bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract Number ‐ 164: Clot Density as a Predictor for Successful Mechanical Thrombectomy
Authors: Radaideh Yazan , Thind Sonam
Published: April 2023

Introduction

Switching mechanical thrombectomy techniques (ADAPT, SR or combination) mid procedure has the potential to prolong time to recanalization as well as increase associated healthcare costs. The basis of selecting the frontline technique still relies heavily on the operators’ preference. Conflicting results indicating the varying performance of techniques relative to clot composition have been reported. Clot composition can be estimated based on clot density calculated in Hounsfield Units (HU) on pre‐intervention CT. Identifying how various clot composites behave can aid in the decision making for selecting a frontline technique.Our objective is to determine if clot density as measured by Hounsfield units can predict successful recanalization with ADAPT and the need for rescue stentriever when using ADAPT as the first line technique.

Methods

Retrospective review of all patients undergoing mechanical thrombectomy with first pass ADAPT at a single urban tertiary care academic stroke center. Clot HU values were calculated on pre‐intervention scans. We evaluated the number of passes, the use of rescue SR, the post intervention TICI grade and mRS on final follow up.

Results

There were 167 patients that underwent MT with ADAPT as the frontline approach. 122 were excluded for inability to calculate HU on pre‐ intervention scans, most often due to contamination with contrast media. 45 patients were included in the final analysis. 18/45 (40%) required SR rescue due to incomplete recanalization with first pass ADAPT. HU were dichotomized around the mean to “high” and “low”. Higher HU value was associated higher likelihood of SR use and higher final mRS scores, these however did not reach statistical significance. There was no difference in the total number of passes or the final TICI grade. AUC and ROC did not show a correlation between HU value and the use of SR or a higher number of passes need to achieve TICI ≥ 2b recanalization.

Conclusions

In our patient cohort, HU value was not able to predetermine the success rate of MT using ADAPT. There was no correlation between HU value and functional outcomes of patients. Reliability of clot HU value in determining MT success with ADAPT could not be established. Other factors should be considered when selecting frontline technique in mechanical thrombectomy.
Abstract Number ‐ 165: Are Smaller Stentrievers the Answer for Achieving Procedural Success in Distal Vessel Occlusions (DiVO)?
Authors: Zainab Anika , Dharwadkar Niti , Desai Sohum , Tekle Wondwossen G
Published: April 2023

Introduction

Distal vessel occlusions (DiVO) represent the next frontier of interventional stroke care. Although many experts agree the current generation of stentrievers appear to be ill‐suited to address challenges presented by DiVO, some practitioners advocate utilizing smaller devices.We sought to examine whether smaller diameter devices (3,4 or 5 mm) had any edge over standard sized 6 mm device.

Methods

A prospectively maintained neuro‐endovascular database was queried for patients between January 2013 to August 2022. Patients included in the analysis had undergone mechanical thrombectomy of distal circulation defined as M2, M3, P2, P3, A2 and A3 segments of the MCA, PCA, and ACA respectively.Primary outcomes measured were TICI post procedure, mRS at discharge and mRS at 90 days.

Results

A total of 33 patients with DiVO were identified out of a database containing 826 mechanical thrombectomies. There were no other differences in baseline characteristics such as presentation NIHSS (p = 0.58) or comorbid medical conditions. We found no differences in post procedure recanalization TICI between large device and small devices cohorts (p = 1.00), symptomatic ICH (p = 0.52), mRS at discharge (p = 0.154) and mRS at 90 days (p = 0.22).

Conclusions

There do not appear to be any clinical or radiographic difference in utilizing smaller diameter stentrievers in setting of DiVO.
Abstract Number ‐ 170: Trends for Endovascular Mechanical Thrombectomy versus Intravenous Tissue Plasminogen Activator for Vertebrobasilar Stroke Treatment
Authors: Saha Ram , Solanki Shantanu , Bozkurt Subutay , Roy Anil
Published: April 2023

Introduction

Acute vertebrobasilar artery occlusion (VBAO) represents approximately 20% of patients presenting with acute ischemic stroke. The occlusion is caused by an embolus or underlying atherosclerotic disease plaque rupture forming an acute thrombus. Without treatment, VBAO’s mortality nears 80–90%, thus, effective and timely treatment strategies become paramount in managing the patients. Herein, we analyzed the age difference and outcomes in patients that underwent either Endovascular Mechanical Thrombectomy (MT) or intravenous (IV) tissue plasminogen activator (tPA).

Methods

National Inpatient Sample (NIS) was queried from years 2016 to 2018 using ICD‐10 diagnosis and procedure codes for occlusion or thrombosis of vertebral artery or basilar artery (I63.21, I63.22, I63.01, and I63.02), IV tPA (3E03317), and MT (03CG3ZZ, 03CG3Z6, 03CG3Z7, 03CG4Z6, 03CG4ZZ). Chi‐square test and was used for statistical analysis.

Results

From 2016 to 2018, there were 37,310 patients admitted with vertebrobasilar stroke. Out of these, IV tPA was administered in 2,530 (6.8%) admissions, whereas MT was done in 2,330 (6.2%) admissions. IV tPA was used significantly more than MT in age groups 65–84 and > = 85 years. MT was used significantly more than IV tPA in age groups 18–44 and 45–64 (Figure 1). There was no significant difference in their use between men and women. In large hospitals, MT was more common than IV tPA (8.1% vs 7%, p < 0.0001), and in small hospitals, IV tPA usage was significantly higher (3.8% vs 2%, p < 0.0001). All‐cause mortality rate was significantly higher in MT than IV tPA admissions (16.8% vs 8.1%, p < 0.0001). There was no significant difference in mean length of stay (LOS) between the two modalities (Figure 1).

Conclusions

We saw a trend of higher rate of mechcnical thrombectomy in younger age group (18‐64 years) than older, however, no sex difference was noted. All‐cause mortality rate was higher in the mechanical thrombectomy group than intravenous tissue plasminogen activator group. In addition, there was no difference in length of hospital stay.
Abstract Number ‐ 176: Mechanical thrombectomy with or without bridging in stroke: A systematic review and meta‐analysis of RCTs
Authors: Morsi Rami Z. , Zhang Yuan , Carrión‐Penagos Julián , Desai Harsh , Tannous Elie , Kothari Sachin , Khamis Assem , Tarabichi Ammar , Bastin Reena , Hneiny Layal , Thind Sonam , Coleman Elisheva , Brorson James R , Mendelson Scott , Mansour Ali , Prabhakaran Shyam , Kass‐Hout Tareq
Published: April 2023

Introduction

Current published guidelines and meta‐analyses comparing direct mechanical thrombectomy (MT) alone versus MT with bridging intravenous thrombolysis (IVT) suggested that MT alone is non‐inferior to MT with bridging thrombolysis in achieving favorable functional outcome. Because of this controversy, we aimed to systematically update the evidence and meta‐analyze data from randomized trials comparing MT alone versus MT with bridging thrombolysis.

Methods

We searched MEDLINE (through Ovid), EMBASE, and the Cochrane Library from inception to December 14, 2021 without any language restrictions to identify randomized controlled trials (RCTs) and post‐hoc analyses of RCTs comparing direct MT with or without bridging IVT in patients presenting with acute ischemic stroke secondary to a large vessel occlusion. We conducted meta‐analyses using random‐effects models to compare the rates for favorable functional outcome (defined as modified Rankin scale [mRS] score of 0 to 2) and mortality at 90 days, and symptomatic intracranial hemorrhage (sICH), between MT and MT with IVT. We also assessed the risk of bias using the Cochrane risk‐of‐bias tool (RoB) and the certainty of evidence for each outcome using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Of 11,111 citations, we identified 53 eligible studies, and included 8 studies with a total of 3,008 participants. We found low‐certainty evidence suggesting that there is probably a small increase in the proportion of patients with favorable functional outcome with an mRS of 0 to 2 at 90 days for those who underwent MT with IVT compared to those with MT alone (risk ratio [RR] 1.08, 95% CI 0.99 to 1.19); moderate‐certainty evidence that there is probably a small decrease in mortality at 90 days for patients with MT plus IVT compared to MT alone (RR 0.86, 95% CI 0.71 to 1.03); and very low‐certainty evidence that there is possibly an increase in sICH for patients with MT plus IVT compared to MT alone (RR 1.17, 95% CI 0.85 to 1.61). When we restricted the analyses to RCTs only, we found no significant differences in favorable functional outcome (RR 2.05, 95% CI 0.97 to 1.13), mortality (RR 0.94, 95% CI 0.78 to 1.14), or sICH (RR 1.20, 95% CI 0.85 to 1.70).

Conclusions

Low‐certainty evidence shows that there is probably a small increase in the proportion of patients with favorable functional outcome, moderate‐certainty evidence shows that there is probably a small decrease in mortality, and very low‐certainty evidence that there is possibly an increase in sICH for patients with MT plus IVT compared to MT alone.
Abstract Number ‐ 188: Rescue Stenting for Intracranial Stenosis In ELVO patients Using Neuroform Atlas Stent Through Gateway Balloon
Authors: Memon Muhammad Z , Biswas Arundhati , Ezzeldin Mohamad , Nisar Taha , Singla Amit , Zaidat Osama O , Khandelwal Priyank
Published: April 2023

Introduction

Management of acute large vessel occlusion due to intracranial stenosis remains challenging with high complication and poor recanalization rates. Morbidity is also related to the intracranial exchange that is required for stent placement after the rescue angioplasty. We aim to present our initial experience of deployment of Neuroform Atlas stent through the lumen of a Gateway angioplasty balloon to avoid microcatheter exchange.

Methods

Patients were identified from prospectively collected mechanical thrombectomy stroke database from Feb 2019 to July 2021. Demographic and clinical information was collected. Primary outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale (mRS) score of 0–3), and the rate of intracranial hemorrhage (ICH). Good angiographic recanalization (TICI ≥ 2b), and mortality at 30 days were other outcomes.

Results

We identified 5 patients treated with this approach [mean age 54 ± 14 years, all were men] who presented with large vessel occlusion of middle cerebral artery. Initial median NIHSS was 8 (range 6–16) with one patient received IV t‐PA. Patient initially underwent mechanical thrombectomy using the Solumbra technique. Due to reocclusion or impending occlusion with evidence of atherosclerotic plaque, rescue angioplasty with stent placement was performed. Patients were loaded with 650 mg of aspirin and 180 mg of ticagrelor through nasogastric tube prior. Balloon angioplasty was performed using the gateway balloon size ranging from 1.5 to 3 mm which was inflated to subnominal pressures over 1 minutes. This was followed by placing Neuroform atlas stent through the gateway balloon with size ranging from 3 to 4 mm diameter and length ranges from 21–24 mm. TICI ≥ 2b was achieved in 4 patients. Mean time from symptoms onset to revascularization was (336 ± 90) minutes. One patient had asymptomatic ICH. 2 patients had mRs 0–3 at the time of discharge and one patient was dead at 1 month

Conclusions

Our preliminary experience showed lower risk of guidewire perforation as well as potentially decreased operative time and early reperfusion by deploying the Neuroform stent through a compatible gateway balloon microcatheter. This should be investigated further in a large multicenter study
Abstract Number ‐ 190: Acute Ischemic Stroke patients post Endovascular Thrombectomy complicated by gastrointestinal bleeding have worst clinical outcomes
Authors: Ali Syed F , Dominguez Jose , Osman Masha , Meadows Sarah , Das Ankita , Al‐Mufti Fawas
Published: April 2023

Introduction

The objective of this study was to scrutinize the stroke severity markers, complications, and clinical outcomes in patients with AIS who underwent EVT complicated by gastrointestinal bleeding (GIB). It is known that anemia is associated with poor functional outcomes in patients with mechanical thrombectomy (Nisar, 2021). Anemia also predicts poor clinical outcomes despite fair or good collateral circulation (Pienimäki, 2020). With the increasing use of EVT for acute management of AIS, it is prudent to investigate the relationship between gastrointestinal bleeding in acute ischemic stroke patients who have underwent mechanical thrombectomy.

Methods

The 2016–2019 National Inpatient Sample (NIS) database was queried for patients with the diagnosis of acute ischemic stroke (AIS) by using International Classification of Disease, 10threvision (ICD10) diagnosis codes. From this cohort of AIS patients, those that underwent endovascular thrombectomy (EVT) were then identified using ICD 10 procedure codes. A subpopulation of AIS‐EVT patients was created for patients with a diagnosis of GI bleeds. Baseline demographic, stroke severity, complication, and outcome variables were evaluated between GI bleed and no‐GI bleed patients who underwent EVT.

Results

Of 132,210 patients hospitalized for AIS who had underwent EVT, there were 130,970 cases of no GIB (99.1% %) and 1,240 cases of GIB (0.9%) complications. Mean age greater than 65 was 980 (79%) in GI bleed group versus 82,945 (63.3%) in no GI bleed group (p‐value < 0.001, CI 95%: 1.903 ‐ 2.5, OR 2.2). Interestingly, the no GI bleed group had more use of Aspirin 31,790 (24.3%) versus GI bleed group 200 (16.1%) (p‐value < 0.001, CI 95%: 0.515 ‐ 0.698, OR 0.6). Furthermore, the GI bleed group had the following risk factors that were statistically significant: history of atrial fibrillation and chronic renal failure (46% vs 37.2% and 21.8% vs 15.1%, respectively). In fact, this study failed to show increased risk of GI bleed due to being on aspirin, AC, having a history of DM, HTN, HLD, and CHF. Stroke severity was worst in GI bleed group with average NIHSS score 15.92 vs 14.05 (P‐value < 0.001) and worst hemiplegia (75% vs 70.2%, P‐value < 0.001, 1.3 CI 1.118‐1.447). The GI bleed group had statistically worst complications including sepsis, DVT, PE, AKI, and aspiration pneumonia. Lastly, the GI bleed patients were most likely to be discharged to SNF versus routine discharge to home (68.5% vs 49.6%, p‐value < 0.001, CI 1,962 ‐ 2.496, OR 2.2).

Conclusions

GIB occurrence in patients with AIS status post EVT is relatively rare but is associated with poor in‐hospital outcomes, including mortality. We identified risk factors associated with GIB in AIS post EVT, which allows physicians to monitor patient populations at the highest risk.
Abstract Number ‐ 196: The Impact of Pre‐existing Depression on Functional Outcomes After Endovascular Treatment of Ischemic Stroke
Authors: Christopher Kara M , Gao Xiaoyi , Kiaei Benjamin , Chen Yongzhen , Hwee Brenton , Rodriguez Wilson , Scott Jordan , Miremadi Brian , Linares Guillermo
Published: April 2023

Introduction

Stroke is a leading cause of morbidity and mortality, and many factors predict a poor outcome, including age, NIH Stroke Scale (NIHSS), ambulatory status, and ability to swallow1. Mood disorders have previously been associated with an increased risk of cardiovascular disease2. The association between pre‐existing mood disorders and stroke outcome, however, has not been well studied. The objective of the current study was to explore the impact of pre‐existing depression on functional outcomes post‐endovascular treatment.

Methods

We reviewed the records of 178 patients who received mechanical thrombectomy (MT) at our institution[BH1][BM2] from 2019–2022. We collected data on baseline characteristics and demographics, including functional outcome at 90 days as measured by modified Rankin Scale (mRS), which was categorized as favorable (mRS 0–2) or unfavorable (mRS 3–6).

Results

Of patients who received MT, 54 (30.3%) had a prior medical history of depression. On univariate analysis, patients with a history of depression had 2.5 times higher odds of an mRS score of 3–6 (cOR = 2.47, 95% CI = 1.11‐5.48). Multivariate analysis included history of smoking, hypertension, obesity, Alberta Stroke Program Early CT Score (ASPECTS)[YC1][KC2], time to recanalization, and discharge NIHSS score, along with history of depression. We found that the odds of having an unfavorable mRS were 5 times higher in those with a history of depression than those with no history (aOR = 5.15, 95% CI = 1.09‐23.31). Additionally, discharge NIHSS was associated with 1.5 times higher odds of unfavorable mRS for each point increase in NIHSS score (aOR = 1.47, 95%CI = 1.25‐1.74). While pre‐existing depression was associated with poorer functional outcomes, it was not associated with mortality, cOR = 1.12, 95%CI = 0.55‐2.27.

Conclusions

In this study, we found that a prior medical history of depression is associated with unfavorable functional outcomes at 90 days in patients who received MT. Future studies should investigate the association between the severity of depression and stroke outcomes and explore methods to mitigate the impact of depression on stroke outcomes.
Abstract Number ‐ 198: Management of poor grade aneurysmal subarachnoid hemorrhage: illustrative case and literature review
Authors: Brown Nolan , Bamimore Michael , Lee Seung , Perez‐Vega Carlos , Singh Rohin , Gendreau Julian , Ravindran Krishnan , Al‐Shaikh Rana , Jeevaratnam Suren , Freeman William
Published: April 2023

Introduction

Poor‐grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality. Overall, 20–30% of aSAH are described as poor grade. Despite recent advances in management strategies, prognosis of poor‐grade aSAH remains dismal. As such, we review the most current literature regarding management strategies that can be used to decrease the risk of the four most common causes of secondary brain injury: 1) aneurysm re‐rupture, 2) hydrocephalus, 3) cerebral salt wasting, and 4) delayed cerebral ischemia/vasospasm.

Methods

We present a 46‐year‐old female patient with poor‐grade aSAH after a loss of consciousness following thunderclap headache. Examination showed a dilated left pupil and Glasgow Coma Scale (GCS) of 4. Imaging revealed a ruptured anterior communicating artery aneurysm, and she was subsequently taken to the neuro‐interventional radiology suite for EVD placement. On POD 7 Transcranial Doppler (TCD) suggested moderate vasospam of left MCA. Two successful balloon angioplasties of the basilar, ACA‐A1, and MCA‐M1 were successfully performed on separate consecutive days. By POD 10, intermittent severe ICP spikes required targeted temperature management (TTM) with hypothermia. On POD 24, her ICP normalized, she was no longer comatose, and her EVD was clamped and removed. She was rapidly weaned off ventilator and transitioned to rehabilitation. 3‐months postoperatively, Modified Rankin Scale score was 0.

Results

Based upon the result of our literature review, we propose maintaining blood pressure below 160 mmHg prior to intervention, after which it can be increased to 160–240 mmHg to prevent vasospasm. Transcranial Doppler is essential to detect vasospasm as the aSAH symptoms subtle; once identified, vasospasm can be successfully treated with balloon angioplasty. Finally, targeted temperature management, mannitol, hypertonic saline, and neuromuscular paralysis are essential for postoperative management of ICP levels.

Conclusions

The multimodal approach should be considered when managing poor grade aSAH. Further research in aSAH management would benefit the patients who present with poor prognosis, thereby improving patient care and leading to a standard, effective approach for aSAH management.
Abstract Number ‐ 218: Mechanical Thrombectomy in a HIV Patient with Staphylococcus Lugdunensis Bacteremia: A Case Report.
Authors: Collins Braylee W , Collins Braylee , Sadeghpour Shirin , Patel Sunay , Neal Jason
Published: April 2023

Introduction

Occlusion of cerebral arteries account for 40–50% of neurological complications of infective endocarditis with the emboli most commonly lodging in the middle cerebral artery. The management of these occlusions with the use of thrombolytic therapies are associated with intracranial hemorrhage whereas outcomes with endovascular thrombectomy, while still under investigation, appear to be more favorable. In this case report, we present a HIV patient with persistent staphylococcus lugdunenesis bacteremia of unknown origin and acute left middle cerebral artery occlusion, who underwent endovascular thrombectomy.

Methods

Case Report

Results

A 66‐year‐old male past medical history of HIV on Elvitegravir/Cobicistat/Emtricitabine/ Tenofovir, pancytopenia and treated hepatitis C who presented for malaise, back pain, and urinary symptoms for 1 week. Initial labs remarkable for pancytopenia, CD4 count 44 and positive urinalysis. Ceftriaxone was started for UTI and Trimethoprim/Sulfamethoxazole for PJP prophylaxis. Urine and multiple blood cultures were positive for staphylococcus lugdunensis. Vancomycin was added to antibiotic therapy. On day two of hospitalization, patient developed new onset aphasia, right facial droop, and right hemiparesis. Upon evaluation, NIHSS was 14. CT head was negative. CTA head and neck showed left M1 occlusion. CT perfusion showed an infarct core of 20cc and 144cc of penumbra. Due to concern for possible infective endocarditis, thrombolytics were not administered but he was taken for thrombectomy. Emboli retrieval was successful with mTICI‐2c reperfusion. During thrombectomy, clot noted to have septic emboli appearance. Post thrombectomy, patient had complete resolution of neurological deficits. MRI brain showed multiple punctate foci of restricted diffusion in the left middle cerebral artery distribution consistent with embolic process. TTE was inconclusive. Intraoperative cultures of the clot resulted positive for staphylococcus lugdunensis and pathology examination detailed clot with bacterial colonization. TEE was performed and negative for valvular vegetations, mass, thrombus, or endocarditis but there was an intrapulmonary shunt. Patient later developed a small acute left parietal lobe parenchymal hematoma and basal ganglia infarct. His neurological status remained unchanged. He completed 6 weeks of IV antibiotic therapy upon discharge.

Conclusions

This case illustrates the importance of timely endovascular thrombectomy in suspected cerebral septic emboli as outcomes are favorable. It supports prompt recognition of septic emboli bacterial species for targeted antibiotic therapy along with further investigation into staphylococcus lugdunensis and its relation with cerebral septic emboli. This case urges additional exploration into the relationship between HIV patients and cerebrovascular disease including cerebral septic emboli.
Abstract Number ‐ 219: Spinal cord infarct in young: Fibrocartilaginous Embolism with Occlusion of Anterior Spinal Artery
Authors: Tran Thanh Lam N , AlHashim Hayder , Harrigan Mark
Published: April 2023

Introduction

Spinal cord infarctions are rare and account for fewer than 1% of all strokes. Diagnosis is usually established by clinical symptoms of sudden onset paraplegia and sensory dysfunction along with radiographic evidence of a non‐enhancing, diffusion‐restricted T2 hyperintense lesion on spinal cord MRI. We describe an interesting case of anterior spinal artery infarct from suspected fibrocartilaginous embolus from intervertebral disc.

Methods

Case report. Demographics and clinical history were obtained by chart review. MRI and cerebral angiogram images were reviewed and compared to radiology reports.

Results

21‐year‐old female with no prior medical history presented with sudden onset headache, bilateral arm tingling, and neck stiffness that rapidly progressed within the hour to quadriplegia with numbness below the T2 sensory level. She continued to worsen, developed respiratory failure and required intubation. MRI of the cervical cord revealed a longitudinally extensive, non‐enhancing, diffusion‐restricted lesion extending from the bilateral medial medulla to the ventral spinal cord at C5/6 vertebral level. Cerebral and spinal digital subtraction angiography was notable for non‐opacification of the cervical anterior spinal artery. She had extensive work up for dissection, vasculitis, hypercoagulable state, autoimmune conditions that were all negative. However, there was a diminished T2 signal in her C5‐6 intervertebral disc with subtle loss of intervertebral disc space concerning for disc compression, likely related to her job requiring intensive heavy lifting. It was surmised that she developed a ventral cervical cord infarct secondary to fibrocartilaginous embolization and occlusion of anterior spinal artery, from recent mechanical compression of her C5‐6 disc. Cases of spinal cord infarcts following mechanical trigger, such as heavy lifting or falls, with histopathological confirmation of fibrocartilaginous material in the vasculature postmortem are well reported. It is postulated as a mechanism of spinal cord infarct in young patients that compressive forces on the intra‐vertebral body trigger embolization of nucleus pulposus material through persistent nuclear anastomoses to the spinal circulation.

Conclusions

Ischemic infarct should be considered in the differential diagnosis for sudden onset of symptoms localizable to spinal cord, especially when spinal MRI shows restricted diffusion in a vascular distribution. Demonstrating non‐opacification of the anterior spinal artery on digital subtraction angiography confirms the diagnosis. In case of negative work up for spinal cord infarct, the presence of an abnormal signal in the intervertebral disc on MRI may suggest fibrocartilaginous embolism as a mechanism of infarction in young patients.
Abstract Number ‐ 221: Lower Thoracic Spinal Dural Arteriovenous Fistula Presenting With Progressive Paraplegia: A Case Report
Authors: Mehta Amit , Lightfoot Nathan , Khan Fahad , Sur Samir , Barry Brian
Published: April 2023

Introduction

We present a 72‐year‐old male with osteoarthritis, lumbar stenosis, coronary artery disease with a 4‐vessel bypass graft in February 2020, hypertension, hyperlipidemia, and obesity who presented with subacute progressive lower extremity weakness. He began having lower back pain following his cardiac surgery in February 2020. He was evaluated by a rehabilitation doctor in September 2020 who diagnosed him with lumbar radiculopathy and treated him with one round of steroid injections that helped a bit. Six months later he returned for follow‐up with the aid of a wheelchair which he started using in the last two weeks due to progressive lower extremity weakness. He was sent to the ED for neurologic evaluation. He denied radicular pain, saddle anesthesia, and urinary or bowel incontinence.

Methods

On neurologic exam, he had 2/5 bilateral hip flexion strength, 4/5 bilateral distal lower extremity strength, intact sensation to all modalities, and diffuse bilateral hyporeflexia (1+) with flexor plantar responses. An MRI brain was unremarkable. An MRI cervical, thoracic and lumbar spine with contrast showed extensive confluent cord edema with enhancement from T9 to the conus medullaris. He was started on high‐dose IV methylprednisolone for concern of transverse myelitis. Serum metabolic, hematologic, autoimmune, and infectious workup were negative. Due to a lack of improvement, his spinal imaging was reviewed with neuroradiology who recognized previously unidentified posterior T2 flow voids in the subarachnoid space at T1. A spinal angiogram for suspicion of a spinal dural arteriovenous fistula (dAVF) was subsequently scheduled.

Results

Angiography confirmed a type I spinal dAVF which was treated with posterior laminectomy and surgical ligation. The patient’s lower extremity strength improved and he was discharged to acute rehab. At his 1‐month neurology follow‐up appointment, he was ambulating with minimal assistance from a cane with near full lower extremity strength.

Conclusions

With an initial presentation of subacute progressive lower extremity weakness and imaging findings concerning for longitudinally extensive transverse myelitis, our initial suspicion was highest for an underlying autoimmune or infectious disease. However, this case teaches us to not presume all transverse myelitis or enhancing spinal cord lesions must be from an inflammatory, neoplastic, or infectious condition. A wide differential for this presentation including spinal dAVF is necessary as this is one of the most commonly missed neurovascular diagnoses. T2 flow voids are highly suggestive of this condition, but a spinal angiogram is the gold standard for diagnosis.
Abstract Number ‐ 223: Spontaneous Revascularization of Completely Occluded Internal Carotid Artery: Case Report
Authors: Ghani Mohammad , Kemper Nicholas , Coghlan Meghan A , Yousaf Muhammad I , Ander Tracy M , Remmel Kerri , Liu Wei
Published: April 2023

Introduction

Occlusion of the internal carotid artery (ICA), caused by atherosclerotic thrombosis, arterial embolism, or dissection, is associated with high morbidity and mortality of acute stroke. Commonly, these lesions are managed with aggressive medical treatment due to their chronic and usually irreversible nature. Spontaneous recanalization of the occluded ICA has been described in rare instances.

Methods

We present a report here on three cases with spontaneous recanalization of complete occluded carotid arteries.

Results

Our first patient was a 62‐year‐old male with a history of hypertension, who presented with transient left eye vision loss. CT angiography of the head and neck (CTA HN) demonstrated left ICA complete occlusion while the left middle cerebral artery (MCA) and anterior cerebral arteries (ACA) were patent. He was treated with apixaban. At the two‐month follow‐up, the repeat CTA HN demonstrated complete recanalization of the left ICA. The etiology of the occlusion remained cryptogenic. Our second patient was a 71‐year‐old male with a prior history of right carotid endarterectomy, peripheral vascular disease, coronary artery disease, hypertension, and dyslipidemia, who presented with acute right MCA stroke. Work‐up with CTA HN demonstrated right ICA complete occlusion. He was treated medically with aspirin and clopidogrel. Six months later, he presented with a two‐week history of intermittent confusion and left‐sided weakness. His MRI brain was negative foracute stroke. Interestingly, CTA HN demonstrated that the right ICA had complete recanalization. The cause of carotid thrombosis remained cryptogenic. Our third patient was a 46‐year‐old female with a history of hypertension, hyperlipidemia, remote low‐speed vehicle collision, and cervical spine chiropractic treatment (the last neck manipulation was about two years prior), presenting with sudden onset dizziness, right‐sided neck pain, and left homonymous hemianopia. Brain MRI showed acute right posterior cerebral artery (PCA) stroke. CTA HN revealed occlusion of the right ICA with a flare‐up appearance suggestive of a carotid dissection. She also had a right fetal PCA. She was treated medically with rivaroxaban. Four months later, a follow‐up MR angiogramof the neck showed a fully revascularized right ICA. Her hypercoagulable workup revealed that she had a rare form of breast cancer.

Conclusions

Although ICA occlusion is generally considered chronic and irreversible, our case series suggests that the lesion can have spontaneous recanalization with medical treatment. Further studies of characterizing carotid occlusion to predict recanalization are warranted.
Abstract Number ‐ 224: Stroke Mimic—Patient with Symptomatic Amyloid‐Related Imaging Abnormalities Presenting with Stroke‐like Symptoms.
Authors: Kmeid Michael , Blanden Adam R , Kaur Navreet , Clos Siara , Masoud Hesham
Published: April 2023

Introduction

Amyloid‐related imaging abnormalities (ARIA) are rare phenomena in patients taking monoclonal antibodies directed against amyloid beta in Alzheimer’s disease clinical trials. The pathogenesis is unclear, but may be due to an induced inflammatory microangiopathy. While the majority of cases are asymptomatic and resolve without intervention, a small subset can experience symptoms of sudden or uncertain onset. Given the relative rarity of this phenomena and the striking imaging findings, ARIA can be misdiagnosed as ischemic stroke or primary microangiopathy when presenting with acute‐subacute symptoms. Following diagnosis there is no clinical consensus on the optimal management and approaches range from withdrawal of the study drug to pulse‐dose steroids.

Methods

We present a case study of a patient admitted to our inpatient stroke service after 4 days of rapidly progressive confusion and sudden vision loss with MRI workup reporting subacute stroke. The findings were ultimately determined to be secondary to ARIA.

Results

A 67‐year‐old man with early onset Alzheimer’s disease enrolled in a clinical trial for donamemab presented with four days of marked cognitive decline including increased forgetfulness, confusion, and episodic hallucinations following an episode of abrupt vision loss. An outpatient MRI brain demonstrated subcortical hyperintensity that was initially reported as a subacute left occipital stroke. Notably, an MRI performed 3 months prior showed no abnormality. Neurological exam was remarkable for right superior quadrantanopia, memory impairment, and mild confabulation. Repeat MRI demonstrated FLAIR white matter hyperintensities and extensive susceptibility artifact in the left parieto‐occipital lobe, consistent with an inflammatory cerebral amyloid angiopathy (or ARIA). Spot EEG demonstrated no associated epileptiform discharges. Patient was treated with 7‐day course of IV Solumedrol and had improvement in visual symptoms. He was discharged on a prednisone taper and a followup MRI brain 4 weeks later showed near‐ complete resolution of the previously noted subcortical white matter changes.

Conclusions

ARIA can be seen in patients receiving anti‐amyloid monoclonal antibody treatments. Surveillance MRIs have been implemented to screen for such cases as a minority of patients with ARIA present with symptoms. As noted with this case study, a relatively acute presentation and imaging characteristics can lead to an initial misdiagnosis as subacute ischemic stroke. Vascular neurologists should be aware of this clinical entity, noting the natural history and treatment are not well established. This patient was treated aggressively as an inflammatory cerebral amyloid angiopathy with IV steroids and noted positive outcome. More research is required to establish the optimal acute medical management of patients with ARIA.
Abstract Number ‐ 227: Retrograde embolism from a Subclavian Thrombus causing Acute Ischemic Stroke in the Middle Cerebral Artery
Authors: Philip Karan , Blanden Adam , Kleinhenz Elena , Masoud Hesham
Published: April 2023

Introduction

Intracranial embolism to the middle cerebral artery usually occurs because of embolization from the heart, carotid artery or the aorta. Here we describe a case of a subclavian thrombus, embolizing to the middle cerebral artery. Retrograde embolism is a rarely described mechanism of acute ischemic stroke.

Methods

A 49‐year‐old gentleman with a history of hyperlipidemia, peripheral artery disease, smoking, prior stroke, previously treated arteriovenous malformation (AVM) in the left parieto‐occipital region and active methamphetamine use presented with sudden onset dysarthria and left facial weakness (NIH stroke scale–3). CT angiogram (CTA) head and neck demonstrated a right M2 inferior division occlusion and noted nonocclusive thrombus attached to right subclavian artery atherosclerotic plaque, proximal to the origin of the right vertebral artery and otherwise minimal extracranial, and intracranial atherosclerotic disease. He was not a candidate for IV thrombolysis due to his AVM, or mechanical thrombectomy (MT) due to low NIHSS. Apixaban was started. Trans‐esophageal echocardiogram (TEE) demonstrated a grade 2 PFO. Venous doppler ultrasound performed of his upper and lower extremities was negative. On day 2 of hospitalization, his left hemiparesis and dysarthria worsened. Repeat CTA head and neck showed absence of the right subclavian thrombus and new distal M1‐MCA thrombus, suggestive of retrograde embolism from the right subclavian artery. The patient was started on IV heparin and aspirin. A stroke in young work‐up was sent including antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies (ANCA), homocysteine, hexagonal phase phospho proteins, antiphospholipid antibodies, HIV, rheumatoid factor, cryoglobulin, hepatitis B antibodies, hepatitis C antibodies, sickle cell screen, Sjogren’s syndrome antibodies, drug screen, and was negative.

Results

Embolism (cardioembolism and artery–artery embolism) to the intracranial vasculature is an important cause of acute ischemic stroke. Retrograde embolization is rarely described as a cause of ischemic stroke. Our patient presented initially with distal right M2 occlusion and subocclusive thrombus of the right subclavian artery, associated with focal atherosclerosis but otherwise patent extracranial and intracranial cerebral vessels. Work‐up including transesophageal echocardiogram, and hypercoagulable work‐up was unrevealing. Repeat CT angiogram obtained in view of worsening deficits revealed absence of his right subclavian thrombus and new distal M1‐MCA occlusion presumed retrograde embolism from the right subclavian artery. This is may represent the consequence of local turbulence and retrograde flow during diastole.

Conclusions

When considering sources of embolic stroke, retrograde embolism should be considered in patients with focal atherosclerosis.
Abstract Number ‐ 231: Role of Anticoagulation in Recurrent Basilar Artery Thrombosis Secondary to Dolichoectasia, a Case Report
Authors: Mannem Narmada , Yelverton Nicholas B
Published: April 2023

Introduction

Basilar artery thrombosis accounts for a small part of ischemic strokes but contributes to one‐fifth of the posterior circulation strokes. Recurrent basilar artery thrombosis secondary to dolichoectasia is caused by abnormal flow in the dilated artery and can result in cerebral ischemia. We present a similar case of recurrent thrombosis with a missed dose of anticoagulation and dehydration on two separate occasions.

Methods

An 81‐year‐old man with a past medical history of ulcerative colitis with colostomy, provoked deep venous thrombosis presented as a transfer from an outside hospital with acute onset of dysarthria, nausea/vomiting, unsteadiness, and left hemiparesis. CT angiogram of head and neck revealed right vertebral thrombosis extending into the basilar artery with dolichoectasia involving distal right vertebral artery and basilar artery. He was started on heparin infusion with improvement in symptoms and a return to baseline. He was later transitioned to apixaban and discharged home. On a follow‐up office visit two months later, his repeat CT angiogram revealed resolution of the thrombus. He was advised to continue the medication due to the risk of recurrent occlusion secondary to vessel anomaly. After four months, the patient returned to the emergency department with acute onset dizziness, imbalance, nausea, and vomiting. CT angiogram of the head and neck was performed which revealed non‐occlusive thrombosis in the basilar artery. On evaluation by neurology, he admits to three missed doses of apixaban. Clinical and laboratory data were concerning for volume depletion. On further questioning about his symptoms, he mentions decreased oral intake on the day of colostomy change. He was advised to continue apixaban and stay hydrated.

Results

After fifteen months of the first presentation, the patient is symptom‐free but was continued on anticoagulation with apixaban to prevent recurrent events.

Conclusions

The role of short‐term and long‐term anticoagulation in basilar artery occlusion is less studied. No prospective trials were done so far to suggest that antithrombotic therapy lowers the risk of recurrent ischemic events and/or anticoagulation is superior to antiplatelets. Dolichoectasia by itself can increase the risk of recurrent thrombosis and dehydration likely facilitated the thrombosis in our patient during the event of missed anticoagulation.
Abstract Number ‐ 233: Vaccine‐Induced Thrombotic Thrombocytopenia presenting as Massive Stroke: Case Report and Literature Review
Authors: Ghani Mohammad R , Shi Ping , Brown Randall , Coghlan Meghan A , Hasan Saad , Ander Tracy M , Haboubi Michael , Liu Wei
Published: April 2023

Introduction

Vaccines have been pivotal for the COVID‐19 pandemic. Rare adverse effects of the vaccines such as thrombosis have been observed. Here we report a case of an acute malignant ischemic stroke in a young healthy patient caused by thrombosis due to Vaccine‐Induced Thrombotic Thrombocytopenia (VITT).

Methods

Electronic chart review for a case report.

Results

A 43‐year‐old Caucasian female with a medical history of hypertension was found unresponsive on the morning of presentation. Her Last known normal was the night before. On arrival in the emergency department, she was globally aphasic, with left eye deviation, right‐sided neglect, right facial droop, and right‐side hemiplegia. Pupils were equal and reactive to light. NIHSS was 23. Head CT showed large left middle cerebral artery and anterior cerebral artery strokes with significant cerebral edema and midline shift. Head and neck CTA showed left ICA and left MCA occlusions. She was taken for decompressive craniectomy immediately. Ten days prior to the stroke, she received her first COVID vaccination. She smoked but did not take oral contraceptives. She did not have a family history of hypercoagulability. Stroke workup showed LDL 141, A1C 4.8%, and a negative COVID test. She had normal white and red blood cell counts but low platelet counts at 73,000, which was 233,000 one month prior. 2D echocardiogram showed an ejection fraction of 54% and no patent foramen ovale or thrombus. Lower extremity doppler showed deep vein thrombosis. Because of arterial and venous thrombosis with new thrombocytopenia, hematology was consulted. She was found to have positive anti–PF4–heparin antibody, leading to a VITT diagnosis. She received IVIG, rituximab, and steroid treatments, and her platelets gradually returned to the baseline. She was later transferred to a rehabilitation facility.

Conclusions

VITT is characterized by thrombosis and thrombocytopenia with positive PF4 antibodies after a median of 14 days post‐vaccination. It was reported in COVID vaccines from all manufacturers. The mechanism remains unclear. The current hypothesis describes a two‐hit process through which the vaccine triggers neoantigen formation (the first hit) followed by a systemic inflammatory response (the second hit). Incidence of VITT from COVID vaccinations is unknown but the reported cases were rare. VITT‐caused acute stroke, especially malignant strokes, is even rarer.Although the COVID vaccines can cause rare life‐threatening adverse events, they are essential for controlling the pandemic. When encountering an ischemic stroke patient with thrombocytopenia, we should consider VITT. Further study with post‐vaccination registration and monitoring is warranted.
Abstract Number ‐ 262: Cognitive Decline in Patients with Symptomatic Intracranial Stenosis and Effect of Serum Lipid Profile
Authors: Fakih Rami
Published: April 2023

Introduction

We determined the effect of baseline low density lipoprotein (LDL) and triglyceride (TG) concentrations on cognitive decline, in patients with symptomatic high grade intracranial stenosis.

Methods

We analyzed a cohort of stroke patients who had baseline and 4 months follow‐up Montreal Cognitive Assessment (MoCA) scores. MoCA score worsening after 4 months was the outcome of interest, defined as worsening of ≥ 2 points from baseline. Baseline LDL and TG concentrations (mg/dl) were assessed, and univariate and multivariate analysis using logistic regression were performed to identify predictors of worsening MoCA scores.

Results

A total of 349 patients were analyzed. 313 and 315 patients had baseline LDL and TG, respectively. 61 (17%) had a worsening of MoCA scores. The mean baseline LDL was 97.3 (39.1) in the worsening group, compared to 110.6 (44.8) in those with no worsening (p = 0.014). 23% of patients with LDL < 100 had worsening in MoCA score compared to 11% of patients with LDL ≥ 100 (p< 0.006). The mean baseline TG was 145.7 (102.2) in the worsening group, compared to 170.7 (135.4) (p = 0.053). On multivariate analysis, higher age (p = 0.014) and lower baseline LDL (p = 0.046) were predictors of worsening MoCA scores.

Conclusions

Patients who did not undergo any worsening MoCA scores had higher LDL and TG levels at baseline, and only older age and lower baseline LDL scores predicted worsening scores at 4 months. Presumably, the patients with high baseline lipid levels were treated more aggressively with dietary modifications and statins, which could have led to cognitive protective effect regardless of serum lipid profile.
Abstract Number ‐ 265: Reduced‐dose ticagrelor versus full‐dose ticagrelor in patients with stroke: A retrospective cohort study
Authors: Tarabichi Ammar , Morsi Rami Z. , Metman Okker , Desai Harsh , Kothari Sachin , Carrión‐Penagos Julián , Thind Sonam , Coleman Elisheva , Brorson James R. , Mendelson Scott , Mansour Ali , Prabhakaran Shyam , Kass‐Hout Tareq
Published: April 2023

Introduction

There has been an increase in use of ticagrelor in patients with ischemic stroke, particularly in the setting of clopidogrel resistance. Our study aims to retrospectively determine if aspirin plus ticagrelor at a reduced dose is effective in reducing the risk of recurrent stroke and/or other thrombotic events, without increasing the risk of bleeding.

Methods

In a prospectively maintained database, we performed a retrospective analysis of consecutive patients with acute ischemic stroke in a large academic comprehensive stroke center between September 1, 2020 to July 1, 2022. We compared in‐hospital mortality, 90‐day mortality, favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0 to 2, at 90 days, symptomatic intracranial hemorrhage (sICH), and asymptomatic intracranial hemorrhage (ICH), between patients on reduced‐dose ticagrelor versus those on full‐dose ticagrelor, in unadjusted and adjusted logistic regression models.

Results

We included 567 patients in our study. The mean age of these patients was 67.0 ± 15.0 years. Females represented 59.5% of the patients, and the majority of the patients were Black (80.0%). Intracranial atherosclerotic disease was the presumed stroke etiology in 96 patients (17.0%). Out of 567 patients, 432 were on a combination of both ticagrelor and aspirin. A total of 62 patients were on a reduced dose of ticagrelor (45 mg or 60 mg twice daily). The remaining 505 patients were on 90 mg twice daily dosing. New or recurrent ischemic stroke was similar across both groups (10.2% vs. 12.0%, p = 0.08). Symptomatic ICH was also found to be similar across both groups (8.2% vs. 9.3%, p = 0.06). Mortality or favorable functional outcome at 90 days also did not differ between the two groups (25.3% vs. 24.7%, p = 0.007; 28.2% vs. 27.3%, p = 0.006).

Conclusions

A lower dose of ticagrelor (45 or 60 mg twice daily) appears to be a safe and effective regimen in reducing risk of ischemic strokes without increasing hemorrhagic complications when compared to full‐dose ticagrelor at 90 mg twice daily. Further randomized trials are necessary to inform this recommendation.