Showing papers by "Santiago Ortega-Gutierrez published in 2023"

Trial of Endovascular Thrombectomy for Large Ischemic Strokes.

Abstract: BACKGROUND Trials of the efficacy and safety of endovascular thrombectomy in patients with large ischemic strokes have been carried out in limited populations. METHODS We performed a prospective, randomized, open-label, adaptive, international trial involving patients with stroke due to occlusion of the internal carotid artery or the first segment of the middle cerebral artery to assess endovascular thrombectomy within 24 hours after onset. Patients had a large ischemic-core volume, defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower scores indicating larger infarction) or a core volume of at least 50 ml on computed tomography perfusion or diffusion-weighted magnetic resonance imaging. Patients were assigned in a 1:1 ratio to endovascular thrombectomy plus medical care or to medical care alone. The primary outcome was the modified Rankin scale score at 90 days (range, 0 to 6, with higher scores indicating greater disability). Functional independence was a secondary outcome. RESULTS The trial was stopped early for efficacy; 178 patients had been assigned to the thrombectomy group and 174 to the medical-care group. The generalized odds ratio for a shift in the distribution of modified Rankin scale scores toward better outcomes in favor of thrombectomy was 1.51 (95% confidence interval [CI], 1.20 to 1.89; P<0.001). A total of 20% of the patients in the thrombectomy group and 7% in the medical-care group had functional independence (relative risk, 2.97; 95% CI, 1.60 to 5.51). Mortality was similar in the two groups. In the thrombectomy group, arterial access-site complications occurred in 5 patients, dissection in 10, cerebral-vessel perforation in 7, and transient vasospasm in 11. Symptomatic intracranial hemorrhage occurred in 1 patient in the thrombectomy group and in 2 in the medical-care group. CONCLUSIONS Among patients with large ischemic strokes, endovascular thrombectomy resulted in better functional outcomes than medical care but was associated with vascular complications. Cerebral hemorrhages were infrequent in both groups. (Funded by Stryker Neurovascular; SELECT2 ClinicalTrials.gov number, NCT03876457.).

Mechanical Thrombectomy Global Access For Stroke (MT-GLASS): A Mission Thrombectomy (MT-2020 Plus) Study

Abstract: Background: Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Methods: Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. Results: We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70–11.74). MTA was <1.0% for 18 (27%) countries and 0 for 7 (10%) countries. There was a 460-fold disparity between the highest and lowest nonzero MTA regions and low-income countries had 88% lower MTA compared with high-income countries. The global MT operator availability was 16.5% of optimal and the MT center availability was 20.8% of optimal. On multivariable regression, country income level (low or lower–middle versus high: odds ratio, 0.08 [95% CI, 0.04–0.12]), MT operator availability (odds ratio, 3.35 [95% CI, 2.07–5.42]), MT center availability (odds ratio, 2.86 [95% CI, 1.84–4.48]), and presence of prehospital acute stroke bypass protocol (odds ratio, 4.00 [95% CI, 1.70–9.42]) were significantly associated with increased odds of MTA. Conclusions: Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country’s per capita gross national income, prehospital LVO triage policy, and MT operator and center availability.

TESLA Trial: Rationale, Protocol, and Design

Abstract: Mechanical thrombectomy has been shown to be effective in patients with acute ischemic stroke secondary to large‐vessel occlusion and small to moderate infarct volume. However, there are no randomized clinical trials for large‐core infarct volume comparing mechanical thrombectomy to medical therapy in the population selected based solely on noncontrast computed tomography brain scan. The TESLA (Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke) randomized clinical trial is designed to address this clinical question. The TESLA trial aim is to demonstrate the efficacy (3‐month and 1‐year disability following stroke) and safety of intraarterial mechanical thrombectomy in patients with large‐volume infarction assessed with a noncontrast computed tomography scan. The TESLA trial design is a prospective, randomized controlled, multicenter, open‐label, assessor‐blinded anterior circulation acute ischemic stroke trial with adaptive enrichment design, enrolling up to 300 patients. Patients with anterior circulation large‐vessel occlusion who meet the imaging and clinical eligibility criteria with a large‐core infarction on the basis of noncontrast computed tomography Alberta Stroke Program Early CT Score (2–5) adjudicated by a site investigator will be randomized in a 1:1 ratio to undergo intraarterial thrombectomy or best medical management up to 24 hours from last known well. The primary efficacy outcome is utility‐weighted modified Rankin Scale (mRS) score distribution at 90 days between the groups. The results will be based on an intention‐to‐treat analysis that will examine the Bayesian posterior probability that, adjusted for Alberta Stroke Program Early CT Score, patients with large‐core infarct volume treated with intra‐arterial thrombectomy have higher expected utility‐weighted mRS than those treated with best medical management alone. The primary safety outcome is the 90‐day death rate. Key secondary outcomes are dichotomized mRS 0 to 2 and 0 to 3 outcomes, ordinal mRS scores, and quality of life (EuroQol 5 Dimension 5 Level survey) at 90 days and 1 year, utility‐weighted mRS at 1 year, hemicraniectomy rate, and rate of 24‐hour symptomatic intracranial hemorrhage in both groups. TESLA is a pragmatic trial, designed to address the unanswered question of the efficacy and safety of intra‐arterial thrombectomy in patients with large infarcts diagnosed by the site investigator only on noncontrast computed tomography scan secondary to anterior circulation large‐vessel occlusion up to 24 hours from stroke symptoms onset.

Morphological Characteristics of Ruptured Brain Aneurysms: A Systematic Literature Review and Meta‐Analysis

Abstract: It is unclear what morphological features of brain aneurysms are better at predicting risk of rupture. We conducted a meta‐analysis to analyze the best morphological determinants of rupture status. The Nested Knowledge platform was used to perform a search of articles reporting on aneurysm size, aspect ratio (AR), size ratio (SR), ellipticity index, nonsphericity index, and undulation index. The mean differences between ruptured and unruptured aneurysms were used to calculate effect sizes. A total of 63 studies with 13 025 aneurysms were included: 6966 ruptured aneurysms and 6059 unruptured aneurysms. Ruptured aneurysms had a larger size ( P <0.001), AR ( P <0.001), SR ( P <0.001), ellipticity index ( P =0.049), and nonsphericity index ( P =0.049) compared with unruptured aneurysms. The mean size of ruptured aneurysms was 6.1 mm (95% CI, 5.6–6.5). The size of ruptured and unruptured aneurysms was similar in the anterior cerebral artery ( P =0.28), anterior communicating artery ( P =0.31), and basilar artery ( P =0.51). The mean AR of ruptured aneurysms was 1.5 (95% CI, 1.4–1.6), and the mean SR was 2.3 (95% CI, 2.1–2.5). For mirror aneurysms, the mean AR was 1.2 (95% CI, 1.2–1.5), and the mean SR was 2.2 (95% CI, 2.1–2.5). Size is not significantly different between ruptured and unruptured aneurysms located in the anterior cerebral artery, anterior communicating artery, and basilar artery. SR is significantly different between ruptured and unruptured aneurysms in all locations. A mean AR of 1.5 and SR of 2.3 are the thresholds associated with ruptured aneurysm status.

Flow Diverter Performance in Aneurysms Arising From the Posterior Communicating Artery: A Systematic Review and Meta-Analysis.

Abstract: BACKGROUND Flow diverters (FDs) have demonstrated a safe and effective profile. However, the use of FDs for posterior communicating artery (PComA) aneurysms remains controversial. OBJECTIVE To evaluate the safety and effectiveness of FDs for PComA aneurysms using a systematic review and meta-analysis of the literature. METHODS We performed a systematic search from inception until June 2022 for flow diversion in PComA aneurysms. Primary effectiveness was the rate of complete aneurysm occlusion defined by Raymond-Roy class 1. Primary safety outcomes were treatment-related ischemic/hemorrhagic (composite) events causing morbidity and mortality. Secondary safety was PComA patency at follow-up. Random-effects meta-analyses were used to calculate proportions, and statistical heterogeneity was assessed. RESULTS A total of 13 studies with 397 patients harboring 403 aneurysms were included. Mean age was 48 years, and the mean aneurysm size was 5.3 mm. Most aneurysms were unruptured (65%). Complete occlusion at final follow-up was 73% (CI 66%-79%), and adjunctive coils were used in 10% of aneurysms. Retreatment rate was 2% (CI 0%-9%). The primary safety composite outcome was 4% (CI 3%-7%), and mortality was 1%. PComA patency at final follow-up was 76% (CI 57%-89%). Subgroup analysis, patients with fetal PComAs had a lower complete occlusion rate (42% fetal PComA vs 77%, psubgroupdifference = <.01). CONCLUSION The performance of FDs in PComA aneurysms is comparable with outcomes found in other subtypes of supraclinoid aneurysms. Effectiveness was acceptable and safety favorable. However, effectiveness was suboptimal in patients with fetal-type PComAs; alternative treatments should be considered in these cases.

Tissue Clock Beyond Time Clock: Endovascular Thrombectomy for Patients With Large Vessel Occlusion Stroke Beyond 24 Hours

Abstract: Background and Purpose Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT). Methods This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS). Results Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P<0.001). Successful recanalization (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 83%, and 5.6% had symptomatic intracranial hemorrhage compared to 2.5% in the SMT group (P=0.19). MT was associated with mRS 0–2 at 90 days (adjusted odds ratio [aOR] 5.73, P=0.026), less mortality (34% vs. 63%, P<0.001), and better discharge NIHSS (P<0.001) compared to SMT in patients with baseline NIHSS ≥6. This treatment benefit remained after matching both groups. Age (aOR 0.94, P<0.001), baseline NIHSS (aOR 0.91, P=0.017), Alberta Stroke Program Early Computed Tomography (ASPECTS) score ≥8 (aOR 3.06, P=0.041), and collaterals scores (aOR 1.41, P=0.027) were associated with 90-day functional independence. Conclusion In patients with salvageable brain tissue, MT for LVO beyond 24 hours appears to improve outcomes compared to SMT, especially in patients with severe strokes. Patients’ age, ASPECTS, collaterals, and baseline NIHSS score should be considered before discounting MT merely based on LKW.

Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

Abstract: Key Points Question Is carotid artery stenting (CAS) during mechanical thrombectomy (MT) associated with improved functional outcome without an increase in hemorrhagic rates in patients with large vessel occlusion ischemic stroke with tandem lesions, defined as concomitant large vessel occlusion and stenosis or occlusion of the cervical internal carotid artery? Findings In this cross-sectional study of 685 patients with tandem lesions, compared with nonstenting, CAS of the cervical lesion during MT was associated with increased odds of achieving a modified Rankin Scale score of 0 to 2, whereas the rates of symptomatic intracranial hemorrhage were similar at 90 days. Meaning These findings suggest that CAS of the cervical lesion during MT may represent an appropriate endovascular approach for patients with tandem lesions.

Real‐World Outcomes of Endovascular Thrombectomy for Basilar Artery Occlusion: Results of the BArONIS Study

Abstract: To evaluate clinical outcomes of endovascular thrombectomy (EVT) for acute basilar artery occlusion (BAO) using population‐level data from the United States.

Mechanical thrombectomy for the treatment of primary and secondary distal medium-vessel occlusion stroke: systematic review and meta-analysis

Abstract: Background There is limited evidence on the indication and role of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs). The aim of this systematic review and meta-analysis was to evaluate all the evidence available on the efficacy and safety of MT techniques (stent retriever, aspiration) in primary and secondary DMVOs. Methods Five databases were searched from inception to January 2023 for studies of MT in primary and secondary DMVOs. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0–2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Prespecified subgroup meta-analyses according to the specific MT technique and to the vascular territory (distal M2-M5, A2-A5, P2-P5) were also performed. Results A total of 29 studies with 1262 patients were included. For primary DMVOs (n=971 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 84% (95% confidence interval (CI) 76 to 90%), 64% (95% CI 54 to 72%), 12% (95% CI 8 to 18%), and 6% (95% CI 4 to 10%), respectively. For secondary DMVOs (n=291 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 82% (95% CI 73 to 88%), 54% (95% CI 39 to 69%), 11% (95% CI 5 to 20%), and 3% (95% CI 1 to 9%), respectively. Subgroup analyses by MT technique and by vascular territory showed no differences in primary and secondary DMVOs. Conclusion Our findings suggest that MT using aspiration or stent retriever techniques appears to be effective and safe in primary and secondary DMVOs. However, given the level of evidence of our results, further confirmation in well-designed randomized controlled trials is needed.

Abstract Number ‐ 43: Flow Diversion for Intracranial Aneurysms in Large Caliber Vessels: A Case Series

Abstract: The safe and effective profile of flow diverters (FD) has allowed neuro‐interventionalists to consider them as a versatile tool for the treatment of aneurysms with different morphologies, locations, and characteristics. Optimal deployment with complete wall apposition affects FD performance. However, few devices are suitable for aneurysms in large caliber vessels. Herein, we aimed to describe the safety and efficacy of a large caliber (5 mm) FD for the treatment of intracranial aneurysms. We performed a retrospective, multi‐center cohort study of adult patients in whom a 5 mm Surpass Streamline FD was implanted between 2018 and 2021 in the United States. Efficacy outcome was complete occlusion at final follow‐up. Safety outcomes were ischemic/hemorrhagic events and mortality up to 30 days following the procedure. Secondary safety was assessed by the rate of adjunctive devices/treatments to overcome technical complications and improve wall apposition. A total of 29 patients harboring 29 aneurysms were treated with 39 FDs (36 large‐diameter devices). Mean age was 57.8 ± 15.7 years. Aneurysm morphologies were saccular (n = 15), pseudoaneurysm (n = 7), fusiform (n = 6), and dissecting (n = 1). Locations were internal carotid artery (ICA) petro‐cavernous segment (n = 15), ICA paraophthalmic (n = 5), ICA cervical (n = 4), basilar artery (n = 3), and vertebral artery (n = 2). Aneurysm size mean was 11.4 ± 6.7 mm, and neck size mean 6.5 ± 3.9 mm. Proximal FD landing zone vessel diameter was 4.8 ± 1.3 mm and distal 4.5 ± 1.2 mm. At a mean final follow‐up of 12 ± 6 months, 18 (65%) aneurysms were completely occluded. Ischemic/hemorrhagic events occurred in 2 (7%), and 1 patient died during hospitalization. Balloon‐assisted angioplasty was performed in 19 (66%) cases, adjunctive stenting in 8 (28%), and coiling in 1 (3%). Patients who received an adjunctive device/treatment had an 82% (14/17) complete occlusion compared to 66% (4/6) in those who did not. The use of large caliber FDs to treat complex intracranial aneurysms located in large‐diameter dysplastic vessels is technically feasible and safe. The use of adjunctive devices and techniques to achieve optimal wall apposition seems crucial to optimize treatment outcomes. Comparative studies with devices specially designed for this patient population might provide further insights into the best device selection.

Abstract TMP46: Large Vessel Occlusion Stroke Knowledge And Clinical Training In Emergency Medical Service Personnel In The United States

Abstract: Background: Stroke education of emergency medical service (EMS) personnel improves stroke recognition, prenotification, and thrombolytic delivery. Prehospital identification of large vessel occlusion (LVO) stroke may facilitate the creation of a regional bypass protocol and improvement of intrahospital and interhospital workflows. However, the current status of EMS personnel’s knowledge of LVO, their stroke severity assessment training, and preferences in educational methods have not been studied. We conducted an EMS survey across the United States. Methods: The Society of Vascular and Interventional Neurology (SVIN) in collaboration with EMS-World created an online questionnaire distributed to all subscribers of EMS-World involved in pre-hospital work. It included 12 multiple-choice questions to test participants on LVO knowledge, stroke center certification levels, prior LVO education, and preferences on educational content delivery. Results: The survey email was opened by 1830 subscribers out of whom 1107 (60%) completed the survey across 50 states in the United States. Respondents identified themselves as paramedics/EMTs (91.4%), ground critical care (5.7%) and flight crew (2.9%). The number of stroke patients that survey participants transported in the past year was <10 for 618 (55.8%), 10 to 25 for 332 (30%), and >25 (14.2%). Two hundred eighty-five (25.8%) participants answered both LVO knowledge questions correctly and 379 (34.2%) answered one correctly. Only 128 (11.6%) correctly identified all types of centers with thrombectomy capability. Although 877 (79.2%) were familiar with at least one stroke severity scale, 376 (34%) denied receiving training to perform them. Five sixty-seven (51.2%) respondents preferred in-person training for LVO training and 429 (38.8%) an online training program. About half of all respondents (535,48%) picked 'lack of standardized LVO training' as the greatest hurdle to pre-hospital LVO management. Conclusion: EMS providers in the United States reported inadequate LVO training and demonstrated gaps in knowledge of LVO, stroke severity scales, and stroke center levels. Systematic efforts to enhance and standardize the educational content and delivery of LVO education are urgently needed.

Use of the Woven EndoBridge Device for Sidewall Aneurysms: Systematic Review and Meta-analysis

Abstract: BACKGROUND: The Woven EndoBridge device was originally approved to treat intracranial wide-neck saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of sidewall intracranial aneurysms with variable success. PURPOSE: Our aim was to evaluate the safety and efficacy of the Woven EndoBridge device for sidewall aneurysms using a meta-analysis of the literature. DATA SOURCES: We performed a systematic review of all studies including patients treated with the Woven EndoBridge device for sidewall aneurysms from inception until May 2022 on Scopus, EMBASE, MEDLINE, the Web of Science, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Ten studies were selected, and 285 patients with 288 sidewall aneurysms were included. DATA ANALYSIS: A random-effects meta-analysis of proportions using a generalized linear mixed model was performed as appropriate. Statistical heterogeneity across studies was assessed with I2 statistics. DATA SYNTHESIS: The adequate occlusion rate at last follow-up was 89% (95% CI, 81%–94%; I2, = 0%), the composite safety outcome was 8% (95% CI, 3%–17%; I2 = 34%), and the mortality rate was 2% (95% CI, 1%–7%; I2 = 0%). Aneurysm width (OR = 0.5; P = .03) was the only significant predictor of complete occlusion. LIMITATIONS: Given the level of evidence, our results should be interpreted cautiously until confirmation from larger prospective studies is obtained. CONCLUSIONS: The initial evidence evaluating the use of the Woven EndoBridge device for the treatment of wide-neck sidewall intracranial aneurysms has demonstrated high rates of adequate occlusion with low procedural complications. Our findings favor the consideration of the Woven EndoBridge device as an option for the treatment of sidewall aneurysms.

Abstract TP70: Association Between Race And Length Of Stay Among Stroke Patients: The National U.S. Emergency Departments Dataset

Abstract: Background: There remain ongoing racial and ethnic disparities in care and outcomes among stroke patients treated in the US. However, length of stay (LOS) and inpatient costs warrant further evaluation. Methods: The 2019 Nationwide Emergency Department Sample (NEDS), which includes data from roughly 20% of US emergency departments, was queried for patients with cerebral infarction. Multivariable logistic regression was used to estimate the odds of prolonged length of hospital stay (>75th percentile) and inpatient costs among various race/ethnic groups, including income and payor status, age, modified Charlson Comorbidity Index (mCCI), vascular risk factors, and treatment with thrombolysis and thrombectomy. Results: Of 617,946 estimated patients with acute ischemic stroke, 398,661 (65.5%) were > 65y, and 386,096 (63.5%) were Medicare beneficiaries. Lower income and Medicaid or self-pay status were more commonly observed in Black and Hispanic versus White patients (p<0.001). In multivariable regression, Black patients were more likely to have a prolonged LOS (Odds Ratio 1.41, 95% confidence interval 1.28-1.55) compared to Whites. Prolonged LOS was inversely related to income, but there was no significant interaction between race and income bracket (p>0.05). Prolonged LOS was also associated with Medicaid (versus Medicare), higher mCCI, thrombolysis, and thrombectomy (p<0.05). Race was not independently associated with higher inpatient costs. Conclusions: These results build on prior population-based studies that indicate ongoing disparities in stroke care based on differences in socioeconomic status and race, but no difference in inpatient cost.

Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions

Abstract: Background and Purpose: We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions (TLs) and whether using intraprocedural antiplatelet therapy (APT) influences MTs safety with IVT treatment.Methods: This is a sub-analysis of a pooled, international multicenter cohort of patients with acute anterior circulation TLs treated with MT. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2). Additional outcomes included hemorrhagic transformation (HT), successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3), complete reperfusion (mTICI 3), favorable functional outcome (90-day modified Rankin score [mRS] 0-2), excellent functional outcome (90-day mRS 0-1), in-hospital mortality, and 90-days mortality. Results: Of 691 patients, 599 were included (255 underwent IVT+MT and 344 MT alone). There was no difference in the risk of sICH (aOR=1.43; 95%CI:0.722.87; p=0.308), PH2 (aOR=1.14; 95%CI:0.572.28; p=0.705), and HT (aOR=0.92; 95%CI:0.541.57;p=0.751) between the IVT+MT and MT alone groups after adjusting for confounders. There was an IVT-by-intraprocedural APT interaction for sICH (p interaction=0.031). Administration of IVT was associated with an increased risk of sICH in patients who received IV-APT (aOR=3.58; 95%CI:1.1710.89;p=0.025). The IVT+MT group had higher odds of 90-days mRS 0-2 (aOR=1.76; 95%CI:1.052.94;p=0.030). The odds of successful reperfusion, complete reperfusion, 90-days mRS 0-1, in-hospital mortality, or 90-days mortality did not differ between the IVT+MT vs. MT alone groups. Conclusion: Our study showed that the combination of IVT with MT for TL did not increase the overall risk of sICH, PH2, or overall HT independently of the cervical revascularization technique used. However, intraprocedural IV-ATP during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT prior to MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcome at 90 days.

Abstract Number ‐ 45: Curative Embolization for Pediatric Low‐Grade Brain Arteriovenous Malformations

Abstract: Improvements in the safety and efficacy of curative embolization for brain arteriovenous malformations (bAVMs) have allowed to achieve comparable results to microsurgical resection and radiosurgery, especially for low‐grade bAVMs (Spetzler Martin [SM] grade I and II). However, whether this treatment modality is beneficial in the pediatric population remains unknown. Hence, we assessed the safety and efficacy of curative embolization for low‐grade bAVMs in children. In addition, we determined predictors of intraprocedural complications and predictors of complete occlusion in one embolization session. Between 2010 and 2022, a retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization for low‐grade bAVMs was conducted at two institutions. Demographic data, clinical presentation, SM grade, and procedural characteristics were retrieved. The safety (intraprocedural complications and mortality) and efficacy (complete angiographic obliteration after the last embolization session) were evaluated. Multivariable logistic regression analysis was performed to identify potential predictive factors of intraprocedural complications and complete occlusion in one session. For selected variables, odds ratios (OR) with 95% confidence intervals (CI) and p value of the likelihood‐ratio test were presented. Sixty‐eight patients (41 females; mean age 12.9 ± 3.6 years) underwent a total of 102 embolization sessions. Fifty‐one bAVMs (75%) presented ruptured, and headache was the most common clinical presentation (50%). There were 24 (35%) SM grade I lesions and 44 (65%) grade II. Onyx was the most used embolic agent (33%) and the transarterial approach was the most common (93%). The mean volume of embolic agents in each patient was 2.4 ml (range 0.2 to 7.5 ml). Fourteen intraprocedural complications (14% of procedures) were observed and no deaths were reported. The most common complication was microcatheter‐related vessel perforation (6%). Single venous drainage decreased the risk of intraprocedural complications (OR = 0.19; 95% CI 0.04 – 0.78). Complete angiographic obliteration was achieved in 44 patients (65%). In 35 patients (52%) the bAVM was occluded with a single session. A small bAVM size was predictor of complete occlusion in one session (OR = 0.42; 95% CI 0.21 – 0.73). Curative embolization in pediatric low‐grade bAVMs can be performed with an acceptable complete occlusion rate but with a high rate of intraprocedural complications. The risk of intraprocedural complications was low in bAVMs with a single venous drainage. The odds of complete occlusion in one session are high in small bAVMs. Curative embolization should be selected on an individual basis in order to achieve optimal results.

Abstract Number ‐ 126: Use of Woven EndoBridge device for Aneurysms in Off‐Labeled Locations: Systematic Review and Meta‐Analysis

Abstract: The Woven EndoBridge (WEB) device was originally approved to treat intracranial wide‐necked saccular bifurcation aneurysms. Recent studies have suggested its use for the treatment of intracranial aneurysms (IA) in alternative locations with variable success. We aimed to evaluate the safety and efficacy of the WEB for IAs in off‐labeled locations using a meta‐analysis (MA) of the literature. We performed a systematic review of all studies including patients treated with WEB for IAs in locations different than what is currently on‐label FDA until May 2022. Our primary efficacy and safety outcomes were adequate occlusion at last follow up and a composite of intraprocedural and postprocedural complications, respectively. The Raymond‐Roy (RR) scale and the Bicêtre Occlusion Scale Score (BOSS) were used to define complete (RR: 1; BOSS: 0‐0’) and adequate (RR:1‐2; BOSS: 0–2) occlusion. Additional safety outcomes included intraprocedural (thromboembolic, hemorrhagic, device deployment, or air embolism) and postprocedural (ischemic or hemorrhagic) complications, and mortality. We performed a random‐effects MA of proportions and assessed the certainty of the evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I2 statistics. Logistic regression of the patient level data was used to study the predictors of complete occlusion. Ten studies were selected, and 285 patients (79% female; mean age 58 years) with 288 aneurysms (35% ruptured) were included. Adequate and complete occlusion rates were 89% (95% CI 81–94%; I2 = 0%; moderate‐certainty evidence) and 64% (95% CI 57–70%; I2 = 13%; moderate‐certainty evidence), respectively. The composite safety outcome rate was 8% (95% CI 3–17%; I2 = 34%; very low‐certainty evidence). The intraprocedural and postprocedural complication rates were 6% (95% CI 4–10%; I2 = 0%; very low‐certainty evidence) and 1% (95% CI 0–1%; I2 = 33%; very low‐certainty evidence), respectively. The mortality rate was 2% (95% CI 1–7%; I2 = 0%; very low‐certainty evidence). Aneurysm width (OR = 0.5; p = 0.03) was the only significant predictor of complete occlusion. The preliminary studies evaluating the use of WEB for the treatment of IAs in off‐labeled locations has demonstrated rates of adequate occlusion and procedural complications comparable to the landmark studies that evaluated the use of the WEB for on‐label bifurcation aneurysms. Given the level of evidence, we consider the interpretation of our results should be done cautiously until confirmation from larger prospective studies are obtained.

Embolization as stand-alone strategy for pediatric low-grade brain arteriovenous malformations.

Abstract: Objectives We evaluated the safety and efficacy of endovascular embolization as first-line stand-alone strategy for the treatment of low-grade brain arteriovenous malformations (bAVMs) (Spetzler Martin [SM] grade I and II) in pediatric patients. In addition, we assessed the predictors of procedure-related complications and radiographic complete obliteration in a single session. Material and methods We conducted a single center retrospective cohort study of all pediatric (≤18 years) patients who underwent embolization as a stand-alone strategy for low-grade bAVMs between 2010 and 2022. Safety was measured by procedure-related complications and mortality. Efficacy was defined as complete angiographic obliteration after the last embolization session. Results Sixty-eight patients (41 females; median age 14 years) underwent a total of 102 embolization sessions. There were 24 (35%) SM grade I lesions and 44 (65%) grade II. Six procedure-related complications (5.8% of procedures) were observed and no deaths were reported. All the complications were intraoperative nidus ruptures. A single draining vein was the only significant predictor of procedure-related complications (OR=0.10; 95% CI 0.01 – 0.72; p=0.048). Complete angiographic obliteration was achieved in 44 patients (65%). In 35 patients (51%) the bAVM was completely occluded in one session. The bAVM nidal size was a predictor of complete obliteration in one session (OR=0.44; 95% CI, 0.21–0.80; p=0.017). Conclusion Endovascular treatment as a stand-alone strategy for pediatric low-grade bAVMs is an adequate first-line approach in high volume centers with endovascular expertise. Nidal size evaluation is relevant in order to optimize patient selection for embolization as a stand-alone treatment modality.

Hypoperfusion intensity ratio is correlated to infarct growth rate parameters when modelled as a logistic growth function (P6-5.022)

Abstract:

Objective:

To model infarct growth rate as a logistic growth function and determine its association to hypoperfusion intensity ratio (HIR)

Background:

Understanding IGR in patients with Acute Ischemic stroke (AIS) due to Large Vessel Occlusion (LVO) may allow for individualized treatment to improve neurological recovery. Other IGR models, like slow vs fast progressor classification, may be too broad. Additionally, animal studies have successfully modelled IGR as a logistic growth function and found its parameters are dependent on collateral circulation. We present the first logistic model for IGR in human patients.

Design/Methods:

This a secondary analysis of a retrospective cohort of AIS patients due to anterior circulation LVO that underwent successful endovascular therapy in two comprehensive stroke centers. Two time measures were used: from stroke onset to CT perfusion and from this to reperfusion. Final infarct volume was measured with DWI-MRI within 24 hours after EVT. IGR was modelled as a logistic growth function with a maximum infarct volume parameter (Vmax) and infarct growth rate parameter (r). These were estimated for each patient. To assess correlation to HIR, we used Pearson’s correlation coefficient.

Results:

We included 34 patients; 24 classified as having good collaterals (HIR<0.4) and 10 as having poor collaterals (HIR>0.4). Median age was 72.5 (IQR 56.25 – 83.0) and 50% were male. Median baseline NIHSS was 16 (IQR 12.5 – 18). None were different between groups. Vmax was 51.5 (37.6 in good HIR vs 59.6 in poor HIR, p=0.322), while r was 0.024 (0.031 vs 0.024, respectively, p=0.724). HIR’s Pearson’s coefficient was 0.455 (0.13 – 0.68, p=0.006) for Vmax, while it was 0.11 (−0.22 – 0.43, p=0.5076) for r.

Conclusions:

IGR can be modelled as a logistic growth function with parameters dependent on multiple factors. When modelling IGR, we found that HIR was associated with infarct maximum growth, but not growth rate. Disclosure: Dr. Galecio-Castillo has nothing to disclose. Mr. Malaga has nothing to disclose. Dr. Quispe Orozco has nothing to disclose. Mr. Vivanco-Suarez has nothing to disclose. Dr. Rodriguez-Calienes has nothing to disclose. Cynthia Zevallos has nothing to disclose. Ms. Kobsa has nothing to disclose. Mr. Prasad has nothing to disclose. Dr. Farooqui has nothing to disclose. Dr. Petersen has received research support from NIH. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for stryker. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for medtronic. Dr. Ortega Gutierrez has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for microvention. Dr. Ortega Gutierrez has received personal compensation in the range of $0-$499 for serving as an officer or member of the Board of Directors for SVIN. The institution of Dr. Ortega Gutierrez has received research support from stryker. The institution of Dr. Ortega Gutierrez has received research support from Siemens. The institution of Dr. Ortega Gutierrez has received research support from IschemiaView. The institution of Dr. Ortega Gutierrez has received research support from Medtronic.

External Validation of Atherosclerotic Neuroimaging Biomarkers in Emergent Large‐Vessel Occlusion

Abstract: Intracranial atherosclerosis related large vessel occlusion (ICAS‐LVO) is the major cause of failed mechanical thrombectomy. ICAS‐LVO causes reocclusion or a fixed focal stenosis, leading to suboptimal revascularization and poor functional outcomes. We aimed to externally validate 4 preidentified imaging biomarkers of ICAS‐LVO: absent hyperdense sign, Hounsfield units (Hu ratio ≤1.1 and Delta Hu <6) and truncal‐type occlusion, observed on admission noncontrast computed tomography and computed tomography angiography in patients presenting with emergent large‐vessel occlusion (ELVO). We conducted a retrospective cohort observational study of consecutive patients presenting with acute M1/terminal internal carotid artery occlusions undergoing mechanical thrombectomy. Inability to locate a hyperdense vessel on noncontrast computed tomography at the corresponding ELVO on computed tomography angiography was labeled absent hyperdense sign. Delta Hu and Hu ratio were defined as the difference and ratio of the Hu of the ELVO on noncontrast computed tomography and its mirror contralateral patent vessel, respectively. ELVO was classified as truncal‐type occlusion if the bifurcation distal to the occlusion was spared on computed tomography angiography. ICAS‐LVO was defined as the presence of fixed focal stenosis or reocclusion after mechanical thrombectomy. Statistical analysis was performed using C statistics, receiver operating characteristic curve analysis, and multivariate logistic regression. Of 161 patients, 30 (18.6%) had suspected ICAS‐LVO. Absent hyperdense sign had a sensitivity of 90% and specificity of 87% (area under the curve [AUC], 0.88), in predicting ICAS‐LVO. Hu ratio ≤1.1 (AUC, 0.89) and Delta Hu <6 (AUC, 0.96) had sensitivity of 100% and 97% and specificity of 79% and 95%, respectively. Truncal‐type occlusion showed a sensitivity of 75% and specificity of 98% (AUC, 0.87). When comparing receiver operating characteristic AUC, Delta Hu <6 was significantly better than absent hyperdense sign ( P =0.006); Hu ratio ≤1.1 ( P =0.006); and truncal‐type occlusion ( P =0.02). Combination of neuroimaging biomarkers using noncontrast computed tomography and computed tomography angiography in ELVO identify ICAS‐LVO with high predictive power. Larger, prospective, multicenter studies are warranted to further evaluate their effectiveness in diagnosing ICAS‐LVO.

Abstract WMP89: Mechanical Thrombectomy For Distal Medium-vessel Occlusion Stroke: Systematic Review And Meta-analysis

Abstract: Introduction: Definitive evidence about the role and effectiveness of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs) is limited. Objective: To determine the efficacy and safety of MT for DMVOs. Methods: A systematic search was performed until May 2022 in Scopus, Embase, Medline, Web of Science, and Cochrane. An additional cohort of 33 patients from our institutional experience was also included. Primary efficacy and safety outcomes were successful reperfusion (mTICI 2b-3) and sICH, respectively. Additional outcomes were the rate of complete reperfusion (mTICI 3), 90-day excellent and favorable functional outcome (defined as an mRS of 0-1 and 0-2, respectively), and 90-day mortality. We conducted meta-analyses using random-effects models and assessed the certainty of evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I 2 statistics. Results: A total of 24 studies with 1046 patients were included in our analysis. Successful and complete reperfusion rates were 89.8% (95% CI 83.7-93.7%; I 2 =0%; moderate-certainty evidence) and 47.2% (95% CI 32.3-62.5%; I 2 =75%; very low-certainty evidence), respectively. Favorable and excellent functional outcome rates were 59.1% (95% CI 48.4-68.9%; I 2 =73%; moderate-certainty evidence) and 43% (95% CI 32.9-53.7%; I 2 =68%; low-certainty evidence), respectively. Mortality and sICH rates were 12.4% (95% CI 9.3-16.5%; I 2 =16%; high-certainty evidence) and 5.5% (95% CI 3.5-8.5%; I 2 =23%; moderate-certainty evidence), respectively. Conclusion: This systematic review with meta-analysis found that MT for DMVO provides rates of successful reperfusion and sICH comparable to the evidence from MT for LVO stroke and M2 occlusions. Given the level of evidence of our results, further confirmation on well-designed RCTs is needed.

Flow Diversion for Intracranial Aneurysms in Large‐Diameter Vessels: A Subanalysis From the SESSIA Study

Abstract: Flow diverters are now considered first‐line tools for treating intracranial aneurysms. However, few devices are available for patients with large‐diameter vessels (LDVs). Hence, we evaluated the performance of the largest diameter Surpass Streamline for aneurysms in LDVs. We performed a subanalysis of the SESSIA (Safety and Efficacy of the Surpass Streamline for Intracranial Aneurysms) multicenter cohort study of patients treated with Surpass Streamline between 2018 and 2021. Patients in whom a 5‐mm diameter Surpass Streamline was implanted were divided into 2 groups according to vessel diameter at the landing zones (LDV, ≥5.3 mm versus non‐LDV [N‐LDV], <5.3 mm). Efficacy was complete occlusion at final follow‐up. Safety was ischemic/hemorrhagic events and mortality up to 30 days. Thirty patients harboring 30 aneurysms were included. Fifteen cases were included per group (LDV versus N‐LDV). Baseline demographics, clinical characteristics, median aneurysm size (LDV, 11 mm versus N‐LDV, 10 mm), and location were similar. Vessel diameters at the proximal (LDV, 5.3 mm versus N‐LDV, 4.2 mm; P <0.001) and distal (5.6 versus 4.0 mm; P <0.001) flow diverter landing zones were different. Procedural characteristics (including balloon‐assisted angioplasty and stenting) were similar. At the final follow‐up (12±6 months), complete occlusion (LDV, 75% versus N‐LDV, 84%; P =0.548), and ischemic/hemorrhagic events (1 per group; P =1.00) were not different. The use of large‐diameter flow diverters for treating complex intracranial aneurysms arising in LDVs is technically feasible and safe. Comparative studies evaluating devices suitable for this patient population will provide valuable insights for the best device selection.

Abstract Number ‐ 131: Microsurgical Clipping and Endovascular Treatment of Paraclinoid Aneurysms: A Systematic Review and Meta‐Analysis

Abstract: Paraclinoid aneurysms (PAs) have traditionally been treated with clipping. However, with the emergence of new techniques, endovascular treatment (EVT) has supplanted surgical treatment in recent years. We aimed to determine the safety and efficacy of EVT and microsurgical clipping for PAs. A systematic review was performed in Scopus, Embase, Medline, Web of Science, and Cochrane from inception to March 2022 for all studies that tested the safety and efficacy of EVT or microsurgical clipping of PAs. Efficacy outcomes included complete aneurysm occlusion at last follow‐up, immediate complete occlusion, and an mRS 0–2 at last follow‐up. Safety outcomes included mortality, intraoperative and postoperative complications. We performed a random‐effects meta‐analysis of proportions and assessed the statistical heterogeneity across studies with I2 statistics. Eighty‐nine studies included 6496 patients, 3682 treated with EVT and 2814 with microsurgical clipping. Immediate complete occlusion rates were 92% (95% CI 88 – 96%; I2 = 60%) and 46% (95% CI 34 – 59%; I2 = 93%) for clipping and EVT, respectively. The rate of complete occlusion at last follow‐up was 94% (95% CI 91 – 96%; I2 = 0%) and 69% (95% CI 63 – 74%; I2 = 79%) for microsurgical clipping and EVT, respectively. Among EVT studies, the rate of complete occlusion was 54% (95% CI 48 – 59%; I2 = 50%), 52% (95% CI 39 – 64%; I2 = 73%), and 77% (95% CI 54 – 91%; I2 = 91%) for primary coiling, stent‐assisted coiling, and flow diversion, respectively. Among clipping studies, the rate of last follow‐up mRS 0–2 was 86% (95% CI 76 – 92%; I2 = 72%). Among EVT studies, the rate of last follow‐up mRS 0–2 was 94% (95% CI 86 – 98%; I2 = 93%). Mortality rate was 4% (95% CI 3 – 7%; I2 = 57%) and 1% (95% CI 0 – 3%; I2 = 0%) for clipping and EVT, respectively. Among EVT studies, the mortality rate was 3% (95% CI 1 – 6%; I2 = 0%) and 3% (95% CI 1 – 9%; I2 = 39%) for primary coiling and flow diversion, respectively. Intraoperative and postoperative complications were present in 9% (95% CI 6 – 14%; I2 = 68%) and 21% (95% CI 17 – 26%; I2 = 87%) among clipping studies, respectively. Intraoperative and postoperative complications were present in 6% (95% CI 4 – 9%; I2 = 64%) and 9% (95% CI 6 – 13%; I2 = 72%) among EVT studies, respectively. In conclusion, microsurgical clipping and EVT for PAs are both safe and effective treatment modalities. Treatment via either approach should be determined on a case‐by‐case basis and according to institutional experience and resources.

Abstract HUP4: Svin Mt2020 + Global Mechanical Thrombectomy Access Barrier Score

Abstract: Introduction: Mechanical thrombectomy (MT) is a highly safe and effective standard of care for acute ischemic strokes with large vessel occlusion. However, timely access to MT is extremely limited on a global scale, with vast disparities in access between countries. MT2020+, a global non-profit initiative of SVIN, aimed to create a semi-quantitative global MT access barrier score (MTABS) to objectively measure the barriers impeding the implementation of treatment worldwide. Methods: Four independent investigators performed an in-depth systematic literature review using the peer review of electronic search strategies. Barriers to access were identified and categorized into 3 groups: information and diagnostic, physical, and financial. An international expert panel was created and scored each attribute using a modified Delphi process with the assistance of consultants from the University of Calgary W21C. A 1-9-point scale was used, with 1 being not at all important and 9 being extremely important. A meeting was held for the attributes that require deliberation. After an agreement, a list of attributes for access was elaborated. Next, a ranking of importance and individual weighting was done. We assigned a presence of or lack of an attribute a numerical value (1 for yes, 0 for no) and multiply by its weight to determine a final score. Results: After an initial screening of 2864 abstracts, 121 studies were included in the final systematic review. A total of 34 possible attributes that are barriers to access were identified. After the modified Delphi process, 26 individual attributes were selected. The MTABS was made with possible results from 0-62 points, with higher scores meaning higher barriers to access to MT. Conclusions: The global MTABS represents the first tool to quantify barriers to MT access worldwide. Its implementation will objectively measure the magnitude and identify key barriers to guide regional public health interventions to improve MT workflow and access.

Establishing a Roadmap for Acute Stroke Care in the Caribbean Region: The Mission Thrombectomy 2020+ Caribbean Experience (P6-9.003)

Abstract:

Objective:

We describe a pathway to facilitate and establish sustainable stroke systems of care including creating stroke-certified centers across the Caribbean region.

Background:

Stroke is the leading cause of neurological related disability and death in the Caribbean. Intravenous thrombolysis and mechanical thrombectomy (MT) are scarce to non-existing in our region with only one certified stroke center in a region of approximately 60 million inhabitants.

Design/Methods:

We connected with regional Stroke experts and created a dyad model of leadership, under the auspices of MT2020+ initiative. The Caribbean Overseeing Committee included eight experienced stroke specialists, who served as an expert panel, coordinated regional solutions based on local public health initiatives and liaised with local country specific physician’s leaders. Committee members interacted regularly with local leadership, established customized collaborations, and built partnerships with specialized local societies, international stroke organizations, Ministries of Health, key stakeholders, and industry. Hands on MT skill workshops were conducted in English and Spanish. The Overseeing Committee facilitated the stroke center certification pathway by the World Stroke Organization (WSO).

Results:

113 physicians from 15 countries participated in the Regional Committees. Train the Trainers workshop in English and Spanish had 85 attendants. The Angels Initiative provided online education; four hospitals became ‘Angels Hospitals’ for the certification pathway. A preferential rate of identification of large vessel occlusion technology (RAPID AI) was obtained for the region, and MT workshops were delivered to 22 neurointerventionalists, 20 nurses and 15 technicians. WSO collaboration facilitated the certification of the first stroke center in the region, located in the Dominican Republic.

Conclusions:

We report the creation of the first ever WSO stroke center certified in the Caribbean Region with 3 other centers on the pathway of certification. These strategies, along with the commitment of local leadership, accelerated the development of stroke systems of care in our region. Disclosure: Dr. Then has nothing to disclose. Dr. Gordon-Perue has nothing to disclose. Dr. Gayle has nothing to disclose. Dr. Manosalva Alzate has nothing to disclose. Dr. Gonzalez Villaman has nothing to disclose. Dr. Suazo has nothing to disclose. Dr. De Souza has nothing to disclose. Dr. Hepburn has nothing to disclose. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for stryker. Dr. Ortega Gutierrez has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for medtronic. Dr. Ortega Gutierrez has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for microvention. Dr. Ortega Gutierrez has received personal compensation in the range of $0-$499 for serving as an officer or member of the Board of Directors for SVIN. The institution of Dr. Ortega Gutierrez has received research support from stryker. The institution of Dr. Ortega Gutierrez has received research support from Siemens. The institution of Dr. Ortega Gutierrez has received research support from IschemiaView. The institution of Dr. Ortega Gutierrez has received research support from Medtronic. Sheila Martins has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Boehringer Ingelheim. Sheila Martins has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Boehringer Ingelheim. Sheila Martins has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Pfizer. Sheila Martins has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Bayer. Sheila Martins has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Medtronic. Sheila Martins has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Penumbra. Sheila Martins has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Novartis. Sheila Martins has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Novo Nordisk. Dr. Yavagal has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Vascular Dynamics. Dr. Yavagal has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Guidepoint. The institution of Dr. Yavagal has received personal compensation in the range of $500-$4,999 for serving as a Consultant for GLG. Dr. Yavagal has received personal compensation in the range of $0-$499 for serving as a Consultant for Medtronic. Dr. Yavagal has received personal compensation in the range of $0-$499 for serving as a Consultant for Cerenovus. Dr. Yavagal has received personal compensation in the range of $0-$499 for serving as a Consultant for Rapid Medical. Dr. Yavagal has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Poseydon. Dr. Yavagal has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for NeuroSave. Dr. Yavagal has stock in Poseydon. Dr. Yavagal has stock in Galaxy Therapeutics. Dr. Yavagal has stock in Stentrode. Dr. Yavagal has stock in Gravity Medical. Dr. Yavagal has received intellectual property interests from a discovery or technology relating to health care. Dr. Yavagal has received personal compensation in the range of $5,000-$9,999 for serving as a Medicolegal Expert with Royal Carribean Cruise Line. Dr. Yavagal has received personal compensation in the range of $5,000-$9,999 for serving as a Medicolegal Consultant with Carnival Cruise Line. Violiza Inoa has nothing to disclose.

Abstract 50: Rescue Stenting For Failed Mechanical Thrombectomy In Acute Ischemic Stroke: Systematic Review And Meta-analysis

Abstract: Introduction: When mechanical thrombectomy (MT) fails to achieve successful recanalization, rescue stenting (RS) has proven to be a feasible rescue therapy. However, the available evidence remains underpowered to assess its safety and efficacy. Objective: To compare the safety and efficacy of RS versus routine medical treatment in patients who failed MT using an aggregated metanalysis. Methods: A systematic review was performed in Scopus, Embase, Medline, and Web of Science from inception to July 2022 for all studies that tested the safety and efficacy of RS after failed MT. Outcomes of interest included an mRS score of 0-2 at 90 days, successful recanalization (mTICI 2b-3) after RS, symptomatic intracranial hemorrhage (sICH), and all-cause mortality at 90 days. A random-effects meta-analysis was performed between the RS and medical treatment arm to calculate pooled odds ratios (OR) for each outcome. Statistical heterogeneity across studies was assessed with I 2 statistics. Results: In total 12 studies involved 1855 participants, 729 in the RS arm and 1126 in the medical treatment arm. The pooled results indicated that RS was associated with a higher proportion of patients with an mRS score of 0-2 at 90 days (RS: 41% vs. 21%; OR = 3.27; 95% CI 2.08 - 5.16; I 2 = 64%) and a decreased risk of mortality at 90 days (RS: 22.5% vs. 33.8%; OR = 0.47; 95% CI 0.32 - 0.69; I 2 = 45%), compared with medical treatment after failed MT. The pooled rate of successful recanalization after RS was 87% (95% CI 82 - 91; I 2 = 57%). The rate of sICH did not differ between groups (RS: 8.5% vs. 11.7%; OR = 0.85; 95% CI 0.59 - 1.20; I 2 = 7%) Conclusion: RS represents a promising strategy that for maximizing recovery in acute stroke patients after first line MT fails to achieve meaningful reperfusion. However, a randomized trial using a standardized approach/technique and independently adjudicated outcomes is needed to confirm this observation.

Abstract Number ‐ 181: Anterograde versus Retrograde approaches in the Endovascular Management of Tandem Lesions

Abstract: There are two approaches for treating stroke patients with tandem occlusions: the anterograde approach (AA, extracranial lesions first) and the retrograde approach (RA, intracranial lesion first). Both techniques are associated with favorable functional outcomes. We aimed to compare both techniques for efficacy and safety outcomes in a multicenter study. Patient data were pooled from 17 centers and divided into AA and RA groups. We performed multivariable logistic regressions to evaluate the association between each group with efficacy and safety outcomes. 552 patients were included in the study, 270 (48.4%) were treated with the AA, and 288 (51.6%) with the RA. There were no differences between groups for functional outcome (mRS 0–2) at 90 days (aOR = 0.93, 95%CI: 0.58‐1.48, p = 0.75), and successful reperfusion [mTICI >2b] (aOR = 0.83, 95%CI: 0.44‐1.56, p = 0.57). Similarly, we did not observe any differences for safety outcomes related to sICH (OR = 0.57, 95%CI: 0.25‐1.29, p = 0.18), parenchymal hematoma type 2 (OR = 0.61, 95%CI: 0.3‐1.22, p = 0.16), and all‐cause mortality at 90 days (OR = 1.22, 95%CI: 0.66‐2.26, p = 0.52). However, the median puncture‐to‐reperfusion time was higher in AA compared with RA [59 minutes (IQR: 38–92) vs 53.5 minuntes (IQR: 37–87)]. The AA and RA approaches for the treatment of tandem occlusions seem to achieve similar efficacy and safety outcomes. These results are consistent with those of a previous multi‐center study. Additionally, and in line with previous research, there is a puncture‐to‐reperfusion time difference between both approaches, which suggests a potential benefit when using the RA. However, further prospective randomized studies are needed to elucidate its benefit in achieving better clinical outcomes.