bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP103: Neuronal Dysfunction And Hemodynamic Disturbance Due To Venous Congestion In Dural Arteriovenous Fistula Revealed By
123
I-iomazenil Single-photon Emission Computed Tomography
Authors: Kanemaru Kazuya , Yoshioka Hideyuki , Hashimoto Koji , Wakai Takuma , Tateoka Toru , Fukuda Norito , Kinouchi Hiroyuki
Published: February 2023

Objective:
Retrograde leptomeningeal venous drainage (RLVD) of a dural arteriovenous fistula (dAVF) is related to neurological morbidity and unfavorable outcomes. However, the direct damage to cortical neurons by dAVF with RLVD has not been elucidated.
123
I-iomazenil (
123
I-IMZ) single-photon emission computed tomography (SPECT) can reveal cerebral blood flow and cortical neuronal damage in early and late images, respectively. This study aimed to assess the relationship association between cerebral venous congestive encephalopathy caused by dAVF using
123
I-IMZ SPECT.

Methods:
Based on the pre- and post-treatment magnetic resonance imaging findings, patients were divided into three groups: normal, edema, and infarction groups. Radioactivities in the early and late images of
123
I-IMZ SPECT were investigated using the affected-to-contralateral side asymmetry ratio (ACR).

Results:
None of the patients in the normal group showed any symptoms related to venous congestion. In contrast, all the patients in the edema and infarction groups developed neurological symptoms. The ACR in early images in the edema group was significantly lower than that in the normal group and significantly higher than that in the infarction group. The ACR in the late images of the infarction group was significantly lower than those of the normal and edema groups. After treatment, the neurological signs disappeared in the edema group, but only partial improvement was observed in the infarction group. The ACR in early images significantly improved after treatment in the edema group; however, that in late images did not change in any groups.

Conclusions:
123
I-IMZ SPECT is useful for evaluating hemodynamic disturbances and neuronal damage in dAVFs. The reduction in early images was correlated with the severity of venous congestive encephalopathy, and the significant reduction in late images is a reliable indicator of irreversible venous infarction caused by RLVD.
Abstract TP104: Discharge Disposition Before And During The Covid-19 Pandemic For Acute Stroke Inpatients Admitted To California Hospitals
Authors: McHugh Daryl C , Albert George , George Benjamin P
Published: February 2023

Objectives:
The COVID-19 pandemic impacted acute inpatient care for stroke patients resulting in less acute therapy and limitations in rehabilitation services. We sought to characterize differences in acute stroke disposition and readmissions during the COVID-19 pandemic compared to a pre-pandemic period.

Materials and Methods:
We used the California State Inpatient Database in this retrospective observational study of acute stroke, including ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). The pre-pandemic period was January 2019 to February 2020, and the pandemic period was March 2020 to December 2020. We compared discharge disposition across the two periods using cumulative incidence functions (CIF) to account for competing risks. We compared re-admission rates across the two periods using a chi-squared test.

Results:
There were 63,120 stroke hospitalizations in the pre-pandemic period and 40,003 stroke hospitalizations during the pandemic period. Both periods included 81% IS, 15% ICH, and 4% SAH. Baseline demographics were similar in both periods. In the pre-pandemic period, the most common disposition was home [46%], followed by skilled nursing facility (SNF) [23%], and acute rehabilitation [13%]. During the pandemic, disposition shifted to increasing proportions of discharges home [51%], and decreasing discharges to SNF [17%], while discharges to acute rehabilitation were unchanged [CIF, p<0.001]. The increase in home discharges and decrease in SNF discharges were driven by older ages (>85 years). The 30-day readmission rate for acute stroke before the pandemic was 12.7 per 100 hospitalizations compared to 11.6 per 100 hospitalizations during the pandemic [p<0.001]. The readmission rate for those discharged to home (11.0 vs. 10.9 per 100 hospitalizations, p=0.738) was unchanged. However, readmission rate for those discharged to SNF (18.4 vs. 16.7 per 100 hospitalizations, p=0.003) and acute rehabilitation (11.3 vs. 10.1 per 100 hospitalizations, p=0.034) decreased during the pandemic.

Conclusions:
We observed an increase in the proportion of patients discharged to home, and no change in readmission rates for these patients, suggesting improvement in triage during the pandemic period.
Abstract TP105: Intra-individual Blood Pressure Variability For The Duration Of Hospitalization And Subsequent Clinical Outcome After First-ever Ischemic Stroke
Authors: Yousufuddin Mohammed , Peters Jessica , Karam Dhauna , Khandelwal Kanika
Published: February 2023

Background:
The association of in-hospital blood pressure variability (BPV) with readmission or survival after acute ischemic stroke (AIS) have not been fully investigated. We evaluated the relationship between intra-individual systolic blood pressure (SBP) variability (SBPV) for the duration of hospitalization, mean SBP, maximal SBP reached and readmission-free survival, all-cause readmission, or all-cause mortality to one year after hospitalization for a new acute ischemic stroke (AIS).

Methods:
We measured mean SBP, maximal SBP reached, and SBPV as quartiles of standard deviations (SD) and coefficient of variation (CV) across a median of 16 SBP readings per patient, every 4 hours, for the duration of hospitalization in 862 patients (age (mean±SD) 75±15 years, 55% females) with AIS admitted from 2003 to 2018, followed-up to 2019.

Results:
At 1 year, readmission-free survival was 51%, readmission rate was 39%, and mortality was16%. The mean ± SD in mmHg for SBP 146±20, maximal SBP reached 163±26, SD 16±6, and CV 10±5. Adjusted hazard ratios for the highest vs. lowest quartiles of SD or CV were 1.44 (95% confidence interval 1.04 - 1.81) or 1.29 (0.94 - 1.64) for readmission-free survival; 1.29 (0.9 - 1.78) or 1.29 (0.94 - 1.78) for readmission; 1.15 (0.71 - 1.87) or 0.86 (0.55 - 1.36) for mortality. The results remained consistent with mean SBP. However, maximal SBP was inversely associate with readmission-free survival. The accompanying figure shows Kaplan-Meier survival analysis of cumulative incidence of three outcomes by quartiles of SD (upper panel) and CV (lower panel) of SBP.

Conculsions:
Among patients hospitalized with a new AIS, higher in-hospital SBPV was associated with no decrease in readmission-free survival or increase in rates of readmission or mortality to 1 year. We recommend less emphasis on treating blood pressure and more focus on guideline-directed high-value care for the management AIS patients.
Abstract TP107: Utility of routine 24h follow-up CT after thrombolysis
Authors: Zhang Bowei , Schwamm Lee H , Rost Natalia S , Singhal Aneesh
Published: February 2023

Background:
24h CT is routinely acquired post-thrombolysis. Parenchymal hematoma and brain edema are feared complications. Predicting complications that change management would help reduce unnecessary imaging.

Objective:
To evaluate the utility of 24h per-protocol CT scan for stroke patients after thrombolysis.

Methods:
A prospectively collected cohort of consecutive patients presenting with acute ischemic stroke to our hospital from 2013- 2021 who were treated with IV tPA without undergoing endovascular therapy was entered into our IRB-approved stroke registry. Neuroimaging performed within 48h after admission was reviewed. Patients’ demographics, past medical history, admission National Institute of Health Stroke Scale (NIHSS) score, and medical variables were obtained. The primary outcome was significant radiologically findings (parenchymal hematoma or midline shift/herniation) leading to change in management (additional monitoring, emergent procedure, administration of mannitol or alteration in blood pressure goal).

Results:
From 2013 to 2021, 875 patients (mean age 69) who had IV tPA without undergoing endovascular therapy were identified, of which 472 (47.1%) were female. Median (IQR) NIHSS score was 9 (4-16) on admission. Imaging findings: 339 (38.7%) had expected evolving infarctions; 106(13.3%) developed any type of hemorrhagic transformation, including 66 (7.5%) who had hemorrhagic infarction and 50 (5.7%) parenchymal hematomas; 142(16.2%) developed any kind of mass effect, including 63 (7.2%) who had mild mass effect and 79 (9.0%) midline shift/herniation. There were 124 patients (12.1%) had significant findings (including parenchymal hematoma and midline shift/brain herniation) leading to change in the management. Patients who had significant findings had higher NIHSS score 16 (8-21) than those without 8 (4-15) (p<0.001). NIHSS was the only significant outcome predictor both in univariate and the multivariable analysis.

Conclusions and interpretations:
Our study showed that patients with high NIHSS score were more likely to have significant findings. 24-hour follow-up CT scan should be based on the risk of developing significant complications.
Abstract TP116: Procoagulant Reversal Of Warfarin After Intracranial Hemorrhage Is Not Associated With Improved Functional Outcome When Coagulation Is Abnormal Without Full Anticoagulation
Authors: LacKamp Aaron N , Weber Jeremy M , Mac Grory Brian , Caye Adrien , Stenuf Chaeli , Barkley Tiffany , Messe Steven , Alhanti Brooke , Blanco Rosalia G , Fonarow Gregg C , Xian Ying , Mangat Halinder S
Published: February 2023

Introduction:
Although the current guidelines recommend procoagulant reversal of elevated INR >= 2.0 (International Normalized Ratio) in patients with intracranial hemorrhage using warfarin, the benefit of procoagulant reversal is uncertain when patients have abnormal coagulation but are not fully anticoagulated.

Hypothesis:
For patients using warfarin (INR 1.5 to 1.9) who have intracranial hemorrhage the use of procoagulant reversal will improve functional outcome based upon dichotomized discharge mRS (modified Rankin scale) 0-3 vs 4-6.

Methods:
The Get With The Guidelines - Stroke registry was used to identify 239,681 patients with intracranial hemorrhage from hospitals using the comprehensive stroke center form between January 1, 2015 and January 4, 2022. Patients were excluded if they received thrombolytics, were using direct oral anticoagulants, if INR was not between 1.5 and 1.9, or if they were not using warfarin. To evaluate the association between procoagulant reversal and mRS at discharge, 1868 patients with non-missing mRS were analyzed for the primary outcome (mRS 0-3 vs. 4-6). Secondary outcomes that did not require mRS were analyzed among a possible 2569 patients. Propensity scores were estimated and overlap weighting was used to account for confounding. Logistic and negative binomial regression models were fit for binary and count variables, respectively.

Results:
There was an even distribution of patients into treatment and nontreatment (N=974 no reversal, N=894 reversal), and the groups were strikingly similar. Key outcomes are shown in the Table.

Conclusions:
Procoagulant reversal of warfarin for patients with acute intracranial hemorrhage and INR 1.5 - 1.9 was not associated with an improvement in functional outcome based upon mRS 0-3 vs 4-6. Patients that received a reversal agent had 25% lower odds of dying in the hospital or being discharged to hospice, but had a longer hospital stay and were less likely to be fully ambulatory at discharge.
Abstract TP127: Application Of Machine Learning Algorithms For Prediction Of Hematoma Expansion In Spontaneous Intracerebral Hemorrhage
Authors: Prologo-Richardson Paige , Zoghi Zeinab , Castonguay Alicia , Khalid Fatima , McCracken Matthew , Zaidi Syed F , Jumaa Mouhammad A
Published: February 2023

Introduction:
Hematoma expansion (HE) is a known prognostic indicator of spontaneous intracerebral hemorrhage (sICH). Although several scores exist for prediction of HE, universal adoption has been limited due to their lack of sensitivity and specificity. As machine learning (ML) algorithms have shown promise in the stroke field, here we examine the predictive accuracy of several ML algorithms for HE in sICH patients.

Methods:
We retrospectively analyzed demographic, clinical data, and radiographic signs of patients with sICH in our 2-hospital database. A total of 61 clinical, imaging, and treatment variables were included in the study. Nine ML models were applied: Adaptive Boost (AdaBoost), Bernoulli Naïve Bayes (BNB), Decision Tree (DT), Gaussian Naïve Bayes (GNB), Logistic Regression (LR), Multi-Layer Perceptron (MLP), Multinomial Naïve Bayes models (MNB), Random Forest (RF), and Extreme Gradient Boosting (XGBoost). All models were trained to predict HE. Model accuracy was assessed using the area under characteristic curve (AUC).

Results:
Of the 301 patients with sICH, 63 developed HE (21.93%). Of the 9 models studied, MLP had the highest AUC score (0.93±0.042), followed by XGBoost (0.80±0.06). All models demonstrated moderate to high predictive accuracy (AUC 0.64-0.93) for HE. The top predictors in MLP were Baseline NIHSS score, HDL, aPPT, time from last known well to ER, initial hematoma volume, and island sign. MLP had moderate sensitivity of 0.46±0.17 and high specificity of 0.99±0.02. GNB, however, showed the highest sensitivity at 0.86±0.06 and a moderate specificity of 0.65±0.07. Five of the 9 models ranked time last known well to ER presentation as a predictor of HE.

Conclusion:
In our study, we found all ML models applied had moderate to high predictive accuracy for prediction of HE in sICH, with MLP having the highest accuracy of all models. Future studies examining the use of these algorithms are warranted.
Abstract TP131: Trends In Intracerebral Hemorrhage Patients With Seizures: A Propensity Score Matched 20-year Analysis Of The National Inpatient Sample
Authors: Philbrick Brandon D , Hardigan Trevor , Kellner Christopher P , Fifi Johanna T , Mocco J D , Majidi Shahram
Published: February 2023

Introduction:
Intracerebral hemorrhage (ICH) accounts for 15% of strokes, and an early sequelae of hemorrhagic stroke is seizure. Studies have shown up to 43% of ICH patients experience electrographic seizure within 72 hours of ictus. The clinical course of patients with seizures in ICH remains unclear.

Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for the presence of seizures on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.

Results:
2,000,868 patients with ICH were identified; 234,382 had seizures (11.7%). Patients with seizure had higher Elixhauser Comorbidity Score (15.12 ± 8.54 vs. 9.80 ± 8.98, p<0.001) and NIH Stroke Score (13.02 ± 9.85 vs. 11.17 ± 9.46, p<0.001). There were higher rates of coma, fluid/electrolyte dysfunction, CNS infections, craniotomy, and external ventricular drain placement (p<0.01). After propensity matching, patients with seizure were less likely to experience in-hospital mortality (AOR 0.85; 95% CI: 0.82-0.87), more likely to be discharged home or short-term hospital (AOR 1.31; 95% CI: 1.27-1.35), have shorter hospital stay (-0.63 days; 95% CI: -0.82 - -0.45), and lower hospital charges ($-3991.74; 95% CI: $-6196.22- -1787.27) (all p<0.001).

Conclusions:
The rate of seizure among ICH patients remains unchanged over the past 2 decades. Seizure is associated with more severe presentation; however, it does not independently worsen the clinical outcome.
Abstract TP132: Racial Disparity In Outcomes Of Primary Intracerebral Hemorrhage In The United States: A 20-year Analysis Of The National Inpatient Sample
Authors: Hardigan Trevor , Yaeger Kurt , Philbrick Brandon , Fifi Johanna T , Kellner Christopher P , Mocco J D , Majidi Shahram
Published: February 2023

Background:
Primary intracerebral hemorrhage (ICH) is a devastating disease with limited therapeutic options and poor overall outcomes. We aimed to characterize racial disparities in patients with ICH over a 20 year period and examine the prognostic impact of race on functional outcomes.

Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Discharge location was used as a surrogate for functional outcome. Univariate analysis with t-tests or chi-square performed as appropriate, and significant variables were entered into a multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for race on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.

Results:
A total of 2,000,868 patients with ICH were identified. Mean Age was 68.28 ±15.41 years. Patients were 57.2% White, 14.1 % Black, 8.3% Hispanic, and 3.9% Asian. Average Elixhauser Comorbidity Score was significantly different among the groups, with White patients having higher score on average than Asian, Black, or Hispanic Patients. There was no difference in NIH Stroke Scale among the groups. After multivariate analysis, there were no differences in odds of discharge to home or to nursing/long-term care facilities between races (p>0.001). In hospital mortality was less in Black (AOR 0.73, 95%CI: 0.64-0.84) and Hispanic (AOR 0.65, 95% CI: 0.55-0.78) patients compared to White (p<0.001).

Conclusions:
This 20 year nationally representative analysis of racial disparities in ICH patients shows that despite the increasing prevalence in Black and Hispanic patients over 20 years, they have greater odds of survival during their hospital stay when compared to White patients. Further examination of healthcare systems and patient-specific factors are warranted to elucidate this phenomenon.
Abstract TP134: The Effect Of Aortic Arch And Carotid Artery Anatomy Parameters On Door-To-Recanalization Times At A Comprehensive Stroke Center
Authors: Nisar Taha , Lebioda Konrad , Rodriguez Jorge , Patel Jimmy , Lee James , Bach Ivo , Memon Muhammad Z , Singla Amit , Khandelwal Priyank
Published: February 2023

Introduction:
The American Heart Association recommends a Door-to-Recanalization/Reperfusion (DTRp) time of ≤120 minutes. We aim to identify aortic arch and carotid artery anatomy parameters associated with a delayed DTRp at a comprehensive stroke center (CSS).

Methods:
We performed a retrospective chart review of patients who underwent mechanical thrombectomy (MT) for an anterior circulation large vessel occlusion (LVO) at a CSS from 1/2015 to 12/2021. We compared various aortic arch and carotid artery anatomy parameters between patients who achieved DTRp in ≤120 minutes vs.>120 minutes. A blinded board-certified neuroradiologist used the pre-MT CT Angiogram to document different aortic arch and carotid artery anatomy variables. A binary logistic regression analysis was performed, controlling for age, gender, presenting mean arterial pressure (MAP), presenting serum glucose, Hb A1C, LDL, intravenous alteplase, left hemispheric location, location of occlusion [proximal (ICA or M1 segment of the middle cerebral artery) versus distal (M2 segment of the middle cerebral artery)], ASPECTS≥6, general anesthesia, transradial approach, number of passes.

Results:
256 patients met our inclusion criteria. The mean age was 65.18±14.89 years. In our cohort, the presence of a bovine arch was significantly associated with a DTRp of >120 minutes (39.19% vs. 20.59%; OR, 0.37; 95 % CI, 0.15-0.94; P 0.035). Whereas, the other aortic arch and carotid artery anatomy parameters were not significantly associated with DTRp of >120 minutes, as shown in the Table.

Conclusion:
Among aortic arch and carotid artery anatomy parameters, the presence of a bovine arch was associated with significantly delayed DTRp of >120 minutes in our cohort.
Abstract TP14: Does Atrial Fibrillation (Afib) Impact The Rate Of 90 Days Modified Rankin Scale (mRS) In Patients Who Received Intravenous Thrombolytic (IVT) Before Endovascular Treatment (EVT)?results From A Large Health System In Six Western States Of The United States
Authors: Bavarsad Shahripour Reza , Marginean Horia , Corless Leslie , Lowenkopf Ted J , Lesko Alexandra C , Guerrero Adrieanne , Singh Tarvinder , Loh Yince , Pirastehfar Mohsen , Tarpley Jason W
Published: February 2023

Introduction:
Previous studies indicate patients with acute ischemic stroke (AIS) due to Afib may not respond well to intravenous thrombolysis (IVT) compared to those without Afib. We assessed the association between a history of atrial Afib, good 90-day mRS (≤2), and the rate of symptomatic intracerebral hemorrhage (sICH) in patients treated with IVT and/or EVT.

Methods:
Data from a multi-state health system’s stroke registry for patients who received acute stroke treatment and were discharged between 2018 and 2022 were used. Patients were stratified into groups 1:EVT only with or without Afib; 2: IVT plus EVT with or without Afib; 3:IVT only with or without Afib.Multivariable mixed-effect logistic regression was performed and adjusted for baseline NIHSS, age, sex, race, and ethnicity, NIHSS on admission, blood glucose on admission, SBP at admission, and history of diabetes, CAD/prior MI, carotid stenosis, smoking, dyslipidemia, heart failure, being overweight, or renal insufficiency

Results:
Overall, 2558 patients who underwent AIS treatment had a 90-day mRS, of whom 30% had a history of AFib, 48% had a 90-day mRS 0-2; with the median age at arrival 72 years,73% white, median NIHSS was 9, 27% diabetes, 21% CAD, 4% carotid stenosis, 13% smoker, 60% dyslipidemia, 13% HF, 62% overweight, 11% chronic renal insufficiency, median SBP 153 mmHg, median glucose 124.Among group 1(n=978): 39.4% had Afib, 36.1% had a 90-day mRS 0-2 and 5% had sICH .In group 2 (n=402): 28.1% had Afib, 44.3% had a 90-day mRS 0-2 and 5.9% had sICH. In group 3(n=1178): 16.1% had Afib, 59.9% had a 90-day mRS of 0-2, and 2.6% had sICH.After adjustment, there was no association between Afib and 90-day mRS in any group. Also, the rate of sICH did not significantly differ between Afib and non-Afib patients.

Conclusions:
History of Afib did not significantly impact favorable functional outcomes or the rate of sICH in patients who underwent EVT with or without intravenous thrombolytics.
Abstract TP146: Remote Teleproctoring Enabling Vascular Interventionists In Primary Stroke Centres To Perform Mechanical Thrombectomy With Comparable Results To Comprehensive Stroke Centres
Authors: Piñana Carlos , Díaz Lourdes , Carmona Tomás , Requena Manuel , Hernández David , De Dios Lascuevas Marta , Tomasello Alejandro
Published: February 2023

Background:
Increasing efficacy of endovascular thrombectomy for ischemic stroke entails a rising demand for intervention outside Comprehensive Stroke Centers (CSC), in regions where time to treatment and transfer delays result in worse outcomes. We explore the use of a remote teleproctoring system to support vascular interventionists in a remote Local Stroke Center (LSC) to safely perform mechanical thrombectomy (MT) in patients with acute ischemic stroke.

Methods:
Since November 2020, a Tegus Medical Teleproctoring System was installed in a LSC (Arnau de Vilanova Hospital, Lleida) where the potential MT population could be 80-100 procedures/year, however only half that figure is currently being treated, with most patients transferred to the CSC (Vall d’Hebron Hospital, Barcelona) 160 kms away. Since the implementation of this technology, thrombectomy procedures have been performed by vascular interventionists with moderate neurovascular experience at the LSC, remotely assisted by expert neurointerventionists from the CSC. We retrospectively analyzed the safety and effectiveness of MT with the aid of this proctoring System, comparing with procedures performed in the CSC.

Results:
Ten MT were performed in the LSC, comprising 50% of the acute stroke cases taken to the angiosuite in one year. The thrombectomy technique was combined distal aspiration with stent-retriever in all cases. Seven thrombectomies resulted successful after the first pass (70%), achieving complete/near complete recanalization (TICI 2c/3) in 80% of the cases. Comparing with CSC, median puncture to recanalization time was 31 (26-62) vs 42 (27-67) and the rate of final succesful reperfusion (90% in LSC vs 86.5% in CSC) was similar. No technical or procedural complications were reported. At 90 days, 40% of the patients had a mRS 0-2. A survey exploring the personal experience showed that communication was considered optimal and confidence in decision making was considered high at both ends of the system.

Conclusion:
Tegus system seems a valuable tool to support vascular interventionists facing a rise in thrombectomy demands in distant LSCs maintaining enough safety, effectiveness and confidence during the procedures. These data should be challenged by prospective studies.
Abstract TP147: Investigating Potential Racial And Ethnic Biases In Mechanical Thrombectomy Selection For Expanded Indication Populations
Authors: Mehta Amol M , Salazar-Marioni Sergio , Abdelkhaleq Rania , Niktabe Arash , Tariq Muhammad Bilal , Sheth Sunil
Published: February 2023

Introduction:
Endovascular thrombectomy (EVT) performance in clinical practice has grown substantially, including in patient groups previously excluded from clinical trials such as those with advanced age, lower Alberta Stroke Program Early CT Score (ASPECTS) and distal occlusions. However, the access and utilization of EVT in these non-randomized controlled trial (RCT) supported populations across different racial and ethnic groups remains incompletely characterized

Methods:
Using our prospectively maintained multi-center registry which includes four comprehensive stroke centers around the greater Houston area, we identified patients with large vessel occlusion (LVO) acute ischemic stroke (AIS). Patients were included if LVO was confirmed by non-invasive vascular imaging. The primary outcome was rate of performance of EVT in patients with low ASPECTS (0-5), advanced age (> 80), and distal occlusion (M2 and beyond) by race and was determined by Fisher’s exact test.

Results:
Among 2,614 patients with LVO AIS, 1,239 (47%) were female, median NIHSS was 13 [interquartile range 5-20], ASPECTS was 9 [7-10]. 28% of the cohort was black, 52% white and 4% Hispanic. The most common occlusion locations were M1 MCA (34%) and M2 MCA (19%). Among the 538 patients aged > 80 years old, 232 (43%) underwent EVT. There were no significant differences in the proportions of patients treated by race (43% white vs 43% black, p=1) . Among 175 patients with ASPECTS 0-5, 59 (34%) underwent EVT. There were no significant differences in the proportions of patients treated by race (44% white vs 35% black, p=0.37). Among 760 patients with occlusion of M2 and beyond, 224 (30%) underwent EVT. There were no significant differences in the proportions of patients treated by race (33% white, 29% black, p=0.28).

Conclusion:
In this registry from a diverse urban population, we did not identify disparities in EVT performance in patients with non-RCT supported indications by race. Further studies in other clinical settings will be important.
Abstract TP148: Anesthesia Protocol For Acute Ischemic Stroke Facilitates General Anesthesia In EVT And Optimizes Key Performance Measures
Authors: White Andrew , Alabdulkareem Mohammed , Jouett Noah , Pride Lee , Barr John D , Welch Babu G , De Oliveira Sillero Rafael , White Jonathan A , Brown Huong , Novakovic-White Robin
Published: February 2023

Background:
Currently, there is no consensus on the ideal anesthetic strategy for patients undergoing EVT for an LVO. Recently published clinical trials show no difference in mortality, recanalization, and functional outcome related to anesthetic technique, while ongoing trials look at treatment benefits in patients randomized to general anesthesia (GA) compared to conscious sedation during EVT. Utilizing a well-outlined standardized anesthesia protocol for GA in patients undergoing EVT can optimize key performance measures for EVT without adding unnecessary delays.

Methods:
This is a retrospective review of a prospectively collected database of patients who underwent EVT for LVO at a single academic CSC between January 2021 and August 2022. A multispecialty work group convened to outline best practices in the angio suite. All procedures were performed under GA while adhering to the “EVT Anesthesia Workflow.” The endorsed workflow outlined the protocol for notification of anesthesia and the angio team; the responsibility for order placements, request for bed, and procedural consent; and the expectations for all teams members to have lead on prior to patient arrival to the angio suite with biplane placement so that groin access could be obtained concurrently with intubation, to perform all cases under GA if deemed appropriate by anesthesia (unless requested otherwise), and that arterial line monitoring should not delay the procedure start time. Furthermore, pre and intraprocedural blood pressure parameters and post-EVT blood pressure goals were outlined.

Results:
A total of 102 patients were reviewed, all underwent general anesthesia (5% were intubated before angio suite arrival; n=5). Mode of arrival included 47 interfacility transfers, 35 primary facility ED, and 20 inpatients. The overall median angio door-to-intubation time was 6 minutes, and angio door-to-puncture was 10 minutes. The median puncture-to-device time was 24 minutes.

Conclusion:
A multispecialty collaboration to define agreed-upon workflows that outline responsibilities, expectations and goals can facilitate rapid treatments in an emergent setting. An EVT Anesthesia Workflow facilitated the use of GA in EVT without adding delays to key EVT performance measures.
Abstract TP156: Neurological Outcomes After Perinatal Stroke: A Single Center Cohort Study
Authors: Alhadid Kenda , Chui Carrie , Hamel Maura , Musolino Patricia L
Published: February 2023

Introduction:
Neurological outcomes in pediatric stroke survivors have been described in observational studies. The Pediatric Stroke Outcome Measures (PSOM) was the first tool validated in children to describe outcomes specifically in stroke (Kitchen et al, 2012). Patients diagnosed with a perinatal stroke comprised 24% of this cohort, while the remainder of patients had suffered from a childhood stroke. Most patients (~ 65%) had no or mild neurological deficits after 5 years of follow-up, represented with a total PSOM score of 0-1. We examined whether perinatal stroke patients would have similar trajectories to the outcomes previously described in pediatric stroke that occurred beyond the perinatal period.

Methods:
We conducted a retrospective review of our pediatric stroke database at Massachusetts General Hospital. Perinatal stroke survivors were identified, and data extracted from longitudinal follow-up clinic visits. PSOM scores were acquired at: discharge, visits between 2-4 years, 5-7 years, and beyond 7 years.

Results:
Patients who had endured a perinatal stroke with subsequent PSOM measures recorded were identified (N= 78). Neuroimaging was obtained in the neonatal period (n = 50) or at initial clinical presentation (n = 28; presumed perinatal stroke). Preliminary analyses show that perinatal stroke patients trended towards having increased PSOM scores over extended follow-up beyond 7 years from the index clinical encounter.

Discussion:
Interval monitoring will unmask deficits throughout development for perinatal stroke patients and can trend towards accrual of further neurological disability. This is in contrast with prior cohorts of childhood stroke where most patients endured stroke beyond the perinatal period and had total PSOM scores of 0-1 beyond 5 years of follow up. Further analyses are underway to establish effect of stroke mechanism, size, and laterality. Separate analyses to map lesion topography to structural and functional network disruptions that occur after perinatal stroke will be performed. Understanding the relationship between these disruptions and functional outcomes will aid in deficit prediction and trajectory modelling, to guide individualized interventions for the youngest of stroke survivors.
Abstract TP157: Interleukin Plasma Levels And Risk Of Hemorrhage In Pediatric Brain Arteriovenous Malformation Patients
Authors: Chawla Shweta A , Weinsheimer Shantel , Nelson Jeffrey , McCulloch Charles , Abla Adib , Gupta Nalin , Cooke Daniel L , Hetts Steven , Saloner David , Li Yi , Fox Christine K , Fullerton Heather J , Kim Helen
Published: February 2023

Introduction:
Brain arteriovenous malformations (bAVMs) are the leading cause of pediatric hemorrhagic stroke. Prior studies have implicated inflammation as a major contributor to bAVM pathogenesis, with increased inflammatory cell infiltration and IL-6 protein levels reported in bAVM tissue. However, few studies have evaluated circulating inflammatory proteins as biomarkers for bAVM or intracranial hemorrhage (ICH).

Hypothesis:
We hypothesized that higher plasma levels of interleukin (IL)-1B and IL-6 would be associated with bAVM ICH at initial presentation.

Methods:
Pediatric bAVM cases (<19 years) evaluated at our institution between 2005 and 2022 were enrolled into an ongoing cohort study. Plasma samples (n=119) were collected and analyzed using the OLINK Explore 384 Inflammation panel. Protein levels were quantified based on log-log standard curves, and log
2
-transformed for analysis. Multivariable regression analysis compared plasma protein levels between cases with and without ICH presentation, adjusting for sex, race, ethnicity, age, and time between initial presentation and first plasma collection. Exponentiated coefficients are presented as proportional increase (PI).

Results:
Samples were collected a median of 23.5 days after presentation in the ICH group and 140 days in the non-ICH group. Plasma levels of IL-6 were higher in bAVM patients with ICH vs. those without ICH (PI=3.22, 95% CI=1.32-7.85, p=0.011), adjusting for age, sex, race and Hispanic ethnicity. After further adjustment for time to sample collection, the association between IL-6 levels and ICH was no longer significant. (PI =1.36, CI=0.57-3.29, p=0.478). There was no difference in plasma levels of IL-1B between groups (PI=0.85, 95% CI=0.65-1.12, p=0.26).

Conclusion:
Plasma levels of IL-6 were associated with ICH presentation in this pediatric bAVM cohort; however, this association may reflect downstream effects of the hemorrhage. Further studies are needed to help clarify whether plasma IL-6 levels can be used to predict hemorrhage risk in patients with unruptured bAVMs.
Abstract TP166: Changing Trends In Imaging Of Neurological Complaints In Young Adults And Impact On Stroke Incidence
Authors: Moore Caitlin , Leppert Michelle H , Sillau Stefan , Poisson Sharon N
Published: February 2023

Introduction:
Incidence of ischemic stroke in young adults is increasing, but reasons for this change remain unclear. One potential explanation may be increased detection of stroke due to increased use of brain MRI imaging.

Methods:
We performed a retrospective cohort study of adults ages 18-55 who presented to a large, multicenter health system from 1/1/2012-12/31/2018 with predefined focal neurologic chief complaints. Total counts of ischemic strokes based on ICD 9/ICD 10 code and total counts of MRIs were examined. Probability of ischemic stroke conditional on MRI and probability of MRI conditional on ischemic stroke were calculated. Counts were analyzed with Poisson/negative binomial count models and probabilities were analyzed with relative risk.

Results:
A total of 118,486 unique encounters were identified. Of these encounters, 1,179 (0.01%) led to ischemic stroke diagnosis and 8,293 (7.0%) had MRI brain ordered. Sixty-two percent of the encounters and the same proportion of MRIs were in females, but only 50% of ischemic strokes were in females. The probability (risk) of ischemic stroke diagnosis conditional on MRI was estimated to decrease by a proportion of 4.24% per year (95% CI: (0.91%, 7.24%), p value=0.013) (Figure). Yearly percent change from 2012 to 2018 of MRIs ordered and ischemic strokes followed a similar trend.

Conclusion:
The decreasing proportion of ischemic strokes diagnosed when MRIs were ordered suggests that the threshold for ordering MRIs in young adults with focal neurologic symptoms has decreased. Therefore, some of the increased incidence of stroke among young adults may be explained by increased use of MRI.
Abstract TP167: Burden And Impact Of Comorbid Depression On In-hospital Outcomes Of Acute Ischemic Stroke-related Admissions In Women Of Reproductive Age Group: A Propensity-matched Analysis
Authors: Singh Monika , Anil Peethambar Gowri , Rana Nishtha , Jitta Sahas Reddy , Perera Ayodya , Gudiwada Mohan Chandra Vinay Bharadwaj , Sanikommu Sailaja , Juveria Fnu , Desai Rupak
Published: February 2023

Background:
Depression has been identified as a risk factor for acute cerebrovascular events. Due to limited data focused on young females, we studied the burden and impact of comorbid depression on outcomes of acute ischemic stroke (AIS)-related admissions in young women of the reproductive age group.

Methods:
We used the National Inpatient Sample (2018) to identify admissions of young females (age 18-44 years) with AIS; and further classified it into two demographically (age, race, payer status, income) matched (1:1) groups based on the presence of comorbid depression. Comorbidities and outcomes were compared using relevant ICD-10 codes. Multivariable regression was used to analyze the association of comorbid depression with in-hospital mortality.

Results:
In 15850 young females admitted with AIS in 2018, 2465 (15.6%) had comorbid depression. Post-matching, the study cohort consisted of 4610 women admitted with AIS (Median age: 37, 66.2% whites) and 2305 women in each cohort, with and without depression. The matched AIS-depression arm often had younger women (median 37 vs 39 years), patients from the lower-income quartile (47.3% vs. 34.5%), and higher rates of obesity, peripheral vascular disease, and prior history of stroke but a lower prevalence of CVD risk factors
[Table 1].
The depression arm had a non-significant odd of all-cause mortality (OR 1.32, 95%CI:0.64-2.74) when adjusted for sociodemographic confounders and comorbid risk factors (p=0.452). The LOS was shorter (median 4 vs 5 days) with comparable hospital charges in the depression arm vs. no depression arm (p<0.001).

Conclusion:
This study revealed a nearly 15% burden of depression in young females admitted for AIS without significant impact on all-cause mortality when controlled for confounders. The impact of depression on long-term AIS outcomes needs further evaluation.
Abstract TP169: Factors Associated With Intracerebral Hematoma In Patients With Aneurysmal Subarachnoid Hemorrhage In Vietnam: A Multicenter Prospective Cohort Study
Authors: Luong Chinh Q , Mai Ton D , Vu Luu D , Dao Co X , Ngo Hung M , Hoang Hai B , Tran Tuan A , Pham Trang Q , Pham Dung T , Nguyen My H , Nguyen Linh Q , Dao Phuong V , Nguyen Duong N , Vuong Hien T , Vu Hung D , Nguyen Dong D , Vu Thanh D , Nguyen Dung T , Do Anh L , Pham Quynh T , Khuat Nhung H , Duong Ninh V , Ngo Cong C , Do Son N , Nguyen Hao T , Nguyen Chi V , Nguyen Anh D , Nguyen Tuan A
Published: February 2023

Introduction:
Early ICH expansion is associated with a higher rate of poor outcomes and death in aSAH patients, especially in limited-resource settings. This study aimed to investigate the impact of ICH expansion on the outcomes and the factors related to an ICH expansion in aSAH patients in an LMIC.

Hypothesis:
Understanding factors related to ICH after an aneurysmal rupture in different countries, particularly in limited-resource regions, is crucial for reducing poor outcomes and mortality.

Methods:
We performed a multicenter prospective cohort study of patients (≥18 years) presenting with aSAH at three central hospitals in Hanoi, Vietnam, from August 2019 to June 2021. We collected data on the demographics, baseline characteristics, management, and outcomes and compared these data between patients who had an ICH expansion (defined as ICH detected on an admission CT scan) and patients who did not. We assessed factors associated with ICH expansion on admission using logistic regression.

Results:
Of 415 patients, 198 (47.7%) were men, and the median age was 57.0 years (IQR: 48.0-67.0). ICH expansion accounted for 20.5% (85/415) of aSAH patients. There was a significant difference in the 90-day poor outcomes (43.5%; 37/85 and 29.1%; 96/330; p=0.011) and 90-day mortality (36.5%; 31/85 and 20.0%; 66/330; p=0.001) between patients who had ICH and patients who did not have ICH expansion. The multivariate analysis showed that systolic BP of 140 mmHg or more (OR: 2.674; 95% CI: 1.372-5.214), WFNS grades II (OR: 3.683; 95% CI: 1.250-10.858) to V (OR: 6.912; 95% CI: 2.553-18.709), and a ruptured MCA aneurysm (OR: 3.717; 95% CI: 1.848-7.477) were independent predictors of ICH expansion.

Conclusions:
In our study, ICH accounted for a substantial proportion of aSAH patients and contributed significantly to a high rate of poor outcomes and death. On admission, a higher systolic BP, a worse neurological status, and a ruptured MCA aneurysm were independent predictors of ICH expansion. This study indicates independent predictors of an early ICH expansion, such as a higher admission systolic BP and a worse initial neurological status, after aneurysmal ruptures that require only a clinical examination and, therefore, may be particularly valuable in resource-limited settings.
Abstract TP17: Increased Interstitial Free Water Is Detected In Regions Of Increased Blood-brain Barrier Disruption In The White Matter Of Patients With Cerebral Small Vessel Disease.
Authors: Kern Kyle , Gottesman Rebecca F , Wright Clinton B , Leigh Richard
Published: February 2023

Background:
Diffusion tensor imaging (DTI) can be used to detect the accumulation of interstitial free water (FW) in the white matter of patients with cerebral small vessel disease (cSVD). Dynamic susceptibility contrast (DSC) imaging can be used to measure disruption of the blood-brain barrier (BBB). We hypothesized that regions of increased BBB disruption detected with DSC would show increased free water detected with DTI.

Methods:
A subset of patients enrolled in an ongoing study investigating the pathogenesis of cSVD were included. All patients had evidence of cSVD and a history of stroke >3 months prior to imaging. MRIs were performed with both DTI and DSC. White matter was segmented out from gray matter and CSF. FW was calculated from the DTI, and BBB permeability was calculated from aligned DSC. Regions of BBB disruption were grouped into 0.05% intervals ranging from 0-5%. For each echelon of BBB disruption, the average free water in that region was calculated for each patient. Mixed effects linear regression was used to test whether the degree of BBB disruption was associated with colocalized mean FW across all subjects while covarying for age and sex.

Results:
There were 11 subjects included in the analysis with a median age of 70, 45% were female. Increasing BBB disruption was associated with increased colocalized FW (beta = 0.13 [0.008 - 0.018], p < 0.0001). The figure shows a scatter of all data points with slopes fitted for each individual patient. Within subject linear regression of FW with BBB was significant for all patients and for the 9 patients with p<0.001, the R2 values ranged from 0.83 to 0.97 with a mean value of 0.91, suggesting that in most cases the FW increase is attributable largely to the disruption of the BBB.

Conclusions:
Disruption of the BBB leads to increased FW in the white matter of patients with cSVD. This proof of principle study demonstrates how these two biomarkers may be informative in when studying the pathogenesis of cSVD.
Abstract TP179: Laterality Of Carotid Plaque Is Associated With Aortic Complicated Lesion In Embolic Stroke Of Undetermined Source
Authors: Kida Hiroyuki , Sato Takeo , Takahashi Junichiro , Nakada Ryoji , Kitagawa Tomomichi , Takatsu Hiroki , Komatsu Teppei , Sakuta Kenichi , Sakai Kenichiro , Umehara Tadashi , Mitsumura Hidetaka , Iguchi Yasuyuki
Published: February 2023

Background and Purpose:
To compare clinical features including carotid ultrasound findings, especially carotid plaque features, between patients with and without aortic complicated lesion (ACL) in embolic stroke of undetermined source (ESUS).

Methods:
Patients were selected from a comprehensive stroke center between April 2013 and April 2022. Inclusion criteria were: 1) consecutive ischemic stroke patients 2) who fulfilled ESUS criteria based on NAVIGATE-ESUS trial, and 3) who underwent transesophageal echocardiogram (TEE), and 4) admitted 7 days from onset. We compared clinical features, including carotid ultrasound findings in common carotid artery and internal carotid artery such as carotid plaque thickness on the each side, maximum carotid plaque thickness and carotid plaque laterality ratio defined as maximum left carotid plaque thickness divided by maximum right carotid plaque thickness, between ESUS patients with ACL (ACL-ESUS) and without ACL (non ACL-ESUS).

Results:
We screened 2,066 consecutive ischemic stroke patients, including 177 ESUS patients (136 [77%] male, median age 64 years old). Of all, 35 patients had ACL (30 [86%] male, median age 71 years old, Figure A). ACL-ESUS showed older age (ACL-ESUS vs. non ACL-ESUS; 71 vs. 64 years old,
p
= 0.004), higher frequency of having carotid plaque more than 1.6mm ipsilateral to the infarct (82% vs. 53%,
p
= 0.013), higher frequency of having cortical lesion (46% vs. 26%,
p
= 0.023), and higher carotid plaque laterality ratio (1.18 vs. 1.00,
p
= 0.042). In multivariable analysis, demonstrating cortical lesion (OR 2.86, 95%CI 1.03-7.92,
p
= 0.043), carotid plaque laterality ratio (OR 2.75, 95%CI 1.03-7.32,
p
=0.043) were independently associated with ACL (Figure B).

Conclusions:
In ESUS patients, higher carotid plaque laterality ratio was associated with ACL, suggesting TEE should be conducted to reveal ACL in ESUS patients with left-dominant carotid plaque.