bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP83: Macrophage Metabolic Reprograming to Face Ferroptosis After ICH
Authors: Bories Gael , DeLong Jonathan , Sansing Lauren H
Published: February 2024

Intracerebral Hemorrhage (ICH) is a destructive neurovascular disease with no efficient treatment. Trapped Red Blood Cells (RBCs) in the brain lyse releasing toxic heme from hemoglobin. Heme, a lipophilic molecule with iron, triggers severe oxidative stress, particularly to lipid-rich cell plasma membranes (PM), causing cell death via ferroptosis. Macrophages are specialized in hematoma phagocytosis; their survival determines hematoma detoxification in the brain.

Using in vitro murine macrophage cultures treated with heme, we noted heme induced cell death (Fig 1A), along with heightened oxidized fatty acids (FAs), a marker of ferroptosis (Fig 1B). Heme-triggered cell death was countered by the ferroptosis inhibitors ferrostatin-1 (Fer-1), NAC, β-ME and Deferoxamine (DFO) (Fig 1C-F), which confirm that heme induces ferroptosis in macrophages.

Macrophages may shift metabolism to the Pentose Phosphate Pathway (PPP) in the presence of heme to promotes NADPH synthesis, vital for heme degradation and oxidation defense. Dehydroisoandrosterone (DHEA), a potent PPP inhibitor, worsened heme-induced ferroptosis (Fig 1 G&H). This underscores the PPP's vital role against heme-driven ferroptosis.

Ferroptosis involves PM oxidation and loss of integrity, causing cell death. Heme induced rapid extracellular ATP release (Fig I). Lysosomes contain abundant ATP, thus we hypothesized that ATP release triggers by heme is the result of PM repair by lysosomal exocytosis/endocytosis. Using metabolomics, we found that heme induced accumulation of membrane components like phospholipids, sphingolipids, and cholesterol (Fig J-L), all which require NADPH for synthesis. This suggests PPP aids NADPH production, aiding lysosomal synthesis for PM repair. Overall, the findings support a critical role for the PPP in macrophage resistance to ferroptosis in the presence of heme and suggest a possible new therapeutic target for macrophage survival after ICH.
Abstract TMP85: Endovascular Thrombectomy for Large Ischemic Strokes With Tandem Lesions:
A SELECT2 Subanalysis
Authors: Ortega-Gutierrez Santiago , Samaniego Edgar A , Vivanco-Suarez Juan , Hassan Ameer E , Abraham Michael G , Chen Michael , Hussain Muhammad S , Churilov Leonid , Johns Hannah , Mendes Pereira Vitor , Pujara Deep , Shaker Faris , Kass-Hout Tareq , Blackburn Spiros , Abdulrazzak Mohammad A , Sitton Clark W , Ghannam Malik , Leira Enrique C , Roeder Hannah , Olalde Heena M , Lansberg Maarten G , Hill Michael D , Grotta James C , Albers Gregory W , Ribo Marc , Campbell Bruce , Sarraj Amrou ,   The SELECT2 Investigators
Published: February 2024

Introduction:
Trials evaluating thrombectomy (EVT) efficacy and safety in large vessel occlusion (LVO) excluded patients with cervical tandem lesions (TL). We aimed to evaluate EVT efficacy and safety in large stroke patients with TL from the SELECT2 trial.

Methods:
SELECT2
was a randomized controlled trial evaluating EVT vs. medical management (MM) in patients with LVO ischemic strokes (ASPECTS 3-5 on computed tomography (CT) or ischemic core ≥50 ml on CT Perfusion/MR diffusion-perfusion). TL were defined as internal carotid artery occlusion with a concomitant LVO as determined by the core lab. Functional, safety, and imaging outcomes were compared between patients in EVT vs. MM.

Results:
Of 352 enrolled, 100 (28%) had tandem occlusions, with 56 receiving EVT. ASPECTS (EVT: 4 [3-5] vs. MM: 4 [4-5]), ischemic core estimates (EVT: 86 [58-133] ml vs. MM: 81 [61-121] ml) and critically hypoperfused tissue volume (EVT: 185 [131-266] ml vs. MM: 192 [142-252] ml) were similar between groups. TL Patients receiving EVT demonstrated significantly better functional outcomes (mRS at 90d: EVT 4[3-6] vs MM 5[4-6]; aGenOR: 2.22; 95%CI, 1.47-3.34; p<0.001), similar to those without TL (aGenOR: 1.59, 95% CI: 1.23-2.05, p<0.001; P-int-0.29) and a higher proportion of patients achieving functional independence (EVT: 20% vs. MM: 2%; aRR: 9.53; 95%CI, 1.71-53.21; p=0.010) and independent ambulation (EVT: 38% vs MM: 11%; aRR: 3.60; 95%CI, 1.68-7.67; p=0.001), with significantly reduced complete dependence or death (mRS 5-6) (aRR: 0.66 (0.48-0.90), p=0.009). There was no difference in symptomatic ICH (EVT: 2% vs MM: 0%) or parenchymal hemorrhage (EVT: 2% vs MM: 0%). Complications occurred in 10 (18%) patients receiving EVT. In the EVT group, successful reperfusion (mTICI 2b-3) was associated with better functional outcome (aGenOR: 2.30; 95%CI, 1.14-4.65; p=0.021).

Conclusion:
In patients with tandem lesions, EVT and successful reperfusion were associated with better functional outcomes. Frequency of vascular complications was similar to those without tandem lesions and no patients receiving immediate stenting demonstrated parenchymal hemorrhage. Our findings support consideration of EVT in patients with tandem lesions with large ischemic strokes.

NCT03876457
Abstract TMP87: Thrombus Age in Ischemic Stroke With Atrial Fibrillation
Authors: Koge Junpei , Hatakeyama Kinta , Tanaka Kanta , Yoshimoto Takeshi , Shiozawa Masayuki , Naruhiko Kamogawa , Abe Soichiro , Ishiyama Hiroyuki , Yoshie Tomohide , Imamura Hirotoshi , Kataoka Hiroharu , Ihara Masafumi , Toyoda Kazunori , Koga Masatoshi
Published: February 2024

Background and purpose:
Because the biochemical composition of thrombus changes after formation over time, thrombus maturation in the left atrium may affect clot compositions in ischemic stroke with atrial fibrillation (AF). We aimed to investigate the association of the age of retrieved thrombi with clinical features and outcomes after MT for ischemic stroke with AF.

Methods:
We retrospectively reviewed consecutive patients with ischemic stroke with known AF or AF diagnosed after stroke onset who underwent MT and whose retrieved thrombi were pathologically analyzed. Thrombi were classified as fresh (<1 day) and older (1-5 days) based on the areas (≤20 % or >20 %) of lytic features of granulocytes in the section. Components of thrombi were quantified using immunostaining. Outcomes included first pass effect (FPE, extended Thrombolysis in Cerebral Infarction [eTICI] 2c/3 after first pass) and favorable outcome (3-month modified Rankin Scale score of 0 to 2 or equal to premorbid mRS score).

Results:
Of 168 patients, 62 patients (37%) had older thrombi. The presence of older thrombi was independently associated with the higher CHADS
2
score (adjusted OR [aOR], 1.46; 95% confidence interval [CI], 1.07-1.99). Older thrombi had the higher proportion of fibrin, platelets, von Willebrand factor, and neutrophil extracellular traps than fresh thrombi. FPE was less frequently achieved in patients with older thrombi than those with fresh thrombi (21% versus 43%; aOR, 0.36; 95% CI, 0.17-0.77). Favorable outcomes were fewer in patients with older thrombi than those with fresh thrombi (40% versus 73%; aOR, 0.37; 95% CI, 0.16-0.85).

Conclusions:
In patients with ischemic stroke with AF, older thrombi was associated with cardiovascular risk factors and included abundant amounts of components associated with the thrombectomy resistance. Patients with older thrombi had poorer functional outcomes presumably due to concomitant risk factors and worse revascularization outcomes.
Abstract TP110: Strengthening Neurology and Cardiology Care Collaboration: Getting to the Heart of Stroke Initiative
Authors: Olson Liz , Leesch Tharen , Congdon Michelle , Manoukian Steven V , Schneider Alexander T , Canby Robert , Bailey Alison , Moody Ashley , Harper Russell , Orndorff Kevin , Stergar Lindsay , Jauch Edward C
Published: February 2024

Introduction:
The American Heart Association (AHA) estimates 1 in 3 acute ischemic strokes (AIS) are cryptogenic and approximately 1 in 4 survivors will have another event. Identifying the AIS etiology will help define appropriate therapy and lower the likelihood of having another stroke. Over 67% of Black Americans have at least 1 risk factor for AIS and a higher morbidity & mortality compared to any other racial group. To address these gaps, the AHA launched Getting To The Heart Of Stroke in 2022, in conjunction with HCA Healthcare and HCA Healthcare Foundation, to improve the identification of stroke etiology by strengthening neurology & cardiology care collaboration. An overarching goal of this initiative is to improve healthcare disparities by assuring correct data collection of socioeconomic data, assessing barriers to care and addressing social determinants of health.

Methods:
Using a learning collaborative model, 10 HCA Comprehensive Stroke Centers, along with their clinical and administrative leadership were engaged. Monthly virtual performance improvement consultations are held to discuss actions taken, identify trends between sites, and develop PDSAs (Plan-Do-Study-Act). Their clinical multidisciplinary teams defined custom and existing metrics using Get With The Guidelines®-Stroke to measure the impact of best practice implementation.

Results:
Gaps include inconsistent identification of stroke etiology, lack of race documentation and lack of standardized social needs assessments. Barriers include a lack of standard triggers for cardiology and neurology consults on cryptogenic stroke and widely variable documentation by hospital. Sites are creating communication points between departments utilizing a multidisciplinary committee of stroke and cardiology team members.

Conclusion:
Early data suggest the need to establish standardized processes for the identification of cryptogenic stroke. A framework is necessary to build the foundational relationship between neurology & cardiology to positively impact cryptogenic stroke patient care. Over the next 2 years, the initiative will continue to explore an enhanced framework to identify cryptogenic stroke, optimize secondary prevention strategies, and ensure equitable care.
Abstract TP113: Racial Disparities in Dysphagia Screening Outcomes Among Acute Stroke Patients at a United States Comprehensive Stroke Center
Authors: Weiss Martin A , Graybeal Dion F , Rasmussen-Winkler Jennifer , McAlpine Candace , Fournier Lauren E
Published: February 2024

Introduction:
Screening for dysphagia is vital in post-stroke care, with the Yale Swallow Protocol being a widely recognized tool. While passing the screening indicates a lower risk of dysphagia, racial disparities in screening results may also preclude patients from receiving a more comprehensive evaluation.

Objective:
This study aimed to investigate racial disparities in dysphagia screening outcomes in acute stroke patients at high risk for dysphagia based on initial NIHSS, explicitly focusing on the likelihood of black patients compared to non-black patients passing the Yale Swallow Protocol screening.

Methods:
Using data from a single US comprehensive stroke center, we examined the Yale Swallow Protocol dysphagia screening results amongst patients admitted for acute ischemic and hemorrhagic stroke with an initial NIHSS of 12 or greater between January 1 and December 31, 2022. Our NIHSS inclusion criteria was based on prior literature proposing an NIHSS score of 12 as a cutoff for a formal swallow evaluation. The primary outcome was the rate of passing the Yale Swallow Protocol screening, with data stratified by race. The association between race and swallow screening results was assessed using the chi-square test. A p-value of <0.05 was considered statistically significant.

Results:
This study included 243 acute ischemic/hemorrhagic stroke patients, of which 99 were black. The chi-square test revealed a significant association between race and passing the dysphagia screen (p <0.05). The odds of passing dysphagia screening were 2.13 times higher in black vs. non-black patients (OR 2.13, 95% CI 1.67-2.73). No statistically significant associations were found between passing the dysphagia screen and other factors such as age, gender, or NIHSS (p >0.05 for all).

Conclusion:
These results underscore significant racial disparity in dysphagia screening outcomes, with black patients more likely to pass the initial screening. These findings raise concerns about potential missed opportunities for comprehensive speech and language pathology assessments in black patients. Further research to understand the underlying reasons for these disparities is needed to ensure comprehensive and equitable care for all patients.
Abstract TP120: Racial Disparities and Predictors of All-Cause Mortality in Postmenopausal Women Hospitalized for Stroke: A Nationwide Analysis, 2019
Authors: Guddeti Ananth V , Doshi Preet , Kohli Muskan , AKELLA SAI ANUSHA , Baskara Salian Rishabh , Faiz Haseeb , Shaik Mahboob Younus , Subarmani Shobana Lokeash , Raghavan Pavithra , Gowda Supreeth N , Desai Rupak
Published: February 2024

Background:
Racial disparities in stroke prevalence and outcomes have been well documented in previous studies, but there is not sufficient data based on post-menopausal women. In this study, we aim to analyze stroke hospitalization rates and subsequent mortality rates by race among females aged 55 years and older. We also sought to identify independent predictors of mortality based on race.

Methods:
We queried the 2019 National Inpatient Sample to identify stroke hospitalizations in women aged >55 years by using ICD-10 CM codes. Demographics were analyzed after stratifying the population by race. Multivariable regression analysis was performed taking stroke admission rates and mortality by race as a primary outcome of interest and the co-primary outcome was independent predictors of mortality by race.

Results:
A total of 140,805 patients with a median age of 76 [67-85] were included in the study of which 66.9% were white, 16.5% black, 7.5% Hispanic, 3.6% Asian/Pacific Islander 0.6% Native Americans, and 2.5% in the other race category. Blacks (52.8%) and Native Americans (47.9%) were significantly present in the lowest national household income quartile compared to Asians/Pacific Islanders (26.1%). COPD (OR: 1.19 95%, p- 0.017), cancer (OR: 1.27 p - 0.030), and age at admission (OR: 1.02 p <0.001) were independent positive predictors for all-cause mortality in whites, while complicated hypertension (OR: 2.64 p - 0.039), and age at admission (OR: 1.04 p - 0.004) were the independent positive predictors for the Asian population.

Conclusion:
Among post-menopausal women hospitalized with stroke, all-cause mortality was the highest in Asians, followed by whites and Hispanics. Interventions and targeted strategies can be developed to address these disparities, further studies should be conducted to investigate the causes and etiologies of these disparities.
Abstract TP121: Using Visual Cues to Improve Dysphagia Screening Compliance in Acute Stroke Patients
Authors: Ostermann Ruth , Bianco Toniann
Published: February 2024

Introduction:
Dysphagia or difficulty swallowing after a stroke is a common neurological symptom which occurs in 35-67% of all acute stroke patients. Dysphagia can lead to complications such as aspiration, pneumonia, dehydration, weight loss or death. National guidelines recommend dysphagia screening before oral intake in stroke patients to reduce hospital acquired pneumonia. A dysphagia screening tool used by nurses at the bedside that allows for the direct observation of the patient’s ability to swallow is the Water Swallow Test. Upon analysis of patient data, a practice gap was identified in which the dysphagia screening was not performed prior to first oral intake of medication. With collaboration of our multi-disciplinary stroke team to identify opportunities for improvements in the dysphagia performance measure, we hypothesized that if a visual cue was in place prior to first oral administration of medication, we can improve our compliance in the dysphagia performance measure.

Method:
When a patient presents with stroke symptoms, a purple dot sticker will be placed on the patient’s identification band. This purple dot sticker will serve as a visual cue that will trigger a reminder to the nurse when scanning the patient’s identification band prior to administration of the first oral medication to perform the dysphagia screening. If screening has been performed and the patient passed, the purple sticker will be removed. If the patient fails the screening, the nurse will notify the provider and the patient will be kept NPO (no meds) pending a speech/swallow consult. Upon admission, SBAR handoff to the floor will include failure of dysphagia screening / NPO status and an order for a speech/swallow consult.

Result:
In 2022, the dysphagia screening compliance was 67%. Following the visual cue implementation, our compliance improved to 100% in June 2023 and 92% in July 2023.

Conclusion:
Preliminary metrics indicate that this tool has positively impacted our compliance rate. Education to the staff is ongoing. Integration of the visual tool into our hospital guidelines for care of the acute stroke patient is under consideration pending additional analysis of compliance rates.
Abstract TP124: Evaluating Secondary Stroke Prevention Following Discharge From a Community Hospital
Authors: Loparo Dominique , Pascal Pamela , Andrefsky John
Published: February 2024

Background:
Having major effects on both morbidity and mortality, stroke has become a large health burden worldwide. This disease state not only is the second leading cause of death; but also leaves about half of survivors chronically disabled. The 2021 AHA guidelines state that the risk of a recurrent stroke can be mitigated with appropriate secondary stroke prevention. The success of these interventions following discharge from the hospital largely lies in the hands of both the primary care physician and the patient. The goal of this investigation is to determine patient and provider compliance with risk factor modification and drug therapy within 3 months of hospitalization for acute ischemic stroke or transient ischemic attack.

Methods:
This quality improvement project is a single-center, retrospective chart review of the current secondary stroke prevention procedures exercised at a community hospital within a large healthcare system. This project has received Institutional Review Board approval. To be included, subject were required to have established primary care within the health system, discharged home following admission, and a final principle diagnosis of acute ischemic or transient ischemic event. The primary outcome assessed the percentage of patients that received a follow-up visit with a primary care provider within 30 days of hospital discharge. Additionally, this investigation also assessed modifiable risk factor management for secondary ischemic stroke prophylaxis.

Results:
Of the 97 patients that met inclusion criteria, 49 of them received a follow-up visit with a primary care provider within 30 days of hospital discharge (50.5%). In regards to secondary outcomes, all outcomes assessed showed to achieve appropriate clinical follow-up except for management of hypertension. It was reported that of the 49 patients, twenty-seven were reported to have controlled blood pressure at follow-up (55%).

Conclusions:
Results from the primary outcome of this quality improvement project highlighted the need for additional intervention to establish primary care prior to hospital discharge. Additionally this evaluation also highlighted further need for management of hypertension as a modifiable secondary risk factor.
Abstract TP126: Diffusion Weighted Image Lesion Dynamics in Acute Ischemic Stroke and Functional Recovery: Application of an Automated Software to 7000 Cases
Authors: Kim Nakhoon , Ko Yoona , Cha Jeongmin , Kang Dong-wan , Ryu Wi Sun , Kim Jun Yup Y , Han Moon Ku , BAE Hee-joon , Kim Beom Joon
Published: February 2024

Introduction:
The change in DWI lesion volume in acute ischemic stroke has not been investigated in detail. We aimed to investigate the effect of DWI lesion growth or regression within seven days of onset on functional recovery after ischemic stroke.

Methods:
From a prospective stroke registry, we retrieved acute ischemic stroke cases who had more than two DWIs during in-hospital care between 2005 and 2022. The DWI lesion volume was automatically measured using JBS-01K (JLK Inc., South Korea), a fully automated and validated deep learning algorithm using 3D U-net. The association between categorized DWI lesion volume change (10, 25, 50, and 75 percentiles corresponding to -45%, 0%, 57%, and 220% of volume change) and functional recovery was assessed using multivariable ordinal logistic regression analysis taking lower modified Rankin scale (mRS) as a dependent variable, adjusting for relevant covariates.

Results:
A total of 7308 patients with ischemic stroke who underwent follow-up DWIs were included. A male was 62%, mean age of 67.5±13.5, and a median of initial NIHSS 4 [IQR 1-7]. The median of interval between the initial and follow-up DWI was 90 hours [IQR 68.25 - 112.20]. The median of the initial DW lesion volume was 1.00 ml [IQR 0.27-5.98], and the median of the follow-up DW lesion volume was 2.05 ml [IQR 0.27-5.98]. DWI lesion volume was regressed in 1844 cases (25%); 136 cases (13%) of EVT and 1708 cases (27%) of non-EVT cases. Compared with patients with 25-50 percentile strata, the adjusted odds ratios (OR) of having favorable functional recovery for < 10th, 10-25th, 50-75th, and ≥75th percentile were 1.25 [95% CI 1.05 - 1.48], 0.96 [0.83 - 1.11], 0.67 [0.59 - 0.76], and 0.63 [0.55 - 0.72], respectively (Figure).

Conclusions:
We found that approximately a quarter of patients with ischemic stroke had an interval regression of infarct volume on DWI, which is independently associated with favorable functional recovery.
Abstract TP135: Age-Related Differences in DWI Lesion Volume and Reversal in Patients With Recanalization After Mechanical Thrombectomy for Large Vessel Occlusion
Authors: Takaishi Satoshi , Tatsuno Kentaro , Usuki Noriko , Ueda Toshihiro
Published: February 2024

Background and Purpose:
With the development of mechanical thrombectomy (MT) for large vessel occlusion (LVO), post-treatment DWI lesion reversal (DWIR) has been reported. We aimed to retrospectively compare baseline and post-treatment DWI lesion volume and the incidence of DWIR between younger and elderly patients who received successful recanalization by MT for anterior LVO.

Methods:
A total of 177 patients who underwent successful recanalization with MT for occlusion of the anterior LVO between April 2011 and September 2022 were included in our hospital. Patients were divided into two groups: under 70 years of age and over 70 years of age. MRI was performed before and 24 hours after treatment. DWI lesion volume, apparent diffusion coefficient (ADC) value of DWI lesion, and the incidence of DWIR were examined between age groups. Factors associated with DWI lesion volumes were determined by multivariate analysis.

Result:
The median age of the patients was 78 years, 76 (42.9%) were female, 35 (19.8%) were in the <70 years group, and 142 (80.2%) were in the ≥70 years group. No significant differences existed between the age groups in the distribution of occluded vessels, NIHSS, and time from onset to recanalization. Baseline volume was significantly higher in the <70 years group than in the ≥70 years group (16.0ml vs 4.0ml p<0.001). There was no difference in the ADC value of DWI lesion between the two groups. There was no difference in DWIR between the two groups (65% vs. 55%), but the post-treatment DWI lesion was significantly smaller than the baseline lesion n the <70 years group. was Age being also independent of DWI lesion volume before and after treatment.

Conclusions:
In patients undergoing recanalization on MT for anterior LVO, baseline DWI lesions were significantly larger in young patients than in elderly patients. Although DWIR was present in over half of both groups, DWI lesion volume was significantly reduced after recanalization in younger patients.
Abstract TP137: Quantitative Assessment of No-Reflow Zones Predicts Infarct Growth and Functional Outcome
Authors: Mahmoudi Keon , Kim Daniel H , Tavakkol Elham , Qiao Joe , Bahr-Hosseini Mersedeh , Salehi Banafsheh , Cai Stephen , Ledbetter Luke , Cankurtaran Ceylan Z , Speier William , Zhang Haoyue , Arnold Corey , Szeder Viktor , Colby Geoffrey P , Jahan Reza , Duckwiler Gary , Saver Jeffrey L , Liebeskind David S , Nael Kambiz
Published: February 2024

Background:
Technically successful but futile angiographic reperfusion (AR) has been reported in 20-50% of acute ischemic stroke patients undergoing endovascular treatment. Persistent occlusions at distal arteries and ischemic capillary bed (i.e. no-reflow phenomenon) have been shown as one of the culprits resulting in infarct growth and poor functional outcome despite thrombectomy. We aimed to quantify the residual no-reflow perfusion in patients who underwent successful AR and assess its effect on infarct growth and functional outcome.

Methods:
In this retrospective single institution study, patients with anterior circulation LVO, successful AR (TICI ≥ 2b), and pre and posttreatment MR perfusion (MRP) were included. Hypoperfusion volume along the affected territory was calculated on Tmax maps using thresholds >2, 4, and 6 sec on both pre and posttreatment MRP scans. Infarct growth was calculated by subtracting baseline ischemic core from the final infarct volume. A total of 12 variables including demographic, clinical, and Tmax thresholds were evaluated to predict infarct growth and functional outcome (90day mRS).

Results:
A total of 50 patients met inclusion criteria, of whom 19 had infarct growth ≥ 10 mL while 31 had < 10 mL infarct growth. Functional outcome was poor in 27 patients (90day mRS>2). Univariate analysis showed no statistical significance (p>0.05) for either of the baseline Tmax volumes in prediction of infarct growth or functional outcome. Posttreatment hypoperfusion (no-reflow volumes) was significant for prediction of infarct growth at all Tmax volumes (p=0.048, 0.023, 0.021 for Tmax > 2, 4, and 6 sec respectively). Volume of Tmax
>6sec
was significant (p=0.044) for prediction of poor functional outcome. Multivariate logistic regression analysis revealed Tmax
>6 sec
residual hypoperfusion volume as an independent variable for prediction of infarct growth ≥ 10 mL (p=0.002) and functional outcome (p=0.007).

Conclusion:
In conclusion, no-reflow zones following successful AR were associated with infarct growth at all Tmax thresholds, however volume of residual Tmax
> 6 sec
was independently associated with infarct growth > 10 ml and poor functional outcome.
Abstract TP145: Comparison of the Clinical Characteristics of Patients With Minor Ischemic Stroke or TIA Treated Within the Stroke Code Protocol
Authors: Mauri Capdevila Gerard , Vázquez Justes Daniel , Gallego Sánchez Yhovany , Paul Arias Miriam , Salvany Sara , Purroy Francisco
Published: February 2024

Introduction:
There is a lack of evidence regarding revascularization treatments in patients with minor ischemic stroke (NIHSS < 6). CT angiography (CTA) and CT perfusion (CTP) might help select patients who would benefit from revascularization treatments. The main objective of this study is to compare the findings of CTA and CTP in a population of patients with minor ischemic stroke and TIA attended within the Stroke Code Protocol.

Methods:
Consecutive patients from Omic Is Brain cohort attended within the Stroke Code Protocol, diagnosed with minor ischemic stroke or TIA, and undergoing CTA and CTP, were included between May 2021 and April 2023. Clinical profiles were collected and classified into three groups: no large vessel occlusion - LVO - and no abnormalities in CTP (LVO-CTP-); no LVO and the presence of CTP abnormalities (LVO-CTP+); and LVO and CTP abnormalities (LVO+CTP+).

Results:
A total of 319 patients were included. Of these, 24.5% were CTP+, and 15.5% had LVO. The LVO-CTP- group (75.5%) was the youngest (p=0.022). Sex distribution and vascular risk factors were similar, except for hyperlipidemia, which was more frequent in the LVO+CTP+ group (p=0.003). Additionally, 5.3% of TIA patients had CTP+. Aphasia and defects in campimetry were overrepresented in the CTP+ group (p<0.005). Furthermore, 3.5% of strokes classified as lacunar strokes had LVO+. Lacunar strokes were mainly found in the LVO-CTP- group, while cardioembolic strokes were highlighted in the CTP+ group. The LVO+CTP+ group showed the highest variation in NIHSS scores between admission (4 [2.0-5.0]) and discharge (1 [0.0-2.25]) (p=0.024). Reperfusion therapies were more frequently administered in the LVO+ and CTP+ groups (p<0.001).

Conclusions:
The findings of CTA and CTP are directly correlated with clinical manifestations, severity, and acute-phase management.
Abstract TP150: Magnetic Resonance Imaging Predictors of Atrial Fibrillation in Cryptogenic Stroke Cases
Authors: Srinivasan Keshv K , Davis Lisa A ,   Steven J Warach MD PhD for Dell Med Sch-Ascension Texas Stroke Service, Dula Adrienne N
Published: February 2024

Introduction:
Ischemic stroke is a leading cause of death and disability in the US, with 20-40% of cases, classified as cryptogenic or with an unexplained cause. Detection of one cause, paroxysmal atrial fibrillation (AF), is critical to ensuring optimal treatment with direct oral anticoagulant (DOAC). Currently, the most reliable AF detection strategy is use of an insertable cardiac monitor (ICM). However, earlier detection of occult cardioembolic patterns using MRI may promote earlier decisions for DOAC use. The overall goal of this study is to determine if MRI lesion patterns are predictive of AF detection by ICM.

Methodology:
Cases of consecutive patients (1/1/2015 - 12/31/2017) with MRI-confirmed stroke performed 48h from time last known well and prior to endovascular treatment were retrospectively analyzed. The primary outcome, presence of occult atrial fibrillation, was detected by ICM placement within 90 days and follow-up within 180 days from stroke. Four imaging patterns were tested as predictors of AF: i) acute stroke lesion involving multiple vascular territories (MVT, i.e. right or left carotid and/or posterior circulation), ii) MVT plus wedge-shaped cortical infarct or chronic stroke on FLAIR, iii) MVT involving 3 territories, and iv) MVT in 3 territories plus chronic FLAIR lesion. Adjustment variables were based on univariate logistic regression predictors of AF at P ≤0.1000.

Results:
Of the 101 cases in this analysis, the median age was 63 years and 49.5% male. Stroke in multiple vascular territories MVT was present in 22/101 (22%) at baseline. The total AF 6-month detection rate was 36/101 (36%). The imaging pattern most predictive of AF was pattern ii, MVT plus chronic FLAIR with an unadjusted odds ratio (OR) of 3.47, 95% CI of 0.3442-2.1731, P=.0073. The adjusted OR (age ≥ 55, history of stroke, and history of TIA,) was 3.26, 95% CI: 1.0358-11.1860,
P
=.0480.

Conclusion:
The presence of acute lesions in MVT and a chronic FLAIR lesion may be a biomarker of occult cardioembolic source that could be used early after the onset of stroke to determine optimal DOAC use for secondary prevention and potential risk reduction of stroke recurrence from suspected but unproven cardioembolic source.

Funding:
Lone Star Stroke Research Consortium
Abstract TP160: Minimum Intracerebral Hemorrhage Volume to Maximize Diagnostic Accuracy of Simplified Edinburgh Criteria
Authors: Yan Tingmeng , Su Ya , Xu Jiajie , Fu Jiayu , Xu Feifan , Cheng Xin , Dong Qiang
Published: February 2024

Introduction:
Simplified Edinburgh criteria, based on plain CT, facilitates etiology diagnosis of ICH on cerebral amyloid angiopathy (CAA). Excellent performance in autopsy cohort though, the criteria show disparate discrimination ability amongst survivors with smaller hematoma size in external validation. On assumption that diagnostic accuracy may depend on ICH volume, cutoff volume could likely be found to better the application of Edinburgh criteria.

Methods:
Primary lobar ICH patients with CT and one of the following: pathology OR qualified MRI available for probable CAA diagnosis per Boston 2.0 criteria were retrospectively enrolled. Clinical characteristics, ICH volume, histology and markers of CT and MRI were collected for validation test. Additionally, likelihood-ratio curves for rule-in and rule-out criteria were plotted, taking 3.0 and 0.3 as the threshold of positive likelihood ratio (PLR) and negative likelihood ratio (NLR) respectively.

Results:
The criteria were tested among 52 lobar ICH patients with histological proof and 120 with MRI data. Patients with pathology by hematoma evacuation were characterized by larger ICH volume (31.45(31.45), 12.61(16.07), P<0.001) and younger age (67±7, 71±9, P=0.002), compared to those tested on MRI. Discrimination of pathology-evidenced CAA was good (AUC 0.74) for both rule-out (NLR 0.26) and rule-in (PLR 2.97) criteria, while less satisfying when validated against probable CAA on MRI (AUC 0.58, NLR 0.61, PLR 1.42), evincing volume-dependent performance of Edinburgh criteria. According to likelihood-ratio curves (Figure 1), cutoff volume of 30ml may maximize positive likelihood ratio for rule-in criteria and optimize rule-out criteria with NLR≤0.3.

Conclusion:
Simplified Edinburg criteria was initially validated against pathology- or MRI-attested CAA in Asian population. Dependent on ICH volume, the diagnostic accuracy may be considerably augmented when cutoff value of 30ml was applied.
Abstract TP162: Polyamine Levels Are Elevated After Intracerebral Hemorrhage
Authors: Demel Stacie L , Hernandez Rodriguez Luis , Comeau Mary , McCauley Jacob , Langefeld Carl D. , Paredes Daniel , Woo Daniel
Published: February 2024

Introduction:
Intracerebral hemorrhage (ICH) has high morbidity and mortality without available targets for intervention. Polyamines are metabolites implicated in neurological diseases such as traumatic brain injury, Alzheimer’s Disease, and ischemic stroke. No studies have evaluated polyamines as they relate to ICH occurrence or outcomes. In this pilot study, we sought preliminary data on whether polyamines could be potential novel targets to improve outcomes after ICH.

Methods:
We analyzed plasma samples from 7 ICH cases and 10 control participants from the Genetics and Environmental Risk Factors for Stroke (GERFHS) IV study for polyamine measurements using Capillary Electrophoresis with Laser Induced Fluorescence Detection with the modality of Micellar Electrokinetic Chromatography. Plasma samples were deproteinized and derivatized with Fluorescein Isothiocyanate. Samples were spiked with standard solutions and compared with standard curves developed per each polyamine. We report median age and sex of the cohort. Peak spermine, spermidine and putrescine levels were compared using a student’s t-test.

Results:
In this pilot study of participants enrolled into GERFHS IV (median age 67 vs 61, cases vs controls respectively, 50% female) all three unacetylated polyamine levels were higher in cases. Although sample size is modest, there was a trend towards increased spermidine levels with higher mRS at 90 days (r
2
= 0.3342) (Figure 1).

Conclusions:
For the first time, we have shown that polyamines are elevated after ICH, and that higher polyamine levels may be associated with worse outcomes. This preliminary data supports further evaluation of polyamines as potential targets to improve outcomes after ICH in a larger cohort.
Abstract TP176: Radiological Reporting Frequencies of High-Risk Non-Stenosing Carotid Plaque Features: A Follow-Up Observational Study
Authors: Jumah Ammar , Albanna Abdalla , Elfaham Abdelrahman , Zoghoul Sohaib , Eltous lara , Miller Daniel
Published: February 2024

Background:
High-risk non-stenosing carotid plaque features are emerging as a possible source of embolism in the setting of ESUS. Unless there is a hemodynamically significant stenosis, neuroradiology reports tend to be rarely descriptive of these features.

Methods:
In our previous study published in September 2022, we analyzed a patient sample drawn from the stroke registry of the HFHS between June 2016 and June 2021. Our results showed a higher incidence of high-risk plaque features including plaque ulceration (19.08% vs 5.26%, p<0.0001), plaque thickness >3mm: (19.08% vs 7.24%, p=0.001), and length >1cm (13.16% vs 5.92%, p=0.0218) ipsilateral to ESUS. In this subsequent study, we utilized the same patient dataset and used CTA reports on EPIC to explore how frequently neuroradiologists had mentioned those features. We utilized Fisher’s exact test to compare the frequencies of reporting each plaque characteristic.

Results:
We analyzed 152 CTA reports in depth. Our findings indicate that the frequency of reporting plaque ulceration compared to the frequency of reporting plaque calcification was significantly different (8.1% vs 100%, p< 0.00001), this is also noticed with plaque length (4.6%, p< 0.00001) and soft plaques (72.1%, p< 0.00001). Notably, none of the CTA reports had commented on any plaque thickness or the presence of any “high-risk” features when encountering stroke ipsilaterally.

Conclusion:
When carotid plaques are not causing hemodynamically significant stenosis, neuroradiology reports frequently mention the density of plaques, but unfortunately overlook other characteristics. It is essential to conduct algorithms, scoring systems and prediction models to determine which plaque features are highly associated with embolism. These models should help prioritize the description of these features, alongside commonly reported metrics such as plaque density and the degree of stenosis.
Abstract TP188: Diving MCA and First-Pass Reperfusion: A Subgroup Analysis of the Arise II Study
Authors: Ashouri Yazan , Mirza Mahmood , Liaw Nicholas , Kashef Al-gheta Jaafar , Bushnaq Saif , Awad Mark , Abou-Chebl Alex , Andersson Tommy , Yoo Albert J , Saver Jeffrey L , Zaidat Osama
Published: February 2024

Introduction:
Tortuosity of Internal carotid artery impact on achieving first pass in mechanical thrombectomy has been previously described. Here, we investigate the association of middle cerebral artery(MCA) tortuosity on radiographic and functional outcome.

Methods:
The Analysis of Revascularization in Ischemic Stroke with EmboTrap II was utilized to identify patients with anterior circulation stroke. MCA tortuosity was calculated using Inflection Count Metric(ICM) by two blinded readers to angiographical/clinical outcomes. The total cohort was trichotomized into 3 groups (A, B, C) based on M1 tortuosity tertiles. The primary efficacy end point was achievement of modified Thrombolysis in Cerebral Ischemia (mTICI) reperfusion scores of ≥2b on first pass. Good functional outcomes was defined as mRS0-2 on 90-day followup. Baseline and procedural data were compared between groups.

Results:
A total of 200 with known MCA tortuosity were identified. Patients within group A were significantly older (P<0.05) . Group C patient were more likely to have renal disease and atrial fibrillation (P<0.05). There was no differences in terms of NIHSS score at presentation nor ASPECT score between groups. Achieving first-pass success was more likely in group A (60.6%) vs 47% and 38.2%, P=0.033 for groups B and C, respectively. Likewise, the rate of mTICI≥2c was higher in group A (54.5%) vs 36.4% and 26.5%, p=0.003. Achieving mRS0-2 was more likely in group A (76.6%) vs 73.4% and 49.3%, p=0.001. There were no differences in distal emboli, or symptomatic intracranial hemorrhage. Findings of first-pass and angiographic outcomes were consistent with standard tortuosity scoring system.

Conclusion:
Patients with higher MCA tortuosity are less likely to have successful reperfusion and good functional outcome post mechanical thrombectomy for acute ischemic stroke.
Abstract TP207: Endovascular Treatment in the Late Time Window: Strict Perfusion Imaging Screening Criteria in Case Selection
Authors: Hao Manjun , Wang Liyuan , Cao Zhixin , Wu Na , Xiong Yunyun
Published: February 2024

Background and purpose:
Clinical-imaging mismatch or perfusion imaging mismatch criteria per DAWN (Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) or DEFUSE-3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke), respectively were recommended for case selection for endovascular treatment (EVT) of acute ischemic stroke (AIS) in the late time window outside 6 hours of stroke onset. We aimed to compare the clinical functional outcomes in EVT patients with and without strict perfusion imaging screening criteria in the late time window.

Methods:
AIS patients with anterior circulation large vessel occlusion (LVO) presenting within 6 to 24h hours after symptom onset were selected from a retrospectively collected thrombectomy cohort database (RESTORE). According to the imaging criteria of DAWN and DEFUSE-3, we compared proportions of patients with a favorable functional outcome (defined as a modified Rankin Scale [mRS] score of 0-2) at 90 days between the DAWN or DEFUSE-3 patients (D/D) and the non-DAWN or DEFUSE-3 (non-D/D) patients.

Results:
Among 265 adult patients with anterior circulation LVO who received EVT within 6 to 24 hours after symptom onset, 142 patients met either DAWN or DEFUSE-3 imaging criteria. D/D group independently predicted favorable functional outcome at 90 days (50.7% vs. 35.0%, aOR 0.514; 95% CI 0.273-0.966, p=0.039) adjusted for age, sex, previous stroke, hypertension, atrial fibrillation, coronary heart disease, pre-EVT collateral score, successful recanalization, onset to CT time.

Conclusions:
In AIS patients with anterior circulation LVO in the late time window, our real world data support the guideline that DAWN or DEFUSE-3 imaging criteria are strongly recommended for EVT case selection.
Abstract TP209: Prevalence of Spontaneous Recanalization of Internal Carotid Occlusion: A Systematic Scoping Review
Authors: Zhang Sarah Y , Chung Hee Sahng , Dewar Brian , Fahed Robert , Shamy Michel , Dowlatshahi Dar
Published: February 2024

Introduction:
Spontaneous recanalization of occluded internal carotid arteries (ICAs) is thought to be an uncommon etiology of recurrent ischemic stroke. However, there is a growing number of reports describing this phenomenon, suggesting that follow-up investigations and/or intervention may be warranted. Our objective was to perform a scoping review of the literature to estimate the prevalence of spontaneous ICA recanalization and the timing of recanalization, and to describe imaging modalities used in follow-up as well as any post-recanalization interventions.

Methods:
MEDLINE, Embase, Cochrane Central Register of Controlled Trials and Web of Science were searched from inception to June 2022 for studies that included adults with spontaneous recanalization or transient occlusion of the internal carotid artery. Two investigators independently screened the studies and extracted data around recanalization prevalence, timepoints, imaging, and treatment. These results were described qualitatively, and descriptive statistics were calculated where appropriate.

Results:
Among the 2384 studies retrieved, 51 met inclusion criteria, of which 34 were case studies and 17 were cohort studies, with a total of 816 patients. Prevalence of recanalization was reported in 20 studies (3 case studies, 17 cohort studies) at a median of 40.0% (IQR 22.5 - 40.0%) in case studies, and 21.2% (IQR 9.2 - 37.5%) in cohort studies. Forty-one studies reported a time frame for when recanalization was identified, with 53.7% individual cases in case studies and 33.3% amongst cohort studies identified within the first 3 months after occlusion. When reported, antiplatelet treatment was the most common medical treatment pre- and post-recanalization with 189 and 36 individuals, respectively. Finally, doppler imaging was used in 70.6% of studies to identify recanalization, with angiography as the next most common modality at 54.9%. Twenty studies reported an endovascular intervention.

Conclusions:
Spontaneous recanalization occurs more commonly than previously thought. Currently there is no consensus on what intervention is needed (if any), or when this intervention would occur. More data is needed to confirm this data and determine the best time frame to re-image.
Abstract TP211: TICI Scoring Reliability in Proximal vs Distal Vessel Thrombectomy: A Comparative Analysis
Authors: Dolia Jaydevsinh N , Nascimento Pedro , Tarek Mohamed , Damiani Monteiro Mateus , Grossberg Jonathan A , Pabaney Aqueel , Al-Bayati Alhamza , Navalkele Digvijaya , Nogueira Raul G , Haussen Diogo C
Published: February 2024

Introduction:
The extended Thrombolysis in Cerebral Infarction (eTICI) scale has been demonstrated to correlate strongly with clinical outcomes. Thrombectomy has evolved into the pursuit of not only proximal but distal vessel occlusions, however the reliability of eTICI grading for distal occlusions has not been well studied. We aim to study the interrater agreement of proximal as compared to distal occlusions.

Methods:
A fellowship trained Neurointerventionalist retrospectively scored the Digital Subtraction Angiography(DSA) images of consecutive patients with only isolated proximal (MCA-M1 or ICA-T) or distal occlusions (MCA-M3, ACA, or PCA) that underwent MT at a single comprehensive stroke center (2022 for proximal occlusions and 2015-2022 for distals). We assessed the agreement between the Neurointerventionalist and original report for the ordinal eTICI scale using Fleiss-Cohen’s Weighted Kappa with quadratic weights. TICI distributions were compared using Wilcoxon’s rank sum test.

Results:
187 patients were included in the analysis (124 Proximal and 60 patients distal: 32-M3, 20 -ACA, 8-PCA). The distribution of eTICI 0, 2a, 2b50, 2b67, 2c and 3 were comparable between proximal(MCA-M1 or ICA-T) vs distal occlusions (MCA-M3, ACA, or PCA). The Fleiss-Cohen weighted kappa coefficients were assessed. The proximal eTICI score assessment demonstrated moderate reliability with a kappa value of 0.77 (95%CI: 0.67-0.88)(Table 1A), while the distal eTICI score assessment exhibited almost perfect agreement with kappa value of 0.87 (95%CI: 0.71-1.00)(Table 1B).

Conclusion:
This study underscores comparable reliability of eTICI scores in assessing reperfusion post MT for distal as compared to proximal occlusions.