of patients with severe COVID-19. In this context, emergent delivery of endovascular therapy (EVT) requires careful planning and deliberation with special attention to patient selection, resource utilization, and the safety of healthcare providers. With the goal of minimizing the negative impact of COVID-19 on acute stroke patients and healthcare providers, we assembled a multidisciplinary working group to develop consensus-based recommendations and an algorithm for evaluation and treatment of acute stroke patients eligible for EVT during the COVID-19 pandemic. The role of intravenous thrombolysis is not addressed here because EVT presents unique challenges compared with intravenous drug administration. Three populations of potential thrombectomy patients are highlighted: (1) emergency department (ED) patients with stroke and suspected COVID-19, (2) admitted patients with COVID-19 who develop stroke, and (3) patients with stroke who present to a hospital with constrained resources due to COVID-19. Recommendations are discussed and a clinical algorithm is proposed with anticipated decision points of care. This algorithm takes into account the American Heart Association/American Stroke Association (AHA/ASA) EVT guidelines, the safety of patients and staff, the predictors of mortality in patients with COVID-19, and the appropriate utilization of scarce resources. Our working group concluded that diagnosis with COVID-19 is not necessarily a contraindication to EVT for stroke. However, particular care must be taken when preparing patients with COVID-19 for EVT to ensure staff safety. In addition, it may be reasonable during these times of extreme resource limitation to modify current EVT protocols including patient selection and post-EVT care, and to avoid EVT in unstable, severely critically ill patients with COVID-19.

Mechanical Thrombectomy in Patients With Ischemic Stroke With Prestroke Disability.

Abstract: Background and Purpose- We aimed to compare functional and procedural outcomes of patients with acute ischemic stroke with none-to-minimal (modified Rankin Scale [mRS] score, 0-1) and moderate (mRS score, 2-3) prestroke disability treated with mechanical thrombectomy. Methods- Consecutive adult patients undergoing mechanical thrombectomy for an anterior circulation stroke were prospectively identified at 2 comprehensive stroke centers from 2012 to 2018. Procedural and 90-day functional outcomes were compared among patients with prestroke mRS scores 0 to 1 and 2 to 3 using χ2, logistic, and linear regression tests. Primary outcome and significant differences in secondary outcomes were adjusted for prespecified covariates. Results- Of 919 patients treated with mechanical thrombectomy, 761 were included and 259 (34%) patients had moderate prestroke disability. Ninety-day mRS score 0 to 1 or no worsening of prestroke mRS was observed in 36.7% and 26.7% of patients with no-to-minimal and moderate prestroke disability, respectively (odds ratio, 0.63 [0.45-0.88], P=0.008; adjusted odds ratio, 0.90 [0.60-1.35], P=0.6). No increase in the disability at 90 days was observed in 22.4% and 26.7%, respectively. Rate of symptomatic intracerebral hemorrhage (7.3% versus 6.2%, P=0.65), successful recanalization (86.7% versus 83.8%, P=0.33), and median length of hospital stay (5 versus 5 days, P=0.06) were not significantly different. Death by 90 days was higher in patients with moderate prestroke disability (14.3% versus 40.3%; odds ratio, 4.06 [2.82-5.86], P<0.001; adjusted odds ratio, 2.83 [1.84, 4.37], P<0.001). Conclusions- One-third of patients undergoing mechanical thrombectomy had a moderate prestroke disability. There was insufficient evidence that functional and procedural outcomes were different between patients with no-to-minimal and moderate prestroke disability. Patients with prestroke disability were more likely to die by 90 days.

Effect of COVID-19 on Emergent Stroke Care: A Regional Experience.

Abstract: Background and Purpose: Anecdotal evidence suggests that the coronavirus disease 2019 (COVID-19) pandemic mitigation efforts may inadvertently discourage patients from seeking treatment for stroke ...

Redefined Measure of Early Neurological Improvement Shows Treatment Benefit of Alteplase Over Placebo.

Abstract: Background and Purpose- The first of the 2 NINDS (National Institute of Neurological Disorders and Stroke) Study trials did not show a significant increase in early neurological improvement, defined as National Institutes of Health Stroke Scale (NIHSS) improvement by ≥4, with alteplase treatment. We hypothesized that early neurological improvement defined as a percentage change in NIHSS (percent change NIHSS) at 24 hours is superior to other definitions in predicting 3-month functional outcomes and using this definition there would be treatment benefit of alteplase over placebo at 24 hours. Methods- We analyzed the NINDS rt-PA Stroke Study (Parts 1 and 2) trial data. Percent change NIHSS was defined as ([admission NIHSS score-24-hour NIHSS score]×100/admission NIHSS score] and delta NIHSS as (admission NIHSS score-24-hour NIHSS score). We compared early neurological improvement using these definitions between alteplase versus placebo patients. We also used receiver operating characteristic curve to determine the predictive association of early neurological improvement with excellent 3-month functional outcomes (Barthel Index score of 95-100 and modified Rankin Scale score of 0-1), good 3-month functional outcome (modified Rankin Scale score of 0-2), and 3-month infarct volume. Results- There was a significantly greater improvement in the 24-hour median percent change NIHSS among patients treated with alteplase compared with the placebo group (28% versus 15%; P=0.045) but not median delta NIHSS (3 versus 2; P=0.471). Receiver operating characteristic curve comparison showed that percent change NIHSS (ROCpercent) was better than delta NIHSS (ROCdelta) and admission NIHSS (ROCadmission) with regards to excellent 3-month Barthel Index (ROCpercent, 0.83; ROCdelta, 0.76; ROCadmission, 0.75), excellent 3-month modified Rankin Scale (ROCpercent, 0.83; ROCdelta, 0.74; ROCadmission, 0.78), and good 3-month modified Rankin Scale (ROCpercent, 0.83; ROCdelta, 0.76; ROCadmission, 0.78). Conclusions- In the NINDS rt-PA trial, alteplase was associated with a significant percent change improvement in NIHSS at 24 hours. Percent change in NIHSS may be a better surrogate marker of thrombolytic activity and 3-month outcomes.

White Matter Disease and Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke

Abstract: BACKGROUND AND PURPOSE: The increased severity of white matter disease is associated with worse outcomes and an increased rate of intracerebral hemorrhage in patients with ischemic stroke undergoing thrombolytic treatment. However, whether white matter disease is associated with outcomes in patients undergoing endovascular treatment remains unclear. MATERIALS AND METHODS: In this prespecified exploratory analysis of our prospective multi-institutional study that enrolled consecutive adult patients with anterior circulation ischemic stroke undergoing endovascular treatment from November 2017 to September 2018, we compared the following outcomes between patients with none-to-minimal (van Swieten score, 0–2) and moderate-to-severe (van Swieten score, 3–4) white matter disease using logistic regression: 90-day mRS 3–6, death, intracerebral hemorrhage, successful recanalization, and early neurologic recovery. RESULTS: Of the 485 patients enrolled in the Blood Pressure after Endovascular Stroke Therapy (BEST) study, 389 had white matter disease graded (50% women; median age, 68 years; range, 58–79 years). A van Swieten score of 3–4 (n = 74/389, 19%) was associated with a higher rate of 90-day mRS of 3–6 (45% versus 18%; adjusted OR, 2.73; 95% CI, 1.34–5.93; P = .008). Although the death rate was higher in patients with van Swieten scores of 3–4 (26% versus 15%), the adjusted likelihood was not significantly different (adjusted OR, 1.14; 95% CI, 0.56–2.26; P = .710). Ordered regression revealed a shift toward worse mRS scores with increasing van Swieten scores (adjusted common OR, 3.04; 95% CI, 1.93–4.84; P CONCLUSIONS: Moderate-to-severe white matter disease is associated with worse outcomes in patients undergoing endovascular treatment without a significant increase in hemorrhagic complications. Studies comparing patients with and without endovascular treatment are necessary to determine whether the benefit of endovascular treatment is attenuated with greater white matter disease.

Noncontrast CT versus Perfusion-Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study.

Abstract: BACKGROUND AND PURPOSE The 2018 AHA guidelines recommend perfusion imaging to select patients with acute large vessel occlusion (LVO) for thrombectomy in the extended window. However, the relationship between noncontrast CT and CT perfusion imaging has not been sufficiently characterized >6 hours after last known normal (LKN). METHODS From a multicenter prospective cohort of consecutive adults who underwent thrombectomy for anterior LVO 0-24 hours after LKN, we correlated baseline core volume (rCBF < 30%) and the Alberta Stroke Program Early CT Scale (ASPECTS) score. We compared perfusion findings between patients with an unfavorable ASPECTS (<6) against those with a favorable ASPECTS (≥6), and assessed findings over time. RESULTS Of 485 enrolled patients, 177 met inclusion criteria (median age: 69 years, interquartile range [IQR: 57-81], 49% female, median ASPECTS 8 [IQR: 6-9], median core 10 cc [IQR: 0-30]). ASPECTS and core volume moderately correlated (r = -.37). A 0 cc core was observed in 54 (31%) patients, 70% of whom had ASPECTS <10. Of the 28 patients with ASPECTS <6, 3 (11%) had a 0 cc core. After adjustment for age and stroke severity, there was a lower ASPECTS for every 1 hour delay from LKN (cOR: 0.95, 95% confidence of interval [CI]: 0.91-1.00, P = .04). There was no difference in core (P = .51) or penumbra volumes (P = .87) across patients over time. CONCLUSIONS In this multicenter prospective cohort of patients who underwent thrombectomy, one-third of patients had normal CTP core volumes despite nearly three quarters of patients showing ischemic changes on CT. This finding emphasizes the need to carefully assess both noncontrast and perfusion imaging when considering thrombectomy eligibility.

Hypoperfusion Distal to Anterior Circulation Intracranial Atherosclerosis is Associated with Recurrent Stroke

Abstract: BACKGROUND AND PURPOSE In patients with symptomatic vertebrobasilar intracranial atherosclerotic disease (ICAD), impaired distal flow predicts recurrent stroke, but limited data exist on the association between perfusion status and recurrent stroke in anterior circulation ICAD METHODS This is a retrospective study of patients hospitalized for symptomatic ICAD with 50-99% stenosis of the intracranial carotid or middle cerebral artery The primary outcome is recurrent symptomatic ischemic stroke in the territory of the artery with ≥50% stenosis within 90 days The primary predictor is distal hypoperfusion on magnetic resonance (MR) or computed tomography (CT) perfusion, defined as a ≥15 mL volume of territory of the symptomatic artery with Tmax >6 seconds RESULTS Fifty patients met inclusion criteria, including 15 (30%) with recurrent stroke and 15 (30%) with distal hypoperfusion Distal hypoperfusion was present in 10 of 15 (667%) with recurrent stroke versus 5 of 35 (143%) without recurrent stroke (P < 001) The hazard ratio for recurrent stroke in patients with distal hypoperfusion was 680 (95% confidence interval [CI] 231-200) CONCLUSION Distal hypoperfusion in acutely symptomatic ICAD with 50-99% stenosis is associated with stroke recurrence Distal hypoperfusion could be used to enrich future trials of secondary stroke prevention in ICAD patients

Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients: A Subgroup Analysis From the BEST Prospective Cohort Study

Abstract: BACKGROUND Because of the overwhelming benefit of thrombectomy for highly selected trial patients with large vessel occlusion (LVO), some trial-ineligible patients are being treated in practice. OBJECTIVE To determine the safety and efficacy of thrombectomy in DAWN/DEFUSE-3-ineligible patients. METHODS Using a multicenter prospective observational study of consecutive patients with anterior circulation LVO who underwent late thrombectomy, we compared symptomatic intracerebral hemorrhage (sICH) and good outcome (90-d mRS 0-2) among DAWN/DEFUSE-3-ineligible patients to trial-eligible patients and to untreated DAWN/DEFUSE-3 controls. RESULTS Ninety-eight patients had perfusion imaging and underwent thrombectomy >6 h; 46 (47%) were trial ineligible (41% M2 occlusions, 39% mild deficits, 28% ASPECTS <6). In multivariable regression, the odds of a good outcome (aOR 0.76, 95% CI 0.49-1.19) and sICH (aOR 3.33, 95% CI 0.42-26.12) were not different among trial-ineligible vs eligible patients. Patients with mild deficits were more likely to achieve a good outcome (aOR 3.62, 95% CI 1.48-8.86) and less sICH (0% vs 10%, P = .16), whereas patients with ASPECTS <6 had poorer outcomes (aOR 0.14, 95% CI 0.05-0.44) and more sICH (aOR 24, 95% CI 5.7-103). Compared to untreated DAWN/DEFUSE-3 controls, trial-ineligible patients had more sICH (13%BEST vs 3%DAWN [P = .02] vs 4%DEFUSE [P = .05]), but were more likely to achieve a good outcome at 90 d (36%BEST vs 13%DAWN [P < .01] vs 17%DEFUSE [P = .01]). CONCLUSION Thrombectomy is used in practice for some patients ineligible for the DAWN/DEFUSE-3 trials with potentially favorable outcomes. Additional trials are needed to confirm the safety and efficacy of thrombectomy in broader populations, such as large core infarction and M2 occlusions.

National Institutes of Health StrokeNet During the Time of COVID-19 and Beyond.

Abstract: Joseph P. Broderick , MD; Jordan J. Elm, PhD; L. Scott Janis, PhD; Wenle Zhao, PhD; Claudia S. Moy, PhD; Catherine R. Dillon, MS; Marc I. Chimowitz, MBChB; Ralph L. Sacco, MD; Steven C. Cramer, MD; Steven L. Wolf, PhD, PT; Karen C. Johnston, MD; Jeffrey L. Saver, MD; Randolph S. Marshall, MD; Devin Brown, MD; Max Wintermark, MD; Mitchell S.V. Elkind, MD; Hooman Kamel, MD; David L. Tirschwell, MD; W.T. Longstreth, MD; Ronald D. Chervin, MD; Opeolu M. Adeoye, MD; Andrew D. Barreto, MD; James C. Grotta, MD; Sharon L. Ramey, PhD; Warren D. Lo, MD; Wuwei Feng, MD; Gottfried Schlaug, MD, PhD; Kevin N. Sheth, MD; Magdy Selim, MD, PhD; Andrew M. Naidech, MD; Maarten G. Lansberg, MD, PhD; Ronald M. Lazar, PhD; Gregory W. Albers, MD; Jessica S. Griffin, MHA; Logan P. Sirline, MPH; Jamey Frasure, PhD, RN; Clinton B. Wright, MD; Pooja Khatri, MD; on behalf of the NIH StrokeNet Investigators

Mechanical Thrombectomy in Ischemic Stroke Patients with Severe Pre-Stroke Disability.

Abstract: Frequency and outcomes of mechanical thrombectomy (MT) in clinical practice for patients with severe pre-stroke disability are largely unknown. In this case series, we aim to describe the disability make-up and outcomes of 33 patients with severe pre-stroke disability undergoing MT. Patients with a permanent, severe, pre-stroke disability (modified Rankin Score, mRS, 4-5) were identified from a prospectively-maintained database of consecutive, MT-treated, anterior circulation acute ischemic stroke patients at two comprehensive stroke centers in the United States. We present details on the cause of disability and socio-demographic status as well as procedural and functional outcomes. This study, despite the lack of inferential testing due to limited sample size, provides insight into demographics and outcomes of MT-treated patients with severe pre-stroke disability. Rate of return to functional baseline as well as rates of procedural success and complications were comparable to that reported in the literature for patients without any pre-existing disability.

Peri-procedural stroke or death in stenting of symptomatic severe intracranial stenosis.

Abstract: Background and purpose There are limited data on predictors of 30-day stroke or death in patients with symptomatic intracranial atherosclerosis (sICAS) undergoing stenting. We aim to determine the factors associated with stroke or death at 30 days in the stenting arm of the SAMMPRIS trial. Methods This is a post-hoc analysis of the SAMMPRIS trial including patients who underwent angioplasty/stenting. We compared patient-specific variables, lesion-specific variables, procedure-specific variables, and FDA-approved indications between patients with and without the primary outcome (stroke or death at 30 days). Logistic regression analyses were performed to evaluate associations with the primary outcome. Results We identified 213 patients, 30 of whom (14.1%) met the primary outcome. Smoking status and lesion length were associated with the primary outcome: the odds of stroke or death for non-smokers versus smokers (adjusted OR 4.46, 95% CI 1.79 to 11.1, p=0.001) and for increasing lesion length in millimeters (adjusted OR 1.20, 95% CI 1.02 to 1.39, p=0.029). These had a modest predictive value: absence of smoking history (sensitivity 66.7%, specificity 65.4%) and lesion length (area under curve 0.606). Furthermore, event rates were not significantly different between patients with and without the FDA-approved indication for stenting (15.9% vs 12%, p=0.437). Conclusion In SAMMPRIS patients who underwent angioplasty/stenting, neither clinical and neuroimaging variables nor the FDA indication for stenting reliably predicted the primary outcome. Further work in identifying reliable biomarkers of stroke/death in patients with sICAS is needed before considering new clinical trials of stenting. Trial registration number SAMMPRIS NCT00576693; Results.

Endovascular Therapy in Mild Ischemic Strokes Presenting Under 6 hours: An International Survey.

Abstract: Background Endovascular therapy (EVT) for patients with mild ischemic stroke (NIHSS ≤5) and visible intracranial occlusion remains controversial, including within 6 hours of symptom onset. We conducted a survey to evaluate global practice patterns of EVT in this population. Methods Vascular stroke clinicians and neurointerventionalists were invited to participate through professional stroke listservs. The survey consisted of six clinical vignettes of mild stroke patients with intracranial occlusion. Cases varied by NIHSS, neurological symptoms and occlusion site. All had the same risk factors, time from symptom onset (5h) and unremarkable head CT. Advanced imaging data was available upon request. We explored independent case and responder specific factors associated with advanced imaging request and EVT decision. Results A total of 482/492 responders had analyzable data ([median age 44 (IQR 11.25)], 22.7% women, 77% attending, 22% interventionalist). Participants were from USA (45%), Europe (32%), Australia (12%), Canada (6%), and Latin America (5%). EVT was offered in 48% (84% M1, 29% M2 and 19% A2) and decision was made without advanced imaging in 66% of cases. In multivariable analysis, proximal occlusion (M1 vs. M2 or A2, p Conclusions Treatment patterns of EVT in mild stroke vary globally. Our data suggest wide equipoise exists in current treatment of this important subset of mild stroke.

Pre-endovascular therapy change in blood pressure is associated with outcomes in patients with stroke

Abstract: The American Heart Association/American Stroke Association guideline recommends maintaining blood pressure (BP) below 185/110 mm Hg in acute stroke patients prior to initiating any form of reperfusion therapy.1 However, the evidence supporting this recommendation is not strong for patients undergoing endovascular treatment (EVT). Higher BP at presentation in these patients is associated with worse outcomes and haemorrhagic complications.2 However, BP-lowering prior to EVT for avoidance of hyperperfusion as well as induced hypertension for penumbral sustenance have been proposed to improve patient outcomes.2 3 Prior to further testing of these strategies, whether changes in BP in either direction prior to EVT are associated with functional outcomes needs to be assessed. Because any changes in pre-EVT BP may affect ultimate functional outcome through an effect on cerebral perfusion, we aimed to determine the association of the change in pre-EVT mean arterial BP (MAP) with 90-day functional outcomes. We conducted a post-hoc analysis of the ‘Blood pressure after Endovascular Stroke Therapy (BEST)’ study, which prospectively enrolled consecutive adult patients treated with EVT for an anterior (Internal Carotid Artery/M1/M2) acute ischaemic stroke at 12 comprehensive stroke centres across the USA from November 2017 to May 2018.4 Study variables included change in MAP from admission to immediately pre-EVT. MAP was calculated using the following formula: (2×diastolic BP+systolic BP)/3. The primary outcome was dichotomous 90-day modified Rankin score …

Abstract TP221: Cerebellar Infarction Presentations: A Population-Based Study From the Greater Cincinnati/Northern Kentucky Stroke Study

Abstract: Background: Cerebellar lesions reportedly account for 2-7% of acute infarct visits, but this may be an underestimate since prior studies were not population-based or from the modern imaging era. Ce...

Response by Mistry and Khatri to Letter Regarding Article, "Blood Pressure After Endovascular Therapy for Ischemic Stroke (BEST): A Multicenter Prospective Cohort Study".

Abstract: In Response: We greatly appreciate interest in our article by Anadani et al. BEST (Blood Pressure After Endovascular Stroke Therapy) was designed as a prospective, multi-institutional study with a prespecified hypothesis and analysis plan to identify a data-driven target of peak systolic blood pressure (SBP) after endovascular therapy that best dichotomizes good functional outcomes from bad. We intentionally did not supervise our analysis to generate a perceivably feasible SBP target for a future randomized trial. The results of the BEST study are strengthened by reduction of the biases inherent to prior retrospective studies as well as protocolized data collection with centralized data monitoring. Our results are consistent with prior studies that have found a similar peak SBP target that best associated with worse functional outcomes. We appreciate the attempt by Anadani et al to validate our findings in their large retrospective cohort. Their target of 169.5 mm Hg may also be considered for testing in future clinical trials. However, this target will be a subject to the same limitation–lack of separation between observed/achieved interventional SBP values and the standard-of-care SBP value (180 mm Hg)–as Anadani et al have rightly suggested. The target generated in the BEST study informs the selection of a peak SBP goal for testing in future clinical trials. In the BEST study, a U-shaped relationship between peak SBP and 90-day functional outcome was not identified. Thus, lower targets of peak SBP could be employed in such future clinical trial at the investigator’s discretion, while accounting for the potentially harmful effects (ie, worsening of infarct volume and functional outcomes) of induced relative hypotension. Disclosures Dr Mistry Society of Vascular and Interventional Neurology (SVIN), University of Cincinnati Gardner Neuroscience Institute, and National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH/NIHDS; K23NS113858). Dr Khatri reports grants from SVIN, NIH/NINDS, and Intramural source during the conduct of the study and grants from Cerenovus and Nervive outside the submitted work.