Introduction: Early endovascular treatment (EVT) in patients with large vessel occlusions (LVO) is associated with better outcomes. Identifying and categorizing delays to EVT may reveal areas for improvement. Methods: We prospectively identified all patients who underwent EVT at our hospital between May 2022 - 2023. We determined eight steps in acute care: arrival, imaging, IR activation, ED release, arrival to IR, groin puncture, first pass, and recanalization. We classified patients as delayed if any interval exceeded their rolling six-month median. We created 12 categories and 36 subcategories of delays. We used t-test and odds ratios to compare intervals and outcomes between delayed and non-delayed patients. We analyzed subgroups based on causes of delay and location of presentation. Results: Out of 183 LVO patients who underwent EVT, 111 (61%) were delayed. There were no significant differences in age, gender, last known normal to arrival, NIHSS, thrombolytic use, or TICI scale. The delayed group had higher door to groin (99 min), door to device (126 min), and door to recanalization (159 min) compared to the non-delayed group (40, 65, 81 min; p < 0.001). The most common causes of delay were: general case complexity (20%), which was associated with higher door to imaging (59 min, p < 0.001) and imaging to IR activation (37 min, p = 0.03); after hours presentation (19%), which was associated with higher door to imaging (53 min, p = 0.02) and imaging to IR activation (36 min, p = 0.01); and procedural complexity (18%) which was associated with higher groin to device (34 min, p < 0.001) and device to recanalization (53 min, p < 0.001) when compared to other causes of delay. Between the delayed and non-delayed group, there was no significant difference in the length of stay, change in NIHSS at discharge, in-hospital mortality, disposition, or 90-day mRS. Subgroup analysis showed a trend towards higher mortality in delayed patients who presented after hours (OR 3.60 (CI) 0.92-14.10) or in-hospital (OR 2.41 (CI) 0.57-10.19). Conclusions: We determined seven intervals where delays can occur between arrival and recanalization of LVO patients. We created a system for categorizing delays that showed areas for improvement including after hours and in-hospital stroke evaluation.

Introduction Bilateral internal carotid arteries (ICAs), vertebral arteries (VAs), and basilar artery chronic total occlusion is an exceedingly rare condition. Possible underlying etiologies include atherosclerosis, Moyamoya disease, dissection, among others. Methods Here we describe a 58‐year‐old man with chronic total occlusion of the bilateral ICAs, VAs and basilar artery of unknown etiology. Results A 58‐year‐old man who is independent for ADLs/iADLs with a history of prior ischemic strokes (first stroke at 40 years old) with residual left‐sided weakness and dysarthria, hypertension, hyperlipidemia, prior blood clots (previously on warfarin), post‐stroke epilepsy, and never smoker presented as a code stroke to the emergency department after waking that morning with worsening of his residual left‐sided weakness and dysarthria. On arrival, blood pressure was 165/94 mmHg and blood glucose was 108 mg/dL. His NIHSS was 6. His neurologic exam was grossly similar to that documented 19 months ago. In the CT scanner, he developed tonic‐clonic movements of the left arm and leg, confusion, and emesis. Later, he stated he had missed several doses of his prescribed levetiracetam. Head CT and brain MRI revealed encephalomalacia in the brainstem and bilateral cerebellar and cerebral hemispheres. Brain MRI did not demonstrate any diffusion restriction changes. CTA showed chronic occlusion of both ICAs (proximal, distal, and terminus), M1s, VAs (V4 segment), and basilar artery. CTA also revealed that the brain parenchyma was being perfused by collaterals between the external carotid artery (ECA) branches, superficial temporal artery, and M2 branches bilaterally and the bilateral posterior circulation arteries were small and reformed through collaterals. CTP showed a core and penumbra volumes of 0 mL. His presentation was consistent with a seizure. He was admitted to the stroke service for work‐up of his abnormal brain vasculature. Catheter angiography confirmed the CTA results demonstrating occluded bilateral cervical and intracranial segments of the ICAs, collaterals from bilateral ECA branches supplying the intracranial circulation, right VA occlusion distal to the right PICA, and left VA occlusion distal to the V3 segment. Remaining work‐up including A1c, LDL, urine drug screen, EKG, transthoracic echocardiogram, and telemetry was unrevealing other than for an LDL of 152. Routine EEG showed moderate generalized showing. During hospitalization, his home amlodipine and losartan medications were discontinued with the goal of maintaining a blood pressure target of 140‐160 systolic indefinitely, to minimize the risk of hypoperfusion cerebrally. Give his robust collaterals, surgical treatment with revascularization was not pursued. His home aspirin and rosuvastatin 40 mg daily were continued and ezetimibe 10 mg daily was added. His home levetiracetam was increased from 500 to 750 mg twice daily given recent unprovoked seizures at home. He was discharged to an inpatient rehabilitation facility. Conclusion To our knowledge, this is the first case report to show chronic total occlusion of the bilateral ICAs, VAs, and basilar artery. Diagnosis of Moyamoya disease stage VI ("disappearance of the Moyamoya") was entertained but felt to be less likely given involvement of the proximal ICAs and posterior circulation. Other diagnostic consideration included atherosclerosis. Overall, the underlying etiology of his condition remained elusive.

Introduction Reperfusion therapy for patients with large vessel occlusion stroke includes thrombolytics and mechanical thrombectomy. Candidacy for thrombectomy depends on patient factors under active investigation. Historically, patients with large strokes have been excluded from major trials evaluating thrombectomy due to concern that thrombectomy would pose considerable risk with limited benefit. However, new evidence from the Select‐2 Trial found improved modified Rankin scale scores and higher rates of functional independence at 90 days following large stroke in patients who underwent thrombectomy versus medical therapy alone. We explored if patients presenting with large stroke at our institution resemble those in the Select‐2 Trial and, how many previously excluded patients could have possibly benefitted from thrombectomy. Methods Patients presenting as a code stroke at our institution from 1/2022 to 7/2022 were retrospectively analyzed. Large strokes, defined as CTP volume greater than 50mL, were identified. Background information included age, sex, race, and prior stroke. Regarding patient stroke presentation, the following data were gathered: NIHSS, LVO status, CTA results, CTP, tPA, thrombectomy status, TICI score, and discharge status. Our patients included in this study were compared to the patients included the Select‐2 Trial. Mortality rates and NIHSS at discharge were compared between thrombectomized and non‐thrombectomized patients at our institution. Results Of the 365 code strokes activated at our institution during the study period, 26 met criteria for a large stroke. Of those 26, 13 met all criteria for inclusion in SELECT‐2. Only 9 of the 26 patients received thrombectomy, including 7 of 13 patients otherwise meeting SELECT‐2 criteria. 6 patients were excluded from thrombectomy who would have met criteria for SELECT‐2. Of the 9 who underwent thrombectomy, one expired, and the average NIHSS calculated from physical exam at discharge of surviving patients was 13. Of the 17 who did not undergo thrombectomy, seven expired and the average NIHSS at discharge was 19.4. Of large stroke patients, average age was 69.5 years (SD 11.0), similar to Select‐2 (median age 66). Average NIHSS at presentation was 19 (SD 6.55), similar to Select 2. Compared to SELECT2 enrollment, our patients were more likely to be female (50% vs 41%), Black (50% vs 25%), have a history of prior stroke (38% vs. 9%). LVO was identified on 23 of 26 patients. Of these 23, 17 MCA, 3 ACA, 6 ICA, and 2 carotid terminus occlusions were identified (6 had tandem occlusions). The average rCBF volume was 102.3 mL (SD 64.3) compared to median estimated ischemic core volume of 80mL in Select 2. Conclusion The patients presenting to our institution with large stroke resemble those included in the Select 2 trial, which demonstrates positive outcomes following mechanical thrombectomy for this special population. Patients with large strokes are frequently excluded from receiving treatment with mechanical thrombectomy. Analysis of a larger data set, including large stroke patients from 2018 to 2022, is currently pending. In light of the Select 2 trial, patients in our community and in our referral basis stand to benefit from an institutional practice of offering thrombectomy to those presenting with large stroke.

Introduction: Intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) are both standard of care treatments for acute ischemic stroke patients with large vessel occlusion (LVO) who are eligible for one or both treatments. IVT may result in early recanalization in some patients with LVO. The objective of this study is to analyze whether IVT influences pre‐thrombectomy clot lysis in LVO acute ischemic strokes. Methods: We reviewed prospectively collected data for all patients with LVO ischemic strokes who were transferred to the angiography suite with intention to perform EVT at a single comprehensive stroke center between January 2016 to December 2018. We identified subjects who showed partial or complete clot lysis vs no lysis based on the first angiographic picture of the occluded territory at the time of the initial vessel selection. Descriptive statistics were used to summarize demographic and clinical characteristics. We compared key predictor variables between lysis and no lysis groups including baseline variables, effect of IVT, time from IVT to groin puncture, LVO location, final modified treatment in cerebral ischemia (mTICI) score and discharge Modified Rankin Scale (mRS). t‐test or Kruskal‐Wallis test for continuous variables and chi square test or Fisher’s Exact test for categorical variables. Results: Two hundred and fifty‐nine patients were included. Among these patients, 10.8% (28/259) showed partial or complete lysis of the clot vs 89.2% (231/259) with no lysis. Among these patients who showed clot lysis, 16/28 (57.1%) received IVT. The use of IVT did not show differences between both groups (p = 0.18). There were no differences in the baseline characteristics except for gender, which was the only variable significantly associated with clot lysis. Men had 2‐fold higher odds of spontaneous lysis compared to females (OR [95%CI]: 2.39 [1.01, 5.65], p = 0.04). There was significant difference in the final mTICI between both groups (p <0.001). Conclusions: Our study showed that IVT in a modern practice was not associated with pre‐thrombectomy lysis. Some patients had pre‐thrombectomy lysis despite not receiving IVT.

BACKGROUND: The benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO) stroke is uncertain. Conventional metrics of final modified thrombolysis in cerebral ischemia (mTICI) score and 90-d modified Rankin Scale may be insensitive to IVT effects on procedural complexity and duration. OBJECTIVE: To study the effect of IVT prior to MT on clot survival. METHODS: We performed a single-center retrospective analysis of 257 acute stroke patients with LVO undergoing MT and analyzed the effect of IVT prior to MT using a novel, pass-by-pass clot survival methodology. RESULTS: The use of IVT was associated with a significantly lower number of passes to attain mTICI 2B or greater (P = .002) or mTICI 3 (P = .039) reperfusion. The number of patients who achieved mTICI 2B or greater after the first pass was significantly higher in the IVT group (P = .003). This increased rate of reperfusion persisted into subsequent passes. CONCLUSION: IVT prior to MT reduces the number of thrombectomy passes required to achieve mTICI 2B or mTICI 3 reperfusion. This information should be considered as the merits of IVT prior to MT are debated.