bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP186: Small Vessel Disease is Associated With Primary Aldosteronism in Acute Ischemic Stroke
Authors: Okumura Motohiro , Sato Takeo , Tsujimoto Yuki , Yamashiro Kenji , Watanabe Yui , Kida Hiroyuki , Nakada Ryoji , Kitagawa Tomomichi , Takatsu Hiroki , Komatsu Teppei , Sakuta Kenichi , Sakai Kenichiro , Mitsumura Hidetaka , Nishimura Rimei , Iguchi Yasuyuki
Published: January 2025

Background and Purpose:
Primary aldosteronism (PA) is characterized by the autonomous overproduction of aldosterone leading to the risk of occurrence of acute ischemic stroke (AIS), but the exact prevalence of PA is unknown in patients with AIS. PA induces oxidative stress and inflammation through vascular endothelial cells, which may damage small vessel disease (SVD). We conducted a prospective study to investigate the prevalence of screening and definite diagnosis of PA in patients with AIS. Next, we aimed to reveal whether SVD markers could be associated with PA.

Methods:
We screened consecutive patients with AIS who participated in our prospective study to investigate the prevalence of PA and followed up for PA evaluation from October 2020 to December 2022. Inclusion criteria were patients with AIS hospitalized and diagnosed with hypertension. Exclusion criteria were patients taking medications affecting renin, aldosterone, and catecholamines. The screening criteria for PA was defined as the aldosterone-to-renin ratio > 200. Final diagnosis of PA was judged by endocrinologist if one of the captopril challenge test, saline infusion test, and furosemide-upright test was positive following discharge. We evaluated total SVD score based on white matter hyperintensities (separately scored by periventricular hyperintensity [PVH] and deep and subcortical white matter hyperintensity), cerebral microbleeds (CMBs; categorized into deep, lobar, and infratentorial lesions), enlarged perivascular spaces (separately scored in basal ganglia and centrum semiovale), and old lacunes on MRI.

Results:
We included 120 patients with AIS (93 [78%] male, median age 62 years, Figure 1). The screening for PA was positive in 33 (28%) patients and 8 (7%) patients were finally diagnosed with definite PA. In Poisson regression analysis with a robust variance estimator, total SVD score was related to positive PA screening (prevalence ratio [PR] 1.261, 95% CI 1.021-1.556,
p
= 0.031) and definite PA diagnosis (PR 1.946, 95% CI 1.229-3.082,
p
= 0.005, Figure 2). In terms of each SVD marker, severe PVH, and deep and lobar CMBs were associated with positive PA screening and definite PA diagnosis (Figure 3).

Conclusions:
Twenty-eight percent of patients with AIS were positive for PA screening, and then about a quarter of them were confirmed as definite PA. SVD burden, especially PVH, and deep and lobar CMBs, might be associated with positive screening and definite diagnosis of PA.
Abstract WP196: Comparing hypodensity and volume measurements for ischemic stroke patients in admission CT between CTP ischemic core, DWI, and deep learning based CT regions of interest
Authors: van Voorst Henk , Zamarud Aroosa , Liu Yongkai , Wouters Anke , Seners Pierre , Mahammedi Abdelkader , Verhaaren Benjamin , Christensen Soren , Yuen Nicole , Mlynash Michael , Zaharchuk Greg , Lansberg Maarten , Albers Gregory , Heit Jeremy
Published: January 2025

Introduction:
Non-contrast brain CT hypodensity and volume in acute ischemic stroke patients are associated with poor patient outcomes. Currently, abnormal hypodensities in CT are measured using coregistered CT Perfusion or DWI based region of interest (ROI) segmentations. We hypothesized that deep learning based ischemic lesion segmentation on admission CT (DLCT) could serve as an alternative to CTP or DWI ROIs for density and volume measurements in CT.

Methods:
Patients from the prospective CRISP 2 study with admission CT/CTP in the primary stroke center and DWI after transfer to a comprehensive stroke center were included (n=208). We trained a deep learning model for admission CT ischemic lesion segmentation using DEFUSE 3 patients (n=218). Besides this DLCT ROI, we used the admission CTP ischemic core (relative cerebral blood flow <30%) and manually segmented DWI lesion co-registered to the CT space. We report Bland-Altman analyses with mean difference between ROI methods and 95% confidence intervals (mean[95%CI]) for the following measurements: total volume, volume with <26 Hounsfield units (HU) and >26HU, volume with >10% and >20% relative hypodense voxels, average (avg), median, and standard deviation of density (HU) in the ROI, net water uptake (NWU=[1-mean density ischemic/contralateral ROI]), proportion of the total lesion with >10% and >20% relative hypodense voxels. Relative hypodensity was measured as the percentage difference between ischemic and contralateral voxels.

Results:
Mean differences for volume measures varied considerably for DLCT-CTP (total volume 1.6mL [-54.8;61.6]); volume<26HU 1.3mL [-16.5;19.0]), DLCT-DWI (total volume -22.0mL [-114.5; 70.6]; volume<26HU -3.0mL [-19.9; 13.9]), and CTP-DWI (total volume -23.6mL [100.6; 53.4]; volume<26HU -4.3mL [-22.4; 13.9]). However, DLCT-DWI and CTP-DWI had similar differences. Contrary to volume measure, average density and net water uptake measures had lower differences between DLCT-CTP (avg: -0.7HU [-5.1; 3.8]; NWU: 3% [-9;15]), DLCT-DWI (avg: -1.6HU [-6.8; 3.6]; NWU: 5% [-7; 18]), and CTP-DWI (avg: -1.6HU [-4.8; 1.7]; NWU: 2% [-8; 11]). Figure 2 describes all other variables.

Conclusion:
DLCT, CTP, and DWI techniques demonstrate relatively low mean differences for volume and hypodensity measurements, but substantial variability is present despite this agreement on average. Further research should identify if these variations alter associations with clinical outcomes.
Abstract WP198: Multimodal MRI sequences are vital for the diagnosis of Vertebrobasilar Artery Dissection
Authors: Nakayama Yoshitaka , Kida Hiroyuki , Maku Takahiro , Nakada Ryoji , Kitagawa Tomomichi , Takatsu Hiroki , Komatsu Teppei , Sakuta Kenichi , Sakai Kenichiro , Mitsumura Hidetaka , Iguchi Yasuyuki
Published: January 2025

Introduction:
Vertebrobasilar artery dissection (VBD) results from blood entering a tear in the intima of the vertebral artery (VA), basilar artery, and their branches. T1-Sampling Perfection with Application optimized Contrast using different flip angle Evolution (T1-SPACE) is valuable for detecting intramural hematoma (IMH). Despite the potential of susceptibility-weighted imaging (SWI) for IMH detection, its clinical adoption remains limited. This study aimed to clarify the usefulness of SWI and T1-SPACE in detecting IMH in VBD.

Methods:
Consecutive patients admitted with symptomatic VBD within 28 days of initial symptom onset between November 2014 and September 2023 were retrospectively screened from the Jikei University School of Medicine Stroke Registry. The inclusion criteria were (1) definitive VBD diagnosis based on the Spontaneous Cervicocephalic Arterial Dissections Study criteria, and (2) performance of both SWI and T1-SPACE simultaneously. IMH on SWI was identified by (1) eccentric or concentric areas of hypointensity adjacent to the vessel wall, (2) hyperintensity on phase maps corresponding to hypointensity on SWI, and (3) absence of calcification on CT. We compared the IMH detectability between SWI and T1-SPACE.

Results:
The study included 74 patients (52 males, median age 45). The 65 patients detected IMH on SWI, the 66 patients detected on T1-SPACE; IMH detection rates were equivalent (88% vs. 89%; p=1.00). T1-SPACE had a higher detection rate in VA dissection compared to PICA dissection (97 vs 14%, p<0.001). SWI showed no significant difference (VA, 88% vs PICA, 86%, p=0.613). SWI detected IMH more frequently in intracranial artery dissection compared to extracranial artery dissection (94% vs 38%, p<0.001), but T1-SPACE showed no significant difference (88% vs 100%, p=0.381).

Conclusions:
IMH detectability on VBD is remarkable by SWI in PICA and T1-SPACE in extracranial artery. For the diagnosis of VBD, it is essential to perform both SWI and T1-SPACE.
Abstract WP2: Transcranial Direct Current Stimulation Is Safe and Feasible in Hyperacute Ischemic Stroke
Authors: Slovak Matej , Kemlink David , Dusek Pavel , Rekova Petra , Fabián Vratislav , Jurka Martin , Carone Davide , Perry Alistair , Harston George , Ruzicka Evzen , Altmanova Dagmar , Lambert Lukas , Burgetova Andrea , Knotkova Helena , Datta Abhishek , Bikson Marom , Nitsche Michael , Bahr-Hosseini Mersedeh , Saver Jeffrey
Published: January 2025

Introduction:
Cathodal transcranial direct current stimulation (C-tDCS) is a potential neuroprotective method in the hyperacute phase of ischemic stroke. In rodent models, C-tDCS reduced final infarct volume and improved functional outcome. Our aim was to assess safety, tolerability, feasibility, and potential efficacy of C-tDCS in stroke patients with salvageable penumbra.

Methods:
Our study was a single-center, double-blind, randomized, sham-controlled (3 active: 1 sham), 3+3 dose-escalation trial. Inclusion criteria were stroke due to occlusion of the internal carotid or middle cerebral artery, last well-known time within 24 h, evidence of substantial penumbra on baseline CT perfusion, and ineligibility for mechanical thrombectomy. We applied C-tDCS at six dose tiers over the affected primary motor cortex (1 or 2 mA for 20 min in 1 to 3 cycles with 20 min breaks). The primary safety outcome was the symptomatic intracranial hemorrhage (SICH) rate at 24 h post-stimulation. The secondary safety outcomes were the rates of asymptomatic intracranial hemorrhage (AICH), early neurologic deterioration, serious adverse events, and mortality within 90-day follow-up. Tolerability was assessed by the rate of patients completing the entire stimulation period and by structured questionnaires. The success threshold for feasibility was median randomization-to-C-tDCS start time within 10 min in the last ten patients. Exploratory efficacy outcomes included infarct growth at 24 h, and National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale at day 90.

Results:
A total of 25 patients were enrolled (19 active, 6 sham), mean age (SD) 81 (12) years, 9 males, median NIHSS (Q1–Q3) 8 (6–16) points. Ten active and 4 sham patients were treated with thrombolysis. No SICH and 3 AICH (2 after thrombolysis) occurred in the active arm. We observed no significant difference in serious adverse events. The mortality rate was also comparable (4 active vs 2 sham patients). C-tDCS was well tolerated, all patients completed the stimulation period. Side effects were only mild and transient. C-tDCS was feasible, median randomization-to-C-tDCS start time was 8 (7–9) min. No significant differences in other outcome measures were observed.

Conclusions:
The application of C-tDCS in hyperacute ischemic stroke was safe, well tolerated, and feasible. Our results support the use of C-tDCS in larger efficacy trials.
Abstract WP205: Association Between Bovine Aortic Arch Anatomy and Carotid Artery Stenosis
Authors: Kalina Samuel , Mahmoudi Hamidabad Negin , Benson John , Nogami Kai , Mahmoudi Elham , Saba Luca , Lanzino Giuseppe , Nardi Valentina , Lerman Amir
Published: January 2025

Background:
The bovine aortic arch is a vascular variant in which the left common carotid artery originates from the brachiocephalic trunk rather than directly from the aortic arch. The bovine anatomical variation may alter the blood flow dynamics, potentially contributing to the formation and progression of carotid plaques. In this study, we evaluated the association of the bovine aortic arch and the severity of carotid stenosis.

Methods:
In this retrospective study, we included patients with carotid artery disease undergoing carotid endarterectomy (CEA) and pre-surgical computed tomography angiography (CTA). CTAs were reviewed to assess the carotid stenosis and the anatomy of the aortic arch. The left carotid artery was classified as normal if it originated from the aortic arch and as bovine if it originated from the brachiocephalic trunk
(Figure 1)
. Unlimited propensity score matching was performed to balance baseline characteristics between patients with bovine and normal anatomies. The Mann-Whitney U test was applied to compare carotid stenosis between bovine and normal arteries.

Results:
A total of 203 patients (bovine:23, normal:180) were initially enrolled. Using propensity score matching, 20 patients with bovine anatomy were matched to 45 patients with normal anatomy
(Figure 2)
. Among the 65 patients included, 47 (74.6%) were male, with a median age of 70 [IQR:65.0-76.0] years. Left-sided carotid artery disease was more prevalent in the bovine compared to normal group (N=12, 66.7% vs. N=16, 36.4%; p=0.030). Additionally, the severity of carotid stenosis in CEA-treated side was higher in patients with bovine arch compared to normal controls (82.5% [76.2-88.7] vs. 70.0% [50.0-95.0]; p=0.030)
(Figure 3)
.

Conclusions:
The association of a bovine aortic arch with more severe carotid stenosis suggests that this anatomical variant may be a marker for increased cerebrovascular risk.
Abstract WP207: A Multi-Tier, Natural-Language Processing Framework to Automate Labeling of Acute Cerebrovascular Events From Radiology Reports and Diagnosis Codes
Authors: Erekat Asala , Stein Laura , Delman Bradley , Karp Adam , Kupersmith Mark , Kummer Benjamin
Published: January 2025

Background:
Machine learning (ML) approaches can solve predictive problems in stroke care but often require large, labeled datasets. We sought to support rapid development of an ML model to predict unnecessary acute stroke alerts – which can strain resources and delay care. To this end, we developed a multi-tiered “weak labeling” algorithm to label a large sample of stroke alerts as being associated with cerebrovascular disease or stroke mimics, based on diagnostic codes and selected neuroradiology reports.

Methods:
Using an unlabeled, previously un-analyzed institutional stroke alert registry, we developed a 4-tiered weak labeling heuristic to assign binary labels (presence/absence of acute cerebrovascular disease) to stroke alerts at each tier. In Tier 1, we developed natural language processing (NLP) rules based on clinical expertise, using report text of brain CT and MRI studies associated with each alert. In Tier 2, we created rules based on combinations of Tier 1 outputs within 48 hours after the first neuroimaging study. In Tier 3, we used validated stroke diagnosis codes at discharge. In Tier 4, we combined labels from Tiers 2 and 3 to assign a final binary label. We conducted manual, clinical expert validation of Tiers 1, 2, and 4 across three statistically significant samples. We determined performance by calculating accuracy, sensitivity, specificity, and area under the receiver-operating curve (AUROC) vis-à-vis manual review as ground-truth.

Results:
We identified 16,515 stroke alerts with 28,548 neuroradiology studies between 2011 and 2021. We reviewed random, stratified samples (Tiers 1, 2: 800 reports each, Tier 4: 240 encounters). Tier 1 achieved 91.9% accuracy, 89.4% sensitivity, 93.2% specificity, and 91.4% AUROC. Tier 2 showed 91.7% accuracy, 92.8% sensitivity, 90.8% specificity, and 91.8% AUROC. Tier 4 had 86.8% accuracy, 90.7% sensitivity, 82.7% specificity, and 87.1% AUROC.

Conclusions:
We developed an algorithm to weakly label stroke alerts with a binary outcome that demonstrated good classifying ability and required minimal manual review. However, tiers based on NLP only generally performed better than tiers using NLP and diagnostic codes. Our results suggest that similar approaches can be used for labeling clinical cohorts, particularly those comprising diseases or treatments that heavily rely on diagnostic imaging. The benefits of this approach should be weighed against the required technical expertise and computational resources.
Abstract WP208: Continuity of Inpatient Stroke Care Provided by Telemedicine Stroke Fellowship Educated Nurse Practitioners
Authors: Dusenbury Wendy , Swatzell Victoria , Krishnaiah Balaji , Elangovan Cheran , Nearing Katherine , Alexandrov Andrei , Alexandrov Anne
Published: January 2025

Background:
Primary stroke centers (PSC) lacking vascular neurologists are often challenged with evidence-compliant inpatient care. We determined impact of stroke fellowship educated nurse practitioners (NP) for PSC inpatient care.

Methods:
Stroke patients arriving at 3 PSCs were emergently evaluated by CSC vascular neurologists via telestroke; uncomplicated ischemic strokes were admitted/triaged by local hospitalists to either general neurologist (GN) or NP telestroke inpatient management. Demographics, medical management, complications, and core measure compliance data were analyzed.

Results:
A total of 1237 patients were managed by GN (n=720) and NPs (n=517) (Table). Sex, premorbid mRS (overall 0 [IQR 0-2]) and admission NIHSS (overall 2 [IQR 1-5]) were similar, however NP patients were younger (64.5+14 vs. 69+13; p<0.001) and more racially diverse (p=0.012). NPs managed most post-tPA patients (p<0.001), due to GN refusing management. Although hospital LOS was similar, NPs were more compliant with stroke mechanism work-up/documentation (p<0.001), utilized more long-term cardiac monitoring (p<0.001), had lower rates of post-stroke pneumonia (p=0.005), were more compliant with stroke core measures (statins p=0.009; NIHSS p<0.001), and had fewer new stroke readmissions within 30-days of discharge (p=0.027).

Conclusions:
Implementation of stroke fellowship-educated NP telestroke inpatient management is feasible and improves stroke care quality in vascular neurology underserved PSCs.
Abstract WP209: Comparative Functional Outcomes for Ischemic Stroke Patients with and without COVID-19
Authors: Howard Christopher , Pascual Jacob , LaRosa Samantha , Cross Michelle , Moore Katherine , Reichert Julie , Filippone Isabella , Chiota-McCollum Nicole , Cross Danielle , Perea Lindsey
Published: January 2025

Background:
COVID-19, primarily a respiratory illness caused by SARS-CoV-2, is associated with vascular complications like ischemia due to endothelial injury, hypercoagulability, and inflammation. This study examines how COVID-19 affects functional outcomes of ischemic stroke patients.

Methods:
Ischemic stroke patients admitted to our Joint Commission-certified primary stroke center were retrospectively analyzed from March 1, 2020, to March 1, 2022. A subgroup analysis was conducted for patients during the vaccination period (April 14, 2021, to March 1, 2022). Patients were included if they were ≥18 years old and had a stroke on admission or during hospitalization. Univariate and multivariable analyses were used, with a significance threshold of p<0.05.

Results:
Out of 1,171 patients, those who tested positive for COVID-19 had significantly worse outcomes. Demographics, clinical data, and outcomes are found in Table 1. COVID-19 Positive patients experienced fewer days between stroke and death (4 days vs. 25 days, p=0.047), higher modified Rankin Scale (mRS) scores at discharge (3 vs. 1, p=0.001), and increased rates of altered consciousness (41.46% vs. 21.86%, p=0.03). In the vaccination period subgroup, COVID-positive patients had fewer days from stroke to death (4 days vs. 42 days, p=0.047), worse mRS scores (3 vs. 1, p=0.009), longer delays in discharge placement (0 vs. 1 day, p=0.020), and higher rates of altered consciousness (57.89% vs. 23.71%, p=0.001). Additionally, COVID-negative patients were more likely to be discharged home (49.52% vs. 36.84%, p=0.021). Multivariable analysis identified higher NIHSS at admission (OR: 1.028 [1.003–1.053], p=0.027), older age (OR: 1.027 [1.011–1.045], p=0.001), and a history of diabetes (OR: 1.596 [1.056–2.413], p=0.027) as increased mortality risks.

Conclusion:
COVID-19 is associated with worse recovery outcomes and discharge delays for ischemic stroke patients compared to those without COVID-19. Further research is needed to explore these differences and their implications for stroke management amid the ongoing global health crisis.
Abstract WP210: Quality of Death and End-of-Life Care of Mexican American versus Non-Hispanic White Stroke Patients: The OASIS Study
Authors: Hijazi Imadeddin , Morgenstern Lewis , Miller Robert , Zahuranec Darin
Published: January 2025

Introduction:
Prior research suggests racial and ethnic differences in the quality of death and end-of-life care among patients who die after severe illnesses.

Hypothesis:
Surrogate decision makers of deceased Mexican American (MA) stroke patients will report lower quality of death and end-of-life care than surrogates of non-Hispanic White (NHW) patients.

Methods:
Stroke patients and their family surrogate decision makers were recruited from the BASIC and OASIS studies in Nueces County, Texas (4/2016-9/2020). Surrogates completed the validated Quality of End-of-Life Care (QOEOLC) and single-item Quality of Death and Dying (QODD-1) instruments (both range 0-10 with higher=better quality). Linear regression models were used to assess the relationship between patient ethnicity and outcome, using generalized estimating equations and multiple imputation for missing covariate data. Model covariates were pre-specified based on their known or theoretical association with ethnicity and/or outcome.

Results:
Data from 138 surrogates for 113 MA or NHW stroke patients were included. Patient characteristics were median age: 78 years; female: 53%; education beyond high school: 40%; median NIHSS: 18; admitted to ICU: 58%; died in the hospital: 51%; and race-ethnicity (MA 59%, NHW 41%). Surrogate characteristics were median age: 60 years; female: 75%; child of patient: 65%; and education beyond high school 69%. There was no difference in the QEOLC in MA vs. NHW stroke patients on unadjusted [Beta=-0.13 SE=0.46, p=0.78] or fully adjusted analysis [Beta=0.02 SE=0.54, p=0.97]. For the QODD-1, surrogates of MA patients reported a lower of quality of death on unadjusted analysis [Beta=-0.99 SE=0.48, p=0.04], though this was no longer significant after adjustment for patient age, sex and surrogate relationship, or in the final fully adjusted model (see Table). While overall QODD-1 scores were high (Median 10 IQR 8,10), surrogates with education beyond high school reported QODD-1 scores nearly 4 points higher than those with high school education or less, after adjustment.

Conclusions:
In contrast to other work, we did not find differences in the quality of death or end-of-life care by ethnicity among Mexican American and non-Hispanic White stroke patients after adjusting for demographics and other factors. Further exploration of the differences in QODD-1 scores may help understand how to best support all families facing death after stroke.
Abstract WP214: NIBP Measured Blood Pressure Fails to Agree with Blood Pressure Taken by Other Methods in Acute ICH Patients
Authors: Cihelka Desiree , Paliwal Mani , Jauch Edward , Graff Carolyn , Alexandrov Anne
Published: January 2025

Introduction:
NIBP monitoring is commonly used for BP measurement but only measures MAP while algorithmically assigning SBP/DBP. We sought to understand agreement between SBP, DBP and MAP measured by NIBP with manual BP and A-lines in acute ICH.

Methods:
A prospective observational study was conducted in acute ICH patients using standardized, evidence-based measurement methods for BP by NIBP, A-line, and manual cuffs with dual auscultatory stethoscopes. Methods mirrored the ANSI/AAMI/ISO standard protocol for BP device validation. Data were analyzed using Bland-Altman analyses and Lin Concordance correlation coefficient.

Results:
650 paired manual and NIBP measurements were obtained, and no agreement was found in SBP, DBP, and MAP. DBP (
p
= <.001) showed the least agreement between methods, followed by SBP (
p
= .005), with MAP having the best agreement. Percentage of measurements within the ANSI/AAMI/ISO recommended guideline (10 mmHg difference) was 58% SBP, 63% DBP, and 76% MAP. A total of 25 paired A-line, manual, and NIBP measures were obtained with no agreement found between the three different techniques; MAP showed the closest agreement, followed by DBP and SBP.

Conclusion:
Our study findings mirror those in systemic thrombolysis patients, showing no agreement in SBP and DBP values taken by NIBP compared to other BP methods. Since NIBP only measures MAP, future work should focus on setting MAP parameters in ICH patients. Additionally, the validity of recommended BP values for acute ICH patients should be carefully considered in relation to measurement and device heterogeneity.
Abstract WP217: Risks and Benefits of Lecanemab and Anticoagulants: Results from a Simulation Model
Authors: Shah Sachin , Dinger Tai , Blacker Deborah , Greenberg Steven , Newhouse Joseph , Lykken Jacquelyn , Pandya Ankur , Hsu John , Hyle Emily
Published: January 2025

Background:
In CLARITY-AD, lecanemab slowed cognitive decline but increased intracranial hemorrhages (ICHs), particularly with concurrent anticoagulant use. The Alzheimer’s Association’s expert guidance is to avoid co-prescribing; however, CMS and FDA do not restrict or warn against it. We used a microsimulation model to quantify the potential benefits and harms of co-prescribing lecanemab and apixaban in people with atrial fibrillation (AF) experiencing mild cognitive impairment or early Alzheimer’s.

Methods:
We developed a microsimulation model to estimate the health and cognition-related quality of life among persons 65-90 years with AF and cognitive impairment. We compared 4 strategies over 18 months in a cohort of 100,000 people: apixaban alone, lecanemab and apixaban, lecanemab alone, and neither. The model was populated with the Health and Retirement Study-AF cohort. Monthly model outcomes included ICH, ischemic stroke, cognitive impairment, quality-adjusted life months (QALMs), and survival. Increased ICH risk was a key input: a trial-reported 2.02-fold increase for lecanemab alone, a 1.84-fold increase for apixaban alone (anticoagulant literature), and a trial-reported 9.92-fold increase for lecanemab and anticoagulants together. We assigned quality-of-life estimates and mortality rates for people with cognitive impairment, stroke, and ICH. Background mortality rates increased with cognitive decline and following a stroke or ICH event.

Results:
For ages 65-74, apixaban alone and lecanemab added to apixaban produced a similar net benefit (13.2 QALM each,
Table
). Over 100,000 simulated persons aged 65-74 years, adding lecanemab to apixaban would result in greater ICH events (2000 vs. 400) and all-cause deaths (5860 vs. 5180) and slower cognitive decline (mean change in CDR-SB 1.11 vs. 1.53). One-way sensitivity analyses show that the net benefit for people aged 65-74 years is sensitive to the determinants of ICH—lecanemab/anticoagulant interaction, lecanemab effect on ICH, apixaban effect on ICH, baseline ICH risk—and lecanemab effect on CDR-SB (
Figure
). Apixaban alone was preferred for people 75 years and older.

Conclusion:
The model-based results suggest equipoise between apixaban alone and lecanemab with apixaban for people with cognitive impairment and AF aged 65-74 years. Improving lecanemab efficacy or reducing its effect on ICH could produce a net benefit for this age group. For people 75 and older, apixaban alone would be preferred.
Abstract WP220: Assessing the Therapeutic Time Window for Tranexamic Acid in Intracerebral Hemorrhage – A Systematic Review and Meta-analysis
Authors: Riya Israt Jahan , Piya Ifrat , Menezes Shenelle , Hariyanto Jesslyn , Quiros Marco , Koduru Sriharsha
Published: January 2025

Background:
Several studies have shown that tranexamic acid (TXA), an anti-fibrinolytic agent, may reduce hematoma expansion (HE) in intracerebral hemorrhage (ICH), but its therapeutic time window is unclear. We analyzed the efficacy and safety of TXA based on its time of administration after hemorrhage onset.

Methods:
We searched PubMed, Embase and Cochrane databases for randomized controlled trials (RCTs) published up to July 27, 2024 comparing TXA with placebo in ICH. We excluded trials that used TXA for longer than 3 days which causes delayed vasospasm, increasing the risk of cerebral ischemia. The primary outcomes were HE, 24-hour hemorrhagic volume change, 90-day mortality and poor functional outcome. We grouped the trials into 2 hours, 8 hours or 24 hours of TXA administration after hemorrhage onset. We pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI) using Rstudio. Heterogeneity was examined with the I2 test.

Results:
We included 12 studies with 3,567 patients. Most of the studies used 1 g TXA in patients with Glasgow Coma Scale score ranging from 13-15. TXA reduced HE risk (OR 0.85; 95% CI 0.73 to 0.98; p= 0.03; I2= 0%). This reduction was observed in studies that administered TXA within 8 hours of ICH onset (OR 0.82; 95% CI 0.70 to 0.97; p= 0.02; I2= 0%). TXA slightly reduced 24-hour hemorrhagic volume (MD -1.30 mL; 95% CI -2.51; -0.09; p= 0.04; I2= 47%). This reduction was mainly seen in patients who were administered TXA within 8 hours of hemorrhage onset (MD -1.86 mL; 95% CI -3.15 to -0.58; p< 0.01; I2= 35%). There were no significant differences in poor functional outcome (OR 0.87; 95% CI 0.67 to 1.15; p= 0.34; I2= 24%), 90-day mortality (OR 1.00; 95% CI 0.84 to 1.19; p= 0.96; I2= 0%), major thromboembolic events (OR 1.22; 95% CI 0.82 to 1.82; p= 0.33; I2= 0%), neurosurgical intervention (OR 0.94; 95% CI 0.61-1.45; p= 0.78; I2= 0%) or length of hospital stay (MD -0.49 days; 95% CI -3.27 to 2.29; p= 0.73; I2= 0%).

Conclusion:
TXA reduced the risk of HE and slightly reduced 24-hour hemorrhagic volume in patients with ICH within 8 hours. Larger RCTs stratifying administration timing are required to establish these findings.
Abstract WP227: Physiological Magnetic Resonance Imaging Biomarkers for Early Detection of Microvascular Dysfunction in Acute Intracerebral Hemorrhage
Authors: Yang Xiuli , Wei Zhiliang
Published: January 2025

Introduction:
Intracerebral hemorrhage (ICH) is commonly associated with poor neurologic outcomes. Early intervention has been shown to improve patient prognosis, highlighting the necessity of sensitive biomarkers. In this study, we aim to explore the potential of magnetic resonance imaging (MRI)-based physiological parameters for detecting microvascular dysfunction in an acute ICH mouse model.

Methods:
Young (5 months old, N=2) and aged (22 months old, N=2) C57BL/6 male mice were utilized. ICH was induced via a stereotaxic intra-striatal injection of collagenase. These mice were scanned before and 1 day after surgery longitudinally. We employed a range of non-invasive MRI techniques at 11.7T to characterize microvascular dysfunctions. These techniques included: (a) spin echo MRI for brain volume, (b) T
2
-relaxation-under-spin-tagging (TRUST) and phase contrast MRI for cerebral metabolic rate of oxygen (CMRO
2
), (c) arterial spin labeling MRI for regional cerebral perfusion, and (d) water-extraction-with-phase-contrast-arterial-spin-tagging (WEPCAST) MRI for blood-brain-barrier (BBB) permeability.

Results:
Brain volume demonstrated a significant age effect (linear mixed effect [LME] model: P=0.044), but was not significantly influenced by ICH, indicating negligible brain dwelling at the examined timepoints. TRUST imaging reveals distinct patterns of change from baseline to ICH between young and aged mice (Fig. 1A). A significant ICH-by-age interaction effect (LME: P=0.004) suggests that the impact of ICH on brain metabolism varies between young and aged mice. ICH-affected brain regions were identifiable in the perfusion maps for both age groups with hemorrhagic areas showing associated hypoperfusion, as indicated by the arrows (Fig. 2). In terms of BBB function, there was a notable reduction in the WEPCAST signal observed around the great vein of Galen (arrows in Fig. 3A). The significant ICH-by-age effect on the permeability-by-area-product (PS) (P=0.006, Fig. 3B) of LME analysis indicates that aged mice are more vulnerable to the BBB disruption following ICH.

Conclusion:
Our study highlights the potential of physiological imaging biomarkers for detecting early microvascular dysfunctions in ICH. Specifically, functional parameters (i.e., CMRO
2
and BBB permeability) show promise as sensitive indicators for the early detection of ICH. These biomarkers could facilitate timely interventions, potentially improving outcomes for stroke patients.
Abstract WP229: Cerebral Amyloid Angiopathy Prevalence and Associated Risk of Subsequent Ischemic and Hemorrhagic Stroke and Mortality in a Nationally Representative Sample
Authors: Bruce Samuel , Zhang Cenai , Liberman Ava , Merkler Alexander , Navi Babak , Chiang Gloria , Iadecola Costantino , Kamel Hooman , Murthy Santosh
Published: January 2025

Introduction:
Cerebral amyloid angiopathy (CAA) is a significant cause of cerebrovascular disease and cognitive decline in elderly patients. There are limited population-based data regarding the prevalence of CAA and associated risks of mortality and incident cerebrovascular events.

Methods:
We performed a retrospective cohort study using inpatient and outpatient claims from 2008 to 2018 from a nationally representative 5% sample of Medicare beneficiaries. CAA and ischemic and hemorrhagic stroke were identified using previously validated ICD-10 codes. Mortality data was obtained from Medicare beneficiary files. We calculated prevalence of CAA during 2016-2018, and used Cox regression to examine the association of CAA with subsequent death and incident stroke after adjustment for demographics, vascular risk factors, and Charlson comorbidities.

Results:
Among 1,487,851 Medicare beneficiaries in our sample, 913 (0.06%) had a diagnosis of CAA during 2016-2018. In multivariable Cox regression analysis, there was no association between CAA and subsequent mortality (adjusted hazard ratio [aHR], 1.2; 95% CI, 0.7-1.9). Among 1,455,257 patients without prevalent stroke, including 355 of the CAA patients, there was a significant association between CAA and subsequent increased risk of any stroke (aHR, 6.3; 95% CI, 4.4-9.1), ischemic stroke (aHR, 2.5; 95% CI, 1.3-4.7), intracerebral hemorrhage (aHR, 32.1; 95% CI, 19.6-52.4), and subarachnoid hemorrhage (aHR, 9.5; 95% CI, 3.6-25.4) [Figure 1]
.

Conclusions:
In a nationally representative cohort of Medicare beneficiaries, the prevalence of clinically diagnosed CAA was approximately 6 per 10,000. CAA was not associated with an increased risk of mortality but was associated with an increased risk of incident stroke, both hemorrhagic and ischemic.
Abstract WP23: LDL-C levels and Statins in Patients with Acute Ischemic Stroke: An Updated Meta-Analysis of 175,225 Patients
Authors: Abdelaziz Ahmed , Cicani Laura , Desouki Mariam , Onwujiogu Queeneth , shaikh shifa , Allam Sanjana , Jeswani Bijay
Published: January 2025

Introduction:
Acute ischemic stroke is the second leading cause of death worldwide. Levels of LDL-C were correlated with the risk of recurrent stroke or transient ischemic attack (TIA). However, there are controversial data regarding the effect of statins on recurrent stroke across different baseline LDL levels. We aimed to assess the effect of statins across different LDL levels to prevent recurrent stroke in patients with acute ischemic stroke.

Methods:
PubMed, Scopus, Web of Science, and the Cochrane Library were searched for Randomized Controlled Trials (RCTs) assessing the impact of statins across levels of baseline LDL from inception until April 2024. The primary outcome was the incidence of recurrent stroke which was categorized according to baseline LDL levels, absolute decrease in LDL levels, and percentage decrease in LDL levels. The odds ratio (OR) with its 95% confidence interval (CI) was used in a random-effect model.

Results:
Eighteen RCTs comprising 175,225 patients (mean follow-up of 3 years) were included in the final analysis. Statins were associated with a reduced incidence of recurrent stroke in patients with baseline LDL <100 mg/dl, or >100 mg/dl, with the following values, respectively (OR: 0.85, 95% CI: 0.72 to 0.98, p= 0.04, and 0.88, 95% CI: 0.78 to 0.98, p= 0.03). Additional analysis in patients with an absolute decrease in LDL levels >3 mg/dl showed a lower incidence of recurrent stroke (OR: 0.85, 95% CI: 0.77 to 0.94, p <0.001). Regarding percentage decrease in LDL levels (30-49% and >50%), statins showed a lower risk of recurrent stroke, respectively as follows (OR: 0.65, 95% CI: 0.44 to 0.97, p =0.03, and 0.83, 95% CI: 0.7 to 0.98, p =0.03).

Conclusion:
This study suggests that statins-based therapies were associated with recurrent stroke risk reduction across baseline LDL levels, absolute and percentage decrease in LDL levels. Additional data on the evidence of atherosclerosis might be warranted to study the impact of statins on high LDL levels in the presence of atherosclerosis.
Abstract WP230: Neuroinflammation Biomarker in the Course and Prognosis of Hemorrhagic Strokes
Authors: Kuranbaeva Satima , Rakhimbaeva Gulnara , USMANOVA GULCHEKHRA
Published: January 2025

Hemorrhagic strokes (HS) are increasingly significant causes of disability and mortality worldwide, making the use of blood biomarkers for their diagnosis and prognosis critical. Inflammatory markers in peripheral blood reflect the body's response to acute cerebrovascular incidents, and monitoring these during the acute phase of HS can provide valuable insights into disease progression and potential deterioration.

This prospective observational study, conducted without medical intervention, involved 130 patients with clinically and instrumentally verified hemorrhagic strokes in the acute phase, all with hypertension, and a control group of 30 individuals without stroke, average age 60 years. Upon admission, patients were assessed for consciousness and neurological status using the FOUR and NIHSS scales. Blood samples for Glial Fibrillary Acidic Protein (GFAP), a marker of astroglial damage, were collected within the first 24-30 hours after onset and analyzed using ELISA. All patients also underwent CT and MRI brain scans.

Statistical analysis was performed using multivariate linear regression and ROC analysis. The study found that GFAP levels were significantly higher in HS patients, particularly among those with fatal outcomes. Survivors had GFAP levels of 1.35 ng/mL, while deceased patients had levels of 1.94 ng/mL (p<0.05), suggesting the utility of GFAP in assessing HS severity and prognosis. GFAP levels were also significantly elevated in patients with an initial hematoma volume > 50 mL. These findings were used to develop multivariate binary logistic regression models for predicting HS outcomes during the acute phase.

The prognostic model, incorporating GFAP levels, FOUR and NIHSS scores, hematoma volume, perifocal edema, and midline structure shift, demonstrated a 95% sensitivity in determining fatal outcomes. GFAP, synthesized by astrocytes, plays a critical role in astrocyte differentiation, neuronal energy supply, blood-brain barrier formation, and reparative processes post-hemorrhage. Given its role as a marker of cellular damage and its regulatory function in brain repair, GFAP and other biomarkers should be employed to assess patient condition severity and guide the development of new therapeutic strategies for hemorrhagic strokes.
Abstract WP232:
Prediction Value of Intravenous Contrast Extravasation for Mortality and Poor Functional Outcomes in Intracerebral Hemorrhage: An Accuracy Meta-analysis
Authors: Godeiro Coelho Lilian Maria , Elfil Mohamed , Alkhachroum Ayham
Published: January 2025

Background:
Intracerebral hemorrhage (ICH) is a critical neurological condition with high rates of mortality and morbidity. Accurate prediction of the clinical outcomes in ICH patients is essential for effective clinical management. Intravenous contrast extravasation, also known as spot sign, identified in conventional vascular imaging, has emerged as a significant radiological marker associated with hematoma expansion, potentially influencing mortality and functional outcomes.

Aim:
We aim to elucidate the predictive value of the spot sign for mortality and poor functional outcomes in patients with ICH.

Methods:
We searched for studies in PubMed, Embase, and Cochrane Library databases. Our inclusion criteria focused on studies assessing mortality and poor functional outcomes (mRS score 3-6) in adult groups with and without a sign spot in head imaging after ICH. We pooled the odds ratio (OR) for both outcomes using random effects and assessed publication bias through Egger’s test, adjusting while using trim-and-fill analysis. Heterogeneity was measured through

I
2

. We also conducted bivariate random-effects models using Bayesian Information Criteria (BIC) to determine pooled sensitivity and specificity for both outcomes. Results are presented with a 95% Confidence Interval (CI).

Results:
We included 29 studies comprising 4,597 patients, with a mortality and poor functional outcomes rates of 21.2% and 47.8%, respectively. Spot sign was consistently identified as a robust predictor of outcomes across multiple studies. For mortality, the pooled specificity was 0.821 (95% CI [0.782-0.855];

I
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=23.44%) with low sensitivity at 0.468 (95% CI [0.391-0.547];

I
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=32.3%). For poor functional outcomes, the specificity was 0.876 (95% CI [0.815-0.920];

I
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=48.5%), and the sensitivity was 0.369 (95% CI [0.295-0.451;

I
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=32.7%). Spot sign significantly increased the odds of both outcomes. After adjusting for publication bias, the OR for mortality was 3.37 (95% CI: 2.41-4.71;

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=73.2%). For poor functional outcomes, OR was 4.13 (95% CI: 3.15-5.42;

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=33%).

Conclusion:
Spot sign visualized in conventional vascular imaging is a highly specific radiological biomarker for predicting mortality and poor functional outcomes in patients with ICH. Recognizing this sign should prompt immediate yet targeted interventions to improve patient survival and recovery. However, fully adopting this biomarker for mortality outcome prediction requires further analysis of heterogeneity sources.
Abstract WP235: Insurance Status and Intracerebral Hemorrhage Outcomes: A Post-Hoc Analysis of the ERICH Study
Authors: Krothapalli Neeharika , Wong Ka-Ho , Littig Lauren , Kim Yvonne , Smith Harper , Calvario Erick , Champagne Alison , Narula Reshma , Sheth Kevin , Sansing Lauren , de Havenon Adam
Published: January 2025

Introduction:
Insurance status may serve as an indicator of social and financial barriers that impede access to quality care. Disparities in outcomes of patients with ischemic stroke have been associated with insurance coverage. However, there are few studies investigating the impact of insurance status on outcomes in patients with intracerebral hemorrhage (ICH).

Methods:
We performed a post-hoc analysis of the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study to investigate the impact of insurance status on good functional outcome (modified Rankin Scale score of 0-3 at 90 days after ICH). A logistic regression model was adjusted for age, sex, race, mechanical ventilation, systolic blood pressure, smoking status, diabetes mellitus, atrial fibrillation, hypertension, congestive heart failure, Glasgow Coma Scale, ICH location (side and deep), ICH volume on CT, and presence of intraventricular hemorrhage. VA patients were excluded from analysis due to small sample size.

Results:
Among 1874 patients included in this study, 428 patients (22.8%) had Medicare, 347 patients (18.5%) had Medicaid, 183 patients (9.8%) had HMO, 568 patients (30.3%) had private insurance, and 348 patients (18.6%) were self-pay. Table 1 illustrates demographics by insurance status. The odds ratio for good outcome in those with private insurance was significantly higher in comparison to Medicare (OR 1.47, 95% CI 1.06-2.03, p=0.022, Figure 1). When comparing private insurance to all other insurance types, the odds ratio was 1.42 (95% CI 1.09-1.84, p=0.009).

Conclusion:
Amongst patients in the ERICH study, private insurance was associated with a higher likelihood of good outcome (mRS 0-3 at 90 days) in ICH patients compared to Medicare or other insurance status. Further study is needed to establish if this observation is causal or an epiphenomenon.
Abstract WP238: Association of pre-thrombectomy infarct topography and hemorrhagic transformation in patients with acute ischemic stroke: A multicenter Bayesian analysis
Authors: Bonkhoff Anna , Schirmer Markus , Favilla Christopher , Das Alvin , Dmytriw Adam , Gupta Rajiv , Rabinov James , Stapleton Christopher , Leslie-Mazwi Thabele , Simonsen Claus , Patel Aman , Rost Natalia , Regenhardt Robert
Published: January 2025

Introduction:
As more patients with stroke, including those with large cores, are treated with endovascular thrombectomy (EVT), understanding the pathophysiology of hemorrhagic transformation (HT) is becoming increasingly important. Pre-EVT infarct topography may have implications for treatment decisions acutely (e.g. stenting) and for post EVT care (e.g. antithrombotics and blood pressure goals). We sought to identify associations between HT and brain regions involved in ischemic lesions.

Methods:
Consecutive patients with LVO treated with EVT who underwent pre-EVT MRI were identified from two tertiary referral centers (2011-2019). Acute ischemic lesions were extracted through a deep learning enabled pipeline from DWI and spatially normalized. Individual lesions were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to ten essential lesion patterns using unsupervised dimensionality reduction techniques. HT, defined as ECASS PH1 or PH2, was modeled via Bayesian regression, taking the ten lesion patterns as inputs, and controlling for total lesion volume, age, sex, initial NIH Stroke Scale (NIHSS), thrombolysis treatment, good reperfusion (TICI2b-3), acute stenting, last known well-to-puncture time, diabetes mellitus, hypertension, coronary artery disease, smoking, atrial fibrillation, and site of enrollment.

Results:
A total of 567 (mean age 69 ±15 years; 45% female) patients had pre-EVT DWI without significant artifacts that could undergo lesion segmentation and registration. The median NIHSS was 16 (IQR 11-20) and mean total infarct volume was 22.5 ±36.7ml. Thrombolysis was administered in 51% and good reperfusion was achieved in 83%. HT occurred in 10%. Lesion locations predictive of HT (
Figure
) involved bilateral caudate, putamen, pallidum, and anterior thalamic radiation; and, right more than left thalamus, corticospinal tract, and inferior fronto-occipital fasciculus (area under the curve: 0.73).

Conclusions:
These data from a large, multicenter cohort with precise MRI-defined infarcts underscore the significance for HT of specific brain regions involved in ischemic lesions before EVT. An understanding of this pathophysiology can inform not only current clinical practice but also the development of future novel therapeutic strategies to prevent HT and reperfusion injury as more patients with large infarct cores are treated with EVT.