bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 1122‐000096: Transradial Results in Faster Recanalization in Left Anterior Circulation Stroke and Bovine Arch
Authors: Moreno Jorge H , Maud Alberto , Faheem Sheriff , Chaudry Mohammad Rauf A , Gupta Vikas , Khatri Rakesh , Rodriguez Gustavo J
Published: December 2021

Introduction
: We compared technical and clinical outcomes of transradial (TRA) versus transfemoral (TFA) access for mechanical thrombectomy (MT) of acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the left anterior cerebral circulation of bovine origin.

Methods
: A single‐center retrospective review of a prospectively maintained neuro‐interventional database from a large volume service in a tertiary academic center. Procedural metrics, technical, and clinical outcomes data were collected and analyzed for patients who underwent MT presenting with AIS and LVO in the left anterior circulation of bovine origin. Primary outcomes included the average number of passes, single first effective pass, rate of successful recanalization (thrombolysis in cerebral infarction (TICI) score ≥ 2b), 3‐month disability modified Rankin Scale (mRS) score ≤2, time from skin puncture to microcatheter placement and recanalization.

Results
: Between January 2018 and January 2021, 26 patients (TRA = 13, TFA = 13) underwent MT. The TRA cohort had a significantly shorter time in minutes for skin puncture to microcatheter placement (TRA: 17.0± 5.8 vs TFA: 35.4± 20.5, P = 0.0001), shorter skin puncture to recanalization (TRA: 34.0± 15.6 vs TFA: 58.1± 34.6, P = 0.01), and shorter total fluoroscopy time (TRA: 13.8±9.4 vs TFA: 29.5±18.0, P = 0.03). The 3‐month mRS score of 0–1 was higher in the TRA group (38.5% vs 7.69%, P = 0.06).

Conclusions
: In patients with LVO in the left anterior cerebral circulation of bovine origin, right TRA access permits more direct navigation and provides a stable platform resulting in shorter procedure times and faster recanalization with the potential to improve functional outcomes.
Abstract 1122‐000097: Recurrent Carotid Cavernous Fistula Requiring Complex Repair of Ruptured Cavernous Carotid Aneurysm: A Case Report
Authors: Morsi Rami Z. , Ammar Faten El , Thind Sonam , Mendelson Scott J. , McKoy Cedric , Coleman Elisheva , Brorson James R. , Prabhakaran Shyam , Mansour Ali , Kass‐Hout Tareq
Published: December 2021

Introduction
: There are no studies investigating the safety and efficacy of covered stent grafts, particularly the newly developed stents such as the PK Papyrus stent, for endovascular treatment of direct carotid cavernous fistulas (CCFs).

Methods
: We present a case of a 75‐year‐old female who presented to the hospital with a three‐week history of worsening left eye vision, chemosis, proptosis, and partial third nerve palsy. Patient was found to have left direct Type A CCF secondary to ruptured cavernous segment carotid aneurysm.

Results
: The CCF was treated with coil embolization and pipeline Shield stent embolization devices with immediate stagnation and improvement of symptoms. Patient had history of an aortic mechanical valve and thus was started on warfarin and ASA. After achieving INR level of 2.5‐3.5, patient started to have recurrent swelling of the left eye associated and decreased visual acuity. Repeated diagnostic cerebral angiogram revealed residual CCF. Onyx liquid embolization and a Surpass Evolve Flow Diverter were attempted to slow the fistulization with no success. Multiple attempts for direct percutaneous superior ophthalmic vein cannulation were also unsuccessful. At this point, two coronary graft‐covered PK Papyrus stents were implanted across the fistula pouch, which resulted in immediate resolution of the CCF with evidence of persistent normal flow within left ophthalmic artery. Patient’s visual acuity and left eye movement improved.

Conclusions
: This case report highlights the effectiveness and safety of covered stent grafts, particularly more flexible stents such as the PK Papyrus stent, in navigating the carotid vasculature and closing direct CCFs and may be used as a first‐line technique. More large‐scale studies are warranted to investigate the safety and efficacy of using such stent grafts to treat direct CCFs in the setting of antithrombotic agents and anticoagulation.
Abstract 1122‐000105: Does Persistence in Reperfusion Pay Off?
Authors: Hassan Ameer E , Fifi Johanna T , Zaidat Osama O
Published: December 2021

Introduction
: Reperfusion with mechanical thrombectomy improves outcomes in patients with Large Vessel Occlusion Acute Ischemic Stroke (LVO‐AIS). The technical goal of thrombectomy is reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b. Here we investigate if procedures requiring multiple passes to achieve complete reperfusion (MP mTICI 3) result in better outcomes compared to procedures stopped after achieving mTICI 2b‐2c on the first pass (FP mTICI 2b‐2c).

Methods
: Using data from the COMPLETE registry (a global prospective study of LVO‐AIS patients who underwent mechanical thrombectomy using the Penumbra System), we grouped patients into MP mTICI 3 and FP mTICI 2b‐2c. Functional independence (mRS 0–2) at 90 days, all‐cause mortality at 90 days, device‐related serious adverse events (SAE) ≤ 24 hours, procedure‐related SAEs ≤ 24 hours, embolization to new or previously uninvolved territories (ENT), symptomatic intracranial hemorrhage (sICH) ≤ 24 hours, vessel perforation, vessel dissection, and length of stay were compared.

Results
: Of the 650 patients in the COMPLETE registry, 215 were included in this subgroup analysis; 111 were categorized as MP mTICI 3, and 104 as FP mTICI 2b‐2c. The MP mTICI 3 group has fewer M1 occlusions (48% vs 67%, p = 0.004) and more ICA‐T occlusions (19% vs. 9%, p = 0.032). The groups were otherwise well matched with respect to age, sex, medical history, pre‐procedure ASPECTS, NIHSS, IV tPA use, onset‐to‐puncture time, and occlusion etiology. Outcomes are shown in table 1.

Conclusions
: In this exploratory subgroup analysis, we found that procedures requiring multiple passes to achieve complete revascularization were not associated with improved outcomes compared to procedures stopping after achieving mTICI 2b‐2c on the first pass.
Abstract 1122‐000122: The Role of the Venous System in Infarct Burden in Patients with Acute Ischemic Stroke
Authors: Thanki Shail S , Pressman Elliot , Thanki Shail S , Mayfield John D , Rabil Maximilian J , Mokin Maxim
Published: December 2021

Introduction
: Acute ischemic stroke (AIS) is a leading cause of disability internationally. Most therapies focus on intra‐arterial treatment to improve post‐stroke deficits and neurologic status. However, if a relationship between venous anatomy and post‐stroke deficits or infarct size can be shown, then venous augmentation strategies represent a possibility for future interventions as an adjunct to intra‐arterial treatment.

Methods
: We retrospectively reviewed all ischemic infarcts at our institution that underwent thrombectomy from January 2018 – October 2020. From these, we selected cases that were demonstrated as M1 occlusions on intra‐procedural angiogram and those who had a CT Head obtained within six hours of the patient’s last known normal (LKN). Patients without a CT Head or CT Angiogram of their head were excluded. Using axial and sagittal reconstructed views of 0.9mm slices, cross‐sectional area measurements were taken of the superior sagittal sinus 1cm above the Torcula, in three locations of the ipsilateral and contralateral transverse sinus, in three locations of the ipsilateral and contralateral sigmoid sinus, and of the ipsilateral and contralateral internal jugular vein (IJV) at the external surface of the skull. For the transverse and sigmoid sinuses, the three measurements were averaged together. These measurements were then compared against patient’s Alberta Stroke Program Early CT Score (ASPECTS).

Results
: 77 patients were identified in the study period. Average ASPECTS was 8.9, ranging from 5–10. There were three patients included with ASPECTS < 6. Average ipsilateral transverse sinus area was 34.4mm ± 3.34, average ipsilateral sigmoid sinus area was 32.8mm ± 2.74, average ipsilateral IJV area was 46.9 mm ± 5.00. Correlation tests to identify relationships between venous sinus area and ASPECTS was unremarkable (ipsilateral transverse sinus p = 0.574, ipsilateral sigmoid sinus p = 0.548, ipsilateral IJV p = 0.798). When assessed as a ratio of ipsilateral venous sinus area to contralateral sinus area to assess correlation with ASPECTS, results were unremarkable (transverse sinus p = 0.891, sigmoid sinus p = 0.292, IJV p = 0.499).

Conclusions
: Venous sinus size was not found to be predictive or associated with predominantly favorable ASPECTS for strokes found within six hours. We believe this may be due to our cohort lacking significant numbers of patients with low ASPECTS, yielding a false negative result. We are currently expanding this project to include a comparable number of patients with ASPECTS < 6 to determine the role of venous collateral system in infarct progression.
Abstract 1122‐000126: Mobile Stroke Unit Process Metrics in Large Vessel Occlusion Stroke Patients: BEST‐MSU Substudy
Authors: Czap Alexandra L , Alexandrov Anne W , Nour May , Singh Noopur , Wang Mengxi , Yamal Jose‐Miguel , Parker Stephanie A , Bowry Ritvij , Grotta James C
Published: December 2021

Introduction
: Mobile Stroke Units (MSUs) speed thrombolytic treatment for acute ischemic stroke and improve clinical outcomes compared to standard management by Emergency Medical Services (EMS). However, MSU process metrics in the subset of patients with large vessel occlusions (LVOs) having endovascular thrombectomy (EVT) have yet to be optimized.

Methods
: A pre‐specified Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU) substudy of tPA‐eligible stroke patients with imaging evident LVOs was conducted. The primary outcome was process metrics related to treatment times from stroke onset and first medical alert. Safety outcomes included rates of symptomatic intracerebral hemorrhage and procedural complications. Groups were compared using Chi‐square or Fisher’s exact tests for categorical variables, and Wilcoxon rank‐sum tests for continuous variables.

Results
: A total of 295 patients were included, 169 in the MSU group and 126 in the EMS group. Baseline characteristics were comparable between the groups, with the exception of baseline NIHSS (MSU mean 19.0 [IQR 13.0,23.0] vs EMS 16.0 [11.0, 20.0], p = 0.003). 92% of MSU and 87% of EMS LVO patients received tPA, and 78% and 85% went on to have EVT. Process metrics are detailed in Table 1. MSU LVO patients had faster tPA bolus from 911‐alert (MSU 45.0 minutes [40.0, 53.5] vs EMS 76.0 [64.0, 87.8], p<0.001), however the two groups had similar alert to groin puncture (MSU 142.5 [116.8, 171.0] versus EMS 131.5 [114.0, 159.8], p = 0.15). MSU patients spent more time on‐scene, (EMS arrival to ED arrival, 53.0 [45.0, 62.0] vs 27.0 [22.0, 33.0], p<0.001) however less time prior to EVT (door to groin puncture, 76.5 [54.8, 108.5] vs 94.0 [72.0, 123.0], p<0.001) with variable use of field CTAs and direct cath lab admission with ED bypass, yielding a net neutral result. The variability among site protocols is reflected in the range of median alert to groin puncture times (minimum 107.0 minutes, maximum 152.0). In the 222 patients undergoing EVT, median alert to recanalization time was 181.5 minutes [146.8, 225.5] in the MSU group and 190.5 [157.5, 227.5] in the EMS group (p = 0.47). Recanalization (Thrombolysis In Cerebral Infarction [TICI] 2b/3) was achieved in 76% of MSU and 70% of EMS (p = 0.32) with comparable rates of EVT complications (including hemorrhage, perforation, dissection, hematoma). 54% MSU and 44% of EMS LVO patients achieved good functional outcome (modified Rankin Scale [mRS] ≤ 2) at 90 days (p = 0.11).

Conclusions
: In tPA‐eligible LVO stroke patients, MSU management did not increase or expedite EVT treatment times as compared to standard EMS management. Future MSU processes should include field CTA with direct admission to cath labs to maximize the early treatment advantage this technology provides.
Abstract 1122‐000128: Imaging Follow‐Up in Carotid Webs: Is There Vascular Remodeling?
Authors: Koneru Sitara , Nogueira Raul G , Landzberg David , Osehobo Ehizele , AlShaer Qasem , Al‐Bayati Alhamza R , Nahab Fadi , Haussen Diogo C
Published: December 2021

Introduction
: Carotid web (CaW) is a shelf‐like fibrotic projection at the carotid bulb and constitutes an underrecognized cause of ischemic stroke. Atherosclerotic lesions are known to have dynamic remodeling with time however, little is known regarding the evolution of CaW over time. We aimed to better understand if CaW is a static or dynamic entity on delayed vascular imaging.

Methods
: This was a retrospective analysis of the CaW database at our comprehensive stroke center, including patients diagnosed with CaW between September 2014 through June 2021. Patients who had at least two good quality CT angiograms (CTAs) that were at least 6 months apart were included (CTAs with CaW and superimposed thrombus were excluded). CaW were quantified with 3‐D measurements using Horos software. This was done via volumetric analysis of free‐hand delineated CaW borders on thin cuts of axial CTA (Figure 1 Panel A). NASCET criteria was used to evaluate the degree of stenosis.

Results
: Sixteen CaW in 13 patients were identified and included. The median imaging follow‐up window was 16 months (IQR 12–22, range 6–29). Median patient age was 45.5 years‐old, 69% were women, 25% had hypertension, 38% hyperlipidemia, 25% diabetes mellitus, 0% atrial fibrillation, and 13% active smokers. 75% of the included CaW were symptomatic while 25% were asymptomatic. Median volume of CaW on initial CTA (8.52 mm3 [IQR 3.7‐13], range 2.2‐30.4) was comparable to median volume of CaW on most recent CTA (8.47 mm3 [IQR 4.0‐12.8], range 2.3‐29.4; p = <0.001 (Figure 1 Panel B). The CaW volumetric measurement correlation between the initial and most recent CTA was near perfect (rs = ‐0.99, p = <0.001). The median change in measured volume of CaW between first and last CTA was ‐0.19 mm3 [IQR ‐0.6‐0.4], range ‐1‐0.8. Median degree of stenosis was 8.1% [IQR 4.5‐17.1], range 0.4‐31.2. The duration of follow‐up imaging was not correlated with the change in CaW volume (Kendall tau‐b[τb] = ‐0.17, p = 0.93). The initial CaW volume was not found to be correlated to the degree of stenosis (τb = ‐0.08, p = 0.65).

Conclusions
: The volume of the CaW was not found to change over time, reinforcing the idea that this is a relatively static lesion. The CaW volume was not found to correlate with the degree of stenosis caused by it. Further longitudinal studies with longer follow‐up intervals are warranted.
Abstract 1122‐000147: Factors associated with the Delayed Door to Puncture Time for the Basilar Artery Occlusion patient
Authors: Nguyen Brandon , Yuki Ichiro , Stradling Dana , Xu Jordan C , Golshani Kiarash , Yu Wengui , Suzuki Shuichi
Published: December 2021

Introduction
: Performing mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO) is currently not evidence‐based. In the real‐world practice, it is also often encountered that the delayed initiation of the MT happens for this particular patient groups due to lack of cortical signs and other medical confounding factors.

Methods
: We retrospectively analyzed the angiographical and clinical outcomes of consecutive BAO patient who underwent MT in single institution. Onset to treatment (OTT), Door to Puncture (DTP) time were compared with those in anterior circulation large vessel occlusion (ACLVO) group who underwent MT in the same time period. For those showed significantly longer DTP time, the factors associated with the delayed initiation of the MT were analyzed.

Results
: A total of 271 patients underwent mechanical thrombectomy at UCI Medical Center between Jan 2016 and June 2021. Of these, 32 patients diagnosed as BAO by CTA and underwent MT were included in the study. Successful recanalization was achieved in 28 cases (87.5%), and symptomatic ICH occurred in 3 cases (9.4%). Nine patients (28.1%) showed good clinical outcomes (mRS 0–3) at 3 months. The median Onset to Puncture Time (OTT) was 340 min. The median DTP time (145 min) was significantly longer as compared to the ACLVO patients (99 min) (p value = 0.04). Of the 6 patients who showed significant delay in the initiation of intervention (DTP>300 min), 5 patients (83.3%) did not have the initial “stroke‐code activation” at the time of ED arrival. The cause of the delay was due to lack of cortical sign (3), bilateral spontaneous sustained clonus, which misinterpreted as seizure (1), AMS with non‐focal neurological signs interpreted as encephalopathy (2).

Conclusions
: DTP of the patients who underwent MT for BAO was significantly longer than that in ACLAO. Lack of cortical sings which are markers of ACLVO were associated with delayed activation of stroke code. Establishment of BAO screening in the ED assessment and prompt activation of Stroke code may contribute to the improvement of MT treatment for the BAO patients.
Abstract 1122‐000148: Rare Anterior Inferior Cerebellar Artery Origin of Middle Meningeal Artery
Authors: Kareem Samer Abdul , Anwar Arsalan , Liaw Nicholas , Kareem Mustafa , Zaidat Osama
Published: December 2021

Introduction
: Middle meningeal artery (MMA) anatomy has very important surgical implications during endovascular and open based skull procedures. Various anatomical origins have been identified in the literature besides its most common origin as the largest branch of the maxillary artery. It runs parallel and close contact of the lateral skull face therefore during trauma to this area is prone to rupture resulting in subdural hemorrhage(SDH). In our case report, we present its peculiar origin from anterior inferior cerebellar artery which has never been reported before. The origin of MMA may reflects the risk involved with embolization therapy for chronic SDH.

Methods
: A case of MMA originated form AICA. A literature review was conducted of reports of MMA origins.

Results
: A 35‐year‐old male with a history of alcohol abuse presented to the ED after falling down from the stairs. In the ED, the patient had multiple episodes of seizures along with respiratory distress therefore was intubated due to concern of airway protection. CT head showed bilateral SDH. Patient underwent diagnostic angiogram for possible bilateral embolization of MMA. During the procedure, the left MMA origin was seen from the AICA whereas the right MMA arising from the external carotid artery. Embolization of the left MMA was aborted. Patient remained intubated and was later transferred to a long term care facility.

Conclusions
: In the last 80 years, the anatomy of the MMA has been part of the discussion of various literature. Seeger et.al, highlighted the embryological changes manifested as anastomosis between Sphenomaxillary artery and lateral pontine artery resulting in origin of MMA from Basilar artery along with absence of foramen spinosum. Since 1973, multiple literature highlighted the origin of MMA including the lacrimal artery, ICA, ascending pharyngeal artery, opthalmic and occipital arteries. Recently, In 2011 Kuruvuilla et.al showed the origin of MMA from posterior inferior cerebellar artery. MMA clinical significance can be seen in multiple diseases. Older populations with chronic subdural hematomas, embolization of MMA has shown to be a less invasive and cost effective procedure. In patients with anterior and middle cranial fossa meningiomas embolization of MMA has been a crucial part of management. Similarly, understanding of its anatomy is also important while treating MMA aneurysm or pseudoaneurysms. In our case, the origin of middle meningeal artery from AICA has been significant as it supplies the posterior fossa structures and was not reported in the literature before, hence the procedure was aborted. This anatomical variant has shown us a new light upon embryological evolution and has helped us widen the horizons of our approach towards brain vasculature. This finding will help the future Interventionists to develop new ways of embolization of the MMA and understanding its anatomy.
Abstract 1122‐000153: Larger Functional Shunts are Associated with Greater Cerebrovascular Disease Burden
Authors: Gadallah Nancy , Torres Danisette , Ghori Arifa , Suhan Laura , Panezai Spozhmy , Mehta Siddhart , Fourcand Farrah , Kirmani Jawad
Published: December 2021

Introduction
: The relationship between embolic stroke and patent foramen ovale (PFO) is well‐established. Our objective was to evaluate the association between high intensity transient signals (HITS) in contrast‐enhanced transcranial doppler ultrasonography (ceTCD), baseline MRI brain small vessel ischemic changes, and rates of acute ischemic stroke in the setting of focal neurological deficits.

Methods
: Electronic medical records of subjects with acute onset neurological symptoms who had ceTCD and MRI brain were evaluated. Subjects without a reported Spencer grade and/or MRI brain without available DWI and FLAIR sequences were excluded. Acute stroke rates and baseline Fazekas score in low‐grade (Spencer grade 1–2) and high‐grade (Spender grade 3–5) shunts were analyzed using Z score for 2 population proportions and Mann‐Whitney U test, respectively. Social Science Statistics was used for data analysis.

Results
: From June 2016 to August 2021, of 7,498 consecutive ischemic stroke patients, 132 patients were identified as possible strokes related to PFO and were hospitalized with focal neurological deficit, underwent ceTCD and MRI brain. Acute stroke was confirmed on DWI in 60% of Spencer grade 1 (n = 73), 72.2% of grade 2 (n = 19), 72.7% of grade 3 (n = 29), and 80% of grades 4 and 5 shunts (n = 11). Acute stroke rates between low grade (grades 1–2) and high grade shunts (grades 3–5), did not reach statistical significance (z = ‐0.9181; p = 0.17879). There was no significant difference in periventricular white matter disease (z = 0.85697; p = 0.19489). Fazekas scores assessing deep white matter disease were statistically significant between low‐ and high‐grade shunts (z = 1.92818; p = 0.0268

Conclusions
: A trend towards statistical significance was observed in high‐grade shunt association with higher rate of acute stroke. Deep white matter disease burden may be significantly higher in high‐grade shunts. Further prospective studies are needed to corroborate our findings.
Abstract 1122‐000154: Effect of Intravenous Thrombolysis on Early Clot Lysis in Large Vessel Occlusion Strokes Undergoing Thrombectomy
Authors: Shehabeldin Mohamed , Eby Brendan , Wallace Adam N , Salter Amber , Chatterjee Arindam R , Osbun Joshua W , Moran Christopher J , Cross DeWitte T , Kansagra Akash P
Published: December 2021

Introduction
: Intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) are both standard of care treatments for acute ischemic stroke patients with large vessel occlusion (LVO) who are eligible for one or both treatments. IVT may result in early recanalization in some patients with LVO. The objective of this study is to analyze whether IVT influences pre‐thrombectomy clot lysis in LVO acute ischemic strokes.

Methods
: We reviewed prospectively collected data for all patients with LVO ischemic strokes who were transferred to the angiography suite with intention to perform EVT at a single comprehensive stroke center between January 2016 to December 2018. We identified subjects who showed partial or complete clot lysis vs no lysis based on the first angiographic picture of the occluded territory at the time of the initial vessel selection. Descriptive statistics were used to summarize demographic and clinical characteristics. We compared key predictor variables between lysis and no lysis groups including baseline variables, effect of IVT, time from IVT to groin puncture, LVO location, final modified treatment in cerebral ischemia (mTICI) score and discharge Modified Rankin Scale (mRS). t‐test or Kruskal‐Wallis test for continuous variables and chi square test or Fisher’s Exact test for categorical variables.

Results
: Two hundred and fifty‐nine patients were included. Among these patients, 10.8% (28/259) showed partial or complete lysis of the clot vs 89.2% (231/259) with no lysis. Among these patients who showed clot lysis, 16/28 (57.1%) received IVT. The use of IVT did not show differences between both groups (p = 0.18). There were no differences in the baseline characteristics except for gender, which was the only variable significantly associated with clot lysis. Men had 2‐fold higher odds of spontaneous lysis compared to females (OR [95%CI]: 2.39 [1.01, 5.65], p = 0.04). There was significant difference in the final mTICI between both groups (p <0.001).

Conclusions
: Our study showed that IVT in a modern practice was not associated with pre‐thrombectomy lysis. Some patients had pre‐thrombectomy lysis despite not receiving IVT.
Abstract 1122‐000171: Unusual Multicompartmental Intracranial Hemorrhage After Tenecteplase Administration
Authors: Amireh Abdallah , Nagy Muhammad , Ali Hassan , Mehta Siddhart , Zacharatos Haralabos , Fourcand Farah , Kirmani Jawad
Published: December 2021

Introduction
: The 2019 AHA/ASA updated Guidelines for the Early Management of Patients with Acute Ischemic Stroke mention tenecteplase (TNK) as a reasonable therapy in patients without contraindications for IV fibrinolysis who are also eligible to undergo mechanical thrombectomy. We describe a case of acute left MCA ischemic stroke treated with IV TNK (IV bolus of 0.25 mg/kg) followed by mechanical thrombectomy with subsequent multicompartmental intracranial hemorrhages unrelated to area of infraction.

Methods
: A retrospective review at a single center university hospital was performed for all intravenous TNK administrations outside of a clinical trial setting from October 2020 to July 2021.

Results
: A 61‐year‐old male with history of HTN and cardiomyopathy (EF<20%). Presented with sudden onset right sided weakness, aphasia and left gaze. Presenting NIHSS was 28. CT head with hyperdense left MCA sign and ASPECTS score of 10. CTA confirmed proximal left MCA M1 segment occlusion. IV TNK was given within 01:23 hours of symptoms onset. Subsequently, patient underwent emergent mechanical thrombectomy for disabling large vessel occlusion stroke. Spontaneous near complete recanalization of left MCA occlusion was noted on initial angiography run with small non flow limiting distal thrombi visualized in the distal MCA territories. Immediate post procedure CT head was negative for any intracranial hemorrhage. Patient’s exam was noted to improve to NIHSS of 2. Approximately 6 hours after the TNK administration, patient became acutely unresponsive with NIHSS of 26. With Glasgow Coma Scale 7 patient required emergent intubation. CT head revealed bilateral cerebellar intraparenchymal hemorrhages, extensive subarachnoid hemorrhage in basal cisterns and within the sulci in bilateral frontotemporal regions, as well as subdural hemorrhages along the falx and tentorial dural folds. Hypertonic saline was administered followed by emergent extraventricular drain placement. Tranexamic acid 1000 mg was given as emergent reversal, fibrinogen level was 155 mg/dL. Despite aggressive medical management and over following 24 hours, exam worsened with loss of pupillary reflexes. Patient was terminally extubated 2 days after initial presentation in accordance with his advance directives.

Conclusions
: Tenecteplase was a reasonable choice in this case given LVO and disabling stroke. The patient’s neurological exam improved significantly after TNK with evidence of spontaneous recanalization. However, patient’s multicompartmental intracranial hemorrhages unrelated to area of infraction were unusual in the absence of any vascular lesions to predispose hemorrhage based on CT and conventional angiography. Further observational studies are warranted to evaluate similar complications of Tenecteplase administration and their occurrence rates.
Abstract 1122‐000174: Stroke Risk of Carotid Artery Stenting Using Balloon‐Guide Catheter Versus Distal Embolic Protection Devices
Authors: Nahhas Michael I , Meeks Grant J , Martinez‐Gutierrez Juan Carlos , Spiegel Gary R , Alderazi Yazan , Chen Peng Roc , Dannenbaum Mark J , Blackburn Spiros L , Sheth Sunil A
Published: December 2021

Introduction
: Prevention of distal embolization during carotid artery stenting (CAS) is a key element of procedural technique and is standardly performed using distal protection devices (DPDs). Data in support of DPDs, however, are limited. Here, we present our experience of proximal occlusion using a balloon guide catheter (BGC) during CAS as the primary method of distal embolic protection.

Methods
: We conducted a retrospective review of patients undergoing CAS at our healthcare system between January of 2018 to March of 2021. Procedures were categorized by embolic protection strategy: DPD or BGC (with or without DPD). Emergent cases were defined as patients receiving CAS within <24 hours of presenting with an ischemic stroke or TIA ipsilateral to the carotid disease side. Severe stenosis was defined as 70–99% per NASCET criteria. The primary outcome was rate of procedural ischemic stroke between the DPD and BGC groups, and was defined as acute focal neurological deficit lasting for ≥ 24 hours following CAS related to an embolic event during the procedure.

Results
: A total of 126 CAS procedures were performed during the study period. 91 cases were performed under proximal BGC protection (of which 24 also included DPD usage) and 35 CAS cases via DPD as a primary mean for embolic protection. The median age for the cohort was 68 [IQR 62‐76], 37% females, 31% (n = 39) cases were treated emergently, and elective cases were 69% (n = 87). Baseline characteristics were similar in both groups except for hyperlipidemia (BGC vs DPD, 71.4% vs 42.9%; p = 0.003) and history of smoking (BGC vs DPD, 56% vs 34.4%; p = 0.029). Severe carotid stenosis was present in 80.2% BGC group and 77.1% in DPD (p = 0.573). Post‐stenting balloon angioplasty was more frequent in the BGC group as compared with DPD (54% vs. 26%, BGC vs. DPD, p = 0.005). Procedural embolic stroke rates were low in both groups, and not significantly different (1.1% vs. 2.9%, BGC vs. DPD, p = 0.48).

Conclusions
: CAS with BGC as the primary means of distal embolic protection showed comparable, low rates of procedural embolic ischemic events compared to those with DPD. These findings suggest BGC embolic strategies may be a viable alternative to DPD usage.
Abstract 1122‐000177: Dural Arteriovenous Fistulas with Traumatic Subdural Hematomas: A Case Series
Authors: Shehabeldin Mohamed , Mackenzie Larami , Choe Hana , Kozak Osman
Published: December 2021

Introduction
: Dural arteriovenous fistula (dAVF) is a pathological shunt between the dural arterial supply and venous system including cortical veins and/or venous sinuses. Middle meningeal artery (MMA) embolization as an indication for chronic subdural hematomas (SDH) treatment has been evolving over the past few years. The relationship between traumatic SDH and dAVF is not well established.

Methods
: Twenty‐one consecutive patients who received MMA embolization for chronic SDH performed in a single center from July 2020 to June 2021 were reviewed. We report a series of four cases of dAVF discovered immediately before or during MMA embolization for chronic SDH secondary to trauma.

Results
: 15/21 (71%) patients were traumatic SDH. 4/15 (27%) of the patients were found to have dAVF on cerebral angiography immediately before or during MMA embolization. In two patients, the dAVF was demonstrated via super‐selective microcatheter angiography of the external carotid and middle meningeal artery prior to embolization. The two patients, dAVF developed via the MMA distal to catheter placement during embolizing agent administration. These latter fistulae were uncovered due to the change of vascular resistance to surrounding meningeal branches. All four fistulae were successfully obliterated.

Conclusions
: Our case series demonstrate that traumatic SDH can be associated with dAVF. These fistulae may be associated with persistent SDH collections or refractory reaccumulations. While the true incidence and natural history of dAVF associated with traumatic SDH is unknown, we posit that cerebral angiography may be a necessary component in the complete evaluation of traumatic SDH.
Abstract 1122‐000180: Contrast‐Enhanced Transcranial Doppler Ultrasonography Versus Transesophageal Echocardiography as Screening Tool in Embolic Stroke
Authors: Fourcand Farrah , Gadallah Nancy , Ghori Arifa , Torres Danisette , Panezai Spozhmy , Suhan Laura , Mehta Siddhart , Kirmani Jawad
Published: December 2021

Introduction
: Right‐to‐left (RtL) intracardiac and intrapulmonary shunts are associated with embolic stroke. Although contrast‐enhanced transcranial doppler ultrasonography (ceTCD) and transesophageal echocardiography (TEE) are used in embolic stroke work up, there are no standardized guidelines as to which test should be considered as ‘gold standard’. Our objective is to evaluate the sensitivity of contrast‐enhanced TCD and TEE in detecting right‐to‐left shunt to determine respective utilities as screening tools.

Methods
: Electronic medical records of subjects presenting with acute neurological symptoms who had ceTCD and TEE were evaluated. Sensitivity and specificity were calculated. Based on the respective prevalence of intracardiac and intrapulmonary shunts, positive predictive value, negative predictive value, and test accuracy were determined for ceTCD and TEE. Social Science Statistics was used for data analysis.

Results
: From June 2016 to August 2021, of 7,498 ischemic stroke patients, 260 patients were suspected of having strokes related to right to left shunts and underwent ceTCD and TEE for detection of cardioembolic sources for stroke. A positive right‐to‐left shunt was detected in 83 subjects. Detection by ceTCD was confirmed by the operator for 81 patients while 2 were considered false positive results (delayed sporadic High Intensity Transient Signals (HITS)). Sensitivity of ceTCD was 97.65% (95% CI [91.76%, 99.71%]). No safety concerns were identified in patients undergoing ceTCD. Of those with positive ceTCD (68.57%, n = 35) were detected by Valsalva, and all of those 35 patients had negative TEE. TEE had sensitivity of 70.34% (95% CI [61.23%, 78.39%]).

Conclusions
: Contrast‐enhanced TCD has superior sensitivity, is cost‐effective, practical, and a safe alternative to TEE in identifying intracardiac or intrapulmonary shunts. Screening superiority of ceTCD may lie in ability to elicit shunts during Valsalva maneuvers. To our knowledge this is the largest single center series confirming ceTCD as a gold standard tool for screening of right to left shunts.
Abstract 1122‐000186: Predictors of Functional Outcome in Ischemic Stroke Patients with High Pass Number During Endovascular Therapy
Authors: D'Amato Salvatore A , Gutierrez Juan Carlos Martinez , Salazar‐Marioni Sergio , Abdelkhaleq Rania , Niktabe Arash , Kim Youngran , Chen Peng R , Blackburn Spiros , Dannenbaum Mark , Sheth Sunil A
Published: December 2021

Introduction
: The number of thrombectomy passes during endovascular therapy (EVT) for large vessel occlusion (LVO) in acute ischemic stroke (AIS) has been associated with probability of favorable functional outcome, with worse outcomes correlating with greater pass number. While first‐pass recanalization is a strong predictor of functional outcomes, the optimal or maximum recommended number of passes at which patients continue to benefit from EVT remains controversial. Moreover, among patients requiring more attempts, it is unclear if a certain subset of patients continue to benefit despite multiple passes. In this study, we determine predictors of functional outcome among patients requiring a high pass number to achieve successful vessel recanalization.

Methods
: From our prospectively maintained multi‐institutional registry across 4 comprehensive stroke centers, we identified patients with LVO AIS who underwent EVT requiring ≥ 3 passes to achieve successful reperfusion, defined as ≥ TICI 2b. Patient demographics, co‐morbidities, and severity of stroke based on NIHSS and ASPECTS were included within the analysis. Favorable outcome was defined as 90‐day post‐stroke modified Rankin Scale (mRS) 0–2. The primary outcomes were predictors of favorable outcome, which was assessed by multivariable logistic regression adjusted for age, baseline mRS, NIHSS, admission systolic and diastolic blood pressure, administration of tPA, number of passes during thrombectomy, history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease, congestive heart failure, carotid stenosis, and diabetes.

Results
: Among 116 patients, median age was 70 (IQR 59–80), 48% were female, median NIHSS was 16.5 (IQR 13–22), and median number of passes was 3 (IQR 3–4, range 3–8). Patients with favorable outcome were younger (mean age 63±18.1 vs 70±14.5, favorable vs. non‐favorable, p = 0.041), and had lower NIHSS on presentation (mean 13.9±6.0 vs 18.3±7.4, favorable vs. non‐favorable p = 0.003). Patients with favorable outcome also had lower initial systolic blood pressure (149.6±32.8 vs 163.0±30.0 mmHg, favorable vs. non‐favorable, p = 0.047). In multivariable logistic regression adjusted for demographics and clinical characteristics, lower NIHSS was significantly associated with likelihood of good outcome (OR 0.88, 95% CI 0.81‐0.97, p = 0.009).

Conclusions
: Patients presenting with lower NIHSS are more likely to benefit from continued EVT attempts. These findings suggest that this population benefits from continued attempts at revascularization.
Abstract 1122‐000190: Persistent DWI Signal for 18 Months in Ischemic Stroke Patient with Carotid Web
Authors: Shay James , Malik Afeerah , Author Second , Wagle Binod , Author Last
Published: December 2021

Introduction
: Diagnostic tools for acute ischemic infarcts include the use of DWI sequence on MRI to identify acute infarcts is especially useful since lesions can become hyperintense on this sequence very rapidly (Albers 1998). Over the next 15 days, DWI hyperintensity slowly decreases back to isointense. In some patients, however, there is persistent DWI hyperintensity past 1 month. There are theories that these persistent areas exhibit delayed onset infarct, prolonged ischemia, or perhaps different repair processes (Rivers, et al 2006). To this day, all DWI signals have been known to resolve within a few months even for persistent hyperintensities (Rivers, et al 2006).

Carotid webs are a rare form of fibromuscular dysplasia that protrudes from the intimal tissues of carotid arteries. They are shelf‐like projections that grow into the lumen and disrupt normal blood flow (Zhang, et al 2018). These outgrowths are theorized to lead to ischemic strokes due to flow stasis and subsequent embolization of clots that form (Zhang, et al 2018). There is no consensus on the best management of carotid webs, and secondary prevention of recurrent strokes range from medical management to carotid stenting.

Methods
: This is a case report, and information for the patient was gathered through review of medical records on the EMR.

Results
: We present a case of ischemic stroke in the right basal ganglia/corona radiata, who presented with left sided weakness. The patient was found to have prediabetes, HTN, and HLD. However, she had recurrence of her symptoms over the next 18 months (figure 1). Repeat MRIs showed persistent DWI hyperintensity that slowly decreased in size and signal intensity over this period but in the same area as the initial infarct. The rest of the work up was only significant for a carotid web in the right internal carotid artery identified on conventional angiography. Ultimately she was managed with medical therapy including aspirin, statin, and antihypertensives.

Conclusions
: It is unclear whether the carotid web is associated with persistent DWI for such an extended time frame. There is very little research that explores the pathophysiology of ischemic strokes from carotid webs. In addition, there is even less information about the physiology of an evolving infarct that shows persistent DWI signals for such an extended time frame. Further studies that look into carotid webs may help us understand the best long term management in such patients. Future studies that explore the physiology of ischemic strokes that show such persistent DWI signals may elucidate and perhaps expand upon current management options and possibly identify new areas for intervention.
Abstract 1122‐000198: Failure of Tenecteplase in Maintaining Collateral Circulation in Large Vessel Occlusion Strokes.
Authors: Fourcand Farrah
Published: December 2021

Introduction
: Acute administration of alteplase with collateral patency has been systematically evaluated in acute ischemic stroke (AIS) patients. Large studies evaluating alteplase demonstrate a significant association of successful recanalization (TICI score) and good clinical outcome (mRS) with ASITN/SIR collateral grade greater than 2. However there is paucity of data looking at the association between IV tenecteplase (TNK) and acute collateralization. Our objective was to investigate early TNK use association for the degree of collateralization in subjects with AIS secondary to large vessel occlusion (LVO).

Methods
: Collateralization was assessed on digital subtraction angiography using the American Society of Intervention and Therapeutic Neuroradiology/Society of Interventional Radiology (ASTIN/SIR) scale. Grades were defined by the following: 0 no collaterals to ischemic region; 1 slow collaterals peripherally; 2 rapid collaterals peripherally; 3 slow collaterals within ischemic region; 4 complete retrograde perfusion to ischemic region. Subjects with LVO undergoing mechanical thrombectomy status post TNK as part of the pilot early clinical use of TNK within 4.5 hours of last known well were assigned a grade. Mean ASITN/SIR collateral grade was determined. Spearman’s rho was used to measure association of collateral grade with thrombolysis in cerebral infarction (TICI) score. Patients with TNK‐associated recanalization at time of cerebral angiogram were excluded from study. Social Science Statistics was used for data analysis.

Results
: From October 2020 to April 2021, 16 subjects (6 females; age, 63.25 95% CI [54.9207, 71.5793]) received TNK and underwent mechanical thrombectomy. From those subjects, 25 % (n = 4) had IV TNK‐associated recanalization with normalization of collateral blood flow and were excluded. Of the rest (n = 12, 75%) had a mean ASITN/SIR collateral grade of 1.08 (95% CI [0.5762, 1.5838]). Association between collateral grade and final TICI score was not statistically significant (rs = ‐0.33576, p = 0.28598) suggesting inability of TNK to result in/maintain a robust collateral flow.

Conclusions
: Poor correlation of collateral grade and final TICI score may have implications of faster progression in patients with ischemic stroke receiving TNK in the setting of LVO if immediate recanalization is not achieved. Larger prospective studies are needed to evaluate the effect of TNK on collateralization when compared to Alteplase.
Abstract 1122‐000201: Is Neutrophilia a Risk Factor for Fast Stroke Progression in Large Vessel Occlusion?
Authors: Kirmani Jawad , Fourcand Farrah , Gadallah Nancy , Ghori Arifa , Torres Danisette , Amireh Abdallah , Zacharatos Haralabos , Mehta Siddhart
Published: December 2021

Introduction
: Rapid stroke progressors with large vessel occlusion (LVO) have a worse prognosis than their time‐matched cohorts receiving IV thrombolytics and/or mechanical thrombectomy. Our objective was to evaluate the association of neutrophilia with rapid stroke progression.

Methods
: Initial white blood cell (WBC) and absolute neutrophil counts (ANC) were collected for subjects presenting with acute ischemic stroke secondary to LVO who received IV thrombolytics and/or mechanical thrombectomy within 4.5 and 6 hours, respectively. Rapid stroke progression was determined by Alberta Stroke Program Early CT Score (ASPECTS) on initial CT head. Baseline and discharge NIHSS, age, and follow up mRS were also compared to presenting WBC and ANC. Spearman’s rho was used for correlation. Social Science Statistics was used for data analysis.

Results
: From October 2020 to April 2021, the association between neurophilia and stroke progression was evaluated in 19 subjects receiving tenecteplase (n = 16; 6 females; age, 63.25 95% CI [54.9207, 71.5793]) and alteplase (n = 4; 2 females; mean age 59, 95% CI [38.13, 79.87]) for LVO causing disabling neurological deficits. Mechanical thrombectomy was attempted in all subjects. The association between higher ANC and lower ASPECTS score reached statistical significance (rs = ‐0.49255, p = 0.04457). There was no significant association of white blood cell (WBC) and ASPECTS score. WBC and ANC were not associated with baseline or discharge NIHSS, age, or follow up mRS.

Conclusions
: Rapid stroke progression as measured by presenting ASPECTS score may be associated with neutrophilia. Larger prospective clinical trials are needed to validate our results.
Abstract 1122‐000205: Bilateral ACA Stroke ‐ A Case Report of an Unusual Presentation
Authors: Suryadevara Tejeswi , Narapureddy Bhavya , Lopez Carlos Y , Albright Karen C
Published: December 2021

Introduction
: Bilateral ACA strokes are rare, with one stroke registry reporting 2 cases out of 1490 strokes (1). These strokes are even less common in the absence of anatomic variants, such as an azygos ACA. Diagnosis may be difficult given the variability in clinical presentation.

Methods
: This is a case report.

Results
: A 51‐year‐old right handed man with no cerebrovascular risk factors on no antithrombotic medications presented two hours from last known well with complaints of generalized weakness, inability to speak or move, and feeling numb all‐over during intercourse. He reported rapid improvement in symptoms. Emergency room exam was notable for right leg weakness (3/5) and left leg plegia with intact sensation. Hoover’s sign was positive in the left leg and the patient was able to bear some weight while standing with a two‐person assist. A computed tomography angiogram (CTA) of his head and neck was preliminarily interpreted as normal. No azygos ACA or single internal carotid artery origin for the ACAs were present. His exam improved to an isolated left foot dorsiflexor and plantar flexor weakness. The decision was made not to use thrombolytics based on his symptoms and exam which were improving and not entirely consistent with acute stroke. Brain magnetic resonance imaging demonstrated bilateral parasagittal acute strokes. It was later noted the that non‐contrast head CT demonstrated bilateral hyperdense ACAs.

Conclusions
: This case demonstrates the difficulty in diagnosing bilateral ACA infarcts in a previously healthy adult in the setting of whole‐body numbness and positive Hoover’s sign. In retrospect, his transient inability to speak or move may have been transient akinetic mutism or callosal disconnection syndrome. Additionally, this case emphasizes the importance of evaluating for the hyperdense ACA sign (2) in patients complaining of bilateral leg weakness.