Why are most stroke patients deemed poor candidates for intraaterial therapy? A prospective study (P4.306)

Background/Objectives: Current options for early intervention in acute ischemic stroke (AIS) include intravenous tissue plasminogen activator (IV-tPA) and/or intra-arterial (IA) therapy in eligible patients. While there are well-defined indications and contraindications for IV-tPA, similar guidelines have not emerged for IA-therapy. The resulting practice variability may partly explain why IA-therapy continues to represent only a small fraction of overall acute AIS interventions. Methods: This is a prospective single-center study of consecutive patients presenting with AIS due to large vessel occlusion involving the intracranial internal carotid artery, proximal anterior cerebral artery, or proximal middle cerebral artery. All patients underwent non-contrast computed tomography (CT) of the head, CT-angiography of the head and neck, and CT-perfusion imaging of the brain. Possible reasons for withholding IA therapy were divided into three categories: (A) clinical, (B) anatomic, and (C) radiographic. Results: Of 147 AIS patients, 34 (23.1[percnt]) met study inclusion criteria, of which only 5 (14.7[percnt]) underwent IA therapy. The remaining 29 (85.3[percnt]) were excluded from IA therapy due to clinical (58.6[percnt]), radiographic (58.6[percnt]), and/or anatomic (31[percnt]) reasons. The most common reasons for withholding IA therapy were “established core infarct too large” (41.4[percnt]); “occlusion too distal” (24.1[percnt]); “NIHSS score too low” (20.7[percnt]); and “early non-contrast CT infarction signs” (20.7[percnt]). Of the 29 patients excluded from IA therapy, 16 (55.20[percnt]) had one reason, and 13 (44.8[percnt]) had multiple reasons for being deemed poor IA candidates by the neurointerventionalist. Conclusion: The majority of patients presenting to a large tertiary referral center with AIS due to a large vessel occlusion were found to be poor IA candidates, with more than half excluded for a single reason. Such data addressing the volume and proportion of patients found ineligible for IA therapy in real-world practice can help target efforts to develop new interventional options and improve future clinical trial design. Disclosure: Dr. Damania has nothing to disclose. Dr. Noto has nothing to disclose. Dr. Kung has nothing to disclose. Dr. Liew has nothing to disclose. Dr. Finley has nothing to disclose. Dr. Mangla has nothing to disclose. Dr. Miranpuri has nothing to disclose. Dr. Sahin has nothing to disclose. Dr. Jahromi has nothing to disclose.