bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP123: Impact of Hospital Procedure Volume of Mechanical Thrombectomy on Outcomes in Patients With Acute Ischemic Stroke in the United States
Authors: Qureshi Adnan I , Maqsood Hamza , Bains Navpreet K , Gillani Syed A , Fakih Rami , Siddiq Farhan , Gomez Camilo R , Kwok Chun Shing
Published: February 2024

Background:
Hospitals with higher procedure volume are more likely to have lower rates of death or disability, with most neurovascular surgical and endovascular procedures. The volume of mechanical thrombectomy (MT) performed at hospitals is used as one of the criteria for advanced-level designation for stroke care.

Objective:
To determine the relationship between procedure volume for MT and in-hospital outcomes in acute ischemic stroke patients in the United States.

Methods:
We analyzed the nationally representative data from the Nationwide Inpatient Sample (NIS) from 2016 to 2020. The hospitals were grouped into quartiles based on the volume of MT procedures performed within the calendar year. We compared the rates of routine discharge/home health care (excluding those with palliative care), in-hospital mortality, and post-treatment intracranial hemorrhage (ICH) between the quartiles after adjusting for potential confounders.

Results:
In the logistic regression analysis, the odds of post-procedure ICH increased to 1.81 (p<0.001), 1.84 (p<0.001), and 1.98 (p<0.001) among the quartiles from lowest to highest procedural volumes after adjusting for potential confounders including clinical severity makers. The odds of home discharge/self-care decreased to 0.66 (p<0.001), 0.60 (p<0.001), and 0.63 (p<0.001) among the quartiles from lowest to highest procedural volumes. The odds of in-hospital mortality increased to 1.92 (p<0.001), 1.99 (p<0.001), and 1.84 (p<0.001) among the quartiles from lowest to highest procedural volumes.

Conclusions:
We observed a paradoxical relationship between adverse outcomes and procedure volume of MT at the hospital, presumably due to the higher severity of acute ischemic stroke at high-volume hospitals.
Abstract TP127: Pretreatment CT Collateral Parameters Predict Good Outcomes in Successfully Recanalized Middle Cerebral Artery Distal Medium Vessel Occlusions
Authors: Yedavalli Vivek , Koneru Manisha , Hamam Omar , HOSEINYAZDI MEISAM , Urrutia Victor C , Llinas Rafael H , Marsh Elisabeth B , Xu Risheng , Huang Judy , Caplan Justin M , Gonzalez Fernando , Heit Jeremy J , Guenego Adrien , Dmytriw Adam A , albers Greg , nael kambiz , Hillis Argye E
Published: February 2024

Background/Purpose:
Distal medium vessel occlusions (DMVOs) account for a large percentage of vessel occlusions resulting in acute ischemic stroke (AIS) with disabling symptoms. We aim to assess whether pretreatment CTP collateral status (CS) parameters can serve as imaging biomarkers for good clinical outcomes prediction in successfully recanalized middle cerebral artery (MCA) DMVOs.

Methods:
We performed a retrospective analysis of consecutive patients with AIS secondary to primary MCA-DMVOs who were successfully recanalized by mechanical thrombectomy (MT) defined as modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3. We evaluated the association between CBV index and HIR independently with good clinical outcomes (modified Rankin score 0-2) using Spearman rank correlation, logistic regression, and ROC analyses.

Results:
From 8/22/2018 to 10/18/2022, 60 consecutive patients met our inclusion criteria (mean age 71.2 +- 13.9 years old [mean+-SD], 35 female). CBV index (r = -0.693, p < 0.001) and HIR (0.687, p < 0.001) strongly correlated with 90 day mRS. A CBV index >= 0.7 ((OR 2.27 [6.94 - 21.23], p = 0.001)) and lower likelihood of prior stroke (0.13 [0.33 - 0.86]), p = 0.024) were independently associated with good outcomes.ROC analysis demonstrated good performance of CBV Index in predicting good 90 day mRS (AUC 0.73, p = 0.003) with a threshold of 0.7 for optimal sensitivity (71% [52.0-85.8%]) and specificity (76% [54.9 - 90.6%]). HIR also demonstrated strong performance in predicting good 90 day mRS (AUC 0.77, p = 0.001) with a threshold of 0.3 for optimal sensitivity (64.5% [45.4-80.8%]) and specificity (76.0% [54.9 - 90.6%]).

Conclusion:
A CBV index ≥ 0.7 may be independently associated with good clinical outcomes in our cohort of AIS caused by MCA-DMVOs that were successfully treated with MT. An HIR < 0.3 is also associated with good clinical outcomes. This is the first study of which we are aware to identify a CBV index threshold for MCA-DMVOs.
Abstract TP129: Automated Vessel Density Maps on CT Angiography Identify M2 Occlusions
Authors: Yedavalli Vivek , Koneru Manisha , HOSEINYAZDI MEISAM , Guenego Adrien , Dmytriw Adam A , Luna Licia , Heit Jeremy J , Albers Greg
Published: February 2024

Introduction:
Patients with occlusions of the M2 branch of the middle cerebral artery are frequently considered for endovascular thrombectomy. Most AI software programs focus on identification of large vessel occlusions and frequently miss M2 inclusions. An automated software program with good sensitivity for detecting more distal occlusions could help rapidly identify patients for reperfusion therapies.

Methods:
Consecutive patients with a final diagnosis of occlusion of an M2 branch of the middle cerebral artery were identified from the Johns Hopkins Stroke database. All occlusions were verified by a neuroradiologist (VY). The baseline CTA from these patients was evaluated with the Rapid CTA vessel density software. This software identifies a reduction in vessel density within the middle cerebral artery territory and classifies the vessel density reduction as as: 20-25%, 26-40%,41-55% or >55%. A reduction of greater than 20% or greater was consider positive as a potential indicator of M2 occlusion. Adding a sample of about 50 pts with no evidence of vessel occlusion would be desirable to be able to report specificity.

Results:
Forty-four of 62 patients (71%) with M2 occlusions had a reduction in vessel density of at least 20% on automated CTA. Among the positive cases, 20 percent had a 20-25% reduction, 20% had 26-40%, 30% had 41-55% and 30% had a >55% reduction.

Conclusion:
The Rapid CTA hyperdensity program identified 71% of M2 occlusions with most patients having more than a 25% reduction in vessel density. Automated software has the potential to quickly identify patients with M2 branch inclusions.
Abstract TP13: Association Between Education Level and Post-Stroke Cognitive Decline - A Pooled Cohort Analysis of Four Cohorts
Authors: Springer Mellanie V , Whitney Rachael T , Ye Wen , Briceño Emily M , Gross Alden L , Aparicio Hugo J , Beiser Alexa S , Burke James F , Elkind Mitchell S , Ferber Rebecca A , Giordani Bruno J , Gottesman Rebecca F , Hayward Rodney A , Howard Virginia J , Kollipara Adam S , Koton Silvia , Lazar Ronald M , Longstreth William T , Pendlebury Sarah T , Sussman Jeremy B , Thacker Evan L , Levine Deborah A
Published: February 2024

Introduction:
We evaluated whether education level is associated with post-stroke cognitive decline and whether age modifies the association.

Methods:
We analyzed pooled data from 2,019 stroke survivors from the Atherosclerosis Risk in Communities, REasons for Geographic and Racial Differences in Stroke, Cardiovascular Health, and Framingham Offspring studies from 1971-2019. Participants ≥18 years with incident stroke and free of dementia were included (52% female and 39% Black). Repeated cognitive tests were administered in person or by telephone by trained cohort staff. Linear mixed-effects models were used to examine the association between education (less than high school, completed high school, some college, college graduate or more) and post-stroke cognitive decline for global cognition (primary outcome), executive function, and memory harmonized across cohorts and to examine effect modification by age. Median (IQR) follow-up was 4.1 (1.8, 7.2) years.

Results:
Compared to those with less than a high school education (n=339), stroke survivors with some college education (n=484) and stroke survivors with a college degree or more (n=583) had higher first post-stroke cognitive scores (Models M1a, M1b, and M1c, Table). Having some college education was associated with slower post-stroke decline in global cognition (Model M1a) compared to those with less than a high school education. Having some college education or a college degree was associated with faster post-stroke decline in executive function (Model M1b, Table) compared to those with less than a high school education. Significant interactions by age were lacking for all outcomes.

Conclusions:
Higher education level was associated with higher initial post-stroke cognitive scores, slower decline in global cognition, and faster decline in executive function, regardless of age. Stroke might narrow the gap in executive function between stroke survivors with higher and lower education.
Abstract TP130: Prevalence of Fast Progressors of Infarct Growth in Anterior Circulation Large Vessel Occlusions <6 Hours From Onset
Authors: Lin Sidney , Raince Avtar , Byrns Kory
Published: February 2024

Background/Purpose:
Fast progressors (FP) of infarct growth in anterior circulation large vessel occlusions (LVO) may be prevalent in the <6h period depending on how it is defined. The 3 recently completed randomized trials of endovascular thrombectomy (EVT) on large infarct core volumes (ICV) all used ASPECTS criterion of 3-5 which approximates 70-100mL in absolute volume. We aimed to investigate the prevalence of FP in LVO <6h and how many of these were at or on pace to reach the 70mL or 100mL ICV threshold for EVT selection.

Methods:
We retrospectively included consecutive stroke patients arriving <6h from symptom onset with ICA and/or M1 occlusion on CTA and had concurrent CT perfusion (CTP). RAPID AI software generated maps of ICV depicted as rCBF<30% and critical hypoperfusion depicted as Tmax>6s. Infarct growth rate (IGR) was calculated as ICV/onset-to-imaging time. FP was defined at 2 levels: as "FP70" with IGR >11.7mL/h (which would result in an ICV >70mL by 6h)
and
had >=70mL of overall hypoperfusion present; and as "FP100" with IGR >16.7mL/h (which would result in an ICV >100mL by 6h)
and
had >=100mL of overall hypoperfusion present.

Results:
108 patients were included with median (IQR) age of 75.5 (67-85), NIHSS of 20 (12-24), onset time of 2h (1.5-4), median ICV of 11mL (0-40), hypoperfusion volume of 122mL (70-164), and mismatch volume of 86.5mL (58-130). The sites of LVO were ICA 12 (11.1%), M1 73 (67.6%), and both 23 (21.3%). Median IGR for the cohort was 3.8mL/h (0-16.4). 31 FP70 were found (28.7%, 95% CI: 19.5-40.7%) with median IGR of 31.3mL/h (16.8-42). 14 of these (45.2%, 95% CI: 24.7-75.8%) already had ICV>70mL upon arrival, with median of 100mL (86-156) and 8 of 14 also showed mismatch ratio <1.8. 25 FP100 were found (23.1%, 95% CI: 16.2-36.9%) with median IGR of 38.7mL/h (24.6-51.4). 8 of these (32.0%, 95% CI: 13.8-63.1%) already had ICV>100mL upon arrival, with median of 138mL (101-172) and 5 of 8 also showed mismatch ratio <1.8.

Conclusion:
In a cohort of acute anterior circulation LVO strokes <6h from onset, the vast majority were good candidates for EVT with small to medium size core volumes. However, ~25% were fast progressors that may require more caution in selection, with ICV at or on pace to reach 70-100mL thresholds by 6h.
Abstract TP138: Image Quality Assessment of Photon Counting Computed Tomography Angiography of the Head and Neck
Authors: Song Jae W , Colfer Michael , Pasyar Pouyan , Kasner Scott E , Cucchiara Brett L , Saba Luca , Noel Peter B , Woo John H
Published: February 2024

Introduction:
Photon-counting computed tomography (PCCT) is a novel advanced CT technology that enables higher spatial resolution, spectral imaging to resolve tissue types and can reduce artifacts. Cerebrovascular image quality from head and neck CTAs acquired on a photon-counting detector was assessed.

Methods:
Subjects who underwent head and neck PCCTAs for suspected ischemic stroke were retrospectively identified (mean age=57.5 years, N=6 men). Images were acquired with a tube voltage of 120 kVp. Tube current was adjusted based on patient size. Image quality was assessed on a polyenergetic reconstruction. Two neuroradiologists measured mean attenuation [Hounsfield unit (HU)], image noise, and contrast-to-noise ratio (CNR)] of the head/neck arteries. Beam hardening effects on the arteries were calculated using regions of interests (ROIs). CNR was calculated as the absolute difference between the HU
mean
of the arterial segment and surrounding fat divided by image noise. Intraclass correlation coefficients (ICC) were calculated to measure reliability.

Results:
Ten head and neck PCCTAs met criteria for diagnostic quality (100% interrater agreement). The CNR of all arterial segments of the extra- and intracranial arteries ranged from 40.7 to 52.7. Effects of beam hardening were worse at the vertebral artery origins, internal carotid artery (ICA)-C3 (cavernous) and ICA-C4 (clinoid) segments. Artifact could be reduced using higher virtual monoenergetic levels, an advantage for segments vulnerable to arterial dissections, such as the vertebral artery origins. Interreader agreement of HU
ROIs
was ICC>0.7 for each arterial segment.

Conclusions:
Vertebral artery origins near the arch in the neck and cavernous/clinoid ICA segments in the head showed the greatest need for optimization to reduce artifacts and image noise. Future work will focus on leveraging PCCT technology to select the optimal energy level, reduce artifacts and improve diagnostic accuracy.
Abstract TP143: Longitudinal Evaluation of Vessel Wall MRI Demonstrates Bilaterally Symmetric Evolution of Carotid Atherosclerosis
Authors: Guo Yin , Akcicek Ebru Y , Hippe Daniel S , HashemizadehKolowri SeyyedKazem , Canton Gador , Akcicek Halit , Wang Xin , Zhang Kaiyu , Balu Niranjan , Mossa-basha Mahmud , Hatsukami Thomas S , Yuan Chun
Published: February 2024

Introduction:
Carotid atherosclerosis is a leading cause of stroke worldwide. Previous studies demonstrated bilateral symmetry in atherosclerotic plaque burden and calcification scores. By leveraging longitudinal 3D vessel wall MRI, this study aims to investigate if there is a symmetrical trend of bilateral plaque progression.

Methods:
Asymptomatic patients with confirmed carotid stenosis were prospectively recruited in the study. Subjects underwent baseline and follow-up 3D vessel wall imaging for a time span up to 8 years. A deep learning-based pipeline was used to bilaterally segment the carotid lumen and vessel wall on axial image slices. Within each artery, the range of slices with wall thickness > 2mm on any scan was included as potential atherosclerotic plaque. Plaque burden, positively associated with stroke risk, was defined as the percent wall volume (wall volume / total vessel volume х 100%). For each plaque, a linear model was fitted across all available time points to determine the growth rate of plaque burden. We used generalized estimating equation-based linear regression models to evaluate associations of the growth rate of each side with the contralateral side, adjusted for clinical risk factors and medications. Effect sizes were summarized using the partial correlation coefficient.

Results:
20 subjects (mean age 73.5 years, 3 females, 14 on statins) who underwent at least three scans with bilateral carotid plaque were included in the analysis. Each subject underwent an average of 4.8 scans over 5.2 years. Overall, the plaque growth rate of one side was moderately correlated with the contralateral side (r=0.50, p=0.004), even after adjusting for age, sex and statins use. Then, for each subject, the larger of the two plaques at baseline (left or right side) was identified. The growth rate of the larger plaque was also predictive of the growth rate of the smaller plaque over the same time period (r=0.66, p=0.004).

Conclusion:
The systemic nature of atherosclerotic disease entails an association in symmetrical disease evolution for left and right carotid arteries. In bilaterally diseased patients, the longitudinal monitoring of the more advanced carotid lesion may provide prognostic information on the less advanced contralateral plaque.
Abstract TP151: Usefulness of 3D I-Flow Application in Predicting the Outcome of Flow Diverter Stenting for Large or Giant Carotid Aneurysms
Authors: Arimura Koichi , Koyanagi Yuya , Iwaki Katsuma , Takagishi Soh , Kurogi Ryota , Nakamizo Akira , Yoshimoto Koji
Published: February 2024

Background and Purpose:
The flow diverter (FD) has dramatically improved the treatment outcome of large / giant internal carotid artery (IC) aneurysms. However, it is difficult to predict the treatment outcome of FD just after the treatment. 3D iFlow is a novel application of 4D-digital subtraction angiography (4D-DSA) that can evaluate the arrival time of contrast media in 3D images, but its usefulness for neurointervention is unclear. Therefore, the aim of this study was to elucidate the utility of 3D iFlow in predicting the outcome of FD treatment for large / giant IC aneurysms.

Methods:
A total of 8 cases of large / giant aneurysms at IC cavernous portion treated with FD and were enrolled in this study. 3D iFlow images before and after placement of FD were acquired in all cases. Treatment outcome was evaluated by O’Kelly-Marotta(OKM) Grading Scale with DSA 6 months after treatment. The regions of interests (ROI) were set in IC bifurcation and petrous segment with 3D iFlow application, and the 3D iFlow transit time was measured by comparing the peak contrast intensities in 2 ROIs. We investigated the rate of changes in 3D iFlow transit time before and after the placement of FD.

Results:
FD was deployed successfully in all cases without coils. The number of OKM grade B, C and D with DSA 6 months after treatment were 2, 3 and 3 cases, respectively. The rate of changes in 3D iFlow transit time was significantly shorter in OKM grade D cases compared with grade B and C (52.5% vs 84.7%, p=0.03).

Conclusion:
3D iFlow application may be effective to predict the treatment outcome of FD.
Abstract TP153: Etiology and Radiological Features of Pregnancy-Associated and Non-Pregnancy Associated Intracerebral Hemorrhage in Young Adults
Authors: Sariyeva Mehriban , Haghighi Noora , Booker Whitney , Petersen Nils H , Mitchell Amanda , Ghoshal Shivani , Agarwal Sachin , Park Soojin , Claassen Jan , Connolly Sander , Roh David , Miller Eliza C
Published: February 2024

Introduction:
Intracerebral hemorrhage (ICH) is a major cause of maternal mortality, but its pathophysiology is not well characterized. We investigated characteristics of pregnancy-associated ICH (PICH), compared with ICH in non-pregnant young adults of both sexes.

Methods:
We performed a cross-sectional analysis of 134 adults aged 18-44 years admitted with non-traumatic ICH from 1/01/2012 - 12/31/2021. Participants were identified from an internal stroke registry and through the ICHOP (Intracerebral Hemorrhage Outcomes Project) study. We compared ICH etiology between three exposure groups: PICH (ICH occurring in pregnancy or within 3 months postpartum), NPICH in females, and NPICH in males. We categorized ICH etiology as primary (hypertension, amyloid angiopathy, or unknown by SMASH-U criteria) vs secondary (structural, medication, or systemic disease-related). We calculated odds ratios (OR) and 95% confidence intervals (95%CI) for the association of exposure group status with primary vs. secondary ICH, using non-pregnant females as the reference group.

Results:
Of 134 young adults with non-traumatic ICH, 25 (19%) were pregnant or postpartum. More than half of PICH were in lobar locations (Table) and 40% had unknown etiology (Figure). Adjusting for age, chronic hypertension, and ICH location, pregnant/postpartum patients had highest odds of primary (vs. secondary) ICH (adjusted OR 4.9, 95% CI 1.5-15.9 compared with female NPICH reference group).

Conclusion:
Almost 1 in 5 young adults with ICH were pregnant or postpartum. PICH differed in location and underlying etiology compared with ICH in non-pregnant young adults, suggesting unique pathophysiology
Abstract TP159: Baseline Viscoelastic Hemostatic Assays and Associations With DWI Ischemic Lesions in Intracerebral Hemorrhage Patients
Authors: Mao Eric , Sieh Laura , Ridha Mohamed , Simonetta Marialaura , Carvalho Poyraz Fernanda , Peasley Emma , Mitchell Amanda , Heinonen Gregory , Kumar Aditya , Hess Evan , Ghoshal Shivani , Agarwal Sachin , Park Soojin , Claassen Jan , Connolly Sander , Roh David
Published: February 2024

Introduction:
Remote ischemic lesions identified on MRI neuroimaging after intracerebral hemorrhage (ICH) may be related to microthrombosis. We sought to evaluate whether hypercoagulability identified on viscoelastic hemostatic assay relates to these ischemic lesions.

Methods:
Spontaneous ICH patients enrolled in a single-center prospective observational study from 2009 to 2019 receiving baseline viscoelastic hemostatic assay: Rotational Thromboelastometry (ROTEM) and MRI neuroimaging were included. The presence and count of ischemic lesions identified on DWI imaging >10 mm from the ICH were the outcome variables. ROTEM assessments of clot strength were the primary exposure variable. Logistic and linear regression assessed the association of ROTEM clot strength with DWI lesion presence and count after adjusting for ICH severity, ICH location, and anticoagulant use. Relationships of ROTEM assessments of coagulation kinetics and lysis with DWI lesions were explored.

Results:
Of 19 patients assessed, the mean age was 68, 37% were female, and DWI lesions were identified in 42%. Associations of greater ROTEM clot strength (FIBTEM MCF) with DWI lesions were imprecise (adjusted OR 1.16, 95%CI: 0.98-1.37, p=0.08). However, we identified that greater FIBTEM MCF significantly associated with increased DWI lesion count (adjusted β 0.16, 95%CI: 0.02-0.30, p=0.02). Exploratory analyses revealed that slower intrinsic pathway coagulation kinetics (INTEM CT) associated with increased DWI lesion count (adjusted β 0.06, 95% CI: 0.01-0.10, p=0.01).

Conclusions:
Baseline hypercoagulable ROTEM tracings may associate with DWI ischemic lesions after ICH. Further work is needed to clarify the generalizability of these findings and if specific coagulopathy mechanisms drive DWI lesion formation to assess whether there are relevant therapeutic targets to prevent secondary brain injury after ICH.
Abstract TP163: Associations Between Prior Oral Anticoagulant Use and Stroke Outcomes in a National Stroke Cohort: A Scottish Database Study
Authors: Sterling Kadie-Ann , Turner Melanie , Macleod Mary J
Published: February 2024

Background and aims:
Recent studies suggest that oral anticoagulant (OAC) use prior to stroke is associated with better functional outcomes after ischaemic stroke, but worse outcomes after non-traumatic intracerebral haemorrhage (ICH). We aimed to assess the impact of prior OAC use on stroke subtype and outcomes (mortality and discharge to home) in a Scottish stroke cohort.

Methods:
Data on first-ever strokes between January 1, 2011, and December 31, 2018, were gathered from the Scottish Stroke Care Audit. The Prescribing Information System was used to identify patients with a prescription for OAC within 90-days before stroke, and further linked to hospital admission and discharge data in the Scottish Morbidity Record 01, and mortality data in the National Records of Scotland. Multivariable logistic regression models were adjusted for sociodemographic factors, atrial fibrillation, stroke severity, acute management and Charlson Comorbidity scores.

Results:
Among 52 988 stroke patients (50.1% women; mean age 72.8 [±13.3] years), 88.9% were ischaemic and 18.3% had a history of atrial fibrillation. OACs (warfarin [73%] and direct oral anticoagulants [28%]) were prescribed to 3533 (7.5%) patients with ischaemic stroke and 847 (14.4%) patients with ICH within 90 days prior to first-ever stroke. After model adjustments, prior OAC use was associated with a three-fold increase in the odds of experiencing an ICH (adjusted Odds Ratio [aOR], 2.92; 95% CI, 2.61 - 3.26]). In patients with ischaemic stroke or ICH, prior OAC use was not associated with better or worse outcomes in 30-day discharge to usual place of residence (aOR, 0.99; 95% CI, 0.89 - 1.09 and aOR, 0.86; 95% CI, 0.66 - 1.12 respectively) or 30-day mortality (aOR, 1.06; 95% CI, 0.94 - 1.21 and aOR, 1.20, 95% CI, 0.93 - 1.56 respectively) in comparison to those with no prior OAC use. Additionally, no statistically significant differences were observed for discharge or mortality outcomes within 90 days after stroke.

Conclusions:
Prior OAC use was higher in patients with ICH, which may partly reflect ischaemic stroke reduction in patients taking OAC. However, prior OAC use was not associated with better or worse outcomes in terms of mortality and discharge to home in either ischaemic or ICH populations.
Abstract TP166: White Matter Hyperintensity Burden Associated With Stroke Severity, Aphasia, and Motor Deficits During Intracerebral Hemorrhage Hospitalization
Authors: Borei Karim , Bako Abdulaziz , Pan Alan P , Prince Taya , Khan Osman , Vahidy Farhaan , Britz Gavin W , Potter Thomas B
Published: February 2024

Introduction:
Cerebral Small Vessel Disease (CSVD) is associated with cognitive disruptions after intracerebral hemorrhage (ICH), however evidence connecting CSVD to specific neurological deficits after ICH is limited.

Methods:
Electronic medical record data were retrieved for adult patients (>18 years) with admission for primary non-traumatic ICH, available admission NIHSS scores, and CSVD assessment. CSVD burden was graded from 0-4, with 1 point assessed for: 1) deep Fazekas white matter hyperintensity (WMH) score of 2-3 or periventricular (PV) Fazekas score of 3; 2) cerebral microbleed presence; 3) lacune presence; 4) > 20 basal ganglia perivascular spaces. Severe CSVD was assessed scores ≥ 3, and individual marker severity was assessed using the same criteria. The primary outcome was moderate-severe stroke (total NIHSS score ≥5). Secondary outcomes were severe motor deficit (motor score >12), complete aphasia (language score = 3), and cortical deficit (any impairment in language, extinction, and gaze). Associations between CSVD and NIHSS were determined using multivariable logistic regression, adjusting for major clinical and demographic factors. Adjusted odds ratios (aOR) and 95% confidence interval (CI) are reported.

Results:
The cohort included 1024 patients (median age [interquartile range]: 71 [61-79], 53% male). Patients were 22% Hispanic and had a racial distribution of 61% White, 24% Black, 8% Asian, 7% other. The median NIHSS score was 4 [1-11]; 477 (47%) showed moderate-severe NIHSS scores and 262 (26%) showed severe CSVD. Severe PV WMH burden was independently associated with moderate-severe NIHSS score (vs non-severe; aOR, 95% CI: 1.55, [1.02-2.36]). Severe deep WMH burden (vs non-severe) was independently associated with aphasia (1.97, [1.02-3.81]), and motor deficit (3.95, [1.22-12.73]) (Figure 1).

Conclusion:
Severe WMH burdens increase odds of neurological deficit among patients with primary ICH.
Abstract TP168: Association of Factors With Disorders of Consciousness in Hemorrhagic Stroke Patients
Authors: Houston Kaiulani , Kuohn Lindsey , Lewis Ariane , Lord Aaron S , Ishida Koto , Zhang Cen , Torres Jose , Dickstein Leah , Brush Benjamin , Zhou Ting , Kahn D. Ethan , Frontera Jennifer , Melmed Kara
Published: February 2024

Objective:
Disorders of consciousness (DoC) are known to correlate with worse functional outcome after hemorrhagic stroke. Here we evaluate factors associated low Glasgow Coma Scale [GCS] score at time of admission in patients with hemorrhagic stroke.

Methods:
We performed a prospective cohort study of patients enrolled in the Neurological Emergencies Outcomes Study between January 2014 and June 2023 of patients with primary intracranial hemorrhage (intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH)). The primary outcome was coma (GCS ≤ 8) at time of admission. Univariable analysis with chi-squared test and Mann Whitney U test followed by adjusted logistic regression were used to assess the relationship between admission factors and DoC. We then confirmed the association with admission GCS and discharge modified Rankin score (mRS).

Results:
We included 314 patients admitted with intracranial hemorrhage, 51 (16%) of whom had GCS ≤ 8 at time of admission, 51% female and median [interquartile (IQR)] age of 63 [51-73]. The median [IQR] ICH volume was 9.3 ml [2.5-27.2] for ICH patients and the median [IQR] modified Fisher score was 3 [3-4] for SAH patients. Female gender, Asian race, hematoma size, hydrocephalus, peak temperature, lowest hemoglobin, and peak glucose in the first 24 hours were all associated with DoC (p<0.05 for all). Controlling for age, disease process (ICH vs SAH), and all factors with p < 0.05, we found female gender (OR 4.7, 95% CI 1.7-13.4), highest temperature (OR 3.8, 95% CI 1.9-7.3), lowest hemoglobin (OR 0.8, 95% CI 0.6-0.99), and highest glucose OR 1.01, 95% CI 1.00-1.02) remained significantly associated with coma at time of admission. Premorbid dependency as measured by Barthel Index was not a predictor of coma. However, coma at time of admission was associated with a worse discharge mRS (median discharge mRS [IQR] for patients with coma 5 [4-6] vs without 3 [2-4], p < 0.001).

Conclusions:
We found that female gender, low hemoglobin, high body temperature, and elevated glucose at time of admission were all associated with coma. Low admission GSC (≤ 8) was associated with higher mRS at time of discharge. These modifiable risk factors are an important therapeutic target for improving outcomes for patients with DoC.
Abstract TP17: SPAK Kinase Inhibitor ZT-1a Prevents Reactive Astrogliosis, Blood-Brain Barrier Breakdown, and Demyelination in a Mouse Model of VCID
Authors: Habib Khadija , Sultan Md Tipu , Jahan Israt , Rahman Md Shamim , Sun Dandan , Cao Guodong , Bhuiyan Mohammad Iqbal
Published: February 2024

Background:
Blood-brain barrier (BBB) breakdown, reactive astrogliosis, and myelin losses are the key features of vascular contributions to cognitive impairment and dementia (VCID). However, the molecular and cellular mechanisms underlying VCID are not well understood. Stimulation of Na-K-Cl cotransport 1 (NKCC1) and its downstream kinase SPAK (the STE20/SPS1-related proline/alanine-rich kinase) causes intracellular Na
+
overload, astrocytic hypertrophy, and swelling. In this study, we investigated the effect of SPAK inhibitor ZT-1a on bilateral carotid artery stenosis (BCAS)-mediated reactive astrogliosis, BBB breakdown, demyelination, and cerebral blood flow (CBF) in mice.

Methods:
BCAS was induced in male mice using two metal microcoils twined around both carotid arteries. Sham or BCAS mice receiving vehicle or a selective SPAK inhibitor ZT-1a were monitored for changes in CBF by laser speckle imaging and cognitive functions by the novel object recognition test. Expression of NKCC1 and BBB proteins, reactive astrogliosis, and demyelination were examined by immunofluorescence staining.

Results:
BCAS mice exhibited sustained CBF reduction and cognitive function deficits along with significant demyelination in corpus callosum and external capsule 8 weeks after BCAS procedure. Compared to sham mice, the BCAS mice showed increased NKCC1 expression in GFAP
+
astrocytes, reduced expression of ZO-1 and Claudin-5 in GLUT1
+
endothelial cells, decreased APC
+
mature oligodendrocyte and NG2
+
oligodendrocyte progenitor cells. Interestingly, delayed administration of ZT-1a (4-8 weeks post-BCAS) prevented BCAS-induced reactive astrogliosis, BBB breakdown, demyelination, and significantly improved CBF and cognitive functions.

Conclusion:
Our study demonstrates that BCAS-induced stimulation of NKCC1 involves in reactive astrogliosis, BBB breakdown, OL death, and cognitive impairment. Inhibition of the SPAK-NKCC1 cascade by pharmacological inhibitor has therapeutic potential for VCID therapy.

This research was supported by NIH R01 166199 Grant (M.I.H.B.).
Abstract TP174: Balloon Expandable Stents versus Self-Expanding Stents for Treatment of Intracranial Arterial Stenosis: A Systematic Review and Meta-Analysis
Authors: Suri M. Fareed K , Lodhi Abdullah , Ma Xiaoyu , Ahmed Rehan , Liaqat Jahanzeb , Maqsood Hamza , Kwok Chun , Hassan Ameer E , Siddiq Farhan , Gomez Camilo R , Qureshi Adnan I
Published: February 2024

Background:
There is limited data regarding the comparison of balloon-expanding stents (BES) and self-expanding stents (SES) for the treatment of intracranial arterial stenosis.

Methods:
We conducted a systematic review to identify studies that compared SES and BES in patients with symptomatic intracranial arterial stenosis. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until May 2023. Statistical pooling with random-effects meta-analysis was undertaken to compare the rates/severity of post-procedure stenosis, technical success, stroke and/or mortality, long-term events, and restenosis rates between BES and SES.

Results:
A total of 20 studies were included. The standardized mean difference (SMD) for post-procedure stenosis (%) was significantly lower (SMD: -0.52, 95% confidence interval [CI]: -0.79 to -0.24, p < 0.001, 10 studies involving 1515 patients) with BES. The odds for technical success were non-significantly lower (odds ratio [OR]: 0.99, 95% CI 0.43-2.26, p = 0.983, 9 studies involving 1001 patients) with BES. The odds for post-procedure 30-day stroke and/or death were significantly lower (OR 0.68, 95% CI: 0.50-0.94, p = 0.019, 15 studies involving 2431 patients), and stroke and/or death beyond 30 days were non-significantly lower (OR 0.64, 95% CI: 0.30-1.37, p = 0.250, 10 studies involving 947 patients) with BES. The odds for restenosis rate were significantly lower (OR 0.50, 95% CI: 0.31-0.80, p = 0.004, 13 studies involving 1115 patients) with BES.

Conclusions:
Compared with SES, BES was associated with lower rates of post-procedure 30-day stroke and/or death presumably due to less severe post-procedure stenosis in the treatment of symptomatic intracranial arterial stenosis.
Abstract TP181: Endovascular Therapy for Acute Ischemic Stroke With Large Infarct: A Meta Analysis of Randomized Controlled Trials
Authors: Jaiswal Vikash , Jaiswal Akash , Raj Nishchita , Kalra Kriti , Ang Song Peng , Patel Nirmit , Suresh Vinay , Gupta Shiva , Goyal Aman , Kumar Danisha , Nasir Yusra , Shah Viraj , Naz Sidra
Published: February 2024

Background:
The efficacy of endovascular thrombectomy (EVT) in patients with large infarct among acute ischemic stroke patients has not been exclusively studied, with conflicting results till date.

Objective:
We sought to evaluate the outcomes comparing EVT and medical therapy among stroke patients with large infarcts.

Methods:
We performed a systematic literature search on PubMed, EMBASE, and Clinicaltrial.gov for relevant randomized controlled trials (RCTs) from inception until August 30th, 2023. Odds ratios (OR) were pooled using a random-effect model, and a p-value of <0.05 was considered statistically significant.

Results:
A total of 3 randomized controlled trials with 1010 patients (509 in EVT and 501 in MT) were included in the analysis. Pooled analysis of primary and secondary endpoints showed that ET was associated with a significantly greater rate of MRS 0-2 (OR, 2.53(95%CI: 1.76-3.64), P<0.001), MRS 0-3 (OR, 1.75(95%CI: 1.28-2.39), P<0.001). ET group of patients were having a significantly higher risk of any intracranial hemorrhage (OR, 2.34(95%CI: 1.53-3.58), P>0.001), and a trend of higher risk of incidence of symptomatic intracranial hemorrhage (OR, 1.83(95%CI: 0.90-3.70), P=0.09) compared to medical therapy. However, the risk of incidence of 90 days mortality (OR, 0.95(95%CI: 0.73-1.24), P=0.71), hemi craniotomy (OR, 0.97(95%CI: 0.45-2.12), P=0.95), and adverse cardiovascular event (OR, 1.68(95%CI: 0.50-5.59), P=0.40) was comparable between ET and MT group.

Conclusion:
Patients with large infarcts had better functional outcomes with ET than with MT alone. However, intracranial hemorrhage was higher among ET compared with MT group, while 90 days mortality being comparable between both groups of patients.
Abstract TP185: Resolute Onyx Stent for Symptomatic Intracranial Stenosis: Short and Long-Term Results (R.O.S.S.I.S. Study) With 18-month Follow-Up
Authors: Hassan Ameer E , Shoman Ahmed M , Hagrass Abdulrahman I , Desai Sohum , Saei Hamzah , Tekle Wondwossen G
Published: February 2024

Introduction:
The Resolute Onyx stent has shown promise as an effective treatment for symptomatic intracranial atherosclerotic disease (sICAD), with positive clinical outcomes and low procedural complication rates. However, previous studies were limited by small sample sizes and lacked long-term follow-up.

Methods:
In this retrospective analysis, we examined patients who underwent Resolute Onyx stent placement for sICAD. Primary outcomes included stroke, intracerebral hemorrhage (ICH), and mortality rates at 1-, 6-, 12-, and 18-month follow-ups, and in-stent restenosis. Multivariable logistic regression identified predictors of stroke and mortality. Subgroup analyses assessed patients who underwent stenting at least 8 days after the qualifying event to ensure comparability with WEAVE registry data.

Results:
Our study included 77 patients with 84 procedures. The mean age was 61.9±13.0, with 35% being female. The median time from qualifying event to procedure was 5 days (IQR: 2-11). Among adherent patients, no disease-related deaths occurred after the first month. However, one ICH and two strokes occurred within 6 and 12 months, respectively. Comparison of WEAVE-matched and non-matched patients revealed no significant difference in complications during short- and long-term follow-up. Postprocedural complications within 72 hours were <2% in the non-WEAVE group and 3% in the WEAVE group.

Conclusions:
The Resolute Onyx stent demonstrates safety and effectiveness in treating intracranial stenosis, with potentially lower rates of peri- and post-procedural complications compared to other stents. Our findings challenge the practice of delaying stent placement, emphasizing the importance of early intervention and questioning the validity of the WEAVE criteria.
Abstract TP191: National Trends in Rescue Therapy for Failed Thrombectomy 2009-2020
Authors: Alexander Michael J , Menaker Simon
Published: February 2024

Introduction:
For a subset of patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) mechanical thrombectomy with a stent retriever and/or aspiration is insufficient to revascularize the target artery. Rescue therapy with angioplasty alone or with stenting has been utilized. This study assesses the longitudinal trends for adjunctive treatments following failed thrombectomy in the U.S.

Methods:
We performed a data search from the National Inpatient Sample (NIS) database using ICD9 and ICD10 procedure codes from 2009 through 2020. Data was collected for patients with stroke who underwent thrombectomy for LVO and subsequent angioplasty or angioplasty and stenting. The use of drug eluting stents, patient demographics, regional trends, length of stay, and mortality statistics were also assessed.

Results:
Between 2009 and 2020, the NIS data shows a significant increase in the use of stenting as adjunctive therapy to thrombectomy for LVO. In 2009, stenting with thrombectomy in LVO represented 5.6% (25/443) of patients stented with stroke from ICAD. In 2020, these cases represented 48.6% (520/1,070) of the patients stented. Over the study period, this increase in stent use during LVO treatment was significant (p<0.001). There has been a mild increase in the use of drug eluting stents in rescue therapy, but not as significant as bare metal stents. Angioplasty as an adjunct to thrombectomy for LVO has steadily increased over the study period, with 87 cases in 2009 and 265 cases in 2020, representing a 205% increase.

Conclusion:
There has been a progressive, significant increase in the number of rescue procedures for failed thrombectomy over the study period with stent procedures outnumbering angioplasty alone. Referencing published data these cases represent approximately 2-3% of the total number of thrombectomies performed for AIS.
Abstract TP193: Impact of Number of Passes on Outcomes of Mechanical Thrombectomy in Stroke Patients With Low ASPECTS
Authors: Sowlat Mohammad-Mahdi , Elawady Sameh S , Matsukawa Hidetoshi , Cunningham Conor , Orscelik Atakan , Zandpazandi Sara , Lee Nawabi Noah , Maier Ilko , Al Kasab Sami , Jabbour Pascal M , Kim Joon-Tae , Quintero Stacey C , rai ansaar , Starke Robert , Psychogios Marios , Samaniego Edgar A , Arthur Adam S , Yoshimura Shinichi , Cuellar Hugo , Grossberg Jonathan A , Alawieh Ali , Romano Daniele G. , Tanweer Omar , Mascitelli Justin , Fragata Isabel , Polifka Adam , Osbun Joshua , Crosa Roberto , Matouk Charles C , Park Min S , Levitt Michael , Brinjikji Waleed , Moss Mark , Dumont Travis , Williamson Richard , Navia Pedro , Kan Peter , De Leacy Reade A , Chowdhry Shakeel A , Ezzeldin Mohamad , Spiotta Alejandro M
Published: February 2024

Introduction:
Real-world data showed that less than half of the acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) presenting with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (2-5) achieved favorable outcomes at 90 days after mechanical thrombectomy (MT). In this study, we aim to investigate the relationship between the number of MT passes at which successful recanalization is obtained and outcomes in LVO-related AIS patients with low ASPECTS.

Methods:
This retrospective cohort study was performed on the data from 31 thrombectomy-capable centers between 2013 to 2022. Successful recanalization was defined as modified Thrombolysis in Cerebral Ischemia Score≥ 2b. The primary outcome was a 90-day modified Rankin Scale (mRS) of 0-3. Secondary outcomes were symptomatic intracranial hemorrhage and intracranial hemorrhage within 24 hours and mortality at 90 days. Outcomes were compared among patients with unsuccessful recanalization, and successful recanalization at first, second, third, and more than four passes.

Results:
A total of 297 patients with a median age of 70 [IQR 59-78] years were included and 140 (47.1%) were female. In 239 (80.4%) patients, successful recanalization was achieved: 88 patients (29.6 %) with 1 pass, 59 patients (19.9 %) with 2 passes, 35 patients(11.8%) with 3 passes, and 57 patients (19.2%) with more than 4 passes. Compared to unsuccessful recanalization, successful recanalization at first pass (adjusted OR 5.25, 95% CI 1.78 - 17.1), second passes (adjusted OR 5.20, 95% CI 1.68 - 17.6), and passes 4 (adjusted OR 4.90, 95% CI 1.68 - 17.6) was related to 90-day mRS 0-3. Recanalization status and MT attempt number were not related to secondary outcomes except for 90-day mortality. Compared to unsuccessful recanalization, successful recanalization at second and third passes were inversely related to 90-day mortality (adjusted OR 0.37, 95% CI 0.14 - 0.93; adjusted OR 0.33, 95% CI 0.11 - 0.95, respectively).

Conclusion:
The present results indicated that successful recanalization was related to 90-day good outcome regardless of the number of MT passes but the odds of achieving favorable outcome declines with each pass.
Abstract TP197: Impact of First-Pass Effect on Clinical Outcomes in Stroke Patients With Low Aspects
Authors: Elawady Sameh S , Sowlat Mohammad Mahdi , Matsukawa Hidetoshi , Cunningham Conor , Orscelik Atakan , Zandpazandi Sara , Al Kasab Sami , Maier Ilko , Jabbour Pascal M , Kim Joon-Tae , Wolfe Stacey Q , Rai Ansaar , Starke Robert , Samaniego Edgar A , Arthur Adam S , Yoshimura Shinichi , Cuellar Hugo , Grossberg Jonathan A , Alawieh Ali , Romano Daniele G. , Tanweer Omar , mascitelli Justin , Fragata Isabel , Polifka Adam , Osbun Joshua , Crosa Roberto , Matouk Charles C , Park Min S , Levitt Michael , Brinjikji Waleed , Moss Mark , Dumont Travis , Williamson Richard , Navia Pedro , Kan Peter , De Leacy Reade A , Chowdhry Shakeel A , Ezzeldin Mohamad , Spiotta Alejandro M
Published: February 2024

Introduction:
The first-pass effect (FPE), defined as a complete or near-complete recanalization after a single pass of a mechanical thrombectomy (MT) device, has been linked to favorable clinical outcomes. However, its effectiveness in acute ischemic stroke (AIS) patients with low ASPECTS (Alberta Stroke Program Early CT Score 2-5) has not been validated.

Method:
We utilized data from STAR, a multicenter database of 84 centers worldwide, to conduct a retrospective, cohort study on patients who underwent MT for internal carotid artery (ICA) or M1 occlusion presenting with ASPECTS 2-5. We compared the outcomes of patients who achieved FPE (successful recanalization with an mTICI score of 2c or higher in one pass) to those who did not. The primary outcome was a 90-day favorable outcome, defined as mRS 0-3. Secondary outcomes included any intracranial hemorrhage (ICH), symptomatic ICH (sICH), and 90-day mortality.

Results:
Out of 10,229 patients in the STAR database, 250 patients met our inclusion criteria. Among those, 60 (24%) achieved FPE. There were no significant differences between the two groups in baseline, imaging, and procedural characteristics. FPE was significantly associated with higher odds of 90-day mRS 0-3 (adjusted odds ratio (aOR): 2.17, 95% confidence interval (CI): 1.04 - 4.20; P-value: 0.04) and lower rates of ICH (OR: 0.49, 95% CI: 0.25 - 0.93, P-value: 0.03). However, there was no significant difference in sICH rates (OR: 0.84, 95% CI: 0.31 - 2.04, P-value: 0.70).

Conclusion:
Achieving FPE in AIS stroke patients with low ASPECTS was associated with significantly higher rates of good functional outcomes and lower rates of ICH.
Abstract TP202: Safety and Efficacy of Drug-Eluting Stents in Intracranial Atherosclerotic Disease: A Systematic Review and Meta-Analysis
Authors: Byer Stefano , Dharia Anand , Abraham Nihil , Le Kevin , Abraham Michael G
Published: February 2024

Background:
Advancements in arterial stenting technology have challenged prior notions favoring medical management over endovascular intervention for intracranial atherosclerotic disease (ICAD). Where previous conclusions were drawn from bare metal stent (BMS) technology, recent studies suggest drug-eluting stents (DES) are favorable over BMS due to their anti-proliferative effect.

Methods:
We conducted a systematic review and meta-analysis of the literature prior to August 2023 reviewing reports of ICAD treated with DES. Our target outcomes were incidence of any stroke, transient ischemic attack (TIA), or death within 30 days (post-procedural complications), ischemic stroke in the territory of the qualifying artery beyond 30 days (long-term complications), radiographically detected in-stent restenosis rate (ISR), and symptomatic ISR during follow-up. A subgroup analysis further stratified pre-procedural mean stenosis above and below 70% into severe and moderate cohorts, respectively.

Results:
PubMed and EMBASE query identified 518 candidate articles, from which 13 studies met inclusion criteria for a total of 475 patients and 508 ICAD lesions. Incidence of post-procedural complications was 8.1% (95% CI 3.1-15.1%) with subgroup analysis demonstrating significantly higher incidence in the severely stenotic group [10.4% (95% CI 5.7%-16.2%)] than the moderately stenotic group [3.0% (95% CI 0.7%- 6.8%)]. Long-term complications were 1.2% (95% CI 0.4%-2.4%). Radiographic ISR was 3.2% (95% CI 1.0%- 6.5%) and symptomatic ISR was 0.0% (95% CI 0.0%-0.5%).

Conclusions:
Our systematic review and meta-analysis suggest that DES can effectively reduce the risk of ISR and may be a viable treatment modality to reduce long-term complications in refractory ICAD patients.