bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract Number ‐ 172: First‐in‐Human Experience: Route 92 Medical 132 cm FreeClimb 88 Catheter for Anterior Circulation LVOs
Authors: English Joey D , Puri Ajit S , Caldwell James , Singh Jasmeet
Published: April 2023

Introduction

Direct aspiration thrombectomy of proximal anterior circulation large vessel occlusions (LVOs) with super‐bore catheters (SBCs, 0.088” ID) may result in improved first pass success, though their consistent delivery to the target occlusion remains challenging. We report the first‐in‐human experience with a novel full‐length 132 cm 0.088” ID FreeClimb ® 88 catheter (Route 92 Medical, San Mateo, CA, currently approved for neurovascular access), and its customized Tenzing ® 8 delivery catheter, for anterior circulation LVO acute stroke patients.

Methods

We performed a retrospective review of thrombectomy cases for proximal anterior circulation large vessel occlusions performed at three stroke centers from May 2022 through August 2022. All patients were treated using the Route 92 Medical 8F Base Camp® guide catheter, FreeClimb ® 88 catheter and Tenzing ® 8 delivery catheter in an off‐label fashion.

Results

Ten consecutive acute stroke patients with anterior circulation LVOs were treated. The median age was 71 (45‐91) and 6 were female (60%). The median presenting NIHSS score and ASPECT score were 17 (8‐24) and 9 (6‐10), respectively. LVO locations were as follows: two right carotid termini, three right M1 middle cerebral arteries, and five left M1 middle cerebral arteries. Three patients also had tandem occlusion/near‐occlusion of the respective cervical internal carotid artery. The FC88 catheter was delivered to the target occlusion with 100% success. The median time from groin puncture to catheter delivery to the target occlusion was 14 minutes (7‐35). First pass complete reperfusion (modified Thrombolysis in Cerebral Infarction score, mTICI, of 3) was achieved in 9/10 (90%) patients (self‐adjudicated). Adjunctive therapy for a residual M2 occlusion was utilized in 1/10 patients. There were no adverse events or post‐procedural symptomatic hemorrhages.

Conclusions

Our first‐in‐human experience with a novel 132 cm full‐length super‐bore catheter (Route 92 FreeClimb ® 88 catheter) and its customized catheter delivery device (Tenzing ® 8) for aspiration thrombectomy of proximal anterior circulation large vessel occlusions demonstrated 100% successful delivery to the target occlusion, with TICI 3 first pass reperfusion achieved in 90% of patients.
Abstract Number ‐ 174: Direct carotid puncture for mechanical thrombectomy in acute ischaemic stroke
Authors: Mutis Jorge , Pabon Boris , Torres Victor , Patiño Manuel , Pelaez Juan , Cardozo Margarita
Published: April 2023

Introduction

While the benefit of mechanical thrombectomy (MT) for patients with acute ischemic stroke with large‐vessel occlusion (AIS‐LVO) has been clearly established, difficult vascular access may make the intervention impossible or unduly prolonge. In the following cases, functional and safety outcomes of mechanical thrombectomy via direct carotid puncture were evaluated in patients with acute ischemic stroke with limited vascular access.

Methods

We evaluated seven patients with AIS‐LVO who underwent attempted MT in last year with limmited vascular access for aborted MT after failed transfemoral access or attempted MT via DCP.

Results

Of 11 patients with AIS‐LVO who underwent attempted MT, Direct carotid access was successfully obtained in all patients, mean age [± SD] 63 ±15 years. Successful reperfusion (thrombolysis in cerebral infarction score 2b or 3) was achieved in 11 patients (100%). Carotid access complications included disection vascular in 1 pacient, with second vascular Access (carotid puncture) required. In 3 patients (42.8%) thrombolysis therapy with IV r‐TPA were administered during thrombectomy by direct carotid puncture. 3 patients presented neck hematomas but they did not require any subsequent interventions. All patients required angio‐seal vascular closure device for direct carotid Access 6F. We found that the final functional outcome was based on modified Rankin Scale score between 1 and 3 achieve in 8 of 11 patients (71.4%).

Conclusions

DCP for emergency MT in patients with AIS‐LVO and prohibitive vascular access is safe and effective and is associated with higher recanalization rates.
Abstract Number ‐ 181: Anterograde versus Retrograde approaches in the Endovascular Management of Tandem Lesions
Authors: Zevallos Cynthia B , Galecio‐Castillo Milagros , Farooqui Mudassir , Abraham Michael , Divani Afshin , Ribo Marc , Petersen Nils , Fifi Johanna , Guerrero Waldo , Malik Amer , Siegler James , Nguyen Thanh N , Sheth Sunil A , Yoo Albert J , Linares Guillermo , Janjua Nazli , Quispe‐Orozco Darko , Tekle Wondewossen , Oliver Marion , Zaidi Syed , Castonguay Alicia , Kobsa Jessica , Prasad Ayush , Ikram Asad , Answer Hamza , Patterson Mary , Requena Manuel , Olive Marta , Qureshi Abid , Barkley Tiffany , Matsoukas Stavros , Rana Ameena , Abdalkader Mohamad , Salazar‐Marioni Sergio , Soomro Jazba , Vivanco‐Suarez Juan , Rodriguez‐Calientes Aaron , Turabova Charoskhon , Edgell Randall , Mokin Maxim , Yavagal Dileep , Zaidat Osama , Jumaa Mouhammad , Hassan Ameer , Ortega‐Gutierrez Santiago
Published: April 2023

Introduction

There are two approaches for treating stroke patients with tandem occlusions: the anterograde approach (AA, extracranial lesions first) and the retrograde approach (RA, intracranial lesion first). Both techniques are associated with favorable functional outcomes. We aimed to compare both techniques for efficacy and safety outcomes in a multicenter study.

Methods

Patient data were pooled from 17 centers and divided into AA and RA groups. We performed multivariable logistic regressions to evaluate the association between each group with efficacy and safety outcomes.

Results

552 patients were included in the study, 270 (48.4%) were treated with the AA, and 288 (51.6%) with the RA. There were no differences between groups for functional outcome (mRS 0–2) at 90 days (aOR = 0.93, 95%CI: 0.58‐1.48, p = 0.75), and successful reperfusion [mTICI >2b] (aOR = 0.83, 95%CI: 0.44‐1.56, p = 0.57). Similarly, we did not observe any differences for safety outcomes related to sICH (OR = 0.57, 95%CI: 0.25‐1.29, p = 0.18), parenchymal hematoma type 2 (OR = 0.61, 95%CI: 0.3‐1.22, p = 0.16), and all‐cause mortality at 90 days (OR = 1.22, 95%CI: 0.66‐2.26, p = 0.52). However, the median puncture‐to‐reperfusion time was higher in AA compared with RA [59 minutes (IQR: 38–92) vs 53.5 minuntes (IQR: 37–87)].

Conclusions

The AA and RA approaches for the treatment of tandem occlusions seem to achieve similar efficacy and safety outcomes. These results are consistent with those of a previous multi‐center study. Additionally, and in line with previous research, there is a puncture‐to‐reperfusion time difference between both approaches, which suggests a potential benefit when using the RA. However, further prospective randomized studies are needed to elucidate its benefit in achieving better clinical outcomes.
Abstract Number ‐ 184: Prediction Model For Medical Rescue Treatment Strategies In Patients With Incomplete Reperfusion
Authors: Mujanovic Adnan , Kurmann Christoph , Dobrocky Tomas , Meinel Thomas , Grunder Lorenz , Beyeler Morin , Lang Matthias F , Jung Simon , Klail Tomas , Hoffmann Angelika , Seiffge David J , Heldner Mirjam , Pilgram‐Pastor Sara , Mordasini Pasquale , Arnold Marcel , Piechowiak Eike I , Gralla Jan , Fischer Urs , Kaesmacher Johannes
Published: April 2023

Introduction

After successful reperfusion is achieved (extended Thrombolysis in Cerebral Infarction (eTICI) ≥ 2b50), decision on pursuing additional treatment strategies in order to achieve complete reperfusion (eTICI = 2c/3), is multifactorial and depends on patient’s clinical and imaging characteristics. We have developed and validated a clinical decision tool to provide individualized predictions on achieving delayed reperfusion based on individual patient data.

Methods

Single‐center registry analysis for all consecutive patients admitted between 02/2015 – 12/2020. Primary variable of interest was perfusion imaging outcome in patients with incomplete reperfusion (eTICI 2a‐2c), evaluated on the 24‐hour follow‐up imaging. This variable was dichotomized into delayed reperfusion, in case of non‐observable perfusion deficit, and persistent perfusion deficit, in case of perfusion deficit captured on the final angiography imaging. Final model variable selection was performed via bootstrapped (n = 200) stepwise backwards regression. Model was split into a training and testing set (80:20 ratio), with 10‐fold cross validation resampling.

Results

372 patients (50.8% female, mean age 74) were included, with 228 (61.2%) of them having delayed reperfusion. Final model identified seven variables of importance including: age, sex, atrial fibrillation, Intervention‐to‐Follow‐Up time, maneuver count, eTICI and collateral status. Model’s discriminative ability for predicting delayed reperfusion was adequate (AUC 0.83, 95% CI 0.74 –0.92), with an overall adjusted calibration (Brier score 0.17, 95% CI 0.15‐0.18).

Conclusions

Current model presents a tool that may aid clinical decision‐making process in selection of patients for pursuing additional treatment strategies after incomplete reperfusion has been achieved. This is an important next step towards personalized treatment of stroke patients undergoing mechanical thrombectomy.
Abstract Number ‐ 191: Barriers to Mechanical Thrombectomy in Africa
Authors: Morakinyo Oreoluwa E , Amuta Augustine C , Ajenaghughrure Godbless , Nriagu Bede N , Mejulu Eunice O
Published: April 2023

Introduction

The emergence of mechanical thrombectomy (MT) as a standard of care has revolutionized the management of proximal large vessel occlusions (LVOs) in patients with acute ischemic stroke (AIS). Endovascular therapy has already been shown to provide better long‐term outcomes when compared to standard treatment alone. However, despite the significant advances and benefits associated with MT in the treatment of proximal LVOs in developed countries, Africa continues to lag in the use and adaptability of the “gold standard” for proximal LVO stroke treatment. With the prevalence of stroke in Africa approaching the highest rates in the world, this study seeks to highlight the problems threatening endovascular therapy in Africa. This is an important step in advocacy for more radical, effective, and evidence‐based management of patients with proximal LVOs in Africa.

Methods

For this narrative review, PubMed and Google Scholar were used to search for literature on mechanical thrombectomy and endovascular treatment of LVOs in Africa. Selection criteria were manuscripts published in the last 10 years, written in English language, and addressed challenges with MT.

Results

42 papers from 21 African nations were found and reviewed. The major challenges and impediments to MT in Africa were, a lack of government policy on stroke care, a suboptimal health care financing model that makes endovascular treatment nearly impossible to afford, delay in presenting to the hospital after stroke onset coupled with very few emergency services with some countries having none, lack of specialized training, as well as, scarcity of neuroradiological infrastructure.

Conclusions

Despite these challenges, there is still hope for Africa. With its four domains (surveillance, prevention, acute treatment, and rehabilitation), the stroke quadrangle, adapted by many countries allows for focused initiatives aimed at successfully lowering the burden of stroke in Africa at the community level through prevention and education. There is still an urgent need for increased global support to address these challenges in Africa, even as programs like the MT2020+ by the Society of Vascular and Interventional Neurology (SVIN) have given Africa hope for the future of endovascular therapy by fostering collaboration, training, and policy development.
Abstract Number ‐ 193: Endovascular Thrombectomy for Basilar Artery Occlusion: Systematic Review and Meta‐analysis
Authors: Chiu Yu‐Ping , Lui Aiden K
Published: April 2023

Introduction

Basilar artery occlusion (BAO), accounting for approximately 1% of all ischemic strokes and 5–10% of all proximal intracranial occlusions, usually causes devastating neurologic sequelae, poor prognosis and even death [1‐2]. Endovascular thrombectomy (EVT) has been recommended for anterior circulation stroke with large vessel occlusion (LVO) [3‐6]. During the past decade, there has been emerging interests in whether EVT could provide similar overwhelming benefits in posterior circulation stroke, especially BAO [7‐8]. The goal of our study is to compare EVT with conservative medical treatment (CMT) about the efficacy and the safety in patients with BAO.

Methods

All relevant literature comparing the outcomes of EVT versus CMT in patients with BAO were recruited via PubMed, Embase and the Cochrane Library until April 2022. Random‐effects model was adopted to pool estimates regrading favorable/good functional outcome, symptomatic intracranial hemorrhage (sICH) and the mortality. The heterogeneity of outcomes was assessed using the Cochran Q test (reported as a Cochran Q p value) and I2 statistics.

Results

Of the eight studies, a total of 3733 patients with pure BAO were enrolled. EVT was conducted in 2573 patients, and the others received CMT. Compared with CMT group, EVT group with or without intravenous thrombolytic therapy achieved more favorable functional outcome (OR 1.26, 95% CI 1.03 to 1.55, I2 = 54%, p = 0.05; Figure 1A) in patients with BAO. Similar trend was also noted in the good functional outcome (OR 1.23, 95% CI 0.97 to 1.57, I2 = 63%, p = 0.02; Figure 1B). Even though EVT group tended to provoke more sICH (OR 2.91, 95% CI 1.38 to 6.18, I2 = 22%, p = 0.27; Figure 1C), it reduced the mortality (OR 0.81, 95% CI 0.70 to 0.93, I2 = 31%, p = 0.19; Figure 1D) in patients with BAO, originally a devastating condition.

Conclusions

Our study worked in concert with the recent climate in the endovascular era [9] that EVT in BAO provides superior functional outcomes and less mortality compared with CMT. Despite the tendency of developing sICH after reperfusion, EVT still brought a dawn to posterior circulation stroke. We are no more at our wits’ end with BAO and its grave prognosis. Furthermore, we still need more future randomized control trials [10] or large‐scale cohorts for conclusive evidence.
Abstract Number ‐ 199: Acute Treatment of Aneurysmal Subarachnoid Patients with Flowdiversion: A Single Center Real World Experience
Authors: Ramakrishnan Pankajavalli , Harris Jatifha , Gibler Dana , Duck Nicole , Leesch Wofgang
Published: April 2023

Introduction

Subarachnoid hemorrhage patients presenting with complex morphology, and those with dissecting /fusiform aneurysms, blister aneurysms have historically posed a challenge for acute endovascular treatment. Flow diversion as a treatment for ruptured intracranial aneurysms is a last resort given the need for dual antiplatelet therapy in the acute setting.

Methods

We present our single center experience, real world experience in the acute treatment of patients with subarachnoid hemorrhage with pipeline flow diversion device.

Results

6 patients presented acutely with a subarachnoid hemorrhage. Two of those had saccular intracranial aneurysms, 1 with a blister aneurysm, and 3 with dissecting aneurysms. 1 patient presented with a ruptured anterior choroidal artery location dissecting aneurysm, 1 with PCA blister aneurysm, 1 with intradural vertebral artery dissecting aneurysm, 1 saccular posterior communicating artery aneurysm, and another with a ruptured complex morphology anterior choroidal artery aneurysm, and 1 with dissecting PCA aneurysm. All patients were emergently loaded with dual antiplatelet therapy consisting of either aspirin and clopidogrel, or aspirin and ticagrelor or pletal and ticagrelor. 1 patient was treated with surface modified pipeline device with shield technology. Technical success was achieved in 100% of these patients. No acute in stent thrombosis was seen in this cohort. Four patients had no residual filling or recurrence at the 1st follow‐up at a median interval of 2–12 months. 1 patient died from fulminant vaso spasm. Follow‐up is pending in 1 patient.

Conclusions

In carefully selected patients, flow diversion in the acute setting is tolerated and can be an alternative treatment strategy with an acceptable safety profile.
Abstract Number ‐ 207: Modeling Optimal Patient Transport in a Stroke Network Capable of Remote Telerobotic Endovascular Therapy
Authors: Beaman Charles , Holodinsky Jessalyn K , Goyal Mayank , Tateshima Satoshi , Hill Michael D , Saver Jeffrey L , Kamal Noreen
Published: April 2023

Introduction

Endovascular therapy (EVT) is the standard‐of‐care for large vessel occlusion stroke; however, timely access to treatment is still limited for a large proportion of the population. Telerobotic EVT has the potential to decrease time to treatment and expand existing networks of care to more rural populations. It is currently unclear how its implementation would impact existing stroke networks.

Methods

Conditional probability models were generated to predict the probability of excellent outcome (modified Rankin Scale 0–1 at 90 days post stroke) for patients with suspected large vessel occlusion (LVO). A baseline stroke network was created for California using existing intravenous thrombolysis (IVT) centers and comprehensive stroke centers (CSCs) capable of IVT and EVT. Optimal transport decisions and catchment areas were generated for the baseline model and three hypothetical scenarios through conversion of IVT centers at various distances from a CSC into centers capable of Telerobotic EVT [i.e. hospitals ≥ 15 and < 50 miles from a CSC were converted (Scenario 1), ≥ 50 and < 100 miles (Scenario 2), and ≥ 100 miles (Scenario 3)]. Catchment areas were calculated for each scenario using varied robotic procedural delay times and success rates.

Results

In the baseline model, 51 hospitals were designated as CSCs and 142 hospitals were designated IVT centers. Conversion of IVT centers into Telerobotic EVT centers decreased median travel time for LVO patients in all three scenarios. The estimated number of robotically treated LVOs per year in Scenarios 1, 2, and 3 were 2172, 740, and 212, respectively. Scenario 1 (15‐50 miles) was the most sensitive to robotic time delay and success rate, but all three scenarios were more sensitive to decreases in procedural success rate compared to time delay.

Conclusions

Telerobotic EVT has the potential to improve care for stroke patients outside of major urban centers. Compared to procedural time delays in robotic EVT, a decrease in procedural success rate would not be well tolerated. This modeling analysis can inform system planning for the potential advent of remote EVT care.
Abstract Number ‐ 210: Curative Embolization of Ruptured Pediatric Cerebral Arteriovenous Malformations
Authors: Saal‐Zapata Giancarlo , Rodriguez‐Calienes Aaron , Vivanco‐Suarez Juan , Galecio‐Castillo Milagros , Farooqui Mudassir , Zevallos Cynthia , Ortega‐Gutierrez Santiago
Published: April 2023

Introduction

The incidence of ruptured cerebral arteriovenous malformations (AVMs) has increased as a consequence of the publication of the ARUBA trial. In the setting of ruptured AVMs, target embolization of high‐risk features can be considered to decrease the risk for recurrent hemorrhage. However, embolization with the intention to cure has not been well studied in ruptured AVMs. Furthermore, the role of primary curative embolization of pediatric AVMs is uncertain. Hence, we aimed to characterize the safety and efficacy of curative embolization for ruptured AVMs in pediatric patients.

Methods

Between 2010 and 2022, a retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization for ruptured AVMs was conducted in two institutions. Demographic data, clinical presentation, Spetzler‐Martin (SM) grade, associated high‐risk vascular structures, and procedural characteristics were retrieved. The safety (intraprocedural complications and mortality) and efficacy (complete angiographic obliteration after the last embolization session) were evaluated.

Results

Sixty‐eight patients (38 females; mean age 12.4 ± 3.4 years) underwent a total of 109 embolization sessions. The most frequent clinical presentation was headache (79%). There were 15 (22%) SM grade I lesions, 34 (51%) grade II, 14 (21%) grade III, and 4 (6%) grade IV. In 21 patients, twenty‐three high‐risk structures were observed (3 prenidal aneurysms, 12 intranidal aneurysms, 3 venous aneurysms, 2 varicose veins, 3 arteriovenous fistulae). Decompressive craniectomy with intracerebral hemorrhage evacuation was performed in 15 patients (22%). The mean number of sessions per patient was 1.6 (range 1 to 6) and n‐butyl cyanoacrylate was the most used embolic agent (30%). The transarterial approach was the most common (91%). The mean volume of embolic agents in each patient was 2.1 ml (range 0.1 to 6 ml). Seventeen intraprocedural complications (16% of procedures) were observed and no deaths were reported. In patients with high‐risk structures the rate of intraprocedural complications was 24%. The most common complication was microcatheter‐related vessel perforation (7%). Complete angiographic obliteration was achieved in 42 patients (62%). In 30 patients (44%) the AVM was occluded with a single embolization session. The rate of complete obliteration in patients with high‐risk structures was 62%.

Conclusions

Curative embolization of ruptured pediatric AVMs shows a high rate of intraprocedural complications, especially when high‐risk associated vascular structures are present. In addition, acceptable complete obliteration rates were found. Appropriate long‐term follow‐up in prospective studies tailored to the pediatric population are required to determine the best therapeutic approach.
Abstract Number ‐ 212: Endovascular vs. Open Surgery for Craniocervical Junction Dural Arteriovenous Fistulas: Assessing Safety and Efficacy
Authors: Brown Nolan , Singh Rohin , Bocanegra‐Becerra Jhon , Bui Nicholas , Hallak Hana , Koester Stefan , Shahrestani Shane , Stonnington Henry , Gendreau Julian
Published: April 2023

Introduction

Arteriovenous fistulas at the craniocervical junction (CCAVFs) are challenging to treat due to variation in angioarchitecture and shunting sites. No consensus exists as to whether open surgery or endovascular approaches are better in regards to outcomes, complications, and need for reintervention. As such, weexplore the efficacy, outcomes, and complications of endovascular versus open surgery for dural arteriovenous fistulas at the craniocervical junction.

Methods

A systematic review was performed using the EMBASE, PubMed,and Cochrane databases in April 2022. MeSH search terms included (craniocervical) AND (arteriovenous OR fistula OR AVF). Inclusion criteria were defined as patients with CCAVFs who were treated with open surgery or endovascular therapy with reported clinical outcomes at 6 months or later.

Results

A total of 357 studies were screened; of which 75 were included. A total of 416 patients (309 males, 91 females) were included with an average age of 61.9 years. A total of 236 patients underwent surgery (mean age: 61.5), 71 patients underwent embolization (mean age: 62.6), and 25 patients underwent a combination (mean age: 54.7). Outcomes were reported in 39 surgery cases (mean follow up time: 31.4 months), and 54 endovascular cases (mean follow up time: 24.2 months). Within the open surgery group 47 (57.3%) had complete symptom resolution, 23 (28%) had symptom improvement or stabilization, 11 (13.4%) permanent deficit, and 1 (1.2%) resulted in death. Within the endovascular group 26 (56.5%) had complete symptom resolution, 5 (10.9%) had symptom improvement or stabilization, 15 (32.6%) permanent deficit, and 0 (0%) resulted in death.

Conclusions

Open surgery and embolization yield comparable symptomatic improvement and stabilization. However, the rate of permanent deficits is higher withembolization, while mortality is higher with open surgery. Further studies are required to better associate these outcomes to baseline parameters including treatment decision making, size of the lesion, patient age, and co‐morbidities.
Abstract Number ‐ 214: Woven EndoBridge in Conjunction with Coiling: Novel Technique for Treatment of a Large Basilar‐tip Aneurysm
Authors: Kiaei Benjamin , Miremadi Brian , Edgell Randall
Published: April 2023

Introduction

Basilar tip aneurysmscan bechallenging to treatgiven their location andoftencomplex geometryand size.Endovascular coilinghas historically been the standardoftreatmentfor less complex aneurysms, proving to bebothsuccessfulandsafe.However, recanalization ratesfor large and giant aneurysmshave beenunacceptably high.More recently, devicessuch asthe Woven EndoBridge (WEB) have been developed toreduce the rate of recanalization.Here we describea uniquecase of alarge basilar tip aneurysm that was treated withcombination oftheWEBdeviceandcoilembolizationsimultaneously.

Methods

Case report.

Results

A woman in her fifties presented with several days of headache, nausea and vomiting, vision changes, and unsteady gait. MRA of the brain visualized a large unruptured basilar tip saccular aneurysm which was confirmed via a diagnostic cerebral angiogram (size: 12.9×11.2×14.0 mm, neck: 4.5 mm) [Figure 2A]. Given the sizeand locationof the aneurysm,we attempted embolization with the largest available WEBSLdevice. This device was undersized for the aneurysm.We therefore utilized a novel combinationcoiling,to partially fill the dome and posterior aneurysm sac,and the largest WEB SL available (11×9 mm). Using a radial system, the WEB device was partly unsheathed at the base of the aneurysm. Then, using a femoral system three coils (18 Hydroframe 28cm 7mm, 18 Hydroframe 15cm 7mm 10, 10 Hydroframe 23cm 7mm) were introduced into the remaining space of the aneurysm, filling the void between the aneurysm dome and the partly deployed WEB SL device. Once all coils were appropriately placed and stable, the WEB device was fully deployed, which lead to successful embolization and occlusion of the aneurysm [Figure 2B].

Conclusions

The challenge of treatinglargebasilar tip aneurysmshasencouragedthedevelopment of innovative devices and novel interventional techniques.Here we demonstratethepossibility ofcombiningaWEBdevicewith standard coilingto treatlarge, wide‐necked basilar tip saccularaneurysms that are not ideal candidates for standard therapy.
Abstract Number ‐ 215: Distinct presentation of RCVS and PRES co‐existence and overlap of their pathophysiology
Authors: Patel Priyadarshee , Garg Aayushi , Rocha Marcelo
Published: April 2023

Introduction

Reversible cerebral vasoconstriction syndrome (RCVS), is characterized by reversible segmental and multifocal vasoconstrictionof cerebral arteries leading to infarcts and cytotoxic edema. Posterior reversible encephalopathy syndrome (PRES) is characterized by vasogenic edema predominantly in the parieto‐occipital regions associated with acute onset encephalopathy, seizures, headache, and visual disturbances.Whether PRES and RCVS are independent syndromes and sometimes overlapped or part of a continuum process, these theories are still debated. We report a case of a patient with distinct overlapping of RCVS and PRES.

Methods

Case Report

Results

52‐year‐old woman with past medical Hx of Hypertension, Diabetes, Migraines and cocaine use, initially presented with hypertensive emergency andsubacute headaches with worsening confusion. Initial CT head was negative for bleed but showed evolving subcortical hypodensities in the right parietal and left frontal lobes. CTA head and neck showed multifocal intracranial irregularities of bilateral ACAs and MCAs with paucity of left anterior M2 branch, left V3/V4 steno‐occlusion. This vasculopathy and clinical presentation is very consistent with RCVS.MRI of brain showed multiple acute / subacute punctate infarcts in the left corona radiata, bilateral basal ganglia, right greater than left thalami, right dorsal pons, right mesial temporal lobe, bilateral occipital regions. Vasogenic edema was noted in the bilateral border zone regions, right parietal being most prominent with some contrast enhancement. The MRI showed vasogenic edema and cytotoxic edema with multiple infarcts which is consistent with PRES and RCVS vasculopathy. CSF analysis was negative for pleocytosis and showed mildly elevated protein. The patient was started on Verapamil and Aspirin and Atorvastatin for secondary stroke prevention. With improvement in mental status was discharged to Rehab.

Conclusions

The pathophysiological mechanisms of PRES and RCVS are still unknown. Theories whether RCVS and PRES are independent syndromes and sometimes overlap or part of spectrum, are still debated. However, some common characteristics make conceivable a common origin linked with impaired cerebral autoregulation, endothelial dysfunction, and BBB breakdown. Increased clinical awareness of their co‐existence may help in quickerdiagnosis and treatment.
Abstract Number ‐ 216: Limb‐Shaking Transient Ischemic Attack in the Setting of Moyamoya Disease
Authors: Xie Sophie J , Xie Sophie J , Rodriguez Wilson , Miremadi Brian B
Published: April 2023

Introduction

Moyamoya disease (MMD) is a cerebrovascular disorder characterized by progressive narrowing of the large intracranial arteries, primarily the internal carotid artery (ICA) and its branches, with secondary development of prominent small‐vessel collaterals. Limb shaking is a rare manifestation of transient ischemic attack (TIA) that is characterized by brief, irregular, involuntary jerking of the arms or legs and momentary disorientation without complete loss of consciousness. It is mainly associated with high grade carotid stenosis. In rare cases, limb‐shaking TIA can occur in the setting of MMD.

Methods

The patient was identified in routine clinical practice.

Results

A woman in her 50s presented with a six‐year history of progressive weakness below the neck when standing and initiating movement. These episodes were followed by violent shaking of her arms and legs that lasted several seconds to minutes. She reported transient confusion after the events, but no seizure activity was seen on multiple EEGs, and anti‐epileptic drugs (AEDs) failed to alleviate her symptoms. Further neurological workup included a MR angiogram of the brain that was suggestive of MMD. Catheter angiography confirmed bilateral occlusion of the M1 segments of the middle cerebral arteries (MCAs) and the A1 segment of the left anterior cerebral artery (ACA). There was neovascularization in the same territories with significant collateral flow from the posterior circulation. She was diagnosed with bilateral limb‐shaking TIA in the setting of MMD. She recently underwent two revascularization procedures, a left superficial temporal artery (STA) to middle cerebral artery (MCA) bypass and a right sided encephaloduroarteriosynangiosis (EDAS).

Conclusions

Limb‐shaking TIA is predominantly associated with severe atherosclerotic extracranial carotid artery stenosis. In rare cases, the limb‐shaking episodes are caused by cerebral hypoperfusion secondary to severe stenosis of the ICAs, and their branches, in the setting of moyamoya disease. Treatment of limb‐shaking TIA to prevent further brain ischemia includes adjustment of fluid intake, careful blood pressure management to avoid episodes of relative brain hypoperfusion, and revascularization procedures. Revascularization is also the most effective method of treating MMD and patients will often experience improvement of their symptoms within one year. Early recognition of limb‐shaking TIA in MMD is critical to avoid unnecessary and potentially harmful treatments (e.g. AEDs), provide patients with accurate explanations of their symptoms, and ensure timely administration of the appropriate treatments.
Abstract Number ‐ 217: Case Study: Snowball strokes
Authors: Pirahanchi Yasaman , Wagner Jeffrey
Published: April 2023

Introduction

55 year old RH female, PMH of hypothyroidism and gastric bypass who presented with complaints of 1–2 weeks of “feeling foggy in the head”, dizziness, and unsteady gait. The patient’s husband said she had delayed responses. She denied headache, vision change, or hearing loss. Exam was without focal neurologic deficit, NIHSS of 0.Though CTA head and neck were unremarkable, MRI Brain showed multiple scattered small acute or subacute infarcts involving the corpus callosum. This distribution was thought to suggest a central embolic source. The patient was admitted for stroke workup which was unrevealing including: Normal echocardiogram including bubble study. Her symptoms progressed and she was unable to find outpatient follow up. Two weeks later, she presented again but this time with progressive generalized weakness. At the time of her initial discharge, the patient was ambulatory with her walker, however upon re‐admission the patient required a wheelchair. Exam showed flaccid bilateral lower extremities, brisk reflexes, bilateral Hoffman’s and Babinski signs.Repeat MRI Brain was concerning for Susac syndrome with new lesions in the corpus callosum. CSF showed pleocytosis with markedly elevated protein (WBC 8, protein 153, glucose 55). Treatment with Solu‐Medrol 1000 mg q12h IV, then IVIG 0.4 kg/mg/day both for 5 days, Rituximab 1000mg for 2 days, then transition to prednisone 80 mg /day and CellCept 1000mg BID. She returned 14 days after with confusion, regression of prior gait improvement, and repeat MRI Brain showed additional new multifocal strokes. She repeated 3 days of 1000mg IV Solu‐Medrol, then was treated with cyclophosphamide due to clinical progression. Fluorescein angiography showed evidence of branch retinal artery occlusions bilaterally. She was placed on a prednisone taper from 80mg/day to 40mg/day over the course of the 2 months, with the plan to continue Cellcept 1000mg BID for 2 years.

Methods

NA‐ Single case study

Results

NA‐Single case study

Conclusions

Susac syndrome is an autoimmune disorder, affecting microvasculature of the brain, retina and cochlea. A triad of symptoms: encephalopathy, branch retinal artery occlusions, and hearing loss is classic, though only 13% have the complete triad at onset. It is often associated with headaches, psychiatric features (paranoia), bilateral cochlear hearing loss, and vertigo. It typically occurs in women 20–40 years of age. Brain MRI WO shows white‐matter disturbance, frequently mistaken for Multiple Sclerosis, however the main difference is that the corpus callosum is always affected with lesions that resemble “snowballs”, or “holes”. Treatment for Susac syndrome is immunosuppression, with high‐dose corticosteroids, also with IVIG, Mycophenolate mofetil, and Cyclophosphamide.
Abstract Number ‐ 220: Internal Carotid Artery Hypoplasia of Unique Anatomical Variance
Authors: Mahmoud Noor A , Alshaqi Ola , Almeida Nyle C , Cornwell Benjamin , Alawwad Ahmad
Published: April 2023

Introduction

Hypoplasia of the internal carotid artery (ICA) is incomplete development of the ICA with the presence of empty carotid canal. Despite anecdotal data reporting less than a 0.01% of developmental anomalies of ICA, the true incidence remains unknown. Many cases are asymptomatic and thus escape diagnostic detection or appropriate intervention. In 1968, Lie and Hage described collateral circulation in ICA developmental anomalies through the Circle of Willis, persistent embryonic vessels, or skull base arteries/anastomosis or rete mirabile. While collateral systems exist, subsequent cerebrovascular insufficiency and vascular malformations may occur as a result. To our knowledge, there is an incomplete body of literature surrounding the implications of ICA hypoplasia of varying anatomy.

Methods

We present a case report of left ICA hypoplasia and a comprehensive literature review.

Results

A 70‐year‐old woman with hypertension, nicotine dependence, and chronic obstructive pulmonary disease (COPD) presented with COPD exacerbation and disorientation. Computed tomography (CT) head angiography showing left cervical/petrous ICA aplasia with presence of a small carotid canal. The left external carotid and vertebral artery originate at the aortic arch. Majority of the blood supply to the left anterior cerebral artery (ACA) and middle cerebral artery (MCA) is suppliedby the right anterior communicating artery (AComA), posterior communicating artery (PComA). There is also a small left supraclinoid and carotid terminus that reconstitute predominantly by right A1 segment and PComA (Figure 1).

Conclusions

Although ICA hypoplasia may be an incidental finding, accurate and promptrecognition is essential for the consideration of endovascular implications, screening for vascular malformations, understanding cerebral vascular flow, managing cerebrovascular risk, and avoiding misinterpretation of clinical and imaging patterns.
Abstract Number ‐ 226: Pontine Stroke Presenting as 1.5 Syndrome Evolving to 9 Syndrome over 72 Hours.
Authors: Nene Yash , Reddy Aravind , Kaur Navreet , Masoud Hesham
Published: April 2023

Introduction

A 75 year old woman with a past medical history of hypertension developed sudden‐onset vertigo, nausea and vomiting. She did not immediately seek medical care, thinking she was suffering from food poisoning. The following day her symptoms improved however she developed new right sided weakness and gait imbalance, prompting her presentation to the ED. Her neurologic exam noted complete loss of adduction of the right eye and loss of horizontal extraocular movements of the left eye. She also displayed right upper extremity paresis, right upper extremity dysmetria and mild dysarthria. MRI of the brain disclosed acute pontine infarcts in the ventral and dorsal left paramedian regions. Over the next three days, her horizontal gaze palsy improved with some return of adduction of the right eye and horizontal movements of the left eye. However right sided paresis worsened, and in addition, progressed to include complete left facial palsy (lower motor neuron lesion). She was able to be discharged to rehab, placed on Aspirin 81 mg daily and Ezetimibe (due to elevated liver function enzymes) and 30 day Cardiac Event Monitor follow up.

Methods

Case report and review of literature.

Results

Due to the combination of multiple cranial nuclei and white matter tracts in the brainstem, ischemia can lead to several clinical manifestations. There are various presenting clinical syndromes, named numerically by structures involved and/or the clinical deficit. One‐and‐a‐half (1.5) syndrome, first reported by Fischer in 1967, is an uncommon entity caused by a lesion (most commonly infarction) in the pontine tegmentum [1]. It consists of complete ipsilateral horizontal gaze palsy (due to involvement of ipsilateral Paramedian Pontine Reticular Formation/Abducens Nucleus and Medial Longitudinal Fasciculus) and loss of adduction of the contralateral eye (due to involvement of the contralateral Medial Longitudinal Fasciculus). Extension of the lesion to the facial nucleus can produce ipsilateral lower motor neuron type facial palsy, leading to an even more uncommon 8.5 syndrome (7 + 1.5), described by Eggenberger in 1998 [2]. When the lesion involves the corticospinal tracts and/or the medial lemniscus, it can lead to contralateral hemiparesis and/or hemisensory deficits; the so called “9 syndrome” first proposed by Rosini et al in 2013 [3]. This rare entity has been reported in only a handful of cases.

Conclusions

The awareness of complex brainstem neuroanatomy enables precise localization of the clinical deficits. The noted slow progression of the clinical syndrome from 1.5 to 8.5 and finally 9 syndrome over 72 hours in this case highlights the complexity of small vessel brainstem ischemia.
Abstract Number ‐ 229: Combined Open and Endovascular Treatment of a Ruptured Aneurysm with Excellent Clinical and Angiographic Outcome
Authors: Browne Declan , Simms Neil
Published: April 2023

Introduction

A 49‐year‐old lady presented to hospital with a WFNS 3 aneurysmal subarachnoid haemorrhage. Her symptomatology included sudden onset headache, vomiting, neck stiffness and mild left‐sided weakness. Her past medical history comprised discoid lupus, scleroderma and hypertension. Plain CT imaging demonstrated a significant blood load distributed primarily around the right Sylvian fissure. CT angiography confirmed two right‐sided middle cerebral artery (MCA) aneurysms. The proximal aneurysm appeared smooth and unruptured. The distal aneurysm appeared irregular and was therefore believed to be the ruptured lesion. The anatomy of this aneurysm precluded endovascular coiling as it was fully incorporated into the inferior MCA M2 branch.

Methods

Following interdisciplinary discussion, the patient proceeded to open surgical clipping of both aneurysms. A clip was placed across the rupture point of the distal aneurysm but a significant neck was left to permit filling of the distal branches. Post‐operative angiography accordingly showed a small residual component to the aneurysm. On follow‐up angiography one week later, this remnant appeared to have increased in size. The decision was therefore made to endovascularly place a contour device to reduce flow to the persistent portion of the aneurysm. This combined treatment approach resulted in excellent clinical and angiographic outcome.

Results

The patient was eventually discharged home with a modified Rankin scale score of 1 and had no residual neurological deficit at 1‐year outpatient follow‐up. Similarly, follow‐up catheter angiography at 1‐year demonstrated continued satisfactory appearances with the combination of clip and contour device.

Conclusions

This case highlights the successful clinical and radiological outcomes of a combined surgical and endovascular approach in aneurysmal subarachnoid haemorrhage ‐ despite an anatomically difficult vascular abnormality ‐ due to good interdisciplinary cooperation and careful patient follow‐up. It furthermore demonstrates the effective use of a relatively novel endovascular device following acute haemorrhage and open surgery which avoided the need for long‐term antiplatelet medication.
Abstract Number ‐ 232: Carotid Webs as an Under‐Reported Etiology of Acute Ischemic Stroke – Current Diagnostic Challenges
Authors: Dawod Giana , Bouslama Mehdi
Published: April 2023

Introduction

Carotid webs are anatomical variants in the internal carotid artery vasculature that predispose patients to stroke. As of now, optimal treatment has yet to be established given the lack of large, randomized trials. Part of this stems from the fact that carotid webs remain under‐recognized sources of ischemic stroke despite a high rate of reoccurrence. Herein, we aim to shed light on the diagnosis with our respective center’s experience as well as discuss diagnostic challenges associated with carotid webs.

Methods

We present a case of a 40‐year‐old male with no past medical history who presented to our center after having developed sudden onset left sided weakness and sensory loss, a left homonymous hemianopia, and dysarthria. Vessel imaging confirmed a right middle cerebral artery occlusion, specifically in the M2 segment, in the setting of a right carotid web.

Results

Once intracerebral hemorrhage was ruled out, tissue plasminogen activator was administered, with improvement in neurologic exam. Mechanical thrombectomy was thus deferred. Review of the MRI brain showed that in addition to an infarct in the right subinsular white matter region, there were scattered multifocal right hemispheric acute to early subacute infarcts raising concern for an underlying embolic etiology. While the right M2 occlusion looked like it had mainly resolved, a new focal non‐occlusive intraluminal thrombus was found in the right carotid bulb on CTA, MRA, and carotid ultrasound, just distal to a small transverse extraluminal carotid web (Figure 1). The decision was made to take the patient for right carotid stenting given that the carotid web served as a high‐risk lesion. A stent was placed in the right carotid artery with no complications, and the patient was continued on dual antiplatelet therapy. Upon being seen in outpatient clinic after discharge, patient had NIHSS score of 0, with no residual deficits, and was continued on DAPT and a statin for secondary stroke prevention.

Conclusions

Knowing that patients with carotid webs are at increased risk for stroke, recognition and accurate diagnosis of webs is crucial for appropriate treatment. Diagnostic challenges of carotid webs should be highlighted to prevent misdiagnosis. These include heightened awareness of the patient population that is most at risk, radiographic mimics, location of the lesion as a confounder, and rule out of other stroke etiologies. Prompt recognition of this high‐risk vascular lesion using multiple imaging modalities at different time points during the patient’s admission allowed for treatment of the underlying etiology of his stroke. By increasing awareness on the appropriate diagnostic approach for carotid webs, more information can be garnered to elucidate optimal treatment strategies.
Abstract Number ‐ 241: Simultaneous IV tPA During Thrombectomy Reduces Post‐Procedure Hypoperfusion Volumes in Anterior LVO Patients
Authors: Ribo Marc , Garcia‐Tornel Alvaro , Olivé‐Gadea Marta , Requena Manuel , Rizzo Federica , Rodrigo Marc , Pagola Jorge , Juega Jesus , Muchada Marian , Rodriguez‐Luna David , Rodriguez‐Villatoro Noelia , Molina Carlos , Rubiera Marta
Published: April 2023

Introduction

Simultaneous tPA administration during mechanical thrombectomy may induce synergistic benefits (1). We aimed to characterize the hypoperfusion status after thrombectomy according to the timing of tPA administration and the degree of final recanalization.

Methods

We studied consecutive anterior circulation large vessel occlusion (LVO) stroke patients treated with mechanical thrombectomy who received a CT perfusion (CTP) immediately after endovascular procedure (2). Patients were divided in three groups according to: no iv tPA treatment (non‐tPA), tPA administration before 120 minutes (tPA>120) or iv tPA administration within 120 min (tPA< 120) of groin puncture. The extend of post‐procedure hypoperfusion (volume Tmax>6s) and relative hypoperfusion reduction compared with admission CTP (volume post‐procedure – admission Tmax>6s/admission Tmax>6s) according to final TICI scores were compared between the three study groups.

Results

One hundred and sixty‐nine patients were included in the study, mean age 72 years and median baseline NIHSS of 15. Thirty (17.8%) patients received iv tPA more than 2h before groin puncture (tPA>120), 32(18.9%) within 2h of the puncture (tPA < 120) and 107(63.3%) were non‐tPA. No difference on stroke severity, pre‐procedure hypoperfusion volume or occlusion location before thrombectomy were detected between groups. The rate of complete recanalization (TICI 3, 38.5%) was also similar in the 3 study groups (p = 0.12). Overall, the post‐procedure hypoperfusion volume was significantly lower in the tPA< 120 group (19.9±4.6cc vs 35.0±5.5, p = 0.04), and the relative hypoperfusion reduction was higher in tPA< 120 (0.86 vs 0.66, p = 0.05) as compared to non‐tPA. No significant differences were detected between non‐tPA and tPA>120 groups. For each final TICI score the post‐procedure hypoperfusion tended to be lower in the tPA< 120‐group, with a stronger reduction in patients with lower degree of recanalization (Figure).

Conclusions

A reduction of post‐thrombectomy hypoperfusion volumes was detected in patients treated with iv tPA during or shortly before thrombectomy, which could be a surrogate marker of the beneficial effect of tPA on the microcirculation. The specific reperfusion synergistic effect of tPA and mechanical thrombectomy beyond LVO recanalization warrants future studies.