Abstract 164: Chronic Total Occlusion of the Bilateral Internal Carotid Arteries, Vertebral Arteries and Basilar Artery

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

Abstract 218: Evaluating Thrombectomy Candidacy in Large Core Strokes: Lessons from the SELECT2 Trial at Our Institution

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

Reconstruction of scalp defects with the radial forearm free flap

BACKGROUND: Advanced and recurrent cutaneous squamous cell carcinoma of the scalp and forehead require aggressive surgical excision often resulting in complex defects requiring reconstruction. This study evaluates various microvascular free flap reconstructions in this patient population, including the rarely utilized radial forearm free flap. PATIENTS AND METHODS: A retrospective review of patients undergoing free flap surgeries (n = 47) of the scalp between 1997 and 2011 were included. Patients were divided primarily into two cohorts: a new primary lesion (n = 21) or recurrence (n = 26). Factors examined include patient demographics, indication for surgery, defect, type of flap used, complications (major and minor), and outcomes. RESULTS: The patients were primarily male (n = 34), with a mean age of 67 years (25–91). A total of 58 microvascular free flap reconstructions were performed (radial forearm free flap: n = 28, latissimus dorsi: n = 20, rectus abdominis: n = 9, scapula: n = 1). Following reconstruction with a radial forearm free flap, duration of hospitalization was shorter (P = 0.04) and complications rates were similar (P = 0.46). Donor site selection correlated with defect area (P < 0.001), but not with the extent of skull defect (P = 0.70). Larger defect areas correlated with higher complications rates (P = 0.03) and longer hospitalization (P = 0.003). Patients were more likely to require multiple reconstructions if referred for a recurrent lesions (P = 0.01) or received prior radiation therapy (P = 0.02). CONCLUSION: Advanced and recurrent malignancies of the scalp are aggressive and challenging to treat. The radial forearm free flap is an underutilized free flap in the reconstruction of complex scalp defects

Blind exchange with mini-pinning technique for distal occlusion thrombectomy

IntroductionTechnical improvements to enhance distal occlusion thrombectomy are desirable. We describe the blind catheter exchange technique and report the pinning technique with small devices (‘mini-pinning’) for distal occlusions.MethodsA retrospective review of a prospective database from January 2015 to August 2018 was performed for cases of distal occlusion in which the ‘blind exchange/mini-pinning’ (BEMP) techniques were used. The technique involves the deployment of a 3 mm Trevo retriever followed by microcatheter removal and blind advancement of a 3MAX aspiration catheter over the bare retriever delivery wire (‘blind exchange’) until clot contact under aspiration. The retriever is subsequently partially recaptured in order to ‘cork’ the thrombus (‘mini-pinning’) and the system pulled as a unit. Patients with distal occlusions treated with BEMP and standard techniques (either 3 mm Trevo or 3MAX) were compared.ResultsTwenty-five vessels were treated in 22 patients. The majority of patients had isolated distal occlusions predominantly in the distal middle cerebral artery (MCA) segments, half of which involved the superior division. The comparison between BEMP (n=25 vessels) and standard techniques (n=144 vessels) revealed balanced groups. One of the highlighted differences was the more distal MCA occlusions among those who underwent BEMP (M3 occlusions 52% vs 22%; p=0.001). Otherwise, the vessel, segments, divisions and luminal diameter were comparable. There was a higher rate of first-pass modified Thrombolysis in Cerebral Infarction 2b–3 (80% vs 56%; p=0.03) and a trend towards higher rates of first-pass full reperfusion (60% vs 40%; p=0.07) with BEMP compared with standard techniques. Final reperfusion and clinical outcomes were comparable.ConclusionBEMP appears to be a safe and effective technique for the treatment of distal occlusions. Additional studies are warranted.</jats:sec

A comparative analysis of 3MAX aspiration versus 3 mm Trevo Retriever for distal occlusion thrombectomy in acute stroke

BackgroundAlthough aspiration and stent retriever thrombectomy perform similarly in proximal occlusions, no comparative series are available in distal occlusions. We aimed to compare the 3 mm Trevo Retriever against the 3MAX thromboaspiration catheter in distal arterial occlusions.MethodsA single-center retrospective review of a prospectively maintained databank for patients treated with the 3 mm Trevo stent retriever or 3MAX thromboaspiration as the upfront approach for distal occlusions (middle cerebral artery mid/distal M2/M3, anterior cerebral artery A1/A2/A3 or posterior cerebral artery P1/P2) from January 2014 to July 2018 was performed. The primary outcome was the rate of distal occlusion first-pass reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b–3).ResultsOf 1100 patients treated within the study period, 137 patients/144 different arteries were treated with the 3 mm Trevo (n=92) or 3MAX device (n=52). The groups had comparable demographics and baseline characteristics. There was a higher rate of first-pass mTICI 2b–3 reperfusion (62% vs 44%; p=0.03), a trend towards a higher rate of final mTICI 2b–3 reperfusion (84% vs 69%; p=0.05), and lower use of adjuvant therapy (15% vs 31%; p=0.03) with the 3 mm Trevo compared with the 3MAX. The median number of passes (p=0.46), frequency of arterial spasm (p=1.00), rates of parenchymal hematomas (p=0.22)/subarachnoid hemorrhage (p=0.37) in the territory of the approached vessel were similar across the two groups. The 90-day rate of good outcomes (45% vs 46% in the 3 mm Trevo and 3MAX groups, respectively; p=0.84) was comparable. Multivariable regression identified baseline NIH Stroke Scale (NIHSS) score (OR 0.9; 95% CI 0.8 to 0.97; p&lt;0.01) and use of 3 mm Trevo (OR 2.2; 95% CI 1.1 to 4.6; p=0.02) independently associated with first-pass mTICI 2b–3 reperfusion.ConclusionsIn the setting of distal arterial occlusions, the 3 mm Trevo may lead to higher rates of first-pass reperfusion than direct 3MAX thromboaspiration. Lower NIHSS was found to be associated with improved reperfusion rates as observed in more proximal lesions. Further studies are warranted.</jats:sec

Abstract 1122‐000154: Effect of Intravenous Thrombolysis on Early Clot Lysis in Large Vessel Occlusion Strokes Undergoing Thrombectomy

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 &lt;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. </jats:p

Abstract 1122‐000154: Effect of Intravenous Thrombolysis on Early Clot Lysis in Large Vessel Occlusion Strokes Undergoing Thrombectomy

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