bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP24: Symptomatic hemorrhage after thrombolysis: results from the Alteplase compared to Tenecteplase in patients with acute ischemic stroke trial
Authors: Kuczynski Andrea , Sujanthan Sajeevan , Singh Nishita , Scales Damon , Adhikari Neill , Gladstone David , Poppe Alexandre , Demchuk Andrew , Menon Bijoy , Almekhlafi Mohammed , Swartz Richard
Published: January 2025

Introduction:
Because of the risk of infarcted tissue leading to symptomatic intracerebral hemorrhage (sICH) after intravenous thrombolysis for acute ischemic stroke, patients are monitored for at least 24 hours in a critical care setting. We aim to assess incidence and risk factors of sICH following thrombolysis for acute ischemic stroke. We hypothesize that the incidence of sICH is higher in patients with older age, longer symptom onset-to-needle (OTN), greater stroke severity, and lower baseline ASPECTS score.

Methods:
Adults ≥18 years with acute ischemic stroke were randomized into the AcT trial to receive either intravenous TNK or tPA between December 2019 to January 2022 in 22 stroke centres in Canada. Patient demographics, stroke details, hemorrhagic complications (ICH, parenchymal hematoma, hemorrhagic infarct), and duration of hospital stay were collected. ANOVA and Chi-square tests compared demographic and clinical details across three groups: sICH, asymptomatic ICH (aICH), and no ICH (nICH). We developed logistic regression models to predict sICH and any ICH accounting for age, sex, pre-treatment NIHSS, OTN, baseline ASPECTS, and thrombolytic agent.

Preliminary Results:
A total of 1556 participants were identified (sICH=51, aICH=261, nICH=1244). Mean age (72.02±14.2 years; p=0.11) and sex (48% female, p=0.13) were comparable between the groups. Mean pre-treatment NIHSS was highest in the sICH group (sICH 14.41±8.5, aICH 13.48±7.0, nICH 1055±6.6; p<0.001). Mean OTN was comparable across groups (sICH 141.90±62.6 min, aICH 142.65±65.1 min, nICH 144.46±69.5 min; p=0.90). Median ASPECTS was lower in the sICH group (sICH 8.00±1.7, aICH 9.00±1.6, nICH 9.00±1.4; p<0.001). There were higher odds of sICH with lower ASPECTS score (OR 0.81, 95% CI [0.66, 1], p=0.054). The risk of any intracranial hemorrhage was lower with higher ASPECTS score (OR 0.82, 95% CI [0.74, 0.91], p<0.001) and higher with worse NIHSS (OR 1.04, 95% CI [1.01, 1.06], p<0.01). Age, sex, OTN, and type of thrombolysis had no association with intracranial hemorrhage (Figure 1).

Conclusions:
The risk of intracranial bleeding is greater when the infarct is more established and in patients with higher pre-treatment neurological deficit. Future analyses will seek to identify predictors of time to symptomatic bleeding, and to understand whether 24-hour ICU monitoring is needed for every recipient of thrombolysis.
Abstract WP240: Prior Antiplatelet Therapy Improves Functional Outcomes in Acute Ischemic Stroke Patients Undergoing Direct Mechanical Thrombectomy
Authors: Benci Zeno , Frediani Luca , Bianco Giovanni , Wegener Susanne , Seiffge David , Gralla Jan , Katan Mira , Psychogios Marios , Pileggi Marco , De Marchis Gian Marco , Leker Ronen , Curtze Sami , Marto Joao Pedro , Zini Andrea , Padjen Visnja , pezzini alessandro , Engelter Stefan , Nederkoorn Paul , Gensicke Henrik , Noseda Roberta , cereda carlo
Published: January 2025

Introduction:
In patients with large vessel occlusion stroke of the anterior circulation who are treated with mechanical thrombectomy (MT) and intravenous thrombolysis (IVT), there is no clear evidence that prior antiplatelet therapy (APT) significantly influences functional outcomes, successful reperfusion rates or the risk of symptomatic intracranial hemorrhage (sICH). Even less studied is the effect of APT - especially dual APT - on the outcomes of direct MT, when IVT is not administered. We therefore aimed to evaluate the effects of prior APT on the outcomes of direct MT.

Methods:
We analyzed patients from the multicentric international EVA-TRISP database (from 2015 to 2023), comparing outcomes of direct MT based on their previous APT regimen, using propensity score matching and multivariable models to address for confounders. The primary efficacy outcome was a shift in the modified Rankin Scale (mRS) at 90 days. Secondary efficacy outcomes included independence at 90 days (mRS 0-2) and the rate of successful reperfusion (expanded treatment in cerebral infarction ≥2B). The primary safety outcome was the rate of sICH according to the European Cooperative Acute Stroke Study criteria.

Results:
Out of 4’444 patients, 1’308 were matched successfully: 480 without APT, 764 on single antiplatelet therapy (SAPT), and 64 on dual antiplatelet therapy (DAPT). SAPT was significantly associated with a shift towards lower mRS scores at 90 days (aOR = 1.29, CI: 1.03 - 1.60). In contrast, we couldn’t confirm the same finding for the DAPT group (aOR = 1.54, CI: 0.93 - 2.57). Nevertheless, independence at 90 days was significantly associated with both SAPT (aOR = 1.56, CI: 1.16 - 2.09) and DAPT (aOR = 3.13, CI: 1.63 - 6.00). Successful reperfusion was not influenced by either SAPT (aOR = 0.90, CI: 0.66 - 1.25) or DAPT (aOR = 0.63, CI: 0.28 - 1.39). Lastly, we did not find any significant association between APT and sICH, in either the SAPT (aOR 0.71, CI: 0.41 - 1.23) or DAPT group (aOR 0.42, CI: 0.09 - 1.92).

Conclusion:
We have found that in patients with large vessel occlusion stroke of the anterior circulation treated with direct MT, SAPT was significantly associated with better functional outcomes at 90 days compared with no previous APT, and that both SAPT and DAPT were safely associated with patient's functional independence at 90 days. These results should be confirmed in a larger randomized controlled trial.
Abstract WP246: Predictors And Outcomes Of Excellent Recanalization Versus Successful Recanalization After Thrombectomy In Proximal And Distal Medium Vessel Occlusion Strokes: A Multinational Study
Authors: Salim Hamza , Koneru Manisha , Pulli Benjamin , Abushehab Nimer , Lakhani Dhairya , Musmar Basel , Faizy Tobias , Heit Jeremy , Wintermark Max , Guenego Adrien , Dmytriw Adam , Yedavalli Vivek
Published: January 2025

Introduction:
Acute ischemic stroke (AIS) arising from Medium vessel occlusions (MeVO) poses substantial challenges in treatment and management. This study aims to elucidate the outcomes and factors contributing to achieving excellent recanalization (mTICI 2c-3) versus successful recanalization (mTICI 2b) in MeVO stroke patients undergoing mechanical thrombectomy (MT).

Methods:
We conducted a multinational study analyzing data from the MAD-MT registry, encompassing 37 centers across North America, Asia, and Europe, collected between September 2017 and July 2023. The study included AIS patients with MeVO treated with MT, with or without intravenous thrombolysis (IVT), who achieved mTICI 2b-3 post-MT.

Results:
Among 1,463 patients with successful recanalization (mTICI 2b-3), 523 achieved mTICI 2b recanalization, and 940 achieved mTICI 2c-3. Distal occlusions exhibited higher odds of excellent recanalization compared to proximal MeVO vessel occlusions (OR, 1.58; 95% CI, 1.17-2.15; p=0.003). Cardioembolic stroke etiology was associated with a higher likelihood of excellent recanalization (1.67; 95% CI, 1.07-2.59; p=0.018). Patients achieving mTICI 2c-3 recanalization demonstrated lower initial NIHSS scores, significant improvements in post-procedural NIHSS shift, and a higher percentage of favorable 90-day outcomes compared to those with mTICI 2b. However, no significant difference in 90-day mortality rates was observed.

Conclusion:
This study underscores that among MeVO stroke patients with successful recanalization (mTICI 2b-3) there is higher likelihood of achieving excellent recanalization (mTICI 2c-3) in distal occlusions and cardioembolic etiology. mTICI 2c-3 scores post-MT correlate with improved clinical outcomes compared to mTICI 2b, affirming the superiority of excellent recanalization over successful recanalization in MeVO stroke patients. Further prospective studies and randomized controlled trials are warranted for validation.
Abstract WP253: A Multicenter, Prospective, Randomized Controlled Trial of Endovascular Treatment with or without Intravenous ThromBolysis in Acute Ischemic Stroke of Basilar Artery Occlusion (BEST-BAO): Study Protocol
Authors: Xiang Yang , Siddiqui Adnan , Yang Shu , Mocco J , Yu Nengwei , Schonewille Wouter , Guo Fuqiang
Published: January 2025

Background and Aims:
Endovascular treatment (EVT) alone has been confirmed to be non-inferior to intravenous thrombolysis (IVT) followed with EVT in acute ischemic stroke (AIS) due to large-vessel occlusion of the anterior circulation. This trial aims to investigate the efficacy and safety of EVT with or without IVT in AIS due to basilar artery occlusion (BAO).

Methods and Design:
The BEST-BAO trial is an investigator-initiated, multicenter, prospective, randomized controlled design. Three hundred and forty eligible patients from planned 115 stroke centers in China with AIS of BAO within 4.5 hours after symptom onset will be randomly assigned in a 1:1 ratio to undergo EVT alone (EVT group) or EVT preceded by IVT (IVT+EVT group; intravenous alteplase, 0.9 mg/kg of body weight, 10% administered as a bolus, followed by a 1-hour infusion of the remaining dose). EVT consists of mechanical thrombectomy, thromboaspiration, balloon dilation, stenting, intra-arterial thrombolysis, or various combinations of these methods. The selection of techniques is left to the discretion of the treating neurointerventionist.

Outcomes:
The primary outcome is the proportion of a good functional status, which is defined as a modified Rankin Scale (mRS) score of 0 to 2 on day 90 after stroke onset. Secondary outcomes include, but are not limited to, the distribution across mRS score categories on day 90, the proportion of patients with an mRS score of 0 to 3 on day 90, the proportion of successful reperfusion on end-of-procedure catheter angiography (modified thrombolysis in cerebral infarction 2b to 3), and vessel revascularization determined by CTA, DSA, or MRA within 24 to 72 hours. Safety outcomes include, but are not limited to, all-cause mortality within 90 days, symptomatic intracranial hemorrhage within 72 hours, and severe adverse events within 90 days.

Discussion:
The BEST-BAO trial may redefine current clinical approaches by determining whether EVT alone is sufficient or if adding IVT confers additional benefits. While EVT alone has been shown to be beneficial in anterior circulation strokes, AIS due to BAO requires a focused investigation owing to unique pathophysiological characteristics.

Trial registration:
NCT05631847 (ClinicalTrials.gov) and ChiCTR2300070584 (Chinese Clinical Trial Registry,
https://www.chictr.org.cn)
.
Abstract WP256: Cognitive Outcomes in Acute Ischemic Stroke with Large Vessel Occlusion After Treatment with Endovascular Thrombectomy with and without Intravenous Thrombolysis
Authors: San Ali , Sanchez-Crawford Cesar , Panico Nicholas , Hunt Suzanne , Yoksh Lauren , Mahnken Jonathan , Abraham Michael , Slavin Sabreena
Published: January 2025

Introduction:
In acute stroke patients who receive revascularization with endovascular thrombectomy (EVT) alone vs intravenous thrombolysis (IVT) followed by EVT, combination treatment has shown improved outcomes measured by the modified Rankin Scale (mRS). However, neurocognitive outcomes beyond functional disability have not been sufficiently assessed.

Hypothesis:
We hypothesize that neurocognitive outcomes will be improved with IVT + EVT compared to EVT alone.

Methods:
This prospective ongoing longitudinal study included patients with a first-ever ischemic stroke with large vessel occlusions admitted to our comprehensive stroke center who received EVT only vs IVT + EVT. Blinded investigators administered the Montreal Cognitive Assessment (MoCA) during the hospital stay. A linear model was used to estimate the difference in MoCA scores between the two treatment groups while adjusting for age, NIHSS obtained within 24 hours of MoCA, and pre-stroke mRS. A visual inspection of residuals was performed to check model assumptions. Box plots were utilized to compare MoCA differences across treatment groups, NIHSS scores, and stroke laterality.

Results:
50 participants had a mean age of 66.7 years (64% male). The mean post treatment NIHSS was 3.6, and the mean MoCA score was 20.5. The adjusted difference in MoCA scores between the treatment groups (IVT + EVT vs EVT only) was 0.83 points (95% CI –2.4 - 4.0), indicating no statistically significant difference. Higher NIHSS showed a trend toward negative association with MoCA scores, –0.41 (CI –0.90 - 0.07). For right sided strokes, there was minimal difference between treatment groups. However, for left sided strokes, there was a trend towards improved mean MoCA in the IVT + EVT group (20.3; CI 20.0 - 26.0) compared to EVT only (17.0; CI 15.0 - 21.0). The TICI revascularization score of 2c had the highest mean MoCA (22.1; CI 19.4 - 24.8), followed by TICI score of 3 (20.7; CI 18.9 - 22.7) and then 2b (16.6; CI 9.0 - 24.1).

Conclusion:
There was no significant difference of MoCA with combination treatment vs EVT alone, but there was a trend showing improvement in combination treatment for left-sided strokes. There was also a trend showing decreased MoCA with higher NIHSS. We are currently assessing neurocognitive outcomes with a larger sample size post treatment and at 6 months post-stroke.
Abstract WP257: Persistent Racial Disparity Despite Higher Income in Odds of Receiving Mechanical Thrombectomy and Thrombolysis for Acute Ischemic Stroke Admissions 2006-2021
Authors: Chintaluru Yaswanth , Promruksa Jasmine , Atchaneeyasakul Kunakorn , Liebeskind David , Otite Fadar , Stroke Network ALLOfUS
Published: January 2025

Background:
Non-Hispanic Black (NHB) and other minority patients in the United States (US) receive intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) less frequently compared with non-Hispanic White (NHW) patients during acute ischemic stroke (AIS) admission. It remains uncertain how the interaction between race and the income category of patients influences treatment and outcome.

Methods:
We identified all primary AIS hospitalizations in the 2006-2021 National Inpatient Sample (NIS) receiving IVT and MT using International Classification of Diseases (ICD) codes. Admissions were categorized into income quartiles (Q1-Q4) using the median household income of the patient’s zip code. Multivariable logistic regression models adjusted for age, sex, clinical and hospitalization factors were used to compare odds of IVT, MT, in-hospital mortality and good outcome (defined as routine home discharge) between race and income groups.

Results:
Of 7,476,163 weighted AIS hospitalizations from 2006-2021, 31.1% were in the lowest (Q1) and 19.4% in the highest (Q4) income quartile. 9.3 % of admissions received IVT and 2.7% received MT across the study period. Utilization of both procedures increased in all income groups over time but usage was persistently lower in Q1 admissions compared to Q4 (figure 1). In multivariable-adjusted models restricted to 2015-2021, all minority racial groups including NHB admissions had lower odds of IVT (OR 0.74, 95%CI 0.72-0.76) and MT (OR 0.74, 95%CI 0.71-0.77) vs NHW. Q1, Q2 and Q3 admissions had lower odds of IVT compared to Q4 and Q1 admissions had lower MT odds (OR 0.92, 95%CI 0.90-0.95) vs Q4. Further stratification by income and race, showed that IVT and MT odds increased with income for NHW admissions but notably all quartiles of NHB admissions including Q4 had up to 20% lower odds of IVT and MT compared to Q1 of NHW admissions (Figures 2a and 2c). Among NHB and NHW admissions, odd of in-hospital mortality was significantly lower in Q4 vs Q1, while odds of good outcome was greater in Q4 vs Q1 income categories, but these differences were not consistently seen in Hispanic and Asian hospitalizations (Figure 3).

Conclusion:
Racial disparities in IVT and MT use in the US is not explained by income alone. NHB individuals in all income categories receive IVT and MT at rates less than the lowest income category of NHW individuals. Q1 admissions have higher mortality and lower odds of good outcome compared to Q4 admissions.
Abstract WP259: Endovascular Treatment vs. Best Medical Management for Late Window Ischemic Stroke Patients with Large Vessel Occlusion
Authors: Zerna Charlotte , Ospel Johanna , Harrison Emma , Kleinig Timothy , Puetz Volker , Kaiser Daniel , Graham Brett , Yu Amy Y. X. , Van Adel Brian , Shankar Jai , McTaggart Ryan , Mendes Pereira Vitor , Frei Donald , Goyal Mayank , Hill Michael
Published: January 2025

Background and Purpose:
To compare the benefit of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) presenting >6 hours from last known well outside a clinical trial setting to best medical management and to EVT in a randomized trial setting.

Methods:
Data from a retrospective multicenter cohort study (ESCAPE LATE) of AIS-LVO patients treated with EVT beyond 6 hours from last known well at former ESCAPE trial sites were pooled with historical data from ESCAPE trial late time window patients. Unadjusted and adjusted 90-day modified Rankin score was compared between ESCAPE LATE patients, ESCAPE late time window EVT arm and control arm patients.

Results:
A total of 249 patients were included in the analysis: 200 ESCAPE LATE patients (for 141 of whom 90-day clinical outcomes were available) and 49 ESCAPE patients, for all of whom clinical outcome data were available (control arm: 20 and EVT arm: 29). Good clinical outcome (modified Rankin Score 0-2 at 90 days) was nominally, albeit not significantly, lower in patients not treated with EVT (5/19[26.3%]) as compared to ESCAPE EVT arm patients (13/29[44.8%] and ESCAPE-LATE patients (66/141[46.8%]). After adjustment, a graded mRS pattern was seen, whereby patients treated with EVT did better as compared to non-treated patients, and those who underwent EVT in the ESCAPE trial had better mRS as compared to those included in ESCAPE-LATE who underwent EVT in clinical routine.

Conclusion:
Patients presenting beyond 6 hours from last known well who are treated with EVT in a real-world setting show comparable benefit to patients treated in a clinical trial setting.
Abstract WP262: Prediction of Final Ischemic Infarct Volume Via Virtual Noncontrast Imaging After Stroke Thrombectomy
Authors: Dammavalam Vikalpa , Chong Ji , Santarelli Justin , Al-Mufti Fawaz , Gandhi Chirag , Gurmeen Kaur
Published: January 2025

Introduction:
Early prediction of final infarct volume is a vital component of clinical recovery. Ischemic infarct volume is an independent predictor of stroke prognosis with larger volumes nonlinearly correlating to worse outcomes. Virtual non contrast imaging (VNC) is a dual-energy computed tomography head (CTH) utilized in differentiating post-thrombectomy contrast staining from hemorrhage due to reperfusion injury. Studies show VNC improves visualization of early infarcts and can be a reliable predictor of final infarct volume. This study investigates difference between initial VNC infarct and final CTH infarct volumes as well as association with modified Rankin Scale (mRS).

Methods:
This is a retrospective, observational, single-center study of 14 patients who underwent mechanical thrombectomy for acute ischemic stroke between January 2023 and August 2024. Inclusion and exclusion criteria and exclusion flowchart are listed in Figure 1 and 2, respectively. Demographics, National Institute of Health Stroke Scale (NIHSS) and mRS data were extracted from the electronic medical record. Infarct volumes on initial VNC and final CTH were measured using the ABC/2 or ABC/3 formula for ellipsoid or irregular infarcts, respectively. Statistical analysis was conducted with a paired t-test (p-value <0.05) to compare matched volume differences.

Results:
Patient sample was 50% male and 50% female. Age ranged from 45 to 94 years old with a mean of 71. Mean and median initial NIHSS was 19 with a range 4 to 29. Mean discharge NIHSS was 21. VNC underestimated final infarct volume by a mean difference of 4.68 milliliters in a full sample analysis. This mean difference was statistically significant (p-value 0.038) indicating VNC volume may not reliably predict the final infarct volume in the full sample. However, analysis without outliers yielded a statistically insignificant difference (p-value 0.3102) indicating VNC volume may be a reliable predictor in smaller infarcts. Figure 3 depicts increasing infarct volumes on VNC or final CTH trended towards worse mRS indicating VNC may have a role in prognostication.

Conclusion:
VNC may be a predictor of final infarct volume in patients with small infarct sizes with minimum cerebral edema. Limitations of this study include small sample size and cerebral edema as a confounder in large infarct volume measurements. Further studies correlating VNC infarct with final MRI infarct volume and functional outcome are needed.
Abstract WP265: Stroke Subtypes Drive Distinct Neurological, Cognitive, and Mortality Outcomes in UK Biobank Cohort
Authors: Grover Ambika , Patel Chirag
Published: January 2025

Although the pathophysiological differences between stroke subtypes are well-documented, much remains to be understood about how these variations contribute to long-term neurological and cognitive complications. In a UK Biobank cohort study of ~14,000 individuals with prior history of stroke, we investigated subtypes of stroke based on encoded ICD-10 categories of acute ischemic stroke (AIS), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and other nontraumatic intracranial hemorrhage (ONIH).

We computed the absolute risks of neurological complications, including mortality, dementia, and parkinsonism, in post-stroke patients. We assessed post-stroke cognitive outcomes via cognitive testing data administered on touchscreens at UKB sites. Adjusted for age and lifestyle factors, cognitive scores were compared with the no-stroke UKB population (n=500k) using ANOVA and Tukey tests. Further, we investigated the relationship between UKB image-derived phenotypes and stroke subtypes, including gray and white matter and white matter hyperintensities (WMH). We used a Cox Proportional Hazards (PH) model to calculate the mortality risk hazard ratios (HR) by stroke type.

In the post-stroke follow-up period, individuals with ONIH, followed by individuals with ICH, had the highest absolute risk of developing dementia (6.02% 95%CI: [5.99%, 6.7%]). Patients with ONIH have nearly double the risk (2.97%; 95 CI:[2.96,3.01]) of parkinsonism compared to AIS and ICH patients. In cognitive testing, AIS patients had worse cognitive scores relative to those without stroke. Cognitive reaction times were consistently longer, with ICH and AIS patients showing the largest delays, followed by SAH patients. ICH patients had white matter hyperintensities 6 SD above the no-stroke population, while AIS patients are 4 SD above the no-stroke population. ICH had the highest HR and absolute risk death (HR 3.12 95% CI: [3.00, 3.24], abs. risk 45.03%), followed closely by ONIH (HR 2.94, 95% CI:[2.78, 3.11], abs. risk 35.96%) and SAH (HR 2.89, 95% CI: [2.75, 3.07], abs. risk 19.34%). Cox PH values for AIS were lower than the nearest hemorrhagic type (HR 1.90 95%CI:[1.77,1.85], abs. risk 25.88%). When examining the role of age, sex, and clinical factors in stroke prediction, age was prominently featured, while other factors were heterogeneous. Our findings highlight outcome-level stroke heterogeneity and suggest treatment design and clinical surveillance tailored to stroke subtype.
Abstract WP274: Infection and adult ischemic stroke: a polygenic risk score analysis
Authors: Morath Hope , Gaynor Brady , Fullerton Heather , Mitchell Braxton , Kittner Steven
Published: January 2025

Objective:
To evaluate whether genetic overlap exists between infection and adult ischemic stroke (IS).

Background:
Infection has long been recognized as a risk factor for stroke, but the underlying mechanism remains unknown and little work has been done to investigate the genetic underpinnings of this relationship.

Design/Methods:
We analyzed associations between adult IS and a polygenic risk score (PRS) for childhood ear infections using 6,728 cases from the Early Onset Stroke Consortium and 9,272 cases from the Stroke Genetics Network, for a combined sample size of 16,000 cases and 33,774 controls. This infection type was selected because it showed the greatest number of genome-wide significant associations out of the 32 common infections examined in a previously published GWAS. We then investigated whether this PRS was more strongly associated with cases who had a recent infection. Using data from the Early Onset Stroke study, we compared the association of the PRS between 33 cases with a history of infection in the 2 weeks preceding IS and 357 cases without a preceding infection.

Results:
PRS for childhood ear infections was significantly associated with IS (odds ratio 1.028, P=0.0055). PRS for childhood ear infections showed a stronger association with IS in cases who had a preceding infection (odds ratio 1.482, P=0.024) compared to cases without a preceding infection (odds ratio=1.027, P=0.619) (P for interaction=0.049).

Conclusion:
The novel finding of our study is the existence of genetic overlap between childhood ear infections and adult IS and that this genetic overlap is stronger in cases with a recent infection. This suggests that the association between the PRS for childhood infection and adult IS is mediated by an increased risk of adult infection. Our study was limited in its sample size to evaluate for IS subtypes. Continued investigation of the potential mechanisms of the infection-stroke relationship is warranted.

Study Supported By:
U18NS115388, R01NS100178, and R01NS105150.

Disclosures:
None.
Abstract WP275: Temporal Trends in the Incidence, Mortality, and Disability-Adjusted Life Years of Ischemic Stroke in the Middle East Over 3 Decades
Authors: Abdulelah Ahmed , AlQirem Lina , Al-Husni Dua' , Sultan Hala , Abdulelah Zaid
Published: January 2025

Introduction:
Ischemic stroke is among the leading global health burdens due to the significant resultant morbidity and mortality. Therefore, the assessment of the temporal trends in the burden of ischemic stroke is of substantial importance in risk stratification and public health policy formation, particularly in regions with limited resources such as the Middle East.

Methods:
Data, including age-standardized rates per 100,000 persons, regarding the incidence, mortality, and disability-adjusted life years (DALYs) of ischemic stroke in the Middle East for the period 1990-2019 was retrieved from the Global Burden of Disease database to evaluate the burden of ischemic stroke in the region. Joinpoint Analysis software was utilized to calculate the Annual Percent Change (APC) and Average Annual Percent Change (AAPC) to determine the temporal trends in the incidence, mortality, and DALYs.

Results:
Over the span of 3 decades, an estimated total of 2,776,802 ischemic stroke-related mortalities with an approximately 1:1 male to female ratio were reported in the Middle East. Overall, there was a statistically significant decline in age-standardized mortality rate for all the Middle Eastern nations except for the United Arab Emirates where a statistically insignificant increase in ischemic stroke-related mortality was noted with an AAPC of 0.29 (95%CI -0.48 to 1.01; p=0.47). Qatar witnessed the most significant decrement in age-standardized mortality rate with an AAPC of -3.60 (95CI% -3.91 to 3.28; p<0.0001), followed by Lebanon with an AAPC of -3.34 (95CI% -3.43 to -3.26; p<0.0001). In terms of age-standardized incidence rate, a general decline was noted in the majority of the nations, with the most prominent decline identified in Qatar with AAPC of -1.34 (95%CI -1.38 to -1.30; p<0.0001). However, Yemen has witnessed a statistically significant incline in age-standardized incidence rate with an AAPC of 0.041 (95CI% 0.036 to 0.047; p<0.0001). A total of 61,391,636 DALYs were attributed to ischemic stroke in the Middle East over 30 years. Analysis of the age-standardized DALY rate revealed a statistically significant decline in all reported nations, with the most significant decline reported in Qatar with an AAPC of -3.28 (95%CI -3.55 to -3.00; p<0.0001).

Conclusion:
In conclusion, the Middle East witnessed a significant decline in the age-standardized incidence, mortality and DALYs rate across the vast majority of the countries over a span of 30 years.
Abstract WP276: Association Between Vertebral Artery Hypoplasia and Atherosclerotic Stenosis of Subclavian Artery, Vertebral Artery and Basilar Artery: An Observational Cohort Study
Authors: Zhang Zhao , Luo Anling , Yang Yujia , Li Xuzi , Deng Yiting , He Li , Zhou Muke
Published: January 2025

Background and Objectives:
Vertebral artery hypoplasia (VAH) is a common anatomical variation. We aimed to investigate the association between VAH and atherosclerotic stenosis of subclavian artery (SA), vertebral artery (VA) and basilar artery (BA) based on digital subtraction angiography (DSA).

Methods:
In this observational registry study, we reviewed patients from our comprehensive stroke center who underwent DSA from January 2013 to December 2023. Patients (age ≥ 18 years) with clinical manifestations of arterial disease or risk factors for atherosclerosis were included and classified into the VAH and non-VAH group. VAH and stenosis degree of the artery (i.e., SA, VA and BA) were determined by DSA. To investigate the association between VAH and the occurrence of above artery stenosis, a 1:2 ratio propensity score matching (PSM) and logistic regression analysis were performed. Additionally, we further conducted subgroup analysis.

Results:
In present study, a total of 8,445 patients (mean [SD] age, 57.8 [14.4] years; 5,860 [69.4%] male and 2,585 [30.6%] female) were included. VAH was found in 1,683 of 8,445 patients (19.9%). After PSM, the presence of VAH was associated with frequency of contralateral subclavian artery stenosis (SAS) (left VAH: odd ratio [OR] 0.42, 95% confidence interval [CI] 0.25-0.68,
p
= 0.001; right VAH: OR 0.43, 95% CI 0.32-0.57,
p <
0.001), contralateral vertebral artery stenosis (VAS) (left VAH: OR 1.84, 95% CI 1.52-2.23,
p
= 0.002; right VAH: OR 1.56, 95% CI 1.32-1.84,
p
< 0.001) and basilar artery stenosis (BAS) (left VAH: OR 2.94, 95% CI 2.15-4.04,
p
< 0.001; right VAH: OR 2.51, 95% CI 1.91-3.31,
p
< 0.001). In the subgroup analysis, the association remained significant (Figure 1).

Conclusion:
VAH was associated with lower frequency of contralateral SAS and high frequency of contralateral VAS and BAS，highlighting the role of anatomical factors in the development of atherosclerotic lesions. VAH as an anatomical parameter, with its inherent associated hemodynamic consequences analyzed in future research, may be an important factor in predicting the risk of BAS, SAS and VAS contralateral to VAH.
Abstract WP277: The risk and predictors of stroke recurrence in acute ischemic stroke patients with symptomatic vertebral artery steno-occlusion
Authors: Kim Do Yeon , Kim Jonguk , LEE JEONGYOON , Kim Nakhoon , Guk Hyung Seok , Kang Minkyung , Kim Jun Yup , Kang Jihoon , Kim Beom Joon , Han Moon , Bae Hee-Joon
Published: January 2025

Introduction:
Current guidelines solely recommend optimal medical therapy including antiplatelet, lipid lowering, and antihypertensive treatment due to the unclear efficacy of stenting and endarterectomy for symptomatic vertebral artery (VA) stenosis. However, the incidence of recurrent ischemic stroke(RIS) in symptomatic VA steno-occlusion under optimal medical therapy in the real-world settings is not well established. This study aims to assess the incidence of RIS and identify high-risk populations who might benefit from additional interventions among patients with symptomatic VA steno-occlusion.

Methods:
This retrospective study enrolled acute ischemic stroke and TIA patients from a single comprehensive stroke center between 2011 and 2022. The cumulative incidences of RIS were evaluated in patients with symptomatic VA steno-occlusion (>50% stenosis or occlusion). Outcomes were compared between patients with symptomatic VA stenosis (51-99%) and occlusion. A multivariable Cox proportional hazard model was used to assess the risk of RIS, adjusting demographics, vascular risk factors, discharge treatment, stroke severity and hyperacute treatments. Additionally, the predictors for RIS were separately analyzed in symptomatic VA stenosis and occlusion subgroups.

Results:
Among 11,884 patients with acute ischemic stroke and TIA, 928 (7.8%) had symptomatic VA steno-occlusion. The mean age was 62.7 (± 14.4) years, with a male predominance (72.6%). Most patients prescribed antiplatelets (92.5%) and statins (92.8%) at discharge. EVT and angioplasty were performed in 34 (3.7%) and 29 (3.1%), respectively. The cumulative incidence of RIS in symptomatic VA steno-occlusion was 13.6% (95% CI 11.5-16.0%) at 1 year. The incidence in 517 patients with symptomatic VA stenosis (12.6% [95% CI 10.1-15.7%]) and 14.9% (95% CI 11.6-18.9%) in 386 patients with occlusion, showing similar results (Img 1). In multivariable analysis, age (HR 1.02, 95% CI 1.00-1.03, p=0.022) and endovascular treatment (EVT) (HR 2.68, 95% CI 1.36-5.28, p=0.004) increased the risk of RIS (Img 2). Age and initial NIHSS score increased the risk of RIS in symptomatic VA stenosis subgroup, while EVT increased the risk in symptomatic VA occlusion subgroup (Img 3).

Conclusion:
Despite most patients with symptomatic VA steno-occlusion receiving medical treatment, the risk of RIS remains significant. Additional intervention might be considered, particularly for VA stenosis in elderly and VA occlusion in post-EVT patients.
Abstract WP279: Predicting Stroke in Patients with Infective Endocarditis: A Comprehensive Systematic Review and Meta-Analysis of Risk Factors
Authors: Jumah Ammar , Mohamedelkhair Ahmed , Elfaham Abdelrahman , Batista Savio , Ma Tianwen , Ngo Savannah , Mohn Dennis , Vismara Thomas , Reardon Taylor , Chughtai Fatima , Silva Sanchez Gustavo Jose , Vilardo Marina , Camerotte Raphael , Ramadan Ahmad Riad
Published: January 2025

Introduction:
Neurological complications in patients with infective endocarditis (IE), such as ischemic and hemorrhagic stroke, are well-described, serious complications of IE; however, predicting which patients are most likely to experience stroke remains uncertain. The objective of this systematic review was to identify the factors associated with risk of stroke in patients hospitalized with IE.

Methods:
A systematic search of Ovid MEDLINE, EMBASE, and Web of Science was conducted between January 1990 and to July 2024. Articles evaluating risk of acute ischemic stroke (AIS) and/or intracranial hemorrhage (ICH) in patients with IE were included. Meta-analysis was feasible for only some predictive factors due to study heterogeneity. (PROSPERO protocol CRD42024571058).

Results:
Of 3558 studies identified, 35 were included: The review included 9 prospective and 26 retrospective cohort studies.
Staphylococcus aureus
infection (odds ratio, 3.05 [95% CI, 1.96-4.73]; I
2
=77.2%; 9 studies) and 1 mm longer in vegetation size, on average (odds ratio, 1.26 [95% CI, 1.02-1.55]; I
2
=90.1%; 3 studies) were associated with a higher risk of AIS, adjusting for other covariates. Due to high heterogeneity among the studies, a meta-analysis was not feasible for the other predictive factors. High intensity signals on transcranial doppler, and comorbidities such as hypertension, atrial fibrillation, and hyperlipidemia were also found to have a higher risk of AIS. Risk of ICH was heightened by thrombocytopenia, mycotic aneurysms, prior ICH and/or AIS, and cerebral microbleeds.

Conclusion:
Physicians need to monitor numerous, diverse features of patients hospitalized with IE to mitigate the risk of ensuing stroke. While the causative microorganism, echocardiographic and neuroimaging findings may be particularly informative, underlying comorbidities and various laboratory values may also contribute to predicting IE-associated ischemic and hemorrhagic stroke.
Abstract WP282: Effectiveness and safety of apixaban vs. aspirin for primary prevention of stroke and bleeding risk among patients with atrial fibrillation: A Meta-analysis of randomized controlled trials including ARTESIA trial.
Authors: Jaiswal Vikash , Savaliya Mittal , Shama Nishat , Jaiswal Akash , Munnangi Pragathi , Mashkoor Yusra , Zulfiqar Aayet , Rajak Kripa , Halder Anupam , Ang Song Peng , Younas Ayesha , Hanif Muhammad , Biswas Monodeep
Published: January 2025

Background:
Atrial fibrillation is a common arrhythmia that increases the risk of stroke. However, treatment of such patients with oral anticoagulants when compared with aspirin is not well established with uncertain benefits.

Objective:
We analyzed available study level data comparing Apixaban and Aspirin for efficacy and safety among atrial fibrillation patients.

Methods:
We performed a systematic literature search on PubMed, EMBASE, and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) from inspection until August 10th, 2024, without any language restrictions. Odds ratios (OR) and 95% confidence intervals (CI) were pooled using a random-effect model, and a p-value of <0.05 was considered statistically significant.

Results:
A total of 3 RCTs with 14,224 patients were included (7,129 in apixaban and 7095 in the aspirin group) in the analysis. The mean age of the patients in apixaban and the aspirin groups was 72.4 and 72.8 years, respectively. Pooled analysis of primary and secondary endpoints showed that apixaban significantly reduced the risk of stroke or systemic embolism by 47% (OR, 0.53(95%CI: 0.38-0.75), P<0.001), stroke by 44% (OR, 0.56(95%CI: 0.44-0.70), P<0.001), and ischemic stroke by 51% (OR, 0.49(95%CI: 0.29-0.81), P=0.01) when compared with aspirin. However, the risk of major bleeding (OR, 1.03(95%CI: 0.69-1.53), P=0.88), myocardial infarction (OR, 0.97(95%CI: 0.76-1.23), P=0.78), and all-cause mortality (OR, 0.97(95%CI: 0.80-1.17), P=0.72) was comparable when compared with the aspirin group of patients.

Conclusion:
In this comprehensive analysis of randomized controlled trials data, the use of apixaban was associated with reduction in stroke or systemic embolism, and ischemic stroke, when compared with aspirin therapy. Major bleeding risk, and all cause mortality was comparable between both groups of patients.
Abstract WP285: Lifelong trends in vascular risk factors and cerebral small vessel disease
Authors: Pinheiro Adlin , Mohammed Shariq , Ekenze Oluchi , Aparicio Hugo , Charidimou Antreas , Lioutas Vasileios , Beiser Alexa , DeCarli Charles , Seshadri Sudha , Demissie Serkalem , Romero Jose
Published: January 2025

Introduction:
Cerebral small vessel disease (CSVD) is linked to stroke and dementia risk, often predating clinical events for years to decades. While preventive strategies focus on treatment of modifiable vascular risk factors (VRF), the complex evolution in these VRF over long periods and their association with CSVD burden are not fully understood.

Hypothesis:
Individuals exhibit different VRF trajectories over a lifetime, and these patterns determine their CSVD burden.

Methods:
Framingham Heart Study participants with ≥6 VRF assessments over their lifetime and CSVD markers on brain MRI were included. A multi-marker CSVD score quantified CSVD burden, assigning one point each to cerebral microbleeds, covert infarcts, extensive white matter hyperintensities, cortical superficial siderosis and high burden of visible perivascular spaces (range 0-5), and was categorized for analysis as 0, 1, and ≥2. Using functional data clustering to the trajectories of each VRF, we identified and characterized participant clusters of lifetime trends. Multivariable ordinal logistic regression was employed to associate cluster assignment with multi-marker CSVD scores.

Results:
In 7961 participants with longitudinal VRF data (baseline mean age 39.8 ± 10 years, 45% men), three clusters were identified for each VRF (Figure). These clusters broadly depict groups with long-term exposure to 1) abnormal or undesirable VRF levels, 2) optimal ranges, and 3) levels between optimal and abnormal, varying by VRF. Among 1625 participants with CSVD measurements (mean age at MRI 72.8 ± 9.4 years, 45% men), CSVD score 0 was seen in 47%, 1 in 31% and ≥2 in 22%. In age, sex, and cohort adjusted analyses, VRF cluster assignment for systolic blood pressure (p<0.01), pulse pressure (p<0.01), cigarettes per day (p=0.01), and body mass index (p<0.05) were associated with multi-marker CSVD scores, with the highest risk cluster generally showing the strongest effects. For instance, compared to participants with long-term optimal systolic blood pressure, those with abnormally high levels (OR 1.70; 95% CI 0.97, 3.00) or levels between optimal and abnormal (OR 1.39; 95% CI 1.14, 1.69) had increased odds of having higher CSVD scores.

Conclusions:
Individuals exhibit different lifetime trajectories of modifiable VRF, which are associated with burden of CSVD. Preventive efforts should consider the trajectory of VRF to identify and target high risk individuals to prevent high CSVD burden and its adverse consequences.
Abstract WP290: Cardiovascular and Stroke Outcomes in Bipolar Disorder: A Secondary Analysis of the SPRINT Trial
Authors: Smith Harper , Krothapalli Neeharika , Littig Lauren , de Havenon Adam
Published: January 2025

Introduction:
Prior research has suggested that psychiatric disease, particularly bipolar disorder, may increase the risk of cardiovascular events and stroke.

Methods:
We performed a post-hoc analysis of the Systolic Blood Pressure Intervention Trial (SPRINT). The primary outcome was major adverse cardiovascular events (MACE) and the secondary outcome was stroke. The study exposure was self-reported bipolar disorder at study baseline. We fit time to event models and adjusted for potential confounders.

Results:
We included 9,148 SPRINT participants (Table 1), of which 175 (1.9%) had self-reported bipolar disorder at study baseline. During a mean of 3.7 years of follow-up, MACE events were observed in 7.7% of those without bipolar versus 12% if those with bipolar (p=0.036) (Figure 1). There were only 3 stroke events in the bipolar group, making estimations unreliable so it was discarded as an outcome. In a multivariable Cox model adjusted for demographic variables and medical comorbidities seen in Table 1, the adjusted hazard ratio of MACE associated with bipolar disorder was 2.04 (95% CI 1.31-3.17, p=0.001). When also including other psychiatric comorbidities in the model, we found that none were associated with MACE and that adjusting for them did not impact the findings (HR 1.98, 95% CI 1.24-3.16, p=0.004).

Conclusion:
SPRINT trial patients with bipolar disorder experienced a significantly greater rate of major adverse cardiovascular events compared to those without bipolar disorder. Other psychiatric comorbidities were not associated with an increased risk of MACE. However, due to limited data, it remains uncertain if stroke rates are also elevated in patients with bipolar disorder, highlighting the need for further studies to investigate this potential risk.
Abstract WP298:

R

isk

a

ssessment of Cn

m

-positiv

e

S

treptococcus mutans

in

s

trok

e

s

urvivors (RAMESSES study): A multicenter prospective cohort study
Authors: Hattori Yorito , Abe Soichiro , Hosoki Satoshi , Katayama Masateru , ONODERA Osamu , Higashida Kazuhiro , Kohara Nobuo , Saito Kozue , Aoki Shiro , Matsumoto Riki , Maki Takakuni , Tomimoto Hidekazu , Kitamura Akihiro , Yamagami Hiroshi , Mizuno Toshiki , Hosomi Naohisa , Nakazawa Shinsaku , Yamamoto Akimasa , Tonomura Shuichi , Morita Yoshiaki , Saito Satoshi , Takegami Misa , Nomura Ryota , Nakano Kazuhiko , Ihara Masafumi
Published: January 2025

Introduction:
Oral carriage of
Streptococcus mutans
(the main pathogen of dental caries), positive for
cnm
that encodes the collagen-binding protein Cnm, is associated with the development of hypertensive intracerebral hemorrhage and increase of cerebral microbleeds (CMBs) in our retrospective observational studies. Herein, we prospectively investigated a relationship between Cnm-expressing
S. mutans
and increase in CMBs in a longitudinal multicenter cohort study.

Methods:
We initiated a multicenter, prospective cohort study (RAMESSES:
R
isk
a
ssessment of Cn
m
-positiv
e

S
. mutans

in
s
trok
e
s
urvivors; UMIN Clinical Trials Registry: UMIN000045559) in November 2018 with 14 domestic institutions. We included patients who experienced stroke or transient ischemic attack that developed within the past year, and had deep intracerebral hemorrhage or at least one deep CMBs on T2* weighted brain magnetic resonance imaging. The observation period was 2 years. The primary outcome was the number of newly developed deep CMBs between patients with Cnm-positive
S. mutans
and those without. The newly developed CMBs were compared by Mann-Whitney
U
test, and the frequency of patients who newly developed CMBs was compared by chi-square test.

Results:
Out of 227 patients (138 patients with ischemic stroke, 60 patients with hemorrhagic stroke, 23 patients with ischemic and hemorrhagic stroke, 7 patients with TIA, and 2 patients with hemorrhagic stroke and TIA during the past year), the median age was 70 (interquartile range [IQR]: 62–79) years, and the number of women was 63 (27.8%). The number of patients with Cnm-positive
S. mutans
was 34 (15.0%), and that without was 133 (85.0%). Patients with Cnm-positive
S. mutans
had significantly larger number of newly developed deep CMBs over 2 years than those without (0 [IQR, 0–1] vs. 0 [0–0];
p
= 0.030), and the frequency of patients who had newly developed deep CMBs tended to be higher in patients with Cnm-positive
S. mutans
than in those without (13 [41.9%] vs. 41 [24.7%];
p
= 0.079). Regarding lobar CMBs, the number (
p
= 0.22) and frequency (
p
= 0.22) were comparable between the two groups.

Discussion:
The 2-year longitudinal prospective cohort study unveiled that Cnm-positive
S. mutans
was significantly associated with increase in CMBs, which validated our previous retrospective studies. These findings may provide guidance for novel prophylactic strategies against Cnm-positive
S. mutans
-induced CMBs and intracerebral hemorrhage.