Background and Importance: Since Trousseau’s initial publication, the development of thromboembolic events related to malignancy has been well established. The pathophysiology of this is understood to be through activation of the coagulation cascade through neoplastic cells themselves or the therapy initiated (chemotherapy or surgery). To date, there have been a variety of studies, such as the OASIS-CANCER trial, which highlight the relationship of hypercoagulability to ischemic stroke. Despite these efforts, clear evidence is lacking for the utilization of antiplatelet or anticoagulation therapy in the secondary prevention of stroke following mechanical thrombectomy in patients with suspected or confirmed malignancy. Clinical Presentation: A 71-year-old female with a history of immune thrombocytopenia, diabetes mellitus, and hypertension who was undergoing an evaluation for a lung nodule, later determined to be adenocarcinoma of the lung, underwent three successful mechanical thrombectomies for acute ischemic stroke with large vessel occlusion over a one month period. This patient had improved National Institutes of Health Stroke Scale (NIHSS) scores following each of her thrombectomies. However, her history of immune thrombocytopenia and underlying malignancy complicated her discharge medication regimen following each of her thrombectomies and may have contributed to her repeat strokes. Conclusion: Clear guidance is lacking regarding the utilization of antiplatelet and anticoagulation therapy in patients with suspected or confirmed malignancy following mechanical thrombectomy. Review of the literature suggests that controlling a patient’s hypercoagulability may lead to improved clinical outcomes, but further clinical trials are warranted.

Fenestrated vertebrobasilar junction aneurysms are uncommon vascular lesions. Surgical intervention remains extremely challenging due to the deep location and complex anatomy with adjacent cranial nerves and perforator vessels. Endovascular approach is safer and generally accepted as the primary treatment method. Optimal angiographic projections with three-dimensional reconstructions to guide microcatheter selection remain vital to successfully treating aneurysms with challenging fenestration anatomy. This report details the endovascular methods in two cases of fenestrated vertebrobasilar junction aneurysms with different coiling techniques.

BackgroundPresently accepted criteria for ELVO intervention rely on time from last seen well (LSW) following conformation of LVO diagnosis and favorable baseline imaging. Many patients however present outside established treatment windows or with unknown LSW, and thus, represent a population of great relevance. Here we present in hospital and 90 day outcomes of a large patient cohort, many treated at extended LSW, after MRI assessment.PopulationELVO patients with isolated occlusion of the carotid terminus or M1 segment, baseline mRS ≤2, age ≥18, and no MRI contraindication.MethodsRegression analysis with primary outcome 90d mRS ≤2 and secondary outcomes in-hospital mortality, 90d mortality, 24 hour and discharge stroke severity (NIHSS).ResultsFrom a stroke intervention dataset representing n=80 ELVO patients treated with thrombectomy between 12/25/2014 and 8/14/2016, n=40 cases were identified meeting inclusion criteria. Median patient age was 69, baseline NIHSS was 17.5, and mean CT ASPECTS was 8.78. 15/40 (37.5%) received IV tPA and the median presenting DWI core volume was 15 mL (IQR: 5.0–33.7). Median time to femoral access was 418 min (IQR: 281–936). TICI ≥2B recanalization success was 85%. No patient had PH2 intracranial hemorrhage, 1 had PH1, 3 HT1, and 2 SAH, none requiring additional intervention.90d mRS ≤2 was 20%, in-hospital mortality was 12.5%, 90d mortality was 30%. All patients with 90d mRS ≤2 also had TICI ≥2B recanalization. Many patients (20/40) showed early response to therapy as defined by improvement in NIHSS≥4, an effect that was more likely with TICI ≥2B recanalization (OR 2.53 [95CI: 1.663–3.876]), and equally likely with femoral access before or after 6 hours LSW (OR 1.403 [95CI: 0.782–2.516]). The strongest predictor of 90d mRS ≤2 was baseline MRI core volume (b=−0.364, p=0.013). A similar and more robust effect was observed with discharge NIHSS (b=0.256, p<0.001). Time to femoral access showed a weak interaction with 90 day outcome and discharge NIHSS although a few patients treated at very early time LSW (<3 hour) showed excellent early response to therapy.ConclusionMRI selected ELVO patients represented in this cohort showed favorable response to therapy even at extended time from LSW. Although a few patients treated <3 hours LSW showed excellent response to therapy, MRI core volume was a better predictor of both in hospital and 90 day outcomes than time.Abstract E-031 Table 1 Logistic Regression Analysis 90d mRS ≤2 95 CI for B B Sig Lower Upper Age (yr) −0.088 0.014 −10.6 0.256 Baseline NIHSS 0.050 0.313 −5.54 13.7 Time to Fem Access (min) 0.001 0.013 −0.202 0.130 Baseline DWI Core (mL) −0.364 0.013 −35.3 0.040 Abstract E-031 Table 2 Linear Regression Analysis Discharge NIHSS 95 CI for B B Sig Lower Upper Age (yr) 0.227 0.003 0.110 0.358 TICI≥2B −12.2 0.008 −21.6 −4.8 Time to Fem Acc (min) −0.001 0.182 −0.001 0.007 Baseline DWI Core (mL) 0.256 0.001 0.118 0.369 Disclosures B. Cristiano: None. K. Cicilioni: None. M. Pond: None. J. Lee: None. P. Promod: None. U. Oyoyo,...

BackgroundIsolated occlusion of the MCA M2 segment may result in significant motor or speech symptoms and is often amenable to mechanical thrombectomy. Although isolated M2 occlusions are not uncommon they are unrepresented in recent large randomized controlled trials, and therefore, represent a population of great interest. Here we show significant response to therapy among a cohort of M2 occlusion patients, many treated at extended time LSW after MRI assessment.PopulationELVO patients with isolated occlusion of the right or left MCA M2 segment, baseline NIHSS speech score ≥1, baseline mRS ≤2, age ≥18, and no MRI contraindication.MethodsRetrospective cohort analysis with primary outcome discharge NIHSS speech score and secondary outcome NIHSS speech score improvement.ResultsFrom an institutional stroke intervention dataset representing n=80 ELVO patients treated with thrombectomy between 12/25/2014 and 8/14/2016, n=8 cases were identified meeting inclusion criteria. Median age was 66, median baseline NIHSS was 9 (range: 6–21), and mean CT ASPECTS was 9.25. 3/8 (37.5%) received IV tPA, median time LSW to femoral access was 216 min (IQR: 330–534), and median baseline DWI volume was 6 mL (IQR: 5–18). 7/8 patients studied (87.5%) showed at least one-point improvement in NIHSS speech score at discharge with 6/8 (75%) either insignificant or mild aphasia at discharge. 2/8 patients had time to femoral access ≤6 hour LSW, both had mild aphasia that was resolved at discharge. 4/5 patients presenting beyond 6 hour LSW had insignificant or mild aphasia at discharge, a response rate of 80% and not statistically different from the early presenting group (OR: 1.5 [95CI: 0.82–2.64]).ConclusionMRI selected ELVO patients with isolated M2 occlusion and significant aphasia represented in this cohort showed excellent response to therapy at extended time LSW.Abstract P-011 Table 1 Isolated M2 Occlusion Patients Presenting With Aphasia Case LSW to Fem Access (min) Baseline MRI Core (mL) Bas NIHSS Speech Score 24 hour Speech Score (NIHSS) Aphasia Severity Discharge 90 d mRS 1 467 6 1 -- None -- 2 150 15 1 1 None 3 3 425 5 2 2 Mild 2 4 600 6 3 2 Moderate 4 5 435 5 2 0 None -- 6 956 20 3 3 Moderate 1 7 425 0 3 0 None Dead 8 235 20 2 -- Mild Dead Dash indicates not recorded or unobtainableDisclosures B. Cristiano: None. K. Cicilioni: None. M. Pond: None. J. Lee: None. P. Promod: None. U. Oyoyo: None. J. Jacobson: None.

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