bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 099: Reversible Cerebral Vasoconstriction Syndrome Secondary to Weight Loss Patch: A Case Report​
Authors: Narayanan Karthik K. , Miremadi Brian B. , preet Gunjan , George Tikku , Hendry Heer
Published: March 2024

Introduction

Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a clinico‐radiographical syndrome characterized by severe thunderclap headache and reversible multifocal arterial vasoconstriction1. RCVS can be spontaneous or related to a trigger such as vasoactive medication/supplements. There is no previous data on the association of weight loss patch formulation in the genesis of unexplained RCVS.

Methods

A woman in her 40s presented with five days of recurrent acute onset severe right frontal headaches after starting Thrive weight loss patch supplementation. Head CT showed right frontal lobe hemorrhage with bilateral SAHs (Figure1). Brain MRI redemonstrated hemorrhages, numerous scattered foci of restricted diffusion, and a large area of restricted diffusion in the left insular cortex (Figure 2). Cerebral angiogram showed diffuse multifocal narrowing with a ‘beads‐on‐a‐string’ appearance of the cerebral vasculature and no aneurysms (Figure 3). Thrive patch contains undisclosed amounts of sympathomimetics and vasoactive compounds. Given the history, clinical symptoms of recurrent thunderclap headaches, and angiographic findings, the diagnosis of RCVS was made. Brain MRA 3 months after discharge showed no areas of cerebrovascular focal stenosis (Figure 4). At 4 month follow up, she reported 90% improvement of her symptoms.

Results

We report a temporal relationship between RCVS in a woman in her 40s and usage of a Thrive weight loss patch, which contains green tea extract, L‐arginine, 5‐hydroxytryptophan (5‐HTP), and Yerba Mate. We believe this report represents the first case of RCVS triggered by a weight loss patch. Multiple compounds within the Thrive patch have vasoactive properties that may contribute to RCVS genesis. Epigallocatechin (component of green tea extract) and 5‐HTP are metabolic compounds with potent vasoactive properties. They are components of weight loss and SSRI/SNRI medications respectively. Numerous studies have documented a temporal relationship between their use and subsequent development of RCVS2,3. Resolution of RCVS is reported after their discontinuation. Only one other case in our literature review investigated a patch modality in a temporal relationship with RCVS. It reported development and resolution of RCVS six days after nicotine patch use and discontinuation4. While Thrive patch does not contain nicotine, this case provides a further avenue for exploration as to whether pharmacokinetics of a patch modality influences a patient’s presentation with RCVS, as all prior reports document oral ingestion of substances.

Conclusion

Clinicians should be aware of the role of weight loss patches in RCVS, and their use should be assessed in large RCVS cohorts to clarify the association described in this report.
Abstract 118: Ophtalmic‐ethmoidal dural arteriovenous fistula
Authors: Tello Isaac E. , Montenegro Hector A.
Published: March 2024

Introduction

Ophtalmic dural arteriovenous fistula is not a common diagnosis. They usually present as subarachnoid hemorrhage, or parenquimatous hemorrhage as in our patient. Male, 46 years old, electric worker, right‐handed. Family: Diabetes mellitus, gastric cancer, COVID. Tobacco, Marihuana and alcohol positive. Presents SAH on October 2022 posterior to physical activity. Intense cephalea, nausea and vomit, anxiety, with no neurological deficit, and went to sleep. Two days after, he presents somnolence, altered verbal speech, and disorientation, and next day he presents seizure, then he goes to emergency. Physical examination: Normal. Neurological examination: Disorientation, confused and non‐fluent language, altered mental status. No other signs of focalization. No visual affectation.

Methods

Patient was evaluated at emergency room. CT: SAH and parenquimatous left frontal basal hemorrhage of 2x3.4cm. AngioCT: a dilated orbito frontal vein, and a venous aneurysm at the anterior third of the superior sagittal sinus. Fronto basal fistula was suspected. Angiography was performed, and it was found right fronto‐basal arteriovenous fistula Borden III, Cognard IV. Comunication between righ ophthalmic artery to superior sagittal sinus. Patient was delivered home three days after the event. When patient had recovered clinically, we performed embolization.

Results

We performed doble access, femoral artery and braquial vein. It was not possible to achieve to the fistula through vein system. We catheterized ophthalmic artery, and did embolization through it, with a successful result, and with no ophthalmic symptoms after embolization.

Conclusion

Dural arteriovenous fistulas are shunts found from dural vessels. This type of fistulas ophthalmic‐ethmoidal are rare. We performed angiography which is the know gold standard for diagnosis, and we tried to do a combined access which was not possible, so we performed simple embolization through ophthalmic artery. This approach it is performed and it has been reported as an effective and safe treatment.
Abstract 133: Safe Guiding Catheter Navigation in Carotid Artery Stenting for Low‐positioned Common Carotid Lesions: “No‐touching” Technique
Authors: Takenobu Yohei , Nomura Noriko , Sugita Yoshito , Okada Akihiro , Kawauchi Takeshi , Yang Tao , Hashimoto Kenji
Published: March 2024

Introduction

In carotid artery stenting (CAS), a guiding catheter (GC) placement to the appropriate position is the first step of the successful procedure. In normal settings, GC is navigated along with stable support of guidewire and inner‐catheter which are sent distally to external carotid artery. In cases of low‐positioned common carotid artery (CCA) lesions, however, safe GC placement without touching lesions is often difficult. Herein, we report the technique of safe GC navigation of “no‐touching” to the low‐position CCA plaque using Newton‐shaped stiff inner‐catheter.

Methods

We reviewed CAS procedures with low‐positioned CCA lesions using “no‐touching” technique: a balloon guiding catheter (BGC) was coaxially advanced in combination with 4‐French Newton‐shaped stiff inner‐catheter (Newton‐T®, Medikit, Tokyo, Japan). With its advantage of shape and stiffness buffering the kickback force with support of lesser curvature of aortic arch, BGCs were navigated to the appropriate position without touching to the plaques.

Results

The technique were applied in 5 cases (age: 73‐85 years old, 4 males, 4 left‐sided lesions) among the 37 consequent CAS cases. GC fixation by GooseNeck snare was used concurrently in 2 cases. BGCs were successfully navigated without touching plaques in all cases. CAS procedures were subsequently undergone and no complication was observed.

Conclusion

GC navigation using “no‐touching” technique with Newton‐T catheter was safe and useful in CAS procedures for low‐positioned CCA lesions.
Abstract 154: Training Independent Artificial Intelligence Models for the Detection of Intracranial Pathology
Authors: Eskian Mahsa , Sharashidze Vera , Heit Jeremy , Masoud Hesham , Gould Grahame
Published: March 2024

Introduction

Intracranial hemorrhage (ICH) and brain parenchymal midline shift (MLS) are medical emergencies and require timely diagnosis for early triage to lifesaving care. Artificial intelligence (AI) has shown potential in shortening the time to diagnosis. Although most of models have been compromised with the need of training sample resulting in overfitting as an obstacle to generalizability of models. In this study we introduce independent training models for the early detection of intracranial pathologies in imaging.

Methods

The software was developed using Python version 3.11.3. Software packages NumPy, scipy, skimage, stardist, and matpotlib were used for imaging intensity, color, and a shape‐based auto segmentation of intracranial objects.

Results

The current AI model is able to auto segment the Pineal gland for measurement of MLS (Figure‐1), and can detect imaging evidence of the hyperdense vessel sign (Figure‐2), and demonstrative large intracranial vessel (Figure‐3).

Conclusion

Our auto segmentation model is based on objects features instead of training models, thus providing a fast, generalizable, and feasible AI model. This tool has adjacent utility for detection and segmentation of intracranial vessels, hemorrhage, and midline shift.
Abstract 168: Platelet function testing and risk of periprocedural complications with flow diversion: An international multicenter study
Authors: Vranic Justin E. , Dmytriw Adam A. , Berglar Inka K. , Alotaibi Naif M. , Cancelliere Nicole M. , Stapleton Christopher J. , Rabinov James D. , Harker Pablo , Gupta Rajiv , Koch Matthew J. , Raymond Scott B. , Mascitelli Justin R. , Patterson T. Masoud , Namaani Kareem El , Kühn Anna L. , Pukenas Bryan , Jankowitz Brian , Burkhardt Jan M. , Siddiqui Adnan H. , Jabbour Pascal , Singh Jasmeet , Puri Ajit S. , Regenhardt Robert , Pereira Vitor M. , Patel Aman
Published: March 2024

Introduction

Dual antiplatelet therapy (DAPT) is necessary to minimize the risk of periprocedural thromboembolic complications associated with aneurysm embolization using Pipeline embolization device (PED). We sought to assess the impact of platelet function testing (PFT) on reducing periprocedural thromboembolic complications associated with PED flow diversion in patients receiving aspirin and clopidogrel.

Methods

Patients with unruptured intracranial aneurysms requiring PED flow diversion were identified from 13 centers for retrospective evaluation. Clinical variables including the results of PFT prior to treatment, periprocedural DAPT regimen, and intracranial complications occurring within 72‐hours of embolization were identified from the medical record. Complication rates were compared between PFT and non‐PFT groups. Differences between groups were tested for statistical significance using the Wilcoxon rank sum, Fisher exact, or Chi‐square tests. A p‐value <0.05 was statistically significant.

Results

580 patients underwent PED embolization with 262 patients dichotomized to the PFT group and 318 patients to the non‐PFT group. 13.7% of PFT group patients were clopidogrel non‐responders requiring changes in their pre‐embolization DAPT regimen. 5% of PFT group patients experienced thromboembolic complications versus 1.6% of patients in the non‐PFT group (p=0.019). Two (15.4%) PFT group patients with thromboembolic complications experienced permanent neurological disability versus 4 (80%) non‐PFT group patients. 2.2% of PFT group patients and 3.5% of non‐PFT group patients experienced hemorrhagic intracranial complications (p>0.9).

Conclusion

Pre‐procedural PFT prior to PED treatment of intracranial aneurysms in patients pre‐medicated with an aspirin and clopidogrel DAPT regimen may not be necessary to significantly reduce the risk of procedure‐related intracranial complications.
Abstract 169: Antiplatelet regimens after pseudoaneurysm embolization with phosphorylcholine coated flow diverters: a series of 180 cases
Authors: Bounajem Michael T. , Kuhn Anna , Abdelsalam Ahmed , Cortez Gustavo , Abbas Rawad , Pervez Mubashir , Saei Hamzah , Burke Shane , Hassan Ameer , Malek Adel , Naragum Varun , Dabus Guilherme C. , Tjoumakaris Stavropoula , Jabbour Pascal , Hanel Ricardo A. , Starke Robert M. , Suarez Juan Vivanco , Gutierrez Santiago Ortega , Farooqui Mudassir , Salem Mohamed , Jankowitz Brian , Taussky Philipp , Kilburg Craig , Puri Ajit S. , Grandhi Ramesh
Published: March 2024

Introduction

Indications for flow diversion for the treatment of cerebral aneurysms have increased remarkably in recent years.1 This has been particularly useful for aneurysms that are difficult to treat via endosaccular or open approaches, such as pseudoaneurysms.2 Flow diversion, however, typically requires dual antiplatelet therapy (DAPT), which can contribute to greater morbidity particularly in patients with ruptured aneurysms or other comorbidities.3 The third‐generation iteration of the Pipeline Embolization Device (PED) incorporates Shield technology, a phosphorylcholine coating designed to reduce thrombogenicity via mimicry of native cell membranes.4 In light of this reduced thrombogenicity, there have been reports of early transition to single antiplatelet therapy (SAPT), or other variations on DAPT, in patients treated with PED Shield. We therefore aim to characterize the antiplatelet regimens, and associated thromboembolic/hemorrhagic outcomes, utilized in patients with aneurysms treated with PED Shield.

Methods

Factors including demographics, comorbidities, rupture status, devices placed, and antiplatelet regimen, among others, were collected. Follow‐up data including aneurysm thromboembolic complication, hemorrhagic complication, new neurological deficit, aneurysm occlusion, and in‐stent thrombosis were also recorded.

Results

One‐hundred and eighty patients were included in analysis, 18 of which were acutely ruptured. One hundred and sixty‐two patients had a single device placed, while the remaining had two devices placed. Three patients were maintained on SAPT post‐procedurally (aspirin or clopidogrel), with two additional patients treated with SAPT plus an anticoagulant for other purposes. One hundred and seventy‐two patients were maintained on DAPT, most commonly aspirin/clopidogrel (115), followed by aspirin/ticagrelor (40), and aspirin/prasugrel (16). Seven patients had strokes of any kind, three of which were unrelated to the treatment territory, and two of the remaining 4 were non‐compliant with antiplatelet therapy. One patient had a new intraparenchymal hemorrhage, but no appreciable deficit. Of the 135 patients with 6‐month follow‐up, 77 had complete aneurysm occlusion, and 116 demonstrated no in‐stent thrombosis.

Conclusion

We demonstrate herein the similar safety profile and efficacy of PED Shield with varying antiplatelet regimens, including SAPT in isolated cases.
Abstract 171: Embolization of non‐ruptured intracranial aneurysms with flow diverter devices in Mexico: Quick responses
Authors: Mena Diego López , López Mario Messina , Saldaña Charles Huamani , Martínez Pablo , Carrillo Mauricio Anibal Salazar , Mata Isaac Enrique Tello , Amaya Arturo Miguel Rosales , Velázquez Gerardo Cano , Santamaría Ivan Camilo Baracaldo , Cabrera Claudia Cecilia Cedeño , Canales Marvin Daniel Baltodano , Tello Humberto Montaño , Mawcinitt Isaac Sanchez , Murrieta Yolanda Aburto , Bañares Jorge Luis Balderrama , Romero Alonso Gutiérrez , Rosales Héctor Alfredo Montenegro
Published: March 2024

Introduction

Flow diverters (FD) are stent‐type devices that enable the exclusion of intracranial aneurysms in clinical scenarios where coil‐type devices exhibit high failure rates. However, its effectiveness hasn't been examined in countries with low and middle incomes, like Mexico.

Methods

Longitudinal, retrospective study of the patients who received care at a tertiary center between November 2020 and April 2022. Adults older than 18 with non‐ruptured intracranial aneurysms were included. After treatment with FD, post‐procedure control angiograms were performed between three and six months later. The occlusion rate was evaluated using the O'Kelly‐Marotta scale.

Results

There were 23 patients —2 of whom had double aneurisms—, 20 women, with an average age of 51.4 years (±13.3). 19 saccular aneurysms, 4 fusiform aneurysms, and 2 dissecting aneurysms were treated. Neck measurements were in the range of 1.9 to 19 mm. Angioplasties were performed as part of the procedure on four patients, and successful liberation was achieved in all procedures. Between three and six months of follow up, total occlusion was observed in 14 aneurisms, and three had less than 5% residuals. Only three late procedural related complications were found.

Conclusion

The patients treated with FD at our reference center had complex aneurysms. Complete occlusion was achieved in 56% of the treated aneurysms during follow up. The use of the FD appears to be safe and to have a high level of effectiveness, similar to what has been described in international reports.
Abstract 182: Optimal Timeframe from Securing Mycotic Aneurysms to Cardiac Surgery: A Single Center Study
Authors: Miller Ethan A. , Balabhadra Anvesh , Patel Smit , Tunguturi Ajay , Bruno Charles , Sussman Eric , Ollenschleger Martin , Mehta Tapan
Published: March 2024

Introduction

Infectious Intracranial Aneurysms (IIAs), commonly referred to as mycotic aneurysms, are a common sequela of infective endocarditis (IE). Approximately 65% of patients found to have IIAs also have IE, and IIAs occur in up to 10% of patients with IE. Currently, there are no guidelines for the management of IIAs due to the small sample size of observational studies and no randomized controlled studies. In addition to management techniques regarding IIAs, strategic cardiac valve surgery planning also remains imperative. Standard recommendations are to delay cardiac surgery by four weeks if patients are treated conservatively and if they remain stable. However, if one is able to embolize and secure IIAs, then that delay between endovascular therapy (EVT) and surgery may be shortened. We present a single‐center experience demonstrating the timing between securing mycotic aneurysms and cardiac surgery.

Methods

This is a single‐center retrospective observational study of patients admitted with IE who were found to have IIAs at our institute from 2016 to 2022. Descriptive statistics were performed using SAS statistical software and Microsoft Excel.

Results

Out of a total of 862 patients with IE, 25 patients (3.0%) were identified to have 41 IIAs (single aneurysm in 18 patients and multiple aneurysms in 7 patients). The median (IQR) age of our population was 45 (27‐65) years, with 28/41 (68.3%) male patients. The most common location of IIAs was the distal segments of the posterior and middle cerebral arteries in both groups. Of these 41 IIAs, 24/41 (58.5%) were ruptured and 17/41 (41.5%) were unruptured. A total of 14/24 (58.3%) ruptured IIAs were treated vs. none were treated in the unruptured IIAs group (P=0.001).

A total of 8/41 (19.5%) IIAs were secured before undergoing cardiac valve surgery. The median (minimum‐maximum) number of days between securing aneurysms to valvular surgery was 18 (10‐29). Only 2/41 (4.9%) IIAs were detected following valvular surgery. Those were treated on day 3 and day 15 following surgery. There were 4/41 (9.7%) secured IIAs that did not undergo valvular surgery as they did not meet surgical criteria or had surgery planned at another admission.

Conclusion

Our study demonstrates that a timeframe of 2‐3 weeks from securing IIAs to cardiac surgery is considered safe. However, one should note that our cohort consists of a small sample size. Therefore, additional large multicenter observational studies are warranted to confirm these findings.
Abstract 188: Rescue Left Middle Cerebral Artery Stenting With Xience Skypoint Everolimus‐Eluting Stent: Technical Report
Authors: Singh Raman , Shakir Hakeem , Jen Shyian , Verma Uttam
Published: March 2024

Introduction

Drug‐eluting stent (DES) use in symptomatic intracranial atherosclerosis disease (ICAD) has been described in the literature using different guiding and distal access catheters. We describe a case of deployment of a Xience Skypoint everolimus‐eluting stent (EES) (Abbott Vascular, Abbott Park, Illinois) into a symptomatic stenosed left M1 segment using Armadillo catheter (Q'Apel, Fremont, CA) with a successful result.

Methods

Case report and review of literature

Results

67‐year‐old woman with type II diabetes mellitus, hypertension, hyperlipidemia, and recent admission for transient ischemic attack (resolving right hemiparesis and mild dysnomia in the setting of severe left M1 segment stenosis with discharge on Aspirin, Clopidogrel and Atorvastatin), presented with recurrence of symptoms, and MRI brain showing left basal ganglia acute infarction. No tPA was given low NIHSS and resolution of symptoms. Patient’s aphasia and hemiparesis worsened with segmental hypoperfusion which resolved by maintaining high blood pressures with norepinephrine drip. Decision was made to deploy a drug eluting stent into the stenosed M1 segment. Through femoral access, a 7F long destination sheath was inserted to the left common carotid origin. A 7F Armadillo catheter was then inserted into the left internal carotid artery (ICA) terminus. ASAHI Prowater coronary guidewire was inserted over which Xience Skypoint EES deployment was attempted but was unsuccessful given difficulty traversing the ICA ophthalmic segment. Ultimately, Armadillo catheter was advanced over a Phenom catheter (Medtronic) with good access into the distal M1 segment. The Phenom intermediate catheter was then removed, and the 2.25 mm x 12 mm stent was introduced through the Prowater guidewire into the segment and inflated to a pressure of 8 atm, with restoration of blood flow. Postoperatively, SBP was lowered to prevent reperfusion injury. Patient’s exam stabilized with mild dysnomia and right hemiparesis without any elevated blood pressure requirements. At 5‐months follow‐up, patient’s exam was non‐focal with NIHSS 0 and repeat DSA showed no evidence of stent occlusion and patent M1 segment.

Conclusion

Xience Skypoint EES can be successful in treating symptomatic MCA stenosis refractory to maximal medical therapy with good long term results.
Abstract 195: Changing Trends of Thrombolysis and Thrombectomy for Low Severity Stroke: National Inpatient Sample Analysis (2016‐2020)
Authors: Brake Aaron , Fry Lane , Chouhdry Hira , Lingam Sivani , Samiee Tara , Ebersole Koji , Abraham Michael
Published: March 2024

Introduction

Over the past decade, stroke management has significantly improved with the widespread use of intravenous thrombolysis (IVT) and the establishment of endovascular thrombectomy (EVT) as the standard of care for increasing patients. However, a dilemma arises in cases of low‐severity stroke (NIHSS ≤ 5), as the EVT clinical trials do not include patients with such low NIHSS. There is debate surrounding the topic of EVT and IVT for low‐severity stroke, and often practice does not reflect the patient populations included in the initial clinical trials. Some recent studies suggest a trend toward decreasing pre‐thrombectomy IVT. (1) This study aims to examine the evolving trends of intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), and their combination in low NIHSS acute ischemic stroke (AIS) management in the United States from 2016 to 2020.

Methods

We accessed the national inpatient sample database from 2016 through 2020. We included patients admitted with stroke and who had a recorded NIHSS ≤ 5. To determine if there were changes in the frequency of events over time, we compared the outcome measures utilizing logistic regression models with 2016 as the reference year.

Results

Compared to 2016 the rates of IVT have significantly decreased starting in 2018 through 2020. The rates of EVT have trended upward since 2016 and were significantly higher in the year 2020. The rates of thrombectomy plus thrombolysis have trended upward but have not significantly changed since 2016. These results can be visualized in the Figure below, * = p‐value < 0.05.

Conclusion

Our findings highlight a significant shift in stroke treatment, with the growing use of EVT while simultaneously decreasing rates of IVT for low‐NIHSS strokes. Current clinical trials protocol are submitted to examine EVT's efficacy for low NIHSS stroke (2), but it's also crucial to understand what is driving this change in real‐world practice. This understanding will inform treatment decisions and ensure they align with evidence‐based standards, guaranteeing optimal, standardized patient care.
Abstract 197: Mechanical Thrombectomy Of Basilar Artery Occlusion On A Hypoplastic Vertebrobasilar Circulation
Authors: Ghani Mohammad R. , Ali Syed Zahid , Shi Ping , Gentry Erik , Liu Wei
Published: March 2024

Introduction

Basilar artery occlusion (BAO) is one of the most severe acute ischemic strokes which carries high mortality and morbidity risk. Mechanical thrombectomy (MT) has been used as a promising treatment for BAO. However, the vertebral‐basilar anatomy is more challenging for MT compared to the anterior circulation due to several congenital variants such as hypoplastic vertebral artery, fenestration on the vertebrobasilar junction, or chronic asymptomatic occlusions of vertebral arteries, and tortuous subclavian arteries and vertebral arteries (VAs). Here, we described a BAO case with hypoplastic vertebrobasilar arteries, which was successfully treated with thrombectomy using the direct aspiration technique.

Methods

Electronic Medical Records review of a patient with acute basilar artery occlusion stroke.

Results

55‐year‐old healthy gentleman presented to ER with acute onset with confusion, dysarthria, left‐sided weakness, and right facial droop. Initial NIHSS was 12. CT angiography (CTA) head and neck showed basilar artery was occluded in the distal one third segment. Because of the right fetal posterior cerebral artery and prominent left posterior communicating artery, his bilateral VAs and basilar artery were underdeveloped. The left VA appeared to be slightly bigger than the right one. After the patient received IV tPA, he was taken for mechanical thrombectomy. A Ballast catheter was placed in the left subclavian artery near the left VA origin. The conventional angiography showed the left VA was 2.8 mm and proximal basilar was about 2.1 mm. The Zoom 35 aspiration catheter was then used for mechanical thrombectomy. A complete basilar recanalization was achieved on the first pass. The patient improved after the MT. His NIHSS on discharge was 0.

Conclusion

The benefits of MT on BAO remain unknown despite several clinical trials. One of the reasons is due to more challenged vascular anatomy compared to anterior circulation. Underdevelopment of unilateral VA was commonly seen in posterior circulation ischemic strokes. But the underdevelopment of bilateral VAs with basilar arteries in BAO cases was rare and more difficult to treat. The Zoom 35 aspiration catheter provided a great advantage for this case with its smaller outer diameter, good navigation ability, and great aspiration efficacy. Our experience suggested a direct aspiration first pass technique (ADAPT) has an advantage on BAO, especially in the congenitally underdeveloped vertebrobasilar arteries.
Abstract 210: Mechanical Thrombectomy Outcomes for Tele‐Stroke Inter‐Hospital Transfers vs Direct Admit Patients
Authors: Ali Hamid , Amir Muhammad , Kasab Sami Al
Published: March 2024

Introduction

Mechanical thrombectomy (MT) is the standard of care for patients with large vessel occlusion and salvageable tissue. Whether the benefit of thrombectomy is maintained for patients transferred to a thrombectomy‐capable center in a real‐world setting remains unknown. In this study, we sought to assess clinical outcomes of MT following inter‐hospital transfer.

Methods

We collected data for all patients who underwent MT at a single center between May 2016 and July 2021. Outcomes were compared between transferred and direct admit patients. Our outcomes measurements included National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 90 days. We used Mann‐Whitney U and chi‐square tests for univariate analysis. Multivariate regression analysis was also carried out to assess the relationship between transfer status and long‐term functional independence (90 days mRS 0‐2) controlling for age, sex, symptom‐onset to groin time, IV thrombolysis, and baseline NIHSS.

Results

246/620 (40%) patients undergoing MT were transferred and 374/620 (60%) presented directly to our institution. There was no difference in age (68 vs. 70 years, P=0.58), baseline NIHSS (16 vs. 15, P=0.20), or ASPECTs score (7 vs. 8, P=0.06) in the transferred and direct admit groups, respectively. The duration from symptom‐onset to groin was longer (393 vs. 270 min, P<0.01) and rate of IV thrombolysis was more (48.4% vs. 37.4%, P=0.007) in the transferred patients. Functional independence (mRS 0‐2) at 90 days was observed in 44.6% of the patients in the transferred group compared to 49.2% in the direct thrombectomy group (P=0.928). On multivariate analysis, transfer status was not an independent predictor of long‐term functional independence (ARR 1.976, 95% CI 0.807‐4.838, P=0.136).

Conclusion

In the included cohort, no difference was found in long‐term functional independence between stroke patients who received mechanical thrombectomy following inter‐hospital transfer compared to patients who present directly to a thrombectomy‐capable center. These findings emphasize that optimizing telestroke workflow can mitigate the adverse effects of delay during transportation for patients that present to remote hospitals in rural areas.
Abstract 219: Determining the Proportion of Patients with Poor Premorbid mRS presenting with Large Volume Stroke
Authors: Siddiqi Madheea
Published: March 2024

Introduction

Several lines of evidence demonstrate the effectiveness of endovascular treatment (EVT) for large volume stroke (LVS) as defined by Alberta Stroke Program Early CT Score (ASPECTS) of <6 in decreasing severe disability and death. However EVT cannot improve the degree of disability as measured by modified Rankin Scale to be better than premorbid levels. Despite this limitation, patients with severe disabilities are transferred to acute care facilities for consideration of EVT and are hospitalized resulting in over‐medicalization during a terminal event. We aim to determine the proportion of patients with LVS who have poor premorbid mRS (4‐5) and the number of days this subset spent in hospital prior to palliation/death.

Methods

2485 CT angiograms of head and neck and CT Head examinations performed between 2018‐2021 were obtained from the picture archiving and communication system (PACS). Cases presenting with ASPECTS<6 as assigned by a neuroradiologist were identified. Functional outcome data, as defined by mRS, was obtained prior to the acute presenting event (premorbid mRS) and on discharge (outcome mRS). All patients with a documented outcome mRS were included in the analysis. Patients were excluded if presenting ASPECTS was >=6, if stroke symptoms were attributable to etiology other than large vessel or tandem occlusion, or if the studies had been duplicated. Number of days spent hospitalized was calculated based on admission date and discharge date. Further subgroup analysis was performed to compare the cost of hospitalization with return to long term care (LTC) based on the Canadian national average of $7803 for hospitalization and $2406 for long term care as provided by Canadian Institute of Health Information and Ministry of long term care of Ontario.

Results

From the 2485 examinations, 62 had a baseline ASPECTS<6 and 22 cases met exclusion criteria. 40 cases were available for analysis [premorbid mRS (n): 0=(18), 1=(5), 3=(6), 4=(7), 5=(2), ?=(2); age range: 28‐93; 19 male, 21 female]. 23% (9/40) of patients had premorbid mRS of 4‐5, and of these, 78% (7/9) were from LTC or a retirement home. On average, 5.9 days were spent hospitalized [range 4‐9 days]and $5397/person was spent per hospitalization.

Conclusion

LVS secondary to a LVO can be an acutely terminal illness. 23% of patients presenting with LVS had a poor premorbid mRS. 78% of these patients resided in long term care centers and spent an average of 5.9 days ($5397/person) being hospitalized prior to their demise/palliation.
Abstract 223: Pre‐Thrombectomy Diagnosis of Large Vessel Occlusion with Underlying Intracranial Atherosclerotic Disease
Authors: Tarek Mohamed A. , Damiani Mateus , Mohammaden Mahmoud H. , Rangaraju Srikant , Martins Pedro N. , Dolia Jay N. , Pabaney Aqueel A. , Grossberg Jonathan R. , Nahhas Michael , Nogueira Alhamza R. , Haussen Raul G.
Published: March 2024

Introduction

Intracranial atherosclerotic disease (ICAD) is one of the leading causes of ischemic stroke. We sought to identify variables associated with ICAD underlying large vessel occlusion strokes (LVOS) to facilitate pre‐procedural diagnosis.

Methods

Retrospective analysis of a prospectively collected thrombectomy single comprehensive stroke center database. Inclusion criteria: anterior circulation occlusion involving the intracranial ICA, MCA‐M1/M2/M3 or ACA(A1‐A2‐A3). ICAD cases were matched for age and sex in a 1:1 ratio to non‐ICAD controls.

Results

A total of 348 patients were included in the analysis. Patients with ICAD more frequently presented with vascular risk factors. ICAD LVOS showed less frequent atrial fibrillation(AF)(4%vs31%,P=0.001), and lower baseline NIHSS(14vs17,P=0.002) compared to the non‐ICAD group. The ICAD group less frequently showed hyperdense vessel sign and territorial cortical infarcts, but presented more frequently borderzone, deep subcortical and bilateral infarcts on CT compared to the non‐ICAD group. ICAD strokes had higher ASPECTS, and more frequently had calcifications at the carotid siphon as well as multifocal intracranial stenosis on CTA. CTA collaterals scores were comparable between groups. The ICAD group had lower median infarct core volume (1vs12 ml;P>0.001), Tmax>4s (249vs276 ml;P>0.003), and Tmax>6s (97vs140 ml;P<0.003) and higher Tmax>4:6 s ratio (2vs1;P=0.007) on CTP compared to non‐ICAD group. On multivariable analysis, absence of AF, absence of cortical infarcts, presence calcium at ipsilateral carotid siphon, cerebrovascular stroke risk factors burden (DM‐HTN‐Hyperlipidemia‐smoking), borderzone infarcts either (superficial cortical or Internal deep border zone), and multifocal intracranial stenosis were independent factors associated with ICAD. The model (table 1) by AUC for the whole model had sensitivity of 88% [P=<0.001,95%CI(0.84‐0.91)].

Conclusion

In patients with anterior circulation LVO strokes, our study suggests that presence of CVS risk factors burden, calcium at carotid siphon, borderzone infract pattern, absence of territorial cortical infarct pattern, multifocal intracranial stenosis, and absence of AF were predictors for ICAD. Additional validation is warranted
Abstract 237: Thrombectomy is the Leading Treatment Modality for Symptomatic Sub‐Occlusive Lesions: a Nationwide StrokeNet Survey
Authors: Harker Pablo , Ayala Felipe , Ades Laura , Khatri Pooja , Aziz Yazmin
Published: March 2024

Introduction

Approximately 3% of all acute ischemic stroke are caused by sub‐occlusive thrombi in the proximal intracranial vasculature. There is a paucity of evidence regarding optimal treatment of this stroke etiology, with most evidence derived from retrospective case series preceding the advent of mechanical thrombectomy. We sought to survey the National Institute of Health StrokeNet to determine real‐world treatment patterns in experienced stroke centers. We hypothesized that most providers would choose mechanical thrombectomy (MT) over medical management (MM).

Methods

We conducted an email survey of all StrokeNet regional coordinating centers (RCCs). Each RCC principal investigator (PI) was asked to provide a name of a local stroke endovascular specialist most aligned with their region’s typical practice pattern. A subsequent survey was sent to each if the StrokeNet RCC PIs and their nominated interventionalists. Questions were based on a clinical vignette accompanied by CT angiogram displaying a sub‐occlusive lesion in the left middle cerebral artery (MCA) (Figure 1a). Subsequent questions kept the same basic vignette, changing only one historical, clinical, or radiographic variable at a time. Participants were asked to describe initial management for each scenario. If more than one initial treatment was selected, or if no treatment option was selected, applicants were asked to please explain. Results were gathered from each participant using Google Forms.

Results

Among 27 StrokeNet RCCs, 25 (93%) provided at least one response; responses were received from 43 of 54 (80%) physicians surveyed, including 26 stroke interventionalists. A total of 4 sites selected an alternate responder of the appropriate specialty if their PI or chosen representative was unable to respond. The majority (71.4%) of respondents treated patients with acute sub‐occlusive thrombus with MT (Figure 1b). MT alone, or MT with additional MM, comprised the majority of responses to clinical vignette variation questions[Moderate core (ASPECTS 6): 71.4% MT, 76.2% MT with MM; Last Known Normal 12‐hours prior with Favorable Advanced Imaging: 73.8% MT, 83% MT with MM; Last Known Normal 12‐hours prior without Advanced Imaging: 54.8% MT, 64.3% MT with MM; Severe hypertension (210/110mmHg): 50% MT, 69% MT with MM; Poor Collaterals: 71.4% MT, 78.6% MT with MM]. Only two scenarios, low baseline National Institutes of Health Stroke Score (NIHSS) and history of ipsilateral stenosis, led respondents to favor non‐thrombectomy approaches (Low NIHSS (3): 9.5% MT; History of Ipsilateral Stenosis: 30.9% MT, 47.6 MT with MM) (Figure1c‐d).

Conclusion

Despite limited evidence to support MT versus other treatment strategies, the majority of StrokeNet Regional Coordinating Center sites would use MT to treat acute strokes due to intracranial sub‐occlusive thrombi.
Abstract 251: Characterizing coma in patients presenting with large vessel occlusion stroke
Authors: Young Michael J. , Awad Amine , Andreev Alexander , Bonkhoff Anna K. , Schirmer Markus , Dmytriw Adam A. , Vranic Justin E. , Rabinov James D. , Doron Omer , Stapleton Christopher J. , Das Alvin J. S. , Singhal Aneesh B. , Rost Natalia S. , Patel Aman B. , Regenhardt Robert W.
Published: March 2024

Introduction

Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke.

Methods

Individuals who presented with LVO were retrospectively identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIH Stroke Scale (NIHSS) item 1a.

Results

A total of 28/637 (4.4%) patients with LVO stroke were identified as presenting with coma. The median NIHSS was 32 (IQR 29‐34) for those with coma versus 11 (5‐18) for those without (p<0.0001). In coma, occlusion locations included basilar (13), vertebral (2), internal carotid (5), and middle cerebral (9) arteries. 8/28 were treated with endovascular thrombectomy (EVT), and 20/28 died during the admission. 65% of patients not treated with EVT had delayed presentations or large established infarcts. In models accounting for pre‐stroke modified Rankin Scale (mRS) score, basilar artery occlusion location, intravenous thrombolysis, and EVT, coma independently increased the odds of transitioning to comfort care during the admission (aOR 6.75; 95%CI 2.87,15.84; p <0.001) and decreased the odds of 90‐day mRS 0‐2 (aOR 0.12; 95%CI 0.03,0.55; p=0.007).

Conclusion

It is not uncommon for patients with LVO to present with coma, and delayed recognition of LVO can lead to poor outcomes, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Efforts to improve early diagnosis and care of patients with LVO presenting with coma are crucial, given the poor outcomes.
Abstract 268: Validation of an automated method to assess 24‐hour infarct volume in stroke patients
Authors: Jablonska Magda , Sousa João André , Molina Marc , Canals Pere , Garcia‐Tornel Alvaro , Rodrigo‐Gisbert Marc , Rizzo Federica , Olivé‐Gadea Marta , Requena Manuel , Rodriguez‐Luna David , Rodriguez‐Villatoro Noelia , Juega Jesús M. , Muchada Marián , Pagola Jorge , Rubiera Marta , Tomasello Alejandro , Molina Carlos A. , Tanzi Leonardo , Salvia Victor , Marti Cristian , Ribo Marc
Published: March 2024

Introduction

In stroke patients, accurate infarct volume assessment at 24 hours typically requires manual segmentation of lesions that often are not well defined. We aimed to validate an automated machine learning algorithm (MethinksFIV) specifically trained to automatically segment and measure subacute infarcts on non‐contrast CT (NCCT) scans.

Methods

We retrospectively studied stroke patients with a large vessel occlusion prospectively admitted to a comprehensive stroke center. The final infarct volume was segmented on the 24h NCCT manually (man‐FIV) and with the automated method (auto‐FIV). Both measurements were correlated with clinical outcomes.

Results

We included 346 patients. On 24h‐NCCT median auto‐FIV was lower than man‐FIV (8.6 ml [2.3‐40.7] vs. 16.9 ml [1.1‐70.8], p<0.001). Auto‐FIV and man‐FIV were highly correlated (r=0.8; p<0.001; mean dice coefficient of 0.61). The Auto‐FIV correlated better than man‐FIV with 24h (r=0.54 vs. r=0.51, both p<0.001) and discharge NIHSS (r=0.59 vs r=0.54, both p<0.001). An increase of 1 ml in auto‐FIV was associated with an increase in the odds of higher ordinal mRS at three months (OR=1.01 95%CI 1.01‐1.02, p<0.001). Auto‐FIV was a better predictor of mRS>2 at three months (OR: 1.02 95%CI 1.01‐1.13, p=0.002) than manual segmentation (OR=1.01, 95%CI 1.00‐1.01, p=0.01). In a multivariable analysis, only auto‐FIV remained a significant predictor of mRS>2 at three months (aOR: 1.03 95% CI 1.01‐1.05, p=0.004).

Conclusion

An automated method to measure subacute infarct volumes in stroke patients is accurate and correlates well with further clinical outcomes. The method appears to outperform manual segmentation and may be used to facilitate infarct characterization in large clinical trials.
Abstract 281: The RACE scale for Large Vessel Stroke Diversion to Comprehensive Center by Helicopter Air Ambulance
Authors: Krebs William
Published: March 2024

Introduction

Acute ischemic stroke caused by large vessel occlusion (LVO) occurs frequently and benefits from endovascular therapies available at comprehensive stroke centers (CSC) {Goyal 2016} {Lakomkin, 2019}. Real world evidence shows that endovascular therapy is effective and better than tPA in cases of LVO {Noguria 2016}. Comprehensive stroke centers are also faster at administering tPA and have better tPA metrics for patients with LVO compared to transfers from non CSCs{Shumei M, 2018}{Seker 2020}. Evidence shows that direct transport to an interventional center may provide benefit even if they are not the closest hospital {Benoit J, 2018} {Venema 2020}. Prehospital stroke severity tools such as the RACE scale and others have been devised to detect LVO with reasonable sensitivity and specificity {Krebs 2018} {Dickson 2020}. Helicopter Air Ambulances (HAA) can limit the time to comprehensive stroke care for rural communities {Liera 2016}. Following the recommendations of the American Stroke Society (ASA), regional EMS protocol allow for direct transfer for potential LVO cases within 24 hours by HAA.{NWOEMS consortium protocol}{Powers WJ 2019}. For this reason HAA can enhance access to comprehensive stroke centers into rural communities.

Methods

A retrospective assessment of RACE scales of 5 or greater performed by prehospital providers was used in order to activate HAA. Descriptive statistics were obtained for patients transported with primary goal of determining the positive predictive values of the RACE Scale for LVO occlusions. Secondary outcomes were if patients had other conditions requiring a comprehensive stroke center.

Results

Data from 148 subjects were in the research dataset. Twelve of these were eliminated due to not meeting inclusion criteria, death prior to imaging, and transport to another facility where records were not available. This resulted in analyses from 136 subjects. Of the 136, 53 (39.0%) were true LVO cases as defined by CT, CTA imaging or MRI. There were 83 (61%) falsely positive (no LVO on imaging). Mechanical thrombectomy occurred in 30 cases (22.1%) with 63 (46.4%) requiring a neurologic intervention.

Conclusion

When the RACE scale is used in real world EMS practice to triage rural stroke cases, it has a high positive predictive for HAA activation with delivery to a comprehensive stroke center in suspected stroke cases. Even false positive activations required care at a comprehensive stroke center in most case.
Measures of the coupling between fluctuating brain network organization and heartbeat dynamics
Authors: Candia-Rivera Diego , Chavez Mario , De Vico Fallani Fabrizio
Published: March 2024

In recent years, there has been an increasing interest in studying brain–heart interactions. Methodological advancements have been proposed to investigate how the brain and the heart communicate, leading to new insights into some neural functions. However, most frameworks look at the interaction of only one brain region with heartbeat dynamics, overlooking that the brain has functional networks that change dynamically in response to internal and external demands. We propose a new framework for assessing the functional interplay between cortical networks and cardiac dynamics from noninvasive electrophysiological recordings. We focused on fluctuating network metrics obtained from connectivity matrices of EEG data. Specifically, we quantified the coupling between cardiac sympathetic–vagal activity and brain network metrics of clustering, efficiency, assortativity, and modularity. We validate our proposal using open-source datasets: one that involves emotion elicitation in healthy individuals, and another with resting-state data from patients with Parkinson’s disease. Our results suggest that the connection between cortical network segregation and cardiac dynamics may offer valuable insights into the affective state of healthy participants, and alterations in the network physiology of Parkinson’s disease. By considering multiple network properties, this framework may offer a more comprehensive understanding of brain–heart interactions. Our findings hold promise in the development of biomarkers for diagnostic and cognitive/motor function evaluation.
The Relationships Between Law-Breaking and Law-Abiding Ideological Animal Rights Activists and Their Parents and Spouses
Authors: Inbar-Frohlich Tali , Bensimon Moshe , Ronel Natti
Published: March 2024

This phenomenological research examined family relationships among ideological nonhuman-animal rights activists, while distinguishing between law-breaking and law-abiding activists. Analysis of semi-structured interviews with 30 activists highlighted two phases within the familial dynamics. During the joining phase, conflicts arose between the participants’ identities as activists and their identities as family members, creating a crisis in their relations with their parents and spouses. During the establishing phase, however, different familial dynamics developed among each group. The law-breaking activists were able to balance family life with their activism, ensuring the preservation of the relationship. By contrast, to try and maintain peaceful relations, the law-abiding activists kept their activism from their family, leading to a deterioration in the relationship. The findings are interpreted through literature dealing with the family dynamics of social activists in general, and animal rights activists in particular.
Pneumatological Self-Confidence, Scriptural Interpretation, and the Making of Scripture in the Letter to the Hebrews
Authors: Heidel Andreas-Christian
Published: March 2024

The Letter to the Hebrews has long been overlooked in discussions regarding New Testament pneumatology or even considered ‘inferior’ compared to other New Testament traditions. However, this is a mistake, as the unknown author of this letter demonstrates a remarkable awareness of pneumatology, which plays a key role in the transmission of early Christian traditions and significantly shapes the formation of the New Testament canon. Hebrews presupposes the presence of the Spirit and explicitly associates it with the revelation of God throughout history. Furthermore, the author identifies his own theological and literary work with the Spirit’s function of actualizing scripture, granting him a remarkable position among New Testament and early Christian authors.