bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P42: Genetic Variants Associated With Vasospasm Following Aneurysmal Subarachnoid Hemorrhage
Authors: Weinsheimer Shantel M , Alexander Matthew D , Nelson Jeffrey , Cooke Daniel L , Hetts Steven W , McCulloch Charles E , Kim Helen , Ko Nerissa U
Published: March 2021

Background:
Cerebral vasospasm is a major contributor to poor clinical outcomes in intracranial aneurysm (IA) patients and is involved in delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Little is known about the genetic factors associated with vasospasm pathogenesis. We performed a genome-wide association study (GWAS) to investigate association of common genetic variants with risk of vasospasm in IA patients with SAH.

Methods:
Our Caucasian cohort of 190 aSAH patients (121 with vasospasm diagnosed by angiography) were genotyped using UK Biobank Axiom Arrays. Genotypes were called using the Best Practices Workflow in the Axiom Analysis Suite v4.0.3.3. All samples had >97% call rate, one sample was removed due to sex mismatch, and a total of 634,781 single nucleotide polymorphisms (SNPs) with >0.01 minor allele frequency were analyzed for association with vasospasm in the final cohort of 189 cases (66.7% female, mean age 54.8 years). Logistic regression analysis was performed using an additive model adjusting for age at onset of symptoms and sex. Genome-wide significance was based on Bonferroni correction for multiple testing (P< 7.9x10
-8
).

Results:
No SNPs were significantly associated with vasospasm at the genome-wide level. However, eleven SNPs were nominally associated with vasospasm (P<10E-5) including the most significant SNP mapping to an intron of
GLIS3
(P=9.74E-06, OR=3.94, 95% CI: 2.15-7.22), three intronic SNPs mapping to
ACVR1
, and additional SNPs mapping to introns in
FSTL3
,
TMEM242
,
DCLK1
, one SNP upstream of
RAC2
and two SNPs downstream of
TEX29
and
TGFBR3
, and one missense SNP mapping to
MYO18B.
Interestingly, two of these genes (
ACVR1
and
TGFBR3
) are in the transforming growth factor-beta (TGF-beta) signaling pathway, previously implicated in SAH pathogenesis.

Conclusions:
We performed a GWAS of vasospasm following aSAH. Our study suggests that common SNPs may contribute to vasospasm susceptibility following aSAH and suggests a potential role for TGF-beta signaling pathway genes in vasospasm. These findings warrant further replication in additional independent studies including other DCI outcomes.
Abstract P420: Predominant Juxtacortical White Matter Lesion Hallmarks NOTCH3 Mutation-Related Intracerebral Hemorrhage
Authors: Chen Chih-hao , Hsu Hao-Chia , Chen Ya-Fang , Tang Sung-Chun , Jeng Jiann Shing
Published: March 2021

Introduction:
CADASIL caused by p.R544C point mutation at exon 11 of
NOTCH3
gene is reported to account for 5% of spontaneous intracerebral hemorrhage (ICH) in East Asian patients. We aim to investigate whether computed tomography (CT) features can identify
NOTCH3
-related ICH.

Method:
This study enrolled patients with spontaneous ICH from a single center during 2008 to 2017. All patients were screened for
NOTCH3
p.R544C mutation by polymerase chain reaction. Neuroimaging features of noncontrast CT scans, including burden of white matter lesion (WML, total score 0-4), degree of brain atrophy, number of lacunes, presence of juxtacortical WML, and lobar lacunes, were analyzed by the neuroradiologists who were blinded to the mutation status.

Results:
Of 323 cases with spontaneous ICH, 299 patients (mean age, 61.4±14.7; male, 67.6%; mean ICH volume 14.1±17.8 ml; ICH score 1.14±1.04 ) had available CT scan at stroke onset. Thirteen patients (4.3%) carried p.R544C mutations. The clinical features, stroke severity, hematoma size, and hemorrhagic location were comparable between p.R544C mutation carriers and noncarriers. On CT scan, patient with p.R544C mutation had higher WML score (2.77±1.69 vs. 1.63±1.50,
P
= 0.018) and were more likely to have predominant juxtacortical WML (69.2% vs. 17.8%,
P
< 0.001,

Figure 1

), which usually presented at the level of centrum semiovale (

Figure 2

). In multivariable analysis, predominant juxtacortical WML was the only neuroimaging feature associated with p.R544C mutation (odds ratio 8.82, 95% CI, 2.74-28.4).

Conclusion:
In patients with spontaneous ICH, topographic distribution of WML can help in identifying potential
NOTCH3
mutation-related ICH.
Abstract P430: Inflammatory Survival Gene Expression Patterns Differentiate Favorable and Unfavorable Outcomes Following Surgical Intervention in Intracerebral Hemorrhage
Authors: Iwuchukwu Ifeanyi O , nguyen doan , Warren Jasmine , SHIRAZIAN ALIREZA , Tran Vi , Cuoung Bui , Sulaiman Olawale
Published: March 2021

Background and Aims:
Surgical management of intracerebral (ICH) remains controversial due to unclear benefit. In this study, we analyzed temporal changes in expression of proinflammatory and anti-inflammatory survival genes to discern the molecular differences between favorable and unfavorable outcomes after surgery.

Methods:
Venous blood collected in Paxgene Blood RNA from ICH patients before surgery at ‘early’ (Day 0-2) and at ‘delayed’ (Day 3-5) timepoints. Extracted total RNA was used for real-time Taqman PCR analysis for anti-inflammatory, survival genes superoxide dismutase 1(SOD1), COX-2, IL-10, peroxisome proliferator activated receptor gamma (PPARG), TGF-B1, and IL-10. The pro-inflammatory genes included arginase-1 (ARG1), TNF, IL-1B, monocyte/macrophage activity markers (CD36, CD163) and NF-kB members (NFKB1, NFKB2, RELA, RELB, REL, NFKBIA). Relative fold changes were determined after normalizing to GAPDH. 90-day Modified Rankin Score (mRS) were collected and classified as favorable, mRS 0-3 (n=4) and unfavorable, mRS 4-6 (n=8). Statistical analysis was carried out by Welch’s ANOVA test (p<0.05).

Results:
Mean age was 56.25yrs (SD 19.7). ICH location was 10 deep nuclei (thalamus or basal ganglia), 1 cerebellum, and 1 lobar. ICH volume was lower in the mRS 0-3 group (24.15ml SD21.2 vs 35.8ml SD 31.7 p=0.68). All patients had a decompressive hemicraniectomy and 7 included hematoma evacuation. Overall, the NFkB family gene expression was increased at ‘delayed’ relative to the early time points in both groups. However, RELB expression was significantly higher at the early time point of mRS 0-3 compared to mRS 4-6 group. Expression of ARG1, SOD1, COX2, IL-1B, IL-10, TGF-B1, PPARG and CD36 increased significantly at the delayed compared to the early time point. In the unfavorable outcome group (mRS 4-6), TNF expression increased significantly at the delayed timepoints compared to mRS 0-3 which was unchanged.

Conclusions:
The studied genes were highly expressed and differed significantly between time points. TNF was significantly expressed at the delayed time point in the mRS 4-6 group but unchanged in the mRS 0-3 group. Further studies will explore the role of TNF and related genes in patient selection and outcomes for surgical management of ICH.
Abstract P434: Sex Differences in Outcomes After Subarachnoid Hemorrhage: Insight From the Subarachnoid Hemorrhage International Trialists Repository
Authors: Anadani Mohammad , Kumar Atul , Phuah Chia-ling , De Havenon Adam H , MacDonald Robert ,   Subarachnoid Hemorrhage International Trialists
Published: March 2021

Introduction:
Sex is a known predictor of outcome after acute ischemic stroke. However, the effect of sex on outcome after subarachnoid hemorrhage (SAH) is not well studied.

Methods:
Five studies from the SAH International Trialists repository were included (4 randomized trials and 1 prospective study). Patients were divided into groups based on sex. The primary outcome was favorable outcome which was defined as Glasgow Outcome Score (GOS) of 4 or 5 and the secondary outcome was delayed cerebral ischemia (DCI). Binary logistic regression was done to assess the association between sex and outcomes.

Results:
A total of 8015 patients (2186 males and 5829 females) were included. Female patients were older (mean age 53 vs 50 years, p<0.001) and had more severe neurological deficit on presentation (median World Federation of Neurosurgical Societies [WFNS] grade 2 vs.1; p<0.001). Favorable outcome was achieved less frequently in females in univariate analysis (51% vs. 62%; p<0.001). In a multivariable model adjusted for age, WFNS, Fisher score, aneurysm location, and aneurysm size, female was associated with lower odds of favorable outcome (OR= 0.82; 95% CI:0.73-0.92). DCI occurred more frequently in females (25% vs. 18%; p<0.001). In addition, women had higher risk of DCI after adjusting for potential confounders (women vs. men, OR 1.43; 95%CI: 1.26-1.63). We did not find an interaction between age and sex for both favorable outcome and clinical vasospasm.

Conclusion:
Female patients had worse functional outcome and higher risk of DCI after subarachnoid hemorrhage when compared to men.
Abstract P442: The Association of Amyloid and Tau Burden With Centrum Semiovale Perivascular Spaces in Cerebral Amyloid Angiopathy
Authors: Gokcal Elif , Becker Alex A , Horn Mitchell J , Das Alvin S , Schwab Kristin , Biffi Alessandro , Rosand Jonathan , Viswanathan Anand , Polimeni Jonathan , Johnson Keith A , Greenberg Steven M , Gurol M. Edip
Published: March 2021

Background:
The mechanisms linking cerebral amyloid angiopathy (CAA) to enlarged perivascular spaces in centrum semiovale (CSO-EPVS) and whether other Alzheimer’s Disease (AD) pathologies might affect CSO-EPVS are unclear. We hypothesized that amyloid but not tau load would independently correlate with CSO-EPVS in CAA.

Methods:
Fifty prospectively enrolled nondemented probable CAA patients underwent high-resolution structural MRI, Pittsburgh compound B (PiB, for amyloid), and
18
F-flortaucipir (FTP, for tau) PET imaging. Microbleeds (all lobar, LMB) were counted and white matter hyperintensity volume (WMH) was quantified. CSO-EPVS were counted on T
2
-MRI sequence and graded using a previously validated scale (range 0-4). A multivariate ordinal regression model was used to assess the independent associations between CSO-EPVS and mean cortical amyloid as well as tau deposition, after adjusting for relevant covariates.

Results:
Patients had a mean age of 69.3±7.2. Age, sex, presence of hypertension, intracerebral hemorrhage (ICH), LMB counts, and WMH were not associated with CSO-EPVS grades (p>0.2 for all comparisons). Higher PiB uptake significantly correlated with increased CSO-EPVS (rho=0.45, p=0.001). Higher FTP showed a trend for correlation with CSO-EPVS (rho=0.26, p=0.069). In an ordinal regression model with CSO-EPVS grade as the dependent variable and both amyloid and tau levels included as predictors along with covariates presented above, the association of CSO-EPVS remained significant with higher PiB uptake (β=3.97, 95%CI 1.1-6.8, p=0.007) but not with FTP uptake (p=0.167).

Conclusion:
Results of this study suggest that CSO-EPVS is independently associated with amyloid but not with tau deposition in CAA. CSO-EPVS was not associated with age or classical vascular risk factors or presence of ICH. Our results support the view that vascular amyloid but not other AD pathologies such as tau might contribute to EPVS in patients with CAA.
Abstract P446: African American Women Have Lower Functional Performance During Acute Inpatient Rehabilitation After Intracerebral Hemorrhagic Strokes
Authors: Somani Sana , Nanavati Hely , Zhou Xiaohua , Lin Chen
Published: March 2021

Introduction:
Intracerebral hemorrhage (ICH), a subtype of stroke, leads to significant long-term disability. Research in stroke recovery and rehabilitation has focused on ischemic strokes. Identifying factors that impact the recovery of function for patients at an inpatient rehabilitation facility (IRF) following an ICH is necessary. Our purpose is to identify factors, including racial and gender disparities, associated with inpatient rehabilitation after ICH.

Methods:
We performed a retrospective analysis of a tertiary care academic hospital in the Stroke Belt of the US, the University of Alabama at Birmingham, and subsequently, admitted to an IRF from December 2016 through December 2019. Functional performance was measured using the Functional Independence Measure (FIM), an 18-item scale measuring the level of disability in terms of burden of care. Baseline clinical characteristics, demographics, admission and discharge FIM scores, and ICH characteristics including ICH scores and volumes were collected. FIM efficiency was calculated for all patients by dividing the difference in FIM scores at admission and discharge from the total number of days spent at rehab. The differences in FIM efficiency by gender and race were measured using multiple linear regression.

Results:
We evaluated 65 patients (54.4 ± 14.1 years, 61% males, 46% African American) with a median (interquartile range) ICH score of 1.0 (0.0, 2.0), median ICH volume of 13.4 (4.2, 33.0), and FIM efficiency of 1.6 (1.1, 2.4). In multiple regression, being male was positively associated with FIM efficiency (β=1.02, p = 0.0063) when adjusting for race and ICH score. The FIM efficiency was lower in African Americans (β =-0.95, p = 0.0092) when adjusting for gender and ICH volume. No significant differences were noted in ICH volumes and scores with respect to discharge FIM scores.

Conclusions:
FIM efficiency, is a good measure of improvement in motor function and ADLs over the rehab period. Our results indicate that African American women could potentially benefit from longer periods of rehabilitation intervention.
Abstract P45: White Blood Cell Counts in Aneurysmal Subarachnoid Hemorrhage Patients as a Predictor of Cardiac Injury
Authors: Cheng Tiffany , Geraghty Joseph R , Saini Neil S , Hirsch Yonatan , Lung Tyler J , Nazir Noreen T , Testai Fernando D
Published: March 2021

Introduction:
Up to 50% of subarachnoid hemorrhage (SAH) patients develop cardiac injury. The relationship between early systemic inflammation and cardiac injury after SAH is unknown. Here we examined changes in blood leukocyte counts and their relationship to cardiac dysfunction.

Methods:
We reviewed the medical records of 288 SAH patients admitted to our Comprehensive Stroke Center. Patients were dichotomized based on elevated (≥0.04ng/mL) or normal (<0.04ng/mL) troponin I (TnI). Demographics and labs from admission were then compared among the two groups by Chi-Square or Mann-Whitney test. Ejection fraction (EF) was stratified into low (<50%), normal (50-70%), or high (>70%) from echocardiogram data. We performed univariate and multivariate logistic regression to establish the relationship between blood leukocyte counts and cardiac injury.

Results:
Of 288 SAH patients, 241 had TnI levels performed at the time of admission and 119 (49.4%) of these had elevated TnI on admission. Patients with elevated TnI were significantly older, had higher grade SAH, abnormal EF, and were more likely to have hypertension and dyslipidemia. 10 (4.1%) had low EF while 58 (24.1%) had high EF on admission echocardiogram. In univariate analysis, total leukocyte count (p<0.0001), absolute neutrophil count (p=0.037), absolute monocyte count (p=0.014), and neutrophil-lymphocyte ratio (p=0.010) were associated with elevated TnI. Multivariate analysis adjusting for covariates showed that only total leukocyte count remained a significant predictor of elevated TnI (OR = 1.104, 95% CI= 1.020 - 1.195; p=0.014). Receiver operating characteristic (ROC) analysis demonstrated that adjusted total leukocyte count distinguishes between SAH patients with normal and elevated TnI (area under the curve = 0.787, p=0.001), with the optimal cutoff being 0.521 (sensitivity of 67.0% and specificity of 80.6%).

Conclusions:
Blood total leukocyte count is an independent predictor of cardiac injury in SAH patients. This highlights the role of inflammation in mediating cardiac dysfunction after brain hemorrhage, and raises questions regarding the potential of anti-inflammatory therapy for cardioprotection in SAH.
Abstract P452: Impact of Socioeconomic Status in Intracerebral Hemorrhage
Authors: Kalagara Roshini , Lin Nelson F , Chuck Carlin C , Doelfel Savannah R , Zhou Helen , Moody Scott , Stretz Christoph , Mahta Ali , Wendell Linda C , Thompson Bradford B , Furie Karen L , Reznik Michael E
Published: March 2021

Background:
Socioeconomic status (SES) has been associated with intracerebral hemorrhage (ICH) incidence, but its impact on ICH-related features and outcomes is unclear.

Methods:
We performed a single-center cohort study on consecutive ICH patients admitted over 2 years. Demographics, ICH characteristics, and outcomes were prospectively collected, while SES-related data were retrospectively abstracted. We classified SES quartiles using census estimates of median household incomes corresponding to patients’ home ZIP codes, then categorized patients as “lower SES” if their ZIP code was in the lowest SES quartile, if they were uninsured, or had Medicaid as their source of insurance. We compared ICH characteristics between patients with lower vs. higher SES, then determined associations between lower SES and unfavorable 3-month outcome (modified Rankin Scale 4-6) using multivariable logistic regression.

Results:
Of 665 patients, 31% (n=207) were categorized as lower SES. Patients with lower SES were significantly younger (mean [SD] 64.7 [16.1] vs. 73.1 [14.2] years, p<0.001), more often non-white (38% vs. 8%, p<0.001), and had a higher prevalence of multiple vascular risk factors. There were no significant differences in ICH volume or prevalence of infratentorial or intraventricular hemorrhage. However, patients with lower SES had a shorter time-to-presentation (median [IQR] 4.5 [1.3-15.2] vs. 7.4 [1.4-21.7]), hours from last known well, p=0.01), and had fewer ICH due to cerebral amyloid angiopathy (13% vs. 30%, p<0.001). Despite these differences, patients with lower SES did not have a significantly higher likelihood of unfavorable 3-month outcomes (OR 1.2 [95% CI 0.7-1.8]).

Conclusions:
Differences in ICH features may be driven by pre-morbid healthcare disparities in lower SES patients. Although their younger age and shorter time to presentation may have mitigated the deleterious effects of comorbidities on long-term outcomes, these factors may also belie a greater loss of quality-adjusted life years from ICH-related disability.
Abstract P455: Time to Blood Pressure Control and Association With Outcomes in Intracerebral Hemorrhage
Authors: Chuck Carlin , Kalagara Roshini , Abrantes Tatiana , Doelfel Savannah , Lin Nelson F , Zhou Helen , Dandapani Hari , Kim Daniel , Madsen Tracy , Stretz Christoph , Mahta Ali , Wendell Linda C , Thompson Bradford B , Furie Karen L , Reznik Michael
Published: March 2021

Background:
Urgent blood pressure (BP) control is a mainstay of acute intracerebral hemorrhage (ICH) treatment, but the relationship between time to BP control and clinical outcomes is unclear.

Methods:
We performed a single-center observational cohort study on consecutive patients with ICH who were hypertensive on hospital arrival over a 2-year period. We defined time-to-BP-control as the time from initial hospital arrival to first BP recorded below our institutionally mandated goal (systolic BP [SBP] <160 mmHg). Using multivariable logistic regression models adjusted for established clinical predictors and time from last-known-well to hospital arrival, we determined associations between time-to-BP-control, hematoma expansion (HE), and unfavorable 3-month outcome (modified Rankin Scale 4-6). We performed additional subgroup analyses in patients with arrival SBP >200 mmHg, hypertensive ICH etiology, and anticoagulation-related ICH.

Results:
Among 330 patients in our cohort, mean arrival SBP was 191±131 mmHg and mean time-to-BP-control was 2.3±1.5 hours. On univariate analysis, patients without HE had longer time-to-BP-control than those with HE (mean 2.5 vs. 2.1 hours, p=0.02). This was confirmed in multivariable models, where longer time-to-BP-control was associated with a lower likelihood of HE (OR 0.81 per hour, 95% CI 0.66-0.98), and was not associated with 3-month outcome (OR 0.99 per hour, 95% CI 0.81-1.21). Results were similar in subgroup analyses of patients with arrival SBP >200 mmHg and hypertensive ICH etiology. However, in those with anticoagulation-related ICH, longer time-to-BP-control was associated with a higher likelihood of unfavorable 3-month outcome (OR 2.02 per hour, 95% CI 1.13-3.61).

Conclusion:
Earlier BP control may not improve outcomes in all ICH patients, though some subgroups, such as those with anticoagulation-related ICH, may derive greater benefit from earlier treatment.
Abstract P462: Intensive Lipid Lowering Therapy May Lead to Worse Outcomes of Intracerebral Hemorrahge
Authors: Tang Tianping , Zhang Ligong , Zhang Kai , Zhao Xingquan , Liu Shimeng
Published: March 2021

Background:
Intensive Lipid-lowering therapy (ILLT) is a crucial strategy for secondary prevention of ischemic stroke. While current evidence of the risks of intracerebral hemorrhage (ICH) after ILLT were contradictory; morever, insights into the associations between ILLT and the outcomes of ICH were also limited.

Methods:
Data of consecutive patients with acute ICH and histories of ischemic stroke at an academic stroke center from 2017 to 2019 were retrospectively collected. The study patients were classifed according to their baseline low-density lipoprotein cholesterol (LDL-c) levels: <1.8 mmol/L vs. LDL-c≥1.8 mmol/L.

Results:
A total of 197 patients were included in the study, 31 of them had LDL-c <1.8 mmol/L and 166 had LDL-c≥1.8 mmol/L. We did not tested any significant differences regarding the demographic characteristics or the medical histories (Table 1). Medians of baseline National Institutes of Health Stroke Scale (NIHSS) scores (8 vs. 9, p=0.79) and ICH scores (1 vs.1 , p=0.26) were similar. But patients with LDL-c<1.8 mmol/L had higher bleeding volume (11 (19) vs. 10 (52), p=0.03) and higher risks of secondary intraventricular hemorrhage (13% vs. 4%, p=0.03) (Table 2).Outcomes of the ICH events at discharge were generally similar (Table 3), except that patients with LDL-c≥1.8 mmol/L had significant improvements in their NIHSS scores at discharge (estimated change in means: -2.4, 95% [-3.9, -0.9] ), than patients with LDL-c<1.8 mmol/L (estimated change in means: -1.4, 95% CI [-4.7, 0.5]).

Conclusions:
Achieving LDL-c<1.8 mmol/L was associated with bigger bleeding volume, higher risks of secondary intraventricular hemorrhage, and worse neurological improvements.
Abstract P464: Thirty Day Stroke and Mortality After Carotid Revascularization Among Octogenarians With Symptomatic Carotid Stenosis: Real-World Data Analysis From a National Surgical Quality Registry
Authors: Alvi Mohammed Ali , Yolcu Yagiz , Rajjoub Kenan , Dikilitas Ozan
Published: March 2021

Introduction:
Due to their exclusion from most clinical trials, outcomes of carotid revascularization via a carotid endarterectomy (CEA) or carotid artery stenting (CAS) among octogenarians are not well studied. Herein, we present analysis of thirty-day stroke and mortality of patients aged ≥ 80 using real-world data from a national surgical quality registry.

Methods:
The National Surgical Quality Improvement Program (NSQIP) targeted dataset for CEA and CAS was queried for patients aged ≥ 80 undergoing CEA and CAS between 2012-2018.

Results:
A total of 94 and 2,656 patients aged ≥ 80 with symptomatic carotid stenosis undergoing CAS and CEA (respectively) were identified. Patients in the CAS group were more likely to be over 90 (p=0.006). Patients in the CAS group were more likely to have high-risk anatomy (p<0.001) and more likely to be on aspirin preoperatively (p=0.02) but less likely to have higher ASA (p<0.001). Most patients in the group presented with an ipsilateral stroke (CAS: 43.6% and CEA: 41.7%). The rate of thirty-day composite outcome (stroke or death) was found to be 5.3% in the CAS group and 4.5% in the CEA group (p=0.714) (stroke: 2.1% for CAS and 3.2% for CEA; death: 4.3% for CAS and 1.7% for CEA). Upon multivariable analysis, procedure type (CAS vs CEA) was not found to be associated with the composite-outcome (OR 1.1, 95%CI 0.43-2.82,p=0.836). Symptom presentation other than ipsilateral stroke was found to be associated with significantly decreased odds of 30-day composite outcome (amaurosis-fugax/transient monocular blindness: OR 0.42,95%CI 0.21-0.86, p=0.02; TIA: OR 0.62, 95%CI 0.42-0.93,p=0.02), while higher age was found to be associated with significantly increased odds (OR 1.512, 95%CI 1.01-2.24, p=0.02).

Conclusion:
Real world analysis from a surgical quality registry show that both CAS and CEA are associated with optimal 30-day outcomes among octogenarians with symptomatic carotid stenosis.
Abstract P469: Device-Related Dimensions and Their Effect on First Pass Success and Safety Outcomes After Mechanical Thrombectomy: Is Longer Safer?
Authors: Dibas Mahmoud , Desai Sohum , TEKLE WONDWOSSEN , Ghozy Sherief , Dmytriw Adam A , Sarraj Amrou , Hassan Ameer E
Published: March 2021

Introduction:
Mechanical thrombectomy (MT) results in a marked improvement in outcomes of acute ischemic stroke (AIS) patients. First pass effect (FPE), which is defined as the achievement of complete recanalization (mTICI 3) from a single pass, appears to be associated with higher rates of good outcome. We seek to determine if dimensions of stentreivers such as length and diameter have influence on FPE, and other safety outcomes including hemorrhagic transformation, symptomatic intracerebral hemorrhage (sICH), masseffect, and mortality.

Methodology:
Patients who underwent MT between 2012 and 2020 were identified from a prospectively maintained database at a comprehensive stroke center. Then, these patients were stratified based on dimensions of stentrievers into: "4x20", "4x40", "6x30", and “6x40". Stentrievers used during the study period included Trevo and Solitare.

Results:
This study included 320 AIS patients. The mean (SD) age of the included patients was 70.7 (13.5), and 54.1% of them were males. 79 (24.7%) of the stentrievers were 4x20, 47 (14.7%) were 4x40, 66 (20.6%) were 6x30, while 128 (40%) were 6x40. There was no difference among the four stentreivers in FPE rates (64.6% vs 68.1%, 66.7%, 67.2%, p=0.98), hemorrhagic transformation (10.1% vs 14.9%, 12.1%, 14.8%, p=0.88), mass effect (3.8% vs 6.4%, 9.1%, 11.7%, p=0.134), and mortality rates (17.7% vs 23.7%, 19.7%, 20.3%, p=0.86). Noteworthy, sICH was significantly different among the groups with the lowest rates reported for 4x40 (4.3%) and 6x40 (5.5%), followed by 4x20 (10.1%), and 6x30 (16.7%), respectively (p=0.04).

Conclusions:
Stentriever dimensions do not appear to significantly influence FPE rates. We found that 4x40 and 6x40 stentrievers were significantly associated with lower rates of sICH.
Abstract P479: A Tale of Two Clots: A Multicenter Study on Multiple Territory Thrombectomy
Authors: Grossberg Jonathan , Eshraghi Sheila , Howard Brian , Buster Bryan , Akbik Feras , Maier Ilko , Goyal Nitin , Starke Robert , rai ansaar , Fargen Kyle , Psychogios Marios , Jabbour Pascal M , De Leacy Reade A , Keyrouz Salah G , Dumont Travis , Kan Peter , Arthur Adam S , Crosa Roberto , Gory Benjamin , Spiotta Alejandro M
Published: March 2021

Introduction:
The benefit of thrombectomy for large vessel occlusion (LVO) is well proven. There is minimal data on concurrent thrombectomy for multi-territory occlusions.

Methods:
We reviewed the STAR registry from 2015-8 for patients treated with either right and left sided thrombectomy or anterior and posterior circulation thrombectomy at 15 comprehensive stroke centers.

Results:
There were 4966 patients in the study period who had completed outcome data and LVO thrombectomy. 38 (0.8%) underwent endovascular thrombectomy for multi-territory occlusions. 26% had bilateral occlusions and 74% had anterior and posterior circulation occlusions. Among the 38, 50% were female, 49% were white, and 91% had a prestroke mRS<3. 95% had an ASPECT score of >6 and 55% received iv t-pa. 83% of patients had successful recanalization (TICI 2B/3) for both territories. The overall complication rate was 15%. 5% of patients had sICH or PH2. 26% of patients had a 90day mRS<2. When controlling for admission NIHSS, baseline mRS, age, comorbidities, and ASPECT in logistic regression analysis, multiple territory compared to single territory did not predict increased risk of sICH (p=0.73, 95%CI: 0.2-3.3), rate of TICI2B/3 (OR for TICI2B+: 0.93, p=0.88, CI: 0.38 - 2.3), or worse outcome (OR for good outcome: 0.6, p=.212, CI: 0.3-1.3). On linear regression analysis for attempts and procedure time, multiple territory thrombectomy required significantly higher number of attempts (Coefficient +1.8, p=0.001) without a significantly longer procedure time (Coefficient = +10, p=0.244).

Conclusion:
With similar selection to single territory LVOs, good outcome can be achieved in multi-territory infarction with reasonable procedure time and no additional risk of hemorrhage or poor outcome.
Abstract P480: Impact of Intravenous Thrombolysis on Reperfusion Status in Stroke Thrombectomy
Authors: Carvalho Helio P , Wessell Aaron , Cannarsa Gregory , Miller Timothy R , Gandhi Dheeraj , Jindal Gaurav
Published: March 2021

Introduction:
It remains unclear whether use of intravenous thrombolysis (IVT) with intravenous tissue plasminogen activator (tPA) provides additional benefit to patients with emergent large vessel occlusion (ELVO) stroke undergoing mechanical thrombectomy (MT). We sought to determine the impact of IVT on procedure time, number of passes, and successful reperfusion (SR) during MT.

Method:
We retrospectively analyzed all patients who underwent anterior circulation mechanical thrombectomy for treatment of ELVO stroke at our institution from April 2012 to November 2019. Univariate and multivariate logistic regression analyzes were used to determine independent predictors of poor functional outcome at 90 days,and independent predictors of >2 thrombectomy passes in patients with successful revascularization (SR: TICI 2B, 2C and 3).

Results:
A total of 400 patients were eligible for analysis. 189 patients received IVT before thrombectomy. Last known well time-to-endovascular therapy was shorter in the IVT group (290.0 min vs 452.75 min; P=<0.001). The IVT group had a trend towards better outcomes at 90 days (mRS 0—2: 44% vs 35%; P=0.076). The number of passes and revascularization status did not significantly differ between IVT and non-IVT patients. The number of patients with any intracranial hemorrhage was higher in the IVT group than non- IVT group [10% vs 4%; p=0.038].Multivariate logistic regression demonstrated ICA occlusion site was an independent predictors of >2 passes relative to M1 occlusion in patients with successful revascularization. Multivariate logistic regression revealed that age (OR 1.05, 95% CI 1.03-1.07; p<0.001), NIHSS (OR 1.11, 95% CI 1.06-1.17; p<0.001), ≥3 thrombectomy passes (OR 2.47, 95% CI 1.23-5.00; p=0.011) and intracranial hemorrhage (OR 5.50, 95% CI 1.45-20.84; p=0.012)were independently associated with an increased odds of poor outcome. TICI 2C/3 was associated with reduced odds of poor outcome (OR 0.16, 95% CI 0.07-0.35; p<0,001).

Conclusion:
IVT pretreatment did not increase rates of SR and did not shorten MT procedure time nor number of passes needed to achieve SR during MT in our patient population. Randomized controlled trials are required for further evaluation of the impact of IVT on reperfusion status during MT.
Abstract P486: Mechanical Embolectomy Using a Novel Telescopic System Featuring a Specialized Delivery and 0.088” Aspiration Catheter for the Treatment of Acute Ischemic Stroke: Preliminary Results of the SUMMIT NZ Trial
Authors: McGuinness Ben J , Caldwell James , Barber P A , Holden Andrew , Wu Teddy Y , Krauss Martin , Laing Andrew D , Collecutt Wayne , Liebeskind David S , Hetts Steven W , Brew Stefan
Published: March 2021

Background:
The treatment approach of aspiration rather than use of a stent retriever as first-line therapy is increasingly regarded as standard of care for acute ischemic stroke. Continued technological advances include the ongoing development of aspiration embolectomy catheters that are larger in bore, guided by delivery catheters that are more maneuverable through the tortuous neurovasculature.

Methods:
SUMMIT NZ (ACTRN12619000890134p) was designed as a prospective, single-arm, open label clinical trial at two sites in New Zealand. Eligible participants were patients presenting with acute ischemic stroke from either anterior or posterior circulation large-vessel occlusion within 24 hours of onset, a National Institutes of Health Stroke Scale Score ≥ 6 and a pre-stroke modified Rankin Score of ≤ 2. A novel tapered tip delivery catheter was specifically designed to deliver 0.070” and 0.088” aspiration catheters telescoped through a specialized 8F 90 cm introducer sheath (Route 92 Medical, Inc. San Mateo, CA). The primary effectiveness endpoint was arterial revascularization as measured by a modified Thrombosis in Cerebrovascular Infarction (mTICI) score of 2b or greater at the end of angiography after all endovascular treatments as adjudicated by an independent core laboratory. The primary safety endpoints were device-related peri-procedural complications such as dissection or perforation, symptomatic Intracranial Cerebral Hemorrhage (SICH) at 24 hours and embolization to a previously uninvolved territory.

Results:
From September 27, 2019 to June 23, 2020, 18 subjects (mean age 69.5, NIHSSS 15.2, time last known well 6.2 hours) were enrolled with a diagnosis of acute ischemic stroke. Acute occlusion was located in the middle cerebral artery (78%, 14/18) and internal carotid artery (22%, 4/18). Successful revascularization was achieved in 94% (17/18) of subjects. No serious adverse device effects have been reported.

Conclusions:
Preliminary findings suggest that aspiration first mechanical embolectomy using a novel telescoping system including an 0.088” inner diameter aspiration catheter achieves a high rate of arterial revascularization with an acceptable safety profile. A full report on enrollment and results are to be presented.
Abstract P489: Differences in Characteristics of Octogenarian Patients Undergoing Carotid Artery Stenting and Carotid Endarterectomy for Carotid Stenosis: Insights From a Real World Surgical Quality Registry
Authors: Alvi Mohammed Ali , Yolcu Yagiz , Rajjoub Kenan , Dikilitas Ozan
Published: March 2021

Introduction:
Several clinical trials evaluating the efficacy of a carotid revascularization procedure excluded patients above age 80. In the current study, we sought to assess the differences in characteristics of octogenarians undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) for carotid stenosis using “real-world” data from a national surgical quality registry.

Methods:
The National Surgical Quality Improvement Program (NSQIP) targeted datasets for CEA and CAS were queried for patients aged ≥80 years between 2012-2018.

Results:
We identified 5,814 patients undergoing CEA and 189 patients undergoing CAS. Patients in the CAS group were more likely to be ≥90 years (p=0.004), diabetic (p=0.04), had a history of CHF (p=0.012) and a bleeding-disorder (p<0.001). Patients in the CAS group were also more likely to have high risk anatomy (p<0.001), high-risk-physiology (p=0.028). Ninety-nine (52.4%) patients in the CAS group and 2,775 (47.7%) in the CEA group were symptomatic, with most patients in both groups presenting with an ipsilateral stroke. Among asymptomatic patients, 64 (74%) in the CAS group and 2222 (72.7%) in the CEA group had severe/total stenosis (>80%-100%) of the ipsilateral carotid, while 13(14.5%) in the CAS group and 302 (11%) in the CEA group had severe or total stenosis of contralateral carotid. Among symptomatic patients, 58(61.7%) in the CAS group and 1527 (57.5%) in the CEA group were found to have severe/total stenosis of the ipsilateral-carotid, while 12(12.8%) in the CAS group and 208(7.8%) in the CEA group were found to have severe/total occlusion of the contralateral carotid. In the carotid endarterectomy group, 12.2% (n=711) underwent CEA-alone, 44.3% (n=2,575) CEA with angioplasty, 29.9% (n=1,737) CEA with angioplasty and shunt, 2.9% (n=166) CEA with shunt and 10.7%(n=166) eversion CEA. In the CAS group, 52.4%(n=99) underwent CAS with a single tapered stent, 29.1%(n=55) CAS with single tapered stent with CPD, 11.1%(n=21) single straight stent with CPD and 1.6%(n=3) a single straight stent alone.

Conclusion:
These analyses from real-world data show that there may be some differences in demographic and comorbid characteristics between octogenarians undergoing CAS and CEA.
Abstract P495: Aqua Embolic System: Evaluating the Performance of a New Liquid Embolic System Using a Swine AVM Model
Authors: Yuki Ichiro , Ohkawa Kousaku , Li Shiri , Steward Earl , Frank P.K. Hsu , Xu Jordan C. , Suzuki Shuichi
Published: March 2021

Introduction:
Liquid embolic material (LEM) plays an essential role in the treatment of hemorrhagic stroke caused by vascular malformation such as arteriovenous malformations (AVMs). However, currently available non-adhesive LEMs has the problem of catheter entrapment, and also known to have cytotoxicity due to the organic solvents such as Dimethyl Sulfoxide (DMSO). Aqua Embolic System (AES) is a new liquid embolic material, which is mainly composed of multiple polysaccharides. AES, when injected via a microcatheter, immediately forms a solid and elastic hydrogel cast upon exposure to Ca2+ in the bloodstream. The use of organic solvents, e.g., DMSO, is not required. The performance of AES was evaluated using an established AVM model utilizing swine rete-mirabile.

Methods:
Under general anesthesia, the left ascending pharyngeal artery (APA) of Yorkshire swine (40 kg) was catheterized using a microcatheter (ID:0.013 inches), and AES was slowly injected into the rete-mirabile under fluoroscopy. The following parameters were assessed to evaluate the embolization performance of the AES; 1) the amount of AES required for the complete occlusion of the feeding artery, 2) injection speed, 3) radiopacity during the deployment, and 4) incidence of catheter entrapment after the injection. The same evaluation was performed on the contralateral rete-mirabile and the left renal artery as well.

Results:
12 arteries in 4 swine were treated, and all arteries were completely occluded without technical complications. The injected materials immediately formed AES cast in all vessels, followed by the reflux over the tip of the microcatheter. All catheters were withdrawn without any sign of catheter entrapment. The AES mixed with tantalum based contrasts medium showed sufficient radiopacity under fluoroscopy. With the injection speed of 0.02ml/sec, the average volume required was 0.85mL for the APA and 2.9mL for the renal artery. No increased thrombogenicity or vasospasm near the treated lesion was observed during the procedure.

Conclusions:
AES, which is a DMSO free, non-adhesive polysaccharides-based LEM, may be used as an embolic material for the treatment of hemorrhagic stroke caused by cerebrovascular diseases, such as brain AVM.
Abstract P498: Quality of Reperfusion - Association of Stent Retriever Characteristics and Successful Reperfusion in ESCAPE-NA1 Dataset
Authors: Cimflova Petra , Singh Nishita , Ospel Johanna , Marko Martha , Kashani Nima , Mayank Arnuv , Nogueira Raul G , McTaggart Ryan A , Demchuk Andrew M , Poppe Alexandre Y , Hill Michael D , MENON Bijoy K , GOYAL MAYANK , Almekhlafi Mohammed ,   ESCAPE-NA1 Investigators
Published: March 2021

Background:
We evaluated technical aspects of stent retriever use and its relation to reperfusion in ESCAPE NA1 trial.

Methods:
ESCAPE-NA1 was a multicenter, international randomized trial assessing the efficacy of nerinetide in ischemic stroke patients who underwent EVT within 12h from onset. The following stent retriever characteristics were evaluated: stent retriever length, diameter, thrombus position in relation to stent retriever - proximal, middle or distal third, bypass effect during stent retriever deployment (Figure 1), and stent retriever placement in the anterior or posterior MCA trunk (in M1 occlusions). Primary outcome was reperfusion grade and the unit of analysis was stent retriever attempt.

Results:
Data from 1062 patients were evaluated. Angiographic data for up to three passes were analyzed as only 8.9% of patients required >3 passes. Stent retriever was used in 1241 passes in 808 patients. The occlusion sites were terminal ICA (14.9%), M1 MCA (58.7%), M2 MCA (23.7%), other (2.1%). A successful reperfusion attempt (mTICI 2b-3) was associated with the presence of bypass effect (OR 1.7; 95%CI 1.07-2.72), and positioning of stent retriever so the thrombus was in the proximal and middle third of stent retriever (OR 2.06; 95%CI 1.24-3.40 and OR 1.92; 95%CI 1.16-3.15, respectively). The position of the thrombus in the middle third of stent retriever was a significant predictor of bypass effect (OR 2.71; 95%CI 1.61-4.58). Stent retriever length, diameter, or choice of MCA trunk did not predict successful attempts, Table 1.

Conclusion:
Bypass effect and positioning of stent retriever so the thrombus was in proximal 2/3rds are predictors of successful reperfusion attempts.
Abstract P501: Safety and Efficacy of Repeat Mechanical Thrombectomy After Early and Delayed Reocclusion- A Case Series From Two Comprehensive Stroke Center and Meta-Analysis
Authors: Karim Nurose , Desai Harsh , Henkel Nicholas , Castonguay Alicia , Zaidi Syed F
Published: March 2021

Introduction:
Limited data exist about the safety and efficacy of repeat mechanical thrombectomy (MT) in patients with recurrent large vessel occlusion (rLVO). Here, we present a case series examining the outcome of early and delayed rLVO and the safety of repeat MT.

Methods:
We reviewed our prospectively-collected endovascular database for acute ischemic stroke (AIS) patients with LVO who underwent MT between July 2012 and February 2020. We included patients with recurrent stroke requiring repeat MT after successful first MT, either in the same vessel or in a different vascular territory, within 24 hours up to 924 days and compared it with patients who underwent single MT. Baseline demographics, angiographic, procedural, and outcomes data were compared in AIS patients who underwent recurrent MT (RT) versus single MT (ST). We completed a meta-analysis that evaluated papers from 2015 to 2020 which examined reocclusion after MT.

Result:
A total of 738 MT patients were included, of which 726 (98.4%) were in the ST group and 12 (1.6%) in the RT group (Table 1). Baseline characteristics were well balanced between the cohorts. The most common site of occlusion was in the MCA territory. Last known well (559 ± 982 vs. 267 ± 301 minutes, p = 0.358) was similar between the groups. There was no difference in the median number of passes (2 IQR 1-3, p=0.61) in the ST and RT groups, respectively. In the RT group, the mean time between repeat occlusion was 132.5 ± 275 days. Revascularization success, sICH rates (25% vs. 7.1%, p= 0.306), and mean 90-day mRS (1.3 ± 2.3 vs. 1.8 ± 2.7, p = 0.63) did not differ between the first MT (FT) and RT cohorts. No association between reocclusion and MT device (aspiration or stent-retriever), tPA given, statin, antiplatelet or anticoagulation therapy was found in the meta-analysis.

Conclusion:
Repeat MT in patients with early or delayed reocclusion appears to be safe. Larger, prospective studies are needed to evaluate these findings.
Abstract P504: Outcomes and Predictors of Successful First Pass in MCA Occlusions Using ADAPT Thrombectomy Technique - Insights From STAR
Authors: Almallouhi Eyad , Al Kasab Sami , Alawieh Ali , Al-Kawaz Mais , Starke Robert , Grossberg Jonathan A , Jabbour Pascal M , Wolfe Stacey , Fargen Kyle , Levitt Michael , Arthur Adam S , De Leacy Reade A , Park Min S , Raper Daniel , Polifka Adam , Crowley R. Webster , Dumont Travis , Osbun Joshua , Crosa Roberto , Maier Ilko , Kim Joon-tae , Casagrande Walter , Rai Ansaar , Chowdhry Shakeel , Mokin Maxim , Matouk Charles , Fragata Isabel , Williamson Richard , Yoo Albert J , Mascitelli Justin , Kan Peter , Psychogios Marios , Hui Ferdinand K , Spiotta Alejandro M ,   STAR collaborators
Published: March 2021

Introduction:
Successful first pass (SFP) has been identified as a key benchmark of the success of mechanical thrombectomy (MT). However, studies that evaluate the predictors and outcomes of SFP using ADAPT (A Direct Aspiration first Pass Technique) are limied by the small number of patients or single center design.

Methods:
We used data from the prospectively collected data from 28 stroke centers that are included in the Stroke Thrombectomy and Aneurysm Registry (STAR). Patients with middle cerebral artery (MCA) occlusions at the level of M1 or M2 segments were included. SFP was defined by achieving modified Thrombolysis in Cerebral Infarction (mTICI) score≥2b with a single aspiration attempt. A multivariable logistic regression analysis was used to assess the predictors of SFP and evaluate the relationship between SFP and favorable 90-day outcome (90-day modified Rankin scale ≤2).

Results:
Out of 6123 patients included in STAR, 1002 (16.4%) underwent MT of M1 or M2 occlusion using ADAPT technique. SFP was achieved in 390 (38.9%) patients. SFP patients were older (72 vs. 69, P=0.007), had higher Alberta Stroke Program Early CT Score (ASPECTS) on presentation (9 vs. 8, P=0.018) (Table 1). On multivariable analysis, neither age (aOR 1.006, 95% CI 0.996-1.016, P=0.252) nor ASPECTS (aOR 1.055, 95% CI 0.976-1.141, P=0.179) were independent predictor of SFP. Importantly, SFP was independently associated with favorable 90-day outcome (aOR 2.769, 95% CI 1.988-3.858, P<0.001) after controlling for age, sex, ASPECTS, history of atrial fibrillation, NIHSS on presentation, onset to groin time and IV-tPA.

Conclusion:
In this cohort of patients with M1 or M2 occlsuion undergoing MT using ADAPT technique, patients who had SFP were older and had better ASPECTS. However, both age and ASPECTS were not independently associated with SFP. Also, patients who had SFP were almost 3 times more likely to achieve favorable 90-day outcome.