bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 053: Reduced‐Dose Ticagrelor Versus Full‐Dose Ticagrelor Versus Clopidogrel In Acute Stroke Management: A Retrospective Cohort Study
Authors: Desai Harsh , Tarabichi Ammar , Morsi Rami , Kothari Sachin , Carrion‐Penagos Julian , Metman Okker Verhagen , Smith Matthew , Baskaran Archit , Rana Rohini , Thind Sonam , Narala Vanshika , Thodupunoori Sharanya , Vayani Omar , Coleman Elisheva , Brorson James , Mendelson Scott , Mansour Ali , Prabhakran Shyam , Kass‐Hout Tareq
Published: March 2024

Introduction

Ticagrelor use has become more prominent in acute ischemic stroke management in the presence of clopidogrel resistance(1‐2). This study compares the effectiveness of aspirin plus ticagrelor at different doses versus clopidogrel in reducing the risk of recurrent stroke and other thrombotic events without increasing the risk of bleeding.

Methods

We performed a retrospective chart review of patients diagnosed with acute ischemic stroke at a large academic comprehensive stroke center from September 1, 2020, to July 1, 2022. A total of 3 separate groups, low‐dose ticagrelor (45 mg or 60 mg twice a day), full‐dose ticagrelor (90 mg twice a day) and clopidogrel (75 mg daily) were created. We compared baseline characteristics and completed a one‐way ANOVA to analyze for outcome measures such as in‐hospital mortality, 90‐day mortality, favorable functional outcome defined as modified Rankin Score (mRS) of 0‐2, at 90 days, symptomatic intracranial hemorrhage (sICH) and asymptomatic hemorrhage (aICH) between groups. All data was analyzed via IBM SPSS v28.0.

Results

A total of 445 patients were included in our study. The mean age was 66.1 ± 12.8 years and the majority of patients were female (52.9%). The most common ethnicity was African American (82.9%). Sixty patients were discharged on low‐dose ticagrelor, 39 on full dose ticagrelor and 351 on clopidogrel. A total of 162/433 (36.0%) had a presumed stroke etiology of intracranial atherosclerotic disease (ICAD). Only 24 patients received intravenous thrombolytics (5.3%) and 47 had stent placement (10.4%). Out of 445 patients, 288 were on aspirin 81 mg at time of discharge. Of that group, 228 were on both aspirin and clopidogrel, 60 were on aspirin and low‐dose ticagrelor and 39 were on aspirin and full‐dose ticagrelor. There was no statistical significance for new or recurrent ischemic stroke between groups (low‐dose vs full‐dose vs clopidogrel) determined by one‐way ANOVA (10.0% vs. 17.9% vs. 7.8%, F(2,103) = 0.01, p=0.99). Symptomatic ICH was also similar between the groups (3.3% vs. 2.6% vs. 1.1%, F(2,101) = 0.68, p=0.51). There was no significance for favorable functional outcomes and mortality as well (26.7% vs. 23.1% vs. 24.2%, F(2,173) = 0.62, p=0.54; 80.0% vs. 79.5% vs. 81.5%, F(2,150) = 1.5, p=0.22).

Conclusion

These findings suggest that a lower dose of ticagrelor may be a safe and effective alternative to full dose ticagrelor or clopidogrel for the prevention of recurrent ischemic stroke without increasing hemorrhagic complications. Larger randomized trials are necessary to further evaluate these findings.
Abstract 098: Symphony of Risk: A Case Report of Carotid Artery Dissection Associated with Violin Playing
Authors: Díaz Paulina , Dawod Giana , Michaelson Nara , Greenberg Norman , Oh Stephanie , Ehidom Clinton , Janocko Nicholas
Published: March 2024

Introduction

Carotid artery dissection (CAD) is an uncommon and potentially life‐threatening condition that can have a delayed presentation. More commonly associated with blunt cervical trauma, CAD due to repetitive stress to the neck goes under‐recognized, making it challenging to diagnose. Herein, we aim to shed light on a unique instance of CAD after continuous microtrauma, as well as highlight diagnostic challenges associated with CAD.

Methods

We present a case of a 57‐year‐old man who presented with a one‐week course of unequal pupils, left‐sided headaches, left sided ptosis, and intermittent blurry vision. Exam revealed a callous where he held a violin against his left neck, having endorsed playing for several years with repeated contortion of his head to the left (Figure 1A). Magnetic resonance angiogram (MRA) of the head and neck revealed an acute dissection of the left internal carotid artery (ICA) (Figure 1B). A diagnosis of Horner’s syndrome secondary to acute dissection of the left cervical ICA was made. Consent to share this information was obtained from the patient and witnessed by another physician.

Results

MRA head and neck showed a 2.5 cm irregularity of the distal left ICA with high signal on fat saturated T1‐weighted images consistent with an acute dissection (Figure 1B). The patient underwent an apraclonidine test and was positive for left sided Horner’s syndrome with reversal of anisocoria after application of drops (Figure 1C). Given no evidence of stroke or thrombus on imaging, he was placed on dual antiplatelet therapy (DAPT) for three months. He was advised not to play violin for a month and to restart cautiously with a pad between his neck and the instrument. Follow‐up imaging showed eventual resolution of the CAD, while physical exam revealed improvement in ptosis and miosis.

Conclusion

While playing the violin involves repetitive stress on the neck, there is limited research on this specific activity as a cause of carotid artery dissection, making it a rare occurrence. Common clinical manifestations of CAD include neck pain, headache, Horner’s syndrome, tinnitus, stroke, and lower cranial nerve palsies, occurring suddenly or over time. Diagnosing CAD typically involves a combination of thorough history, physical examination, and diagnostic imaging. Ongoing research in the optimal management of CAD focuses on minimizing the risk of stroke, after factoring in variables such as location of dissection and whether it is symptomatic or not.
Abstract 122: Mechanical Thrombectomy for Acute Stroke in the Elderly: A Single‐Center Case Series in the Philippines
Authors: Garrido Gwen G. , Soliven Jo Ann R.
Published: March 2024

Introduction

Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke (AIS) caused by large‐vessel occlusion. However, the extent of its benefits in elderly populations remains uncertain, as most landmark trials on MT have focused on younger individuals. This single‐center case series aims to shed light on the advantages and disadvantages of MT in higher age groups, particularly within the context of low‐ or middle‐income countries.

Methods

Between January 2018 and June 2023, we conducted a chart review of five patients aged ≥80 years who underwent MT for stroke. The study analyzed the patients' premorbid comorbidities, time to treatment, revascularization rates, procedural complications, mortality, and 90‐day modified Rankin Scale (mRS) scores.

Results

The five cases included individuals aged between 81 and 94 years. Among them, two had mild baseline disability (mRS score 0‐1), and three had moderate baseline disability (mRS score 2‐4). Upon admission, the National Institutes of Health Stroke Scale (NIHSS) scores ranged from 14 to 24. Three of the patients received pre‐thrombectomy intravenous thrombolysis with Alteplase and subsequently underwent MT within 4 to 7 hours of symptom onset. Successful recanalization (TICI score 2b‐3) was achieved in all five patients. However, two patients developed symptomatic intracranial hemorrhage post‐thrombectomy, and one of them succumbed to the complication. Three out of the four discharged patients attained favorable clinical outcomes with a 90‐day mRS score of 0‐2 or equivalent to their prestroke disability.

Conclusion

Our case series suggests that elderly individuals can potentially achieve favorable functional outcomes after MT. Nevertheless, this potential is influenced by stroke severity and the success of the treatment. As the elderly population, including octogenarians, nonagenarians, and centenarians, is expected to grow in the future, cautious patient selection should be exercised when considering thrombectomy in this age group. Further research comparing endovascular and conventional treatments in the elderly is imperative to inform better clinical decisions.
Abstract 123: First Off‐Label Use of the XIENCE Skypoint Stent for Mechanical Thrombectomy Rescue
Authors: Mahmoud Noor A
Published: March 2024

Introduction

Despite technical advances in mechanical thrombectomy (MT), failure to achieve recanalization in the posterior circulation remains a significant challenge. Rescue strategies to increase MT success in the posterior circulation have been explored. We demonstrate the first successful off‐label use of XIENCE Skypoint™ (Abbott), a balloon‐mounted drug‐eluting stent (DES), for intracranial MT rescue in the posterior circulation.

Methods

Case report and endovascular technique.

Results

A 52‐year‐old man with hypertension, hyperlipidemia, and deep venous thrombosis who presented with acute ischemic stroke in bilateral occipital, lateral pons, and cerebellar regions. Computed tomography angiography (CTA) showed bilateral vertebral artery occlusion consistent with a history of dissection in the setting of cervical manipulation. Admission National Institutes of Health Stroke Scale (NIHSS) 20. Last known well less than 12 hours from presentation. Intravenous thrombolysis was deferred as the patient was on pre‐admission anticoagulants. Mechanical thrombectomy failed after several unsuccessful passes (Fig 1). XIENCE Skypoint™ stent was deployed within the left vertebral artery (V4 segment) with restoration of flow preceded by eptifibatide drip (Fig 2). Repeat CTA at six months showed patent left vertebral and basilar arteries.

Conclusion

Rescue stenting using DES may be a successful and safe therapeutic intervention for challenging failed MT. The off‐label use of DES for intracranial pathologies continues to expand. This is the first case report in the literature describing successful rescue stenting using XIENCE Skypoint™ in the posterior circulation. Further investigation is warranted to fully elucidate the risks and benefits of this treatment approach.
Abstract 127: Delayed Thrombectomy In A Patient With Recurrent MCA Strokes
Authors: Joseph Pradeep , Bach Ivo , Khandelwal Priyank
Published: March 2024

Introduction

Prior research has demonstrated mechanical thrombectomy (MT) to be a safe and effective treatment for stroke patients with a large vessel occlusion (LVO).1 However, MT has generally only been studied in a time window of less than 24 hours.2 To the best of the authors' knowledge, this case report is the first publication of a MT done months after the initial stroke event, in a patient with recurrent strokes and an evolving occlusion visualized in the middle cerebral artery (MCA).

Methods

The patient is a 55‐year‐old man with a past medical history of a left‐sided MCA stroke 2 months prior to current admission with multiple transient ischemic attacks (TIAs) on dual antiplatelet therapy (DAPT), with no persistent residual deficits. His first stroke was preceded by about 1 week of intermittent confusion and right arm tingling. MRI at the time showed an acute embolic infarct in left MCA territory, and a CTA showed a sub‐occlusive thrombus vs. atherosclerotic plaque in the superior branch of the left MCA. He was discharged on DAPT, but his prior symptoms began to recur on a weekly basis, lasting for a few minutes each time. The patient eventually presented on this admission to the ED with persistent dysarthria and word finding difficulties. Within 4 hours, his exam improved to an NIHSS of 0. An MRI without contrast showed a new acute punctate infarct in the posterior left lateral temporal cortex. CT angiogram showed a persistent left M2 occlusion which was confirmed by the diagnostic cerebral angiogram. CT Perfusion also showed a large penumbra in the same region. The decision was made to perform MT, and complete recanalization was achieved. On 2‐month follow‐up, the patient continues to report no new symptoms since the time of MT.

Results

The patient’s positive outcome thus far at 60 day follow up indicates that MT can prove safe and efficacious even in significantly delayed time windows. This also shows that the decision to proceed with MT ought not to depend on time interval and degree of collaterals alone, but also on the pattern of symptoms the patient is exhibiting. The recurrent TIAs and strokes our patient was having indicates that, although collaterals had formed in response to his sub‐occlusive thrombus in the MCA, they were still unable to provide full compensation for this lost blood flow, leading to the patient’s intermittent symptoms.

Conclusion

This report demonstrates that MT can be safely and effectively utilized even in significantly delayed time windows in patients with recurrent TIAs or strokes.
Abstract 132: Angioplasty and Stenting for Symptomatic Vertebral Artery Atherosclerotic Disease: A Systematic Review and Meta‐Analysis
Authors: Bouslama Mehdi C. , Monteiro Andre , Donnelly Brianna , Kuo Cathleen , Danziger Hannah , Hugec Silvia , Lim Jaims , Turner Ryan C. , Raygor Kunal P. , Baig Ammad , Lai Rosalind , Snyder Kenneth V. , Davies Jason M. , Levy Elad I. , Siddiqui Adnan H.
Published: March 2024

Introduction

Vertebral artery stenting represents a viable option in treating symptomatic vertebral artery atherosclerotic stenosis. However, its safety and efficacy in improving neurological status and reducing recurrent strokes remain to be established.

Methods

We systematically searched PubMed, Embase, and Cochrane databases using keywords with Boolean operators to increase search sensitivity and specificity (‘extracranial’; ‘stenting’; ‘vertebral artery’; ‘stenosis’). We included articles reporting patients > 18 years old with symptomatic extracranial vertebral artery stenoses due to atherosclerosis treated with stenting (with or without angioplasty). Those reporting patients with vertebral dissections were excluded. Patients’ characteristics, procedural details, complications, and outcomes were extracted. Estimated rates weighted for sample size were generated for each variable using fixed and random effects models.

Results

From 89 unique studies identified, 21 met our inclusion criteria and were included in the analysis, comprising 1499 patients with 1570 lesions. The mean age was 65 years, and 74.4% were men. The mean baseline NIHSS was 4.6. The most frequent stenosis location was the V1 segment of the vertebral artery (88.4%). Device‐related issues occurred in 1.8%. Periprocedural ischemic and hemorrhagic complications occurred in 2.1% and 1.7%, respectively. Neurological improvement post‐procedure was observed in 84.2%, and the in‐hospital mortality rate was 2.1%. During follow‐up, in‐stent stenosis >50% was observed in 12.8%, and retreatment with either re‐stenting or angioplasty was performed in 10.8%. Ischemic complications during follow‐up occurred in 5%, and the overall mortality rate was 5%.

Conclusion

Stenting for the treatment of atherosclerotic vertebral artery stenosis is technically feasible, associated with a high rate of neurological improvement and low short and long‐term complication rates.
Abstract 142: Safety and Efficacy of PCSK9 inhibitor injection in Pathients immediately before mechanical thrombectomy
Authors: Park Hee Kwon , Jeong Sang‐Wuk , Park Jong‐Ho
Published: March 2024

Introduction

Statins are lipid‐lowering agents and have beneficial effects in patients with acute ischemic stroke, including in the hyperacute period around mechanical thrombectomy.Evolucumab, a PCSK9 inhibitor, is a fast‐acting drug that lowers serum LDL with beneficial effects during chronic stroke period. During an hyperacute ischemic stroke, the brain can be vulnerable, especially around reperfusion therapy. However, the clinical effect of PCSK9 inhibitor injection around mechanical thrombectomy is still unknown. Here we showed the efficacy and safety of PCSK9 inhibitor injection immediately prior to mechanical thrombectomy for these patients.

Methods

The subjects were stroke patients who underwent mechanical thrombectomy at Inha University Hospital from April 2019 to March 2023. Clinical profiles between the evolucumab group and the non‐user group were analyzed.

Results

Of the 263 patients enrolled, 112 (42.6%) were male and the mean age was 69.1 years. Of these, 42 patients received a single dose of a PCSK9 inhibitor immediately prior to intervention and additional injections were not made due to insurance issues. Evolukumab injection was determined according to physician preference. There were no significant differences between the two groups in age, gender ratio, major risk factors, stroke etiology, or prior statin treatment. Evolucumab group had a higher stent recovery rate than the non‐user group (70.7 vs 53.4%, p = 0.04). However, there were no significant difference in TICI grade, or symptomatic hemorrhage. Compared with non‐user group, Evolucumab group had the lower NIHSS score on discharge (12.41 vs 8.83, p=0.03) and seemed to have the lower in‐hopital mortality(12.2 vs 2.4% p=0.06) Mean LDL‐C levels at admission and 3 months after stroke did not differ between the two groups. Cardiovascular and other adverse events within 3 months were similar in both groups.

Conclusion

Evolocumab added to conventional high‐intensity statin therapy was well tolerated and appeared to be associated with lower in‐hospital mortality and lower NIHSS scores at discharge without additional side effects. Further large randomized clinical trials might be needed to investigate the beneficial effects of PCSK9i during hyperacute stroke period.
Abstract 158: Association between thrombus characteristics and endovascular therapy outcome in stroke: a systematic review and meta‐analysis
Authors: Abbasi Mohammad Hossein , Warach Steven , Dula Adrienne , Saber Hamidreza
Published: March 2024

Introduction

Background: Prediction of successful revascularization and achieving a favorable functional outcome may help to determine the optimal recanalization strategy and improve the management of stroke. A growing body of literature has implicated a prognostic value for thrombus imaging characteristics for stroke outcomes [1‐5].

Methods

We conducted an electronic search using PubMed, Ovid MEDLINE, and EMBASE, previously published meta‐analyses, and systematic review studies that intervened by endovascular thrombectomy (EVT) or intravenous thrombolysis (IVT) following large vessel occlusion stroke from 2000‐2023 and involved MR‐based thrombus imaging, then screened 2007 studies against our eligibility criteria. We extracted the enrollees’ characteristics and the association between clot features and radiological and functional outcome measures.

Results

Thirty‐three studies were found eligible, with a total number of 6902 enrollees. Susceptibility Vessel Sign (SVS) was reported in 3531 subjects (51.2%). Nine studies only involved the administration of IVT, while 24 studies intervened by EVT. Seventeen studies found at least an association between a thrombus imaging characteristic and successful recanalization while the others reported no association. On the other hand, only thirteen studies found at least an association between thrombus characteristics and functional outcome, while the rest thrombus characteristics showed no association with functional outcome. Pooled meta‐analysis of studies that involved EVT with or without preceding IVT showed a statistically significant association between the presence of SVS and both successful recanalization (RR: 1.57 [1.09 – 2.27]; P: 0.02) and favorable functional outcome (RR: 1.76 [1.17 – 2.66]; P: 0.007).

Conclusion

The presence of SVS on MR‐based clot imaging was associated with functional outcome and successful recanalization following thrombectomy.
Abstract 184: Comparing Characteristics and Outcomes of Ruptured and Unruptured Mycotic Aneurysms: A Single Center Study
Authors: Balabhadra Anvesh A. , Miller Ethan , Patel Smit , Jaffa Matthew , Bruno Charles , Sussman Eric , Ollenschleger Martin , Mehta Tapan
Published: March 2024

Introduction

Infectious intracranial aneurysms (IIAs), commonly referred to as mycotic aneurysms, are a common sequela of infective endocarditis (IE). Approximately 65% of patients found to have IIAs also have IE, and IIAs occur in up to 10% of patients with IE. Clinically, it is important to be able to identify IIAs as well as their etiologies to adequately manage these insidious vascular lesions. Mortality rates have been reported up to 30% for unruptured and 80% for ruptured mycotic aneurysms. With upcoming advances in the neuro‐endovascular field, there has been a surge in pursuing endovascular therapies to secure these aneurysms which have yielded positive outcomes. We present a single‐center experience describing the characteristics and outcomes of ruptured and unruptured IIAs.

Methods

This is a single‐center retrospective observational study of patients admitted with IE who developed IIAs and were admitted at our institute from 2016 to 2022. Descriptive statistics were performed using SAS statistical software and Microsoft Excel.

Results

Out of a total of 862 patients with IE, 25 patients (3.0%) were identified to have 41 IIAs (single aneurysm in 18 patients and multiple aneurysms in 7 patients). The median (IQR) age of our population was 45 (27‐65) years, with 28/41 (68.3%) male patients. The most common location of IIAs was the distal segments of the posterior and middle cerebral arteries in both groups.

The overall mean (minimum‐maximum) size of all IIAs was 2.8 (0.2‐11) mm. Of these 41 IIAs, 24/41 (58.5%) were ruptured and 17/41 (41.5%) were unruptured. A total of 14/24 (58.3%) ruptured IIAs were treated vs. none were treated in the unruptured IIAs group (P=0.001). The average (minimum‐maximum; mm) size of ruptured IIAs was 3.3 (0.2‐11) vs. 2.1 (0.8‐5) in the unruptured IIAs group (P=0.324).

More patients died while hospitalized with ruptured aneurysms vs unruptured aneurysms at 29.1% and 11.7%, respectively (P=0.18). Additionally, 16.7% of those in the ruptured group were discharged home, whereas 41.2% in the unruptured IIA group were discharged home (P=0.08).

Conclusion

This study emphasizes the significant mortality rate observed among patients with ruptured IIAs. Clinicians should remain vigilant when screening patients. Our study suggests that ruptured IIAs should be secured while unruptured IIAs may be monitored closely.
Abstract 192: Throwing The Kitchen Sink At Tandem Occlusions: A Safety Analysis
Authors: Ajgaonkar Ryan K. , Miller Samantha E. , Hassan Ameer
Published: March 2024

Introduction

The risk of tandem occlusion treatment in the setting of intravenous thrombolysis is unclear. Angioplasty and stenting typically require the administration of glycoprotein IIb/IIIa inhibitors and/or dual‐antiplatelets which may increase the risk of hemorrhage in the setting of recent thrombolysis administration.

Methods

We conducted a retrospective analysis of a prospectively maintained patient registry at a comprehensive stroke center. Patients who received thrombolysis and subsequently underwent endovascular therapy for acute ischemic stroke between 2012 and 2022 were included. Patients were separated into two groups depending on whether or not rescue angioplasty or stenting was performed. Per local practice patterns, patients who underwent angioplasty or stenting were immediately started on dual antiplatelets with or without a glycoprotein IIb/IIIa inhibitor bridge. Baseline demographics and clinical characteristics were compared. Outcomes of interest included symptomatic intracerebral hemorrhage (ICH), asymptomatic ICH, hemorrhagic transformation, mass effect and death. Analysis was completed using Chi Square and Fisher’s exact test for categorical variables and Mann‐Whitney U for continuous variables.

Results

Baseline demographics and clinical characteristics were compared between groups. Patients who underwent treatment of a tandem occlusion were on average younger (67 vs 73, p=0.08) and male (70.1% vs 55%, p=0.03). Median LDL was higher (94 vs 67, p=0.01) and there was a higher rate of diabetes (55.2% vs 40%, p=0.03) and lower rate of atrial fibrillation (12.1% vs 26.6%, p=0.01). Median NIHSS on admission was lower in the tandem occlusion group (15 vs 18, 0.02). Otherwise groups did not significantly differ in level of hemoglobin a1c or rates of hypertension, coronary artery disease, congestive heart failure, smoking status or prior stroke or transient ischemic attack. There was no significant different in hemorrhagic transformation (OR 1.02, 95% CI 0.49, 2.13), mass effect (OR 1.73, 95% CI 0.79, 3.79), symptomatic intracranial hemorrhage (OR 1.27, 95% CI (0.54, 2.99), asymptomatic intracerebral hemorrhage (OR 0.53, 95% CI 0.12, 2.43) or death (OR 0.55, 95% CI 0.24, 1.22) between groups. Limitations include a single center study and the retrospective nature of this analysis.

Conclusion

We did not find significant risk associated with the treatment of tandem occlusions in the setting of intravenous thrombolysis. Future prospective, multi‐center studies would be beneficial.
Abstract 201: Feasibility of an 088” Catheter in the M1 segment for Mechanical Thrombectomy
Authors: Khan Muhammad W. , Meyer Benjamen M. , Campos Jessica K. , Laghari Fahad , Zarrin David A. , de Beaufort Jonathan C. Collard , Amin Gizal , Golshani Kiarash , Beaty Narlin , Bender Matthew T. , Colby Geoffrey P. , Lin Li‐Mei , Coon Alexander L.
Published: March 2024

Introduction

Placement of 088” aspiration catheters in the internal carotid artery (ICA) for aspiration in mechanical thrombectomy (MT) has been previously described. However, the use and safety of 088” aspiration catheters beyond the ICA has not been established. Here, we report the utilization and early safety outcomes of 088” catheter placement in the M1 segment for MT.

Methods

We reviewed a prospectively maintained IRB‐approved database of the senior author to identify consecutive cases where the 088” catheter was navigated to the MCA for use in mechanical thrombectomy.

Results

We identified 13 cases with placement of an 088” aspiration catheter in the MCA segment (all cases performed in 2023). Average patient age was 71±4 years (range 56‐97 years), with 10 (77%) females, presenting NIHSS was 12±2.1, and 3 (23%) patients received tPA. Location of the thrombus includes 7 (54%) in the M1 and 6 (46%) in the M2. In 13 (100%) cases, the Zoom88 (OD = 2.7 mm, Imperative Care, Campbell, CA) catheter was advanced to at least the M1 segment, and it was used with a coaxial Zoom71 catheter. The average M1 diameter prior to MT was 2.5±0.2mm, 2.3±0.2mm, and 2.2±0.1 in the proximal, mid, and distal M1‐segment, respectively. After MT, the average M1 diameter was 2.4±0.1mm, 2.2±0.1mm, and 2.1±0.2mm in the proximal, mid, and distal M1‐segment, respectively. 85% (n=11) of cases used one or more stentrievers including a Tigertriever, Solitaire, and Trevo. Average number of passes was 1.9±0.2. There were no vessel perforations, catheter‐related dissections, or hemorrhagic complications noted in any case. TICI 2C/3 recanalization was achieved in 100% of cases. The average mRS on discharge was 1.2±0.4.

Figure 1. (A) AP angiography demonstrating an M1 branch occlusion (orange). (B) Native view, 088” catheter under aspiration in the MCA (green). (C) Post‐thrombectomy final angiography demonstrating TICI 3 reperfusion.

Conclusion

The use of large‐bore 088” aspiration catheters in the MCA may offer a safe strategy for direct clot ingestion during mechanical thrombectomy in MCA vasculature that is smaller than the 8‐Fr aspiration catheter.
Abstract 212: Percutaneous Carotid access in Mechanical Thrombectomy ‐ a safe alternative to transfemoral approach
Authors: Bellara Sonia , Zumofen Daniel , Mulatu Yohannes
Published: March 2024

Introduction

Emergent percutaneous carotid artery MER approach for acute ischemic large vessel strokes are rare given the risk of complications and seldom reported.

Methods

75‐year‐old left‐handed functional male (mRs:0) with past medical history of HTN, HLD presented to ED after being found on the floor by his family with slurred speech, new onset right sided weakness, with a last known well of 17 hours. NIHSS on arrival was 14 for expressive aphasia, right visual field defect, right facial weakness, significant dysarthria, right hemiparesis, and sensory defect. CT Head demonstrated left MCA territory early ischemic changes. CTA head/neck demonstrated left M1 occlusion with large penumbra. Perfusion data demonstrated no area of core infarct with area of ischemic penumbra in the left MCA territory involving the left frontal, temporal and parietal lobes measuring 161 ml. ASPECT score 5‐6. The patient was deemed a candidate for mechanical endovascular thrombectomy (MER). The procedure was initiated via ultrasound‐guided right common femoral access. After multiple attempts using a wide range of techniques and wire/catheter combinations in order to establish left intracranial access and given extreme angulation/tortuosity/elongation in the proximal left common carotid artery, it was decided to proceed with the catheter position in the left common carotid or the left internal carotid artery that would allow for subsequent catheterization of the intracranial circulation for MER.

Results

Near complete revascularization with minimal distal thrombus material beyond endovascular reach corresponding to a TICI 2C degree of revascularization was achieved. Closure of the femoral puncture site was performed using an Angio seal femoral closure device. Surgical closure of the puncture site was performed by vascular surgery. The patient was eventually discharged to short term acute rehabilitation and continues to follow up outpatient with the Stroke clinic.

Conclusion

Older patients with ischemic stroke commonly have tortuous vessels or peripheral vascular disease. As a result, they may greatly benefit from emergent direct carotid access, as the trans‐femoral approach often poses challenges in accessing the thrombus. For patients with complex and unfavorable vascular anatomy for mechanical endo‐vascularization, direct percutaneous carotid puncture can be advantageous, effectively reducing the aforementioned difficulties. When opting for such an approach it is vital to factor in the aortic arch appearance and its branches.
Abstract 222: Immediate post thrombectomy extubation is associated with improved clinical outcomes
Authors: Miremadi Brian B. , Morrison Mark , Lakey Ashley , Overberg Rachel , Esechie Aimalohi , Scott Jordan , Coppens Jeroen , Christopher Kara , Linares Guillermo , Edgell Randall
Published: March 2024

Introduction

Recent findings suggest that general anesthesia with endotracheal intubation (GA) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) who receive mechanical thrombectomy (MT) is associated with similar outcomes to conscious sedation (CS). [1][2] However, these trials involved stroke specific GA protocols in which immediate, post‐operative extubation was emphasized. In this study, we investigated outcomes of MT in AIS due to LVO as a function of the timing of extubation and explored variables that could delay extubation.

Methods

We performed a retrospective analysis of collected data gathered during a 5‐year period (2018‐2022) for all our patients with AIS due to LVO who received MT. We analyzed the stroke outcomes and complications between patients who had received GA and those who had received CS. We also investigated the relationships between associated pulmonary risk factors, timing of extubation, and tracheostomy, on the outcomes of stroke.

Results

A total of 242 patients were included in our study. 83 patients received GA and 159 patients received CS. Our study shows CS in MT had a 2.74 (95% CI = 1.21‐6.22) higher odds of having a final TICI rating of 0‐2a compared to those who had GA. A logistic regression model was fitted that included NIHSS prior to MT; in this analysis, patients who received GA had 2.71 times higher odds of reaching TICI 2b or higher (OR = 2.71, 95% CI = 1.19‐6.17). NIHSS was not a significant predictor of recanalization in our patients. Patients extubated in the IR suite vs. elsewhere (excluding patients who were not extubated in hospital) had 3.82 (95% CI = 1.03‐14.18) times higher odds of having an excellent mRS at 90 days (n=65). Those extubated late had higher odds of transitioning to comfort care (OR=4.50, 95% CI = 1.52‐13.31, p=0.004), and 90‐day mortality (OR=5.49, 95% CI = 1.71‐17.65, p=0.002). Those who were extubated early had a lower NIHSS post MT (mean = 10.89 vs 19.18), t=‐5.79, p<0.001), and a lower NIHSS at discharge (mean = 9.20 vs 17.11), t=‐5.79, p<0.001). There were no significant correlations between history of COPD or the BMI and the timing of extubation or the outcomes of MT. In addition, COPD was not associated with any significant changes in discharge or 90 days mRS.

Conclusion

Administration of GA to patients who receive MT for AIS was associated with better outcomes in our cohort. Immediate extubation was associated with better outcomes than delayed extubation in the GA group. A history of COPD or high BMI should not affect the decision to provide with GA for MT.
Abstract 238: Gender Differences In Clinical Factors In Obese Ischemic Stroke Patients With A History Of Smoking
Authors: Ojo Dami T. , Brewer Philip , Garg Sahil , Broughton Philip , Nathaniel Thomas
Published: March 2024

Introduction

Clinical risk factors and co‐morbidities in obese male and female ischemic stroke patients with a history of smoking may contribute to differing stroke outcomes. The objective of this study is to determine gender differences in risk factors in obese ischemic stroke patients with a history of smoking.

Methods

A retrospective study was conducted on 6‐year data from 5469 patients with an ischemic stroke event from a regional stroke center. A logistic regression model was used to predict clinical risk factors associated with male or female patients. Multicollinearity was assessed using variance inflation factors (VIFs), with values >5 suggestive of multicollinearity

Results

In the adjusted analysis, (OR = 1.806, 95% CI, 1.028–3.174, P =0.040*), a history of drugs and alcohol (OR = 2.873, 95% CI, 1.349–6.166, P =0.006), Serum Creatinine (OR = 4.724, 95% CI, 2.171–10.281, P<0.001), Age (OR = 1.024, 95% CI, 1.022–1.047, P=0.033), and systolic blood pressure (OR = 1.029, 95% CI, 1.011–1.047, P<0.002) were associated with males. Depression (OR = 0.432, 95% CI, 0.244–0.764, P<0.004), Previous TIA (OR = .319, 95% CI, 0.142–0.714, P<0.005), and higher levels of HDL (OR = 0.938, 95% CI, 0.915–0.962, P<0.001) were associated with female gender.

Conclusion

Gender differences were observed in the clinical factors and comorbidities within the population of AIS patients who were smoking and obese. Further studies should evaluate the effect of specific risk factors to develop specific strategies for the management of identified risk factors to improve the care of obese male and female ischemic stroke patients with a history of smoking.
Abstract 242: Clinical Validation Trial Of BraiN20® Medical Device. PROMISE20 Study Protocol
Authors: Martinez Alicia , Cortes Jordi , Millán Mónica , de la Ossa Natalia Pérez , Ribó Marc , Serena Joaquín , Ruiz Gisela , Coll‐Canti Jaume , Dávalos Antoni
Published: March 2024

Introduction

N20 somatosensory evoked potential (SEP) response shows high predictive accuracy of functional recovery in patients with Acute Ischemic Stroke (AIS) undergoing endovascular thrombectomy (https://www.clinicaltrials.gov/ct2/show/NCT04099615; SVIN Journal, in press). This capacity is independent and even higher than clinical and advanced imaging variables. This study aims to validate BraiN20®, a portable, non‐invasive, AI‐based device to monitor in real‐time the presence and characteristics of N20 in AIS.

Methods

65 patients with AIS and anterior Large Vessel Occlusion (LVO) undergoing EVT within 24 hours from onset are included in three comprehensive stroke centers of Catalonia, Spain. Eligibility criteria are no significant pre‐stroke functional dependence, baseline NIHSS score equal or higher than 6 points, occlusion (mTICI 0‐1) of the intracranial ICA, MCA‐M1 or M2 suitable for EVT per local protocols, without infarct volume restrictions measured by ASPECT score or by CTP/DWI‐MRI prior to EVT . The primary objective is to confirm an optimal/good reliability of N20 registration before EVT higher than 75% by two blind expert neurophysiologists, assuming a true proportion equal to 87.5%. Secondary endpoints are the predictive accuracy of N20 response recorded by BraiN20® before and after EVT on functional outcome evaluated by the mRS at 7 and 90 days and analyzed by using Receiving Operating Characteristic curves. A futility interim analysis is planned after the inclusion of 25% of the sample.

Results

The trial is sponsored by Time is Brain S.L. and will start early September 2023. Primary endpoint results are expected by the end of this year.

Conclusion

BraiN20® could be a useful medical device to predict salvageable brain and functional recovery of patients along the stroke chain.
Abstract 252: The outcomes and complications in patients undergoing subclavian‐carotid artery bypass surgery: A case series
Authors: Wong Serena
Published: March 2024

Introduction

Endovascular intervention has become the mainstay of treatment for acute ischemic stroke. However, in certain cases, open surgery is the only option to achieve revascularization. This study presented two patients with symptomatic common carotid artery occlusion (CCAO) who subsequently underwent subclavian‐carotid artery bypass surgery using the polytetrafluorethylene graft. The complications of the procedure and patient’s outcomes were discussed.

Methods

We identified two patients who were admitted to our medical center between January 2022 to December 2022 for subclavian‐carotid artery bypass procedure. Clinical data were reviewed retrospectively.

Results

Case 1. A 69‐year‐old woman with a history of lung cancer, hypertension, chronic tobacco use, atherosclerosis, and known calcified plaque at the left carotid bifurcation on dual antiplatelet therapy presented with acute onset of expressive aphasia and right hemiparesis due to acute left CCAO. Endovascular procedure was deferred due to difficult arterial access. An endarterectomy of CCA, eversion endarterectomy of external carotid artery, and subclavian‐carotid artery bypass surgery were performed. She developed neck hematoma post‐operatively, requiring evacuation. She was discharged to acute rehabilitation facility and eventually home. Six months after surgery, she still had severe expressive aphasia and spasticity of the right arm and leg (Figure A‐C).

Case 2. A 79‐year‐old man with a strong family history of arterial dissection, hypertension, coronary artery disease, and obesity experienced intense chest pain and left hemiparesis secondary to Type A aortic dissection with extension from the innominate artery to the right carotid bifurcation. Endovascular intervention was deferred given the angulation of aortic arch after surgical repair. Decision was made to perform subclavian‐carotid artery bypass surgery. Post‐operatively, he had evacuation of neck hematoma. He also had tracheostomy and gastrostomy tube placement prior to discharge to skilled nursing facility. At 6‐month follow up, he could ambulate with a walker and oral diet was resumed (Figure D‐F).

Conclusion

CCAO is a rare condition, and there is no prospective randomized trial that compares various treatment strategies for symptomatic CCAO. Consistent with the findings of our study, bypass surgeries have been shown as an effective treatment to prevent further ischemic infarct in patients with symptomatic CCAO. Both patients in our study survived at 6‐month follow up with no recurrence of stroke. Additionally, no other surgical complications were noted except for neck hematoma. Bypass surgery was performed as a salvage procedure for both patients after they suffered from stroke. Early identification of CCAO and collaboration between vascular surgeon and endovascular interventionist would maximize the benefit of this life‐saving procedure to the appropriate candidates.
Abstract 253: Impact of Gender and Marital Status on Door‐To‐Needle and Door‐To‐Puncture time and Acute Stroke Outcome
Authors: Karim Nurose , Tumin Dmitry , Karim Sehrish , Male Shailesh
Published: March 2024

Introduction

Delays in acute treatment of ischemic stroke have been associated with worse outcomes [1]. Women are more likely to present with atypical stroke symptoms than men, causing delay in pre‐hospital diagnosis and seeking medical attention [2‐3]. Additionally, women tend to be older at stroke onset and more likely to be living alone [4‐5]. Among patients presenting with acute stroke, women experience longer emergency department (ED) door‐to‐doctor and door‐to‐imaging (DIT) times, resulting in fewer interventions [6]. It is unclear if gender disparities in the timeliness of ED arrival and stroke assessment are compounded by gender differences in timeliness of treatment after patient arrival in the ED. Therefore, we sought to identify, if gender and marital status were associated with faster door‐to‐needle (DTN) and door‐to‐puncture (DTP) times. We hypothesized that married men would have the fastest DTN and DTP times, associated with female spouses being quicker to recognize traditional signs of stroke, calling 911 who can activate stroke alert, and therefore avoiding delay in acute care.

Methods

Our single‐center stroke database was queried for adults presenting to the ED with acute stroke between 1/1/2018‐1/30/2023. Patients were excluded if they had missing data on marital status or covariates. DTN and DTP times, as well as National Institutes of Health Stroke Scale (NIHSS) at discharge, were analyzed using quantile regression on sex, marital status (dichotomized as married vs. single), age, intervention (TPA alone, or thrombectomy±TPA), and NIHSS score at presentation.

Results

We identified 674 patients meeting inclusion criteria, of whom 31 were excluded due to missing data. In the remaining sample (N=643, median age 66yr), 25%/18% of patients were married men/women, respectively, and 22%/35% were single men/women. Median DTN time, DTP time, and discharge NIHSS were 36min, 79min, and 4, respectively. On multivariable analysis (Table), none of the outcomes were improved among married men relative to any other combination of sex and marital status.

Conclusion

Gender differences in knowledge of warning signs of stroke in community‐based studies and gender disparities in ED assessment did not translate into faster treatment “after” ED arrival based on gender or marital status. More work is needed to find out ways to accelerate care “after” ED arrival to have faster DTN and DTP time.
Abstract 262: National Trends of 90‐day Readmission Rates and Etiologies among Diabetics following Transient Ischemic Attack
Authors: Laswi Ibrahim , Al‐Najjar Yousef , Arabi Maryam , Dargham Soha , Jerdi Salman Al , Khalil Charbel Abi
Published: March 2024

Introduction

Transient Ischemic Attack (TIA) is a common neurologic condition characterized by temporary, focal cerebral ischemia that results in reversible neurological deficits without tissue infarction. Type 2 Diabetes Mellitus (T2DM) is a rapidly growing global health problem with increasing prevalence. Currently, data are lacking regarding the trends of 90‐day readmission rates and etiologies among diabetic patients with TIA.

Methods

We used the Nationwide Readmission Database (NRD) to identify patients with a primary diagnosis of TIA (ICD‐10 code: G45.9) from 2016‐2019 and secondary diagnosis of T2DM. The difference in days between the index admission and the readmission was used to identify patients who were readmitted within 90 days. The primary diagnosis of the readmission was used to identify the etiology of readmission. Data was weighted to allow for representative nationwide estimates.

Results

We identified 426,549 patients who were admitted with a primary diagnosis of TIA between 2016 and 2019. Of those patients, 35.43% (n=273,993) were diabetic and 64.57% (n=151,112) were non‐diabetic. Diabetics were more likely to be younger (70.43 vs 70.71 years, p<0.001) and male (46.62% vs 42.89%, p<0.001) compared to non‐diabetics. All‐cause 90‐day readmission was higher among diabetics compared to non‐diabetics (15.22% vs 12.03%, p<0.001). Nearly half of 90‐day readmissions occurred within 30 days. There was no significant difference in the rate of 90‐day readmission between 2016 and 2019 (13.19% in 2016 and 12.95% in 2019). Among diabetics, readmitted patients were more likely to be older (71.87 vs 70.18 years, p<0.001) and male (47.96% vs 46.38%, p<0.001). Readmitted diabetics had a higher prevalence of valvular disease (10.12% vs 7.94%), chronic renal failure (33.40% vs 23.98%), coronary artery disease (40.20% vs 32.86%), heart failure (23.88% vs 16.07%), atrial fibrillation (24.02% vs 18.88%), dementia (13.87% vs 11.13%), cancer (4.18% vs 2.44%), and prior VTE (5.24% vs 4.44%) (p<0.001 for all). The most common etiologies of 90‐day readmission among diabetics were cardiovascular (28.98%), neurological (12.92%), and infectious (7.72%).

Conclusion

Diabetics had higher 90‐day readmission following TIA than non‐diabetics. Cardiovascular conditions were the most common cause of readmission followed by neurological and infectious causes. Further studies are needed to improve risk stratification for diabetic patients following TIA and prevent all‐cause readmission.
Abstract 274: Mechanical Thrombectomy for Ischemic Stroke in Elderly Population
Authors: Naamani Kareem El , Mudundi Divya , Gooch Michael R. , Tjoumakaris Stavropoula I. , Rosenwasser Robert H. , Jabbour Pascal , Herial Nabeel A.
Published: March 2024

Introduction

Stroke is a leading cause of mortality and morbidity worldwide and the risk increases with age. Mechanical thrombectomy (MT) in eligible patients is proven to improve outcomes and is ow standard of care for acute ischemic stroke. Clinical trials evaluating MT often exclude patients older than 80 and available scientific evidence supporting MT in elderly is limited and varied. Purpose of this systematic review is to examine current literature on efficacy and outcomes of MT in octogenarian and nonagenarian stroke patients.

Methods

A literature search was conducted using PubMed and Scopus from 2013‐2023. All studies that included patients 80 yrs and older with acute ischemic stroke who underwent MT and provided 90‐day clinical outcomes and rates of complications were reviewed.

Results

Review identified 25 publications and the median age of study populations ranged from 82 to 93.3 years with proportion of female patients higher in all studies. Success rate of MT ranged from 66.7% to 97%. Symptomatic intracranial hemorrhage was the common complication ranging from 3% to 28%. The 90‐day mortality rate ranged from 7% to 70%. No differences were noted between octogenarians and nonagenarians.

Conclusion

MT in elderly patients had high reperfusion rates indicating procedural success, and variable clinical outcomes with wide range of complication and mortality rates. Factors influencing MT outcomes in elderly are discussed and the need for randomized control trials providing the highest level of scientific evidence for MT in this population is emphasized.