bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementation of Low-Intensity Thrombolysis Monitoring Care in Routine Practice: Process Evaluation of the Optimal Post rtPA-IV Monitoring in Acute Ischemic Stroke Study in the USA
Authors: Ouyang Menglu , González Francisca , Montalbano Michelle , Pruski April , Jan Stephen , Wang Xia , Johnson Brenda , Summers Debbie V. , Khatri Pooja , Malavera Alejandra , Iacobelli Michael , Faigle Roland , Munoz-Venturelli Paula , Urrutia Goldsack Francisca , Day Diana , Robinson Thompson G. , Durham Alice C. , Ebraimo Ahtasam , Song Lili , Sui Yi , Wan Zaidi Wan Asyraf , Lindley Richard I. , Delcourt Candice , Urrutia Victor Cruz , Anderson Craig S. , Liu Hueiming
Published: March 2024

Introduction: The ongoing OPTIMISTmain study, an international, multicenter, stepped-wedge cluster randomized trial, aims to determine effectiveness and safety of low-intensity versus standard monitoring in thrombolysis-treated patients with mild-to-moderate acute ischemic stroke (AIS). An embedded process evaluation explored integration and impact of the intervention on care processes at participating US sites. Methods: A mixed-methods approach with quantitative and qualitative data was collected between September 2021 and November 2022. Implementer surveys were undertaken at pre- and post-intervention phases to understand the perceptions of low-intensity monitoring strategy. A sample of stroke care nurses were invited to participate in semi-structured interviews at an early stage of post-intervention. Qualitative data were analyzed deductively using the normalization process theory; quantitative data were tabulated. Results: Interviews with 21 nurses at 8 hospitals have shown low-intensity monitoring was well accepted as there were less time constraints and reduced workload for each patient. There were initial safety concerns over missing deteriorating patients and difficulties in changing established routines. Proper training, education, and communication, and changing the habits and culture of care, were key elements to successfully adopting the new monitoring care into routine practice. Similar results were found in the post-intervention survey (42 nurses from 13 hospitals). Nurses reported time being freed up to provide patient education (56%), daily living care (50%), early mobilization (26%), mood/cognition assessment (44%), and other aspects (i.e., communication, family support). Conclusions: Low-intensity monitoring for patients with mild-to-moderate AIS, facilitated by appropriate education and organizational support, appears feasible and acceptable at US hospitals.
Abstract 001: Microvascular reperfusion during endovascular therapy: the balance of supply and demand
Authors: Favilla Christopher G. , Forti Rodrigo M. , Baker Wesley B. , Carter Sarah , Kasner Scott E. , Yodh Arjun G. , Cummings Stephanie , Kung David , Burkhardt Jan‐Karl , Pukenas Bryan A. , Srinivasan Visish M. , Detre John A.
Published: March 2024

Introduction

Endovascular therapy (EVT) has revolutionized acute stroke treatment, but large vessel recanalization does not always result in tissue‐level reperfusion. Cerebral blood flow (CBF) is not routinely monitored during EVT. Here we aimed to leverage diffuse correlation spectroscopy (DCS), a novel transcranial optical imaging technique, to assess the relationship between microvascular CBF and post‐EVT outcomes.

Methods

Frontal lobe CBF was monitored by DCS in 40 patients undergoing EVT. Baseline CBF deficit was calculated as the percentage of CBF impairment on pre‐EVT CT perfusion. Microvascular reperfusion was calculated as the percentage increase in DCS‐derived CBF that occurred with recanalization. The adequacy of reperfusion was defined by persistent CBF deficit, calculated as: baseline CBF deficit ‐ microvascular reperfusion. Good functional outcome was defined as 90‐day modified Rankin Scale ≤2.

Results

36 (of 40) patients achieved successful recanalization, in whom microvascular reperfusion in itself was not associated with infarct volume or functional outcome. However, patients with good functional outcomes had a smaller persistent CBF deficit (median: 1%; IQR: ‐11%–16%) than patients with poor outcomes (median: 28%; IQR: 2%–50%), p=0.02. Smaller persistent CBF deficit was also associated with smaller infarct volume (p=0.004). Multivariate models confirmed that persistent CBF deficit was independently associated with infarct volume and functional outcome.

Conclusion

CBF augmentation alone does not predict post‐EVT outcomes, but when microvascular reperfusion closely matches the baseline CBF deficit, patients experience favorable clinical and radiographic outcomes. By recognizing inadequate reperfusion, bedside CBF monitoring may provide opportunities to personalize post‐EVT care aimed at CBF optimization.
Abstract 007: Device‐related Technical Complications with Flow Diversion of Intracranial Aneurysms: A Systematic Review and Meta‐analysis
Authors: Ortega‐Gutierrez Santiago , Rodriguez‐Calienes Aaron , Vivanco‐Suarez Juan , Dibas Mahmoud , Hanel Ricardo A. , Cekirge Saruhan , Lamih Saleh , Rice Hal , Saatci Isil , Fiorella David , Lylyk Pedro , Lylyk Ivan , Pereira Vitor Mendes , Gounis Matt , Fiehler Jens
Published: March 2024

Introduction

Flow diverters (FD) have become a revolutionary approach in the endovascular treatment of intracranial aneurysms (IAs), supplanting traditional methods (1). Despite their demonstrated efficacy and safety, unforeseeable device‐related technical complications, such as fish‐mouthing, device braid narrowing, deformation, ovalization, and collapsing have been reported during implantation and follow‐up (2,3,4). However, the definitions and reporting of these complications remain inconsistent. We conducted a systematic review and meta‐analysis to assess overall device‐related technical complication rates associated with flow diversion and provide an overview of the current reported definitions.

Methods

We searched six databases up to April 4th, 2023, and included studies that reported device‐related technical complications related to FD treatment for IAs. We considered five main outcome measures as device‐related technical complications: (1) fish‐mouthing, (2) device braid collapsing, (3) device braid narrowing, (4) device braid deformation, and (5) device braid ovalization. The data from these studies were pooled using a random‐effects model.

Results

We included 48 studies involving 3,572 patients and 3,939 aneurysms. Among them, 14 studies (39%) provided definitions for fish‐mouthing. However, none of the included studies offered specific definitions for device braid collapsing, narrowing, or deformation, despite reporting rates for these complications in five, six, and three studies, respectively. The pooled rates for device‐related technical complications were as follows: 3% (95% CI 2 – 4%; I2 = 27%) for fish‐mouthing, 1% (95% CI 0 – 3%; I2 = 0%) for collapsing, 7% (95% CI 2 – 20%; I2 = 85%) for narrowing, and 1% (95% CI 1 – 4%; I2 = 0%) for deformation. Device braid ovalization data were not available.

Conclusion

The findings of this study suggest that FD treatment for IAs generally exhibits low rates of fish‐mouthing, device braid narrowing, collapsing, and deformation. However, the lack of standardized definitions hinders the ability to objectively compare device outcomes, emphasizing the need for uniform device‐related complication definitions in future prospective studies on FD.
Abstract 009: 1‐Year Outcomes of Resolute Onyx Zotarolimus‐Eluting Stent for Intracranial Atherosclerotic Disease: Multicenter Comparison with SAMMPRIS
Authors: Saisree  , Farhan  , S Ravi , Khalid Syed , Khan Inamullah , Tekle Wondwossen G , Tanweer Omar , Burkhardt Jan‐Karl , Jabbour Pascal M , Tjoumakaris Stavropoula , Herial Nabeel A , Siddiqui Adnan H , Grandhi Ramesh , Qureshi Adnan I , Hassan Ameer E
Published: March 2024

Introduction

Intracranial atherosclerotic disease (ICAD) is one of the most prevalent causes of stroke across the world, with a high morbidity and mortality rate. Endovascular treatment (ET) has gained prominence but remains a challenge with unfavorable results. Recent literature has demonstrated that the Resolute Onyx Zotarolimus‐Eluting stent (RO‐ZES) is a technically safe option with low complication rates. Preliminary data has also reported the 30‐day outcomes associated with intracranial stent placement for ICAD with RO‐ZES compared to results from the Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. Here, we aim to compare outcomes at 1 year with the SAMMPRIS trial to further evaluate the efficacy and outcomes of RO‐ZES in a multicenter study with long‐term follow up extending beyond 30 days.

Methods

Prospectively maintained databases across 7 stroke centers were reviewed to identify adult patients undergoing RO‐ZES placement for treatment of ICAD between January 2019 to May 2023. The primary endpoint was composite of 1‐year stroke, ICH, and/or death. This data was propensity score matched using age, sex, hypertension, diabetes mellitus, smoking status, and impacted vessel for comparison between RO‐ZES and the SAMMPRIS percutaneous angioplasty and stenting groups (S‐PTAS).

Results

A total of 104 patients met the inclusion criteria for analysis (mean age 62.6, 31.7% female). Impacted vessels included basilar artery (6.7%), internal carotid artery (26.9%), middle cerebral artery (29.8%), posterior cerebral artery (1.0%), and vertebral artery (35.6%). Propensity score match analysis of the 104 patients with S‐PTAS demonstrated 1‐year stroke, ICH, and/or death rate of 11.5% in the RO‐ZES group and 35.6% in the S‐PTAS group (OR 4.17, 95% CI 2.06‐8.96, p=0.001).

Conclusion

The RO‐ZES system provides a not only safe and effective alternative to other traditional stents, but also demonstrates strong potential to reduce long‐term complications at 1 year compared with the S‐PTAS group. Further prospective multicenter studies are needed to corroborate the findings and compare RO‐ZES directly with other stents.
Abstract 010: Technical Approaches for Intracranial Atherosclerotic Disease Large Vessel Occlusion Strokes
Authors: Koneru Sitara A. , A Mohamed Tarek , Martins Pedro , D Mateus Monteiro , Dolia Jay , Grossberg Jonathan A. , Pabaney Aqueel H. , Nogueira Raul G. , Alhamza A.R , Haussen Diogo C.
Published: March 2024

Introduction

The optimal management strategy for large vessel occlusion strokes (LVOS) from intracranial atherosclerotic disease (ICAD) remains debated. We aimed to evaluate the efficacy and safety of various acute medical and endovascular management options in patients who underwent mechanical thrombectomy of an ICAD‐related occlusion.

Methods

Retrospective analysis of ICAD‐related LVOS of a prospective mechanical thrombectomy database at a comprehensive stroke center between November 2010‐May 2023. Endovascular intervention was defined as either angioplasty, stenting, or a combination of both. Acute management was divided into 5 groups: Group#1: proactive antiplatelets (patients who received antiplatelets prior to groin puncture without further endovascular intervention after initial reperfusion); Group#2: reactive antiplatelets (patients who received antiplatelets after groin puncture without further angioplasty and/or stenting after initial reperfusion), Group#3: proactive revascularization (patients treated with angioplasty and/or stenting after initial reperfusion), Group#4: reactive revascularization (patients treated with angioplasty and/or stenting after vessel re‐occlusion after initial reperfusion), and Group #5: rescue revascularization (patients with unsuccessful reperfusion and subsequent angioplasty and/or stenting).

Results

A total of 200 ICAD‐LVOS MT were identified. Baseline characteristics were comparable between the 5 groups. The rate of TICI2b‐3 final reperfusion was lower in Group 4, while the rate of TICI 2c‐3 final reperfusion was comparable among groups. The rates of in‐hospital re‐occlusion were high even in patients loaded with DAPT before puncture; the rates of re‐occlusion were lower in patients managed with intervention in a proactive manner (Group 3) when compared to those managed in a reactive manner (Group 4) (0% vs 27%, p= 0.005). In ordinal analysis, mRS scores were lowest in Groups 2 and 3.Safety outcomes were comparable with similar rates of symptomatic intracranial hemorrhage (sICH).

Conclusion

While limited by small subgroup sample size, medical management only was associated with relatively high rates of reocclusion, while proactive angioplasty/stenting with performed best. Symptomatic intracranial hemorrhage was low in medically treated patients. Further studies are warranted.
Abstract 040: Hemorrhagic Conversion Patterns After Transition of Stroke Thrombolysis from Alteplase to Tenecteplase; Real‐World Experience
Authors: Ezzeldin Mohamad , Hill Courtney , Percenti Eryn , Kerro Ali , Delora Adam , Santos Juan , Saei Hamza , Greco Lisa , Ezzeldin Rime , Elghanem Mohammad , Alderazi Yazan , Kim Yana , Poitevint Cathleen , Mir Osman
Published: March 2024

Introduction

Importance:Tenecteplase (TNK) use is more prevalent as the thrombolytic drug of choice for acute ischemic stroke (AIS), given its ease of use with results from randomized trials showing non‐ inferiority and comparable safety to Alteplase (tPA). However, there is conflicting data in terms of intracranial hemorrhage risk.

Objective: We are reporting the rate of symptomatic intracranial hemorrhage(sICH) in TNK and tPA treated stroke populations across two large hospital systems.

Methods

Design: Retrospective cohort observational study. Data was collected from April 1, 2022 through March 29, 2023.

Setting: Data was collected from 15 stroke centers: 10 primary and 5 comprehensive stroke centers in Texas.

Participants: Inclusion criteria: 18 years or older, suspected to have an AIS were eligible to receive thrombolytic therapy, and received either IV TNK or tPA at the standard dose. A total of 431 patients were included. 216 patients received alteplase and 215 patients received tenecteplase.

Exposure: Data was collected 90 days before and 90 days after the stroke center changed from tPA to TNK. Main Outcomes: The primary endpoint was to compare the incidence of sICH according to SITS‐MOST/ECASS‐3 criteria in the tPA and TNK groups. Secondary endpoints included the radiographic pattern of hemorrhagic conversion according to the Heidelberg bleeding classification (HBc).

Results

A total of 431 patients; half of them had been administered Alteplase (n=216) and the other half had Tenecteplase (n=215). Approximately half of them were females 110 (51%) for alteplase and 117 (54%) for Tenecteplase. Almost 2/3 of the study population never smoked; 66% for alteplase 64% for Tenecteplase. Majority of the patient population got thrombolytic therapy within 3 hours 174 (81%) for alteplase versus 176 (82%) for Tenecteplase. 34 patients (15%) in the alteplase group as compared to 26 patients (12%) in the Tenecteplase group had endovascular thrombectomy attempted. 7 patients in the tPA group (3.2%) and 14 patients (6.5%) in the TNK group had sICH. An increase in the NIHSS on arrival (p=0.048) was a statistically significant predictor of sICH. A two sample proportion test on TNK produced a statistically significant increase in Heidelberg Bleed class 3 (HBc3) (p=0.040) over tPA.

Conclusion

We observed increased cases of bleeding associated with TNK administration with statistically significant increase in the HBc3 when compared to patients who received tPA. Suggested mechanisms of bleeding are hemorrhagic conversion in clinically silent infarcts, and contusions underlying the lesions. These findings suggest a potential need to reevaluate the criteria for administering TNK to patients. Larger studies are required to confirm this data.
Abstract 056: Patterns of Care in the Management of Intracranial Atherosclerosis‐related Large Vessel Occlusion–the RESCUE‐LVO survey
Authors: Siddiqui Fazeel M. , Fletcher Jeffrey J. , Elias Augusto E. , Dandapat Sudeepta , Kale Sushant P. , Heiferman Daniel , Riedy Loren , Farooqui Mudassir , Calienes Aaron Rodriguez , Vivanco‐Suarez Juan , Pandey Aditya S. , Ortega‐Gutierrez Santiago
Published: March 2024

Introduction

Intracranial atherosclerosis‐related large vessel occlusion (ICAS‐LVO) is a common cause of failed mechanical thrombectomy (MT) in acute ischemic stroke (AIS) [1]. Treatment of ICAS‐LVO with rescue stenting and/or angioplasty has shown promising outcomes, but diagnosing ICAS‐LVO during MT can be challenging [2, 3]. There are uncertainties regarding optimal approaches, techniques, and timing for treating ICAS‐LVO. To understand current practice patterns and address these uncertainties, we conducted a survey among neurointerventional practitioners experienced in ICAS‐LVO management during MT.

Methods

We conducted an international online survey of neurointerventionalist members of the Society of Neurointerventional Surgery (SNIS) and the Society of Vascular and Interventional Neurology (SVIN). The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO.

Results

168 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 40.6% reported an incidence of 6–10% of ICAS‐LVO during MT. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis (FFS) after multiple MT attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS) +/‐ angioplasty. However, in patients who achieved recanalization with a severe FFS, the majority (44%) recommended maximal medical management only. The preferred medication during acute RS was intravenous antiplatelet therapy (69%), and after acute RS was dual oral antiplatelet therapy (58%). Fear of hemorrhagic complications (70%) was the most compelling reason not to perform RS +/‐ angioplasty. Twenty‐five percent of respondents were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before MT treatment.

Conclusion

Our survey highlights the significant variability and uncertainty in the diagnosis and management of ICAS‐LVO during MT among neurointerventional practitioners. There is no equipoise regarding the optimal treatment strategy, and the fear of hemorrhagic complications associated with antithrombotic medications contributes to the variation in practice. Our survey underscores the need for future research and randomized clinical trials to address the uncertainties in the management of ICAS‐LVO during MT. Improved imaging biomarkers and consensus guidelines are essential to guide clinical decision‐making and optimize patient outcomes in this challenging population of AIS patients.
Abstract 067: Outcomes for large vessel occlusion patients with severe baseline disability with and without endovascular thrombectomy
Authors: Awad Amine J. , Young Michael J. , Andreev Alexander , Dmytriw Adam A. , Vranic Justin E. , Rabinov James D. , Stapleton Christopher J. , Das Alvin S. , Bonkhoff Anna K. , de Oliveira Lara Carvalho , Schirmer Markus D. , Leslie‐Mazwi Thabele M. , Singhal Aneesh B. , Patel Aman B. , Rost Natalia S. , Regenhardt Robert R.
Published: March 2024

Introduction

Patients with baseline disability account for one‐third of stroke presentations. However, there remains controversy in treatment selection for endovascular thrombectomy (EVT). We compared long‐term outcomes and likelihood of transitioning to comfort care for large vessel occlusion (LVO) patients with severe pre‐stroke disability treated with EVT versus medical management at a single center from 2017‐2020.

Methods

Individuals who presented with LVO were identified retrospectively from a prospectively maintained database. Severe baseline disability was defined as modified Rankin Scale (mRS) 3‐5. Delta mRS was defined as the difference between baseline and 90‐day mRS. Logistic and ordinal regressions were performed to evaluate the relationships between EVT and outcomes. A mixed‐methods analysis was performed to assess rates and reasons for transitions to comfort care.

Results

A total of 175/1008 (17%) were identified with severe baseline disability. The median age was 82 (IQR 70‐89), and 59% were female. Thirty‐two (18%) with severe baseline disability were treated with EVT. EVT was independently associated with improved delta mRS (B=‐1.048; 95%CI=‐1.777,‐0.318; p=0.005) accounting for age and NIHSS. However, EVT did not reduce the odds of transitioning to comfort care (aOR=0.794; 95%CI=0.347,1.818; p=0.585) accounting for age and NIHSS. Seventy‐six (43%) with severe baseline disability were transitioned to comfort care. Of the 99 not transitioned to comfort care, 18 were treated with EVT, and EVT was independently associated with improved delta mRS (B=‐2.794; 95%CI=‐4.002,‐1.586; p<0.0001) accounting for age and NIHSS. The median time from presentation to comfort care was 2 days (IQR 1‐7) in the non‐EVT group, compared to 7 (IQR 4‐11) in the EVT group (H(1)=5.46, p=0.019). The primary reasons for comfort care were poor perceived prognosis and medical complications.

Conclusion

Among patients with severe baseline disability, EVT is associated with less post‐stroke accumulated disability without limiting transitions to comfort care. EVT may be compatible with goal‐concordant care and should not be routinely withheld on the basis of baseline disability alone.
Abstract 070: Door in‐door out time for stroke thrombectomy transfers in a large hub‐and‐spoke network
Authors: Ahmed Rashid A. , McIntyre Joyce A. , Leslie‐Mazwi Thabele M. , Das Alvin S. , Dmytriw Adam A. , Hirsch Joshua A. , Rabinov James D. , Doron Omer , Stapleton Christopher J. , Singhal Aneesh B. , Rost Natalia S. , Patel Aman B. , Regenhardt Robert W.
Published: March 2024

Introduction

The mantra ‘time is brain’ cannot be overstated for patients suffering from acute ischemic stroke. This is especially true for those with large vessel occlusions (LVO) requiring transfer to an endovascular thrombectomy (EVT) capable center. We sought to evaluate the spoke hospital door in‐door out (DIDO) times for patients transferred to our hub center for EVT.

Methods

Individuals who first presented with LVO to a spoke hospital and were then transferred to the hub for EVT were retrospectively identified from a prospectively maintained database from January 2019 to November 2022. DIDO was defined as the time between spoke hospital door in arrival and door out exit. Baseline characteristics, treatments, and outcomes were compared, dichotomizing DIDO at 90 min based in the American Heart Association goal for DIDO ≤90 min for 50% of transfers. Multivariable regression analyses were performed for determinants of 90‐day ordinal modified Ranking Scale (mRS) and DIDO.

Results

We identified 194 patients transferred for EVT with available DIDO. The median age was 67 (IQR 57‐80), and 46% were female. The median NIHSS was 16 (10‐20), 50% were treated with intravenous thrombolysis at a spoke, and TICI 2B‐3 reperfusion was achieved in 87% at the hub. The median DIDO was 120 min (97‐149), with DIDO ≤90 min achieved in 18%. DIDO was a significant determinant of 90‐day ordinal mRS (B=0.007, 95%CI=0.001‐0.012, p=0.013), even when accounting for last known well‐to‐spoke door in, spoke door out‐to‐hub arrival, hub arrival‐to‐puncture, puncture‐to‐first pass, age, NIHSS, intravenous thrombolysis, TICI 2B‐3, and symptomatic intracranial hemorrhage. Importantly, determinants of DIDO included Black race or Hispanic ethnicity (B=0.918, 95%CI=0.010‐1.826, p=0.048), atrial fibrillation or heart failure (B=0.793, 95%CI=0.257‐1.329, p=0.004), and basilar LVO location (B=2.528, 95%CI=1.154‐3.901, p<0.001).

Conclusion

In this real‐world analysis of a large hub‐and‐spoke network, spoke DIDO was the most important period of time for long term outcomes of LVO stroke patients treated with EVT. Determinants of DIDO were identified which require further investigation and motivate system changes that may reduce DIDO and improve patient outcomes.
Abstract 074: Early Versus Late Anticoagulation In AF‐related Ischemic Stroke: A Systematic Review and Meta‐analysis of RCTs
Authors: Kelani Hesham
Published: March 2024

Introduction

In AF‐associated ischemic stroke, there is increased risk of early stroke recurrence, making anticoagulation treatment is highly recommended for secondary stroke prevention [1‐2]. On the other hand, high rates of ICH were also reported in this population, making it very challenging for physicians to decide when to start anticoagulation treatment [3]. We aim to investigate safety and efficacy of early versus late anticoagulation in AF patients with AIS.

Methods

This meta‐analysis followed the Preferred Reporting Items for Systematic reviews and Meta‐Analysis (PRISMA) guidelines. We searched PubMed, Cochrane Library, WOS, and Scopus up to June 30, 2023, to collect randomized controlled trials comparing early versus late anticoagulation for acute ischemic stroke in AF patients. The primary outcome assessed in this study was the composite efficacy outcome (as defined by individual studies). Secondary outcomes included recurrent ischemic stroke, all‐cause mortality, ICH, and mRS 0‐2 at 90 days. Using the R statistical programming language, risk ratios (RRs) with 95% confidence intervals (95% CIs) were calculated using a common‐effect model for each outcome [4].

Results

Four RCTs were included, involving 3050 patients (with 1527 patients in the early group). In the pooled analysis, early treatment group showed a significantly lower risk of composite efficacy outcome (RR: 0.71, 95% CI: 0.53‐0.96, p‐value: 0.02) compared to late treatment group. Early treatment group demonstrated a lower risk in terms of recurrent ischemic stroke (RR: 0.75, 95% CI: 0.52‐1.08), intracranial hemorrhage (RR: 0.93, 95% CI: 0.59‐1.46), and all‐cause mortality (RR: 0.88, 95% CI: 0.64‐1.22), however these results were not statistically significant. Moreover, the pooled analysis of two studies that reported mRS 0‐2 outcome at 3 months, both treatment groups were found to have similar rates but statistically insignificant.

Conclusion

This meta‐analysis, which pooled data from 3050 ischemic stroke patients with AF, early initiation of anticoagulation treatment was associated with lower risk of composite efficacy outcome. However, no statistically significant differences were found between the two groups regarding ischemic stroke, all‐cause mortality, ICH, and mRS 0‐2 at 90 days. Early anticoagulation treatment in AF patients with AIS may be as safe and effective as late anticoagulation treatment and might provide more benefit. However, more RCTs need to be conducted.
Abstract 076: 2023 Fusarium Meningitis Outbreak: Neuroendovascular Outcomes and Observations of the Angioinvasive Disease from South Texas
Authors: Sadiq Kaiser O , Desai Sohum K , Abualnadi Yazan D , Khalil Zorain M , Miller Samantha , Ravindra Vijay , Tekle Wondwossen G , Georgiadis Alexandros E , Hassan Ameer E
Published: March 2024

Introduction

The Centers for Disease Control and Prevention (CDC) issued a health advisory in response to an outbreak of Fusarium meningitis from exposure to spinal anesthesia for cosmetic surgery performed in Mexico between Jan 1 to May 13, 2023. This paper outlines the neuroendovascular and neurosurgical observations and management of this outbreak at our Comprehensive Stroke Center with a focus on angio‐invasive disease.

Methods

A retrospective chart review was performed for fungal meningitis patients that presented between April and July 2023.

Results

There were a total of 12 patients who were found to have fungal meningitis, 11 of whom were included in the final analysis with angio‐invasive Fusarium solani. The mean age was 31.7 ± 7.15. 92% of patients were female. CT and MRI were initially normal in two‐thirds of patients. No cases demonstrated positive growth on fungal cultures. Only (1→3)‐β‐D‐Glucan assays were positive in all patients who were tested. After several patients in this series developed subarachnoid hemorrhage from a ruptured mycotic aneurysm, we proceeded to institute weekly cerebral angiography protocol. This detected moderate to severe vasospasm in 75%, and aneurysms in 58%, with the most common site being the basilar artery. The aneurysms were seen exclusively in the posterior circulation. The average size of aneurysms when first detected was 5.0 ± 3.8 mm. Patients with brain aneurysms were treated with flow diversion in 57% of cases, primary coiling was performed in 14%, and the remaining expired prior to treatment. 14% in our series actually developed another episode of subarachnoid hemorrhage after treatment from a new angiographically confirmed aneurysm. All patients who presented with subarachnoid hemorrhage from mycotic aneurysms have passed or withdrawn care. With regard to vasospasm treatment, 80% had treatment with intra‐arterial verapamil and 40% underwent mechanical angioplasty. We did not perform balloon angioplasty in any case due to concern for rupture of the weakened compromised vessel walls. Finally with regard to cerebrospinal fluid (CSF) diversion; 67% underwent ventriculostomy, and a minority were converted to ventriculoperitoneal shunts. All but one patient received dual antifungal therapy with Amphotericin B and Voriconazole, and 42% were started on every other day intrathecal Amphotericin B.

Conclusion

We have found that in patients with fusarium meningitis that weekly angiographic surveillance for aneurysms and vasospasm should be performed. Conventional angiography is preferred to computed tomography angiography due to the smaller size of aneurysms. Aneurysms should be primarily coiled prior before flow diversion is attempted, and vasospastic vessels may be mechanically dilated in the setting of vessel wall necrosis.
Abstract 084: Intracranial Onyx Resolute Stenting In Idiopathic Intracranial Hypertension Patient With Pre‐existing Nickel Allergy: Case Report
Authors: Kapoor Vatsala , Tong Brian , Giurgiutiu Dan‐Victor
Published: March 2024

Introduction

Idiopathic intracranial hypertension (IIH) is a pathology involving an increase in intracranial pressure leading to symptoms including papilledema, tinnitus, and elevated cerebrospinal fluid opening pressure. Recent research has identified venous sinus stenosis as a cause of IIH, a common treatment of which is venous stenting and angioplasty. An adverse event of this procedure is in‐stent stenosis (ISS), due to either neointimal hyperplasia or hypersensitivity to an element in the stent. There has been speculation regarding whether nickel in intracranial stents is a cause of concern, due to its potential to cause a Type IV hypersensitivity reaction and ISS, which is an indicator of future stroke. The purpose of this case report is to determine if the cobalt‐based alloy Onyx Resolute intracranial stents can safely treat IIH in patients with allergic contact dermatitis to nickel.

Methods

We present a 38‐year old woman who presented with migraines and IIH with papilledema and severe pulsatile tinnitus. Headaches had been present for 5‐10 years. Ophthalmology consult revealed bilateral papilledema, upon which an MRI and MRV revealed venous stenosis. There was a 17mmHg pressure gradient measured in the patient. Patient could not tolerate acetazolamide, with kidney stones and loss of sheen in hair. Cerebral angiogram indicated right transverse‐sigmoid junction stenosis and atretic left venous sinus. The patient had an Onyx Resolute stent placed in the right transverse sigmoid junction. The Onyx Resolute stent is a Zotarolimus‐eluting stent made up of a cobalt‐based shell and a platinum‐Iridium core and is not recommended for patients with a hypersensitivity to nickel, cobalt, or chromium, but has a lower nickel content than a self‐expanding stent.

Results

Patient underwent cerebral angiogram, revealing right transverse‐sigmoid junction stenosis with a 17mmHg pressure gradient. Stenting and angioplasty were performed; this reduced the venous sinus pressure in the R transverse sinus (pre‐stenotic segment) from 43 mm Hg to 24 mm Hg with resolution of the R transverse‐sigmoid junction pressure gradient. Patient was treated with prasugrel (Effient) for one month. At the one‐month follow‐up, the patient reported an improvement of symptoms, with near‐resolution of her prior headaches in terms of severity and frequency following her procedure. Visual acuity is at baseline, pending formal follow‐up assessment for papilledema. Follow‐up CT Head Venogram with and without contrast showed a patent R transverse to sigmoid venous stent. The patient was continued on aspirin 81mg daily and prasugrel 5mg daily and is to continue follow‐up with yearly ophthalmologic exams.

Conclusion

Although there is speculation regarding the use of metal intracranial stents in patients allergic to nickel, our patient has shown that it is safe to use the Onyx Resolute intracranial stent despite a pre‐existing nickel hypersensitivity.
Abstract 101: Ophthalmic Artery Aneurysm Embolization Resulting in Resolution of Headaches and Visual Symptoms
Authors: Dasgupta Savanna
Published: March 2024

Introduction

Cerebral aneurysms are a rare cause of headaches and visual symptoms. Most common locations include anterior communicating artery, internal carotid arteries (ICAs), middle cerebral arteries, and tip of the basilar artery. While most unruptured aneurysms are asymptomatic, when symptoms do occur, they are most often headaches, cranial nerve palsies, or bilateral temporal hemianopsia due to compression of surrounding nerves or the optic chiasm. Rarely, thrombus formation within an aneurysm can lead to symptoms via distal embolization and infarction. The literature is limited regarding repeated aneurysmal microembolism formation or transient alterations in blood flow dynamics leading to episodic symptoms.

Methods

We report the case of a 55 year‐old woman with Ehlers‐Danlos syndrome and syringomyelia who presented to the hospital with one week of intermittent left eye visual disturbances, characterized by either complete transient monocular vision loss or blurriness lasting for 30 seconds at a time and occurring multiple times per day. These symptoms were also associated with pressure‐like headaches that originated around the left eye and radiated to the left side of her head.

Results

Neurological and ophthalmological examinations were notable for normal cranial nerve function, including intact visual acuity, visual fields, color vision and extraocular movements in each eye. On a dilated fundoscopic exam, there were no retinal or optic disc abnormalities. The rest of the neurological exam was normal. Head and neck CTA and subsequent digital subtraction angiography (DSA) showed multiple bilateral ICA aneurysms, as well as a 4 millimeter left ophthalmic artery aneurysm. Brain and orbits MRI with contrast showed no acute abnormalities, including no evidence of infarction or intracranial hemorrhage. She was started on clopidogrel due to concern for recurrent retinal transient ischemic attacks as well as escalating doses of nortriptyline for empiric treatment of possible ocular migraines. In follow‐up three months later, she continued to have the same visual and headaches symptoms. She underwent a successful elective flow diversion embolization of the ophthalmic artery aneurysm with subsequent resolution of her symptoms

Conclusion

Here we describe a case of a patient who presented with episodic monocular vision changes and headaches ipsilateral to an ophthalmic artery aneurysm, who experienced complete resolution of these symptoms following flow diversion embolization of the aneurysm. Although the precise pathophysiological relationship between the aneurysm and her visual symptoms is unclear, potential mechanisms include aneurysmal microthrombus formation with retinal embolization and dissolution, hemodynamic retinal blood flow changes related to the aneurysm, or recurrent ocular migraines triggered by the ophthalmic artery aneurysm.
Abstract 124: Vertebral Artery Web as a Rare Cause of Ischemic Stroke in a young male
Authors: Kaur Harsimran , Singh Romil , Cerejo Russell
Published: March 2024

Introduction

Vertebral artery web has been rarely identified compared to the frequently reported, carotid artery web as etiology of ischemic stroke. Here we present a young patient with symptomatic vertebral artery web.

Methods

Case Report

Results

35‐year‐old male presented with persistent, intermittent, bilateral visual scintillations lasting 30‐60 seconds for one month. Neurological examination positive for bi nasal superior quadrantanopia. Computed tomography (CT) of head showed patchy hypo density in right posterior circulation artery (PCA) territory. Magnetic resonance imaging (MRI) showed restriction diffusion over bilateral PCA territories right greater than left (image A). MR Angiogram head and neck showed abnormal contour within right vertebral artery in V2 segment compatible with dissection (image B). Patient’s hypercoaguable, inflammatory and rheumatological markers were unremarkable. The patient was started on aspirin 81 mg daily and Plavix 75 mg daily for three weeks followed by aspirin monotherapy. Repeat CT angiogram 11 months later still showed right V1/V2 junction irregularity (image C). DSA performed one month later revealed right cervical vertebral artery web with mild stagnation of blood flow (image D). Patient had no recurrence of symptoms and was continued on aspirin.

Conclusion

Ischemic stroke is rare in young adults. According to recent studies, prevalence of stroke in young adults’ ranges from 10‐15% of entire population stroke burden. Our case describes a young patient with posterior circulation stroke caused by a vertebral artery web which was confirmed with DSA. Vertebral artery web has limited scientific documentation throughout the literature. A literature review performed by B.J.A. Pereira et al. demonstrated that only 7.3% of vessel webs were found in the vertebral artery, compared to 91.66% in the carotid artery (3). Because of this, a review of medical literature showed limited case reports on treatment and surgical options for vertebral webs causing posterior circulation stroke. Lenck et al. first reported 3 patients with vertebral webs diagnosed by DSA and having MRI show ischemic strokes in the vascular territory were treated with endovascular stenting and had no recurrence of an ischemic event (4). A literature review reported by Pereira demonstrated that out of 23 vessel webs, 13 were treated with supportive care (including antiplatelets or anticoagulation), eight were treated with angioplasty and stenting (which included the vertebral artery web case), and two were treated with surgery (3). In other literature, Lizhang et al (2019) diagnosed an incidental vertebral artery web on DSA for anterior circulation TIA and was treated successfully with DAPT therapy and atorvastatin 20 mg (5).
Abstract 136: Antiplatelet Regimens for Secondary Prevention in Minor Ischemic Stroke or TIA: A Network Meta‐Analysis
Authors: Kelani Hesham
Published: March 2024

Introduction

There is increased risk of major cardiovascular events among patients with minor ischemic stroke or transient ischemic attack (TIA) [1]. Antiplatelet drugs have been proven to reduce the risk of major cardiovascular events and highly recommended for secondary stroke prevention in this population [2]. However, using antiplatelets has shown an increase in the risk of bleeding events. Hence there are multiple antiplatelet regimens, we aim to investigate the efficacy and safety of these different regimens in minor ischemic stroke defined as National Institutes of Health Stroke Scale (NIHSS) score of 5 or less and high‐ risk TIA).

Methods

A comprehensive literature search of (PubMed, Cochrane, Scopus, and WOS) was conducted to identify randomized controlled trials comparing different antiplatelet regimens in patients with minor ischemic stroke or TIA. Frequentist NMA was conducted to estimate relative risks (RR) and 95% confidence intervals (CI) for the outcomes of interest using R statistical programming language [3]. The primary outcome measure was recurrent stroke while secondary outcomes included, any bleeding events, serious adverse events (SAEs), hemorrhagic stroke, myocardial infarction (MI), cardiovascular mortality, and all‐cause mortality.

Results

Five RCTs with 34,941 participants were included. Compared to SAPT (aspirin alone), both DAPT regimens (aspirin + clopidogrel and aspirin + ticagrelor) demonstrated a significant reduction in stroke recurrence (RR: 0.72 with 95% CI [0.63, 0.82], P < 0.01) and (RR: 0.75 with 95% CI [0.64, 0.87], P < 0.01), respectively. However, both DAPT regimens were associated with a higher risk of bleeding events (RR: 1.95 with 95% CI [1.09, 3.50], P = 0.02), (RR: 3.07 with 95% CI [1.16, 8.15], P = 0.02), respectively. In contrast, no significant differences were observed among various antiplatelet modalities regarding all‐cause mortality, cardiovascular mortality, hemorrhagic stroke, myocardial infarction, and serious adverse events. In contrast, no significant differences were observed among various antiplatelet modalities regarding all‐cause mortality, cardiovascular mortality, hemorrhagic stroke, myocardial infarction, and serious adverse events.

Conclusion

Our findings indicate that DAPT regimens were effective in reducing stroke recurrence compared to SAPT. However, caution is warranted as both DAPT regimens were associated with a higher risk of bleeding events. Clinicians should weigh the potential benefits of reduced stroke recurrence with DAPT against the increased risk of bleeding events. Further research and clinical trials assessing both safety and efficacy are warranted to better understand the optimal prevention approach for this specific patient population.
Abstract 140: Additive Contralateral MMA Injection for Recurrent Previously Operated cSDH: Experience in 8 Consecutive Cases
Authors: Meyer Benjamen M. , Khan Muhammad W. , K Jessica , Laghari Fahad A. , Zarrin David A. , de Beaufort Jonathan C. Collard , Amin Gizal , Golshani Kiarash , Beaty Narlin B. , Bender Matthew T. , Lin Li‐Mei P. , Colby Geoffrey P. , Coon Alexander L.
Published: March 2024

Introduction

Middle meningeal artery (MMA) embolization has emerged as an adjunctive treatment in the management of chronic subdural hematomas (cSDH). After surgical cSDH evacuation, embolization offers enhanced resorption of cSDH fluid by infarcting the neomembranes at the capillary level. MMA embolization is typically performed on the side ipsilateral to the cSDH, but in the setting of recent surgical evacuation, the ipsilateral meningeal circulation is oftentimes disrupted and/or collateralized. In this situation, penetration of the membranes via an over‐the‐top contralateral injection may provide additional MMA occlusion and efficacy.

Methods

Consecutive cases of unilateral cSDH surgery with contralateral liquid embolic injection were retrospectively identified from a prospectively maintained database of the senior authors.

Results

Eight consecutive cases of recurrent cSDH after surgery were identified (average age = 76±3.5 years, all male). Five subjects (63%) had a previous craniotomy and 3 (38%) had previous burr holes. All subjects had a contralateral MMA embolization in addition to an ipsilateral MMA embolization with regards to their previous index surgery. Average recurrent cSDH thickness was 9.8±1.4mm, midline shift of 1.8±0.9mm. MMA branches embolized included both anterior and posterior (n=5, 63%) anterior only (n=2, 25%), and posterior only (n=1, 12.5%). The falx was penetrated in the contralateral MMA embolization in 3 (38%) cases. Injection of glue across the midline to previously non‐penetrated dura on the index surgery side was successfully achieved in all 8 cases. There were no periprocedural complications encountered.

Conclusion

The addition of contralateral MMA embolization for recurrent cSDH after previous surgery is a safe and potentially additive therapy that may increase the overall efficacy of MMA embolization in these challenging cases.
Abstract 157: Evaluating the Impact of Pre‐Procedural CTA on Fluoroscopy Time and Conversion Rates
Authors: Lodato Zachary , Bach Ivo , Haque Humza , Meltzer Elan , Khandelwal Priyank
Published: March 2024

Introduction

Cerebral angiography, essential in managing cerebrovascular disorders, exposes patients to ionizing radiation, with dose dependence on procedure complexity, patient's body habitus, and equipment used, raising safety concerns (1,2). Conversion from primary to secondary access site, influenced by anatomical variables, further increases procedure and fluoroscopy time (3). We propose using Computed Tomography Angiography (CTA) prior to DSA for anatomical insights, potentially reducing access site conversion, procedure time, and radiation dose/fluoroscopy time. This study evaluates the impact of pre‐procedural CTA on fluoroscopy time and access site conversion rates.

Methods

A retrospective chart review was conducted at a single center to collect data for this study. A total of 93 participants who received DSA were evaluated. Variables of interest included whether a CTA was performed prior to DSA, fluoroscopy time, fluoroscopy dose, time per vessel, dose per vessel, average number of vessels imaged, and the conversion rate from radial to femoral access. Descriptive statistics were used to summarize the data, and independent sample t‐tests were conducted to compare the means of continuous variables between the groups that received a CTA Neck prior to DSA and those that did not. All statistical analyses were performed using a significance level of 0.05.

Results

Out of 93 participants, 61 had a prior CTA neck and 32 did not. The non‐prior CTA group had slightly higher average fluoroscopy time (15.68 vs. 14.30 min, p=0.39) and dose (643.29 vs. 582.90, p=0.37), but lower time per vessel (3.42 vs. 3.65, p=0.58) and higher dose per vessel (162.80 vs. 145.01, p=0.63). They also imaged more vessels on average (4.81 vs. 4.33, p=0.09). Conversion percentage for non‐prior CTA was lower compared to the prior CTA group (6.25% vs. 6.56%) but not statistically significant. Standard deviation for all measures, except for time per vessel, was higher in the non‐prior CTA neck, indicating more variability in this group.

Conclusion

This retrospective analysis suggests that prior computed tomography angiography (CTA) might lead to reduced fluoroscopy times and dosage during procedures, but the results are not statistically significant at this stage. However, the study indicates that prior CTA cases had a higher percentage of access site conversions, though the sample size was small. Due to these findings, further investigation with a larger sample size is needed to explore these variables more thoroughly. If CTA before digital subtraction angiography (DSA) can indeed decrease procedure time, radiation exposure, and the need for access site conversion, it has the potential to significantly improve functional neurological outcomes. Moreover, it may reduce the occurrence of complications related to radiation exposure and decrease the overall costs associated with performing DSA and related neurointerventions.