scholarly journals Tissue no-reflow despite full recanalization following thrombectomy for anterior circulation stroke with proximal occlusion: A clinical study

2020 ◽  
pp. 0271678X2095492
Author(s):  
Adrien ter Schiphorst ◽  
Sylvain Charron ◽  
Wagih Ben Hassen ◽  
Corentin Provost ◽  
Olivier Naggara ◽  
...  
Keyword(s):  
Stroke Onset ◽  
Homologous Region ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
No Reflow ◽  
Excellent Functional Outcome ◽  
Human Stroke ◽  
Operational Criteria ◽  
Proximal Occlusion

Despite early thrombectomy, a sizeable fraction of acute stroke patients with large vessel occlusion have poor outcome. The no-reflow phenomenon, i.e. impaired microvascular reperfusion despite complete recanalization, may contribute to such “futile recanalizations”. Although well reported in animal models, no-reflow is still poorly characterized in man. From a large prospective thrombectomy database, we included all patients with intracranial proximal occlusion, complete recanalization (modified thrombolysis in cerebral infarction score 2c–3), and availability of both baseline and 24 h follow-up MRI including arterial spin labeling perfusion mapping. No-reflow was operationally defined as i) hypoperfusion ≥40% relative to contralateral homologous region, assessed with both visual (two independent investigators) and automatic image analysis, and ii) infarction on follow-up MRI. Thirty-three patients were eligible (median age: 70 years, NIHSS: 18, and stroke onset-to-recanalization delay: 208 min). The operational criteria were met in one patient only, consistently with the visual and automatic analyses. This patient recanalized 160 min after stroke onset and had excellent functional outcome. In our cohort of patients with complete and stable recanalization following thrombectomy for intracranial proximal occlusion, severe ipsilateral hypoperfusion on follow-up imaging associated with newly developed infarction was a rare occurrence. Thus, no-reflow may be infrequent in human stroke and may not substantially contribute to futile recanalizations.

scholarly journals Normative distribution of posterior circulation tissue time-to-maximum: Effects of anatomic variation, tracer kinetics, and implications for patient selection in posterior circulation ischemic stroke

2021 ◽  
pp. 0271678X2098239
Author(s):  
Adam E Goldman-Yassen ◽  
Matus Straka ◽  
Michael Uhouse ◽  
Seena Dehkharghani
Keyword(s):  
Ischemic Stroke ◽  
Selection Criteria ◽  
Arterial Input Function ◽  
Anatomic Variation ◽  
Input Function ◽  
Posterior Circulation ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Perfusion Time

The generalization of perfusion-based, anterior circulation large vessel occlusion selection criteria to posterior circulation stroke is not straightforward due to physiologic delay, which we posit produces physiologic prolongation of the posterior circulation perfusion time-to-maximum (Tmax). To assess normative Tmax distributions, patients undergoing CTA/CTP for suspected ischemic stroke between 1/2018-3/2019 were retrospectively identified. Subjects with any cerebrovascular stenoses, or with follow-up MRI or final clinical diagnosis of stroke were excluded. Posterior circulation anatomic variations were identified. CTP were processed in RAPID and segmented in a custom pipeline permitting manually-enforced arterial input function (AIF) and perfusion estimations constrained to pre-specified vascular territories. Seventy-one subjects (mean 64 ± 19 years) met inclusion. Median Tmax was significantly greater in the cerebellar hemispheres (right: 3.0 s, left: 2.9 s) and PCA territories (right: 2.9 s; left: 3.3 s) than in the anterior circulation (right: 2.4 s; left: 2.3 s, p < 0.001). Fetal PCA disposition eliminated ipsilateral PCA Tmax delays (p = 0.012). Median territorial Tmax was significantly lower with basilar versus any anterior circulation AIF for all vascular territories (p < 0.001). Significant baseline delays in posterior circulation Tmax are observed even without steno-occlusive disease and vary with anatomic variation and AIF selection. The potential for overestimation of at-risk volumes in the posterior circulation merits caution in future trials.

scholarly journals Platelet Activation and Chemokine Release Are Related to Local Neutrophil-Dominant Inflammation During Hyperacute Human Stroke

2021 ◽  
Author(s):  
Alexander M. Kollikowski ◽  
Mirko Pham ◽  
Alexander G. März ◽  
Lena Papp ◽  
Bernhard Nieswandt ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Platelet Activation ◽  
Prospective Observational Study ◽  
Self Control ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Platelet Counts ◽  
Arterial Blood ◽  
Human Stroke ◽  
Leukocyte Counts

AbstractExperimental evidence has emerged that local platelet activation contributes to inflammation and infarct formation in acute ischemic stroke (AIS) which awaits confirmation in human studies. We conducted a prospective observational study on 258 consecutive patients undergoing mechanical thrombectomy (MT) due to large-vessel-occlusion stroke of the anterior circulation (08/2018–05/2020). Intraprocedural microcatheter aspiration of 1 ml of local (occlusion condition) and systemic arterial blood samples (self-control) was performed according to a prespecified protocol. The samples were analyzed for differential leukocyte counts, platelet counts, and plasma levels of the platelet-derived neutrophil-activating chemokine C-X-C-motif ligand (CXCL) 4 (PF-4), the neutrophil attractant CXCL7 (NAP-2), and myeloperoxidase (MPO). The clinical-biological relevance of these variables was corroborated by specific associations with molecular-cellular, structural-radiological, hemodynamic, and clinical-functional parameters. Seventy consecutive patients fulfilling all predefined criteria entered analysis. Mean local CXCL4 (+ 39%: 571 vs 410 ng/ml, P = .0095) and CXCL7 (+ 9%: 693 vs 636 ng/ml, P = .013) concentrations were higher compared with self-controls. Local platelet counts were lower (− 10%: 347,582 vs 383,284/µl, P = .0052), whereas neutrophil counts were elevated (+ 10%: 6022 vs 5485/µl, P = 0.0027). Correlation analyses revealed associations between local platelet and neutrophil counts (r = 0.27, P = .034), and between CXCL7 and MPO (r = 0.24, P = .048). Local CXCL4 was associated with the angiographic degree of reperfusion following recanalization (r =  − 0.2523, P = .0479). Functional outcome at discharge correlated with local MPO concentrations (r = 0.3832, P = .0014) and platelet counts (r = 0.288, P = .0181). This study provides human evidence of cerebral platelet activation and platelet-neutrophil interactions during AIS and points to the relevance of per-ischemic thrombo-inflammatory mechanisms to impaired reperfusion and worse functional outcome following recanalization.

Parent vessel occlusion after Pipeline embolization of cerebral aneurysms of the anterior circulation

2017 ◽  
Vol 127 (6) ◽  
pp. 1333-1341 ◽  
Author(s):  
Matthew B. Potts ◽  
Maksim Shapiro ◽  
Daniel W. Zumofen ◽  
Eytan Raz ◽  
Erez Nossek ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Parent Artery ◽  
Parent Vessel ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Complex Aneurysms ◽  
Aneurysm Size ◽  
Parent Vessel Occlusion ◽  
Anterior Circulation Aneurysms

OBJECTIVEThe Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO).METHODSThe authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded.RESULTSAmong 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented “delayed” PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy.CONCLUSIONSIn this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large–necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.

Catch Plus thrombectomy device in acute stroke: initial evaluation

2016 ◽  
Vol 9 (12) ◽  
pp. 1214-1218 ◽  
Author(s):  
Ahmet Peker ◽  
Ethem Murat Arsava ◽  
Mehmet Akif Topçuoğlu ◽  
Anıl Arat
Keyword(s):  
Mechanical Thrombectomy ◽  
National Institutes Of Health ◽  
Initial Experience ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Thrombectomy Device ◽  
Baseline Characteristics ◽  
Mean Time

ObjectiveTo report our initial experience with the Catch Plus thrombectomy device (CPD) in patients with acute ischemic stroke (AIS).Materials and methodsWe retrospectively evaluated the procedural variables as well as the clinical and angiographic outcomes of patients with acute occlusion of a major intracranial artery in the anterior circulation who were treated with CPD at our center. Baseline characteristics (gender, age, comorbidities, cardiovascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and vessel occlusion sites) of these patients were recorded. Thrombolysis in Cerebral Infarction (TICI) score, incidence of symptomatic and asymptomatic bleeding, and 90 day modified Rankin Scale (mRS) scores were evaluated as indicators of outcome.Results38 patients with a mean age of 67.5 years were treated with CPD. Mean time from symptom onset to procedure initiation was 226.7 min. Recanalization (TICI 2b–3) was achieved in 27 patients (71.1%). The median NIHSS score on admission was 20. Rates of symptomatic and asymptomatic intracerebral hemorrhage were 7.9% and 13.2%, respectively. The 90 day clinical follow-up data were available for 37 patients. The 90 day mortality rate was 18.9%, and the 90 day clinically acceptable functional outcome (mRS score ≤2) rate was 43.2% (mRS score 0–3, 54.1%). Very distal thrombectomy involving the cortical arteries was performed on four patients without complications.ConclusionsOur initial experience suggests that mechanical thrombectomy with the CPD improves 90 day outcomes of patients with AIS by facilitating effective recanalization.

Predictors of 30-day mortality after endovascular thrombectomy for large vessel occlusion in the elderly

2021 ◽  
pp. 159101992110692
Author(s):  
Yen-Jun Lai ◽  
Szu-Hsiang Peng ◽  
Wei-Jen Lai ◽  
Ai-Hsien Li ◽  
Ho-Hsian Yen ◽  
...  
Keyword(s):  
Primary Outcome ◽  
The Elderly ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Age Range ◽  
Number Of Passes

Objectives Elderly acute ischemic stroke (AIS) patients (≥80 years) would have dismal clinical outcomes even after successful endovascular revascularization for large vessel occlusion (LVO) in the anterior circulation. We aimed to identify predictors of 30-day mortality after endovascular thrombectomy (EVT) in the elderly. Materials and Methods We included older patients who underwent EVT for AIS due to LVO within 6 h after stroke onset in the anterior circulation between 2017 and 2019. Patients due to posterior circulation stroke, with intracerebral hemorrhage (ICH) or pre-stroke modified Rankin Scale (mRS) score of 4 and 5 were excluded. The primary outcome was mortality within 30 days of EVT. The association between clinical, imaging, procedural, follow-up imaging and mortality were analyzed. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3. Possible predictors of 30-day mortality were assessed by univariate and multivariable logistic regression. Results Total 238 AIS patients eligible for EVT were identified with 58 patients aged 80 years or more. 48 patients met inclusion criteria. Median age was 86 years (age range, 82–102 years). Successful reperfusion was achieved in 38 (79.2%) patients. The 30-day and 90-day mortality rate were 25% and 33.3%, respectively. The independent predictors of 30-day mortality were collateral scores <3 on mCTA (adjusted OR, 16.571; 95% CI, 1.041–263.868; p = 0.047) and number of passes (adjusted OR, 2.475; 95% CI, 1.047–5.847; p = 0.039). Conclusions Lower collateral scores on mCTA and higher number of passes in thrombectomy were independently predictive of 30-day mortality in the elderly.

Abstract TP91: Unfavorable Baseline Hypoperfusion Intensity Ratio is Associated With Infarct Growth and Poor Outcome in Patients With Distal MCA Occlusions

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Adam MacLellan ◽  
Michael Mlynash ◽  
Stephanie Kemp ◽  
Soren Christensen ◽  
Michael Marks ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Intensity Ratio ◽  
Ct Perfusion ◽  
Anterior Circulation ◽  
Excellent Functional Outcome ◽  
The Mean ◽  
Ischemic Core ◽  
Core Volume ◽  
Distal Middle Cerebral Artery

Background: A low hypoperfusion intensity ratio (HIR) predicts good collateral vessel status and correlates with infarct growth and functional outcome in early window patients with proximal large vessel anterior circulation occlusions. Its performance in predicting clinical and radiologic outcome has not been assessed in patients with more distal occlusions. In this retrospective analysis of the CT Perfusion to Predict Response to Recanalization in Ischemic Stroke (CRISP) study, we hypothesized that a favorable baseline HIR would predict less infarct growth in patients with distal middle cerebral artery (MCA) occlusions. Methodology: Patients with occlusions of an M2 or M3 branch of the MCA on catheter angiography were included; all patients underwent mechanical thrombectomy with TICI2B/3 reperfusion. Baseline ischemic core volume and HIR (Tmax >10s / Tmax >6s) were assessed with RAPID software; late follow-up infarct volumes (>36 hours from initial CT perfusion) were manually determined from DWI MRI. Excellent functional outcome was defined as a modified Rankin score of 0-1. Results: Fourteen patients with baseline perfusion and late follow-up imaging were included; nine patients presented with M2 occlusions, and 5 with M3 occlusions. The mean baseline HIR of 0.48 was used to dichotomize patients into favorable or unfavorable baseline profiles. Patients with a favorable baseline HIR had significantly smaller baseline ischemic core volumes (0 mL [IQR 0-3.3] vs. 14.0 mL [IQR 8.7-22.1], p=0.01), smaller final infarct volumes (16.1 mL [IQR 12.7-41.2] vs. 71.4 mL [IQR 43.8-113.5], p=0.01) and less infarct growth (16.1 mL [IQR 9.4-31.9] vs. 49.0 mL [IQR 31.1-100.8], p=0.03). Excellent functional outcome was achieved in 6/6 (100%) of those with favorable baseline HIR, versus 3/8 (37.5%) with unfavorable baseline profile (p=0.03). Conclusion: In patients with distal MCA occlusions, poor collateral status at baseline as demonstrated by a high HIR score is associated with more infarct growth and worse clinical outcomes. HIR may be helpful for guiding thrombectomy decisions in patients with distal occlusions and warrants further prospective study in this population.

What constitutes the M1 segment of the middle cerebral artery?

2016 ◽  
Vol 8 (12) ◽  
pp. 1273-1277 ◽  
Author(s):  
Mayank Goyal ◽  
Bijoy K Menon ◽  
Timo Krings ◽  
Shivanand Patil ◽  
Emmad Qazi ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Overwhelming Evidence ◽  
Segment Versus ◽  
Proximal Occlusion

Intravenous tissue plasminogen activator has limited efficacy in fibrinolysis of large proximal intracranial thrombi. Thus, recent endovascular acute stroke trials restricted their selection criteria to patients with proximal occlusions in the anterior circulation. Although the terminal internal carotid artery occlusion is relatively easy to identify, there is often a debate as to what constitutes a proximal (involving the M1 segment) versus a distal (involving the M2 segment and beyond) middle cerebral artery occlusion. In light of overwhelming evidence demonstrating superiority of endovascular treatment in patients with proximal occlusion, this distinction has significant practical implications in patient selection. Here we present a brief review of the proximal (M1) segment of the middle cerebral artery anatomy and provide practical methods to recognize and separate the M1 and M2 segments. In keeping with the belief that CT angiography (CTA) (preferably multiphase CTA) is the ideal screening test for patients with emergent large vessel occlusion, we have provided tips for expeditious and accurate vascular imaging interpretation.

scholarly journals Cerebral Revascularization for the Management of Symptomatic Pure Arterial Malformations

2021 ◽  
Vol 12 ◽  
Author(s):  
Xiaocheng Lu ◽  
Xinggen Fang ◽  
Yabo Huang ◽  
Peng Zhou ◽  
Zhong Wang ◽  
...  
Keyword(s):  
Systematic Review ◽  
Cerebral Arteries ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Left Internal Carotid Artery ◽  
Anterior Circulation ◽  
Appropriate Treatment ◽  
The Right ◽  
Proximal Occlusion

Background: Pure arterial malformations (PAMs) are extremely rare abnormalities defined as dilated, overlapping, and tortuous arteries with a coil-like appearance in the absence of venous components. Over the last half century, only seven published reports have described cases of patients with PAMs who received treatment.Methods: Here, we report two cases of women with PAMs who received surgical treatment, and we present a systematic review of the literature. We searched the PubMed, Embase, Web of Science, and Medline databases (up until October 1, 2021) for relevant publications. We performed independent-sample t-tests and Fisher's exact tests to compare continuous and categorical characteristics among the available cases.Results: Our first patient was a 43-year-old woman with PAM of the left internal carotid artery (ICA), who received an ICA-radial artery (RA)-M2 bypass. Post-operative digital subtraction angiography (DSA) revealed the disappearance of the left ICA PAM without ischemic events during follow-up. The second patient was a 53-year-old woman with PAMs of the right ICA and posterior cerebral artery. The P1 lesion was treated by proximal occlusion combined with a superficial temporal artery-P2 bypass. During the 12-month follow-up period, the size of the PAMs decreased significantly as indicated by the post-operative DSA showing the absence of hemorrhages. Our systematic review, which includes 56 PAMs, shows that the reported PAMs were more common in the anterior circulation (33/56, 58.9%) than in the posterior circulation (11/56, 19.7%). Bilateral PAMs were more likely to affect bilateral anterior cerebral arteries (ACA) (ACAbilateral vs. ACAunilateral: 63.6 vs. 26.2%, p = 0.02). In addition, PAMs involving the anterior circulation were likely to affect multiple arteries (anteriormulti vs. posteriormulti: 30.3 vs. 0%, p = 0.038).Conclusion: We found very few reports on treated PAMs; further studies with large sample sizes and long follow-up periods are required to explore the appropriate treatment strategy for PAMs.

Abstract TP9: ASPECTS Values in Patients With Large Vessel Occlusion and Time of Arrival to Emergency Department: Estimation of Eligibility for Endovascular Stroke Therapy

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Maxim Mokin ◽  
Aparna Pendurthi ◽  
Christopher Primiani ◽  
William S Burgin
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Endovascular Therapy ◽  
Stroke Onset ◽  
Time Of Arrival ◽  
Large Vessel Occlusion ◽  
Stroke Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Stroke Therapy

Background: Favorable imaging profile according to The Alberta Stroke Program Early CT Score (ASPECTS) is an important selection criterion for endovascular therapy in patients with acute stroke from anterior circulation large vessel occlusion (LVO). The goal of this study was analyze the relationship between ASPECTS values and time of arrival to emergency department (ED) after stroke onset, and its impact on patient’s eligibility for endovascular stroke therapy. Methods: analysts of ASPECTS values in consecutive patients with acute stroke from anterior circulation LVO admitted within 24 hours of onset was performed. Criteria from American Heart Association/American Stroke Association (AHA/ASA) guidelines based on the proposed class I-II recommendations, including the ‘favorable’ ASPECTS range of 6-10 were applied to determine frequency of potentially eligible patients for endovascular stroke therapy. Results: Of 641 patients with acute ischemic stroke presenting within the first 24 hours of onset, 71 (11%) had anterior circulation LVO. Medium time from arrival to ED to noncontrast head CT was 6 minutes. 72% of patients arrived to ED within the first 6 hours, 18% within 6-12 hours, and 10% within 12-24 hours of symptom onset. Based on ‘favorable’ ASPECTS criterion alone, 80% of patients with anterior circulation LVO who arrive to the ED within the first 6 hours of stroke onset would qualify for endovascular therapy. Of those who arrived to ED within 6-24 hours of stroke onset, 50% had ‘favorable’ ASPECTS. Conclusions: 50% of patients with stroke from anterior circulation LVO who arrive to ED within 6-24 hours of onset have ‘favorable’ ASPECTS, making them potentially eligible for endovascular stroke therapy.

Abstract WMP89: Outcomes No Different in Real World Including Direct vs Drip-and-Ship Patients: Power of Reperfusion From Mechanical Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Darshan G Shah ◽  
Aravi Loganathan ◽  
Dan Truong ◽  
Fiona Chan ◽  
Bruce Campbell ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Real World ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Vessel Occlusion ◽  
Excellent Functional Outcome ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: Mechanical thrombectomy (MT) became standard care in 2015 after positive trials in patients presenting with acute ischemic stroke and large vessel occlusion (LVO) 0-6h and in 2018 for selected patients up to 24h from symptom onset. Objective: To evaluate whether patients receiving MT at our center would have comparable outcomes in patients presenting to our comprehensive stroke center (direct) vs transfer patients (drip-and-ship) Methods: This is a retrospective observational study utilising prospectively collected stroke database for patients receiving MT for LVO in anterior and posterior circulation in South Brisbane network of 7 hospitals (6 drip-and-ship centers and 1 MT-capable center), Australia which serves 1.6 million. Day 90 modified Rankin scale (mRS) was used to assess functional outcomes via outpatient follow up at direct or referral center. The association of drip and ship versus mothership treatment with day 90 mRS was tested in ordinal logistic regression adjusted for age, baseline NIHSS and IV thrombolysis. Results: Of 191 patients who underwent Mechanical Thrombectomy from 2015 to June 2018 at our center, 22 patients were excluded from analysis as either their baseline mRS was >1 (13) or follow up data was missing (9). The mean age was 64.4 years. Median (inter-quartile range, IQR) NIHSS was 16 (9-21) on admission and 7 (2-18) on day 1. Thrombolysis in Cerebral Infarction (TICI) ≥2b was achieved in 88.9%. At 90 days, 50.9% achieved excellent functional outcome (mRS 0-1), 61.4% achieved good functional outcome (mRS 0-2) and 69% achieved favorable outcome (mRS 0-3). Median mRS was 1 (IQR 0-5) in 96 patients presenting directly to the endovascular center and 1 (IQR 1-4) in 73 drip-and-ship patients (common odds ratio 1.07 (95%CI 0.62-1.83), p=0.82) Conclusion: Our 7-center network experience confirms real world reproducibility of trial results, interestingly with no difference in functional outcomes for direct vs drip-and-ship patients.

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