bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP5: The Impact of Enteral Nimodipine on Endothelial Cell Apoptosis in an Animal Subarachnoid Hemorrhage Model
Authors: Cho Young
Published: January 2025

Background:
Enteral nimodipine is the most evidence-based and widely used drug for the treatment of delayed cerebral ischemia and is known to have various neuroprotective functions. However, the neuroprotective mechanism of nimodipine still remains unclear, and the effects of nimodipine remain ambiguous. Herein, we studied the effect of enteral nimodipine on endothelial apoptosis after subarachnoid hemorrhage (SAH).

Methods:
SAH was experimentally introduced in white rabbits (n = 42) that were grouped as follows: enteral nimodipine (SAH-nimodipine group, n = 14), a control that received normal saline (SAH-saline group, n = 13), and a control without hemorrhage (control group, n = 15). On the third day after SAH induction, the brain stem, including the vertebrobasilar vascular system, was extracted. The effects of enteral nimodipine were analyzed by group using histopathologic analysis, including immunohistochemical staining of apoptosis-related proteins (Bcl2 [anti-apoptotic] and Bax [pro-apoptotic]).

Results:
Cytoplasmic vacuolation of smooth muscle cells was observed in two SAH hemorrhagic groups and was more prominent in the SAH-saline group. Endothelial desquamation was observed only in the SAH-saline group. For the basilar artery, expression of Bcl2 and Bax in the SAH-nimodipine group was lower than that in the SAH-saline group, but significant differences were not observed (p
Bcl2
= 0.311 and p
Bax
= 0.720, respectively). In penetrated arterioles, the expression of Bax in the SAH-nimodipine group was significantly lower than that of the SAH-saline group (p < 0.001). The thickness of the tunica media in the basilar artery was thinner in the SAH-nimodipine group than in the SAH-saline group (p < 0.001).

Conclusions:
This study suggests that enteral nimodipine may have a neuroprotective function by inhibiting endothelial apoptosis in small arterioles and preventing smooth muscle cell proliferation in large arteries.
Abstract TP146: Disparities in risk factors between Black and White adults aged 18-64 years hospitalized for acute ischemic stroke, United States 2016-2020
Authors: Tong Xin , Carlson Susan , Yang Quanhe , Merritt Robert
Published: January 2025

Introduction:
Differences in risk factors may contribute to disparities in stroke risk. This study examines differences in the prevalence of stroke risk factors between Black and White adults aged 18-34, 35-54, and 55-64 years hospitalized for acute ischemic stroke (AIS) between 2016 and 2020.

Methods:
The study population consisted of AIS hospitalizations among adults aged 18-64 years from the 2016-2020 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (HCUP, sample size: 691,645). AIS hospitalizations were identified based on a primary diagnosis of ICD 10 CM code I63, and risk factors (RFs) (hypertension, diabetes, hyperlipidemia, and tobacco use) were identified using secondary diagnoses codes. Prevalence ratios (PR) were calculated by dividing the prevalence among non-Hispanic Black adults (NHBA) by the prevalence among non-Hispanic White adults (NHWA).

Results:
The prevalence of hypertension and diabetes were higher among NHBA than NHWA hospitalized with AIS across all age groups. In 2020, the prevalence of hypertension was higher among NHBA compared to NHWA aged 18-34 years (55.3% vs. 33.8%, PR: 1.6), 35-54 years (86.7% vs. 74.4%, PR: 1.2), and 55-64 years (92.5% vs. 82.6%, PR: 1.1). Similarly, the prevalence of diabetes was higher among NHBA compared to NHWA aged 18-34 years (25.6% vs. 15.2%, PR: 1.7), 35-54 years (47.5% vs. 39.2%, PR: 1.2), and 55-64 years (53.8% vs. 44.2%, PR: 1.2). During 2016-2020, the age group specific PRs comparing the annual prevalence of hypertension and diabetes were similar across the years, and in each year, PRs among those aged 18-34 years were consistently higher compared to those aged 35-54 and 55-64 years. For hyperlipidemia, PRs comparing NHBA and NHWA were not significant except among those aged 18-34 years in 2016 (26.8% vs. 18.1%, PR: 1.5). Tobacco use was lower among NHBA compared to NHWA only among those aged 35-54 years (2020: 39.3% vs. 45.9%, PR: 0.8) and this PR was similar across years.

Conclusions:
Persistent disparities in the prevalence of hypertension and diabetes between NHWA and NHBA existed during 2016 and 2020, and disparities were more pronounced among adults aged 18-34 years. The findings highlight the importance of addressing stroke risk factors among NHBA.
Abstract TP15: Argatroban Among Patients with Acute Ischemic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Authors: Dobromir Angheluta Adelina , Zolotarova Tetiana , Levett Jeremy , Seirafi Tara , Filion Kristian , Eisenberg Mark
Published: January 2025

Introduction:
Argatroban, a direct thrombin inhibitor, is currently being investigated as a potential adjunct to the standard of care for the treatment of acute ischemic stroke (AIS). However, data regarding its impact on functional neurological outcomes have been inconclusive. Our objective was to compare neurological outcomes at 90 days among individuals with AIS randomized to argatroban with standard of care versus standard of care alone.

Methods:
We systematically searched MEDLINE, EMBASE, and Cochrane CENTRAL databases from their inception to July 2024 for randomized controlled trials of argatroban. The primary outcome was excellent functional outcome, as defined by a modified Rankin Scale (mRS) score of 0-1 at 90 days. The secondary endpoints were favorable functional outcome, defined by a mRS score of 0-2 at 90 days, and repeat stroke or other vascular events within 90 days. Safety endpoints included symptomatic intracranial hemorrhage and parenchymal hematoma at 90 days. Risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB 2). Random-effects meta-analytic models were used to estimate pooled risk ratios (RRs) and 95% confidence intervals (CIs). Our protocol was preregistered on Open Science Framework (https://osf.io/tygwx/).

Results:
Four randomized controlled trials were included. A total of 1,595 participants were randomized to receive either argatroban with standard of care (n=807) or standard of care alone (n=788). Participants were mostly male (67.1%), and their median/mean age ranged from 57 to 69 years. When data were pooled across trials, the impact of argatroban on the likelihood to have a mRS score of 0-1 was inconclusive due to a wide CI (RR: 1.12; 95% CI: 0.88-1.41; I
2
: 63%) (Figure 1). Similar trends were observed for the other predefined outcomes. The RRs were 1.00 (95% CI: 0.87-1.14) for a mRS score of 0-2 (Figure 2) and 0.79 (95% CI: 0.44-1.44) for stroke or other vascular events. The pooled RRs for symptomatic intracranial hemorrhage and parenchymal hematoma were 1.09 (95% CI: 0.73-1.63) and 0.84 (95% CI: 0.48-1.47), respectively.

Conclusions:
Results were inconclusive due to small sample sizes. Currently, there is insufficient data to support the addition of argatroban to standard of care for the treatment of AIS. Evidence from available trials in this area supports the conduct of larger trials to determine the clinical value of argatroban.
Abstract TP170: White Matter Disease Burden Not Independently Associated with Clinical Outcomes or Hemorrhagic Transformation in DEFUSE 3 Population
Authors: McCullough-Hicks Margy , Thatikunta Prateek , Mlynash Michael , Albers Gregory , Mijalski Sells Christina
Published: January 2025

Introduction:
Cerebrovascular white matter disease (WMD) severity is linked to vascular risk factors like hypertension, hyperlipidemia, and diabetes. In stroke, it has been associated with infarct growth, hemorrhagic transformation, and poor outcomes. WMD severity may also indicate poor collateral circulation, compromise of the blood brain barrier, and microvascular dysfunction, predicting higher infarct burden and stroke severity. We hypothesized that severe WMD in large vessel occlusion (LVO) stroke patients would correlate with worse 90-day functional outcomes, measured by the modified Rankin Scale (mRS).

Methods:
We analyzed the DEFUSE 3 trial dataset, which studied extended window endovascular therapy for LVO patients with a target perfusion mismatch. WMD burden was assessed using Fazekas scoring on post-stroke T2 FLAIR sequences by three raters. Data were categorized into low (Fazekas 0-1) and high (Fazekas 2-3) WMD burden. Analysis was performed using the independent samples Mann-Whitney U and Chi-square tests. Adjusted analysis was done with binary and ordinal logistic regression analysis.

Results:
Of 155 patients with post-stroke FLAIR sequences, 117 (75.5%) had high WMD burden. Patients with high WMD burden were older, more often non-Hispanic, and had more hypertension (Table 1). Initially, high WMD burden was associated with a worse median 90-day mRS (4 vs 3, p=0.010) and fewer patients with good 90-day mRS (27% vs 47%, p=0.022). However, after adjusting for covariates, WMD burden was not independently associated with good 90-day mRS (OR 0.52, 95% CI 0.22-1.26) or 90d mRS shift (cOR 1.50, 95%CI 0.74-3.04, p=0.266) for each point increase in mRS. There was a strong trend to worse 90-day NIH Stroke Scale score in high WMD burden (median 8 vs 4, p=0.059), but no association with presence of post-stroke hemorrhagic transformation, defined as Parenchymal Hematoma type 1 or 2 (13% vs 10%, p=0.566).

Conclusions:
WMD burden did not have an independent association with 90-day functional outcomes or hemorrhagic transformation in the DEFUSE 3 cohort. This analysis is limited by the fact that DEFUSE 3 was not designed to look at the hypothesis in question, included a relatively small sample size, and had very few patients with hemorrhagic transformation. This study confirms the association between age and the presence of hypertension with an increased risk of more severe WMD, but this finding does not necessarily translate to worse outcomes in acute stroke.
Abstract TP171: Automated Large Vessel Occlusions Detection: Improved Diagnostic Accuracy in MCA M2 Segment Using Deep Learning
Authors: Franciosini Angelo , Avare Christophe , Chang Peter , Chow Daniel , Filippi Christopher G , Ayobi Angela , Laletin Vladimir , Chaibi Yasmina
Published: January 2025

Introduction:
Integrating AI into clinical practice enables precise diagnosis and could potentially enhance outcomes for patients with large vessel occlusion (LVO). Although advancements in AI have shown promise in enhancing diagnostic accuracy, several studies have reported very low sensitivities when including MCA-M2 occlusions, resulting in unbalanced performance across different LVO segments. Therefore, continuous retraining and evaluation of these evolving technologies in clinical settings are essential. This study aims to analyze the real-world performance of the latest version of an FDA-approved and CE-marked AI software for LVO detection in computed tomography angiograms (CTAs), specifically designed to provide balanced performance across all LVO segments.

Methods:
This retrospective, multicenter, multinational, and blinded study analyzed anonymized CTA scans from 7 clinical sources across Europe and the USA, acquired using 40 scan models from 5 different CT vendors. The improved version of CINA-LVO (Avicenna.AI, La Ciotat, France) uses deep learning to accurately detect ICA, MCA-M1 and proximal MCA-M2 without impairment, specifically with MCA-M2 segments. Its diagnostic performance was assessed against the ground truth, which was determined through the consensus of three US board-certified senior neuroradiologists who analyzed each LVO segment.

Results:
A total of 557 scans (mean age 66.2 ± 20.5 [SD] years old, 50.3% female, 49.0% positive for LVO) were included. Overall sensitivity and specificity including M2 occlusions (all 557 cases) were 93.8% (95%CI: 90.2%-96.3%) and 91.2% (95%CI: 87.3%-94.2%), respectively. The PPV and NPV were 91.1% and 93.8%, respectively (see Table 1). Moreover, the detection accuracy for LVO exceeded 90% across all LVO segments, including the proximal and distal internal carotid artery and the M1 and proximal M2 segments of the middle cerebral artery (see Table 2). There were no statistically significant differences between the accuracy of each LVO segment (p-value>0.05).

Conclusions:
Unlike previous studies, our results demonstrate balanced performance across all LVO segments, with no impairment in diagnostic accuracy from the inclusion of M2 occlusions in the analysis. These promising findings suggest that the integration of continuously improved AI tools into clinical practice could substantially enhance clinical workflow and diagnostic accuracy for patients with LVO.
Abstract TP174: Prolonged Venous Transit Independently Predicts Worse Functional Outcomes at Discharge in Successfully Reperfused Patients with Large Vessel Occlusion Stroke
Authors: Mei Janet , Alizada Sahar , Salim Hamza , Lakhani Dhairya , Balar Aneri , Musmar Basel , Abushehab Nimer , Dmytriw Adam , HOSEINYAZDI MEISAM , Luna Licia , Deng Francis , Vagal Vaibhav , Hyson Nathan , Guenego Adrien , Faizy Tobias , Heit Jeremy , Albers Gregory , Lu Hanzhang , Urrutia Victor , Nael Kambiz , Marsh Elisabeth , Hillis Argye , Llinas Rafael , Wintermark Max , Yedavalli Vivek
Published: January 2025

Background and Purpose:
Venous outflow (VO) impairment predicts unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). Prolonged venous transit (PVT), a visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps, has been associated with 90-day mortality despite successful reperfusion. This study investigates the association between PVT and modified Rankin Scale (mRS) score at discharge among AIS-LVO patients who have undergone successful reperfusion.

Methods:
We performed a retrospective analysis of prospectively collected data from consecutive adult AIS-LVO patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10s in at least one of the following locations: superior sagittal sinus and/or torcula. The primary outcome was dichotomous mRS scores at discharge (favorable: mRS 0-2; unfavorable: mRS 3-6). Regression analyses were performed to assess the effect of PVT on discharge mRS.

Results:
In 119 patients of median (IQR) age 71 (63-81) years, a significantly higher proportion of PVT+ patients exhibited unfavorable mRS scores compared to PVT- patients (88.8% vs. 62.7%, p=0.004). After adjusting for age, sex, hypertension, hyperlipidemia, diabetes, atrial fibrillation, history of stroke or transient ischemic attack (TIA), tobacco use, administration of intravenous thrombolysis (IVT), admission National Institutes of Health Stroke Scale (NIHSS), Alberta Stroke Program Early CT (ASPECTS) score, and ischemic core volume, the PVT+ remains significantly associated with unfavorable mRS (OR=0.215, 95%CI 0.048-0.959, p=0.044).

Conclusions:
PVT+ was significantly associated with unfavorable mRS at discharge despite successful reperfusion in AIS-LVO patients, underscoring the importance of VO impairment in short-term functional outcomes. PVT serves as a valuable adjunct imaging biomarker derived from CTP for assessing VO profiles in AIS-LVO.
Abstract TP184: MRI Assessment of Blood-Brain Barrier Disruption is Highest in the Penumbral Region of Vascular White Matter Lesions
Authors: Sasannia Sarvin , Knutsson Linda , Matsyuk Mykola , Wang Shimeng , Wang Jinwei , Shin Hyeong-Geol , Prince Jerry , Leigh Richard , van Zijl Peter , Nyquist Paul
Published: January 2025

Introduction:
Disruption of the blood-brain barrier (BBB) is thought occur during the ischemic injury that leads to the formation and progression of vascular white matter hyperintensities (WMH). In this study, we estimated BBB disruption using dynamic contrast-enhanced MRI (DCE-MRI) in human subjects at risk for cardiovascular disease. The volume transfer constant, K
trans
, an indicator of BBB permeability and flow, was estimated in four regions of interest (ROI) surrounding ischemic white matter hyperintensities (WMH) to estimate where the BBB disruption was highest and ongoing ischemic injury was more likely to occur. The ROI consisted of WMH lesions, penumbra (4 voxels beyond the WMH), surrounding normal-appearing white matter (NAWM), and grey matter (GM).

Hypothesis:
Since previous studies have suggested that the penumbra of WMH may be a site of active pathology, our hypothesis was that K
trans
would be larger there.

Methods:
We included 112 volunteers from the GeneSTAR study, an ongoing family-based study of people at risk for cardiovascular disease, age = 63.1 ± 9.6 years, 60.71% females. Anatomical and functional images, including DCE-MRI, were obtained using a 3T MRI. K
trans
was calculated by applying the Patlak model (Nordic ICE
(TM)
). Whole brain segmentation masks, retrieved from the anatomical images, including WMH, the penumbra, NAWM and GM were applied on the K
trans
maps. Mean K
trans
was thereafter calculated for each ROI by first excluding the values below 2SD of the mean K
trans
in NAWM.

Result:
K
trans
(mean±SD) for each ROI is shown in Table 1. Notice that the penumbra had the highest average K
trans
(2.63 ± 0.26) while K
trans
was 2.42 ± 0.23, in WMH, 1.20 ± 0.23, in NAWM, and 1.97 ± 0.21 in NAWM (Table 1). The Wilcoxon signed-rank test shows a statistically significant difference between the K
trans
values in the WMH lesions and the penumbra (p = 0.002).

Conclusion:
Quantitative 3T DCE-MRI analysis revealed that the penumbra surrounding the leading edge of the WMH had the highest estimate of K
trans
which may reveal a higher BBB permeability. This pattern suggests the penumbra, on the edge of the WMH, had the highest ongoing ischemic activity and may be an area of interest for targeted intervention to prevent WMH expansion.
Abstract TP199: Impact of Statin Therapy on Functional Outcomes and Survival in Intracerebral and Subarachnoid Hemorrhage
Authors: Srichawla Bahadar , Gopal Daksha , Moonis Majaz
Published: January 2025

Introduction:
Intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) are severe forms of stroke with high morbidity and mortality rates. HMG-CoA reductase inhibitors commonly referred to as statins, known for their lipid-lowering abilities, also possess pleiotropic properties, including anti-inflammatory and neuroprotective effects, which may improve outcomes in hemorrhagic stroke. However, their role in ICH and SAH remains under-investigated, particularly regarding functional outcomes and survival. We aim to evaluate the impact of statin therapy on functional outcomes and survival in patients with ICH and SAH.

Methods:
This retrospective cohort study analyzed data from the American Heart Association (AHA) Get With The Guidelines (GWTG) stroke registry at a tertiary care center, including patients diagnosed with ICH or SAH between January 2008 and June 2023. Patients were categorized based on prior initiation of statin therapy: no statin, low-intensity statin, or high-intensity statin. The primary outcome was the modified Rankin Scale (mRS) score at discharge, dichotomized to good (0-2) and poor (3-6) outcomes. Due to a small sample size only mortality was assessed in the SAH group. A multivariate logistic regression model controlled for age, gender, and admission National Institutes of Health Stroke Scale (NIHSS) score.

Results:
A total of 663 patients with ICH and 159 patients with SAH were included in the analysis. In ICH patients, low-intensity statin therapy was associated with significantly higher odds of a good functional outcome (
aOR 2.557, 95% CI 1.247-5.246, p = 0.0104
), as was high-intensity statin therapy (
aOR 2.445, 95% CI 1.313-4.552, p = 0.0048
). Among SAH patients, all 39 deaths occurred in the no statin therapy group. Therefore, statin therapy was significantly associated with survival in patients with SAH.

Conclusions:
Statin therapy, particularly at high intensity, is associated with improved functional outcomes in ICH and may offer a survival benefit in SAH. These findings highlight the potential neuroprotective role of statins in hemorrhagic stroke. Further prospective studies and randomized controlled trials are needed to confirm these observations and to clarify the optimal use of statins in this patient population.
Abstract TP2: Association between Statin therapy for preventing recurrent stroke in patients with ischemic stroke: A Meta-analysis of randomized controlled trials.
Authors: Jaiswal Vikash , Hanif Muhammad , Zomkowska Edyta , Jaiswal Akash
Published: January 2025

Background:
Statins are effective in reducing the morbidity and mortality associated with atherosclerotic cardiovascular disease. It has shown to reduce the risk of stroke and is cardioprotective in nature. However, statin might elevate the risk of hemorrhagic stroke and hence it's critically important to evaluate its efficacy and safety among stroke patients.

Objective:
This study aims to investigate the association of statin based therapies with outcomes for patients with stroke.

Methods:
We performed a systematic literature search on PubMed, EMBASE, and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) from inspection until August 10th, 2024, without any language restrictions. Odds ratios (OR) and 95% confidence intervals (CI) were pooled using a random-effect model, and a p-value of <0.05 was considered statistically significant.

Results:
A total of 9 randomized controlled trials with 10, 850 patients (5403 patients in the statin group, and 5447 patients in the placebo group) were included in the analysis. Mean age of patients was 65 years and mean follow up duration was 3.6 years.

Pooled analysis of primary outcomes showed that statin group of patients were having lower odds of recurrent stroke (OR, 0.68(95%CI: 0.47-0.98), P=0.04), ischemic stroke (OR, 0.83(95%CI: 0.72-0.95), P=0.01), major adverse cardiovascular events (OR, 0.83(95%CI: 0.75-0.92), P<0.001), and myocardial infarction (OR, 0.67(95%CI: 0.51-0.88), P<0.001). However, the risk of all-cause mortality (OR, 1.05(95%CI: 0.88-1.25), P=0.63), and hemorrhagic stroke (OR, 1.03(95%CI: 0.71-1.51), P=0.87) was comparable between both group of patients.

Conclusion:
This study findings suggest that statins significantly reduced the risk of recurrent stroke, ischemic stroke, and MACE. However, the risk of hemorrhagic stroke was comparable between both groups of patients.
Abstract TP202: Racial, Ethnic and Age- Related Differences in Spontaneous Intracerebral Hemorrhage – A North Texas Referral Comprehensive Stroke Center Experience
Authors: Ray Debarti , McAlpine Candace , Graybeal Dion , Rasmussen-Winkler Jennifer
Published: January 2025

Introduction:
Early interventions limit morbidity and mortality in ICH patients. Recognizing epidemiological risk factors in local communities helps target specific populations through community education and implement appropriate healthcare delivery measures. We investigated ICH patients presenting and referred to a large “hub and spoke” model comprehensive stroke center in North Texas.

Methods:
Patients admitted directly to the “hub” hospital (via emergency medical services, EMS or private transportation, PT) and transferred from a “spoke” hospital (ST) were investigated. Door-in-door-out (DIDO) time was used to estimate delay at the referring hospital. ICH score estimated disease severity and modified Rankin score (mRS) at discharge defined patient outcome. Comparison between race/ethnicity [i.e., non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanics (HP)] and mode of presentation [i.e., EMS, PT, ST] were performed using Chi-square test and one-way ANOVA.

Results:
Of the 448 ICH patients admitted over 2.5 years, 170 (37.9%) were NHW, 146 (32.6%) were NHB, and 106 (23.7%) were HP. HP patients were younger compared to other racial cohorts [NHW vs. NHB vs. HP – 69.5 (IQR, 58.5, 79.0) vs. 58.0 (50.5, 67.5) vs. 56.0 (47.0, 67.0), p<0.0001] and had longer length of stay (LOS) [NHW vs. NHB vs. HP – 6 (3, 12) vs. 8 (4.5, 16) vs. 10 (6, 23), p<0.0001] despite similar admission severity, outcome and in-hospital mortality. Two hundred and sixteen patients (48.2%) presented to the hub hospital via EMS and 51 (11.3%) via PT compared to 141 (31.7%) transfer-ins from spoke hospitals. Median DIDO at the spoke hospital was 146 min (107, 226). Patients presenting to hub hospital had higher ICH scores [HT vs PT vs ST – 2 (1,3) vs. 0 (0,1) vs. 1 (0,2), p<0.0001] and had longer LOS [HT vs. PT vs. ST – 10 (6, 21.5) vs 6 (3, 9) vs 7 (3, 4.5), p<0.0001] and higher discharge mRS [HT vs PT vs ST – 4 (4, 6) vs 3 (2, 4) vs 4 (4, 12.5), p<0.0001].

Conclusion:
Our regional cohort identifies an early age for ICH occurrence in the HP population. Patients with higher ICH scores presenting directly to the hub hospital could explain increased LOS and adverse clinical outcomes in this sub-cohort. More extensive registry-based or prospective studies are needed to validate these findings.
Abstract TP209: Improving Neuroimaging Data Processing in Clinical Trials Through Automated Cloud-based Analysis
Authors: Walborn Nathan , Senevirathne Kaneel , Mould Andrew , Ryu Paul , Al Khafaji Ahmed , Paresh Trivedi Pranshu , Iacobelli Michael , Holthouse Elizabeth , Hanley Daniel
Published: January 2025

Introduction:
Data sharing and analyses of neuroimaging data can be time-consuming and often represent a rate-limiting factor in clinical trial research. This workflow, which involves downloading imaging data from a clinical trial’s electronic data capture (EDC) system, performing biomarker analyses, and then re-entering data into the EDC, can be cumbersome when performed manually. Integrating the EDC’s application programming interface (API) with cloud-computing processes can significantly reduce the time required for these tasks. The objectives of this study aimed to evaluate whether an automated workflow using cloud computing can reduce the processing time while maintaining accuracy for biomarker evaluation compared to manual methods.

Methods:
We compared the time required for manual imaging data downloads, biomarker analyses, and data entry into a clinical trial’s EDC with that required for the same processes using an automated method. Additionally, we assessed the accuracy of automated biomarker analyses relative to semi-automated analyses performed manually by an expert reader, specifically focusing on the volumetric quantification of intracerebral hemorrhage (ICH).

Results:
The manual process, involving downloading, de-identification, and semi-automated volumetric quantification of ICH, took an average of 12 hours and 57 minutes per CT uploaded to the EDC. Cloud computing completed the same tasks in an average of 8 minutes and 13 seconds. The cloud-based biomarker analysis demonstrated high accuracy, with an average ICH volume difference of -1.29mL (n=214; p=0.0001) compared to the semi-automated method.

Conclusion:
In conclusion, the integration of the EDC’s API with cloud-computing processes for imaging ingestion and analysis reduces processing time of neuroimaging data in clinical trials. Additionally, the automated workflow maintained a high level of accuracy in the volumetric quantification of ICH. Although it may take a human reader 30 minutes to process neuroimaging data, limitations can delay these tasks. Multiple scans could be uploaded at once, delaying the time it takes a reader to analyze the images. Imaging data could be uploaded after workhours or on the weekend, postponing the analyses until the next working day. Yet, the automated cloud-based workflow drastically reduces processing time and ensures high accuracy of ICH volumetric calculations, offering a more efficient alternative to traditional manual methods.
Abstract TP223: Association of Estimated Pulse Wave Velocity on Endovascular Treatment Outcome: A Secondary Analysis of the OPTIMAL-BP trial
Authors: Han Minho , Joo Haram , Lee Hyungwoo , Heo JoonNyung , Jung Jae Wook , Kim Young Dae , Park Eunjeong , Nam Hyo Suk
Published: January 2025

Introduction:
The link between arterial stiffness, measured by estimated pulse wave velocity (ePWV), and outcomes following endovascular treatment (EVT) is unclear.

Hypothesis:
This study aimed to determine whether ePWV predicts post-EVT outcome in patients with acute ischemic stroke.

Methods:
This study was a secondary analysis of the OPTIMAL-BP trial, which enrolled 302 EVT patients from 19 stroke centers in Korea between June 18, 2020 and November 28, 2022. The ePWV was calculated using a regression equation based on age and mean blood pressure at trial enrollment. The primary outcome was functional independence at 3 months, defined as a modified Rankin Scale (mRS) score of 0-2. Logistic, ordinal, or linear regression analyses were employed to estimate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for outcomes per 1 m/s or quartile ePWV increase.

Results:
Among 302 patients (mean age 73.1±11.5 years, 59.6% male), higher ePWV was independently associated with a lower likelihood of functional independence at 3 months (OR 0.799, 95% CI 0.676–0.944 per 1 m/s increase; OR 0.358, 95% CI 0.135–0.947 for the fourth quartile), higher mRS scores (OR 1.220, 95% CI 1.071–1.390 per 1 m/s increase; OR 2.406, 95% CI 1.102–5.254 for the fourth quartile), and lower EQ-5D-3L scores (OR -0.057, 95% CI -0.084 to -0.030 per 1 m/s increase). Incorporating ePWV significantly improved prognostic model performance, with net reclassification improvement (NRI) of 0.279 (95% CI 0.056–0.503) and integrated discrimination improvement (IDI) of 0.019 (95% CI 0.003–0.036) per 1 m/s increase, and NRI of 0.270 (95% CI 0.070–0.470) and IDI of 0.014 (95% CI 0.001–0.027) per quartile increase, respectively.

Conclusions:
ePWV independently predicts functional independence after EVT, suggesting its potential as a practical prognostic tool using age and baseline blood pressure.
Abstract TP248: Factors associated with Silent Brain Infarcts after the Middle Cerebral Artery Stenting or Balloon Angioplasty
Authors: Lee Kyubong , Kim Bum Joon
Published: January 2025

Objective:
Silent brain infarctions (SBIs), which appear as dot-like lesions on diffusion-weighted imaging (DWI) after endovascular procedures, are associated with an increased risk of subsequent stroke, dementia and cognitive decline. Efforts to reduce SBIs are needed. The objective of our study is to identify factors associated with SBIs following middle cerebral artery (MCA) stenting or balloon angioplasty.

Methods:
We retrospectively reviewed patients who underwent MCA stenting or balloon angioplasty, including those with symptomatic, atherosclerotic MCA stenosis of ≥ 50%. DWI was performed before and after the procedure, and newly appeared DWI lesions were regarded as SBIs. We compared variables between patients with and without SBIs and investigated the factors associated with the occurrence of SBIs. Additionally, among those with SBIs, we further analyzed the differences based on lesion location (cortex only vs. involving perforator territory).

Results:
Among 107 patients, 60 (56.1%) exhibited SBIs post-procedure. Factors significantly associated with SBIs included smaller diameter (OR [95% CI] = 0.03[0.003-0.42], p=0.008), and longer stenosis (1.24[1.03-1.50], p=0.024), higher MCA tortuosity (1.25[1.12-1.39], p<0.001), and diffuse involvement of MCA stenosis (4.55[1.40-14.74], p=0.012). Among the patients who exhibited SBIs, 41 (68.3%) had SBIs confined to the cortex, while 19 (31.7%) had SBIs involving the perforator territory. Longer pre-stent balloon length was significantly associated with perforator SBIs (13.5±2.5 for cortical SBIs only vs. 15.3±2.2 for perforator SBIs, p=0.016).

Conclusion:
Stenosis diameter, length, and MCA tortuosity are significant factors for SBIs following MCA stenting. Additionally, the factors associated with SBIs vary depending on the lesion location.
Abstract TP257: Comparing Study Designs and Statistical Methods in Mechanical Thrombectomy Trials in Ischemic Stroke: A Systematic Review
Authors: Gulati Akanksha , Griffin Kim , Perez Malagon Carlos David , Gulati Yudhister , Bharti Anandita , Harnegie Mary Pat , Cho Sung-Min , Uchino Ken
Published: January 2025

Background:
Clinical trial designs have evolved due to changes in therapies, populations, and statistical methods.

Objective:
We aimed to analyze the designs of acute endovascular therapy trials in ischemic stroke over time, and how mechanical thrombectomy has evolved, particularly in patient selection and statistical methods.

Methods:
A systematic search was conducted in PubMed, EMBASE, Cochrane, CINAHL, and SCOPUS for phase 3 or 4 randomized clinical trials of endovascular reperfusion therapy for acute ischemic stroke. Trials with functional outcomes measured at 3 months were included. Data extracted included year of publication, estimated and actual sample sizes, observed outcomes, and statistical methods used. The studies were classified in 3 periods by publication date: Period 1: before 2015, pre-stent retriever; Period 2: 2015-2019, early thrombectomy era; and Period 3: 2020-2024, recent period.

Results:
Of 2693 references, 21 trials met inclusion criteria, 3 in Period 1, 10 in Period 2, 8 in Period 3. Median sample sizes were 150 in Period 1, 206 in Period 2, and 300 in Period 3. Dichotomized Rankin were primary outcomes in 100% in Period 1, 80% in Period 2, and 60% in Period 3, with remainder analyzed by Rankin shift or proportional odds. Early termination occurred in 0% in Period 1, 40% in Period 2, and 0% in Period 3. 7 studies met or almost met their estimated sample size.14 studies did not meet their estimated sample size, due to early terminations (for efficacy or futility), slow recruitment, or positive findings from other trials

Conclusion:
The trials published during the 2015–2019 period had early terminations and positive results for thrombectomy. More recent trials have larger sample sizes and more commonly used methods to analyze the full range of Rankin categories, such as mRS shift or proportional odds models. This might reflect a shift toward capturing more nuanced outcomes in stroke populations.
Abstract TP258: The Rapid Occluded Vessel Etiology Score: A Novel Algorithm to Identify Acute Atherosclerotic Large Vessel Occlusions of the Middle Cerebral Artery
Authors: Fana Michael , Choudhury Omar , Chebl Alex , Latack Katie , Schultz Lonni , Albanna Abdalla , Reardon Taylor , Iqbal Zahid , Kole max , Marin Horia
Published: January 2025

Introduction:
Mechanical thrombectomy (MT) devices were fundamentally designed for the treatment of cardioembolic (CE) strokes despite that 10-20% of large vessel occlusions (LVO) are caused by large artery atherosclerosis (LAA), which may not respond comparably. Therefore, the differentiation between LAA and non-LAA LVO may be critical for selecting the ideal MT technique. Here, we construct an algorithm for use in the emergent setting pre-operatively to differentiate between LAA and non-LAA LVO using clinical and radiographic features.

Methods:
Using our prospectively collected stroke database we identified all middle cerebral artery (MCA) occlusions treated with MT with confirmed etiology as either LAA or non-LAA (CE, cryptogenic) according to TOAST criteria. Stroke risk factors and CT angiography (CTA) of the head and neck features were compared between LAA and non-LAA etiologies in a univariate analysis. An algorithm was then constructed using these variables in a multivariable logistic regression with corresponding score estimates for each variable to assess how well the model distinguished between LAA and non-LAA groups. The sensitivity and specificity were computed for each sum score to identify the ideal cut-off point for differentiating LAA from non-LAA LVOs.

Results:
Final analysis included 33 LAA, 207 CE, and 120 cryptogenic strokes. Patients presenting with LAA LVOs were significantly less likely to have atrial fibrillation (9.1% vs 53.8%;
p<0.0001
), EF
<
35% (9.1% vs 27.8%;
p=0.0208
) and more likely to present with progressive or fluctuating symptoms (21.2% vs 4.6%;
p=0.0018
), intracranial multi-vessel atherosclerotic disease on CTA (84.8% vs 37%;
p<0.0001
), tapered appearance of occlusion with associated collaterals (60.6% vs 0.9%;
p<0.0001
), and ICA bulb plaque with high-risk features (87.9% vs 37.6%;
p<0.0001
) (Table 1). The AUC was 0.9650 (95% CI=0.9332, 0.9968) and the highest combination of sensitivity and specificity (97% and 88%, respectively) was associated with a cut-off score of 9 (Tables 2 and 3).

Conclusion:
Our scoring system reliably differentiates between non-LAA and LAA LVO with high sensitivity and specificity based on 6 clinical and radiographic features. This will need to be validated with an external patient dataset and then in a prospective study.
Abstract TP263: Blood pressure trends during first forty-eight hours post arterial ischemic stroke in children with arteriopathy disease
Authors: Quesnel Elya , Guerguerian Anne-Marie , Chin Norbert , Linds Alexandra , Sheng Min , Pulcine Elizabeth , Moharir Mahendranath , deVeber Gabrielle , Dlamini Nomazulu
Published: January 2025

Introduction:
Children with arteriopathy are at an increased risk to develop ischemic stroke that can lead to lifelong neurological deficits. Blood pressure is an important modifiable factor associated with poor neurological outcomes. However, there is a lack of sufficient evidence to provide patient specific blood pressure guidelines post pediatric ischemic stroke.

Objective:
We aimed to evaluate blood pressure averages and changes in pediatric patients with arteriopathy within the first 48 hours in intensive care after an arterial ischemic stroke.

Method:
We conducted a retrospective study of children diagnosed with acute arterial ischemic stroke admitted to the pediatric intensive care unit (PICU). We reviewed data on demographics, clinical outcome, radiologic, hemodynamic signs, and medication within PICU. Ischemic lesion volume size was obtained from Diffusion-Weighted Imaging by a full-trained neuroradiologist. Blood pressure percentile was obtained based on age, sex, and the 50
th
height rang. We also contrasted blood pressures of stroke patients with age and admission year matched controls without a history of stroke. We used linear regression to model blood pressure trends, t-test to compare continuous data, and chi square analyses to compare discrete data points.

Results:
Forty-five patients (49% female, median age 7.8 years, range age 17 years) were included. Arteriopathy disease included Dissection, Moyamoya, Focal Cerebral Arteriopathy and Vasculitis. Despite only a minority of patients being on vasoactive medications, patients with arteriopathy had higher blood pressures compared to age-matched control PICU patients in the first 48 hours. In addition, 31% of arteriopathy patients had an average systolic blood pressure greater than the 95
th
percentile for the first two days after an acute arterial ischemic stroke, versus only 14% of their control (p-value < 0.05). Neurological deficits and increased brain ischemic lesion volume were associated with higher blood pressures.

Conclusion:
Understanding blood pressure trends and outcomes after an ischemic stroke in children at risk is crucial to guide the management of this modifiable factor. Blood pressure in children with arteriopathy is increased after an ischemic stroke compared to controls admitted to PICU. Further research into the etiology of differences observed here and blood pressure management is crucial to reducing the burden of pediatric ischemic stroke on this at risk population.
Abstract TP274: The Changes in Long-term Disease Burden Associated with the Progression from Asymptomatic to Symptomatic Intracranial Stenosis: A Hospital-Based Cohort Study
Authors: Liu Yiyang , Ding Manqiu , Zou Yinxi , Zhou Huanyu , Zhang Zongmuyu , Li Shun , Hu Yinghuan , Dai Yuexuan , Li Xin , Gao Shan , Zhang Yuelun , Liu Caiyan , Xu Yan , Xu Wei-hai
Published: January 2025

Background:
Intracranial artery stenosis (ICAS) is a progressive pathological process. No study has focused on changes in long-term disease burden associated with the progression from asymptomatic to symptomatic ICAS stages, which inform future preventive strategies and health management.

Methods:
We performed an ambispective cohort study that included consecutive patients with 50% or greater ICAS diagnosed by transcranial Doppler from January 2016 to May 2022. All patients received follow-ups through August 2023. The primary outcomes were ischemic stroke, all-cause mortality, and global cognitive decline.

Results:
Of 1872 eligible patients, 1628 (87.0%) were interviewed (1004 [61.7%] with asymptomatic ICAS; 624 [38.3%] with symptomatic ICAS). The mean age of the patients was 62.4±13.3 years. During a median follow-up of 3.7 years (IQR, 2.4-5.2), 60 (6.0%) patients with asymptomatic ICAS had a first-ever ischemic stroke, 63 (6.3%) died, and 7.6% had self-reported cognitive decline (global Everyday Cognition scale ≥ 2). During a median follow-up of 3.8 years (IQR, 2.2–5.4), 98 (15.7%) patients with symptomatic ICAS had recurrent ischemic stroke, 93 (14.9%) died, and 18.2% had self-reported cognitive decline. The cumulative incidence of ischemic stroke and all-cause mortality by five years were 7.5% (95% CI, 5.4%-9.6%) and 7.7% (95% CI, 5.5%-9.9%) among patients with asymptomatic ICAS, while those in patients with symptomatic ICAS were 18.2% (95% CI, 14.7%-21.8%) and 17.9% (95% CI, 14.0%-21.8%), respectively. Symptomatic ICAS conveyed an increased hazard of ischemic stroke (adjusted HR 2.54, 95% CI 1.82–3.54; P < 0.001) and all-cause mortality (adjusted HR 2.27, 95% CI 1.63-3.16; P < 0.001) compared with asymptomatic ICAS. In multivariable analysis, only hypertension independently predicted stroke occurrence in the asymptomatic ICAS group (adjusted HR 4.06, 95%CI 1.60-10.33, P = 0.003).

Conclusions:
The long-term disease burden increases 2-3-fold when asymptomatic ICAS progresses to symptomatic ICAS. Our study underscores the necessity of intensive management, particularly blood pressure control, for primary stroke prevention in patients with asymptomatic ICAS.
Abstract TP276: Impact of Educational Attainment and Social Support on Stroke Recurrence in a South Texas Community
Authors: Lee Sung Jin , Morgenstern Lewis , Stamm Brian , Royan Regina , Chhabra Nikita , Zhang Guanghao , Kwicklis Madeline , CASE Erin , Lisabeth Lynda , Becker Christopher
Published: January 2025

Background:
Lower educational attainment (EA) and smaller social network are each associated with a greater risk for incident stroke. However, the relationship between EA, social support (SS), and recurrent stroke is less clear.

Objectives:
To evaluate the association of EA and SS with stroke recurrence. We also assessed whether SS modifies the effect of EA on recurrence. We hypothesize that EA and SS each protect against recurrence and additively interact to further decrease risk.

Methods:
Within the Brain Attack Surveillance in Corpus Christi (BASIC) project, we identified patients, age >45, with first-ever ischemic or hemorrhagic strokes from 2008-2019. Structured interviews were conducted to collect levels of EA (<, =, or > high school) and SS. Pre-stroke SS was measured by a 7-item scale (0-14, higher=more support). Multiple imputation was used for missing data on exposures and covariates. Complete case analysis was additionally performed. Kaplan-Meier (KM) curves for recurrence-free survival were plotted by EA level and SS quartile. Multivariate Cox models assessed the association of SS and EA with recurrence after adjustment for multiple covariates.

Results:
Of 1,959 patients with incident stroke between 2008-2019, 305 had a recurrent stroke. In unadjusted KM analyses, higher EA was non-significantly associated with lower recurrence (p=0.10; Figure 1A), and SS was not associated with recurrence (Figure 1B). In both unadjusted and fully adjusted Cox models, neither EA, SS, nor the interaction of SS on EA were significantly associated with recurrence. In fully adjusted models, Mexican-American ethnicity, diabetes, and high cholesterol were associated with higher recurrence. Female sex (HR 0.66, 95% CI 0.50-0.87) and marriage (HR 0.74, 95% CI 0.56-0.97) were associated with lower recurrence risk. Complete case analysis yielded no substantive difference in results.

Conclusions:
Though we observed a trend toward reduced recurrence risk among patients with higher EA in unadjusted KM analysis, no association emerged between EA or SS after adjustment for covariates. We did observe associations between both female sex and marriage with reduced recurrence risk.
Abstract TP277: Hispanic Ethnicity and Diabetes are Associated with High On-Treatment Platelet Reactivity
Authors: Izaguirre Simon , Belits Anna , Pirahanchi Yasaman , Kim Diana , Salottolo Kristin , Bar-Or David , Burrell Christian
Published: January 2025

Introduction:
Clopidogrel (Plavix) is an antiplatelet medication that requires conversion to an active drug through metabolic pathways in the liver using the CYP2C19 enzyme. The objective of this study is to assess the prevalence rate of high on-treatment platelet reactivity (HTPR, poor metabolizers) and evaluate rates of HTPR by principal diagnosis, demographics, and clinical characteristics.

Methods:
This retrospective observational cohort study included 586 patients admitted to a comprehensive stroke center in the USA from 1/1/2022 – 1/1/2024 with a P2Y12 enzyme activity assay. Patients were excluded from the analysis if they were non-compliant on-treatment (n=3) or were clopidogrel naïve and did not receive a timely loading dose > 6 hours before the assay or 3 daily standard doses prior to the assay (n=211). Platelet inhibition assay results were expressed as P2Y12 platelet reaction units (PRUs); >194 PRUs were considered HTPR (poor metabolizers), while <194 PRUs were adequate metabolizers. Chi-square tests were used to compare HTPR by principal diagnosis, demographics (age, sex, race, comorbidities), laboratory findings, and AIS stroke subtype (TOAST classification).

Results:
The analysis population included 372 (63%) patients; most patients (n=284, 76%) were chronic clopidogrel users while 88 patients received therapeutic clopidogrel in-hospital. The most common principal diagnoses were cerebral aneurysm (42%) and AIS (32%). HTPR was identified in 50 patients (13%), Table 1. Compared to adequate responders, patients with HTPR were more likely to be Hispanic (10% vs. 2%, p=0.01), to have diabetes (34% vs. 16%, p<0.001), to have elevated alanine transaminase (ALT; 39% vs. 17%, p=0.01), and less likely to be on dual antiplatelet therapy (46% vs. 69%, p=0.01); there were no differences in age, sex, other examined comorbidities, and other abnormal lab findings (A1C, CRP, AST), or by principal diagnosis, p=0.08. Diabetes was more common in Hispanic patients; however, diabetes was significantly associated with HTPR independent of ethnicity. In the subset of patients with AIS (n=119), similar trends were identified.

Conclusion:
Providers should be aware that patients with diabetes and those of Hispanic ethnicity are at higher risk for HTPR. These findings support greater use of personalized medicine, especially when prescribing medications with known discrepant activity.