bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP91: Ischemic Injury Extent on Different Imaging Modalities and Its Association With Endovascular Thrombectomy Outcomes for Large Core Stroke:
A SELECT2 Imaging Analysis
Authors: Sarraj Amrou , Abraham Michael G , Chen Michael , Hussain Muhammad S , Kasner Scott E , Ortega-Gutierrez Santiago , Churilov Leonid , Mendes Pereira Vitor , Pujara Deep , Shaker Faris , Johns Hannah , Sitton Clark W , Nguyen Thanh , Johanna Fifi T , Lansberg Maarten G , Hill Michael D , Ribo Marc , Hassan Ameer E , Davis Stephen M , Wechsler Lawrence R , Grotta James C , Albers Gregory W , Campbell Bruce ,   The SELECT2 Investigators
Published: February 2024

Introduction:
The association of extent of ischemic injury on various imaging modalities and EVT efficacy and safety in patients with large ischemic core remains unexplored. We analyzed ischemic injury estimates on structural and perfusion imaging modalities and their association with time and EVT treatment effect.

Methods:
In SELECT2, all patients received non contrast CT and CT perfusion/MR diffusion. Baseline ischemic injury was estimated using ASPECTS, CTP/MRI with RAPID processing, manual delineation of CT hypodensity and composite core [the larger of the CT hypodensity and CTP/MRI core volumes], Figure 1A. We assessed how these estimates compared to one another, which correlated best with the outcomes and described EVT treatment effect across their strata.

Results:
Of 352 patients, 16 were excluded for missing mRS/imaging data. 170/336 (51%) received EVT. The median (IQR) CT-ASPECTS was 4 (3-5), CT-hypodensity 86 (49-114) mL, CTP/MRI core 73 mL (46-107). 60% had CT hypodensity > CTP/MRI core volume. CTP core was larger in 81% within 0-3 hours that inverted to 86% patients with larger CT hypodensity in 21-24 hours of LKW [Figure 1B]. Composite core (101 [72-138] ml) had best fit for mRS (Bayesian Information Criteria for mRS shift: ASPECTS - 448, CT hypodensity - 443, CTP core - 434, Composite core - 429 with lower the better). Treatment effect estimates favored EVT across strata (≥70 ml, ≥100ml & ≥150 ml) for CT hypodensity, CTP/MRI core and composite core as well as ASPECTS 3,4 and 5. For a given volume probability of independent ambulation with EVT decreased with age and time to reperfusion.

Conclusions:
CT perfusion and CT hypodensity were complementary and most prognostic when used together, in conjunction with age and time to reperfusion. Thrombectomy benefit was preserved across ischemic volumes and ASPECTS. These findings can assist clinicians in assessing the likely outcome of thrombectomy for individual patients.
Trial Registration: NCT03876457
Abstract WMP95: Anesthesia Modality in Endovascular Treatment for Distal Medium Vessel Occlusion Stroke: Intention-to-Treat Matched Analysis
Authors: Mohammaden Mahmoud H , Dohiem Mohamed F , Abdelhamid Hend M , matsoukas stavros , Schuldt Braxton R , Johanna Fifi , Kuybu Okkes , Gross Bradley , Al-Bayati Alhamza R , Dolia Jaydevsinh , Olive-Gadea Marta , Rodrigo-Gisbert Marc , Requena Manuel , Monteiro Andre , Yu Si , Siegler James E , Farooqui Mudassir , Vivanco-Suarez Juan , Ortega-Gutierrez Santiago , Cortez Gustavo , Hanel Ricardo , Hassan Ameer E , Nguyen Thanh , AbdalKader Mohamad , Klein Piers , Salem Mohamed M , Burkhardt Jan-Karl , Jankowitz Brian , Colasurdo Marco , Kan Peter , Hafeez Muhammad , Tanweer Omar , Peng Sophia , Alaraj Ali A , Siddiqui Adnan , Nogueira Raul G , Haussen Diogo C
Published: February 2024

Background:
The optimal anesthesia modality during endovascular treatment (EVT) for distal medium vessel occlusion (DMVO) strokes is uncertain. We aimed to evaluate the impact of the anesthesia modality on procedural and clinical outcomes following EVT for DMVO strokes.

Methods:
This is a retrospective analysis of a prospectively collected database from 14 comprehensive stroke centers in the United States and Europe. Patients were included if they had DMVO due to MCA-M3/4, ACA-A1/A2-3, or PCA-P1/P2-3 and underwent EVT. The cohort was divided into two groups: general anesthesia (GA) and non-general anesthesia (non-GA). The primary analysis compared the two groups based on the intention-to-treat principle. The secondary analysis compared both groups according to the as-treated approach. We used propensity scores to balance the two groups at a 1:1 ratio. The primary outcome was the shift in the degree of disability as measured by the 90-day mRS. Secondary outcomes included successful reperfusion, mRS0-1, and mRS0-2 at 90-days. Safety measures included procedural complications, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality.

Results:
A total of 365 patients were eligible for analysis. In the intention-to-treat analysis (130 matched pairs), baseline demographic and clinical characteristics were balanced. There was no difference in the degree of disability (mRS ordinal shift; acOR 1.64, 95%-CI [0.78-3.46], P=0.19) between the two groups. GA had comparable rates of successful reperfusion (aOR2.66, 95%CI [0.75-9.42],P=0.13), 90-day mRS0-1 (aOR1.07, 95%CI[0.41-2.78],P=0.89), 90-day mRS0-2 (aOR1.46, 95%CI[0.60-3.55],P=0.41), procedural complications (aOR1.08, 95%CI[0.20-5.79],P=0.93), sICH (aOR3.28, 95%CI[0.81-13.34], P=0.10), and 90-day mortality (aOR0.82, 95%CI [0.35-1.95],P=0.66) compared to the non-GA group. Similarly, when comparing 150 matched pairs using the as-treated principle, GA and non-GA showed comparable outcomes.

Conclusions:
In patients with DMVO undergoing EVT, GA and non-GA had similar procedural and clinical outcomes, as well as safety measures. Further, larger controlled studies are warranted.
Abstract WMP98: Elevated Troponin With and Without Myocardial Infarction in Acute Ischemic Stroke
Authors: Menzies Lauren E , Robinson David , Sucharew Heidi , Kissela Brett M , Stanton Robert J , DeLosRiosLa Rosa Felipe , Mackey Jason , Demel Stacie , Ferioli Simona , Woo Daniel , Mackey Jason , Mistry Eva , Haverbusch Mary , Coleman Elisheva R , Jasne Adam S , Slavin Sabreena , Walsh Kyle , Star Michael , Rothenberg Florence , Kleindorfer Dawn O
Published: February 2024

Introduction:
Elevated cardiac troponin (cTn) in acute ischemic stroke (AIS) is common, and associated with increased risk of death. Whether this association depends on the cause of the cTn elevation is unclear. We examined whether etiology of elevated cTN after AIS modulates the risk of death using a large population-based study in the Greater Cincinnati Northern Kentucky (GCNK) region.

Methods:
Using well-validated methods, all hospitalized AIS cases in the GCNK region were collected and adjudicated in 2015. Cases with a positive cTN underwent retrospective review by cardiologists using the Fourth Universal Definition of Myocardial Infarction (MI). Date/cause of death were obtained from the National Death Index. Kaplan Meier estimates of 3-year cardiac and all-cause death were generated, stratified into the following three categories: Acute MI (Type I/Type II), elevated troponin without acute MI, and nonelevated troponin. Estimates were then compared with a Log Rank test.

Results:
There were 2096 AIS patients during the study period in which a cTN was obtained; cTN was elevated in 464 (22.1%). Among AIS patients with elevated cTN, 107 (23%) had an acute MI, and the remaining 357 (77%) had elevated cTN without MI. At 3 years, cardiac/all cause deaths were more common in patients with elevated cTN when compared with patients without elevated cTN regardless of cause (P<0.01, Figure). Among patients with elevated cTN, death rates were not significantly higher in patients with acute MI (P=0.44 all cause, p=0.67 cardiac).

Discussion:
Elevated cTN after AIS is associated with a higher risk of death at 3 years, regardless of whether an MI occurred. Interventions targeting patients with elevated cTN could improve long-term outcome after AIS.
Abstract WP100: Trends in the Utilization of Intravenous Thrombolysis for Ischemic Stroke in Korea From 2013 to 2022
Authors: Kim Yong Soo , Kang Kyusik , Kim Do Yeon , Lee Ji Sung , Bae Hee-Joon , Park Jong-moo
Published: February 2024

Introduction:
IV thrombolysis is a proven treatment for acute ischemic stroke (AIS), but it is still underutilized in real-world clinical practice. Using a nationwide multicenter stroke registry, we aimed to determine whether there are significant trends in the rate of IV thrombolysis in different patient populations.

Methods:
This study assessed patients with AIS or transient ischemic attack (TIA) registered prospectively in the Clinical Research Center for Stroke-Korea (CRCS-K) registry between 2013 and 2022. Trends in IV thrombolysis rate were respectively analyzed for all patients (cohort 1), patients who arrived at the hospital within 4.5 hours of onset (cohort 2), and patients potentially eligible for IV thrombolysis (cohort 3), using joinpoint regression analysis. Trends in IV thrombolysis rates in cohorts 1-3 were further investigated using generalized linear mixed-effects models adjusted for patient characteristics and accounting for hospital heterogeneity.

Results:
A total of 76535 patients were included in the analysis. The mean age of the patients increased from 67.3 to 69.8 years, and the median time from onset to hospital arrival increased over the 10-year period. During the study period, proportion of patients arriving at the hospital within 4.5 hours of onset and the proportion of patients potentially eligible for IV thrombolysis decreased, especially after 2016. IV thrombolysis rates significantly declined over the 10-year period in cohorts 1-3, with a pronounced decrease in the treatment rate in potentially IV thrombolysis eligible patients from 2013 to 2016 (average annual percent change [95% CI] -4.55% [-5.66% to -3.46%] in cohort 1; -2.63% [-3.95% to -1.34%] in cohort 2; -1.33% [-2.06% to -0.49%] in cohort 3). In the multivariable model, patients who arrived in 2022 were less likely to receive IV thrombolysis compared to patients who arrived in 2013 (adjusted odds ratio [95% CI], 0.83 [0.75 - 0.93]).

Conclusions:
Utilization of IV thrombolysis has declined over the decade in Korea, even accounting for the decline in the number of patients who are candidates for the treatment. Urgent interventions to increase IV thrombolysis rates are needed to improve acute stroke care.
Abstract WP11: The Safety of Emergent Anticoagulation in Acute Ischemic Stroke in Non-Atrial Fibrillation Indications: A Retrospective Analysis
Authors: Jumah Ammar , Fu Siyuan , Albanna Abdalla , Agarwal Utkarsh , Fana Michael , Idris Anas , Iqbal Zaid , Elfaham Abdelrahman , Schultz Lonni , Latack Katie , Brady Megan , Ramadan Ahmad Riad
Published: February 2024

Introduction:
Patients with acute ischemic stroke (AIS) often present with conditions that require emergent anticoagulation (AC) other than atrial fibrillation (AF). Current literature lacks guidance on the safety of administering AC when both pathologies coexist. Therefore, we tend to rely on studies investigating AF and AIS for AC recommendations.

Methods:
We retrospectively reviewed data for patients with AIS who had a non-AF emergent indication for AC (e.g., intraluminal floating thrombus, intracardiac thrombus, acute coronary syndrome, acute limb ischemia, DVT and PE) within 3 days of symptom onset. We did a comparison study between a group of patients who received AC within 72 hours of stroke onset (Group A) versus those who either received it after the initial 72 hours or did not receive it at all (Group B). The primary outcome was the incidence of intracranial hemorrhage (ICH) between both groups. The secondary outcome was a composite risk of arterial and venous thromboembolic events.

Results:
Out of the 560 patients with AIS plus an emergent AC indication, only 88 patients (56.8% for Group A and 43.2% for Group B) met our inclusion criteria. Only 2 patients in Group A, and 1 patient in Group B had developed ICH as a complication of AC which was not statistically significant. Interestingly, Group A patients had a lower incidence of both new diagnosis (2% vs. 50%, p<0.0001) or propagation of an established DVT and/or PE. They also had a lower rate of any thromboembolic complication (2% vs. 44.7%, p<0.0001). Additionally, Group A patients had more favorable outcomes, defined as mRS 0-2 at 30 days (79.3% vs. 46.2%, p=0.40) and 90 days (73% vs 29.5%, p=0.11), and a higher 3-month survival rate (84.6% vs 64.7%, p=0.16).

Conclusion:
Starting AC early (i.e., within 3 days) in non-AF AIS patients with an emergent indication may be safe and carry a lower risk of thromboembolic complications than later AC.
Abstract WP113: An Exploring Qualitative Study of Real Life Experiences and Needs of Psychosocial Recovery Among Chinese Community Dwelling Stroke Survivors
Authors: Chan Mimi Wai Man , Lo Suzanne H , Sit Janet W
Published: February 2024

Introduction:
Stroke survivors may face challenges in managing their psychosocial functions. However, little is known about psychosocial experiences and needs of community-dwelling stroke survivors, particularly in China.

Purpose:
This study explored the experiences and needs of psychosocial recovery among Chinese community-dwelling stroke survivors.

Methods:
Semi-structured and individual interviews were conducted with participants in Macao from community healthcare centers and supported groups using convenience sampling. Participants were asked about their experiences, challenges, and strategies for managing post-stroke psychosocial functions, and desired support for psychosocial recovery. Interview data were transcribed verbatim and analyzed thematically.

Results:
Twenty-six participants (mean age: 69.96±14.06 years old; mean post-stroke duration: 83.88±66.8 months) were recruited to participate in interviews. Regarding the experiences and challenges, most participants faced obstacles in managing emotions and barriers to rebuilding social lives due to the impacts of physical disabilities. Generally, most participants recognized that they were a minority of people in society, and some experienced further invalidation by society. The majority of participants lost motivation and expectations to face challenges, hesitated to disclose their conditions to others, and had less confidence in social interactions as they felt that they were different from others. Meanwhile, some participants adopted strategies to improve their psychosocial functions, including appreciation for oneself and important persons or events supporting them, adjustments to the disparity between expectations and reality, and reinterpretations of unpleasant experiences. Furthermore, communal creative activities offered by health professionals and peer support were recommended.

Conclusion:
To promote post-stroke psychosocial recovery in communities, health professionals should consider designing meaningful group activities for stroke survivors to meet their psychosocial needs. These findings will guide the development of interventions for enhancing psychosocial functions among Chinese community-dwelling stroke survivors.
Abstract WP127: Diagnostic Value of the Ivy Sign Compared to MR With Cerebrovascular Reactivity in Decompensated Moyamoya Arteriopathy
Authors: O'Cearbhaill Roisin , Itsekzon-Hayosh Ze'ev , Venkatraghavan Lakshmikumar , Mikulis David J , Hendriks Eef J , O'Reilly Sean , Fierstra Jorn , Andrade Barazarte Hugo , Schaafsma Joanna D
Published: February 2024

Introduction:
MR cerebrovascular reactivity (CVR) mapping during rapid manipulation of end-tidal pCO2 is used to assess hemodynamic compromise in patients with Moyamoya arteriopathy (MMA). Leptomeningeal ivy sign on MRI FLAIR sequence may indicate regions of decreased perfusion, which would be an inexpensive and easy way to screen for hemodynamic compromise. The purpose of this study was to examine the diagnostic value of the ivy sign compared to MR CVR.

Methods:
For this retrospective cross-sectional study, we included consecutive patients with uncompensated MMA who were eligible for extracranial-intracranial bypass surgery and completed a preoperative MRI FLAIR with CVR study. Patients with incomplete or artefact degraded imaging were excluded. Two neuroradiologists who were blinded for the CVR result independently assessed the degree of ivy sign on axial 2D FLAIR imaging as grade 0, 1 or 2 in 8 predefined brain regions. Two different readers, blinded for ivy sign, independently assessed the presence or absence of steal in the same regions on MR CVR. Consensus was reached for discordant findings. We assessed interrater agreement using weighted kappa followed by diagnostic accuracy measures for the ivy sign using MR CVR as a reference.

Results:
We enrolled 73 patients (41/73 (56.1%) female; mean age 43). 47/73 (64%) patients had bilateral MMA with on average 3 brain regions with abnormal CVR. Interrater agreement was good for ivy sign (weighted kappa 0.63 (95%CI 0.54-0.71)) and excellent for CVR (kappa 0.95 (95% CI 0.87-1.00)). For a total of 156/584 (26.7%) brain regions, there was agreement between a positive ivy sign and the presence of steal on CVR and 240/584 (41%) brain regions had no ivy sign and normal CVR. The sensitivity of the ivy sign was 64.5%, specificity 70.2%, positive predictive value 60.5% and negative predictive value 73.6% with an AUC of 0.68 (95% CI 0.64-0.72)

Conclusions:
In this preselected cohort with high pretest probability for hemodynamic compromise, the diagnostic accuracy of the ivy sign compared to MR CVR was limited and needs to be used with caution to determine haemodynamic status in MMA.
Abstract WP131: A Proposed Weighted-ASPECTS Based on the NIH Stroke Scale
Authors: Andrade Joao B , Terehoff Igor V , Pacheco Evelyn , Camilo Millene R , Ferreira Rafael A , Pontes-Neto Octavio , Silva Gisele S
Published: February 2024

The Alberta Stroke Program Early CT score (ASPECTS) is a 10-item score of the territory of the middle cerebral artery (MCA). Helpful in defining the extent of ischemia, prognosis, and neurological severity, the role of each item in the score is not clear in the literature. Variables such as age, cerebral hemisphere, vascular occlusion, and collateral status seem to influence the role of each item in terms of neurological severity measured by the NIH Stroke Scale (NIHSS). Recognizing the clinical role of these items can be useful for accurately measuring the clinical-radiological mismatch and maybe allow for expanded therapeutic windows in stroke. We aim to identify the correlation of each ASPECTS item with neurological severity. In an ambispective analysis, patients with ischemic Stroke from a national network of hospitals were included. We conducted a linear regression model, with the NIHSS scores at admission serving as the dependent variable. Models were adjusted for age, time from stroke symptom onset and hemisphere involvement. We excluded patients with an ASPECTS of 10 and those without an arterial-CT brain scan at admission. In total, 587 patients from 32 hospitals were included in the final analysis. Males represented 39.5% of the sample, with a mean age of 68 (±16) years. The median NIHSS score was 11 [5, 17], and the median ASPECTS was 8 [6, 9]. Among patients without occlusion of MCA 1, 2, and 3 (n=352), factors significantly associated with NIHSS scores included age (beta-coefficient 0.08), time from stroke onset (-0.001), left hemisphere (1.58), and ASPECTS subitems M1 (4.7), M3 (2.5), M4 (1.9), M5 (1.8), Insula (1.7), and Lentiform (2.8). In patients with proximal occlusion (n=235), factors significantly associated with NIHSS scores were age (0.07), left hemisphere (4.1), ASPECTS subitems M6 (2.4) and Lentiform (2.4), MCA 1 occlusion (3.3), and absent collateral status (5.8). Our results confirm the different roles of each ASPECTS item on neurological severity in acute stroke patients. Adjusted equations with confidence intervals were created to predict the NIHSS score. Our results bring to the literature an innovative tool for numerically assessing the clinical-radiological mismatch using a simple and accessible neuroimaging method.
Abstract WP133: Phase MRI Clot Characteristic and Radiologic Thrombectomy Outcomes in Acute Ischemic Stroke
Authors: Edalatpour Roya , Abbasi Mohammad Hossein , Warach Steven J , Saber Hamidreza
Published: February 2024

Background:
Magnetic Resonance (MR) susceptibility weighted imaging (SWI) sequences produce filtered Phase images where blood products demonstrate signal intensities opposite to calcifications. Though susceptibility Vessel Sign (SVS) on pre-interventional MRI has been reported as an indicator of outcome following thrombectomy, the association of Phase MR imaging with thrombectomy outcomes is not previously studied.

Methods:
In this retrospective cohort study of consecutive acute large vessel occlusion strokes with Phase MR imaging prior to thrombectomy, we evaluated the correlation between clot features on pre-interventional MR imaging with radiographic outcomes following thrombectomy. The clot characteristics included the presence of SVS and its geometrical features on both Phase and GRE sequenced MRIs and thrombus extension.

Results:
A total of 57 patients were included in this analysis (mean age: 65.04 ± 15.8, 33% Female, mean NIHSS: 13.0 (7.5, 19.5), 33% M1 occlusion), among which 52 (91%) patients had positive SVS on phase-sequence MRI. Successful recanalization was achieved in 91% and successful first pass recanalization was observed in 46%. In univariate analysis, baseline demographics and clinical characteristics including age, sex, and comorbidities were not associated with successful recanalization. Homogeneity of Phase-SVS was significantly associated with the first pass successful recanalization (Odds ratio (OR) 1.81; Confidence interval (CI) [1.14-2.88], p: 0.006).

Conclusion:
Our study suggests MRI Phase-SVS clot homogeneity as a novel predictor of first pass successful recanalization following mechanical thrombectomy in acute stroke.
Abstract WP138: Collateral Status Measured by Hypoperfusion Intensity Ratio Correlates With Infarct Core Size and Growth Rate in MCA Medium Vessel Occlusions <6 Hours and 6-24 Hours Post Onset
Authors: Lin Sidney , Raince Avtar , Byrns Kory
Published: February 2024

Purpose:
Hypoperfusion intensity ratio (HIR) derived from CT perfusion (CTP) has shown to be a useful surrogate marker of collateral status, but prior studies focused on ICA/M1 large vessel occlusions (LVO). We aimed to determine: associations between HIR and clinical/imaging metrics of stroke severity for M2 and M3 medium vessel occlusions (MVO), any differences between <6h and 6-24h from onset as MVO often present later than LVO, and what optimal HIR threshold describes infarct growth rate (IGR) >10mL/h (fast progressor).

Methods:
We retrospectively analyzed consecutive patients arriving within 24h from onset, with M2 or M3 occlusion on CTA, and had concurrent CTP. RAPID generated maps of infarct core defined as rCBF<30% and HIR defined as Tmax>10s/Tmax>6s. IGR was defined as core size/onset-to-CTP time. ASPECTS and NIHSS data were also collected. Correlations were tested using Spearman's rank analysis, for the cohort and separately for <6h and 6-24h subgroups. Difference in HIR between subgroups was tested using Mann-Whitney U. Optimal threshold for IGR>10mL/h was determined by ROC analysis.

Results:
78 patients included with median (IQR) age of 79 (64-84), onset of 7.5h (2.5-14.5), NIHSS of 12 (7-18), ASPECTS of 7 (9-10), core size of 4 mL (0-22), and IGR of 0.57 mL/h (0-2.8). 63 M2 and 15 M3 occlusions identified with median HIR of 0.35 (0.06-0.52). For the cohort, HIR was highly correlated to core size r=0.740 and IGR r=0.710, moderately correlated to NIHSS r=0.474 and ASPECTS r=-0.331 (all p<0.003). 28 and 50 patients presented <6h and 6-24h, respectively, without significant difference in HIR, median 0.31 vs 0.36 (p=0.543). For <6h, HIR was moderately correlated to core size r=0.672, IGR r=0.639, NIHSS r=0.435, and ASPECTS r=-0.496 (all p<0.021). For 6-24h, HIR was highly correlated to core size r=0.791 and IGR r=0.777, moderately correlated to NIHSS r=0.502 and ASPECTS r=-0.376 (all p<0.007). ROC analysis showed AUC of 0.860 (p<0.001) for IGR>10mL/h, with optimal HIR threshold at 0.43 for sensitivity of 100% [95% CI: 59.0-100], specificity of 64.8% [95% CI: 52.5-75.5].

Conclusion:
In acute MCA MVO strokes <6h and 6-24h, HIR as marker of collateral status is moderate to highly correlated to stroke severity, especially size and growth rate of the infarct core.
Abstract WP139: Impact of Intracranial Atherosclerosis Burden on Vasospasm Risk and Outcomes in Aneurysmal Subarachnoid Hemorrhage
Authors: Jayaweera Milidu , Hernandez Manriquez Alex , Shah Asghar , Stretz Christoph , Furie Karen L , Yaghi Shadi , Mahta Ali
Published: February 2024

Background:
Cerebral vasospasm is a well-known complication after aneurysmal subarachnoid hemorrhage (aSAH) and occurs more commonly in younger patients. We hypothesized that intracranial atherosclerosis, which is seen predominantly in older patients, affects vasospasm risk in aSAH. We sought to determine association between intracranial atherosclerosis burden with vasospasm and outcomes in aSAH.

Design/Methods:
We performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH admitted to a Comprehensive Stroke Center between July 2016 and April 2023. Intracranial atherosclerosis burden was quantified by using modified Woodcock (MW) score on CT angiograms measured by trained assessors. Vasospasm was defined based on transcranial Doppler (TCD) criteria. Worse outcome was defined as 3-month modified Rankin Scale 4-6. Univariable and multivariable logistic regression were used to test the association of predictors with outcomes.

Results:
We reviewed 302 cases of aSAH (mean age 56.8 years [SD 13.3], 65% female and 70% white). Cerebral vasospasm was reported in 46% of patients and was more common in younger patients (OR 0.91 for each year increase, 95% CI 0.89-0.94; p<0.001). MW scores were measured with excellent intra-rater and inter-rater reliability (Cohen’s kappa coefficient 0.9 and 0.83 respectively) ranging from 0 to 3 (median 0, IQR 0-1) with higher scores in older patients (beta coefficient 0.019, 95% CI 0.009-0.028; p<0.001). Higher MW calcification score was associated with lower risk of vasospasm (odds ratio 0.52 per point increase, 95% CI 0.36-0.78; p=0.001). There was an inverse correlation between MW scores and severity of vasospasm (beta coefficient -0.29, 95% CI -0.48, -0.1; p=0.003). However, MW score was not independently associated with worse functional outcome (p=0.62) when adjusted for age, Hunt and Hess grades, modified Fisher scores.

Conclusions:
Intracranial atherosclerosis is a potential mechanism for lower vasospasm rate in older SAH patients, however, it may not impact functional outcome. This may suggest intracranial atherosclerosis may affect TCD velocities without any clinical correlation. Larger prospective studies are needed to confirm our findings.
Abstract WP143: Towards What Goal? Palliative Care Utilization for the Post Endovascular Therapy Patient
Authors: Bu Julia , Hansra Harjot , Davila Claire H , Wood Carla N , Torres Dolores , Meyer Dawn M
Published: February 2024

Introduction:
AHA Guidelines call for utilization of Palliative Care (PC) for all patients with serious, life-threatening stroke. The purpose of this study was to assess factors associated with change in Code Status and PC utilization for patients with large vessel occlusion undergoing EVT.

Methods:
We retrospectively reviewed prospectively collected data in an IRB-approved stroke registry at two large, academic Comprehensive Stroke Centers. Subjects who received EVT for acute ischemic stroke (AIS) between 2014-2022 were included. Patients were grouped by change in code status during hospitalization. Baseline demographics were compared between groups with frequencies, chi-squared or t-test as appropriate. A correlation matrix was constructed and regression was performed.

Results:
Of the 411 included patients, 88 had code status changes. There was a significant difference in age, history of diabetes, last known well to hospital arrival, groin puncture to recanalization, and sICH within 36 hours between groups (Table 1). Goals of care (GOC) discussion was documented in only 36% of patients, with a mean of 4 days from stroke onset to code status change. Code status change was significantly associated with female sex (p=0.04), history of diabetes (p=0.01), sICH at 36 hours post rt-PA (p<0.001), PC consult (p<0.001), and rt-PA treatment (p=0.004). Code status change was best predicted with a model including age, DM, Initial NIHSS, and sICH within 36 hours.

Conclusions:
Despite undergoing acute intervention, few AIS patients had documented GOC discussions or code status change during hospitalization. Biases must be addressed in utilizing PC in AIS to provide comprehensive care. Standardized GOC discussions result in caregivers being more informed of prognosis and ensuring that patient’s GOC are honored. Further research is needed to determine barriers to GOC discussions and PC utilization in AIS.
Abstract WP146: Critical Care After Thrombolytic Therapy in Acute Stroke: Who Really Needs the ICU?
Authors: Moore Katherine , Harshaw Nathaniel , Larosa Samantha , Indeck Daria , Cross Danielle B , Chiota-McCollum Nicole , Perea Lindsey
Published: February 2024

Introduction:
Intravenous thrombolytic therapy remains the cornerstone of management in acute ischemic stroke (AIS) patients. Given the potential adverse effects of thrombolysis, patients are admitted to an intensive care unit (ICU) for close monitoring following administration. Alternative post-thrombolytic pathways may provide for safe cost-effective care in certain populations. We aimed to determine the proportion of patients treated with thrombolytics who required ICU care for reasons other than frequent neurologic monitoring and define their characteristics.

Methods:
We retrospectively reviewed patients ≥ 18 years of age who received TNK/ tPA for AIS at our community-based stroke center between May 2020 and August 2022. Patients were classified as requiring ICU care if they required intubation within 24 hours of admission or neurosurgical intervention, had symptomatic hemorrhagic conversion or brain compression, required a continuous infusion for hemodynamic management, or were in status epilepticus. Univariate and multivariate statistical analysis was performed. The study protocol was deemed exempt by our institutional IRB.

Results:
262 patients met inclusion criteria. 54 (20.6%) required ICU level of care. Characteristics of those requiring ICU level of care are described in Table 1. Multivariate analysis showed that patients on antiplatelet or anticoagulant therapies prior to arrival (AOR: 2.205, p= 0.021) or who presented with higher initial NIH stroke scale (AOR: 1.108, p < 0.001) had significantly higher likelihood of requiring ICU level of care.

Conclusions:
In our cohort, approximately 21% of patients required critical care. Anticoagulant or antiplatelet therapy prior to admission and greater NIH stroke scale on arrival were associated with an increased likelihood of requiring ICU level of care. Further prospective studies are indicated to assess the efficacy of alternative settings for post-thrombolytic care in selected AIS patients.
Abstract WP163: Therapeutic Efficacy and Safety Evaluation of Cilostazol for Intracerebral Hemorrhage Through Enhancing Meningeal Lymphatic Function: A Preclinical Study
Authors: Hsieh Yung-Chia , Chen Wan-Ru , Lin Jhih Syuan , Huang Yong-Yun , Chen Shiou-Yi , Tung Hsiao-Yen , Tsai Hsin-Hsi C , Chang Che-Feng
Published: February 2024

Background:
Intracerebral hemorrhage (ICH) is the deadliest form of stroke with no effective treatment to date. Toxic byproducts from hematoma-lysis affected ICH-induced brain injury and long-term behavioral impairment. Enhancing hematoma clearance has shown therapeutic potential in reducing brain damage and neurologic deficits. Our previous work shows that cilostazol (CSZ) promotes meningeal lymphangiogenesis and drainage, aiding hematoma resolution and brain recovery after ICH. Here we explore the optimal dosage, therapeutic window, and potential adverse effects of CSZ treatment in preclinical ICH.

Methods:
A dose of 200 mg/day CSZ is used in clinics which translates to around 40 mg/kg in mice. CSZ (10, 20, and 40 mg/kg) or vehicle was given after ICH induction and was continued for various durations. Pretreatment of CSZ before ICH induction was used to assess its antiplatelet property on intra-parenchymal bleeding. Meningeal lymphatic vessel (mLV) complexity and coverage rate were measured. Lymphatic drainage was evaluated by fluorescent microbead accumulation in the mLV and deep cervical lymph nodes. Neurobehaviors were tested by corner turn test, whisker-evoked tactile responses, hindlimb abduction test, and neurologic deficit scoring. Iron deposition, hematoma, and neuron loss were assessed by immunohistochemistry.

Results:
ICH mice treated with CSZ showed enhanced mLV complexity and proliferation at the transverse, superior sagittal, and confluence of sinuses in the meninges. In parallel, histological, and behavioral outcomes also improved. Pretreatment with CSZ for 3 days before ICH induction did not increase hematoma volume, suggesting minimal to no adverse anticoagulant effect of CSZ in this setting.

Conclusion:
In all, our results unfold the effects of CSZ on mLV function regarding ICH. These findings may be applied as outcome parameters and provide a roadmap for sample size estimation in future clinical trials using CSZ as ICH treatment.
Abstract WP165: Meth Use and Intracerebral Hemorrhage: Really "Breaking Bad"
Authors: Anderson Elizabeth , Schroeder Tracie , Waters Michael F , Gonzalez Daniel , Kaur Supreet , Ashby Lynn , Sheehan Tiffany O , Teran Patricia , Wang David Z
Published: February 2024

Background:
Unlike other stimulants, methamphetamine (meth) is highly addictive and can be injected, snorted, smoked, or ingested orally. Due to increased access, its use has increased globally. Recent studies have shown that there was no significant difference in hospital outcomes between ICH positive patients who utilize meth versus those who do not. However, there has not been a comprehensive evaluation of methamphetamine related ICH in recent times. Our objective is to determine if meth use impacts ICU length of stay/need for sedating agents, and if meth use varies by ethnicity in the ICH population.

Methods:
This is an IRB approved retrospective review of all patients with acute ICH at a large academic stroke center from 2017 to 2023. Data collected and analyzed include demographics, ICH score/size, intraventricular hemorrhage, location of hematoma, surgical intervention, GCS/NIHSS scores, ICU length of stay (LOS), and discharge destiny. Statistics used include Pearson’s Chi-squared test and Wilcoxon rank sum test.

Results:
Of 70 ICH patients with all data elements, 32 (46%) were meth users, with an average age of meth positive patients at 59. In our Hispanic population, significant meth use was seen (41% v 13%, p = 0.009). ICH patients had significant NICU LOS (10.1 v 6.1 days, p < 0.001), with longer hospital mean LOS (12.4 v 7.8 days, p = 0.007). They also required more sedatives (63% v 37%, p = 0.032). Meth use was not associated with larger ICH size (15.7 v 29.2, p = 0.406), but was associated with higher discharge mRS (4.7 v 4.3, p = 0.788).

Conclusions:
Our study demonstrates that in ICH positive patients, meth-use was associated with increased use of sedatives and increased length of stay, as well as higher discharge mRS. However, it was not associated with larger ICH size. Hispanic ethnicity and ICH also appear to have a relationship, although that relationship needs to be further elucidated.

Discussion:
Methamphetamine is easily and relatively inexpensive to make, with over-the-counter ingredients such as pseudoephedrine. With over 35 million people using meth worldwide, our data found that the average user was older than previously thought. As ICH is one of the major complications of meth use, ICH has a major impact on complexity of care and health economics.
Abstract WP166: Bleeding Risks Among Hemorrhagic Stroke Patients Started on Serotonergic Antidepressants During Subacute Recovery
Authors: Simmonds Kent P , Chavez Audrie , Ifejika Nneka L
Published: February 2024

Background:
Early initiation of antidepressants (ADs) are associated with improved functional recovery, but are associated with an increased risk of major bleeds among hemorrhagic stroke (HS) patients. Our objectives were to determine if increased bleeding risk remained if ADs were initiated during subacute recovery and if bleed risks were comparable between AD classes.

Methods:
A cohort of AD naive first time HS patients (ICD-10 codes 160-162) were identified from Electronic Medical Records of 70 large healthcare organizations (2003-2023). Patients without AD use were considered “No AD” whereas patients started on ADs during subacute recovery (i.e., at least 3 months after the indexed HS) were grouped as Selective Serotonin/Serotonin & Norepinephrine Reuptake Inhibitors (SSRI/SNRI) or “Other AD” (i.e., Mirtazapine, bupropion, trazodone, or tricyclic ADs). Baseline differences were adjusted for using 1:1 matched propensity score (PS). Outcomes included the 1-year risk of a major bleeding event (e.g., gastrointestinal/intracranial bleed or shock), recurrent HS, fall, ischemic stroke (IS) and death

Results:
The cohort consisted of n=257,595 patients split into 3 groups: No AD (n=250,103), SSRI/SNRI (n=4,180) or Other AD (n=3,312). Matching resulted in good covariate balance for both the SSRI/SNRI vs. No AD (n=8,250 patients) and Other AD vs. SSRI/SNRI (n=6,380 patients) comparisons. SSRI/SNRIs (vs. No AD) were associated with a 33% increase in the risk of a major bleed (RR: 1.33, 95%CI: 1.22-1.45) and significantly higher risks of recurrent HS, fall, IS and death. There were no significant differences in adverse outcomes between AD classes.

Discussion:
Increased risk of major bleeds and recurrent HS remains if ADs are started during subacute recovery, a time period which aligns with community-based recovery. Our findings may inform care practices of primary care providers and rehabilitation professionals to decrease preventable adverse outcomes.
Abstract WP174: A Reassessment of Cost Effectiveness and Clinical Effectiveness of Anticoagulation Reversal in Direct Oral Anticoagulant - Related Intracerebral Hemorrhage
Authors: Madour Joseph , Shu Liqi , Yaghi Shadi , Furie Karen L , Stretz Christoph
Published: February 2024

Introduction:
Anticoagulation use is associated with increased risk of hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH). We sought to assess rates of HE in patients with ICH on direct oral anticoagulants (DOAC) and annual cost associated with anticoagulation reversal and occurrence of HE.

Methods:
We performed an observational cohort study on consecutive patients with ICH on DOAC admitted to a Comprehensive Stroke Center over 3 years, using data from an institutional ICH registry. We prospectively collected baseline demographic and clinical variables, neuroimaging data on baseline and follow-up hematoma volumes (HV) and HE and outcomes on discharge via modified Rankin scale (mRS). Hemostatic efficacy on hematoma size was adjudicated based on the Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors-4 (ANNEXA-4) trial, with a ≤20% increase in HV compared to baseline considered “excellent” and a ≤ 35% increase in HV compared to baseline considered “good.” Weighted hematoma expansion cost was estimated based on common odds ratio of mRS increase with HE and distributions of mRS with HE.

Results:
We identified 103 patients who met inclusion criteria: mean age 75.8 (± 11.4) years, 55.3% female. 92 patients (89.3%) received anticoagulation reversal with prothrombin complex concentrate (PCC), of which 19 (20.7%) had HE. A more severe coagulopathy (antiXa > 0.5) was associated with increased risk of HE (p<0.05). 74 patients (80.4%) achieved good or excellent hemostasis. Use of PCC was associated with a 19.6% hematoma expansion rate using the definition above, which translates into a $6700 increase in annual cost per every ICH patient attributed to HE.

Conclusion:
Cost effective and clinically effective treatments for anticoagulation reversal are needed to reduce the risk and cost associated with HE in anticoagulation-related ICH.
Abstract WP175: Effect of Acute Blood Pressure Management on Outcomes in Patients With Nontraumatic Intracerebral Hemorrhage: Quality Assurance Study
Authors: Makhoul Karim , Yang Bo , Mehta Vishal , Ohara Joseph , Jimenez Jean , Sanelli Pina C , Rohan Arora
Published: February 2024

Current guidelines for blood pressure (BP) management in patients with intracerebral hemorrhage (ICH) recommend acute lowering of systolic BP (SBP) to 140 mm Hg with a maintenance goal of 130 - 150 mm Hg. There remains a knowledge gap regarding frequency of BP monitoring, and level of SBP lowering in acute phase of ICH. Our study aimed to investigate effect of frequency of BP monitoring and acute SBP lowering in ICH patients within 48 hours of their admission.

Methods:
We conducted a retrospective review of study from our institutional SHOUT database (Stroke Health Outcomes Database) database. All ICH patients from 2018 through 2022 were included. Data involving BP measurements, maximum SBP and average BP within the first 48 hours of admission were collected. BP was categorized into 3 categories of <140, 140-160 and >160 mmHg. Frequency of BP measurements was obtained and was classified as <25, 25-50 and > 50 measurements of BP in the first 48 hours. Demographic data along with comorbidities were included in the analysis. Outcome was considered good if the patients were discharged home or had discharge mRS of 0-2. Outcome was considered poor if patient was discharged to a subacute rehabilitation facility or had mRS of 3-5.

Results:
2998 patients were found to have ICH. 64.2 % of patients achieved lower mean BP < 140 mm Hg and were found to have good outcome of home disposition. These results were statistically significant (P= 0.002). BP monitoring of > 50 times was more likely to result in better outcomes in patients with ICH when compared to less monitoring (P<0.001).

Discussion:
ICH patients who had higher number of BP readings during first 48 hours of their admission were more likely to have good outcome. Aggressive lowering of SBP was associated with higher likelihood of discharge to home or mrs 0-2.
Abstract WP182: Effect of Prior Anticoagulation With Non-Vitamin K Oral Anticoagulants in Patients With Atrial Fibrillation on Functional and Procedural Outcomes in Patients Undergoing Thrombectomy
Authors: Shaheen Yanal , Al Qudah Abdullah , Doheim Mohamed , Al-Bayati Alhamza , Starr Matthew , Rocha Marcelo , Raul Nogueira , Lang Michael , Gross Bradley , Bhatt Nirav
Published: February 2024

Background:
Atrial fibrillation (AF) has been shown to be associated with better procedural outcomes in patients with anterior circulation large vessel occlusion (aLVO) undergoing endovascular therapy (EVT). However, data surrounding the impact of pre-treatment with NOACs on procedural outcomes among patients with AF undergoing EVT for aLVO remains limited.

Methods:
We conducted a retrospective analysis of a prospectively maintained institutional database of EVT cases on all patients with a diagnosis of AF between Jan 2021 and Mar 2023, grouped by anticoagulation (AC) status (AC vs no AC). In the anticoagulated group, only patients on NOACs were included. Outcomes compared between groups were 90-day mRS, successful reperfusion (Thrombolysis In Cerebral Infarction (TICI) 2b-3), first-pass effect (FPE), time from skin puncture to recanalization, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality.

Results:
Of 197 AF patients included, 97 (49.2%) had a history of being on NOAC at the time of stroke. Forty-four percent of the no AC group received intravenous thrombolysis (IVT). In the NOAC group, 59.5% of patients achieved 90-day mRS of 0-2 vs 49.3% in the no AC group (aOR=1.32, p=0.57). The rate of successful reperfusion in the NOAC group was 98.7% vs 93% in no AC group, (aOR 0.48, p=0.24). No difference was observed with regards to FPE and skin puncture to recanalization time. There was a non-significant trend of higher mortality in the no AC group (23.9% versus 12.2% in NOAC group), despite similar sICH rates (5.0% in no AC and 6.2% in NOAC group, aOR 1.08, p=0.91). Subgroup analysis of patients with a single, non-tandem occlusion of ICA or M1 analyzed by NOAC status yielded similar findings. All outcomes were adjusted for age, gender, baseline NIHSS, and IVT status.

Conclusion:
Among patients with AF undergoing EVT for LVO, our study did not find an association of prior anticoagulation with NOACs on procedural outcomes, although there was a trend towards better functional outcomes and numerically higher successful reperfusion rate among patients pretreated with NOACs. Further research is needed to study the impact of NOACs on procedural outcomes among patients undergoing EVT.
Abstract WP189: TIGER Study: Effectiveness and Safety of Tigertriever Are Maintained When Treating Large Clot Size
Authors: Gupta Rishi , Saver Jeffrey L
Published: February 2024

Introduction:
Larger volume thrombi are associated with a lower probability of functional independence defined as a modified Rankin Score (mRS) ≤2 and a higher number of retrieval attempts. A subanalysis of the TIGER study data was performed in order to assess the effectiveness and safety of Tigertriever in small and large clot sizes.

Methods:
The TIGER study was a single arm, prospective, multi-center trial assessing the efficacy and safety of the Tigertriever, a radially-adjustable stent retriever, for LVO-related stroke. The trial enrolled 160 subjects, of which 150 had successful mTICI 2b-3 revascularization (94%) at end of all procedures. The interventionalists evaluated the clot length angiographically prior to the treatment, and analysis was performed to compare the Tigertriever performance in short clots with long clots.

Results:
Data is available from 135 (78 males) out of the 160 subjects enrolled in the study.The median clot length was 9mm with a range of 1-50mm. Subjects were divided into two subgroups: Group A; subjects with small clot length, ≤9mm (n=69) and group B, subjects with large clot length, >9mm (n=66). Baseline NIHSS was significantly smaller in group A compared to group B (16.9 vs.19, respectively, P=0.02). Median clot size in group A was 6.1mm and 16.5mm in group B. The mean number of passes with Tigertriever to achieve successful revascularization (mTICI 2b-3) was slightly higher in group B, but not statistically different (1.7 in group A vs. 2 in group B, P=0.07). First pass effect (63% vs. 50% NS), good clinical outcome (62% vs. 53% NS), sICH (1.4% vs. 3% NS) and ENT (Embolization to new territory 2.9% vs. 1.5% NS) were comparable in group A and group B, respectively.

Conclusions:
Despite the impaired neurological functioning as indicated by significantly higher baseline NIHSS in subjects admitted with larger clot length, Tigertriever efficacy and safety were maintained when treating these large clots compared to small clots.