M Mulder

Comparison of clinical outcomes in patients with acute ischemic strokes treated with mechanical thrombectomy using either Solumbra or ADAPT techniques

Purpose To compare rates of symptomatic intracranial hemorrhage (SICH) and good clinical outcome at 90 days in patients with ischemic strokes from anterior circulation emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy using either Solumbra or A Direct Aspiration first-Pass Thrombectomy (ADAPT) techniques. Methods We compared clinical characteristics, procedural variables, and clinical outcomes in patients with anterior circulation ELVOs treated with mechanical thrombectomy using either a Solumbra or ADAPT technique at our institution over a 38-month period. SICH was defined using the SITS-MOST criteria. A good clinical outcome was defined as a modified Rankin Scale score of 0–2 at 90 days. Results One hundred patients were included, 55 in the Solumbra group and 45 in the ADAPT group. Patients in the ADAPT group had higher National Institutes of Health Stroke Scale (NIHSS) (19.2 vs 16.8, p=0.02) and a higher proportion of internal carotid artery terminus thrombi (42.2% vs 20%, p=0.03) than patients in the Solumbra group. Patients in the ADAPT group had a trend toward a lower rate of SICH than patients in the Solumbra group (2.2% vs 12.7%, p=0.07). Patients in the ADAPT group had a significantly higher rate of good clinical outcome at 90 days than patients in the Solumbra group (55.6% vs 30.9%, p=0.015). Use of the ADAPT technique (OR 6 (95% CI 1.0 to 31.2), p=0.049) was an independent predictor of a good clinical outcome at 90 days in our cohort. Conclusions In our cohort, the ADAPT technique was associated with significantly higher good clinical outcomes at 90 days in patients with acute ischemic stroke due to anterior circulation ELVOs treated with mechanical thrombectomy.

Efficacy of a two-test protocol for achieving a therapeutic response to clopidogrel prior to elective endovascular intracranial aneurysm treatment and an ‘induced’ postoperative hyper-response

Introduction Variable response to clopidogrel can impact perioperative risk in elective endovascular intracranial aneurysm treatment. The present study aims to determine the efficacy of a two-test protocol in reaching in-range preoperative P2Y12 reaction units (PRU) of 60–240 and the rate of postoperative conversion to hyper-response. Methods A 17-day two-test protocol (with tests on days 10 and 17) for patients starting clopidogrel in anticipation of elective endovascular intracranial aneurysm treatment was introduced in February 2013 at our institution. Records for patients started on this protocol through December 2014 were reviewed for preoperative and postoperative PRUs, patient and procedural data, and thromboembolic and hemorrhagic events within 30 days. Logistic regression analyses were performed to identify predictors of postoperative hyper-response (p<0.05 considered significant). Results 103 patients (80 women) of mean age 57 years were included. 74 patients (71.8%) were in range at the first test and 92 patients (89.3%) were in range at the second test. A postoperative test was performed in 82 patients (79.6%) at a median of 9 days. 51 patients (62.2%) converted into hyper-responders. There were five non-disabling strokes and one intracranial hemorrhage within 30 days. There were no major strokes (modified Rankin Scale score >2) or deaths. There was no association between out-of-range PRU and thromboembolic or hemorrhagic neurological complications. Conclusions The protocol achieves in-range preoperative PRU by the second test in almost nine of 10 patients. Nearly two-thirds of patients exhibited postoperative hyper-response to clopidogrel. Out-of-range PRU was not associated with thromboembolic or hemorrhagic neurological complications in this cohort of patients with actively managed P2Y12 inhibition.

Improved Outcomes With Integrated Intensivist Consultation for Cardiac Surgery Patients

This study examined the impact of integrated intensivist consultation in the immediate postoperative period on outcomes for cardiac surgery patients. A retrospective cohort study was conducted in 1711 adult cardiac surgery patients from a single quaternary care center in Minnesota. Outcomes were compared across 2 consecutive 2-year time periods reflecting an elective intensivist model (n = 801) and an integrated intensivist model (n = 910). Patients under the 2 models were comparable with respect to demographics, comorbidities, procedure types, and Society for Thoracic Surgery predicted risk of mortality score; however, patients in the earlier cohort were slightly older and more likely to have chronic kidney disease (P = .003). Integrated intensivist involvement was associated with reduced postoperative ventilator time, length of stay (LOS), stroke, encephalopathy, and reoperations for bleeding (all P < .01) but was not associated with mortality. Intensivist integration into the postoperative care of cardiac surgery patients may reduce ventilator time, LOS, and complications but may not improve survival.

A case of right middle cerebral artery ‘tendonectomy’ following mitral valve replacement surgery

Following mechanical mitral valve replacement surgery, a 69-year-old woman had an ischemic stroke in the right middle cerebral artery territory. Mechanical thrombectomy showed the embolus to be a piece of chordae tendineae excised during the valve replacement surgery.

E-057 Process Improvement in Door-to-Groin Puncture Times at a Comprehensive Stroke Center Shows a Trend Towards Reduced Mortality at 90 Days

Introduction Safe and effective endovascular treatment of acute ischemic stroke is dependent on prompt intervention. In light of the positive trials published last year, we intensified our efforts to improve the process of taking patients from the emergency department to the angiography suite for mechanical thrombectomy. Methods At the beginning of 2015, a process improvement project to improve door-to-groin puncture times for mechanical thrombectomy for emergent large vessel occlusions was undertaken at our institution. After a systematic analysis of the process, the following key changes were standardized: early consultation with the neurointerventionalist for patients presenting with a high National Institutes of Health Stroke Scale (NIHSS ≥6), the stroke neurologist and the neurointerventionalist meet the patient in the emergency department for transfers or meet in the CT department for non-transfers, elimination of emergency physician triage for medically stable patients, elimination of lab tests such as creatinine, establishment of a minimum level of clinical information required for the sedation nurse to care for stroke patients safely, institution of a “stroke bag” containing all necessary devices to perform efficient thrombectomy, standardized setup of the procedure table and devices for all operators, calling for patients when the sedation nurse is ready without waiting for the entire team, elimination of unnecessary preoperative steps (e.g. Foley catheter placement, groin shaving, checking of distal pulses), and institution of an abbreviated time-out procedure. All attempted thrombectomies performed in 2013 and 2014 were compared to those performed in 2015 visà-vis the following variables: door-to-groin puncture time, symptomatic intracranial hemorrhage (SICH) rate as defined by SITS-MOST criteria, 90 day mortality rate, and 90 day rate of good clinical outcome defined by a modified Rankin Scale (mRS) of 0–2. A one-tailed Student’s t-test and Fisher’s exact tests were performed. A p-value <0.05 was considered statistically significant. Results From January 2013 to December 2015, we attempted 108 mechanical thrombectomies. Of these, 43 were in 2015 (40%). Both the mean and median door-to-groin puncture times were significantly reduced from the previous two years (35 minutes versus 89 minutes and 22 minutes versus 73 minutes, respectively, p < 0.001). There was a trend towards reduced mortality at 90 days (16% versus 26%, p = 0.166). The rates of SICH and mRS 0–2 at 90 days were not significantly different (see Table 1).Abstract E-057 Table 1 2013 and 2014 2015 p-value Thrombectomies 65 43 Door-to-groin punctureMean time (minutes)Median time (minutes) 8973 3522 <0.001 SICH 3 (5%) 3 (7%) 0.452 90 day mortality 17 (26%) 7 (16%) 0.166 90 day mRS 0–2 24 (37%) 18 (42%) 0.376 Conclusion Our systematic process improvement initiative significantly reduced door-to-groin puncture times and showed a trend towards reduced mortality at 90 days. A multidisciplinary approach and ensuring hospital system investment are key to an effective process. Disclosures Y. Kayan: 2; C; Medtronic, Penumbra. J. Delgado Almandoz: 2; C; Medtronic, Penumbra. M. Young: None. J. Fease: None. J. Scholz: None. A. Milner: None. T. Hehr: None. M. Mulder: None. P. Roohani: None. R. Tarrel: None.

Larger ACE 68 aspiration catheter increases first-pass efficacy of ADAPT technique

Purpose To report the efficacy of A Direct Aspiration first-Pass Thrombectomy (ADAPT) technique with larger-bore ACE aspiration catheters as first-line treatment for anterior circulation emergent large vessel occlusions (ELVOs), and assess for the presence of a first-pass effect with ADAPT. Methods We retrospectively reviewed 152 consecutive patients with anterior circulation ELVOs treated with the ADAPT technique as first-line treatment using ACE60, 64, or 68 at our institution. Baseline characteristics, procedural variables, and modified Rankin Scale (mRS) at 90 days were recorded. Results Fifty-seven patients were treated with ACE60 (37.5%), 35 with ACE64 (23%), and 60 with ACE68 (39.5%). Median groin puncture to reperfusion time was 30 min with ACE60, 26 min with ACE64, and 19.5 min with ACE68. Successful reperfusion after the first ADAPT pass was 33% with ACE60 and 53% with ACE68 (P=0.04). The stent-retriever rescue rate was 26% with ACE60, 3% with ACE64, and 10% with ACE68 (P=0.004). In multivariate logistic regression analysis, use of the ACE68 aspiration catheter was an independent predictor of successful reperfusion after the first ADAPT pass (P=0.016, OR1.67, 95% CI 1.1 to 2.54), and successful reperfusion after the first ADAPT pass was an independent predictor of good clinical outcome at 90 days (P=0.0004, OR6.2, 95% CI 2.27 to 16.8). Conclusion Use of the larger-bore ACE 68 aspiration catheter was associated with shorter groin puncture to reperfusion time, higher rate of successful reperfusion after the first ADAPT pass, and lower rate of stent-retriever rescue. Further, a first-pass effect was demonstrated in our ADAPT patient cohort.

Management of Anoxic Brain Injury

This chapter aims to provide clinicians with an evidence based approach to the principles of management of patients who have suffered anoxic brain injury following cardiac arrest. The diagnosis of anoxic brain injury is discussed, followed by an in depth review of the history and evolution of therapeutic hypothermia and its evolution into targeted temperature management including subsequent maintenance of normothermia. This chapter also provides evidence based recommendations on supportive care and comprehensive multi-system management of patients with anoxic brain injury as well as in-depth review of the current state of the evidence in neurologic prognostication.

O-029 Ace aspiration is a safe and effective first-line treatment for acute ischemic strokes in the anterior circulation

Purpose To evaluate the effectiveness of the Penumbra system with ACE reperfusion catheters only (ACE only) versus ACE followed by Solitaire stent-retriever rescue (Solumbra rescue) for the treatment of anterior circulation emergent large vessel occlusions (ELVOs). Methods We performed a single center, retrospective review of 100 consecutive patients with anterior circulation ELVOs treated with ACE as first-line therapy. If successful revascularization (TICI 2b-3) was not achieved with ACE only, then Solumbra rescue was utilized. Baseline characteristics, procedural variables, and modified Rankin Scale (mRS) at 90 days were recorded. Results 84 patients were treated with ACE only and 16 patients required Solumbra rescue. 53 patients received iv-tPA prior to mechanical thrombectomy. Overall successful revascularization for all 100 consecutive patients was 90%, with puncture to reperfusion time of 38.7 min, embolization to new territory rate of 5%, and post-procedure symptomatic intracranial hemorrhage rate of 3% (2 subarachnoid, 1 intraparenchymal). Successful revascularization using ACE only was achieved in 78 patients (38 after a single pass), while 12 of the 16 patients requiring Solumbra rescue were successfully revascularized (75%). Puncture to reperfusion time for ACE only versus Solumbra rescue were 30.5 and 81.8 min, respectively (p<0.0001). A good clinical outcome, mRS 0–2 at 90 days, was achieved in 46% (46/100) of patients, including 49% (41/84) of patients treated with ACE only and 31% (5/16) of patients requiring Solumbra rescue. There was a statistically-significant difference in the rate of successful revascularization with ACE only as well as Solumbra rescue rate between the first 20 and subsequent 80 cases (Table 1). Successful revascularization with ACE only was achieved in 64% of patients treated with ACE 60, 88% with ACE 64, and 100% with ACE 68 (p<0.001, Table 2). One-pass successful revascularization rate was 31% with ACE 60, 38% with ACE 64, and 50% with ACE 68 (p=0.09). Mean puncture to reperfusion time was 49 min with ACE 60 and 30 min with ACE 64/68 (p=0.002). The Solumbra rescue rate was 29% in patients treated with ACE 60, 3% with ACE 64 and 0 with ACE 68 (p=<0.001). Abstract O-029 Table 1 Learning curve for ADAPT technique Mean time puncture to reperfusion (min): TICI 2b/3 after 1 ADAPT pass: TICI 2b/3 with ADAPT only: Mean total number of ADAPT passes: Solumbra rescue rate: All 100 cases: 38.7 38 78 2.4 16% First 20 cases: 48.7 30 50 2.1 45% Next 80 cases: 36.2 40 85 2.5 8.8% p-value: 0.09 0.45 0.002 0.27 <0.001 Abstract O-029 Table 2 Efficacy of ADAPT Technique with Evolving Aspiration Catheter Technology First aspiration catheter used: Mean time puncture to reperfusion (min): TICI 2b/3 after 1 ADAPT pass: TICI 2b/3 with ADAPT only: Mean total number of ADAPT passes: Solumbra rescue rate: 3 Max: (n=2) 55.5 0 0 2.5 100 ACE 60: (n=45) 48.8 31% 64% 2.4 29% ACE 64: (n=34) 30.2 38% 88% 2.5 3% ACE 68: (n=16) 29.3 50% 100% 2.6 0 NeuronMax: (n=3) 22.7 100% 100% 1 0 p-value: 0.002 (ACE 60 vs ACE 64/68) 0.09 <0.001 0.78 (ACE 60 vs ACE 64/68) <0.001 Conclusion Aspiration thrombectomy using the Penumbra system with ACE reperfusion catheters is an effective first-line treatment for anterior circulation ELVOs, with the option to use adjunctive stent-retriever devices if aspiration alone is not sufficient. Advancements in reperfusion catheter technology from ACE 60 to ACE 68 have resulted in shorter procedural times and reduced need for adjunctive stent-retriever device use. Disclosures J. Delgado Almandoz: 2; C; Penumbra, Inc, Medtronic Neurovacular. Y. Kayan: 2; C; Penumbra, Inc, Medtronic Neurovacular. M. Young: None. J. Scholz: None. A. Milner: None. J. Fease: None. P. Roohani: None. A. Wallace: None. M. Mulder: None. R. Tarrel: None.

E-042 Clinical and cost effectiveness of using evolving ace reperfusion catheters as first-line treatment of acute ischemic stroke due to large vessel occlusions

Introduction Larger bore reperfusion catheters have been designed to increase the effectiveness of direct aspiration for treatment of acute ischemic stroke due to large vessel occlusions. The present study has two goals: 1. To compare the reperfusion rate of the newest large bore reperfusion catheter, ACE68, with previous generations of ACE catheters, ACE64 and ACE60, and 2. To compare the cost associated with three first-line approaches to mechanical thrombectomy: ADAPT using evolving ACE technology, Solumbra, and stent-retriever (SR) with balloon-guide catheter (BGC). Methods The prospectively populated acute stroke intervention database at our institution was retrospectively reviewed for mechanical thrombectomies performed using the ADAPT technique as a first-line approach from July 2013 through February 2017. Successful reperfusion (defined as TICI 2b/3) rates amongst the successive generations of ACE reperfusion catheters were compared. The costs of the procedures were also compared, including the costs of salvage therapy using adjunctive devices when necessary (additional reperfusion catheters or SR). These costs were then compared to the costs of hypothetically performing these procedures using Solumbra or SR as first-line approaches. List prices for devices were used in the cost comparison. The two-tailed Fisher’s exact test was used for the reperfusion rate comparisons, and Student’s t-test was used for the cost comparisons with p<0.05 considered statistically significant. Results Between July 2013 and February 2017, 131 ADAPT cases were performed using ACE reperfusion catheters. There were 42 cases using the ACE68 as first-line, with a successful reperfusion rate using aspiration alone of 90% (38 of 42). This was significantly higher than with previous generations of ACE as first-line, where the rate of successful reperfusion was 73% using aspiration alone (65 of 89 cases, p=0.02). The rate of successful reperfusion with a single aspiration pass was higher with ACE68 compared to previous generations (50% versus 37%) but this difference was not statistically significant (p=0.19). Overall successful reperfusion was similar when SR was used as salvage therapy (95% with ACE68 as first-line versus 85% with previous ACE generations, p=0.14). Out of 131 patients, 15% (n=20) required the use of SR after aspiration alone, with an improvement to TICI 2b/3 in 13 patients (65%). For ADAPT cases with salvage therapy included, the average device cost per case was not significantly different comparing previous ACE devices with ACE68:

E-001 Comparison of Clinical Outcomes in Patients with Anterior Circulation Acute Ischemic Strokes Treated with Mechanical Thrombectomy using the ADAPT Technique Only versus ADAPT with Solumbra Salvage

6669 and