bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P61: Safety and
E
fficacy of
I
ntravenous
E
ptifibatide as
S
tandalone
T
herapy for select
A
cute Ischemic Stroke Patients (SIESTA-I trial)
Authors: Mehta Siddhart , Ahmad Javaad , Hussain Mohammed , Brar Jaskiran , Chahal Harina , Shah Yash , Moussavi Mohammad , Kirmani Jawad F
Published: March 2022

Background and Objective:
There is existence of data on the successful application of Eptifibatide, a cyclic heptapeptide inhibitor of glycoprotein IIb/IIIa receptor with its short half-life in coronary interventions. There is minimal literature in the application of stroke treatment. Our objective was to report the results of an open labeled retrospective registry to evaluate the safety (in regards to hemorrhagic complications) and efficacy (regarding discharge NIHSS) of administering high dose IV Eptifibatide as a standalone therapy for acute stroke in patients ineligible for IV r-tPa or neurointervention.

Methods:
All patients with acute ischemic events between 2010-13 were included that presented to our university affiliated comprehensive stroke center. Patients that received Eptifibatide as standalone therapy were reviewed. Eptifibatide was administered intravenously as a 135-μg/kg single-dose bolus, then a 0.5-μg/kg/min infusion. Charts were reviewed for all patients to assess for primary safety and efficacy endpoint. The primary safety endpoint was bleeding. Bleeding complications were classified as major (symptomatic intracranial hemorrhage and hemoglobin decrease by >5mg/dl), minor (hemoglobin decrease 3-5 mg/dl) and insignificant as proposed by the TIMI score (Thrombolysis in Myocardial Infarction). The primary efficacy end point was neurological improvement/deterioration as defined by a change in discharge NIHSS by > 4 points compared to initial NIHSS respectively.

Results:
Of a total patient population of 2,329, total of 20 patients (mean age of 73, 50% male (n=10)) received Eptifibatide administered intravenously for a mean duration of 32.5 hours (range 17-67 hours). No major or minor bleeding was observed except for a patient who exhibited minor complication of knee hemarthroses. 9 patients demonstrated early neurological improvement with only 2 exhibiting neurological deterioration related to extension of ischemic core.

Conclusion:
Application of IV Eptifibatide in achieving recanalization and preventing extension may be a safe standalone therapy in acute ischemic stroke patients ineligible for other neurological interventions. Larger randomized trials are required to corroborate our findings.
Abstract W P68: Safety of Carotid Revascularization During the Acute Period of Neurological Symptom Onset in Female Patients
Authors: De Rango Paola , Lenti Massimo , Cieri Enrico , Farchioni Luca , Parlani Giovanbattista , Fiorucci Beatrice , Caso Valeria
Published: March 2022

Background:
Benefit from carotid revascularization might be lower in female patients due to increased periprocedural stroke/death risks exposure.

Aim of this study was to define the 30-day risks of stroke/death after carotid endarterectomy (CEA) and carotid stenting (CAS) in symptomatic female patients treated within 15 days from last neurological event.

Methods:
Data of 227 consecutive patients treated during 2009-2014 by CEA or CAS within 15 days from neurological symptoms were analyzed by sex and stratified according to the delay of symptom onset.

Results:
There were sixty-six (29.1%) females (mean age 74.6y): 32 were treated within the first 7 days and 13 within 48hours from symptom onset. Stroke was the index event in 33 (50%), while in 17 (25.8%) recurrent TIA were recorded in the last 2 weeks before intervention. Twenty-six procedures were performed by CAS with similar rates in males and females. Baseline comorbidity profile, presenting symptoms (stroke, TIA, recurrent TIA) and timing of treatment were comparable between sexes, but there was a tendency for higher proportion of preoperative cerebral lesions in females compared to males (60.7% vs 42.8%; P=.022).

The 30-day stroke and death rate was 3.0% in females (2/66) and 2.5% (4/161) in males (Odds ratio 1.27; 95% Confidence Interval, 0.27-7.12; P=.99).There were no 30-day deaths or cerebral hemorrhage in the female group. No 30-day stroke or death occurred in patients undergoing the procedure within the first 48 hours. In adjusted analyses female sex was not associated with increased stroke/death risk. At 4 years survival rates were 98% in female and 87.6% in male patients (P=.11); freedom from stroke rates were 90.1% vs. 95.5% (P=.19) in females and males, respectively.

Conclusions:
Female patients with symptomatic carotid stenosis may benefit from carotid intervention when performed within the acute (15 days) or hyperacute (48 hours) period after neurologic ischemic event. 30-day stroke and death rates were below or comparable to those of previous randomized trials and treatment was effective in preventing new strokes at mid-term.
Abstract W P69: Remote Intracerebral Hemorrhage After Intravenous Thrombolysis in Patients With Ischemic Stroke: An Uncommon Complication With an Unfavourable Outcome
Authors: Prats-Sánchez Luis , Almendrote Miriam , Sotoca-Fernández Javier , Martínez-Domeño Alejandro , Delgado-Mederos Raquel , Marín Rebeca , Camps Pol , Casoni Francesca , Dorado Laura , Codas Javier , Gómez-Gonzalez Alejandra , Purroy Francisco , Gómez-Choco Manuel , Cánovas David , Cocho Dolores , Garces Moises , Martí-Fàbregas Joan ,   Stroke Programme, Catalan Agency for Health Information, Assessment and Quality (Barcelona,Spain)
Published: March 2022

Background and purpose:
Few studies have examined Remote parenchymal hemorrhage (PHr) after intravenous thrombolysis (IV-tPA). The aim of this study was to determine frequency, risk factors, associated clinical and radiological features, and prognosis in patients with PHr.

Methods:
This is a multicentre (n=9 hospitals) study of consecutive patients included in the SONIIA registry- monitors quality of reperfusion therapies in Catalonia-(January 2011 - August 2013). All patients were treated with IV-tPA according to the SITS-MOST criteria and had a follow-up CT within the first 36 hours. PHr, solitary or multiple (≥2), was defined as any hemorrhage detected by CT in regions without visible ischemic damage. Variables collected: Demographics; Vascular risk factors; NIHSS (admission and at 24 hours); Etiology; Previous treatments; Hypertensive episodes (≥185/105mmHg) and hyperglycemia (≥140mg/dl) during treatment and within the first 24 hours; Functional outcome (favourable when Rankin scale ≤2) and mortality at 3 months. We reviewed neuroimaging of PHr and PH, and we considered symptomatic PHr when NIHSS increased ≥4 points. Bivariate and multivariate analyses compared patients with any PHr, pure PHr (PHr without associated PH) with those without PHr/PH.

Results:
We studied 992 patients (age 73.7 ± 13.4 years, 52.9% of them were men). We observed 34 (3.4%) patients with PHr and 26 (2.6%) of them were pure PHr, 75 (7.5%) PH and 883 (89%) without PHr/PH. PHr distribution: 11 (32.3%) of PHr were lobar, 7 (20.5%) deep, 3 (8.8%) brainstem/cerebellum, 5 (14.7 %) multiple and 8 (23.5%) associated to a PH. PHr was symptomatic in 17 (50%) cases. We found no significant differences between groups in demographics, frequency of traditional vascular risk factors, previous treatments, baseline NIHSS and etiology. However, hypertensive episodes (p=0.031) and hyperglycemia (p=0.012) during IV-tPA were independent predictors of pure PHr. Both PHr and pure PHr had worse neurological status at 24 hours (both p<0.001), worse functional outcome (p=0.003 and p=0.007) and higher mortality at 3 months (p=0.014 and p= 0.023).

Conclusions:
In conclusion, PHr was observed in 3.4% of patients and it was associated with a worse functional outcome and higher mortality at 3 months.
Abstract W P71: Analysis of Large Volume Penumbra PC400 Coil and 025” ID Microcatheter in Treatment of Anterior Communicating Artery Aneurysm Embolization: Safety and Efficacy Outcomes from a Multicenter Experience
Authors: Baxter Blaise , Deshaies Eric , Kabbani Mouhammed , Lynch John , Liu Kenneth , Lopes Demetrius , Klucznik Richard , Moyle Henry , Turk Aquilla , Gailloud Philippe , Roth Christian , Chowdhary Abhineet , Rappard George , Knauth Michael , Hui Ferdinand , Pergolizzi Richard , Prothmann Sascha , Khaldi Ahmad , Luong Emily , Hak Susana , Kuo Sophia , Nguyen Nam , Ueda Dawn , Sit Siu Po
Published: March 2022

Purpose:
We report clinical experience and long-term results in treating 39 AcomA aneurysms in 39 patients using the Penumbra PC400 large volume coil at 13 high volume centers. With its .020” coil size and use of 025” ID microcatheter, the safety and efficacy of the Penumbra Coil 400 (PC400) System in embolization of AcomA aneurysms has not yet been characterized.

Methods:
Our treatment cohort consisted of 39 aneurysms ranging between 3.5mm and 17mm, treated between March 2012 and May 2014. Six-month follow up were assessed. Data on angiographic results and procedural complications were collected prospectively and analyzed.

Results:
The mean aneurysm size was 6.2 mm, with 40.8% mean packing density. All aneurysms were treated entirely with PC400 coils, with mean of 5.1 coils placed. Twenty were ruptured and 19 unruptured. Sixty-six percent of the cases achieved an initial Raymond Scale of 1, and 23.7% achieved a Raymond scale of 2. The overall rate of retreatment was 0%, while the rate of morbidity and mortality caused by stroke <30 days was 1.8%. Comparison with a recently published meta-analysis showed similar or superior outcomes with lower procedural complication rates, most notably lower overall vasospasm rate of 6% vs 17% (p=0.023), lower retreatment rate of 0% vs 9% and higher long-term complete and near-complete occlusion of 96% vs 83% with PC400 coils (Tables 1, 2).

Conclusion:
ACE study data demonstrate that embolization using the PC400 System and 025” ID microcatheter in AcomA aneurysms leads to safe and effective short- and long-term outcomes.
Abstract W P74: The Effects of Hypertension and Hypotension on Patient-Specific Computer Modeled Clipping of an ICA Aneurysm
Authors: Riccardello Gerald J , Changa Abhinav R , Thomas Kiran G , Roman Max , Barr Luke K , Lott Dawn A , Singh Paul , Gandhi Chirag D , Prestigiacomo Charles J
Published: March 2022

INTRODUCTION:
Studies suggest that blood pressure changes alter the potential for development and rupture of aneurysms. This study aims to distinguish hemodynamic differences between hypertensive, hypotensive, and normotensive milieus in 3D patient-specific simulated clipping in various clip orientations.

MATERIALS AND METHODS:
A patient-specific 3D-geometric mesh model of a terminal ICA aneurysm was reconstructed with Mimics 17 (Materialise) from angiographic data. The 3D-model was modified in SolidWorks to simulate clip configurations. The volumetric flow rate waveform of the ICA in a patient was scaled to a 1.5 Pa cycle averaged WSS at the ICA; flow rate was changed by +/-25% to simulate hypertensive and hypotensive events. CFD was carried out in Fluent (ANSYS). WSS of the aneurysm in various clipping orientations were compared.

RESULTS:
The results of the CFD analysis of increased flow rates demonstrate clip-oriented-based differences in WSS that contribute to the potential for growth of aneurysm residuals. When pressures were scaled to hypo- or hypertensive pressure profiles, a qualitatively proportional change in WSS was identified. The patterns of WSS on the complete clipping differed from those on the incomplete clipping, with a shift in the regions of elevated WSS to areas of residual dome.

CONCLUSIONS:
The results suggest that changes in blood pressure contribute to the hemodynamic milieu proportionately. Though proportional, the area of impingement is shown to expand to areas of known abnormal histology, namely that of the residual dome. These data suggest that control of blood pressure may be paramount in the short and long term postoperative care of these patients.
Abstract W P79: Hyperhomocysteinemia Is Associated With Vulnerability of the Cerebral Aneurysmal Wall to Rupture in Ovariectomized Rats
Authors: Korai Masaaki
Published: March 2022

Introduction:
The pathogenesis of cerebral aneurysms is multifactorial. Hyperhomocysteinemia (HHcy) leads to endothelial and platelet deterioration and may be associated with the formation of cerebral aneurysms. We tested the hypothesis that HHcy plays a role in the growth and/or rupture of cerebral aneurysms.

Methods:
We exposed 13-week-old female Sprague-Dawley rats fed a high-salt diet to estrogen deficiency, hemodynamic stress, and induced hypertension. To induce HHcy we added methionine to their drinking water.

Results:
In methionine induced rats the aneurysms the total rupture rate was higher than in rats not treated with methionine. One fourth of the aneurysms arising at the anterior communicating (Acom) artery, and half of the aneurysms at the posterior half of the circle of Willis, but no aneurysms at the anterior cerebral artery-olfactory artery (ACA-OA) bifurcation ruptured. Immunohistochemically, the infiltration of M1 macrophages was increased at the Acom artery in methionine induced rats and the messenger ribonucleic acid level of matrix metalloproteinase (MMP)-9, the ratio of MMP-9 to tissue inhibitor of metalloprotease (TIMP)2, and the interleukin-6 level were higher at the Acom artery than the ACA-OA bifurcation. Treatment with folic acid abolished the exacerbated effects due to HHcy, suggesting that the propensity of cerebral aneurysms at the Acom artery to rupture is attributable to disequilibrium between the degradation molecules and their inhibitors and to macrophage infiltration.

Conclusion:
HHcy may be associated with vulnerability of the cerebral aneurysmal wall to rupture in hypertensive ovariectomized rats.
Abstract W P83: The Clinical Sequelae of Intraprocedural Aneurysmal Ruptures
Authors: Peneva Rali , Vargas Jan , Turk Aquilla S , Chaudry M. Imran , Turner Raymond D , Spiotta Alejandro
Published: March 2022

Introduction:
Aneurysmal (SAH) continues to be a significant cause of morbidity and mortality, despite advances in neuro critical care and management of vasospasm. Endovascular techniques have evolved rapidly and are safe alternatives to surgical clipping. Nonetheless, intra procedural ruptures are a serious complication with long term consequences. Our aims were to note the vital sign changes leading up to an intraprocedural rupture and to determine clinical outcomes of patients who had experienced such an event. We investigated whether patients who received immediate balloon assistance upon rupture fared better post-procedurally.

Methods:
This study utilized a single institution retrospective analysis of consecutive cases of intraprocedural aneurysmal ruptures from July of 2009 to July 2014 at the Medical University of South Carolina. Patient charts and angiographic records were reviewed. All cases were performed under general anesthesia in the neuro interventional suite with invasive blood pressure monitoring.

Results:
13 intraprocedural aneurysmal ruptures were reviewed. 8 were female and 5 were male, with ages ranging from 35 to 80 years. 8 aneurysms were unruptured at the time of the procedure, while 5 presented with SAH. 10 ruptures were treated with balloon inflation, 4 of which did not have a balloon immediately in place at the time of rupture. 4 patients had the rupture treated with balloon inflation only, 1 was treated with protamine injection, and 5 were treated with both balloon inflation and protamine. Mean heart rate was 77.6 bmp (+/- 10.9) prior to rupture and mean post rupture heart rate was 75.9 bmp (+/- 12.2), for an average change of -1.63 bpm (+/- 10.8). Average SBP prior to rupture was 106.4 mmHg (+/- 11.5), with a post rupture SBP of 119.2 mmHg (+/- 18) for an average elevation of 12.8 mmHg (+/- 11.6). Of the 5 patients whose CT scans remained unchanged from baseline, all had a balloon available for inflation, none needed a EVD, and no neurological deficits due to intraprocedural perforation were noted.

Conclusions:
Our study suggests that balloon assisted embolization procedures tend to produce better clinical outcomes. Further examination of the effects of both heart rate and systolic blood pressure leading up to ruptures will be necessary.
Abstract W P85: Immediate Balloon Assistance Leads to Improved Outcomes Following Intraprocedural Aneurysmal Ruptures
Authors: Peneva Ralitza , Kalan Beau , Spiotta Ajelandro
Published: March 2022

Introduction:
Aneurysms are balloon-like outpouchings of weakened arterial walls which can rupture and cause severe complications in patients, including subarachnoid hemorrhaging and hydrocephalus. Current treatment for cerebral aneurysms include surgical clipping or interventional radiology procedures using coiling or stenting.

Aims:
Our study aimed to (1) note the vital sign changes leading up to an intraprocedural aneurysmal rupture and (2) determine whether or not patients who received immediate balloon assistance upon rupture fared better than those who did not.

Hypothesis:
We assessed the hypothesis that 1) there will be significant spikes in heart rate and systolic blood pressure upon rupture and that (2) patients receiving immediate balloon assistance fared better post-procedurally.

Methods:
A single institution retrospective analysis of all intraprocedural aneurysmal ruptures from July of 2009 to present day at the Medical University of South Carolina was utilized.

Results:
In this time period, 13 intraprocedural aneurysmal ruptures occurred in 8 female and 5 male patients. In 9 cases, rupture was directly attributable to aneurysm perforation via coil or microcatheter. Heart rate spikes immediately upon rupture averaged -1.63 bpm +/- 10.8 while systolic blood pressure spikes averaged 12.7 mmHg +/- 11.6. Balloon assistance was available for 10 ruptures. Balloon inflation was the sole method of rupture treatment for 4 patients, 1 was treated via protamine injection to reverse heparinization, and 5 were treated with a combination of these. Of the 5 patients whose CT scans remained unchanged from baseline rather than indicating an increase in hemorrhage or hydrocephalus, all had a balloon available for immediate inflation and all were discharged with no need for a ventriculostomy and no neurological deficits.

Conclusions:
Our limited sample size suggests that a significant heart rate and systolic blood pressure spike does not appear to consistently occur upon aneurysmal rupture. A larger sample size is necessary to further explore vital sign changes. Balloon assisted embolization procedures tend to produce better clinical outcomes in instances of intraprocedural rupture. Future directions will involve expanding to more institutions.
Abstract W P86: The Barrel Vascular Reconstruction Device for the Treatment of Wide-Neck Bifurcation Aneurysms
Authors: Piotin Michel , Blanc Raphaël , Berge Jérôme , Turjman Francis
Published: March 2022

PURPOSE:
Complex wide-necked bifurcation aneurysms by using a single-stent and double (X and Y) stenting remain challenging. The purpose of the French Barrel™ Prospective Registry, an intention to treat study, is to evaluate the safety and probable benefit of the Barrel VRD when used to facilitate endovascular coiling of wide-neck bifurcating.

METHODS:
The Barrel VRD was intended for use with embolic coils for the treatment of wide-neck bifurcating intracranial aneurysms arising from a parent vessel with a diameter of ≥ 2mm and ≤ 4 mm. A wide-neck is defined as having a neck width ≥ 4 mm or a dome-to-neck ratio < 2. Patients (all harboring unruptured aneurysms) were placed on a double anti-platelet protocol (Clopidogrel and ASA) prior to treatment.

RESULTS:
From December 2013 to June 2014, 18 patients harboring 18 aneurysms (7 MCA, 4 basilar tip, 4 AcoA, 3 ICA termination) were enrolled within the French Barrel Registry thus far. One patient was enrolled, but not treated due to being a low anti-platelet responder. Aneurysm necks ranged from 3.1 to 8.0 mm (mean: 4.8) and dome/neck ratio ranged from 0.6 to 1.7 (mean : 1.2). Trans-cell microcatheter placement was obtained in all cases. Technical success was 88.2% (15/17). In 1 case, 2 coil loops protruded outside the Barrel within the parent vessel, in another case the Barrel moved slightly during coil delivery microcatheter placement into the sac. Discharge mRS was 0 for all but 1 patients (this patient was mRS 2 at admission). Adverse events included 1 groin hematoma, and 1 aneurysm coil perforation, related to the procedure, but not the Barrel VRD.

CONCLUSIONS:
The initial French Barrel Registry results demonstrate that the Barrel VRD device is new tool for the endovascular treatment of wide neck bifurcation aneurysms.
Abstract W P88: THINkS: A Novel Tool for Multiscale CFD Calculations of the Cerebral Vasculature
Authors: Huang P G , Yu Hongtao , Schwieterman Ryan S , Yang Zifeng , Ludwig Bryan R
Published: March 2022

Background:
Computational Fluid Dynamics (CFD) is emerging as a tool for better assessment and management of cerebral aneurysms. However, CFD calculations are often restricted to a small arterial zone and the solution could be inaccurate depending on the boundary conditions prescribed. A 1D simulation of the complete vessel network, THINkS (Total Human Intravascular NetworK Simulation), is introduced to better describe boundary conditions and to provide flow information related to the complete complex vessel network.

Methods:
THINkS is a modifiable, 1D network simulation of the complete human blood circulatory system. A validation of THINkS was performed using volumetric flow rates recorded in the cerebral vasculature waveforms over the cardiac cycle. Validated waveforms of the; (1) ICA proximal to the siphon, (2) ICA proximal to circle of Willis (CoW), and (3) mid- basilar artery were obtained. THINkS predictions were compared to the experimental bounds for both absolute and dimensionless flow rate quantities.

Results:
THINkS calculations indicated usefulness of the model in predicting the trends of cerebral flow patterns. THINkS solutions were validated with a number of in vivo experimental data and the agreement was excellent. A comparison with experiments for the impact of incomplete CoW to the flow patterns was also made and the trend shows an excellent agreement with reported data.

Conclusion:
THINkS allows for more accurate boundary conditions for 3D zonal-based CFD calculations. THINkS has been validated against available experimental data and shown to respond correctly to the flow pattern change caused by the variation in CoW. It provides the detailed flow information of the entire human body including cerebral vessel network. Our aim is to use THINkS to generate accurate flow assessments, guide surgical treatment plans, and more reliably predict risks associated with vascular lesions.
Abstract W P99: OCT4B-190 Exerts Neuroprotection After Stroke by Regulating GSK-3β and HDAC-6
Authors: Chen Yanting , Wu Zhengzheng , Zhu Xiaolei , Jin Jiali , Zang Xuefeng , Ye Dan , Li Xiaoxi , Xu Yun
Published: March 2022

Backgrounds and Objectives:
OCT4 is a key regulator in maintaining the pluripotency and self-renewal of embryonic stem cells (ESCs). Human
OCT4
gene has three mRNA isoforms, termed OCT4A, OCT4B, and OCT4B1. OCT4A mRNA can translate into OCT4A protein. OCT4B mRNA has been recently found to generate three protein isoforms by alternative translation initiation, including the 265-amino-acid protein isoform OCT4B-265, the 190-amino-acid protein isoform OCT4B-190, and the 164-amino-acid protein isoform OCT4B-164. OCT4A is now widely recognized as a transcription factor responsible for the stemness of ESCs, while the biological functions of OCT4B protein isoforms are still not identified. A previous study showed that OCT4B-190 functioned in stress response. In this study, we further investigated biological roles of OCT4B-190 in stroke setting
in vivo
and
in vitro
.

Methods and Results:
Using primary neuron cultures, we demonstrated that OCT4B-190 overexpression enhanced neuronal viability 24hr after oxygen-glucose deprivation (OGD) treatment, with downregulated OGD-induced histone deacetylase 6 (HDAC6) and glycogen synthase kinase-3 (GSK-3). Furthermore, it was shown that HDAC6 and GSK3 were co-expressed in the cytosol of neurons, and OCT4 had an effect on interactions between HDAC6 and GSK3 after OGD that could be mimicked by GSK-3 inhibitors. Moreover, in male C57BL/6 mice subjected to transit middle cerebral artery occlusion (tMCAO), OCT4B-190 overexpression reduced post-stroke infarct volume and improved neurological functions at 3d after stroke. In addition, OCT4B-190 demonstrated similar impacts on HDAC6 and GSK3 alterations after MCAO treatment.

Conclusions:
These evidence suggest that OCT4B-190 exerts neuroprotection potentially by regulating GSK-3/HDAC6 pathway in ischemic stroke.
Abstract 1: Effect of Intra-arterial Treatment in Patients Who are not Eligible for Intravenous alteplase. A Post-hoc Mr Clean Subgroup Analysis and Meta-analysis
Authors: Dippel Diederik W , Mulder Maxim J , Fransen Puck S , Beumer Debbie , Van den Berg Lucie A , Berkhemer Olvert A , Lingsma Hester F , Roos Yvo B , van Oostenbrugge Robert J , van Zwam Wim H , Majoie Charles B , van der Lugt Aad ,   MR CLEAN Investigators
Published: March 2022

Introduction:
MR CLEAN showed benefit of intra-arterial therapy (IAT) with retrievable stents in patients with acute ischemic stroke caused by a proximal intracranial occlusion in the anterior circulation. Uncertainty exists about the effect of IAT in patients who are not eligible for pretreatment with intravenous alteplase (IVT). We tested for treatment effect modification of IAT by IVT.

Hypothesis:
The effect of IAT is not modified by IVT in patients with acute ischemic stroke.

Methods:
All 500 patients who were randomized in MR CLEAN were included in this substudy. We distinguished between patients who were and were not pretreated with IVT. Primary outcome was the modified Rankin Scale (mRS) at 90 days. We estimated the effect of IAT on the shift on the mRS and tested for interaction of IVT with IAT by introducing a multiplicative term in a multivariable ordinal logistic regression model. We then combined published unadjusted treatment effect estimates in patients without IVT from MR CLEAN, REVASCAT and ESCAPE trials, of treatment effect in patients without IVT in a fixed effects model after testing for heterogeneity.

Results:
In MR CLEAN, 55 (11%) patients were not pre-treated with IVT, The effect size in patients not treated with IVT was 2.06 [95% Confidence Interval (CI): 0.69-6.13], and 1.71 [95% CI: 1.22-2.40] in patients pretreated with IVT, without statistical interaction between IAT and IVT (p=0.92). In REVASCAT, the effect of IAT in 56 patients not treated with IVT was 2.6 [95% CI: 1.0-7.1]) and in ESCAPE it was 2.6 [95% CI: 1.1-5.9] in 76 patients. The combined estimate was 2.3 [95% CI: 1.5-3.7], without heterogeneity (p=0.78).

Conclusion:
The available evidence suggests that patients with acute ischemic stroke and a proximal intracranial anterior circulation occlusion, presenting within 6 hours with contra-indications for intravenous alteplase, benefit from IAT.
Abstract 101: Repeat Bypass Surgery for Moyamoya Disease Refractory to Previous Surgery
Authors: Kuroda Satoshi , Kashiwazaki Daina , Akioka Naoki , Kuwayama Naoya
Published: March 2022

Purpose:
Surgical revascularization is known to reduce subsequent incidence of ischemic and hemorrhagic stroke with low morbidity in moyamoya disease. However, repeat bypass surgery is required for a certain subgroup of patients, although the information on indication, surgical technique, and outcome is limited. Therefore, this study was aimed to precisely analyze clinical features, surgical technique, and long-term outcome of repeat bypass surgery for refractory moyamoya disease.

Methods:
This study included 16 patients who underwent repeat bypass surgery because previous surgery was inadequate in 10 patients or because the posterior cerebral artery was further involved after surgery in 6. There were 7 males and 9 females. Their age ranged from one to 69 years. Precise radiological examinations were performed before surgery, using MRI, cerebral angiography, and SPECT. All 10 patients who previously underwent inadequate surgery repeated headache attack, TIA, or hemorrhagic stroke, and underwent repeat bypass surgery targeted to the non-revascularized area, using STA-MCA anastomosis and/or indirect synangiosis as appropriate. OA-PCA anastomosis and/or indirect bypass was required in 6 patients who developed disease progression in the PCA.

Results:
All 16 patients successfully underwent repeat bypass surgery. Postoperative course was uneventful. Postoperative examinations revealed good revascularization in the operated hemispheres and the improvement of cerebral hemodynamics. Headache attack and TIA disappeared within 6 months at the latest after surgery. During follow-up periods, one of 16 patients died of recurrent hemorrhagic stroke two years after repeat bypass surgery.

Conclusion:
Repeat bypass surgery is feasible and effective to reduce further incidence of headache attack, TIA, and ischemic and hemorrhagic stroke. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.
Abstract 106: A Simple Screening Tool to Identify Stroke or TIA Patients With Moderate or Severe Obstructive Sleep Apnea: The CHA2TS2 Score
Authors: Rangaraju Srikant , Gadodia Gaurav , Razzak Ammar , Davis Brittaine , Henriquez Laura , Trotti Lynn Marie , Nahab Fadi
Published: March 2022

Introduction:
The frequency of obstructive sleep apnea (OSA) among stroke and TIA patients varies from 14% to 72% depending on apnea-hypopnea index (AHI) cut-off points and the study population. Various screening tools have been validated in unselected patients referred for diagnostic polysomnography (DP) but a screening tool that identifies stroke/TIA patients at highest risk of moderate-severe OSA is lacking.

Hypothesis:
A simple screening tool that considers medical comorbidities and sleep-related symptoms can identify stroke/TIA patients who are most likely to have moderate-severe OSA.

Methods:
Consecutive stroke and TIA patients referred by vascular neurology for DP from September 2012 to February 2015 were included in a retrospective analysis. Baseline clinical characteristics, DP results and outcomes were collected retrospectively. Moderate-severe OSA was defined as AHI≥15.

Results:
Of 65 patients (mean age 61±14 years, 48% female, 51% African-American) included in this analysis, 19 (29.2%) were diagnosed with moderate-severe OSA. In multivariable analysis using backward elimination (entry and exit thresholds 0.15), predictors of moderate-severe OSA included history of Coronary artery disease, Hyperlipidemia, older Age, history of Atrial fibrillation, former or current Tobacco use and self- or family-reported Snoring or daytime Sleepiness (CHA2TS2). Variables excluded were sex, race, hypertension, diabetes, depression, chronic obstructive pulmonary disease, patent foramen ovale, body mass index, stroke subtype and wakeup onset . The CHA2TS2 model had excellent predictive power for moderate-severe OSA (AUC= 0.91). CHA2TS2 ≥5 had 100% sensitivity and 54% specificity for detecting moderate-severe OSA.

Conclusions:
We developed a simple screening tool that can identify stroke and TIA patients who have high likelihood of having moderate or severe OSA identified on their DP. Prospective validation of CHA2TS2 score is currently underway.
Abstract 107: Dextromethorphan/Quinidine for Treatment of Pseudobulbar Affect Secondary to Stroke: Results from the PRISM-II Study
Authors: Zorowitz Richard , Alexander David , Shin Paul , Ledon Fred , Formella Andrea , Yonan Charles , Davis Charles , Siffert Joao
Published: March 2022

Introduction:
Pseudobulbar affect (PBA) is characterized by sudden, frequent, uncontrollable laughing/crying episodes that are out of proportion or disconnected from mood or social context. PRISM-II evaluated dextromethorphan/quinidine (DM/Q) effectiveness for PBA secondary to stroke (reported here), dementia, or traumatic brain injury.

Hypothesis:
DM/Q is effective and well tolerated for PBA secondary to neurologic disease such as stroke.

Methods:
Open-label, 12-week, US multicenter trial of DM/Q 20/10 mg twice/day (starting once/day in week 1). Eligible patients had PBA with Center for Neurologic Study-Lability Scale (CNS-LS) ≥13 (range 7-35), were ≥3 months post-stroke (ischemic or hemorrhagic) and neurologically stable. Primary endpoint: CNS-LS change at Day 90/early withdrawal; secondary endpoints: PBA episode count, CGI-C, PGI-C, PHQ-9, QOL-VAS, patient satisfaction, MMSE, Stroke Impact Scale, and adverse events.

Results:
113 enrolled; 91 (80.5%) completed. CNS-LS improved by mean [95% CI] -7.6 [-9.0, -6.2] points at Day 90/endpoint from baseline mean (SD) of 20.8 (4.7), P<.001 vs baseline. PBA baseline mean (SD) weekly episode count of 19.6 (29.6) was reduced by 75.5% at Day 90/endpoint (P<.001 vs baseline). Patients or clinicians reported “much” or “very much” improvement with respect to PBA in 67.7% (PGI-C) and 75.0% (CGI-C) of patients. Improvements were also seen for PHQ-9, QOL-VAS and MMSE. All Stroke Impact Scale domain scores improved vs baseline (P=.02 to P<.001); Adverse events were reported by 40 (35.4%), assessed as treatment-related in 16 (14.2%), and led to discontinuation in 6 (5.3%).

Conclusion:
Consistent with the approved indication, DM/Q improved PBA symptoms, reduced frequency of PBA episodes and was well tolerated in patients with PBA secondary to stroke. CNS-LS change from baseline was similar to that seen with DM/Q in a Phase 3 trial in ALS or MS (mean change [95% CI] -8.2 [-9.4, -7.0]) and greater than improvement with placebo in that trial (mean change -5.7[-6.8,-4.7]). DM/Q was associated with global clinical improvements (PGI-C, CGI-C), along with improvements in cognition, depressive symptoms, stroke-related function and quality of life. Supported by: Avanir Pharmaceuticals, Inc.
Abstract 114: Equitable Improvements in Sex and Race/Ethnic Specific Door-to-Needle Times in Acute Ischemic Stroke: Findings From Target: Stroke Phase I
Authors: Fonarow Gregg C , Zhao Xin , Smith Eric , Saver Jeffrey , Reeves Mathew J , Bhatt Deepak L , Schulte Philip J , Xian Ying , Hernandez Adrian , Peterson Eric , Schwamm Lee H
Published: March 2022

Background:
Prior studies have demonstrated that women and black patients with acute ischemic stroke were significantly less likely to be treated with intravenous tPA with door-to-needle (DTN) times of ≤60 minutes. Whether stroke quality improvement programs can impact care to a similar degree among sex and race/ethnic groups has not been well studied. This study aims to assess sex and race/ethnicity specific improvements in DTN times before and after the launch of Target: Stroke Phase I in 2010.

Methods:
Target: Stroke identified and disseminated 10 best practice strategies, provided clinical decision support tools, and set hospital recognition goals. Rates of DTN times ≤60 minutes and cumulative improvements pre- 2003-2009 were compared to post-Target Stroke 2010-2013 for sex and race/ethnic groups. Data were adjusted for patient and hospital characteristics.

Results:
There were 71,169 intravenous tPA treated patients (27,303 pre-; 43,866 post-Target Stroke) from 1030 GWTG-Stroke hospitals. Patients were median age 72, 50.1% women, and 72.0% white, 13.8% black, and 6.6% Hispanic. Overall, patients with DTN times ≤ 60 minutes increased from 26.5% (95% CI 26.0-27.1%) pre-intervention to 41.3% (95% CI 40.8-41.7%) post-intervention (P<.0001), reaching 51.0% in 2013. There were no significant differences in cumulative improvements in DTN times by sex and race/ethnic groups, even after adjustment for other patient and hospital characteristics (Table).

Conclusions:
The implementation of Target: Stroke was associated with equitable improvements in DTN times for men and women and for black, white, and Hispanic ischemic stroke patients. These findings highlight the role that quality improvement programs can play in providing more timely and effective stroke care for all patients, irrespective of sex and race/ethnicity.
Abstract 116: Impact of Cerebral White Matter Disease Burden on the Critical Infarct Volume Predicting a Good 90-day Outcome
Authors: Patti Jatinder S , Helenius Johana , Moonis Majas , Goddeau Richard P , Henninger Nils
Published: March 2022

Introduction and Hypothesis:
Several studies found that critical infarct volumes <30 mL best predict good outcome after acute ischemic stroke. This is an important issue in light of increasing use of advanced imaging methodologies to select patients based on imaging rather than purely time-based criteria. The burden of pre-existing white matter disease (WMD) has been shown to impact infarct extent, functional deficit severity, and final outcome. We hypothesized that the threshold best predicting outcome is significantly modulated by the degree of pre-existing WMD burden.

Methods:
We quantified infarct volumes on diffusion-weighted imaging using manual planimetry in 371 consecutive patients with supratentorial, anterior circulation ischemic strokes evaluated between January 2014 and December 2014. WMD was graded according to the Fazekas score and dichotomized to mild (Fazekas 0-2) vs. severe (Fazekas 3-6). Receiver operator characteristics curves were calculated to determine the lesion-threshold (mL) best predicting an excellent, good, and favorable outcome at 90-days as defined as modified Rankin scale score of 0-1, 0-2, and 0-3, respectively.

Results:
Figure 1.
In the entire cohort, the ischemic lesion thresholds best predicting outcome were similar across 90-day outcome categories (∼25-30 mL; Figure 1 A&B) and consistent with thresholds defined by prior studies. However, patients with mild WMD tolerated 51% and 72% greater ischemic infarct volumes than patients with severe WMD to achieve good and favorable outcomes, respectively.

Conclusions:
“Standard” lesion thresholds may be too restrictive in predicting a good outcome in patients with mild WMD. Adjusting for markers of brain health such as WMD burden may improve on lesion threshold definition to predict outcome.
Abstract 118: External Validation of the TeleStroke Mimic (TM) Score for Predicting Stroke Mimics Evaluated During Telestroke
Authors: Ali Syed F , Hubert Gordian , Switzer Jeffrey , Majersik Jennifer , Backhaus Roland , Vedala Kishore , Sundararaghavan Anirudh , Shepard Lucy Wylie , Schwamm Lee
Published: March 2022

Introduction:
Up to 30% of acute stroke evaluations are deemed stroke mimics, and these are common in telestroke as well. We recently published a risk prediction score, derived from the Partners TeleStroke Network, for use during telestroke encounters to differentiate stroke mimics (SM) from ischemic cerebrovascular disease (iCVD). Using data from 3 distinct US and European telestroke networks, we sought to externally validate the TM score in a broader population.

Methods:
We evaluated the TM score in 1,985 telestroke consults from the University of Utah Telestroke Program (n=190), Georgia Regents University Telestroke Network (n=719) and the Bavarian TeleMedical Project for integrative Stroke Care (TEMPiS) in Germany (n=1076). We report the AUC in ROC curve analysis with 95% CI. The TM score = 0.2*(Age in years) + 6*(Hx of atrial fib) + 3*(Hx of HTN) + 9*(facial weakness) + 5*(NIHSS > 14) - 6*(Hx of seizure). Lower TM scores correspond with a higher likelihood of being a stroke mimic.

Results:
Based on final diagnosis at the end of the telestroke consultation, there were 691/1985 (34.8%) SM in the external validation cohort. We tested the association between the TM score and the diagnosis of stroke mimic (Table). The TM score performed well at the external centers on ROC curve analysis with an AUC of 0.70 (0.67 - 0.73; p<0.001), similar to what we observed during the development of the score at our center.

Conclusion:
As telestroke consultation expands, increasing numbers of SM patients are being evaluated. The TM score correctly predicted the presence of a SM in these diverse cohorts just as well as in our original cohort. Decision-support tools based on predictive models, like the TM score, may help highlight key clinical differences during complex, time-critical telestroke evaluations.
Abstract 122: Cortical Superficial Siderosis is a Predictor of Early Recurrent Intracerebral Hemorrhage in Cerebral Amyloid Angiopathy
Authors: Roongpiboonsopit Duangnapa , Charidimou Andreas , William Christopher M , Lauer Arne , Falcone Guido J , Raminez Sergi M , Biffi Alessandro , Ayres Alison , Vashkevich Anastasia , Awosika Oluwole O , Rosand Jonathan , Silverman Scott B , Gurol M. E , Greenberg Steven M , Viswanathan Anand
Published: March 2022

Background and Purpose:
Cerebral amyloid angiopathy (CAA) is a major cause of lobar intracerebral hemorrhage (ICH). A subgroup of patients with CAA experience multiple, recurrent ICHs over a short period of time. In this study, we investigated predictors of early lobar ICH recurrence (defined as ICH within six month after index event) in order to better understand the mechanisms for early recurrence in CAA-related ICH.

Methods:
Subjects were consecutive survivors (age≥55) of spontaneous symptomatic CAA-related lobar ICH according to the Boston criteria drawn from an ongoing longitudinal cohort study. All subjects had brain computed tomography (CT) scan and magnetic resonance imaging (MRI) at presentation. Baseline clinical, imaging and laboratory data were collected. Neuroimaging markers including focal (≤3 sulci) or disseminated (>3 sulci) cortical superficial siderosis (cSS), acute convexity subarachanoid hemorrhage (cSAH), cerebral microbleeds (CMBs), white matter hyperintensities and baseline ICH volume, on CT and/or MRI were evaluated. Subjects were followed prospectively for future recurrent symptomatic ICH. Cox proportional hazard models were used to identify predictors of early recurrent ICH adjusting for potential confounders.

Results:
A total of 296 patients with probable or possible CAA were enrolled. In univariable analysis, the presence of disseminated cSS, cSAH, and number of CMBs were predictors of early recurrent ICH (p<0.05 for all comparisons). After adjusting for age and previous symptomatic ICH history, disseminated cSS on MRI and cSAH on CT were independent predictors of early recurrent ICH (HR 3.79, 95% CI 1.46-9.84, p=0.006, HR 3.16, 95% CI 1.05-9.51, p=0.041, respectively).

Conclusions:
Disseminated cSS on MRI and cSAH on CT are independent imaging markers of increased risk for early recurrent ICH. These markers may provide additional insights into the mechanisms of ICH recurrence in patients with CAA.
Abstract 123: Correlation of Cerebral Microbleeds Distribution to Amyloid Burden in Patients With Spontaneous Intracerebral Hemorrhage
Authors: Tsai Hsin-Hsi , Tsai Li-Kai , Chen Ya-Fang , Yen Ruoh-Fang , Jeng Jiann-Shing
Published: March 2022

Background and Purpose:
The diagnosis of cerebral amyloid angiopathy (CAA) mainly depends on clinical estimation such as the location of ICH or cerebral microbleeds (CMBs). We aimed to use [11C]PiB PET to image cerebral β-amyloid deposition and validate the CAA diagnosis in patients with ICH.

Methods:
Twenty six patients with spontaneous ICH received cerebral [11C]PiB PET to measure the amyloid burden and 3-T magnetic resonance susceptibility weighted imaging (SWI) to analyze the distribution of CMBs. Seven patients with Alzheimer’s disease (AD) and 7 healthy subjects were included for a comparison. The lobar amyloid burden was expressed as average standardized uptake value (SUV) using the commercial software package PMOD. The number of CMBs was counted using the Microbleed Anatomical Rating Scale (MARS).

Results:
The amyloid burden in patients with ICH (0.72±0.27) was significantly higher than that of heathy controls (0.47±0.17, p=0.03), but lower than that of AD patients (1.31±0.38, p=0.001). The amyloid burden was not significantly different between the patients with cortico-subcortical (frontal, temporal, parietal and occipital lobes) ICH and those with deep (putamen, thalamus, caudate and cerebellum) ICH (0.77±0.32 vs. 0.67±0.20, p=0.66). CMBs were present in 23 of 26 patients (88.5%). The amyloid burden was higher in patients with CMBs located predominantly at the cortico-subcortical areas (n=8) than those with CMBs located predominantly at the deep regions (n=9) (0.96±0.30 vs. 0.54±0.13, p=0.009). The ratio of cortico-subcortical CMB number to deep CMB number was positively correlated with the amyloid burden (γ=0.65, p=0.004).

Conclusion:
The distribution of CMBs is a better indicator than the ICH location to predict cerebral β-amyloid deposition in patients with ICH.
Abstract 124: Progression of Brain Network Alterations in Patients With Cerebral Amyloid Angiopathy
Authors: Reijmer Yael D , Fotiadis Panagiotis , Martinez-Ramirez Sergi , Ayres Alison M , Vashkevich Anastasia , Schwab Kristin , Rosand Jonathan , Viswanathan Anand , Gurol M. E , Greenberg Steven M
Published: March 2022

Introduction:
Cerebral amyloid angiopathy (CAA) is a common form of small vessel disease. We recently showed that CAA is associated with functionally relevant brain network alterations, in particular affecting white matter connections in posterior regions. Here we examined how these brain network alterations progress over time.

Hypothesis:
Brain white matter network alterations in CAA progress from posterior to frontal regions.

Methods:
Thirty-three patients with probable CAA (16 with intracerebral hemorrhage (ICH)) underwent multimodal brain MRI at two time points (mean follow-up time: 1.3±0.4 years). Brain networks were reconstructed using graph theory and the global efficiency and mean fractional anisotropies (FA) of posterior-posterior, frontal-frontal, and posterior-frontal connections of the ICH-free hemisphere were calculated. Microbleed count, dichotomized at the median, was used as a marker of CAA severity. We evaluated changes in FA and global efficiency over time in patients with moderate (n<35) vs. high (n≥35) microbleed counts with repeated measures analysis adjusted for age.

Results:
For all CAA patients, the FA of posterior-posterior connections declined between baseline and follow-up (effect of time: p=0.02; time x group interaction: p=0.16). A decline in FA of posterior-frontal and frontal-frontal connections was observed for patients with high but not moderate microbleed counts (time x group interaction: p=0.007 and p=0.005). A similar time x group interaction effect was observed for global network efficiency (p=0.03). Associations were independent of ICH, white matter hyperintensity volume, or total brain volume.

Conclusions:
Brain network alterations in patients with CAA worsen measurably over just 1.3-year follow-up and appear to progress from posterior to frontal regions with increasing disease severity.