bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP76: Carotid Revascularization Slows Hemispheric White Matter Disease Progression
Authors: Lin Michelle P , Demirer Mutlu , Craver Emily , Middlebrooks Erik , Anisetti Bhrugun , Youssef Hossam , Elkhair Ahamed , Okromelidze Leila , Barrett Kevin M , Ertekin-Taner Nilufer , Brott Thomas , Meschia James F
Published: February 2023

Introduction:
Carotid revascularization is known to prevent stroke in patients with high-grade carotid stenosis, but whether carotid revascularization may slow the progression of hemispheric WMD in patients with carotid stenosis to prevent cognitive decline have not been well described.

Methods:
We conducted a longitudinal study involving patients age ≥40 years with carotid stenosis on ultrasound from 2011-2015 with serial brain MRI scans at least 1 year apart followed for radiographic and clinical outcomes to 2020. Severity of carotid stenosis was defined as moderate 50-69%, high-grade 70-99%, or occluded. Hemispheric WMD volume was quantified from axial T2 FLAIR images. Patients were stratified by revascularization status. Primary outcome was change in WMD volume per year ipsilateral or contralateral to the index carotid. Hemispheric differences in the annual rate of WMD progression (cc/yr) were compared between revascularized vs not revascularized using multivariable linear regression analysis adjusted for variables that differed between revascularization status.

Results:
Of the 150 patients, moderate stenosis was present in 37.3%, high-grade stenosis in 42.0%, and carotid occlusion in 20.7%. Mean age was 71±10 years, 36.7% were female. Seventy-three (48.7%) had carotid revascularization with a median follow-up of 5.1 years. Baseline WMD volume was 4.86cc ipsilateral and 4.39cc contralateral to the index carotid. Patients who underwent revascularization trended to have slower WMD progression in the hemisphere ipsilateral to the index carotid compared to those not revascularized (0.32cc/yr vs 0.63 cc/yr, p=0.340). The same trend was not observed in the contralateral hemisphere. In adjusted models, carotid revascularization was associated with a 0.33 cc per year decrease in WMD progression between hemispheres compared to those not revascularized (β= -0.33, p=0.070).

Conclusions:
In this study with a median follow-up of 5 years, we found that carotid revascularization resulted in a 50% reduction in the annual rate of WMD progression. Intervention trials should test whether carotid revascularization slows WMD progression in patients with cognitive impairment to prevent further cerebrovascular events and cognitive decline.
Abstract WMP77: High Early Recurrence In Symptomatic Intracranial Atherosclerosis Treated Medically In The Real World Compared To Clinical Trials
Authors: Goldstein Eric , Chang Allison , Shu Liqi , Kala Narendra , Stretz Christoph , Burton Tina M , Perelstein Elizabeth , Furie Karen L , Jayaraman Mahesh , Torabi Radhmer , Moldovan Krisztina , Khatri Pooja , Gebregziabher Mulugeta , Liebeskind David S , Prabhakaran Shyam , Yaghi Shadi
Published: February 2023

Background:
While optimizing medical treatment contributed to the low recurrence risk seen in SAMMPRIS medical arm, other factors such as delayed enrollment may have contributed to this low event rate. In this study, we aim to determine the 30-day recurrence risk in a real-world setting in patients with symptomatic intracranial atherosclerosis.

Methods:
We used a stroke registry of a comprehensive stroke center to identify hospitalized patients with acute ischemic stroke in the setting of symptomatic intracranial atherosclerosis of the ICA, M1, vertebral, or basilar with 50-99% luminal narrowing. We excluded patients with a clear indication for anticoagulation and those who received endovascular treatment. The outcome was recurrent stroke attributed to the affected artery within 30-days. We used adjusted Cox regression models to identify factors associated with increased recurrence risk.

Results:
Among 131 symptomatic 50-99% intracranial stenosis hospitalizations over 3 years, 66 patients met the inclusion criteria. The mean age was 71.9 years and 51.5% were men; 75.8% were treated with best medical management (dual antiplatelet therapy/high intensity stain therapy). Over 30-day follow-up, 21.2 % had recurrent stroke, 57.1% (8/14) occurred within first 7 days. The recurrence risk was similar to another real world ICAD cohort, and higher than that seen in SAMMPRIS (Figure). While maximal medical treatment was the only factor associated with a lower rate of recurrence (OR 0.32 95% CI 0.09-1.12, p = 0.075), the recurrence rate in patients treated with maximal medical therapy (16.0%, 95% CI 8.1-29.3%) and those SAMMPRIS eligible (17.6%, 95% CI 7.9-34.9%) remained elevated.

Conclusions:
In patients with symptomatic ICAS, the real-world recurrence is higher than that seen in clinical trials, despite optimally using the same medical treatment strategies. This may suggest that the low risk of recurrence achieved in clinical trials may not apply to real world practice.
Abstract WMP81: Dynamic Changes In Intracranial Atherosclerotic Stenosis In Serial Follow-up Of High-resolution Magnetic Resonance Imaging
Authors: Kim Jonguk , Kim Do Y , BAE Hee-joon , Kim Jun Y , Kang Jihoon , Han Moon-Ku , Jung Cheolkyu , Baik Sung Hyun , Sunwoo Leonard , Kim Jae Hyoung , Kim Beom J
Published: February 2023

Background:
Pathophysiology of intracranial atherosclerotic stenosis (ICAS) development and subsequent stroke occurrence is diverse, including cholesterol deposition, arterial dissection, and intrinsic vasculopathies. To differentiate these specific etiologies, performing high-resolution MRI (HR-MRI) has increased. However, the information on serial change of ICAS on HR-MRI was limited.

Methods:
Patients hospitalized at a tertiary university hospital for AIS and who took HR-MRI more than twice between 2015 and 2019 were collected. Two specialists manually segmented the contour of the culprit and reference vessel's inner lumen, outer wall, and plaque. The stenotic degree, remodeling index, and enhancement signal were measured for the culprit lesion at each examination.

Results:
A total of 202 HR-MRI examinations from 93 patients were analyzed. The Median follow-up was 270 days (118-390). The ranges of the serial change in stenotic degree (-86% to 41%), remodeling index (-83% to 266%), and enhancement signal (-85% to 71%) were very diverse. Changes in stenotic degree and enhancement according to the initial stenotic degree were insignificant. On the other hand, the change in enhancement signal was greater in the initially more enhanced lesions (0.1±23.0; mild vs. -23.1±22.6; moderate vs. -35.5±28; severe, p
difference
<.001) and in the other determined etiology (-14.6±22.8; large atherosclerosis vs. -30.7±30.8; other determined vs. -0.8±30.2; etc., p
difference
=.005).

Conclusions:
ICAS showed very dynamic changes in the follow-up HR-MRIs. To identify the underlying etiology, such as arterial dissection and Moyamoya disease, serial HR-MRI will be helpful.
Abstract WMP89: Mechanical Thrombectomy For Distal Medium-vessel Occlusion Stroke: Systematic Review And Meta-analysis
Authors: Rodriguez-Calienes Aaron , Galecio-Castillo Milagros , Vivanco-Suarez Juan , Zevallos Mau Cynthia , Farooqui Mudassir , Ortega-Gutierrez Santiago
Published: February 2023

Introduction:
Definitive evidence about the role and effectiveness of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs) is limited.

Objective:
To determine the efficacy and safety of MT for DMVOs.

Methods:
A systematic search was performed until May 2022 in Scopus, Embase, Medline, Web of Science, and Cochrane. An additional cohort of 33 patients from our institutional experience was also included. Primary efficacy and safety outcomes were successful reperfusion (mTICI 2b-3) and sICH, respectively. Additional outcomes were the rate of complete reperfusion (mTICI 3), 90-day excellent and favorable functional outcome (defined as an mRS of 0-1 and 0-2, respectively), and 90-day mortality. We conducted meta-analyses using random-effects models and assessed the certainty of evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I
2
statistics.

Results:
A total of 24 studies with 1046 patients were included in our analysis. Successful and complete reperfusion rates were 89.8% (95% CI 83.7-93.7%; I
2
=0%; moderate-certainty evidence) and 47.2% (95% CI 32.3-62.5%; I
2
=75%; very low-certainty evidence), respectively. Favorable and excellent functional outcome rates were 59.1% (95% CI 48.4-68.9%; I
2
=73%; moderate-certainty evidence) and 43% (95% CI 32.9-53.7%; I
2
=68%; low-certainty evidence), respectively. Mortality and sICH rates were 12.4% (95% CI 9.3-16.5%; I
2
=16%; high-certainty evidence) and 5.5% (95% CI 3.5-8.5%; I
2
=23%; moderate-certainty evidence), respectively.

Conclusion:
This systematic review with meta-analysis found that MT for DMVO provides rates of successful reperfusion and sICH comparable to the evidence from MT for LVO stroke and M2 occlusions. Given the level of evidence of our results, further confirmation on well-designed RCTs is needed.
Abstract WMP97: Symptomatic Steno-occlusion Of Major Cerebral Arteries And Stroke Recurrence In Acute Ischemic Stroke Patients With Atrial Fibrillation
Authors: Guk Hyung Seok , Kim Do Yeon , Hong Keun-Sik , Kim Jun Yup , Kang Jihoon , Kim Beom J , Han Moon Ku , Choi Kang-Ho , Kim Joon-Tae , Park Man Seok , Yum Kyu Sun , Shin Dong-Ick , Gwak Dong-Seok , Kim Dong-Eog , Kim Yong Soo , Kang Kyusik , Kim Jae G , Lee Soo Joo , Lee Minwoo , Oh Mi-Sun , Yu Kyung-Ho , Lee Byung-Chul , Park Hong-Kyun , Cho Yong-Jin , Kang Chul-Hoo , Kim Joong-Goo , Choi Jay Chol , Jang Seong Hwa , Park Hyungjong , Hong Jeong-Ho , Sohn Sung-il , Park Tai H , Kim Wook-joo , Kwon Jee-Hyun , Lee Kyung Bok , Kwon Doo Hyuk , Lee Jun , Lee Keon-Joo , Lee Sang-Hwa , Chul Ho Kim , Lee Ji Sung , Lee Juneyoung , Bae Hee-Joon ,   On behalf of CRCS-K Investigators
Published: February 2023

Introduction:
There is lack of knowledge on whether symptomatic steno-occlusion (SYSO), common in acute ischemic stroke (AIS) patients with atrial fibrillation (AF), could increase the long-term risk of stroke recurrence in these patients.

Methods:
From a prospective cohort of patients with AIS and AF enrolled in 14 centers between Oct 2017 and Dec 2018, we identified patients who underwent MR angiography during hospitalization and completed 3-year follow-up including death during follow-up. SYSO was defined as (1)
≥
50% stenosis or occlusion of cerebral arteries relevant to acute infarction or (2) any residual stenosis after endovascular treatment. Using cause-specific hazard models with non-stroke death as a competing risk, the risk of any recurrent stroke and recurrent ischemic stroke was estimated according to SYSO, respectively.

Results:
A total of 889 patients (mean age, 74.4 years; men, 54.6 %; median NIHSS, 6) were analyzed for this study. During the median 1096 days of follow-up, 152 any recurrent strokes, 142 recurrent ischemic strokes, and 208 deaths were observed. Patients with SYSO, compared to those without, were more likely to be older, be female, have hypertension, diabetes and history of stroke/TIA, and be on antiplatelets at discharge and were less likely to be on anticoagulants at discharge (
p
<.05). The cumulative incidence of recurrent stroke in patients with and without SYSO was 25.2% and 8.3% at 1 month, 33.1% and 9.9% at 1 year, and 41.8% and 13.1% at 3 years, respectively (
p
<.001). With adjusting age, sex, hypertension, diabetes, history of stroke/TIA, discharge antiplatelets, and discharge anticoagulants, SYSO increased the risk of any stroke recurrence (adjusted hazard ratio [95% confidence interval]; 3.02 [2.18-4.20];
p
<.001) and ischemic stroke recurrence (3.20 [2.28-4.51];
p
<.001).

Conclusions:
SYSO in AIS patients with AF substantially increased the risk of recurrent stroke by a 3-fold or more. Accordingly, SYSO should be considered in stratifying the risk of recurrence in AIS patients with AF.
Abstract WP100: Elevated Hypoperfusion Intensity Ratio (HIR) Observed In Patients With A Large Vessel Occlusion (LVO) Presenting In The Evening
Authors: Sreekrishnan Anirudh , Seners Pierre , Yuen Nicole , Lansberg Maarten G , Heit Jeremy J , Lee Sarah , Albers Greg
Published: February 2023

Introduction:
Circadian variability has been implicated in timing of stroke onset, yet the impact of circadian rhythm on stroke evolution is not known. We aimed to describe this relationship in patients with large vessel occlusion (LVO) with perfusion imaging.

Methods:
A retrospective observational study was conducted from (1) prospective registries of two stroke centers with systematic use of perfusion imaging and (2) two thrombectomy trials where enrollment was not based on perfusion imaging results. Included patients had stroke due to ICA, M1 or M2 occlusion and baseline perfusion imaging performed within 24h from last-seen-well (LSW). Stroke onset was examined in 8hrs intervals: (1) Night: 23:00-6:59, (2) Day: 7:00-14:59, (3) Evening: 15:00-22:59. Core volume was estimated on CT perfusion (rCBF <30%) or DWI (ADC <620) and the collateral circulation was estimated with the hypoperfusion intensity ratio (HIR = [Tmax>10s]/[Tmax>6s]). Non-parametric testing was conducted using SPSS to account for the non-normalized dependent variables.

Results:
A total of 1098 cases were included (mean age 69 years, SD 15.5). Median NIHSS, core volumes, and HIR were 16 (IQR 9-21), 18mL (IQR 5-50), and 0.4 (IQR 0.3-0.6) respectively. Most strokes occurred during the Day (n=490, 44.6%), compared to Night (n=242, 22.0%), and evening (n=366, 33.3%). HIR was highest, indicating worse collaterals, in the Evening (p=0.005). Controlling for age and time to scanner, Evening strokes (Figure 1) had significantly elevated HIR compared to Night (p = 0.016) and Day (p = 0.038). Similarly, the largest core volumes were observed in the Evening (p = 0.023) compared to Day.

Conclusion:
Our retrospective analysis suggests that HIR is significantly higher in the evening, indicating poorer collateral activation which may account for the larger core volumes observed at this time-point.
Abstract WP101: Vessel Wall Enhancement Is Associated With Symptomatic Adult Moyamoya Disease And Syndrome In An American Population
Authors: Tran Conny H , Rana Chahat , Moore William , Shang Ty T
Published: February 2023

Introduction:
Moyamoya Disease (MMD) and Moyamoya Syndrome (MMS) are chronic progressive cerebrovascular disease characterized by bilateral or unilateral stenotic arteries around the circle of Willis with subsequent development of collateral blood vessels. MMS is associated with conditions such as Down Syndrome (DS) or sickle cell disease (SCD). The presence of vessel wall enhancement (VWE) on high resolution magnetic resonance vessel wall imaging (HR MR VWI) in MMD or MMS is controversial. Recent studies suggest VWE is associated with recent ischemic or hemorrhagic stroke. The significance of VWE in MMD or MMS in non-Asian population has not been well established. Our study aimed to investigate the prevalence of VWE in adult MMD/MMS in the United States and identify its predictive value for stenosis progression.

Methods:
We retrospectively reviewed patients with MMD or MMS admitted to Clements University Hospital and Parkland Memorial Hospital affiliated with University of Texas Southwestern Medical Center from January 2014 to March 2022. Patients were included if HR MR VWI was performed during workup. Patients were excluded if intracranial atherosclerosis was the suspected stroke etiology from cardiovascular risk factors. The presence of the VWE on HR MR VWI and stenosis grading were evaluated by blinded neuroradiologists and vascular neurologists. Symptomatic disease was defined as ischemic stroke, hemorrhagic stroke or transient ischemic attack within 24 months before HR MR VWI was obtained.

Results:
A total of 32 patients were included, of which 28 had MMD, 3 had MMS from SCD and 1 had MMS from DS. Mean age at diagnosis was 34 ± 10 years old, and 29 (90.6%) were female. VWE was seen in 22 (68.8%) patients. VWE is more common in symptomatic disease than asymptomatic disease (95% vs 20%). 24 patients had follow up MR angiogram with average time from HR MR VWI of 25.8 ± 16.7 months. Among 12 patients with 16 non-occlusive arteries, stenosis progression was seen in 67% of arteries with VWE compared to 25% of arteries without VWE.

Conclusions:
In a North American population with MMD or MMS, VWE on HR MR VWI was more common in symptomatic disease. The presence of VWE was associated with increased risk of stenosis progression. More studies are needed to confirm these findings.
Abstract WP104: Core/perfusion Mismatch Prevalence According To ASPECT Score In Acute Ischemic Stroke With Large Vessel Occlusion.
Authors: Seners Pierre , Yuen Nicole , Escribano Paredes Jose Bernardo , Snyder Sarah J , Carrera Emmanuel , Mlynash Michael , Heit Jeremy J , Lansberg Maarten G , Christensen Soren , Albucher Jean-Francois , Cognard Christophe , Sibon Igor , Obadia Michael , Savatovsky Julien , Olivot Jean-Marc , Albers Gregory W
Published: February 2023

Background:
In acute ischemic stroke (AIS) with large vessel occlusion (LVO), core/perfusion mismatch modifies the effect of mechanical thrombectomy (MT) on clinical outcome, MT appears to have greater benefit in patients with significant mismatch. We aimed to study the prevalence of core/perfusion mismatch according to ASPECT score in a large population of LVO-related AIS imaged either with MRI or CT.

Methods:
Retrospective study including AIS patients with ICA/M1 occlusion and baseline perfusion imaging (MRI or CT) performed within 24hrs from last seen well. To avoid selection bias, patients were selected from (1) the registries of 3 comprehensive centers with systematic use of MRI- or CT-perfusion imaging and including both MT-treated and untreated patients, and (2) one thrombectomy trial where MT decisions were performed blinded to the results of MRI perfusion imaging. Core/perfusion mismatch was defined as mismatch ratio (Tmax>6s volume/ core volume) >1.8 and volume (Tmax>6s - core volume) >15 mL. ASPECT score was rated on diffusion weighted imaging (DWI) or non-contrast CT blinded from the perfusion imaging.

Results:
Overall, 580 and 350 patients were included in the MRI and CT cohorts. Last-seen-well to imaging time was 4.8hrs (IQR 3.0-8.7) and 3.2hrs (1.3-8.0) in the MRI and CT cohorts, respectively, median ASPECT score was 7 (5-8) and 8 (7-9), and core/perfusion mismatch was present in 393/580 (68%) and 315/350 (90%) patients. In both cohorts, 75% of patients were treated with MT following imaging. In the MRI cohort, mismatch prevalence was 44% (75/170) and 92% (378/410) for DWI-ASPECTS 0-5 and 6-10, respectively. In the CT cohort, mismatch prevalence was 47% (15/32) and 94% (300/318) for ASPECTS 0-5 and 6-10, respectively.

Conclusion:
About 90% of patients with ASPECTS 6-10 have a core/perfusion mismatch regardless of imaging type. However, patients with ASPECTS ≤5 are heterogeneous in terms of mismatch status. Therefore, perfusion imaging may be particularly useful to select appropriate MT candidates with low ASPECT scores, regardless of imaging type, which has implications for large core trials.
Abstract WP117: Effectiveness Of Minimally Invasive Surgery With Thrombolysis For Evacuation Of Intracerebral Hemorrhage: Post Hoc Bayesian Analysis Of A Phase 3 Randomized Controlled Trial
Authors: Bako Abdulaziz , Tannous Jonika , Potter Thomas B , Pan Alan P , Britz Gavin W , Ziai Wendy C , Awad Issam A , Hanley Daniel F , Vahidy Farhaan S
Published: February 2023

Introduction:
Bayesian analyses provide meaningful interpretations of clinical trial data in terms of probabilities of treatment effect. This extends the value of results beyond that obtained from traditional binary cut offs. Such interpretations provide actionable information for conditions with high mortality and no proven treatments, such as intracerebral hemorrhage (ICH).

Methods:
The minimally invasive surgery with thrombolysis in ICH evacuation (MISTIE 3) trial randomized 506 adults with spontaneous, supratentorial ICH of ≥ 30mL to receive either MISTIE intervention or standard medical care. Using reference priors (minimally informative, enthusiastic, skeptical) and a MISTIE 2-derived prior, we estimated probabilities that the effect of MISTIE intervention exceeds pre-specified thresholds of relative risks (RR) for achieving a 365-day Modified Rankin Scale (mRS) score of 0-3. We also computed the effects of MISTIE intervention on 180 and 30-day mRS and 365, 180 and 30-day mortality.

Results:
Using a minimally informative prior, the posterior probability of MISTIE intervention having any beneficial effect (RR > 1) on 365-day mRS was 70%. The probabilities of observing RR > 1.02 and > 1.10 were 63% and 34%, respectively. The probabilities of observing RR > 1, 1.02 and 1.10, with other priors are: 87%, 82% and 55% (enthusiastic); 68%, 60% and 30% (skeptical); and 73%, 66% and 38% (MISTIE 2-derived). The probabilities that MISTIE intervention has any beneficial effect on 180 and 30-day mRS, and 365, 180, and 30-day mortality are 65%,80%, 93%, 98% and 99%, respectively. RR, 95% credible intervals across various priors are shown in Figure.

Conclusions:
The probability that the MISTIE intervention has a favorable functional outcome at 365-days among ICH patients is 68 to 87%. Bayesian-derived probabilities of treatment effect may facilitate shared decision making in ICH management, above and beyond p-value-based frequentist interpretation of trial results.
Abstract WP118: Mechanistic Implications Of Cortical Superficial Siderosis In Patients With Mixed Location Intracerebral Hemorrhage And Cerebral Microbleeds
Authors: Das Alvin S , Gokcal Elif , Biffi Alessandro , Regenhardt Robert , Abramovitz Fouks Avia , Viswanathan Anand , Kimberly W T , Goldstein Joshua N , Schwamm Lee H , Rosand Jonathan , Greenberg Steven , Gurol Edip M
Published: February 2023

Introduction:
Hypertensive cerebral small vessel disease (HTN-cSVD) is the predominant microangiopathy in patients with a combination of lobar and deep cerebral microbleeds (CMBs) and intracerebral hemorrhage (mixed ICH/CMB). We tested the hypothesis that cerebral amyloid angiopathy (CAA) is also a contributing microangiopathy in mixed ICH/CMB patients with cortical superficial siderosis (cSS), a marker that is strongly associated with CAA.

Methods:
Brain MRIs from a prospective database of consecutive non-traumatic ICH patients admitted to a single referral center (2003 to 2019) were reviewed for the presence of CMBs, cSS, and non-hemorrhagic CAA markers (lobar lacunes, centrum semiovale enlarged perivascular spaces (CSO-EPVS), and multispot pattern of leukoaraiosis). The frequency of CAA markers and left ventricular hypertrophy (LVH), a marker for hypertensive end-organ damage, were compared between mixed ICH/CMB patients with cSS (mixed
+cSS
) and without cSS (mixed
-cSS
) in univariate and multivariate models.

Results:
Of the 1824 ICH patients, 40 had mixed
+cSS
and 256 had mixed
-cSS
. LVH was less common in patients with mixed
+cSS
compared to those with mixed
-cSS
(34% vs. 59%,
p =
0.01). The frequency of multispot pattern (18% vs. 4%,
p
< 0.01) and severe CSO-EPVS (33% vs. 11%,
p
< 0.01) were higher in patients with mixed
+cSS
compared to mixed
-cSS
, whereas lobar lacune frequency was similar (23% vs. 20%,
p
= 0.67). In a logistic regression model, older age (aOR 1.04 per year, 95% CI [1.01-1.08],
p
= 0.01), presence of multispot pattern (aOR 5.82, 95% CI [1.82-18.60],
p
< 0.03), severe CSO-EPVS (aOR 4.08, 95% CI [1.73-9.61],
p
< 0.01), and LVH (aOR 0.43, 95% CI [0.20-0.94],
p
= 0.03) were independently associated with mixed
+cSS
after further adjustment for sex and hypertension (Table).

Conclusions:
CAA and HTN-cSVD appear to confer injury in patients with mixed ICH/CMB and cSS, a finding that warrants confirmation in studies incorporating advanced imaging/pathology.
Abstract WP121: Can The Extended Glasgow Outcome Scale (e-gos) Augment The Interpretation Of Results From Clinical Trials Of Minimally Invasive Surgery Of Spontaneous Intracerebral Hemorrhage Using The Modified Rankin Scale (mrs): A Secondary Analysis Of The Clear-iii And Mistie-iii Trials
Authors: Sun Philip Y , Thompson Richard , Akindahunsi Taiwo , Avadhani Radhika , Nyquist Paul A , Awad Issam A , Hanley Daniel F , Ziai Wendy C
Published: February 2023

Introduction:
Currently, the modified Rankin scale (mRS) is most commonly used to assess functional outcome in clinical trials of interventions for spontaneous intracerebral hemorrhage (ICH). Extended Glasgow Outcome Score (eGOS) is often used to assess global disability/recovery after traumatic brain injury and provides additional discrimination of vegetative state (VS) from lower severe disability (LSD). We compared primary outcomes from 2 clinical trials of minimally invasive surgery for intracerebral and intraventricular hemorrhage (ICH/IVH) at different thresholds of eGOS.

Methods:
Post-hoc analysis of primary outcomes (PO) from the CLEAR-III trial (intraventricular alteplase [IVtPA] vs. saline for obstructive IVH; N=500; PO: mRS 0-3 at day 180), and MISTIE-III trial (stereotactic thrombolysis [MIS+tPA] vs. conservative management; N=499; PO: mRS 0-3 at day 365). eGOS was derived from functional outcome scales obtained during the trials. Outcomes on eGOS were categorized into 5 subgroups: good outcomes: 7-8 (A), 5-6 (B), 4 (C), and poor outcomes: 3 (D), and 1-2 (E). Generalized, ordered logistic regression analysis was performed, adjusting for age, ICH location, stability ICH and IVH volumes, and randomization GCS.

Results:
eGOS scales were available in 481 (96%) patients at day 180 in CLEAR-III and 478 (96%) patients at day 365 in MISTIE-III. In CLEAR-III, odds of being in eGOS category D (LSD) or E (death or VS) vs. the others, were approximately 40% lower for IVtPA group compared to saline group (aOR = 0.59; 95% CI, 0.38-0.90; p=0.016), and odds of being in category E (vs. the others) were almost 50% lower (aOR = 0.51; 95% CI, 0.33-0.80; p=0.004). VS occurred in 2.49% of IVtPA and 2.07% of saline group patients. In MISTIE-III, odds of being in eGOS category D or E (vs. the others) were not significantly different for MIS+tPA vs. conservative treatment: aOR = 0.84; 95% CI, 0.55-1.28; p=0.41), as were odds for being in eGOS category E (vs. the others), aOR = 0.77; 95% CI, 0.48-1.24; p=0.29).

Conclusions:
The 5-category dichotomized eGOS (4-8 vs. 1-3) defines a functional outcome improvement in CLEAR-III at day 180, which was not observed using the PO with mRS. Use of eGOS did not result in a different interpretation of the MISTIE-III trial.
Abstract WP129: Sociodemographic, Clinical, And Outcomes Characteristics Of Young Adult Patients With Intracerebral Hemorrhage
Authors: Johnson Carnayla , Kelly Hannah , Baig Eman , Jefferson Imory , Adegbindin Sofiat , Potter Thomas , Bako Abdulaziz , Pan Alan P , Khan Osman , Nair Rejani R , McCane Charles D , Garg Tanu , Misra Vivek , Gadhia Rajan , Volpi John J , Chiu David , Britz Gavin W , Vahidy Farhaan , Tannous Jonika
Published: February 2023

Intro:
Incidence of intracerebral hemorrhage (ICH) in the young is increasing but risk factors and outcomes are not well characterized.

Methods:
Using a stroke-specific bioinformatics pipeline across a 7-hospital certified stroke healthcare system, we identified adult non-traumatic ICH cases between 05/16 and 08/22 and flagged young ICH patients (YIP) aged 18 – 45. We compared sociodemographic, comorbidity, clinical, imaging, and treatment characteristics, and outcomes between YIP and non-YIP using logistic regression.

Results:
Among 1 869 ICH patients, 187 (10%) were YIP. YIP (vs. Non-YIP) were predominantly privately insured (71.1 % vs. 29.8 %), non-Hispanic Black (33.7% vs. 22.2%), Hispanic (26.7% vs. 21.7%), and single (41.2% vs. 20.5%). A higher proportion of YIP were obese and a lower proportion had pre-existing comorbidities (Figure). A lower proportion of YIP were on statins, antiplatelets, or anticoagulants prior to ICH. A significantly smaller proportion of YIP had large hemorrhage volumes (> 30 ml) and experienced lower rates of in-hospital complications such as delirium and SIRS. A significantly greater proportion of YIP underwent craniotomy and had longer lengths of stay. After adjusting for important clinical and sociodemographic correlates of in-hospital mortality, YIP had a 59% lower likelihood of in-hospital mortality or hospice discharge OR (CI): 0.41 (0.20 – 0.82). Additionally, for outcome assessment, YIP were more likely to be contacted [2.9 (1.26, 8.08)], consented [3.7 (1.8, 7.8)], and complete follow-up survey [1.9 (1.0, 3.8)] than non-YIP. Though 50.5% of YIP had a 90-day mRS >3, there was a 51% lower likelihood of severe disability or death in YIP vs. non-YIP.

Conclusion:
YIP poses a high morbidity burden and understanding long-term functional and cognitive outcomes is important. High follow-up rates provide an opportunity for engaging this often overlooked and underrepresented cohort of critically ill patients in future research.
Abstract WP137: Carotid Distension And Remodeling Is Associated With The Aorta-carotid Stiffness Gradient
Authors: Scheuermann Britton , Colburn Trenton , Parr Shannon , Kunkel Olivia , Hammond Stephen , Rosenkranz Sara K , Ade Carl J
Published: February 2023

Background:
Recent studies have suggested that the arterial stiffness gradient between the aorta and cerebrovasculature, versus aortic stiffness alone, better predicts incidence of cerebrovascular disease, due to increased transmission of pulsatile energy to the cerebral microcirculation. Our aim was to evaluate the association of structural and functional alterations in the carotid artery with the aorta-carotid stiffness gradient versus using aortic stiffness alone.

Methods:
We evaluated vascular measures in 29 subjects (50±2.4 yrs, range 33–75 yrs, 65.5% women). Carotid pulse wave velocity (an index of stiffness, using the Bramwell-Hill equation), intima-media thickness (cIMT), cIMT-lumen ratio, and strain were calculated from Doppler ultrasound images. Carotid-femoral PWV (cfPWV) was calculated using the distance between the carotid and femoral sites and the timing of the velocity upstrokes relative to the R-wave on simultaneous electrocardiography. The aorta-carotid stiffness gradient (cf/c) was estimated as the ratio of cfPWV to carotid PWV. Blood pressures were taken as the average of two resting measurements prior to testing. The cf/c ratio was log-transformed to account for positive skewness.

Results:
In univariate analysis, both cfPWV and log(cf/c) were associated with carotid strain (β=-0.76 and β=-15.91 respectively; both p<0.05). The cIMT-lumen ratio was associated with cfPWV (β=0.0049, p=0.019) but not with log(cf/c) (p=0.125). After adjustment for age, sex, BMI and SBP, the association between cfPWV and carotid strain was nonsignificant (p>0.05) while log(cf/c) remained independently associated with carotid strain (β=-12.69, p<0.05). In the adjusted model, both cfPWV and log(cf/c) were independently associated with cIMT-lumen ratio (β=0.0059 and β=0.082 respectively, both p<0.05).

Conclusion:
After adjustment, cfPWV and cf/c were associated with increases in the cIMT-lumen ratio, an indicator of inward remodeling. However, only cf/c was associated with carotid strain, a measure of vessel distension and an index of vessel stiffness. These results suggest that, compared to aortic stiffness alone, the aorta-carotid stiffness gradient may be a more robust indicator of alterations in carotid structure and function.
Abstract WP146: The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score Compares Favorably To The Critical Area Perfusion Score After Basilar Thrombectomy
Authors: Karamchandani Rahul R , Satyanarayana Sagar , Yang Hongmei , Rhoten Jeremy B , Strong Dale , Clemente Jonathan , DeFilipp Gary , Hazim Manuel , Patel Nikhil M , Bernard Joe , Stetler William , Parish Jonathan M , Blackwell Thomas A , Asimos Andrew W
Published: February 2023

Introduction:
The critical area perfusion score (CAPS) identifies patients with vertebrobasilar occlusions who may benefit from endovascular thrombectomy based on computed tomography perfusion (CTP) regions of severe hypoperfusion. We compared CAPS to the recently described Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS).

Methods:
Acute basilar artery occlusion (BAO) patients from January 2017-December 2021 with pre-thrombectomy CTP were included in this retrospective analysis from a health system’s stroke registry. CAPS (0-6 points) = CTP Tmax > 10 (cerebellar hemispheres,1 point each; pons, 2 points; midbrain and/or thalamus, 2 points) and CLEOS = (5 x age) + (10 x National Institutes of Health Stroke Scale [NIHSS]) + Glucose - (150 x CTP cerebral blood volume index). Inter-rater reliability was assessed using light’s kappa for 6 CAPS raters. A logistic regression with CAPS and CLEOS as predictors was performed to predict the primary outcome, 90-day modified Rankin Scale (mRS) 4-6. Receiver operator characteristics (ROC) curve analyses were performed to evaluate the prognostic ability of each score. Performance of the two scores was assessed among reperfused patients (modified thrombolysis in cerebral infarction 2b-3).

Results:
55 patients, mean age 65.8 (± 13.1) years and median NIHSS score 15.5 (5-24), were included. Light’s kappa among all 6 raters for favorable versus unfavorable CAPS (0-3 versus 4-6) was 0.633 (95% CI 0.497-0.785). Increased CLEOS was associated with elevated odds of a poor outcome (odds ratio [OR] 1.0010, 95% CI 1.0007-1.0014, p < 0.01), though CAPS was not (OR 1.0028, 95% CI 0.9420-1.0676, p = 0.93). In the ROC analysis, a favorable trend was observed for CLEOS (area under the curve [AUC] 0.69, 95% CI 0.54-0.84) compared to CAPS (AUC 0.49, 95% CI 0.34-0.64; p = 0.051). Of the approximately 85% of patients who reperfused, CLEOS had a sensitivity, specificity, positive predictive value, and negative predictive value of 71%, 70%, 74%, and 67%, respectively, compared to 24%, 86%, 67%, and 50% for CAPS.

Conclusions:
CAPS has fair inter-rater agreement. CLEOS demonstrated better predictive ability than CAPS for poor outcomes overall and poor outcomes stratified by reperfusion status after BAO thrombectomy.
Abstract WP162: Primary Results Of Mechanical Thrombectomy For Acute Ischemic Stroke In Clinical Practice: K-net Registry
Authors: Ueda Toshihiro , TAKEUCHI MASATAKA , MORIMOTO MASAFUMI , Tsuboi Yoshifumi , Yamamoto Ryoo , Kaku Shogo , Ayabe Junichi , Akiyama Takekazu , Ishima Daisuke , Yoshie Tomohide , Hasegawa Yasuhiro ,   K-NET Registry Investigators
Published: February 2023

Background:
Endovascular treatment (EVT) for acute large vessel occlusion has been found to be effective in several randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in patients with acute ischemic stroke in a metropolitan area with a high population density and a large number of comprehensive stroke centers.

Methods:
We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA), in Kanagawa, Japan. Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0 to 2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis.

Results:
The median age was 77 years and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 minutes. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Furthermore, 49.3% of patients with anterior circulation obstruction who had pre-stroke mRS 0-2 had good outcome, which was higher than the HERMES trial. Overall mortality was 12.6%. Significant predictors for a good outcome were: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization.

Conclusions:
EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous registries and RCTs, despite the high proportion of patients with older age, pretreatment mRS score of > 2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.
Abstract WP168: Percutaneous Left Atrial Appendage Closure Device For Patients With Atrial Fibrillation In New York
Authors: Shu Liqi , Xiao Han , Yaghi Shadi
Published: February 2023

Introduction:
Trials have shown that WATCHMAN left atrial appendage closure (LAAC) for stroke is noninferior to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). Since the approval of WATCHMAN, real world clinical outcome of LAAC is still limited. We performed a state wide analysis to evaluate clinical outcomes for AF patients undergo LAAC.

Methods:
Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database, we included New York state adult patients, who had AF diagnosis with and without LAAC procedure from 2011 to 2017. Patients who had acute ischemic stroke (AIS) or history of AIS prior or during index admission were excluded. AF, AIS and other diagnosis were identified based on standard ICD-9 CM and ICD-10 CM codes. We compared rates of AIS, intracranial hemorrhage (ICH) and death between patients with and without LAAC. We also constructed a Cox regression model to determine hazard ratios (HR) of LAAC associated with each outcome.

Results:
Of the 627,972 patients with AF admitted, the mean age was 75.8 and 33.1% were female, and 773 (0.1%) underwent LAAC. AIS readmission occurred in 0.030% of AF patients without LAAC while it occurred in 0.012% of patients underwent LAAC. In the Cox regression model, LAAC had similar AIS readmission (HR 0.84, 95% CI 0.44-1.62, P = 0.602) and ICH readmission (HR 1.688, 95% CI 0.63-4.50, P = 0.296), but LAAC was associated with less death (HR 0.295, 95% CI 0.20-0.43, P < 0.001). These outcomes remained the same despite adjustment with common risk factors and insurance type, or adjustment with CHADS
2
VASC
2
scores. In sensitivity analysis, after restricting to patients that had ICH prior to index admission, LAAC again had similar AIS readmission (HR 1.884, 95% CI 0.26-13.46, P = 0.528) compared to non-LAAC group but still marginally associated with less death (HR 0.289, 95% CI 0.07-1.16, P = 0.080).

Conclusion:
In New York state, AF patients underwent LAAC procedural are less likely to have death during follow up despite adjustment of common risk factors or CHADS
2
VASC
2
score, while AIS and ICH readmission appears to be similar. However, given potential underlying confounding by treatment indication, these findings need confirmation by ongoing randomized control trials.
Abstract WP172: Delayed Leukoencephalopathy Following Acute Ischemic Stroke
Authors: Sato Takeo , Matsushima Satoshi , Maku Takahiro , Kitagawa Tomomichi , Tanabe Maki , Takatsu Hiroki , Komatsu Teppei , Sakai Kenichiro , Sakuta Kenichi , Umehara Tadashi , Murakami Hidetomo , Mitsumura Hidetaka , Matsushima Masato , Iguchi Yasuyuki
Published: February 2023

Background and Purpose:
Delayed leukoencephalopathy (DL) following ischemic stroke with large vessel occlusion (LVO) is rarely reported and the pathophysiology is unclear. We aimed to investigate the incidence, clinical characteristics of DL following acute ischemic stroke.

Methods:
Consecutive ischemic stroke patients were screened. Inclusion criteria were: 1) onset to door time within 7 days; and 2) availability of initial and a second or more MRI after 14 days from onset with DWI, FLAIR, and MRA. We defined DL as newly detected diffuse hyperintensities restricted to the white matter on FLAIR mostly accompanied with partial DWI hyperintensities after 14 days from onset. First, we estimated the incidence of DL and whether a LVO would be a factor associated with DL following all the acute ischemic stroke. Second, limiting the patients with LVO, we evaluated the incidence and the factors associated with DL.

Results:
We screened 1,857 consecutive ischemic stroke patients. Of all, 792 with all the acute ischemic stroke (573 (72%) male, median age 67 years), and 183 with LVO (128 (70%) male, median age 67 years) were included in each analysis. DL were detected in 18 patients in all the acute ischemic stroke (2%), and 17 in patients with LVO (9%) (Figure). First, LVO was strongly associated with DL following all the acute ischemic stroke (OR 62.3, 95% CI 8.23 to 471,
p
<0.001). Second, limiting the patients with LVO, factors associated with DL were age/10 years (OR 1.64, 95% CI 1.08 to 2.47,
p
= 0.019), NIHSS score at admission (OR 1.06, 95% CI 1.01 to 1.11,
p
= 0.014), complete recanalization (OR unable to calculate due to 100% prevalence in DL group,
p
<0.001), and mechanical thrombectomy (OR 14.2, 95% CI 3.90 to 52.0
p
<0.001).

Conclusions:
DL is not an uncommon phenomenon especially after LVO. Age, neurological severity, mechanical thrombectomy, and complete recanalization might be related to DL.
Abstract WP191: Post Stroke Dysphagia Prediction Score In Acute Ischemic Stroke In Japan
Authors: Ikenouchi Hajime , Nozue Kei , Miyamoto Tatsuo , Yamamoto Naoki , Endo Kaoru
Published: February 2023

Background and Purpose:
Post stroke dysphagia (PSD) is a common complication after stroke. The earlier prediction of PSD is essential for patient stratification for intensive rehabilitation, but there was no scoring system for predicting PSD. We aimed to develop the PSD prediction score.

Methods:
We examined consecutive patients with acute ischemic stroke between 2018-2020. Patients with in-hospital-death were excluded. Dysphagia state was assessed using food oral intake scale (FOIS) score at hospital discharge. PSD was defined as FOIS 1-3, which represent tube-dependent nutrition. For the assessment of reproducibility of PSD score, patients were divided into derivation and validation cohort. Using the derivation cohort, PSD score was developed from associated factors to discriminate PSD by logistic regression analysis. Discriminative performance was analyzed by receiver operating curve (ROC) analysis. Reproducibility of PSD score was validated using the validation cohort.

Results:
Among 795 patients (median 77 years; male, 57%), 556 (70%) patients were assigned as derivation cohort and 239 (30%) patients were assigned as validation cohort. In the derivation cohort, older age (≥85 years), low BMI (≦18.5 kg/m
2
for aged <70 years and ≦ 20 kg/m
2
for aged ≥70 years), high NIHSS score (≥16), and low serum albumin (≦3.0 mg/dl) were associated with PSD (Table). PSD score were ranged from 0 to 6 from these factors (Table). Area under the curve (AUC) of PSD score for PSD was 0.83 (95% confidence interval [CI] 0.78-0.88) with an appropriate cut-off value of 2 (sensitivity, 69%; specificity, 88%). In the validation cohort, the AUC of PSD score for PSD was 0.78 (95% CI 0.70-0.86), which was not significantly different in the AUC of the derivation cohort (AUC; 0.83 vs 0.78, p=0.30).

Conclusions:
In acute ischemic stroke population, the discriminative performance of PSD score had acceptable for diagnosing PSD.
Abstract WP193: Neighborhood-level Ethnic And Racial Segregation And Incident Stroke Risk
Authors: de Havenon Adam , Bangad Aaron , Abbasi Mehdi , Sharma Richa , Sheth Kevin N , Skolarus Lesli
Published: February 2023

Background:
Neighborhood-level ethnic and racial segregation has been linked to health status. We explored whether community level segregation is associated with incident stroke.

Methods:
We used data from Multi-Ethnic Study of Atherosclerosis (MESA). The exposure was neighborhood racial/ethnic segregation measured separately for self-identified White, Black and Hispanic participants and calculated as the Getis-Ord Gi* statistic based on the geocoded address of the participant. The Gi* statistic was categorized using the validated cut points of low, medium, and high neighborhood racial/ethnic segregation (high segregation means that the participant’s neighborhood primarily contained individuals of their race/ethnicity). The primary outcome was incident stroke (ischemic and hemorrhagic) during follow-up. We fit time-to-event Cox models with an interaction between race*segregation and adjustment for age, sex, hypertension, diabetes, hyperlipidemia, and current smoking. The results were further evaluated using marginal effects after logistic regression.

Results:
We included 5,411 MESA participants (mean age 62.0±10.1, 47.4% male, 44.4% White, 31.0% Black, 24.6% Hispanic), of which 111 (2.1%) had incident stroke during 8.0±1.3 years of follow-up. In the low, medium, and high neighborhood segregation categories there were 1,603 (29.6%), 1,667 (30.8%), and 2,141 (39.6%) individuals. High neighborhood segregation was more common in Black (45.7%) and Hispanic (39.7%) individuals than White (14.6%) (p<0.001). In Cox regression, the interaction between race and segregation was significant (p<0.1). Compared to low segregation, high segregation among White individuals was associated with 3.1% LOWER probability of incident stroke (p<0.001, from 3.4% to 0.3%), among Black individuals with 1.2% HIGHER probability of incident stroke (p=0.046, from 0.7% to 1.9%), and in Hispanic individuals there was an insignificant difference (p=0.842).

Conclusions:
For White individuals, a high level of segregation is associated with a lower probability of stroke, but for Black individuals with a higher probability of stroke. These findings call for further research into the mechanisms by which neighborhood segregation may mediate stroke risk.
Abstract WP195: Dietary Fat Intake, Food Insecurity, And Anxiety Among Stroke Survivors
Authors: Almohamad Maha , Mofleh Dania , Altema-Johnson Daphene , Fries Joseph , Sharrief Anjail Z
Published: February 2023

Introduction:
During recovery, stroke patients are at risk of developing psychological complications impacting their quality of life. Diets rich in fat negatively impact anxiety disorders; however, this relationship has not been explored among stroke survivors considering food insecurity status, a social determinant of health (SDOH).

Methods:
In a population-based cohort of 309 patients with acute stroke, we retrospectively assessed self-administered surveys to evaluate the association between dietary fat intake and anxiety in stroke survivors presenting for an initial visit at a University-based stroke clinic from January 2021-July 2021 in Houston, Texas. Anxiety was measured using the GAD-7 scoring system and dichotomized to either “None/Mild” or “Moderate/Severe.” Dietary fat intake was calculated using the quality frequency screener; food insecurity status, using the Hunger Vital sign screener.

Results:
Among this population, 15.46% reported food insecurity and 50.8% (N=157) had moderate to severe anxiety. The multivariable logistic regression model showed that total fat intake (Odds Ratio (OR)=1.01, 95% CI: 1.00, 1.03; P-value=0.016) and percent fat (OR=1.06, 95% CI: 1.01, 1.11; P-value=0.018) dietary intake had a statistically significant negative impact on anxiety, adjusting for covariates and an interaction term between food insecurity status and dietary fat intake.

Conclusion:
Although studies describe the role of a healthy diet in stroke, this is the first study that looks at dietary fat intake as it relates to stroke and anxiety, as well as, food insecurity among stroke survivors. SDOH including food access and affordability are associated with stroke risk and dietary fat outcomes. A better understanding of fat intake and associated factors in this population will provide an opportunity for developing interventions for those at highest risk. Access to healthy foods may prevent higher intake of fat in one’s diet and reduce the risk of stroke.