Venous outflow profiles are associated with early edema progression in ischemic stroke

Background: In patients with acute ischemic stroke due to large vessel occlusion (AIS–LVO), development of extensive early ischemic brain edema is associated with poor functional outcomes, despite timely treatment. Robust cortical venous outflow (VO) profiles correlate with favorable tissue perfusion. We hypothesized that favorable VO profiles (VO+) correlate with a reduced early edema progression rate (EPR) and good functional outcomes. Methods: Multicenter, retrospective analysis to investigate AIS–LVO patients treated by mechanical thrombectomy between May 2013 and December 2020. Baseline computed tomography angiography (CTA) was used to determine VO using the cortical vein opacification score (COVES); VO+ was defined as COVES ⩾ 3 and unfavorable as COVES ⩽ 2. EPR was determined as the ratio of net water uptake (NWU) on baseline non-contrast CT and time from symptom onset to admission imaging. Multivariable regression analysis was performed to assess primary (EPR) and secondary outcome (good functional outcomes defined as 0–2 points on the modified Rankin scale). Results: A total of 728 patients were included. Primary outcome analysis showed VO+ (β: –0.03, SE: 0.009, p = 0.002), lower presentation National Institutes of Health Stroke Scale (NIHSS; β: 0.002, SE: 0.001, p = 0.002), and decreased time from onset to admission imaging (β: –0.00002, SE: 0.00004, p < 0.001) were independently associated with reduced EPR. VO+ also predicted good functional outcomes (odds ratio (OR): 5.07, 95% CI: 2.839–9.039, p < 0.001), while controlling for presentation NIHSS, time from onset to imaging, general vessel reperfusion, baseline Alberta Stroke Program Early CT Score, infarct core volume, EPR, and favorable arterial collaterals. Conclusions: Favorable VO profiles were associated with slower infarct edema progression and good long-term functional outcomes as well as better neurological status and ischemic brain alterations at admission.

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Association of Venous Outflow Profiles and Successful Vessel Reperfusion After Thrombectomy

Neurology ◽

10.1212/wnl.0000000000012106 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012106

Author(s):

Tobias Djamsched Faizy ◽

Reza Kabiri ◽

Soren Christensen ◽

Michael Mlynash ◽

Gabriella Kuraitis ◽

...

Keyword(s):

Functional Outcome ◽

Tissue Perfusion ◽

Secondary Outcome ◽

Multivariable Logistic Regression Analysis ◽

Venous Outflow ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Cortical Vein ◽

Good Functional Outcome ◽

Pre Treatment

Objective:Robust arterial collaterals are associated with successful reperfusion after thrombectomy treatment of acute ischemic stroke due to large vessel occlusion (AIS-LVO). Excellent venous outflow (VO) reflects excellent tissue perfusion and collateral status in AIS-LVO patients. To determine whether favorable VO profiles assessed on pre-treatment CT angiography (CTA) images correlate with successful vessel reperfusion after thrombectomy in AIS-LVO patients.Methods:Multicenter retrospective cohort study of consecutive AIS-LVO patients treated by thrombectomy. Baseline CTA was used to assess collateral status (Tan scale) and VO using the cortical vein opacification score (COVES). Favorable VO was defined as COVES ≥3. Primary outcome was excellent vessel reperfusion status (modified Thrombolysis In Cerebral Infarction [TICI] 2c-3). Secondary outcome was good functional outcome defined as 0-2 on the Modified Ranking Scale (mRS) after 90 days.Results:565 patients met inclusion criteria. Multivariable logistic regression analysis showed that favorable VO (OR= 2.10 [95% CI 1.39-3.16]; p<0.001) was associated with excellent vessel reperfusion during thrombectomy, regardless of good CTA collateral status (OR= 0.87 [95%CI 0.58-1.34]; p=0.48). A favorable VO profile (OR= 8.9 [95%CI 5.3-14.9]; p<0.001) and excellent vessel reperfusion status (OR = 2.7 [95%CI 1.7-4.4]; p<0.001) were independently associated with good functional outcome adjusted for age, sex, glucose, tPA administration, good CTA collateral status and presentation NIHSS.Conclusion:A favorable VO profile is associated with reperfusion success and good functional outcomes in patients with AIS-LVO treated by endovascular thrombectomy.

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Cerebral venous outflow profiles are associated with the first pass effect in endovascular thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018078 ◽

2021 ◽

pp. neurintsurg-2021-018078

Author(s):

Noel van Horn ◽

Jeremy J Heit ◽

Reza Kabiri ◽

Marius M Mader ◽

Soren Christensen ◽

...

Keyword(s):

Functional Outcomes ◽

Mechanical Thrombectomy ◽

Univariate Analysis ◽

Multivariable Logistic Regression Analysis ◽

Venous Outflow ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Cortical Vein ◽

Number Of Patients ◽

First Pass

BackgroundRecent studies found that favorable venous outflow (VO) profiles are associated with higher reperfusion rates after mechanical thrombectomy (MT) in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Fewer retrieval attempts and first-pass revascularization during MT lead to better functional outcomes.ObjectiveTo examine the hypothesis that favorable VO profiles assessed on baseline CT angiography (CTA) images correlate with successful vessel reperfusion after the first retrieval attempt and fewer retrieval attempts.MethodsA multicenter retrospective cohort study of patients with AIS-LVO treated by MT. Baseline CTA was used to determine the cortical vein opacification score (COVES). Favorable VO was defined as COVES ≥3. Primary outcomes were successful with excellent vessel reperfusion status, defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 and 2c/3 after first retrieval attempt.Results617 patients were included in this study, of whom 205 (33.2%) had first pass reperfusion. In univariate analysis, ordinal COVES (p=0.011) values were significantly higher in patients with first pass than in those with non-first pass reperfusion, while the number of patients exhibiting favorable pial arterial collaterals using the Maas scale on CTA did not differ (p=0.243). In multivariable logistic regression analysis, higher COVES were independently associated with TICI 2b/3 (OR=1.25, 95% CI 1.1 to 1.42; p=0.001) and TICI 2c/3 (OR=1.2, 95% CI 1.04 to 1.36; p=0.011) reperfusion after one retrieval attempt, controlling for penumbra volume and time from symptom onset to vessel reperfusion.ConclusionsFavorable VO, classified as higher COVES, is independently associated with successful and excellent first pass reperfusion in patients with AIS-LVO treated by endovascular thrombectomy.

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Association of CT-Based Hypoperfusion Index With Ischemic Core Enlargement in Patients With Medium and Large Vessel Stroke

Neurology ◽

10.1212/wnl.0000000000012855 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012855

Author(s):

Ali Z Nomani ◽

Joseph Kamtchum Tatuene ◽

Jeremy L Rempel ◽

Thomas Jeerakathil ◽

Ian Winship ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Reperfusion Therapy ◽

Stroke Onset ◽

Progression Rate ◽

Stroke Patients ◽

Infarct Core ◽

Vessel Occlusion ◽

Slow Progressors

Objective:The rate of infarct core progression in patients with acute ischemic stroke is variable and affects outcome of reperfusion therapy. We evaluated hypoperfusion index (HI) to estimate the initial rate of core progression in patients with medium-vessel-occlusion (MeVO) compared to large-vessel-occlusion (LVO) stroke and within a larger time frame since stroke onset.Methods:Core progression was assessed in 106 patients with acute stroke and CT perfusion. Using reperfusion trial core-time criteria, fast progressors had core>70-mL within 6-hours of stroke onset and slow progressors had core ≤70mL, mismatch ≥15mL and mismatch-to-core-ratio ≥1.8 within 6-24-hours. The relationship between HI and infarct core progression (core/time) was examined using receiver-operating-characteristics to determine optimal HI cut-off. The HI cut-off was then tested in overall cohort, compared between MeVO and LVO, and evaluated in patients up to 24-hours from stroke onset to differentiate fast from slow rate of core progression. HI threshold was assessed in a second independent cohort of 110 acute ischemic stroke patients.Results:In 106 patients with acute stroke, 6.6% were fast progressors, 27.4% were slow progressors, and 66% were not classified as fast or slow progressor by reperfusion trial core-time criteria. HI>0.5 was associated with fast progression and able to distinguish fast from slow progressors (AUC=0.94;95%CI=0.80-0.99). In MeVO patients (n=26) HI>0.5 had a core progression of 0.30-mL/min compared to 0.03-mL/min with HI≤0.5 (p<0.001). In LVO patients (n=80), HI>0.5 had a core progression of 0.26-mL/min compared to 0.02-mL/min with HI≤0.5 (p<0.001). In patients not classified as fast or slow progressor by reperfusion trial criteria, those with HI>0.5 had progression rate of 0.21-mL/min compared to 0.03-mL/min with HI≤0.5 (p<0.001). Validation in a second cohort of patients with acute ischemic stroke (n=110; MeVO n=42, LVO n=68) yielded similar results for HI>0.5 to distinguish fast and slow core progression with an AUC of 0.84(95%CI=0.72-0.97).Conclusions:HI can differentiate fast from slow core progression in MeVO and LVO patients within the first 24-hours of acute ischemic stroke. Consideration of core progression rate at time of stroke evaluation may have implications in the selection of MeVO and LVO stroke patients for reperfusion therapy that warrant further study.

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Abstract P321: The Cerebral Collateral Cascade: Rethinking the Assessment of Vascular Pathways in Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.52.suppl_1.p321 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Tobias D Faizy ◽

Michael Mlynash ◽

Reza Kabiri ◽

Soren Christensen ◽

Gabriella Kuraitis ◽

...

Keyword(s):

Blood Flow ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Ct Perfusion ◽

Infarct Volume ◽

Strong Predictor ◽

Secondary Outcome ◽

Collateral Blood Flow ◽

Vessel Occlusion ◽

Cortical Vein

Background and Purpose: Robust collateral blood flow in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) has been correlated with favorable outcomes. Collaterals are commonly assessed by the number of arteries present on non-invasive CT angiography (CTA) overlying ischemic brain, but blood transit from these arteries through the brain tissue and the venous drainage is not assessed by this technique. We hypothesized that a comprehensive imaging analysis of the cerebral collateral cascade (CCC) would predict clinical and radiological outcomes in patients with AIS-LVO patients. Materials and Methods: Multicenter retrospective cohort study of AIS-LVO patients undergoing thrombectomy triage. CCC was determined on pre-treatment imaging by scoring for pial arterial collaterals, tissue-level collaterals (TLC), and venous outflow. Pial arterial collaterals were determined by CTA (Tan scale), TLC were assessed on CT perfusion data using the Hypoperfusion Intensity Ratio, and venous egress was assessed on CTA using the cortical vein opacification score system. 3 groups were defined: CCC+ (good pial collaterals, TLC, and venous perfusion), CCC- (poor pial collaterals, TLC, and venous perfusion) and CCCmixed (reminder of patients). Primary outcome was a good functional outcome (modified Rankin Scale [mRS] 0-2 at 90 days). Secondary outcome was final infarct volume. Results: 647 patients met inclusion criteria: 176 CCC+, 345 CCCmixed and 126 CCC-. Multivariate ordinal logistic regression showed that CCC+ predicted good functional outcomes (mRS 0-2: OR=20.8 [95% CI 9.3-46.8]; p<0.001) compared to CCC- and CCCmixed. CCCmixed (β: 27.1, SE: 7.7; p<0.001) and CCC- (β: 86.6, SE: 9.9; p<0.001) profiles were associated with higher final infarct volumes after treatment compared to CCC+. Conclusion: Comprehensive assessment of the collateral blood flow cascade in AIS-LVO patients is a strong predictor of clinical and radiological outcomes in AIS-LVO patients.

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Abstract WMP15: Automated Volumetric Assessment of Infarct Core in Non-Contrast Computed Tomography in Patients With Acute Ischemic Stroke Secondary to Large Vessel Occlusion

Stroke ◽

10.1161/str.51.suppl_1.wmp15 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Alvaro Garcia-Tornel ◽

Matias Deck ◽

Marc Ribo ◽

David Rodriguez-Luna ◽

Jorge Pagola ◽

...

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Infarct Volume ◽

Large Vessel Occlusion ◽

Infarct Core ◽

Vessel Occlusion ◽

Good Functional Outcome ◽

Volumetric Assessment

Introduction: Perfusion imaging has emerged as an imaging tool to select patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) for endovascular treatment (EVT). We aim to compare an automated method to assess the infarct ischemic core (IC) in Non-Contrast Computed Tomography (NCCT) with Computed Tomography Perfusion (CTP) imaging and its ability to predict functional outcome and final infarct volume (FIV). Methods: 494 patients with anterior circulation stroke treated with EVT were included. Volumetric assessment of IC in NCCT (eA-IC) was calculated using eASPECTS™ (Brainomix, Oxford). CTP was processed using availaible software considering CTP-IC as volume of Cerebral Blood Flow (CBF) <30% comparing with the contralateral hemisphere. FIV was calculated in patients with complete recanalization using a semiautomated method with a NCCT performed 48-72 hours after EVT. Complete recanalization was considered as modified Thrombolysis In Cerebral Ischemia (mTICI) ≥2B after EVT. Good functional outcome was defined as modified Rankin score (mRs) ≤2 at 90 days. Statistical analysis was performed to assess the correlation between EA-IC and CTP-IC and its ability to predict prognosis and FIV. Results: Median eA-IC and CTP-IC were 16 (IQR 7-31) and 8 (IQR 0-28), respectively. 419 patients (85%) achieved complete recanalization, and their median FIV was 17.5cc (IQR 5-52). Good functional outcome was achieved in 230 patients (47%). EA-IC and CTP-IC had moderate correlation between them (r=0.52, p<0.01) and similar correlation with FIV (r=0.52 and 0.51, respectively, p<0.01). Using ROC curves, both methods had similar performance in its ability to predict good functional outcome (EA-IC AUC 0.68 p<0.01, CTP-IC AUC 0.66 p<0.01). Multivariate analysis adjusted by confounding factors showed that eA-IC and CTP-IC predicted good functional outcome (for every 10cc and >40cc, OR 1.5, IC1.3-1.8, p<0.01 and OR 1.3, IC1.1-1.5, p<0.01, respectively). Conclusion: Automated volumetric assessment of infarct core in NCCT has similar performance predicting prognosis and final infarct volume than CTP. Prospective studies should evaluate a NCCT-core / vessel occlusion penumbra missmatch as an alternative method to select patients for EVT.

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Performance of angiographic parametric imaging in locating infarct core in large vessel occlusion acute ischemic stroke patients

Journal of Medical Imaging ◽

10.1117/1.jmi.7.1.016001 ◽

2020 ◽

Vol 7 (01) ◽

pp. 1

Author(s):

Ryan A. Rava ◽

Maxim Mokin ◽

Kenneth V. Snyder ◽

Muhammad Waqas ◽

Adnan H. Siddiqui ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Parametric Imaging ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Infarct Core ◽

Vessel Occlusion

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Automated prediction of final infarct volume in patients with large-vessel occlusion acute ischemic stroke

Neurosurgical FOCUS ◽

10.3171/2021.4.focus21134 ◽

2021 ◽

Vol 51 (1) ◽

pp. E13

Author(s):

Rania Abdelkhaleq ◽

Youngran Kim ◽

Swapnil Khose ◽

Peter Kan ◽

Sergio Salazar-Marioni ◽

...

Keyword(s):

Machine Learning ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Large Vessel Occlusion ◽

Infarct Core ◽

Vessel Occlusion ◽

Automated Method ◽

Machine Learning Model ◽

Time Of Presentation

OBJECTIVE In patients with large-vessel occlusion (LVO) acute ischemic stroke (AIS), determinations of infarct size play a key role in the identification of candidates for endovascular stroke therapy (EVT). An accurate, automated method to quantify infarct at the time of presentation using widely available imaging modalities would improve screening for EVT. Here, the authors aimed to compare the performance of three measures of infarct core at presentation, including an automated method using machine learning. METHODS Patients with LVO AIS who underwent successful EVT at four comprehensive stroke centers were identified. Patients were included if they underwent concurrent noncontrast head CT (NCHCT), CT angiography (CTA), and CT perfusion (CTP) with Rapid imaging at the time of presentation, and MRI 24 to 48 hours after reperfusion. NCHCT scans were analyzed using the Alberta Stroke Program Early CT Score (ASPECTS) graded by neuroradiology or neurology expert readers. CTA source images were analyzed using a previously described machine learning model named DeepSymNet (DSN). Final infarct volume (FIV) was determined from diffusion-weighted MRI sequences using manual segmentation. The primary outcome was the performance of the three infarct core measurements (NCHCT-ASPECTS, CTA with DSN, and CTP-Rapid) to predict FIV, which was measured using area under the receiver operating characteristic (ROC) curve (AUC) analysis. RESULTS Among 76 patients with LVO AIS who underwent EVT and met inclusion criteria, the median age was 67 years (IQR 54–76 years), 45% were female, and 37% were White. The median National Institutes of Health Stroke Scale score was 16 (IQR 12–22), and the median NCHCT-ASPECTS on presentation was 8 (IQR 7–8). The median time between when the patient was last known to be well and arrival was 156 minutes (IQR 73–303 minutes), and between NCHCT/CTA/CTP to groin puncture was 73 minutes (IQR 54–81 minutes). The AUC was obtained at three different cutoff points: 10 ml, 30 ml, and 50 ml FIV. At the 50-ml FIV cutoff, the AUC of ASPECTS was 0.74; of CTP core volume, 0.72; and of DSN, 0.82. Differences in AUCs for the three predictors were not significant for the three FIV cutoffs. CONCLUSIONS In a cohort of patients with LVO AIS in whom reperfusion was achieved, determinations of infarct core at presentation by NCHCT-ASPECTS and a machine learning model analyzing CTA source images were equivalent to CTP in predicting FIV. These findings have suggested that the information to accurately predict infarct core in patients with LVO AIS was present in conventional imaging modalities (NCHCT and CTA) and accessible by machine learning methods.

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Abstract P148: Safety And Efficacy Of Edaravone Dexborneol Versus Edaravone Alone For The Treatment Of Acute Ischemic Stroke Patients With Hypertention: Analysis From Taste Trial

Hypertension ◽

10.1161/hyp.78.suppl_1.p148 ◽

2021 ◽

Vol 78 (Suppl_1) ◽

Author(s):

Jie Xu ◽

Yongjun Wang

Keyword(s):

Ischemic Stroke ◽

Adverse Events ◽

Acute Ischemic Stroke ◽

Medical History ◽

Functional Outcomes ◽

Group Versus ◽

Phase Iii ◽

Secondary Outcome ◽

Serious Adverse Events ◽

Intention To Treat

Background and Aims: Evidenced by TASTE phase III trial, 90-day good functional outcomes favored the edaravone dexborneol group versus edaravone group when administered within 48 hours after Acute Ischemic Stroke (AIS). The present study aimed to investigate the effects of edaravone dexborneol versus edaravone in AIS patients with hypertension medical history. Methods: This study was a subgroup analysis of the TASTE trial with hypertension medical history. The primary outcome was the proportion of patients with modified Rankin Scale (mRS) score ≤1 on day 90 after randomization. The secondary outcome was the mRS score on day 90. The safety endpoints were the incidences of adverse events, serious adverse events and deaths. Analyses were by intention to treat. Results: We included 767 AIS patients with hypertension (390 in edaravone dexborneol group, 377 in edaravone group) in this analysis. Among them, 252 (64.62%) in edaravone dexborneol group versus 199 (52.79%) in edaravone group reached mRS score ≤1 on D90, revealing significantly higher proportion of mRS score ≤1 on D90 in edaravone dexborneol group (OR 1.63 [95% CI, 1.22-2.18]; P<0.001). Significant differences occurred between two groups in mRS score on D90 ([OR 1.32 [95% CI, 1.02-1.72]; P=0.038). The safety outcomes indicated that the two groups were similar in incidences of adverse events (366 [93.85%] versus 352 [93.37%], p=0.787), serious adverse events (48 [12.31%] versus 34 [9.02%], p=0.1405) and number of deaths (6 [1.54%] versus 4 [1.06%], p=0.56). Conclusion: This analysis demonstrated that AIS patients with hypertension receiving edaravone dexborneol had better functional outcomes than those with edaravone, which provided evidences for the clinical application of edaravone dexborneol in AIS patients with hypertension. Keywords: Edaravone dexborneol, Acute ischemic stroke, Hypertension, mRS score

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Neuroprotection of Early Locomotor Exercise Poststroke: Evidence From Animal Studies

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2015.39 ◽

2015 ◽

Vol 42 (4) ◽

pp. 213-220 ◽

Cited By ~ 11

Author(s):

Pengyue Zhang ◽

Jia Xianglei ◽

Yang Hongbo ◽

Jichuan Zhang ◽

Ce Xu

Keyword(s):

Ischemic Stroke ◽

Brain Injury ◽

Animal Models ◽

Inflammatory Response ◽

Functional Outcomes ◽

Animal Studies ◽

Acute Inflammatory Response ◽

Ischemic Brain Injury ◽

Ischemic Brain ◽

Neuron Apoptosis

AbstractEarly locomotor exercise after stroke has attracted a great deal of attention in clinical and animal research in recent years. A series of animal studies showed that early locomotor exercise poststroke could protect against ischemic brain injury and improve functional outcomes through the promotion of angiogenesis, inhibition of acute inflammatory response and neuron apoptosis, and protection of the blood-brain barrier. However, to date, the clinical application of early locomotor exercise poststroke was limited because some clinicians have little confidence in its effectiveness. Here we review the current progress of early locomotor exercise poststroke in animal models. We hope that a comprehensive awareness of the early locomotor exercise poststroke may help to implement early locomotor exercise more appropriately in treatment for ischemic stroke.

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Abstract WP411: Evaluation of Strategies to Reduce Time to Revascularization in Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.wp411 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Abbigayle M Doerr ◽

Janet Davis ◽

Sheryl Jenkins

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Process Improvement ◽

Stroke Patient ◽

Endovascular Therapy ◽

Functional Outcomes ◽

Primary Outcome ◽

Outcome Analysis ◽

Ischemic Stroke Patient ◽

Acute Ischemic Stroke Patient

Background: There is growing support for the need for process improvement surrounding treatment of acute ischemic stroke, specifically, reducing time to reperfusion in endovascular therapy (EVT). Streamlining protocols from patient presentation to revascularization can lead to improved timelines to treatment and functional outcomes. Purpose: The purpose of this study was to identify the impact on specific hospital based process improvement strategies in the acute ischemic stroke patient population undergoing endovascular therapy with specific intent to decrease median arrival to revascularization time, thus increasing the potential for good functional outcome. Methods: The study includes a pre- and post-intervention retrospective review of patients 18 years or older, hospital admission between January 1, 2014 and December 31, 2015, who underwent EVT for treatment acute ischemic stroke. The primary outcome variable was time from arrival to revascularization during the acute ischemic stroke admission. The secondary outcome variables were specific to functional outcome analysis in the acute ischemic stroke patient. The data points were collected from the local America Heart Association’s Get with the Guidelines-Stroke (GWTG) dataset. Results: Twenty eight consecutive endovascular ischemic stroke patients were reviewed, pre process improvement (PI) (Group 1, n=10) and post PI (Group 2, n=18). There were no significant differences between baseline characteristics between the groups. The primary outcome analysis revealed significant improvement in door to revascularization between the pre and post PI groups, 2:56 and 2:11 (p=.002) respectively, a 45 minute decrease in time to treatment. Rates of good clinical outcomes (modified Rankin Scale 0-2 at 3 months) were similar in both groups, 33.3% pre PI and 46.2% post PI (p=0.59). Conclusions: Hospital based PI initiatives including: early notification, streamlined transport process, and utilization of feedback tool significantly improve door to revascularization times and can potentially lead to improved functional outcomes in the acute ischemic stroke patient undergoing EVT.

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