PURPOSE:Large bore catheters are increasingly used in mechanical thrombectomy (MT) for large vessel occlusions (LVOs). OBJECTIVE:To evaluate the efficacy and safety of the super-large bore Cereglide 0.092" (C-92) catheter, featuring the largest inner diameter available. METHODS:A multicenter observational study was conducted across 12 comprehensive stroke centers in the United States. Efficacy outcomes included the first pass effect (FPE) and successful reperfusion. FPE was defined as a first MT pass achieving a modified Treatment in Cerebral Infarction (mTICI) score of ≥2c. Successful reperfusion was defined as final mTICI score ≥2c. Safety outcomes involved device-related complications, symptomatic intracranial hemorrhage (sICH), and inpatient mortality. Functional outcomes included modified Rankin Scale (mRS) score at discharge and delta National Institutes of Health Stroke Scale (NIHSS) score. RESULTS:Fifty patients were included. The most common LVO was the first segment of the middle cerebral artery in 31/50 cases (62%). The C-92 reached the thrombus in 41 patients (82%). Median puncture-to-thrombus and puncture-to-reperfusion times were 15 min (IQR 10-25) and 26 min (IQR 15-49), respectively. FPE was achieved in 25/50 (50%) cases, and in 25/41 (61%) cases when the C-92 reached the thrombus. Successful reperfusion occurred in 36/41 patients (88%). There were no vessel perforations, or sICH. Distal embolization occurred in 4/50 (8%) cases, and 4/50 (8%) died. The mRS score at discharge was 3 (IQR 2-6), and the delta NIHSS score was 8 (IQR 5-12). CONCLUSION:The C-92 catheter demonstrated a safe profile achieving an overall FPE rate of 50%, and favorable functional outcomes in 88% of cases.

Background Carotid web (CaW)-related contrast stagnation on digital subtraction angiography (DSA) may be a marker supporting the pathophysiological theory of stasis and thrombosis/embolization. We aim to assess the correlation between DSA hemodynamic parameters with CT angiography (CTA) structural measurements and clinical characteristics.Methods Cross-sectional analysis of consecutive patients with CaW who underwent CTA+DSA. DSA-derived hemodynamic parameters were calculated based on a region of interest at the carotid bulb (time-density curves; TDC). The correlation between duration of contrast stagnation with CaW structural features and with clinical characteristics was evaluated with a mixed effects model.Results Sixty patients of mean +/- SD age 52.2 +/- 10.3 years were included, of whom 38 (63.3%) were women, 51 (85%) were black, and 59 (98.3%) had symptomatic lesions. The median CaW base was 2.46 mm (range 1.95-3.76), length 2.7 mm (range 2.15-3.96), thickness (length/base) 1.05 (IQR 0.81-1.36), caudal angle 31.93 degrees (IQR 22.35-43.58), mean +/- SD distal angle 66.91 +/- 15.84 degrees, pocket area 1.62 mm(2) (0.96-1.62), and pocket perimeter 6.03 +/- 2.6 mm. The TDC consistently showed an initial fast decay from the peak concentration followed by a plateau with a negative exponential pattern. The median stagnation time from peak density to 80% contrast clearance was 2.91 s (range 1.81-4.94). No significant associations were observed between the stagnation time and CaW CTA structural measurements (length/base/thickness, caudal and cranial angles web surface angles, web pocket area/perimeter) or clinical characteristics.Conclusions A negative exponential pattern in the DSA contrast clearance of the CaW pocket was observed. There were no morphological or clinical features clearly associated with the duration of contrast stagnation on DSA. The hemodynamic disruption caused by CaW and its thrombotic risk may not be appropriately measured by contrast stagnation time.

Background Fast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes. The effect of changing the technical approach following initially unsuccessful passes remains undetermined. Objective To evaluate the association between early changes to the EVT approach and reperfusion. Methods Multicenter retrospective analysis of prospectively collected data for patients who underwent EVT for intracranial internal carotid artery, middle cerebral artery (M1/M2), or basilar artery occlusions. Changes in EVT technique after one or two failed passes with stent retriever (SR), contact aspiration (CA), or a combined technique (CT) were compared with repeating the previous strategy. The primary outcome was complete/near-complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) of 2c–3, following the second and third passes. Results Among 2968 included patients, median age was 66 years and 52% were men. Changing from SR to CA on the second or third pass was not observed to influence the rates of eTICI 2c–3, whereas changing from SR to CT after two failed passes was associated with higher chances of eTICI 2c–3 (OR=5.3, 95% CI 1.9 to 14.6). Changing from CA to CT was associated with higher eTICI 2c–3 chances after one (OR=2.9, 95% CI 1.6 to 5.5) or two (OR=2.7, 95% CI 1.0 to 7.4) failed CA passes, while switching to SR was not significantly associated with reperfusion. Following one or two failed CT passes, switching to SR was not associated with different reperfusion rates, but changing to CA after two failed CT passes was associated with lower chances of eTICI 2c–3 (OR=0.3, 95% CI 0.1 to 0.9). Rates of functional independence were similar. Conclusions Early changes in EVT strategies were associated with higher reperfusion and should be contemplated following failed attempts with stand-alone CA or SR.

Introduction: Early identification of intracranial atherosclerotic disease (ICAD) underlying large vessel occlusion strokes (LVOS) may allow for mechanical thrombectomy (MT) optimization. We sought to create a pre-procedural scoring system to predict ICAD. Methods: Retrospective analysis of prospectively collected MT databases from 2 comprehensive stroke centers (derivation and validation) including patients with anterior circulation LVOS. ICAD cases were matched for age / sex (1:1) to non-ICAD controls and stepwise logistic regression utilized for various clinical and radiological (NCCT, CTA and CTP) variables. Calibration slope / intercept as well as the area under curve (auROC) were assessed. Results: Of 2870 MTs within the study period, 174 anterior circulation ICAD (6.6%) were matched with 174 controls (n=348) in the derivation cohort. Multivariable analysis β coefficients lead to a 20 point-scale: absence of AF (5), vascular risk factor burden (1 for each: hypertension, diabetes, smoking, hyperlipidemia), CTA multifocal ICAD (3), absence of cortical infarcts (3), presence of borderzone infarct (3), calcium at the siphon (2). The validation cohort comprised 75 ICAD patients (6.9% of 1359 MTs) and 75 controls. AuROC for the derivation cohort was 0.88(0.84-0.91) while for the validation cohort 0.82(0.73-0.89). Calibration slope and intercept showed a good fit for the development cohort although with overestimated risk for the validation cohort. After intercept adjustment, the overestimation was corrected (intercept 0; 95%CI -0.5-0.5 / slope 0.8 95%CI 0.5-1.1). In the full cohort (n=498), ≥ 11 points showed the best performance for distinguishing ICAD from non-ICAD patients, with a sensitivity 0.71 (0.65-0.78) and specificity 0.82 (0.77-0.87), a positive likelihood ratio of 3.92 (2.92, 5.28) and a negative LR of 0.35 (0.28, 0.44). Scores ≥ 12 showed 90% specificity, although sensitivity of 63% (55%-69%). Conclusion: We developed a predictive scoring system for pre-procedural diagnosis of ICAD LVOS with satisfactory discrimination and calibration based on clinical and non-invasive radiological data.

Introduction :The recently developed MR-PREDICTS@24 h model showed excellent performance in the MR-CLEAN Registry cohort in patients presenting within 12 h from onset. However, its applicability to an U.S. population and to patients presenting beyond 12 h from last known normal are still undetermined. We aim to externally validate the MR-PREDICTS@24 h model in a new geographic setting and in the late window. Methods: In this retrospective analysis of a prospectively collected database from a comprehensive stroke center in the United States, we included patients with intracranial carotid artery or middle cerebral artery M1 or M2 segment occlusions who underwent endovascular therapy and applied the MR-PREDICTS@24 h formula to estimate the probabilities of functional outcome at day 90. The primary endpoint was the modified Rankin Scale (mRS) at 90 days. Results: We included 1246 patients, 879 in the early (<12 h) and 367 in the late (>= 12 h) cohort. For both cohorts, calibration and discrimination of the model were accurate throughout mRS levels, with absolute differences between estimated and predicted proportions ranging from 1% to 5%. Calibration metrics and curve inspections showed good performance for estimating the probabilities of mRS <= 1 to mRS <= 5 for the early cohort. For the late cohort, predictions were reliable for the probabilities of mRS <= 1 to mRS <= 4. Conclusion: The MR-PREDICTS@24 h was transferrable to a real-world U.S.-based cohort in the early window and showed consistently accurate predictions for patients presenting in the late window without need for updating.

Background Competitive leptomeningeal flow (CLF) can be observed immediately after mechanical thrombectomy (MT) reperfusion with retrograde contrast clearing of the distal leptomeningeal branches from non-contrast opacified flow through different vascular territories. We aim to evaluate the frequency of the CLF phenomenon, to determine if it has an association with the degree of leptomeningeal collateral status, and to understand the potentia impact it may have on the final expanded Treatment in Cerebral Ischemia (eTICI) score rating.Methods Retrospective analysis of a prospective MT database spanning November 2020 to December 2021. Consecutive cases of intracranial internal carotid (i-ICA) or middle cerebral artery (MCA) M1 occlusions were included. CLF was defined by the observation of retrograde clearing of distal MCA branches that were previously opacified by antegrade reperfusion. The clearance of the distal branches is presumed to occur due to CLF via non-contrast opacified posterior cerebral artery or anterior cerebral artery flow. The washout was considered CLF if it cleared abruptly with or without forward reconstitution of antegrade opacification.Results A total of 125 patients met the inclusion criteria. The median age was 64 years (IQR 52.5-75) and 64 (51%) were men. The baseline median National Institutes of Health Stroke Scale score was 17 (IQR 12-22) and the Alberta Stroke Program Early CT Score was 9 (IQR 8-10). Median last known well time to puncture was 7 hours (IQR 4-13.1) and 30.4% received tissue plasminogen activator. Final eTICI 2c-3 was achieved in 80%. CLF was present in 32 (25.6%) patients, who had comparable baseline characteristics to patients without CLF. Twelve (37.5%) patients had regional CLF and 20 (62.5%) had focal CLF. The CLF arm had better leptomeningeal single-phase CTA collaterals than the non-CLF arm (P=0.01). The inter-rater agreement for the eTICI score was moderate when CLF was present and strong in its absence (Krippendorf's alpha=0.65 and 0.81, respectively). There was minimal agreement (Kappa=0.3) for the presence versus absence of CLF between the two operators, possibly related to reader experience.Conclusion CLF was observed in 32% of patients, was associated with better collateral flow, and impacted the reported procedural eTICI rating.

Background and importance Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process.Methods A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)].Conclusion Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process.

Background Rapid expansion of mechanical thrombectomy and swift manufacturing development has translated into significant evolution of large‐bore catheter technology. The objective of this study was to evaluate the association among diverse structural components of large‐bore aspiration catheters on procedural performance. Methods Retrospective analysis of a prospectively maintained mechanical thrombectomy consortium (SVIN [Society of Vascular Interventional Neurology] Registry) treated with stand‐alone contact aspiration for the first pass in the middle cerebral artery M1 or intracranial internal carotid artery occlusions from 2012 to 2021. Catheters were stratified on the basis of construction materials, tip technology, catheter sizing, and catheter lining. Factors associated with first‐pass effect (first‐pass eTICI 2c–3 reperfusion) as well as speed of clot engagement were analyzed. Results We identified 983 patients with proximal occlusion and aspiration as the first‐pass technique. First‐pass effect was observed in 34% and associated with age (odds ratio [OR], 1.02 [95% CI, 1.01–1.03]), cardioembolic stroke pathogenesis (OR, 1.69 [95% CI, 1.77–2.41]), middle cerebral artery M1 (OR, 2.74 [95% CI, 1.09–1.87]), nongeneral anesthesia (OR, 0.55 [95% CI, 0.39–0.767]), as well as with 0.070‐inch (OR, 2.04 95% CI, 1.01–3.78]), and 0.088‐inch (OR, 3.90 [95% CI, 1.58–9.61]) distal catheter inner diameter in the adjusted analysis. Mean time from arterial access to clot contact was 17 minutes, with faster times observed in younger patients (OR, 0.99 [95% CI, 0.98–0.996]) as well as with the use of aspiration catheters with shorter length of distal outer hydrophilic coating (18–30 cm) on multivariable regression (OR, 0.30 [95% CI, 0.11–0.82]). Conclusion Larger aspiration catheter distal inner diameter was associated with higher rates of first‐pass effect. Aspiration catheter construction components were found to influence times from arterial access to clot contact.

Introduction: While patients with small core stroke (SCS) and large core stroke(LCS) benefit from Mechanical Thrombectomy(MT), the impact of reperfusion (Thrombolysis in Cerebral Infarction (eTICI) grade and the first pass effect (FPE)) on clinical outcomes remains poorly understood. We aim to study the interplay between these factors in LCS and SCS patients. Methodology: Retrospective analysis of a comprehensive stroke center prospective database for patients with MCA-M1 or ICA-T occlusions who underwent MT between November 2010-March 2023. Logistic regression models assessed ASPECTS and eTICI score relationships and their impact on outcomes, adjusted for age, NIHSS, tPA, hypertension, general anesthesia and clot location. Results: Of 1548 included patients (mean age 65±16 years, 50.0% males)Table 1, 9.1%(141/1548) were categorized as a LCS (ASPECTS 0-5: 3.5% ASPECTS 0-2 and 96.0% 3-5) while 90.9%(1407/1548) as a SMC (53.0% ASPECTS 6-8 and 47.0% ASPECTS 9-10)(Table1). Lower rates of FPE were achieved in the LCS cohort (26%) compared to the SCS cohort (36%). First pass effect had comparable relative impact on independence rates on LCS and SCS (Figure1A; p>0.05). Final reperfusion rates were comparable LCS and SCS cohorts; In LCS, 5%, 11%, 26%, and 49% achieved eTICI grades 0-2a, 2b50, 2b67, and 2c-3, while in SCS, the percentages were 5.3%, 11%, 18%, and 66%. The relative benefit of final eTICI2c-3 vs 2b50 was comparable between LCS and SCS (p>0.05;Figure1B) Conclusion: The magnitude of benefit of achieving FPE as well as final full reperfusion (eTICI2c-3 vs eTICI2b) is comparable in large and smaller core strokes.

Background The optimal anesthesia modality during endovascular treatment (EVT) for distal medium vessel occlusion (DMVO) stroke is uncertain. We aimed to evaluate the association of the anesthesia modality with procedural and clinical outcomes following EVT for DMVO stroke. Methods This is a multicenter retrospective analysis of a prospectively collected database. Patients were included if they had DMVO involving the middle cerebral artery-M3/4, anterior cerebral artery-A2/3, or posterior cerebral artery-P1/P2-3, and underwent EVT. The cohort was divided into two groups, general anesthesia (GA) and non-general anesthesia (non-GA), and compared based on the intention-to-treat principle as primary analysis. We used propensity scores to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the 90-day modified Rankin Scale (mRS). Secondary outcomes included successful reperfusion, as well as excellent (mRS 0-1) and good (mRS 0-2) clinical outcomes at 90 days. Safety measures included procedural complications, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Results Among 366 DMVO thrombectomies, 61 matched pairs were eligible for analysis. Median age and National Institutes of Health Stroke Scale score as well as other baseline demographic and clinical characteristics were balanced between both groups. The GA group had no difference in the overall degree of disability (common OR 1.19, 95% CI 0.52 to 2.86, P=0.67) compared with the non-GA arm. Likewise, the GA group had comparable rates of successful reperfusion (OR 2.38, 95% CI 0.80 to 7.07, P=0.12), good/excellent clinical outcomes (OR 1.14, 95% CI 0.44 to 2.96, P=0.79/(OR 0.65, 95% CI 0.24 to 1.81, P=0.41), procedural complications (OR 1.00, 95% CI 0.19 to 5.16, P>0.99), sICH (OR 3.24, 95% CI 0.83 to 12.68, P=0.09), and 90-day mortality (OR 1.43, 95% CI 0.48 to 4.27, P=0.52) compared with the non-GA group. Conclusions In patients with DMVO, our study showed that GA and non-GA groups had similar procedural and clinical outcomes, as well as safety measures. Further larger controlled studies are warranted.

Background: Carotid free-floating-thrombus(CFT)is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by contrast. Unfortunately, there is no clear consensus among experts on the ideal treatment for CFT. Methods: Retrospective analysis of acute ischemic stroke(AIS)patients diagnosed with internal carotid CFT on CTA between January2015-March2023.We aimed to compare two treatment regimens: antiplatelet(APT) and anticoagulation(ACT) in the treatment of CFT. APT regimens included the use of dual or single APT (aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin+/-aspirin. Patients that underwent thrombectomy were excluded. Results: During study time there were 8252 AIS patients, of which 137(1.6%) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.4years + 12.8;p<0.01) (Table 1) .Other demographic variables were similar between groups. Complete CFT resolution by repeat imaging was comparable between groups at 30 days (58.8vs31.6%;p=0.1) and at latest follow-up (70.8vs50%;p=0.1) on ACT vs APT, respectively. There were similar rates of any ICH (13.5vs27.6%;p=0.5), PH1/2, independence at discharge and similar hospital length of stay between APT and ACT groups, respectively ( Table 1 ). Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5vs55.2%;p<0.001).The rate of recurrent AIS was comparable among APT and ACT at 30 days (0vs3.4%;p=0.1,respectively).Sensitivity analysis comparing DAPT to exclusive ACT lead to similar results. Conclusion: Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed with APT vs ACT. Larger prospective studies are needed.

Background Mechanical thrombectomy has become the standard of care for treatment of acute ischemic stroke secondary to large‐vessel occlusion up to 24 hours from last known normal time. Multiple different techniques for mechanical thrombectomy have been described, including a direct aspiration first‐pass technique and stent retriever thrombectomy. With a direct aspiration first‐pass technique, classically, a large‐bore aspiration catheter is delivered over a microcatheter and microwire to the clot. Recently, a novel macrowire has been introduced as a potential alternative to the use of microwire–microcatheter to allow the delivery of the aspiration catheter. The aim of this study is to develop a multicenter registry comparing delivery of an aspiration catheter for intracranial thrombectomy for acute ischemic stroke secondary to emergent large‐vessel occlusion over a macrowire in comparison with traditional use of microcatheter and microwire. Methods MINT (Macrowire for Intracranial Thrombectomy) is a multicenter, observational study currently enrolling patients with large‐vessel occlusion who underwent mechanical thrombectomy using a macrowire to deliver the aspiration catheter to the intracranial occlusion. All the participating sites will screen and report cases on a monthly basis. The decision to use the macrowire and various aspiration catheters is at the discretion of the interventionalist. Results We will collect patient's clinical, demographic, and radiographic data. In addition, we plan to collect procedure variables and postprocedure clinical and imaging data. Outcomes include successful delivery of the reperfusion catheter to the clot interface, time taken from groin access to first pass, and a bailout strategy for thrombectomy in cases where this is not feasible. Conclusion The MINT registry will add to our understanding of safety and efficacy of this novel macrowire in intracranial thrombectomy. This registry will also highlight and allow for understanding in workflow improvements from simplifying setup and possibly cost effectiveness of this technique.

BackgroundEarly identification of intracranial atherosclerotic disease (ICAD) may impact the management of patients undergoing mechanical thrombectomy (MT). We sought to develop and validate a scoring system for pre-thrombectomy diagnosis of ICAD in anterior circulation large vessel/distal medium vessel occlusion strokes (LVOs/DMVOs).MethodsRetrospective analysis of two prospectively maintained comprehensive stroke center databases including patients with anterior circulation occlusions spanning 2010–22 (development cohort) and 2018–22 (validation cohort). ICAD cases were matched for age and sex (1:1) to non-ICAD controls.ResultsOf 2870 MTs within the study period, 348 patients were included in the development cohort: 174 anterior circulation ICAD (6% of 2870 MTs) and 174 controls. Multivariable analysis β coefficients led to a 20 point scale: absence of atrial fibrillation (5); vascular risk factor burden (1) for each of hypertension, diabetes, smoking, and hyperlipidemia; multifocal single artery stenoses on CT angiography (3); absence of territorial cortical infarct (3); presence of borderzone infarct (3); or ipsilateral carotid siphon calcification (2). The validation cohort comprised 56 ICAD patients (4.1% of 1359 MTs): 56 controls. Area under the receiver operating characteristic curve was 0.88 (0.84–0.91) and 0.82 (0.73–0.89) in the development and validation cohorts, respectively. Calibration slope and intercept showed a good fit for the development cohort although with overestimated risk for the validation cohort. After intercept adjustment, the overestimation was corrected (intercept 0, 95% CI −0.5 to –0.5; slope 0.8, 95% CI 0.5 to 1.1). In the full cohort (n=414), ≥11 points showed the best performance for distinguishing ICAD from non-ICAD, with 0.71 (95% CI 0.65 to 0.78) sensitivity and 0.82 (95% CI 0.77 to 0.87) specificity, and 3.92 (95% CI 2.92 to 5.28) positive and 0.35 (95% CI 0.28 to 0.44) negative likelihood ratio. Scores ≥12 showed 90% specificity and 63% sensitivity.ConclusionThe proposed scoring system for preprocedural diagnosis of ICAD LVOs and DMVOs presented satisfactory discrimination and calibration based on clinical and non-invasive radiological data.

Background The eThrombolysis in Cerebral Infarction (eTICI) score has been validated in proximal large artery occlusion (pLAOs). Despite the growing number of distal medium vessel occlusions (DMVOs) mechanical thrombectomies (MT) and the widespread utilization of the eTICI scoring system, its reliability and standardization for more distal occlusions have not been validated. We aim to evaluate the interrater reliability of eTICI scores in primary DMVOs.Methods This was a retrospective analysis of a prospectively maintained database for consecutive patients with pLAO and DMVO MT at a single comprehensive stroke center from 2015 to 2022. Two fellowship-trained neurointerventionalists blindly/independently assessed digital subtraction angiograms for final eTICI, followed by consensus reads for discrepancies.Results 59 DMVO of 2248 thrombectomies [M3:29(50%)/M4:1(2%)/A1:3(5%)/A2:12(22%)/A3: 5(9%)/P1:7(12%)/P2:1(2%)] and 124 pLAOs of 308 thrombectomies [i-ICA:13(11%)/MCA-M1: 111(90%)] were included. The distribution of final eTICI scores was comparable between pLAO vs DMVOs (p = 0.82). The pLAO final eTICI score assessment between two readers demonstrated moderate reliability with a kappa0.77 (95%CI: 0.67-0.88), while the DMVO eTICI score assessment exhibited almost-perfect agreement with kappa 0.94 (95%CI: 0.90-0.99). The agreement between the consensus read and the original report in DMVOs was 0.86 (95% CI: 0.71-1.00) while for pLAO it was 0.83(95% CI: 0.76-0.90). The performance of eTICI was comparable amongst different DMVO territories as well as for distal vs. very distal occlusions.Conclusion eTICI score exhibited comparable performance for DMVO as compared to pLAO strokes. Further studies investigating DMVO eTICI grading and clinical outcomes are warranted.

Background: The use of balloon guide catheter (BGC) has been associated with better reperfusion and clinical outcomes in mechanical thrombectomy (MT) for large vessel occlusion strokes (LVOS). The association between BGC and angiographic and clinical outcomes in patients with distal medium vessel occlusion strokes (DMVO) undergoing MT has not been investigated. Methods: This is a retrospective analysis of a prospectively collected database from 14 comprehensive stroke centers in the United States and Europe. Patients were included if they had anterior circulation DMVO due to MCA-M3/M4 or ACA-A1/A2-3 and were treated with MT using stentriever, contact aspiration, or a combination of both techniques as first-line therapy. The cohort was divided into two groups: 1) BGC and 2) non-BGC. Uni and multivariable analyses were used to identify predictors of first pass effect (FPE) defined as eTICI grade 2C or 3 after single device pass, as well as mRS0-1, mRS0-2, and mortality at 90 days. Results: A total of 199 patients were eligible for analysis. The BGC group (n=73) had comparable baseline characteristics as compared to the non-BGC group (n=126), except for lower median age and frequency of hyperlipidemia, atrial fibrillation, and White patients, and higher frequency of tandems. Procedurally, the BGC group had a less frequent use of contact aspiration (23.3% vs. 53.2%), and higher proportions of stent-retriever use (35.6% vs. 13.5%) and combined technique (41.1% vs. 33.3%; P<0.001) as first-line therapy. A lower number of passes (1 vs. 2, P<0.001), shorter procedure time (40 vs. 46 minutes, P=0.029), and higher FPE rates (53% vs 13%; P<0.001) were observed in the BGC group. On multivariable analysis, the BGC group showed higher rates of FPE (53.4% vs. 13.7%, aOR 6.74, 95%CI [3.08-14.75], P<0.001), 90-day mRS 0-1 (42.9% vs. 27.1%, aOR 2.28, 95%CI [1.06-4.91], P=0.035), and 90-day mRS 0-2 (60.3% vs. 41.5%, aOR 2.47, 95%CI [1.15-5.31], P=0.02). The rates of successful reperfusion at the end of the procedure, sICH, and 90-day mortality were comparable between both groups. Conclusions: The present study suggests that the use of BGC in DMVO undergoing MT is associated with improved angiographic and clinical outcomes with no safety concerns. Prospective studies are warranted.

BACKGROUND: Carotid free-floating thrombus (CFT) is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by flow on vascular imaging. Unfortunately, there is no clear consensus among experts on the ideal treatment for this pathology. METHODS: Retrospective analysis of acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients diagnosed with CFT on computed tomography angiogram (CTA) between January 2015-March 2023. We aimed to compare two treatment regimens: anticoagulation (ACT) and antiplatelet (APT) in the treatment of CFT. APT regimens included the use of dual or single antiplatelets (DAPT or SAPT; aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin +/- ASA. Patients that underwent mechanical thrombectomy were excluded. RESULTS: During study time there were 8252 acute ischemic stroke hospitalizations, of which 135 (1.63 %) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.41years +/- 12.82;p < 0.01). Other demographic variables were similar between ACT and APT groups. Complete CFT resolution on repeat vascular imaging was numerically higher at 30 days (58.8 vs 31.6 %, respectively; p = 0.1) and at latest follow-up (70.8 vs 50 %; p = 0.1) on ACT vs APT, respectively without reaching statistical significance. Similarly, there was numerically higher rates of any ICH with ACT compared to APT but it did not achieve statistical significance (27.6 % vs 13.5 %; p = 0.5). There were similar rates of PH1/2 hemorrhagic transformation, independence at discharge and similar hospital length of stay between ACT and APT groups. Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5 vs 55.2 %; p < 0.001). The rate of 30-day recurrent stroke was comparable among ACT and APT at 30 days (3.4 vs 0 %; p = 0.1, respectively). Subgroup analysis comparing exclusive ACT vs Dual APT lead to similar results. CONCLUSION: Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed medically with ACT vs APT. Larger prospective studies are needed.

Background: The extent of reperfusion following thrombectomy (MT) for large vessel occlusion strokes is predictive of outcomes. There is still inter-rater variability in the reperfusion scoring. We noticed that some patients present with retrograde contrast clearing of the distal branches from non-contrast-opacified flow originated from different territories. We aim to evaluate the frequency of this phenomenon (“competitive flow” (CF)), to evaluate if it has an association with the degree of leptomeningeal collaterals, and its impact on eTICI score. Methods: This is a retrospective-analysis of our MT database spanning 11/2020-12/2021. We included consecutive cases of intracranial internal carotid (i-ICA) and middle cerebral artery (MCA) M1 occlusions. CF was defined by the observation of retrograde clearing of distal MCA branches that were previously opacified by antegrade reperfusion. The clearance of the distal branches is presumed to occur due to CF via non-contrast-opacified PCA or ACA flow. The washout was considered CF if it cleared abruptly with or without forward reconstitution of antegrade opacification. Results: We included a 125 patients. Median age was 64years, 51%were males. Baseline median NIHSS was 17 and ASPECTS 9. Median last-known-well-time to puncture was 7 hours, 30.4% received tPA. Final eTICI2c-3 was achieved in 81.6%. CF was present in 32(25.6%)patients. Baseline characteristics were similar between both groups. The CF arm had better leptomeningeal single-phase-CTA-collaterals(p=0.01) and smaller CTP malignant hypoperfusion volume(p=0.06) VS non-CF. The inter-rater-agreement for eTICI score was moderate when CF was present and excellent in its absence (Krippendorf’s alpha=0.65 and 0.81,respectively). There was poor agreement (K-value=0.3) for the presence versus absence of CF between both operators. Reviewer 1 (2-year-post-training) had correctly identified 46% of patients with consensus CF vs 90% to Reviewer 2 (9-year-post-training) after the consensus read. Conclusion: CF was observed in 32% of patients. CF was found to be associated with better collateral flow, and to impact the reported procedural eTICI rating.

Introduction: Earlier and greater reperfusion in mechanical thrombectomy (MT) leads to better clinical outcomes. The timing and potential benefit of switching thrombectomy techniques after failed device passes remains unclear. Methods: Retrospective analysis of a prospective comprehensive stroke center database including patients with intracranial ICA, MCA M1/M2, or Basilar occlusions undergoing MT with either Stent-Retriever (SR), Contact Aspiration (CA) or Combined technique (CT) from 2015 to 2023. Our primary endpoint was complete/near-complete reperfusion (eTICI 2c-3) at pass #2 (after pass #1 failure). Secondary endpoints included 1) eTICI2b-3 at pass#2, and 2) eTICI2c-3 with pass #3 (following failure in two consecutive passes with the same technique). We used logistic or Firth regression to compare reperfusion rates and Kaplan-Meier analysis for cumulative rates. Results: Among 3130 MTs in the study period, 1810 met inclusion criteria. Median age [IQR] was 65 [55 - 76] years and 51.5% were male. Following a failed first pass, switching from CA to either CT or SR was associated with higher eTICI 2c-3 (aOR [95%CI] 2.8 [1.3 - 6.5] and 7.4 [1.4-54.8], respectively). Changing from CT or SR to any other technique was not associated with higher reperfusion. Secondary endpoint analysis for eTICI2b-3 yielded comparable results. For the third pass, switching to CT after two repeated failed SR or two repeated failed CA attempts was associated with higher eTICI 2c-3 as compared to repeating the original strategy (SR aOR 5.8 [1.4 - 33.3]; AC aOR 5.6 [1.1 - 41.2]). We did not observe benefit in switching to alternative technique following one or two consecutive passes with CT. After three repeated attempts with the same technique, CT led to greater eTICI 2c-3 as compared to SR and CA (83% vs. 72% vs. 64%, p < 0.001). Conclusions: While limited by small subgroup sample sizes, our study strengthens the hypothesis that early changes in MT technique may have an impact on reperfusion. Our data indicates that if CA fails on first pass, transition to SR or CT should be considered. After two failed consecutive SR or CA passes, transition to CT should be contemplated.