bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract Number ‐ 245: Machine Learning‐Enabled Detection of Unruptured Cerebral Aneurysms Improves Detection Rates and Clinical Care
Authors: Ali Iman J , Salazar‐Marioni Sergio A , Abdelkhaleq Rania , Niktabe Arash , Giancardo Luca , Love Christopher J , Paz Dan , Bibas Orin , Segev Omri , Sheth Sunil A
Published: April 2023

Introduction

Unruptured cerebral aneurysms (UCAs) have a relatively low prevalence of approximately 3%, but detection can prevent devastating consequences of subarachnoid hemorrhage. Here, we assess the performance of a machine‐learning (ML) algorithm to identify UCAs and determine whether routine use of the algorithm would have improved detection rates and patient care.

Methods

From a prospectively maintained multi‐center registry across 8 certified stroke centers (1 comprehensive, 7 primary), we identified patients who underwent CT angiogram for evaluation of stroke from 3/14/21 – 11/31/21. An FDA‐cleared convolutional deep neural network (Viz ANEURYSM, Viz.ai, Inc.) trained to identify UCAs at least 4mm analyzed the images. Ground truth was provided by independent expert neuroradiology read. The primary outcome was rate of UCAs detected by the ML algorithm but not detected or addressed in the clinical radiology report or clinical notes, which was determined by two independent researchers.

Results

Among 1191 CT angiogram scans performed during the study period, 49 were flagged by the ML algorithm as possibly demonstrating an UCA, of which 26 cases were confirmed as true positive (PPV 53%).The most common locations included posterior communicating artery (22%), followed by MCA bifurcation (19%). Of these cases, 9 (35%) were not noted in the clinical radiology report or clinical notes, with a median size of 4.2 mm [IQR 3–7.5 mm], and 22 (85%) were not referred for follow up, with median size of 5 mm [IQR 3.7‐11.3 mm]. Of the 22 cases not referred for follow up, 13 (59%) had been noted in the radiology report. 46% (6/13) of the detected but not referred cases had a diameter greater than 10mm.

Conclusions

UCAs of sizes and intra‐dural locations that may warrant treatment are frequently missed or not followed up in routine clinical care. An ML algorithm that flags studies and notifies clinicians may minimize missed treatment opportunities.
Abstract Number ‐ 248: Association Between Vertebrobasilar Stenosis, Location, and Quantitative Magnetic Resonance Angiography Flow State
Authors: Ballout Ahmad A , Ballout Ahmad A , Schneider Julia R , Black Karen , Sideras Panagiotis , Huang Brendan , Katz Jeffrey M , Libman Richard B
Published: April 2023

Introduction

The relationship between the degree of vertebrobasilar stenosis and QMRA distal‐flow status is uncertain. Our aim was to investigate this relationship.

Methods

We retrospectively reviewed patients who presented with acute ischemic stroke, had neurovascular imaging demonstrating ≥ 50% stenosis of extracranial or intracranial vertebral or basilar arteries, and QMRA within one year of stroke, between 2009 and 2021 at two institutions. The WASID and CAVATAS methods were used to measure the degree of intracranial and extracranial vertebrobasilar stenosis, respectively. Patients were grouped as: high‐grade (≥ 70% stenosis) in (1) one vertebral artery; (2) two vertebral arteries; or (3) basilar artery; and (4) moderate grade (≤70% stenosis) in either intracranial vertebral and basilar arteries or exclusive extracranial vertebral stenosis or occlusion. QMRA distal‐flow status was used to dichotomize patients into low‐flow and normal‐flow states based on VERiTAS criteria. P‐values were calculated using chi‐squared analysis and Fisher exact test with statistical significance defined as p < 0.05.

Results

Of the 303 patients undergoing QMRA for vertebrobasilar disease, 69 met study inclusion, consisting of 31 patients with low‐flow and 38 patients with normal‐flow states. High‐grade stenosis was most commonly found in one vertebral artery (34.8%), followed by both vertebral arteries (29.0%), and the basilar artery (27.5%), and moderate stenosis or exclusive extracranial disease made up 21.7% of patients. High‐grade stenosis in at least one vertebral or basilar artery was significantly associated with low‐flow states compared to patients with moderate‐grade stenosis or exclusive extracranial disease (53.7% versus 13.3%, p = 0.007). High‐grade stenosis in both vertebral arteries was significantly more likely to result in a low‐flow state compared to high‐grade stenosis in one vertebral artery (75.0% versus 41.7%, p = 0.001) or to high‐grade stenosis in the basilar artery (75.0% versus 42.1%, p = 0.040).

Conclusions

Low distal flow status on QMRA is strongly associated with high‐grade intracranial stenosis compared to moderate‐grade or exclusive extracranial stenosis and is nearly twice as frequent with high‐grade intracranial stenosis of both vertebral arteries compared to one. The location, degree of stenosis, and distal‐flow status should be considered as possible entry points for future prospective treatment trials in intracranial atherosclerotic disease.
Abstract Number ‐ 249: Differential Ischemic Vulnerability depicted by White Matter‐Sparing Infarction following Alteplase Recanalization
Authors: Ballout Ahmad A , Patel Krishna , Saad Ayesha , Parikh Krutee , Libman Richard B
Published: April 2023

Introduction

Gray and white matter possess different ischemic thresholds and therefore will undergo infarction at different rates of cerebral blood flow. We present a patient that presented with a large vessel occlusion and recanalized following alteplase administration within hours of symptom onset. Follow‐up imaging revealed a white matter‐sparing infarction, visually depicting the differential ischemic vulnerability between gray and white matter.

Methods

Case Report.

Results

An 83‐year‐old woman with a medical history of dementia, hypertension, and atrial fibrillation, not on anticoagulation due to recent gastrointestinal hemorrhage, presented with speech difficulty and right sided weakness. Her blood pressure was elevated at 170/86 and neurological exam demonstrated mixed aphasia, right homonymous hemianopia, left gaze deviation, and dense right hemiparesis with a National Institutes of Health Stroke Scale of 23. Non‐contrast CT of the head showed a hyperdense left terminal internal cerebral artery (ICA) and was otherwise unremarkable (Figure 1, A). CT angiography of the head and neck revealed an ICA “T” occlusion with no flow seen at the ICA terminus, the left anterior cerebral (A1) and middle cerebral (M1) segments (Figure 1, B). She was treated with intravenous alteplase 132 minutes from when she was last known normal. She was transferred to our comprehensive stroke center for mechanical thrombectomy, however, catheter angiography showed spontaneous recanalization of left ICA (Figure 1, C). Brain MRI the following day showed a white matter‐sparing infarction involving the left ICA territory (Figure 1, D‐F). She was discharged to rehab with moderate improvement in her aphasia and right hemiparesis.

Conclusions

This case visually depicts the differential ischemic vulnerability between gray and white matter since recanalization likely occurred at a cerebral blood flow level below the gray matter ischemic threshold while remaining above the white matter threshold. While pretreatment ischemic core volumes are inversely correlated with functional outcomes after recanalization of large vessel occlusions,1 selective white matter‐sparing infarction on post‐treatment MRI is associated with more favorable outcomes.2 Predicting ischemic core volume with perfusion imaging using the same CBF threshold for both gray and white matter may over‐estimate the ischemic core if CBF is between the gray and white matter thresholds.
Abstract Number ‐ 258: Effect of COVID‐19 Vaccination on COVID‐19 associated Stroke: A Propensity‐Matched Case‐Control Study
Authors: El‐Seblani Nader , Nagaraja Nandakumar
Published: April 2023

Introduction

Coronavirus disease 2019 (COVID‐19) vaccines have demonstrated efficacy in protecting against severe respiratory distress, averting hospitalization and long‐term sequelae of COVID‐19 infection. The study aimed to determine the effect of COVID‐19 vaccination on mortality and complications due to COVID‐19 associated acute ischemic stroke (AIS).

Methods

Using TriNetX COVID‐19 research database, patients who had received full vaccination from December 1, 2020, to April 30, 2021, and later had AIS within 30 days of COVID‐19 infection during the period from June 1, 2021, to November 30, 2021, were identified. A control group with unvaccinated COVID‐19 patients with AIS was identified in the same study period. The two groups were matched for demographics and comorbidities with 1:1 propensity score matching. All‐cause mortality was the primary outcome while intracranial hemorrhage (ICH) and venous thromboembolism (VTE) were secondary outcomes at 30 days.

Results

During the study period, 21814 patients were admitted with AIS within 30 days of COVID‐19 diagnosis: 21233 patients were unvaccinated while 581 patients were vaccinated before their AIS. After propensity score matching, 581 patients in both groups were balanced for relevant characteristics. Patients fully vaccinated prior to acquiring COVID‐19‐associated AIS had lower rates of all‐cause mortality [6.9% (40/581) vs 10.7% (62/581), P = 0.02, hazard ratio = 0.62; 95% confidence interval = 0.41, 0.92)], ICH (3.1% vs 6.9%; OR 0.44, p = 0.005) and VTE (2.9% vs 7.9%; p = 0.0007) when compared with unvaccinated patients.

Conclusions

Within the limitations of retrospective observational study, prior vaccination for COVID‐19 is associated with improved one‐month survival and reduced complications after COVID‐19 associated AIS.
Abstract Number ‐ 260: Endovascular Thrombectomy for Acute Ischemic Stroke with Acute Cancer: Updated Meta‐analysis
Authors: Jhou Hong‐Jie , Yang Li‐Yu , Chen Po‐Huang , Lee Cho‐Hao
Published: April 2023

Introduction

Acute cancer is associated with poorer prognosis and death in patients with acute ischemic stroke (AIS).1 Endovascular treatment has shown to be effective and safety treatment (EVT) for AIS with large vessel occlusion2; however, the effect of acute cancer on outcomes secondary to EVT in patients with AIS remains unclear.

Methods

We searched PubMed, Embase, as well as Cochrane for all relevant literature until June 1, 2022. Random‐effects model was used to estimate outcomes including good functional outcome, successful reperfusion, mortality at 3‐month, and symptomatic intracerebral hemorrhage. The heterogeneity of outcomes was assessed using the Cochran Q test and I2 statistics.

Results

Of the 12 studies, a total of 5,944 patients with AIS were enrolled. 389 (6.5%) patients had acute cancer. A quarter of patients regained functional independence after EVT. Compared with patients without acute cancer, those with acute cancer following EVT had similar rate of successful reperfusion (76.9% versus 72.6%; OR, 0.90; 95% CI, 0.63–1.30; I2 = 27%; p = 0.18; Figure 1A) and did not increase the risk of symptomatic intracerebral hemorrhage (6.0% versus 7.7%; OR, 0.85; 95% CI, 0.51–1.42; I2 = 0%; p = 0.45; Figure 1B). However, patients with acute cancer had more functional dependence (28.2% versus 42.3%; OR, 0.53; 95% CI, 0.41–0.67; I2 = 1%; p = 0.43; Figure 1C) and death at 3‐month (39.3% versus 18.6%; OR, 3.64; 95% CI, 2.35–6.27; I2 = 64%; p < 0.01; Figure 1D) than those without acute cancer.

Conclusions

The results of study showed that patients with acute cancer and AIS had a higher risk of functional dependence and mortality than those without acute cancer despite successful reperfusion and no increment in the occurrence of symptomatic intracerebral hemorrhage. Only 28.2% of patients with acute cancer regained functional independence, so physicians and patients should consider whether to use EVT for patients with acute cancer. There remained the need for further randomized control studies for better clinical evidence.
Abstract Number ‐ 264: Examining The Impact Of Area Deprivation On Patient Outcomes In LVO AIS
Authors: Abdelkhaleq Rania , Dongarwar Deepa , Salazar‐Marioni Sergio , Niktabe Arash , Tariq Muhammad B , Sheth Sunil A
Published: April 2023

Introduction

The Area Deprivation Index (ADI) is a validated neighborhood‐level measure that utilizes variables such as income, education, and employment to quantify relative socioeconomic disadvantages. Here we explore the impact of disparities on EVT access.

Methods

From our prospectively maintained multi‐hospital registry, we identified patients with LVO AIS from January 2019‐ June 2020. Patient addresses and zip‐codes were validated using US Postal Service codes and matched to census‐tract level ADI scores that were obtained from Neighborhood Atlas. ADI were categorized into high and low using the median ADI as the cuto!. The primary outcome was utilization of EVT and IV tPA and was determined using multivariable logistic regression and expressed as OR [95% CI]. All p‐values are two‐sided with p < 0.05 defined as statistically significant. All analyses were conducted using RStudio (Version 1.2.5001).

Results

Among 637 patients with LVO AIS, median age was 68, 46% were female, 53% were white, 27% were black, and 78% identified as Hispanic. Median state ADI was 5 IQR [5]. NIHSS was similar between low/high ADI (mean(SD): 13.3(7.75) vs 13.6(8.62), p‐value 0.69) regions. ADI was significantly associated with race (6.41 vs 4, black vs. white, p‐value 0.03). In the univariable analysis, patients treated with EVT had lower mean ADIs (5.2 vs. 4.6, no EVT vs. EVT, p< 0.02). In multivariable analysis adjusted for age, sex, race, ethnicity and NIHSS, higher ADI was significantly associated with greater rates of IV tPA usage (OR 1.7 [1.01‐ 2.98]) but not EVT usage (OR 0.63 [0.04‐1.0])

Conclusions

Patients residing in disadvantaged neighborhoods may have reduced rates of reperfusion therapy, despite comparable acute stroke presentation symptoms. These findings are consistent with prior studies demonstrating poorer health outcomes in these populations.
Abstract Number ‐ 266: Focal Cerebral CNS Vasculitis due to SARS‐CoV‐2 Infection
Authors: Reyes Cleo Zarina A , Villar Manny , Cheponis Kathryn E , Yacoub Hussam A
Published: April 2023

Introduction

Several neurological manifestations of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection, including anosmia, encephalopathy, and stroke, have been reported. We report a case of a 42‐year‐old man presenting with ischemic stroke due to cerebral vasculitis in the setting of SARS‐CoV‐2 infection.

Methods

Case report

Results

A 42‐year‐old man, recently diagnosed with SARS‐CoV‐2 infection, presented with nonfluent aphasia and right‐sided hemiparesis that started five hours prior. Neurological examination revealed nonfluent aphasia, right‐sided facial palsy, and hemiparesis. Computed tomography (CT) of the head showed left‐sided caudate infarct and early ischemic changes in the left putamen. CT angiography (CTA) revealed occlusion of the proximal left M1 segment. Patient’s symptoms rapidly improved and mechanical thrombectomy was not pursued. Patient was started on dual antiplatelet therapy with aspirin and clopidogrel. Magnetic resonance imaging (MRI) of the brain showed acute infarcts in the left posterior parietal, lentiform nucleus, and frontal cortex. CT of the chest revealed bilateral subsegmental pulmonary emboli. Patient was discharged on apixaban and atorvastatin daily, with mild residual aphasia. A month later, the patient returned with dysarthria and right‐sided paresthesia that began three hours prior. CTA showed severe left proximal M1 stenosis involving a longer segment. He was started on vasopressor. Symptoms resolved within 24 hours with residual mild aphasia. MRI brain revealed multiple foci of cortical infarcts within the left MCA territory with no diffusion/ perfusion mismatch. MRA head showed further pruning of the distal MCA branches within the left sylvian fissure with severe stenosis along the mid‐M1 and minimal flow anteriorly, with contrast enhancement at the site of the stenosis, suggestive of vasculitis. Autoimmune vasculitis panel was unremarkable. Due to suspicion of focal inflammatory vasculopathy related to recent SARS‐CoV‐2 infection, patient was started on intravenous methylprednisolone 1 gram daily for 5 days followed by a prednisone taper. MRA revealed improved blood flow in the left middle cerebral artery and branches. The was discharged on apixaban, aspirin, atorvastatin, and a prednisone taper with mild residual aphasia.

Conclusions

To our knowledge, this is the first reported case of CNS vasculitis associated with an underlying SARS‐CoV‐2 infection with radiographic improvement of blood flow in the affected vessel within 4 days of treatment with high‐dose steroids. This case supports the use of high‐dose steroids in patients with CNS vasculitis associated with SARS‐CoV‐2 to prevent further stroke burden.
Abstract Number ‐ 268: Sarcoid Induced Posterior Circulation Abnormality With Recurrent Ischemic Strokes
Authors: Karim Nurose , Nour Hassan Aboul
Published: April 2023

Introduction

The estimated incidence of Neurosarcoidosis is ∼5‐15%. Most of these cases involve anterior circulation. Here we are presenting a case of recurrent posterior circulation ischemic stroke in a patient with neurosarcoidosis.

Methods

A 41‐year‐old Male had biopsy proven sarcoidosis diagnosed in 2012 with pulmonary involvement. He was on chronic low dose Corticosteroid. In 2014, he presented with right pontine ischemic infarction causing left‐sided hemiplegia. He underwent extensive workup including conventional angiogram that showed irregular intracranial left vertebral artery with mild narrowing distal to posterior inferior cerebellar artery (PICA) and mild dilatation proximal to basilar artery (Image on the top). He was started on Aspirin 81 mg. In 2021, he had a right inferior cerebellar peduncle infarction with repeat angiogram showing abnormal dysplastic dilatation of the left vertebral artery at V4 segment and the top of basilar artery that has progressed since 2014 (image on the bottom). Workup showed that he was Aspirin non‐responder and has been switched to Clopidogrel.

Results

The most common presentation of neurosarcoidosis is cranial neuropathy, mostly facial nerve. Ischemic stroke is one of the uncommon presentation of neurosarcoidosis. The likely mechanism could begranulomatous invasion of the blood vessel wall with vasculitic disruption of the media and internal elastic lamina.

Conclusions

To our knowledge, this is a rare case of neurosarcoidosis progressively affecting posterior circulation causing recurrent stroke.
Abstract Number ‐ 270: Assessing Biceps Brachii Functional Recovery after Stroke: Comprehensive Analysis of Two Decades of Patient Data
Authors: Brown Nolan , Aguirre Alexander , Hsu Timothy , Harris Mark , Yang Chenyi , Kortz Michael , Shahrestani Shane , Singh Rohin , Sahyouni Ronald
Published: April 2023

Introduction

Severe loss of muscle strength is common following stroke, and rehabilitation in the form of targeted physical therapy is often needed to recover partial muscular function. Although lower limb weakness is typical in stroke patients, upper body complications presenting as decreased grip strength and hand motor coordination can also occur. The biceps brachii, one of the most frequently used upper body muscles, often shows weakness post‐stroke. Although recent literature has touched on various techniques to help regain biceps brachii function, studies looking at quantifiable recovery of muscular strength are limited.In this review, we summarize strength recordings of the biceps brachii from stroke patients collected over the past 20 years to better characterize upper extremity functional recovery after stroke.

Methods

Using PRISMA guidelines, we queried 3 databases to identify all studies reporting findings of stroke recovery including isolated strength measurement of the bicep brachii muscle in newtons (N).

Results

15 studies describing 384 patients (mean age range: 55.7‐73.6 years) were included for formal analysis. Baseline biceps strength range following stroke was 12.1‐91.23 N. At 4 weeks, strength ranged from 16.3‐85.8N, and this range improved to 85.31‐97.38N and 29–125.04N at 5 and 8 weeks, respectively. Additionally,Folkerts et al. found a significant improvement in biceps function from the 5 week value (97.38N) to the 10 week final follow‐up (108.46N). Over 12 weeks post‐stroke, Donaldson and colleagues observed a significant improvement in bicep strength range (27.1‐61.0N vs. 59.5‐76.1N).

Conclusions

Our study is the first systematic review assessing the recovery of biceps function with time following stroke in the current literature. Singular timepoint studies showed a significant loss of bicep function post‐stroke. Multiple timepoint studies showed semi‐linear relationships between biceps strength recovery and time within studies but no patterns when comparing between studies. Further research is required to quantify biceps strength recovery in a sex‐specific manner.
Abstract Number ‐ 272: Effect of the Time between Thrombolysis and Mechanical Thrombectomy on Outcomes of Stroke
Authors: Miremadi Brian B , Chen Willian , Gasimova Ulviyya , Khasiyev Farid , Rodriguez Wilson , Hakoun Abdullah , Scott Jordan , Gordon Weston , Christopher Kara , Linares Guillermo , Edgell Randall , Miremadi Brian B
Published: April 2023

Introduction

Administration of intravenous thrombolytics (IVT) within 4.5 hoursof symptoms onset, prior to performing mechanical thrombectomy(MT) in patients with acute ischemic stroke (AIS) secondary tolarge vessel occlusion (LVO) is thoroughly studied and hassuggested to improve reperfusion rates and clinical outcomes. [1,2] The outcomes of combined IVT and MT in STEMI patientshavebeen studied comprehensively and revealed worsening clinicaloutcomes when a shorter Lapse of Time (LoT) isintroduced.[3,4]Those studies stemmed the question of whetherLoTbetween IVT and MT in AIS patients has any significance. We investigated the effects of theLoTbetween IVT and MT onoutcomes of MT revascularization, as well as on the functionaloutcomes in patient with AIS with LVO.

Methods

We performed a retrospective analysis ofgathereddataduring a 6‐year period (2016‐2021) for all ourpatients with AIS and LVO who received both IVT and MT. We analyzed the MT revascularization outcomes using thethrombolysis in cerebral infarction(TICI)scale, as well as thestroke functional outcomes using the modified Rankin Scale(mRS)at discharge and 90 days to detectany significant differencesin positive or negative direction.LoT was measured as minutes from tPA administration and reperfusion on a continuous scale. Nonparametric tests (Kruskal‐Wallis analysis of variance on ranks, K‐W H) were used to determine if there were differences between mRS at discharge and at 90 days (as an ordinal variable, possible score 0–6) based on LoT.

Results

A total of 48 patients who received both IVT and MT were includedin the study.Those included were primarilyBlack (57.1%) and male(59.2%). Mean age was62.5 years (sd = 15.5, range 21–89 years).Median minutes between tPA and reperfusion was 74 minutes (min‐max = 44‐143 minutes). There were no significant differences betweenmRSatdischarge (K‐W H = 5.13, p = 0.40), nor at 90 days (K‐W H = 8.71, p = 0.19) as a function of theLoTbetween IVT and MT. There were no significant differences between TICI scores, as afunction of theLoTbetween IVT and MT, (K‐W H = 5.49,p = 0.14).

Conclusions

In this study we compared the impact of the time differencebetween IVT and MT on revascularization and functionaloutcome in patients with AIS and LVO.Unlike the findings in STEMI, we did not detect any significant outcomedifferences in MT results (TICI scale) and functional outcomes(mRSat discharge and 90 days), when IVT was given at differentLoTbeforeMT.
Abstract Number ‐ 280: A Unique Case of Pial AVF Presenting as Hemispheric Cerebral Edema
Authors: Welsh Connor , Youn Jina , Venkatesh Anita
Published: April 2023

Introduction

To describe a unique case of pial arteriovenous fistula presenting as left hemispheric cerebral edema with hemianopsia, sensory change and ataxia.

Methods

Case report

Results

Our patient is a 38 year old male with a history of diabetes, hyperlipidemia and congenital deafness with a left cochlear implant who presented to an outside hospital for visual complaints. Non‐contrast CT of the head was negative at that time; he could not obtain an MRI due to his cochlear implant. He developed worsening right hemianopia and aphasia, prompting his transfer to our facility. Upon arrival, repeat imaging was done, including a CTA of the head and neck. This revealed a large region of hypodensity involving the left PCA and distal MCA territories. An MRI was attempted but artifact from his implant obscured visualization of the left hemisphere. Post‐contrast CT was negative for evidence of tumor. CT venogram was negative for veno‐occlusive disease. He complained of worsening headache and demonstrated worsening word‐finding ability. He received100g total of mannitol divided across 3 boluses which improved his symptoms mildly. Over the following days he began to become ataxic and clumsy in the right upper extremity and his headache worsened further and he began to develop focal seizures electrographically localized to the left parietal lobe. Repeat CTA demonstrated expanding hypodensity with marked vascular engorgement in the left hemisphere. He underwent 6‐vessel digital subtraction angiography (DSA) of the head which revealed gross left hemispheric venous congestion with early filling of the left hemispheric venous system by a parasagittal pial ateriovenous fistula believed to be responsible for his hemispheric edema. He was discharged on acetazolamide and acetaminophen for headache management and plans for outpatient follow‐up and potential intervention. Follow‐up DSA revealed improvement in his venous congestion and reduction in the degree of his early venous filling with some symptomatic improvement by medical management.

Conclusions

Pial arteriovenous fistulae (pAVF) are a rare entity and can present in a variety of ways, with symptomatic intracranial hemorrhage and ischemia being two of the most common. This case illustrates an unusual instance of hemispheric edema initially mistaken for venous infarct caused by a pAVF, and prompts the physician to consider angiography and further exploration when initial workup for cerebral edema and/or venous infarct is initially unrevealing.
Abstract Number ‐ 282: Surgical Treatment for Moyamoya Disease with Coexisting Autoimmune Conditions: A Systematic Review
Authors: Brown Nolan , Singh Rohin , Bauman Megan , Harrison Daniel , Seas Andreas , Shahrestani Shane , Quinones‐Hinojosa Alfredo , Gottfried Oren , Grant Gerald
Published: April 2023

Introduction

There have been several studies of Moyamoya disease (MMD) with concurrent autoimmune (AI) disease. It has been proposed that there may be a causal or synergistic effect of autoimmune and inflammatory conditions in patients with MMD. As such, in the present study we seek to characterizethe surgical outcomes of adults and children with MMD and coexisting AI conditions.

Methods

A systematic review was performed of published studies reporting patient level data of Moyamoya disease and concomitant autoimmune disease. Relevant studies were identified using Preferred reporting Items for Systematic Reviews and Meta‐Analysis criteria.

Results

A total of 149 studies were included, encompassing 257 patients. Of the 257 patients with concurrent AI and MMD, 107 (88 females, 19 males) underwent surgery. The average age was 31.3 years (Range 5–65; SD 12.5). Five cases presented with hemorrhagic symptoms, 87 ischemic, and 15 were unspecified. The most commonly associated AI conditions were Graves’ disease (71 cases, 66.4%), Lupus (17 cases, 15.9%), and T1DM (6 cases, 5.6%).Follow‐up was reported in 25 cases and was an average of 17.8 months. Surgical outcomes were reported in 82 cases; 63 (76.8%) improved, 7 (8.5%) were stable, 9 (10.9%) developed a new deficit, and 3 (3.7%) died at most recent follow up. Eight patients (7.5%) had disease progression. 63 (58.8%) patients were treated with additional autoimmune therapy although this therapy did not lead to any difference in outcomes. Twenty patients (18.7%) required additional supportive medical therapy (eg: aspirin, statins).

Conclusions

Moyamoya disease may be multifactorial. Patients with concomitant AI and Moyamoya disease may be at increased risk and warrant additional surveillance or intervention. The ideal therapy for these patients remains to be understood. These findings warrant further study into optimal diagnostic and therapeutic techniques for concomitant MMD and AI conditions.
Abstract Number: LBA11 CADASIL revealed by COVID‐19: A case report and systematic review
Authors: Najdawi Zaid R , Kurra Nithin , Elfil Mohamed , Aladawi Mohammad , Fayad Pierre
Published: April 2023

Introduction

Cerebral Autosomal Dominant Arteriopathy with subcortical Infarcts and leuko‐encephalopathy (CADASIL) is a genetic condition characterized by migraine, ischemic strokes, mood disturbances, and cognitive impairment. Since COVID‐19 pandemic started in late 2019, six patients (including our case) were reported to present with neurological symptoms associated with CADASIL mutation and four of them were diagnosed while hospitalized for COVID‐19 illness.

Methods

A case report anda systematic literature review done via PubMed search that was performed up to Oct 15, 2022. Studies reporting on CADASIL and COVID‐19 infection were included.

Results

In addition to our case report, 5 case‐reports were identified, and full articles were reviewed and summarized. Including our case, the mean age of patients was 45.44 years, and all of them were females. The diagnosis of CADASIL was established after COVID‐19 infection in four of the cases including ours, while the diagnosis of CADASIL was established in the other two patients after neurological symptoms and prior strokes warranting investigations and stroke workup. CADASIL diagnosis was confirmed with genetic testing in all of them. Two cases had history of migraines with aura, three cases had hypertension, and two patients had unremarkable past medical history. Four cases reported dysarthria as one of the initial symptoms at presentation. The initial MRI brain reported involvement of corona radiata in two cases, centrum semiovale in two cases, cerebellum in one case. All cases reported bilateral changes on imaging. Aspirin, clopidogrel, statins, intravenous immunoglobulins, and steroids were the medical treatment modalities used amongst those patients. Four cases had mild‐complete recovery of symptoms, one case was reported to have partial resolution of deficits, and one patient had complete resolution of motor deficit and persistent mild neurocognitive dysfunction.

Conclusions

COVID‐19 infection might be a triggering factor forCADASIL flare. Although it is unclear whether CADASIL mutations would be the only etiology behind the neurological deficits in these patients, as COVID‐19 infection has been reported to be associated with many neurological manifestations, the reported imaging findings along with the genetic confirmation weighs more towards COVID‐19 infection acting as a trigger for CADASIL flare.
Abstract Number: LBA12 Cortical Venous Thrombosis As Cause Of Atypical Cortical Intracerebral Hemorrhage
Authors: Amireh Abdallah , Scarpiello Sean , Fourcand Farah , Haimi Joshua , Bozkurt Sokutay , Sindhu Sindhu , Tabibzadeh Navid , Gadallah Nancy , Mehta Siddhart , Kirmani Jawad F
Published: April 2023

Introduction

Cortical venous thrombosis is a rare and underrepresented etiology for atypical cortical intracerebral hemorrhages (ICH). Cortical venous thrombosis poses a diagnostic challenge compared to dural venous sinus thrombosis. Venogram studies may show a dural sinus filling defect in cases but may not demonstrate thrombosed cortical veins, especially given their variable anatomy. Our aim was to identify cases of atypical cortical ICH in the absence of other secondary ICH risk factors that may have been associated with cortical venous thrombosis.

Methods

Retrospective chart review of cases of nonaneurysmal ICH over a 3‐year period at our comprehensive stroke center were reviewed. Imaging study and clinical data were reviewed to include only atypical cortical hemorrhages. All subjects were required to have computed tomography (CT) with thin 0.625 mm slices, CT angiogram (CTA) that included venous phases, diagnostic cerebral angiograms without identifiable vascular etiologies, and MR imaging. Atypical ICH was defined as cortical hemorrhage in the absence of vascular malformation, hematological disorders, suspected amyloid angiopathy, hypertension, trauma, dural venous sinus thrombosis, and other secondary etiologies. Social science statistics software was used for data analysis.

Results

From April 2019 to July 2022, out of 344 total ICH cases, 10 cases were deemed idiopathic despite rigorous investigation, including evaluation for venous sinus thrombosis. Six subjects were male. Mean age was 46.5 (95% CI 35.99, 57.02), and median NIHSS was 7 (95% CI 1.86, 12.54). Two of the ten patients were identified to have ICH‐adjacent hyperdense cortical vein on CT indicating thrombosis. On MRI brain, both patients had susceptibility weighted imaging (SWI) blooming within an adjacent cortical vein as well as hyperintense filling defect of veins on T2 sequence.

Conclusions

In our study population of atypical intracerebral hemorrhages, cortical venous thrombosis was identified in 20% of subjects. Cortical venous thrombosis may not represent a rare etiology in this unique patient population. Multimodal neuroimaging may be required to identify this underdiagnosed pathology.
Abstract Number: LBA14 Incidence of Intracranial Hemorrhage & Clinical Outcomes in Fast Versus Slow Progressors as per ASPECTS
Authors: Fourcand Farah , Sahito Sindhu , Fourcand Farah , Ghori Arifa , Abbasi Hamidreza , Singh Zamir , Joshi Rudra , Amireh Abdallah , Gadallah Nancy , Tabibzadeh Navid , Mehta Siddhart , Kirmani Jawad
Published: April 2023

Introduction

Heterogeneity of collateralization in patients with acute ischemic stroke (AIS) is a marker of fast versus slow progression of penumbral consumption and infarct expansion. Our aim was to evaluate the relationship between time‐dependent stroke progression and incidence of intracranial hemorrhage (ICH) and acute neurological deficits.

Methods

Retrospective chart review of patients presenting with anterior circulation large vessel occlusion (LVO)‐associated AIS at our comprehensive stroke center with 24 hours last known normal (LKN) who underwent endovascular thrombectomy (EVT) without intra‐arterial thrombolytics or non‐thrombolytics were included. We used Alberta Stroke Program Early CT Score (ASPECTS) on initial non‐contrast CT to identify slow versus fast progressors. ASPECTS < = 7 was defined as fast progressor. Subgroup analysis was performed based on LKN < 3 hours, 3–9 hours, and 9–24 hours. We evaluated rate of hemorrhagic transformation using ECASS‐3 criteria and determined change in NIHSS from baseline to discharge. Mann‐Whitney U test and Fisher exact test statistic with Social science statistics software used for data analysis.

Results

From September 2019 to December 2021, out of 268 subjects who underwent EVT, 48 met inclusion criteria. Mean age was 65.29 (95% CI 61.32, 69.27), and median presenting NIHSS was 16 (95% CI 14.39, 18.40). Mean ASPECTS was 7.71 (95% CI 7.21, 8.20). There was significant difference is hemorrhagic transformation rate between ASPECTS >7 and < = 7 (Fisher value = 0.018). Sample size was not large enough to perform subgroup analysis based on last known normal. However, there was a trend towards increase in hemorrhagic transformation rate with greater time from last known well at same ASPECTS score. Slow progressors also had a significant improvement in presenting and discharge NIHSS as compared to fast progressors (z‐score is ‐3.10, p‐value is 0.002).

Conclusions

Our study suggests that ASPECTS score as assessed in different time windows to differentiate fast versus slow progressors is not only a predictor of clinical outcome, but also independently associated with risk of hemorrhagic transformation. Larger, prospective studies are needed to validate our results.
Abstract Number: LBA17 SARS‐CoV‐2 Infection Might be a Predictor of Mortality in Intracerebral Hemorrhage
Authors: Mowla Ashkan , Shakibajahromi Banafsheh , Shahjouei Shima , Zand Ramin
Published: April 2023

Introduction

SARS‐CoV‐2 infection may be associated with uncommon complications such as intracerebral hemorrhage (ICH), with a high mortality rate. We compared a series of hospitalized ICH cases infected with SARS‐CoV‐2 with a non‐SARS‐CoV‐2 infected control group and evaluated if the SARS‐CoV‐2 infection is a predictor of mortality in ICH patients.

Methods

In a multinational retrospective study, 63 cases of ICH in SARS‐CoV‐2 infected patients admitted to 13 tertiary centers from the beginning of the pandemic were collected. We compared the clinical and radiological characteristics and in‐hospital mortality of these patients with a control group of non‐SARS‐CoV‐2 infected ICH patients of a previous cohort from the country where the majority of cases were recruited.

Results

Among 63 ICH patients with SARS‐CoV‐2 infection, 23 (36.5%) were women. Compared to the non‐SARS‐CoV‐2 infected control group, in SARS‐CoV‐2 infected patients, ICH occurred at a younger age (61.4± 18.1 years versus 66.8± 16.2 years, P = 0.044). These patients had higher median ICH scores ([3 (IQR 2–4)] versus [2 (IQR 1–3)], P = 0.025), a more frequent history of diabetes (34% versus 16%, P = 0.007), and lower platelet counts (177.8± 77.8 × 109/L versus 240.5± 79.3 × 109/L, P< 0.001). The in‐hospital mortality was not significantly different between cases and controls (65% versus 62%, P = 0.658) in univariate analysis; however, SARS‐CoV‐2 infection was significantly associated with in‐hospital mortality (aOR = 4.3, 95% CI: 1.28‐14.52) in multivariable analysis adjusting for potential confounders.

Conclusions

Infection with SARS‐CoV‐2 may be associated with increased odds of in‐hospital mortality in ICH patients.
Abstract Number: LBA19 Network‐Wide Incidence of Intracranial Hemorrhage in Patients with Acute Ischemic Stroke Receiving Tenecteplase
Authors: Fourcand Farah Y , Sahito Sindhu , Ali Ch Hassan , Marandi Elahe , Haimi Joshua , Dubinsky Ilya , Song Yong‐Bum , Mehta Siddhart , Tabibzadeh Navid , Gadallah Nancy , Panezai Spozhmy , Kirmani Jawad F
Published: April 2023

Introduction

Intravenous tenecteplase (TNK) is currently being used as a thrombolytic agent in acute ischemic stroke (AIS) and has has been shown to be non‐inferior to intravenous alteplase according to recent studies. Intracranial hemorrhage (ICH) as a complication of alteplase is approximately at 6%. The aim of our study was to determine the rate of significant ICH in patients receiving TNK indicated for AIS in a real world setting.

Methods

A network‐wide (3 CSCs, 6 PSCs), multicenter retrospective chart review of patients receiving TNK from February 2020 to January 2022 was performed using the Get With The Guidelines database. TNK bolus dose of 0.25mg/kg was used according to a network‐wide policy. ICH was categorized using ECASS‐3 criteria. Fisher exact test statistic was used to determine if a significant association existed between the presence of ICH and baseline ASPECTS score, endovascular treatment (EVT), and IV eptifibatide use. A benchmark less than 2% PH‐2 incidence was set based on historical alteplase related PH‐2 rates within our network. Social science statistics software was used for data analysis.

Results

Out of 180 patients who received TNK, 25 subjects (13.89%) developed hemorrhagic transformation. Mean age was 71.88 (95% CI 65.54, 78.22). Forty‐eight percent of subjects were female. Median ASPECTS score was 8 (95% CI 7.54, 8.78). Median 90 day mRS was 3 (95% CI 2.1, 3.9). Hemorrhagic transformation was classified as HI‐1 in 5% (n = 9), HI‐2 in 1.7% (n = 3), PH‐1 in 3.8% (n = 7), and PH‐2 in 3.3% (n = 6) subjects. No significant difference between subjects with other subtypes versus PH‐2 was identified when adjusting for ASPECTS score > = 7 versus < 7 (Fisher value = 1), EVT versus no EVT (Fisher value = 0.65), or use of IV eptifibatide (Fisher value = 0.06).

Conclusions

Tenecteplase is associated with higher rates of PH‐2 intracranial hemorrhage when compared with our benchmark rates of alteplase‐related PH‐2. This study is significantly limited by small sample size, retrospective nature, and uncontrolled variables. Larger, prospective studies are needed to validate our results.
Abstract Number: LBA23 Endovascular treatment of large vessel occlusion stroke caused by infective endocarditis
Authors: Mowla Ashkan , Abdollahifard Saeed , Sizdahkhani Saman , Khatibi Kasra
Published: April 2023

Introduction

Infective endocarditis (IE) often presents as an acute ischemic stroke (AIS) secondary to a thromboembolic event leading to large vessel occlusion (LVO). These patients are at significant risk for intracerebral hemorrhage when given intravenous thrombolytics (IT) and are therefore better candidates for mechanical thrombectomy (MT). Current reports in the literature are divided on the safety of MT in this setting and no randomized control studies exist. With the advent of modern thrombectomy devices, we believe MT might be safe in this patient population.

Methods

Here we report a patient with IE who presented with LVO stroke (MCA syndrome) and underwent MT leading to first‐pass Thrombolysis inCerebral Infarction (TICI) score of 3 revascularization. In addition to presenting our case, we did a comprehensive review of the current literature on this topic.

Results

A thirty‐year‐old female with a history of cocaine abuse presented with acute onset left hemiplegia, dysarthria, and rightward gaze deviation. NIHSS was 19 and she presented 90 minutes from her last known well time . Computed Tomography (CT) head and CT perfusion imaging demonstrated a large MCA distribution stroke, an AlbertaStrokeProgram Early CT Score (ASPECTS) of 10, with significant perfusion mismatch of right MCA territory. CT angiography (CTA) confirmed a proximal large vessel occlusion (LVO) at the proximal M1. On initial assessment, the patient was febrile with a temperature of 40 degrees Celsius with a high clinical suspicion for IE; therefore, intravenous thrombolytic was not administered. MT was performed with one pull of stent retrieval under aspiration led to a successful opening of the vessel with TICI score of 3. Positive cocaine on urine toxicology was noted as well as, two sets of gram‐positive blood cultures which later resulted in Staph Aureus, oxacillin susceptible, unremarkable transthoracic echo, but with TEE demonstrating vegetative thickening within atrial aspects of both anterior andposterior mitral valve leaflets(Figure1). On hospital day two, magnetic resonance imaging of the brain shows small acute infarct with no bleed. The patient underwent a mitral valve replacement on hospital day nine. The patient was discharged to rehabilitation facilities with an NIHSS of two for mild left facial droop and mild left arm weakness; her degree of disability was measured as a modified Rankin Scale (mRS) one at 3 months.

Conclusions

In case IE is suspected, giving IV tPA (tissue‐type plasminogen activator) is contraindicated as it increases the chance of hemorrhagic complications and when LVO is confirmed in the setting of AIS, MT might be safe and effective to be considered .
Abstract Number: LBA25 Validating Artificial Intelligence Model to Optimize Radiologist Detection of Intracerebral Hemorrhage
Authors: Roshan Mona P , Linfante Italo , Antony Thompson , Noman Raihan , Clarke Jamie , Azim Seema , Britton Sean , Abrams Kevin , Sidani Charif
Published: April 2023

Introduction

Artificial intelligence (AI) has shown to be able to alert the radiologist to the presence of ischemic stroke secondary to large artery occlusion (LVO) as fast as 1–2 minutes from scan completion hence leading to faster diagnosis and treatment. In addition to acute LVO, AI has become increasingly used for various intracranial pathologies. In particular, accurate and timely detection of intracerebral hemorrhage (ICH) is crucial to provide prompt life‐saving interventions. Therefore, we aimed to validate a new AI application called Viz.ai ICH with the intent to improve diagnostic identification of suspected ICH.

Methods

We performed a retrospective database analysis of 4,203 consecutive non‐contrast brain CT reports between September 2021 to December 2021 within a single institution. The reports were made by experienced neuroradiologists who reviewed each case for the presence of ICH. Medical students reviewed the neuroradiologists’ reports and identified cases with positive findings for ICH. Each positive case was categorized based on subtype, timing, and size/volume via imaging review by a neuroradiologist. The Viz.ai ICH output was reviewed for positive cases by medical students. This AI model was validated by using descriptive analysis and assessing its diagnostic performance with Viz.ai ICH as the index test compared to the neuroradiologists’ interpretation as the gold standard.

Results

387 of 4,203 non‐contrast brain CT reports were positive for ICH according to neuroradiologists. The overall sensitivity of Viz.ai ICH was 68%, specificity was 99%, positive predictive value (PPV) was 90%, and negative predictive value (NPV) was 97%. Subgroup analysis was performed based on hemorrhage subtypes of intraparenchymal, subarachnoid, subdural, and intraventricular. Sensitivities were calculated to be 86%, 57%, 56%, and 42% respectively. Further stratification revealed sensitivity improves with higher acuity and volume/size across all ICH subtypes. Meningioma was found to be a common false‐positive finding (3 of 22, 14%). Table 1 provides a summary of the results.

Conclusions

Our analysis seems to indicate that AI can accurately detect the presence of ICH particularly for large volume/size ICH.