bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP22: Propranolol's Potential Role in Cutting Stroke Risk for Patients With Migraine: An In-Depth Analysis of Two Databases
Authors: Jeong Eugene , Chen You , Mogos Mulubrhan
Published: January 2025

Background:
Migraine, a neurological disorder characterized by recurrent headaches, affects about 20% of the global population and is linked to an increased risk of stroke, particularly ischemic stroke. Propranolol, a non-selective beta-blocker, is widely used for migraine prevention, but its role in reducing stroke risk among migraine patients remains controversial.

Method:
Using data from the Synthetic Derivative (SD) at Vanderbilt University Medical Center (VUMC) and the All of Us Research Program, we condcuted a retrospective case-control study. Migraine and Stroke cases were identified using International Classification Disease codes (ICD 9 and 10). Stroke cases were defined as patients with a primary diagnosis of stroke after the first onset of migraine, while controls had no stroke diagnosis after the first onset of migraine. Logistic regression models adjusted for potential confounders were used to assess the association between propranolol use and stroke risk, stratified by sex. An-adjusted Cox proportional hazards regression model was fitted to estimate the hazard ratios (HR).

Results:
In the SD database, 378 cases and 15,209 controls were identified, while the All of Us database included 267 cases and 6,579 controls. Propranolol was significantly associated with a reduced risk of overall stroke in female migraine patients (SD: OR = 0.52,
P
= 0.006; All of Us: OR = 0.39,
P
= 0.007), but not in males. The protective effect was more pronounced for ischemic stroke and in females with migraines without aura. Cumulative incidence analyses showed lower stroke rates in propranolol-treated females at multiple time points within both EHR databases.

Conclusion:
Propranolol is associated with a significant reduction in ischemic stroke among female migraine patients. These findings suggest that propranolol may be beneficial not only for migraine prophylaxis but also for stroke prevention in high-risk populations. Further prospective studies are warranted to validate these results and inform clinical guidelines.
Abstract TMP33: Recanalization of intracranial vessel occlusion in Acute Ischemic Stroke and Thrombolysis “Dwell Time”
Authors: Han Alexander , Forrest Cassandra , Ciaramitaro Cody , Nimjee Shahid , Lee Vivien
Published: January 2025

Introduction:
Acute ischemic stroke (AIS) with large vessel occlusion (LVO) benefits from mechanical thrombectomy (MT), but the majority of Americans require interhospital transfer for MT. Thrombolysis at the spoke hospital with the patient transferred to the hub for MT is a model known as “drip-and-ship.” In contrast, “mothership” patients present directly to MT capable centers and have immediate access to MT. We sought to evaluate the effects of thrombolysis dwell time (time for the drug to work) and drip-and-ship versus mothership status on recanalization rates.

Methods:
Among 385 patients who received thrombolysis for AIS at our academic comprehensive stroke center from January 1, 2023 to June 30 2024, 76 patients had LVO and repeat vessel imaging available to evaluate for recanalization status. Thrombolysis dwell time was defined as the time

from administration of thrombolysis to repeat vascular imaging. Recanalization was defined as complete resolution of the occlusion. Partial recanalization was defined as some recanalization (i.e. M1 transformed into M2). Patients without vascular imaging or without repeat vessel imaging were excluded. Data was collected on demographics, last known normal time (LKN), National Institutes of Health Stroke Scale (NIHSS), thrombolysis administration time, and repeat vascular imaging results.

Results:
Among 76 AIS LVO patients, the mean age was 68.8 years (range, 25.1 to 96.8), and 40 (52.6%) were women. The mean initial NIHSS was 14.7 (range, 0 to 34). Twenty-three (30%) were mothership and 53 (69.7%) were drip-and-ship. The mean time from LKN to thrombolysis was 2.2 hours (range, 0 to 4.9). The site of LVO occlusion was as follows: 56 (76.7%) M1, 8 (10.5%) M2s occlusions, 5 (6.6%) carotid terminus, 5 (6.6%) basilar, and 2 (2.6%) PCA occlusions. In 69 (90.8%), repeat vascular imaging was cerebral angiogram. There were 7 (9.2%) complete recanalization, and 20 (26.2%) partial recanalization. Mothership status was associated with lower rates of partial recanalization (8.7% vs 34%, p 0.016) and shorter mean thrombolysis dwell time (0.9 hours vs 2.7 hours, p < 0.0001) compared to drip-and-ship status.

Conclusions:
In LVO AIS patients who receive thrombolysis, drip-and ship status is associated with higher partial recanalization rates and longer thrombolysis drug dwell time compared to mothership status. This may impact strategy for recruitment of sites in clinical trials.
Abstract TMP40: Estimates of Long-term Social Isolation Among Patients with Intracerebral Hemorrhage
Authors: Borei Karim , Bako Abdulaziz , Pan Alan , Khan Osman , Vahidy Farhaan , Potter Thomas
Published: January 2025

Introduction:
Stroke patients experience higher levels of social isolation (SI) compared to their age matched healthy cohorts which is associated with poor quality of life and increased morbidity and mortality. However, frequency and associates of SI among patients with intracerebral hemorrhage (ICH) have not been described.

Methods:
Data for adult (>18 years) primary non-traumatic ICH patients with prospectively collected Patient-Reported Outcomes Measurement Information System (PROMIS) measures and modified Rankin scores (mRS) on 1-year follow up were extracted from a stroke outcomes registry for a 7-hospital stroke certified healthcare system. Socioeconomic deprivation was measured using the state-level Area Deprivation Index (ADI; high deprivation defined as ADI > 7). Comorbidity burden was graded by Charlson Comorbidity Index (CCI). The PROMIS short form v2.0 social isolation 4a score was used to assess SI, with SI considered positive at T-scores above 54.9 and further categorized into mild (55-60) and moderate-severe (≥60). Patients with mRS ≥ 3 were considered functionally dependent. Descriptive statistics are provided as proportions (%) and medians with interquartile ranges (IQR). Demographic and comorbidity differences were assessed using chi-squared and Mann-Whitney U tests.

Results:
The cohort included 110 ICH patients (age median [IQR]: 60 [47-71], 43.6% female), of whom 20% were Hispanic and had a racial distribution of 59.0% White, 27.2% Black, 8.2% Asian, 5.5% other (Table 1). Overall, 24 (21.8%) patients experienced some degree of social isolation (54.2% mild, and 45.8% moderate-severe). Among patients with 1-year SI, 33.3% were initially discharged home, 33.3% to rehab, 16.7% to long-term acute care (LTAC), 12.5% to skilled-nursing facility, and 4.2% other. SI patients had higher comorbidity burden (vs non-isolation group; 95.8% vs. 68.6%, p=0.025), higher rates of functional dependence (70.8% vs. 30.8%, p=0.001), and higher rates of diabetes (33.3% vs 12.8%, p=0.040). Finally, patients with moderate-severe SI showed a significantly greater proportion of high socioeconomic deprivation (vs mild; 54.5% vs 7.7%, p=0.039) (Table 2).

Conclusion:
More than 1 in 5 ICH patients may experience long-term SI particularly those with higher comorbidity burden. Furthermore, long-term dependency is associated with higher likelihood of SI among ICH patients. .SI risk stratification for ICH patients is a critical gap in improving post-ICH outcomes.
Abstract TMP42: Enhancing Stroke Rehabilitation: A Quality Improvement Initiative
Authors: Gordon Clifford , Oyesanmi Olubenga , Kallins Marc , Mhaskar Rahul , Tewari Sanjiv , Garamong Lisa , Ellison-Snow Kristy , Koski Cynthia
Published: January 2025

Background:
Ischemic strokes occur due to a blood supply blockage in one of the brain’s blood vessels, and Hemorrhagic strokes occur when one of the brain’s blood vessels ruptures. The American Stroke Association cites strokes as the fifth leading cause of death in the United States. This study aimed to determine the average minutes needed for patients to achieve their Medicare-calculate goals at our inpatient rehabilitation program.

Methods:
A retrospective study of 393 patients with stroke (age
>
18: 209 men, 184 women) that received either 3 hours of therapy 5 days per week or 2 hours and 20 minutes of therapy 7 days a week for the length of their stay in our program from January 2021-December 2023.

Results:
Main outcome measures were the Medicare calculated self-care and mobility scores on admission and on discharge. 283 patients met at least one of their Medicare calculated discharge goals. Those that met their self-care goals needed less PT, OT, and ST minutes. They also had a higher AMS than those that did not meet their self-care goals. Those that met their mobility goals required more PT, OT, and ST minutes, and had a higher AMS than those that did not meet their mobility goals. Those that met both their self-care and mobility goals required more PT and OT minutes, less ST minutes, and had a higher AMS.

Discussion:
ST minutes were an independent predictor of whether people would meet their self-care goal. Patients with higher BMIs were not likely to meet their mobility goal. Patients with a higher AMS were more likely to meet their mobility goal. BMI and AMS were independent predictors of whether people met their mobility goal. There were no independent predictors as to whether patients would meet both their self-care and mobility goals. Those achieving their
self-care goal
needed an average of 831.5 minutes (PT), 826.8 minutes (OT), and 397.2 minutes (ST). Those achieving their
mobility goal
needed an average of 845.8 minutes (PT), 833.7 minutes (OT), and 403.8 minutes (ST). Those achieving both their
self-care and mobility goals
needed an average of 835.5 minutes (PT), 830.3 minutes (OT), and 417.1 minutes (ST).

Conclusion:
Stroke patients are more likely to meet their Medicare-required self-care goals if they require less ST minutes. Patients with a higher BMI and lower AMS score are less likely to meet their Medicare-required mobility goals. There was not an independent predictor for patients that met both their self-care and mobility goals.
Abstract TMP43: Age, Race, and Insurance Status Influences on Anticoagulation Therapy and Discharge Disposition: A Retrospective Analysis
Authors: Tran Vi , Tjionas Panayiotis , Bowry Ritvij , Samuel Sophie
Published: January 2025

Background:
Disparities in anticoagulation therapy, driven by race, age, and insurance status, affect access to direct oral anticoagulants (DOACs). These factors also influence discharge disposition across patient groups.

Objective:
To assess differences in anticoagulation therapy and discharge dispositions between self-pay and insured patients, with a focus on age and race.

Methods:
This retrospective cohort study analyzed 3,966 patients discharged on anticoagulation therapy for atrial fibrillation (AF), deep vein thrombosis (DVT), or pulmonary embolism (PE). Patients were drawn from neurology, cardiology, and other services. Descriptive statistics were used to compare trends across these groups.

Results:
Of the 3,966 patients, AF was the most common diagnosis (47.16% self-pay, 67.14% insured), followed by DVT and PE. DOACs were used in 59.09% of self-pay and 65.38% of insured AF patients, while warfarin was more common in self-pay AF patients (25.00% vs. 21.61%). DOAC use in DVT was 82.00% for self-pay and 78.39% for insured patients. For PE, 95.65% of self-pay and 72.40% of insured patients were discharged on DOACs. Warfarin use peaked at 27.6% for insured patients aged 70-79. Non-White self-pay patients were less likely to be discharged on DOACs compared to White patients. Specifically, 52.46% of African American self-pay patients were discharged on DOACs compared to 73.91% of White self-pay patients and 50.85% of patients from other racial backgrounds. Warfarin use was higher among non-White self-pay patients. In the insured group, DOAC usage was consistent across racial groups, with 64.71% of African American patients, 65.06% of White patients, and 63.47% of patients from other racial backgrounds discharged on DOACs. Asian patients had lower overall anticoagulant usage. Discharge disposition varied by age and insurance status; insured elderly patients were more likely to be discharged to extended care facilities. Gender disparities were also observed, with more self-pay males discharged to skilled nursing facilities compared to females (3.8% vs. 0.9%).

Conclusion:
Among insured patients, age was a more significant factor than race in determining warfarin use, with older patients more likely to receive warfarin. In contrast, among self-pay patients, non-Whites were less likely to be discharged on DOACs, highlighting the influence of race and financial status on anticoagulation therapy.
Abstract TP180: Deep Learning for Identifying Ischemic Core in Acute Ischemic Stroke Based on Non-contrast enhanced Computed Tomography
Authors: Wang Xinru , Qi Gao , Cheng Xin , Shan Hongming , Hong Lan , Dong Qiang , Liu Ying , Zhou Feng , Li Siyuan , HE ZHIJIAO , Zhang Anqi , Cao Nan
Published: January 2025

Introduction:
Although non-contrast enhanced CT (NCCT) is commonly used in emergency rooms and may be utilized to determine the extent of ischemic changes, its limited agreement between different raters prevents widespread use of NCCT in deciding whether to provide reperfusion therapies to patients with suspected acute ischemic stroke (AIS). Therefore, this study aimed to develop an automated approach for evaluating infarction in patients with AIS using NCCT.

Methods:
This multi-center retrospective study included patients with suspected AIS who presented within 24 hours from the last known well time and underwent NCCT and DWI (diffusion weighted imaging) within 3 hours between 2021 and 2024, regardless of occlusion sites and reperfusion therapies. The infarct lesions delineated on DWI were utilized as the golden reference. An UNet architecture-based infarction segmentation model was developed using data from 3 institutions (n = 949), which was divided into training and testing sets with an 8:2 split. The performance of the model was compared with the reference standard by using the Pearson correlation coefficient regarding the ischemic core volume and the Dice similarity coefficient regarding the spatial accuracy. Furthermore, the accuracy was provided to assess the discriminative ability to identify a large ischemic core.

Results:
In the entire cohort, the median time interval between CT and DWI was 49 min, and approximately half of the patients (51.3%) arrived in the late window (>4.5 hours). To better differentiate patients with a large ischemic core, the model's performance was primarily assessed by excluding the subgroup of patients with a negative to small ischemic core (≤5 ml). The model's core volume showed a strong positive correlation with the reference standard, with a Pearson correlation coefficient of 0.94 (P<0.01). Similarly, the Dice similarity coefficient indicated a strong spatial accuracy, with values of 0.601, 0.689, and 0.768 for cases >20 ml, >50 ml, and >70 ml, respectively. Moreover, the model demonstrated good performance in distinguishing a moderate to large ischemic core, with an accuracy of 83.3%, 72.2%, and 80.0% for cases >20 ml, >50 ml, and >70 ml, respectively.

Conclusion:
The UNet architecture-based infarction segmentation model on NCCT demonstrated good agreement with DWI, particularly in AIS patients with a large ischemic core, which is crucial for guiding treatment choices.
Abstract TP186: Patients with Acute Ischemic Stroke in the United States Exhibit more Dependency 90 Days after Stroke than those in a Matched Norwegian Cohort
Authors: Aamodt Eva , Rovang Martin , Beyer Mona Kristiansen , MacIntosh Bradley , Potter Thomas , Vahidy Farhaan
Published: January 2025

Introduction:
Acute ischemic stroke (AIS) imposes a disparate burden across global populations. Understanding drivers of such heterogeneity is particularly important in the context of international stroke clinical trials design. We sought to identify the differential clinical and neuroimaging characteristics, and outcomes in matched AIS cohorts from Norway (NOR) and the United States (US).

Methods:
AIS data was retrieved from the ‘Norwegian Cognitive Impairment After Stroke study (Nor-COAST; NOR) and the Registry for Neurological Endpoints among patients with Ischemic and Hemorrhagic Stroke(REINAH; US). White matter hyperintensities (WMH) and intracranial volumes (ICV) were extracted from MRI images by training a deep learning model, and the softwares FreeSurfer and FSL. Cohorts were matched on age, sex, diabetes, atrial fibrillation, and hypertension. We applied inferential statistics, as well as fit a logistic regression model to evaluate dependency (mRS >=3) in the cohorts, adjusting for age, sex, race, NIHSS, smoking, hypercholesterolemia, thrombolysis, thrombectomy, and ICV-normalized WMH.

Results:
A total of 384 matched AIS patients (192 in each cohort) were included. Demographic, clinical, and imaging characteristics along with outcomes are reported in fig. 1. The cohorts were not statistically different across the matched characteristics. Likewise, WMH burden was similar across cohorts. The NOR cohort had a significantly higher proportion of previous/current smokers and a higher prevalence of hypercholesterolemia. The US cohort had greater ethno-racial heterogenity, higher BMI, and higher NIHSS on admission. A greater proportion of the US cohort underwent IV thrombolysis (30.7% vs. 26.7%), however this difference was not statistically significant. Conversely, a significantly higher proportion of the US cohort received thrombectomies (13% vs 2.6%). The US cohort had higher levels of 90-day dependency (mRS≥3; fig. 2) as compared to NOR (39.1% vs. 17.7%). This difference translated into a significantly higher likelihood of 90-day dependency among the US patients (vs. NOR) in the fully adjusted model (OR = 2.28, 95% CI 1.23, 4.24).

Conclusion:
Cohorts from the US and Norway demonstrated significant differences in demographic, clinical, treatment profiles, and 90-day dependency after stroke. The differences may be driven by an interplay of demographic, genetic, healthcare system, socio-behavioral, and societal factors within the global stroke population.
Abstract TP190: Intracerebral Hemorrhage Laterality and Associations with Mood and Quality of Life Outcomes: A MISTIE III Substudy
Authors: Cooper Dawson , Abramson Efrat , Ziai Wendy , Flaherty Matthew , Shah Vishank , Avadhani Radhika , Ostapkovich Noeleen , Carhuapoma Lourdes , Awad Issam , Zuccarello Mario , Hanley Daniel , Sansing Lauren
Published: January 2025

Background:
The prognostic significance of the affected hemisphere in hemorrhagic stroke remains uncertain. We aimed to determine the relationship between the affected hemisphere (right or left) and differences in non-motor outcomes (pain, mood) in patients with acute intracerebral hemorrhage (ICH). These non-motor outcomes are often overlooked in studies following ICH but impact patient recovery and well-being.

Methods:
A post-hoc analysis of the MISTIE III study–a randomized, multicenter, placebo-controlled trial of participants with spontaneous, nontraumatic, supratentorial ICH of 30 mL or more that evaluated minimally invasive surgery (MIS) with thrombolysis compared to standard medical care. Prespecified outcomes included modified Rankin scale (mRS) scores, EuroQol Visual Analogue Scale (EQ-VAS), and EQ-5D 3 level version (EQ-5D-3L, composite and individual components) at 30, 180, and 365 days post-ICH. The association of ICH laterality with clinical outcomes was estimated using multiple linear regression models. Prespecified clinical covariates included gender, race (black, white, Asian, other), ethnicity (Hispanic or non-hispanic), premorbid mRS, randomization group (MIS or medical arm), and ICH severity index.

Results:
A total of 493 participants were eligible for analysis at day 30 post-ICH. In multivariable analyses, patients with a right hemispheric ICH were more likely to report problems with pain and discomfort at days 30 (β=0.257, [0.131, 0.383], p<0.001), 180 (β=0.213, [0.090, 0.336], p<0.001) and 365 (β=0.209, [0.090, 0.328], p<0.001) post-ICH. Patients with right hemispheric ICH were also more likely to report problems with anxiety and depression at days 30 (β=0.160, [0.030, 0.291], p<0.05) and 180 (β=0.171, [0.049, 0.293], p<0.01) post-ICH. There were no differences between patients with left or right-sided hemorrhages regarding mRS scores.

Conclusions:
Right hemispheric lesions were independently associated with increased reports of anxiety and pain in patients with acute ICH across time despite no differences in mRS. Further studies on these outcomes and patient recovery are needed.
Abstract TP205: Alzheimer’s Disease and Risk of Intracranial Hemorrhage
Authors: Zhang Cenai , Bruce Samuel , Navi Babak , Murthy Santosh , Kamel Hooman
Published: January 2025

Introduction:
Alzheimer’s Disease (AD), characterized by extracellular deposition of amyloid beta (Aβ) plaques in brain tissue, is often comorbid with cerebral amyloid angiopathy, which carries an elevated risk of intracranial hemorrhage. Furthermore, severe hemorrhagic complications have been observed following the use of new Aβ-targeted immunotherapies for AD. However, there are limited population-based data regarding the risk of intracranial hemorrhage associated with AD.

Methods:
We performed a retrospective cohort study using inpatient and outpatient claims between 2008-2018 from a nationally representative 5% sample of Medicare beneficiaries ≥65 years of age. The exposure variable was AD, defined by
ICD-9-CM
code 331.0 and
ICD-10-CM
code G30.x. The primary outcome was non-traumatic intracranial hemorrhage, defined as a composite of intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and subdural hemorrhage (SDH) using validated
ICD-9-CM
and
ICD-10-CM
diagnosis codes. Secondary outcomes were ICH, SAH, and SDH assessed separately. Cox proportional hazards models were used to determine the associations between AD and outcomes after adjustment for demographics, vascular risk factors, and Charlson comorbidities.

Results:
Of 2,107,151 patients included, 87,751 (4.1%) had a diagnosis of AD. A total of 14,400 (0.7%) patients were diagnosed with ICH, 6,003 with SAH (0.3%), and 6,650 (0.3%) with SDH. In multivariable Cox proportional hazards analysis, AD was associated with an increased risk of intracranial hemorrhage (adjusted hazard ratio [aHR], 1.54, 95% confidence interval [CI], 1.44-1.65). In adjusted analyses of secondary outcomes, AD was associated with an increased risk of ICH (aHR, 1.35; 95% CI, 1.23-1.48), SAH (aHR, 2.59; 95% CI, 2.26-2.97), and SDH (aHR, 2.05; 95% CI, 1.83-2.30).

Conclusions:
In a nationally representative cohort of Medicare beneficiaries, AD was associated with an increased risk of spontaneous intracranial hemorrhage. This increased risk was also present for ICH, SAH, and SDH when examined separately.
Abstract TP215: Impact of Carotid Stenosis on Cerebral Glucose Metabolism
Authors: Vallamchetla Sai Krishna , Jain Manoj , Young Jason , Shourav Md Manjurul Islam , Abdelkader Omar , Lin Michelle
Published: January 2025

Background:
Carotid stenosis has been associated with stroke and cognitive impairment. It remains unclear if hypometablism, a marker for neurodegeneration, may be in the mechanistic pathway in the association between carotid stenosis and cognitive decline. This study aims to investigate whether patients with carotid stenosis exhibit reduced cerebral glucose metabolism, using 18-FDG PET imaging as a sensitive measure of brain’s glucose metabolism.

Methods:
We have identified 138 patients from one health care system who underwent 18-FDG PET imaging and had extracranial carotid imaging (doppler ultrasound/CT angiography/MR angiography) within 1 year of PET scan. Severity of carotid stenosis was defined using NASCET criteria as <50% (mild), 50-69% (moderate), >70% (high-grade). Cerebral glucose metabolism was quantified by measuring standardized uptake value ratio (SUVR) after normalizing to pons in 12 different regions of interest (ROI). Hypometabolism was defined using the cutoff of SUVR <1.41. SUVR and hypometabolism measures were compared across severity of carotid stenosis.

Results:
Of 138 patients identified, 54 were excluded due to indeterminant ipsilateral hemisphere status. Mild, moderate and severe stenosis was present in 86.9%, 4.8%, 8.3%, respectively. The analysis revealed a numerically reduced cerebral glucose metabolism in patients with moderate to severe carotid stenosis compared to control subjects (Table 1). The most pronounced decrease in FDG uptake was observed in regions supplied by the affected carotid artery, particularly the ipsilateral cortical areas. There was a numerically increased risk of hypometabolism with increasing carotid stenosis: Adjusted odds of hypometabolism ipsilateral to the carotid stenosis were 2.90, 5.56 across patients with moderate and high-grade carotid stenosis in sensorimotor cortex (trend-P=0.095). These findings were consistent across different regions supplied by the stenotic carotid artery but attenuated in territories supplied by unaffected posterior arteries (Table 2).

Conclusions:
FDG-PET imaging demonstrates reduced glucose metabolism in patients with carotid stenosis, suggesting that cerebral hypoperfusion may contribute to the metabolic disturbances observed in these patients. These results underscore the importance of early detection and management of carotid stenosis to mitigate potential cerebral metabolic deficits and the associated risk of dementia and ischemic stroke.
Abstract TP224: Design of Extracranial-Intracranial Bypass Surgery for Symptomatic Chronic Middle Cerebral Artery Occlusion Trial (CMOSS-2)
Authors: Ma Yan , Wang Tao , Wang Haibo , YANG YIFAN , Wang Jie , Derdeyn Colin , Gu Yuxiang , Jiao Liqun
Published: January 2025

Rationale:
Uncertainty exists over the optimal treatment for chronic middle cerebral artery occlusion (MCAO). However, with strict perioperative management and surgeon selection, the CMOSS trial exhibited lower perioperative stroke risk than previous trials. In the subgroup analysis, EC-IC bypass exhibited a relatively better effect for patients with hemodynamically impaired MCAO.

Aim:
We aim to determine the efficacy and safety of EC-IC bypass for patients with hemodynamically impaired MCAO.

Methods and Design:
The CMOSS-2 trial is a government-funded, multi-center, prospective, randomized, open-label, blinded-endpoint (PROBE) trial, which will recruit patients with symptomatic MCAO (parallel design, 1:1 allocation ratio) and severe hemodynamic insufficiency defined by brain CT perfusion (MTT≥6s or rCBF≤0.8). Thirteen high-volume centers are included. Patients will be randomized to EC-IC bypass surgery plus medical treatment or medical treatment alone.

Study Outcomes:
The primary outcome is the ischemic stroke in territory of qualifying artery within 2 years after randomization. Key secondary outcomes are: Any stroke or death within 30 days after randomization, ischemic stroke in territory of qualifying artery beyond 30 days to 2 years after randomization, any stroke or death within 30 days, or ischemic stroke in territory of qualifying artery beyond 30 days to 2 years after randomization.

Sample Size Estimates:
The estimated difference is 10% in proportions of the primary outcome between the EC-IC bypass group and medical group, which requires 420 (210 per group) participants to provide valid data to achieve a statistical power of 80% and two-tailed alpha of 5% significance after 10% loss to follow-up or early withdrawal.

Discussion:
CMOSS-2 study is expected to confirm the effect of EC-IC bypass surgery for symptomatic MCAO patients through the stricter standard for perioperative risk factors management, surgeon screening, and hemodynamic impairment definition.

Trial Registration:
ClinicalTrials.gov NCT05899582; registered 15 September 2023.

Sponsor:
Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support (ZLRK202320).
Abstract TP232: Thrombolytic Transition to Tenecteplase Improves Door-to-Puncture Times: The Lone Star Stroke Consortium
Authors: Luo Anqi , Bandela Sujani , Goldberg Mark , Gealogo Brown Gretchel , Jafarli Alibay , BEHROUZ Reza , Slusher Andrew , Prasad Sidarrth , Olson Daiwai , Gebreyohanns Mehari , prabhakaran Akshaya , Denbow Maria , Anderson Jane , Kimmel Barbara , Warach Steven , Savitz Sean , Flores Salvador Cruz , Birnbaum Lee
Published: January 2025

Introduction:
Thrombolytic and mechanical thrombectomy therapies are the current standard of care for large vessel occlusion (LVO) stroke. Multiple studies emphasized the impact of time metrics on patient outcomes, particularly door-to-needle and door-to-puncture (DTP) times. Tenecteplase (TNK) offers potential advantages over alteplase (tPA), including a simplified one-time bolus administration, which may reduce DTP time. While studies suggested TNK is non-inferior to tPA in terms of clinical outcomes, few large cohort studies have compared DTP times between patients receiving TNK or tPA prior to thrombectomy. This study aimed to compare DTP times and outcomes at discharge in patients treated with TNK versus tPA before thrombectomy.

Methods:
We conducted a retrospective analysis of patients treated at three comprehensive stroke centers (CSC) in Texas, United States that transitioned from tPA to TNK between October 2019 and March 2023. The study included patients who received either tPA or TNK followed by thrombectomy and excluded those with DTP times exceeding 180 minutes. Baseline characteristics were compared. The primary outcome was DTP time. Secondary outcomes were TICI scores and ambulatory status upon discharge. Data was extracted from Get with the Guidelines (GWTG) Stroke Patient Management Tool.

Results:
A total of 102 patients were included, with 53 receiving TNK and 49 receiving tPA. Baseline characteristics were similar between groups (Table 1). Patients in the TNK group had significantly faster DTP time compared to the tPA group, with a median time (IQR) of 81 [65, 105] vs 104 [81, 128] minutes (P=0.005) (Figure 1). No significant differences were observed in door-to-needle, door-to-imaging, or imaging-to-needle times; however, the needle-to-puncture time was notably shorter in the TNK group, median (IQR) 43 [27, 63] vs 60 [43, 83] minutes (P=0.003) (Figure 2). There were no significant differences between the groups in terms of TICI scores or ambulatory status upon discharge.

Conclusion:
Our analysis of CSCs that transitioned to TNK found reduced DTP times compared to tPA. This finding was driven by shorter needle-to-puncture times and thus, may be due to the simplified, single bolus TNK administration. Both TNK and tPA groups yielded high rates of successful recanalization and similar functional outcomes at discharge. Given its faster DTP time, TNK may be a better option for LVO stroke patients requiring both thrombolysis and thrombectomy.
Abstract TP239: Rescue Angioplasty with or without stenting after failed thrombectomy in Medium / Distal Vessel Occlusions: A retrospective analysis of a large international multi-center registry.
Authors: Anastasiou Aikaterini , Brehm Alex , Mujanovic Adnan , Carmona Tomas , Moreu Manuel , Maurer Christoph , Nguyen Thanh , Michel Patrik , Machi Paolo , Kuwahara Shuntaro , Wenderoth Jason , Karwacki Grzegorz , Tessitore Agostino , Rollo Claudia , Inoa Violiza , Rautio Riitta , Romano Daniele , Clarke Julian , Hui Ferdinand , Weiss Daniel Arvid , Cognard Christophe , Schulze-Zachau Victor , Rommers Nikki , Katan Mira , Psychogios Marios
Published: January 2025

Background:
There are limited therapy options in case of failed reperfusion after stent-retriever and/or aspiration based endovascular treatment (EVT) for acute ischemic stroke. Despite the absence of data supporting its use, rescue angioplasty (RA; with or without stent implantation) is often utilized in such cases. Studies are limited to large vessel occlusions, while the outcomes and complications after RA in medium/distal vessel occlusions (MDVOs) have not been reported. This study aims to report the outcomes of RA in MDVO stroke patients.

Methods:
We performed a retrospective sub-analysis of the “Blood pressure and Antiplatelet medication management after reScue angioplasty after failed Endovascular treatment in Large and distal vessel occlusions with probable IntraCranial Atherosclerotic Disease” (BASEL ICAD) registry. All MDVO stroke patients were included in the analysis.

Results:
Out of 718 patients, 92 (12.8%) presented with an MDVO. Sixty-one patients (65.9%) presented with an occlusion of the M2 segment of the middle cerebral artery. Rescue stenting (RS) was performed in 83 patients (90.2%) and balloon angioplasty alone was performed in 9 patients (9.8%). Successful reperfusion (modified thrombolysis in cerebral infarction (mTICI) score ≥ 2b) before RA was achieved in 34 patients (36.9%) and after RA in 76 (82.6%) patients. Symptomatic intracranial hemorrhage (sICH) occurred in 8 patients (9.1%) and post-treatment stent occlusion in 14 patients (16.7%). 90 days mortality was 24.1%. Twenty-nine patients (34.9%) achieved functional independence at 90 days (modified Rankin Scale 0 – 2).

Conclusion:
Rescue Angioplasty might be a viable treatment option in case of failed reperfusion after conventional EVT in selected MDVO patients. However, safety concerns remain.
Abstract TP249: Atrial Fibrillation Is Associated With Lower Likelihood Of First Pass Effect In Thrombectomy For Medium Vessel Occlusion Acute Ischemic Stroke
Authors: Elgendy Omnea , Dubinski Michael , Yi Zixin , Patel Karan , Penckofer Mary , Santucci Joshua , Ballout Ahmad , Khalife Jane , Thon Jesse , Schumacher Hermann , Hanafy Khalid , Patel Pratit , Tonetti Daniel , Shaikh Hamza , Jovin Tudor , Koneru Manisha
Published: January 2025

Introduction:
First pass effect (FPE) in endovascular thrombectomy (EVT) is associated with favorable treatment course and recovery, making it an important prognostic indicator for patients undergoing EVT. Atrial fibrillation (AF) related strokes have been shown to be associated with greater rates of FPE in acute large vessel occlusions; however, the association between AF and FPE in medium vessel occlusions (MeVO) is unknown. We aimed to assess the association between AF and achieving FPE in MeVO.

Methods:
A prospectively-maintained retrospective registry of adult acute ischemic stroke patients was retrospectively reviewed (10/2019-10/2023). Patients undergoing EVT for a MeVO in a middle cerebral artery segment (M2/M3) were included. Multivariable logistic regressions with 2500 bootstrap iterations for modified FPE (mFPE, defined as modified Treatment in Cerebral Infarction [mTICI] 2B/2C/3) and FPE (mTICI 2C/3) was performed using the following covariables: age, sex, comorbid conditions, anticoagulation/antiplatelet use, premorbid modified Rankin score, admission National Institutes of Health Stroke Scale, Alberta Stroke Program Early Computed Tomography Score, occlusion location and laterality, thrombolytic administration, and EVT approach (either aspiration-only or combination aspiration with stent retriever). Receiver operator characteristics curve analysis was performed to derive area under the curve (AUC) to assess model performance.

Results:
Of 67 patients included, median age was 70 years (IQR 63-82). Most occlusions were in the distal M2 segment (88.1%). Rate of mFPE was 58.2% (39/67); rate of FPE was 34.3% (23/67). In multivariable regressions, AF (adjusted OR 0.04, 95% CI 0.01-0.49, p=0.01) and lack of antiplatelet/anticoagulant use (adjusted OR 0.05, 95% CI 0.01-0.71, p=0.03) were independently associated with lower likelihood of mFPE. AF was the only covariable significantly associated with lower odds of FPE (adjusted OR 0.08, 95% CI 0.01-0.63, p=0.02). Models for mFPE and FPE had AUCs of 0.86 (95% CI 0.78-0.94) and 0.80 (0.75-0.85), respectively.

Conclusion:
AF was associated with a significantly lower likelihood of FPE and mFPE in thrombectomy for MeVOs. This may suggest a need to prepare for additional passes and rescue intraprocedural strategies in EVT for MeVO patients with AF. Future studies are needed to further investigate this relationship.
Abstract TP25: Benefits and Risks of Antiplatelet Versus Thrombolysis for Mild Acute Ischemic Stroke: Update of a Living Systematic Review and Meta-analysis
Authors: Qin Mingzhen , Qi Baoyun , Shi Xinyi , Xu Dan , Zhou Congren , Cheng Sisong , Zhang Chi , Gao Ying
Published: January 2025

Background:
Previous study found that compared with thrombolysis, antiplatelet did not improve outcomes but reduce the risk of symptomatic intracranial hemorrhage(sICH) for mild acute ischemic stroke(AIS) defined as National Institutes of Health Stroke Scale score 0 to 5. As relevant studies have been released recently, the benefits and risks of the two treatments are still unclear based on latest evidences.

Objective:
To compare the efficacy/effectiveness and safety of antiplatelet with thrombolysis for mild AIS in the first update of a living systematic review and meta-analysis.

Methods:
MEDLINE, Embase and Cochrane Library were systematically searched from July 2023 until August 2024. Randomized clinical trials(RCTs) and observational studies were selected and checked eligibility for inclusion based on the same criteria as before. The primary outcome was 90-day functional outcome measured by the modified Rankin Scale(mRS). Data extraction and certainty of evidence assessment were conducted in duplicate. This study was registered in the PROSPERO.

Results:
Since July 2023, two new studies were added, for a total of three RCTs and five observational studies with 5526 patients(3333 treated with antiplatelet and 2193 treated with thrombolysis). There were no significant differences between antiplatelet and thrombolysis in 90-day functional outcome(mRS 0-1, odds ratio, 0.96 [95% CI, 0.68 to 1.35]; mRS 0-2, odds ratio, 1.06 [95% CI, 0.73 to 1.51]), and stroke recurrence(odds ratio, 1.19 [95% CI, 0.73 to 1.93]). Compared with thrombolysis, antiplatelet was significantly associated with reduced risks on death(odds ratio, 0.36 [95% CI, 0.18 to 0.71]), and sICH(odds ratio, 0.21 [95% CI, 0.08 to 0.56]).

Conclusions:
In patients with mild AIS, antiplatelet was similar in functional outcomes and stroke recurrence against thrombolysis, but reduced the risks of death and sICH. Thrombolysis should be used with caution in such patients in clinical practice.
Abstract TP253: Can the clot meniscus and claw signs predict thrombectomy and clinical outcomes in stroke patients? A Systematic Review and Meta-Analysis
Authors: Reda Abdullah , Cortese Jonathan , Gajjar Aryan , Douri Dani , Ghozy Sherief , Kallmes David F
Published: January 2025

Background:
Angiographic shape of occlusion, like the clot meniscus sign and the claw-sign, have been reported to potentially impact recanalization rate and clinical outcome in patient undergoing mechanical thrombectomy for acute ischemic strokes.

Method:
Following PRISMA guidelines, a systematic literature search was conducted across PubMed, Scopus, and Web of Science databases. Patients were grouped into clot meniscus/claw sign positive and negative groups based on the definitions obtained from each study. Primary outcomes included technical success, with a meta-analysis performed using a random-effects model to calculate proportions and odds ratios (OR) with 95% confidence intervals (Cl).

Results:
We included seven studies recruiting 1572 patients. The results indicated that the positive and negative groups had comparable first-pass effect (OR: 1.95; 95%CI: 0.76 – 5.01; P = 0.167) and final recanalization (OR: 1.36; 95%CI: 0.81 – 2.27; P = 0.248) rates. However, the rate of having a favorable functional outcome was significantly higher in the positive than negative sign groups (OR: 1.91; 95%CI: 1.25 – 2.92; P < 0.003). Within the sign-positive population, the use of contact aspiration was associated with a significantly higher rate of recanalization compared to using a stent retriever (OR: 0.18; 95%CI: 0.07 – 0.49; P < 0.001). This result did not translate into a clinical impact, as both stent retriever and contact aspiration showed comparable rates of functional independence at three months (OR: 0.22; 95%CI: 0.02 – 2.33; P = 0.210).

Conclusion:
The presence of the clot meniscus/claw sign is not associated with recanalization outcomes after thrombectomy. However, it might be a good sign to predict which thrombectomy technique might be associated with better recanalization, although current evidence might need further confirmation.
Abstract TP254: Endovascular thrombectomy versus medical management for large vessel stroke patients with infective endocarditis
Authors: Chen Huanwen , Colasurdo Marco , Khunte Mihir , Malhotra Ajay , Gandhi Dheeraj
Published: January 2025

Background:
The safety and efficacy of endovascular thrombectomy (EVT) for large vessel occlusion (LVO) strokes associated with infective endocarditis (IE) compared to medical management (MM) is unclear.

Methods:
In this nationwide analysis of hospitalizations in the United States, we assessed the outcomes of EVT vs. medical management (MM) for LVO patients with IE. Primary outcome was routine discharge to home with self-care. Secondary outcomes include discharge to home, in-hospital mortality, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Propensity score matching (PSM) was performed to adjust for confounders. Additional multivariable adjustments were performed for doubly robust analyses.

Results:
2,574 patients were identified; 656 (25.5%) received EVT. After PSM, EVT was associated with more favorable hospitalization outcomes (Figure 1). The rate of routine discharge was significantly higher for EVT patients compared to MM (14.6% vs. 8.5%, p=0.021), and EVT patients had significantly higher rate of home discharge (34.5% vs. 26.5%, p=0.041), lower rate of in-hospital death (14.8% vs. 25.2%, p=0.002), and lower rate of ICH (15.8% vs. 23.1%, p=0.039). EVT was not associated with a different rate of SAH compared to MM (11.2% vs. 7.9%, p=0.17). These associations remained unchanged with additional multivariable adjustments.

Conclusion:
For LVO stroke patients with IE, EVT was associated with significantly higher odds of favorable hospitalization outcomes and lower odds of ICH compared to MM.
Abstract TP261: Stroke in pediatric heart transplant patients
Authors: Ubeda Tikkanen Ana , Ferreira Fabiana , Vanderpluym Christina , Esteso Paul , Rivkin Michael
Published: January 2025

Introduction:
Pediatric heart transplant (PHT) recipient survival has improved. Yet, neurologic morbidity related to heart failure and its treatment persist. It can affect the functional outcome, increase risk of major adverse events, prolong LOS and increase the use of rehabilitation therapies (RT). We aim to describe the clinical characteristics, functional status and RT use of PHT Pts with stroke during the PHT admission.

Methods:
Retrospective cohort study of consecutive PHT Pts at a tertiary center between 09/01/2012 and 09/30/2022. Demographic, and pre-, intra-, and post-PHT clinical, brain imaging and RT (physical, occupational, speech and feeding therapy) data were collected up to PHT hospitalization. Data are presented as frequency (%) or median (Inter Quartile Range-IQR).

Results:
Of the 83 PHT Pts 34(40%) of them had a stroke 20(59%) pre-PHT, 7(21%) post-PHT, 4(12%) pre- and post-PHT and unknown timing in 3(9%). Median age of HT in these Pts was 6 yrs(1,13) (Table 1), 21(62%) were male. CHD was the pre-PHT diagnosis in 21(62%) of stroke Pts, cardiomyopathy in 12(35%) and acquired heart disease in 1(3%). Mechanical circulatory support were used in 27(79%) PHT with stroke.

Total no. of distinct areas of neurologic injury on brain MRI was 85 (Table 2). Neurologic events per imaging were 2(1, 2). MCA was affected in 22(26%), PCA 8(9%), ACA 8(9%), MCA+ACA 5(6%), and MCA+PCA 2(2%). Additionally, 38(45%) were ischemic and 34(40%) were hemorrhagic strokes.

Of the acute and/or sub-acute brain MRI findings with known stroke dates(N=41), the week prior, 8(20%) of Pts had a cardiac surgery, 4(10%) had a cardiac cath, 3(7%) had a cardiac arrest, 7(17%) had an arrest+procedure, 5(12%) arrest+cath, 3(7%) had a cath+ procedure, and 1(3%) had an arrest+cath+procedure.

Of the 41 brain MRI findings with known stroke dates, 1 day prior, 8(24%) pts were on anticoagulation agents, 10(24%) on antiplatelet, 15(37%) were on both, and 8(20%) were on neither. Pts who required ECMO and/or VAD(76%) had more strokes.

Total LOS for Pts with strokes was 91 days(28, 167) vs. the total HT cohort 117 days(58, 186). Of the stroke Pts, Pre-HT and Post-HT RT were required in 27(79%) and 31(91%), respectively (Table 3). Acute inpatient rehabilitation was required in 9(26%).

Conclusions:
Strokes are found in almost half of PHT Pts. Most of them occur pre-HT. Cause of stroke is likely multifactorial. Their functional status is frequently impacted and requires RT pre- and post-HT.
Abstract TP268: Xylitol, Xylose, and MicroRNAs Associated with Thrombosis and the Clotting Cascade in a Multi-Omics Cross-Sectional Study of Adults at Risk for Type 2 Diabetes and Stroke
Authors: Lewis Kimberly , Stroebel Benjamin , Longoria Kayla , Kanaya Alka , flowers elena
Published: January 2025

Introduction:
Xylitol, a sugar alcohol with a global market estimated at 161,500 metric tons, has been linked to increased thrombosis and risk of stroke and heart attack. Older adults with obesity and metabolic syndrome may have decreased elimination of the xylitol metabolite xylose, which may explain the higher observed risk of thrombosis and stroke in older adults who consume foods with sugar alcohols. MicroRNAs (miRs) have been associated with thrombosis and the blood clotting cascade and can provide additional insight about pathogenesis or biomarkers to help establish safe dietary intake guidelines. However, multiomics studies of both xylitol metabolites and these miRs in humans have not been done. This study aims to measure these associations in a sample of adults with obesity and metabolic syndrome.

Methods:
We analyzed data from a subset of
N
=70 obese adults with metabolic syndrome who had both baseline metabolome and miR data from the PRYSMS randomized controlled trial. Pearson's correlations were used to test associations between xylitol, xylose, and 20 miRs associated with thrombosis and the clotting cascade, using the false discovery rate method to adjust for multiple comparisons.

Results:
Participants were 55 ± 6 years (range 32-65) and 24% male. The mean BMI was 35.2 ± 7.4 kg/m2, HbA1c was 5.9% ± 0.4, fasting blood glucose was 103 ± 13 mg/dL, HDL cholesterol was 49 ± 10 mg/dL, and triglycerides were 173 ± 63 mg/dL. Xylose concentrations were inversely correlated with six miRs (miR-15b, miR-151a-3p, miR-151a-5p, miR-151b, miR-24-3p, and miR-27a-3p). Relevant target proteins of these miRs may include Factor XI (F11), Fibrinogen Alpha (F1 or FGG_A), Coagulation Factor VIII (F8), Von Wilebrand Factor (VWF), and Toxoplasma gondii (TFP1).

Conclusion:
Our findings demonstrate an inverse association between xylose levels and six miRs associated with thrombosis and the clotting cascade in adults with obesity and metabolic syndrome. Xylitol metabolite concentration was not associated with any miRs in our sample, suggesting that circulating xylose may be a better indicator of clotting risk. Dietary intake of xylitol-containing foods may provide additional detail about these associations. Future research should explore multiomics relationships to refine and validate these results, to provide a more complex understanding of the biological processes involved for people at risk of T2D and stroke, and to help establish safe guidelines for dietary xylitol intake.