bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP182: Predictors of Utility of Advanced Cardiac Workup in Revealing Anterior Choroidal Artery Stroke Etiology
Authors: Gao Xiaoyi , Yelam Theja , Alqudah Alex , Sambhu Madhav , Kravitz Alana , Schachter Daniel
Published: January 2025

Introduction:
The anterior choroidal artery (AChA) is an artery that typically originates from the internal carotid artery and supplies areas including the posterior limb of the internal capsule, optic tract, and lateral geniculate body. The etiology of AChA infarcts remains poorly understood. Advanced cardiac workup (ACW), including transesophageal echocardiogram (TEE) and implantable loop recorder (ILR) are widely considered a crucial element in the ESUS work-up. Due to the uncertainty in etiology of AChA infarcts, appropriate selection of patients to undergo ACW is largely anecdotal. This study aims to evaluate the diagnostic yield of ACW and to identify positive and negative predictors that ACW would uncover etiology in AChA infarcts.

Methods:
We conducted a retrospective review of AChA ischemic strokes, admitted to a large urban academic single center from 2011 to 2024. Patient characteristics and imaging findings were analyzed to determine diagnostic yields and to identify positive and negative predictors that ACW would uncover etiology. Data were adjusted for ejection fraction (EF), prior antithrombotic use, and ipsilateral intracranial atherosclerotic diseases (ICAD).

Results:
Out of 42 AChA strokes reviewed, 6 patients (14%) were found to have new atrial fibrillation (A fib), with ILR identifying the etiology in 4 cases (9.5%). 29 patients had TEE, no of which identified etiology. The median age of the sample was 57.5 (IQR of 13.5) and 47.6% were female. Baseline characteristics such as diabetes, hypertension, smoking, ipsilateral ICAD, etc. can be seen in the table appendix. Adjusted analysis revealed that EF < 50% is significantly associated with finding an etiology with ILR (p= 0.03). This association is particularly strong when comparing EF between 30-50% to normal EF >50% (p = 0.003). Additionally, prior antithrombotic use is significantly associated with finding new A fib as an etiology for AChA stroke (p = 0.03).

Conclusion:
Our data indicate that in AChA stroke, EF < 50% is significantly associated with an increased likelihood that ILR will find an etiology. This significance warrants ILR in patients with even mildly/moderately low EF. Additionally, patients with prior antithrombotic use are more likely to be diagnosed with new A fib during the workup for AChA stroke. No etiology is identified with TEE in this sample and a larger sample size is required to reach a conclusion about the utility of TEE in finding etiology of AChA stroke.
Abstract TP183: Predicting Hemorrhagic Transformation After Thrombolytics with Computed Tomography using a 3D Convolutional Neural Network
Authors: Stanton Robert , Williamson Brady , Maloney Thomas , Khandwala Vivek , Behymer Tyler , Robinson David , Aziz Yasmin , Woo Daniel , Broderick Joseph , Kleindorfer Dawn , Khatri Pooja , Kissela Brett , Vagal Achala
Published: January 2025

Background:
Hemorrhagic transformation (HT) of ischemic stroke after intravenous thrombolytics is the most feared complication of treatment, occurring in 2-7% of patients. Patients with the most severe hemorrhage have an 18-fold increased risk of 24-hour deterioration and an 11-fold increase in 3-month mortality. Predicting those at higher risk of HT would allow more individualized care, potentially reducing the risk of harm. Utilizing only non-contrast computed tomography (NCCT) of the head, we sought to create a deep learning model to predict those at higher risk of HT from within a large, population-based study.

Methods:
Utilizing the Greater Cincinnati/Northern Kentucky Stroke Study, we identified patients in the 2015 study epoch who presented with acute ischemic stroke and received intravenous thrombolytics. Images were obtained, visually checked for quality, brain extracted, aligned to a template, windowed to 10-100 HU, and cropped to maximize the ratio of brain-specific voxels in the image. Data were input into a 101-layer 3D Convolutional Neural Network with Residual Connections (ResNet-101) with a binary output (HT vs no HT) trained on weighted focal binary cross-entropy loss. Stratified 5-fold cross-validation was used to evaluate model performance. Smoothed salience mapping was used to interpret model output.

Results:
194 patients were initially evaluated, with 24 having imaging diagnosed HT. After quality checks, 121 images were used for analysis,17 having HT. Table 1 shows the demographics and clinical data which would be typically available at the time of thrombolytic administration. Cross-validation AUC varied from 0.73 to 0.87, with the full results displayed in Figure 2. Saliency map differences between correctly and incorrectly identified HT suggested the network focused on deep, subcortical structures and ventricles when predicting HT accurately (Figure 1).

Conclusions:
We report pilot data of an accurate artificial neural network that correctly identifies HT after thrombolytics utilizing only baseline NCCT. Our results are consistent with a previous study suggesting a higher risk of HT after mechanical thrombectomy in patients with subcortical infarcts. More data is required to refine the algorithm, especially to understand why the ventricles were an area of interest to the model. Further work and improvement of this model has the potential to estimate risk of HT in a more individualized manner and provide decision support.
Abstract TP185: Perihematomal Edema and Hematoma Coagulation a Double-Edged Sword After Acute Spontaneous Intracerebral Hemorrhage (ICH).
Authors: Galan Castro Gabriel , Boren Seth , Hossain Md Faruk , Hasan Khader , Maroufy Vahed , sitton clark , Aronowski Jaroslaw , Savitz Sean , Haque Muhammad
Published: January 2025

Objective:
To investigate the post-ICH association between the hematoma coagulation and an increase in surrounding perihematomal edema (PHE) volume using serial non-invasive MRI in patients with acute hemorrhagic stroke.

Introduction:
PHE is excessive fluid accumulation encompassing brain swelling, elevated intracranial pressure (ICP), tissue herniation, and midline shift. Typical treatment strategies include decompressive hemicraniectomy and hyperosmolar therapy. Post-ICH release of lysed blood products and other neurotoxins has been associated with PHE growth. However, very little is known about the role of hematoma coagulation in PHE growth. Here, using a recently developed imaging marker of cerebral coagulation, we investigated the relation between the clotted blood volume within hematoma and PHE development.

Methods:
In this retrospective serial MRI image analysis, twenty-four patients with acute spontaneous ICH were imaged 3 times within 12-24 (V1), 36-48 (V2), and 60-72(V3) hours of last seen well (LSW) on a 3T MRI system. 3D anatomical (FLAIR, T1W), multi gradient echo (mGRE), and diffusion tensor (DTI) images were acquired. Using FLAIR images, hematoma and PHE volumes (HV, EV) were segmented and applied as a region of interest (ROI). Quantitative Susceptibility Maps (QSM) and Mean Diffusivity (MD) maps were created using mGRE and DTI images. The HV voxel with susceptibility less and greater than 0.5ppm were categorized as liquid and clotted blood voxel respectively. The clotted blood volume (CBV) was associated with HV, EV, NIHSS, and MD. A non-linear regression model was used for statistical analysis.

Results:
We enrolled 14M/10F, with an average age of 65.8±12y diagnosed with mild spontaneous ICH. Temporally, between the V1 and V3 imaging, the EV (22.9±12.3 to 31.4±19 mL; P<0.05) and CBV (3.36±3.3 to 5.58±4.8 mL; P< 0.05) significantly increased. A significant increase (R=0.42, P = 0.08 to R = 0.80, P < 0.05) positive correlation between EV and CBV was recorded. A positive (P < 0.05) association was also observed between EV and HV whereas no association among MD, NIHSS, and CBV was recorded at any time. These results are summarized in Figure 1.

Conclusion:
Here, we showed hematoma coagulopathy plays a significant role in perihematomal growth in patients with acute ICH. We speculate that the presence of non-coagulated and coagulated blood within the hematoma increases the risk of hematoma and PHE expansion respectively.
Abstract TP191: Cerebrospinal Fluid Proinflammatory Cytokines are Associated with Poor Outcome following Hemorrhagic Stroke
Authors: Sorensen Gracey , Grychowski Lauren , Yan Jennifer , Herman Alison , He Zili , Johnson Conor , Beatty Hannah , Jayasundara Sithmi , Falcone Guido , Gilmore Emily , Matouk Charles , Sheth Kevin , Kim Jennifer , Petersen Nils , Sansing Lauren , Magid-Bernstein Jessica
Published: January 2025

Introduction:
The immune response within the central nervous system (CNS) is heightened after hemorrhagic stroke, yet the association between inflammation and outcome is unclear. Analysis of cerebrospinal fluid (CSF) from patients with external ventricular drains (EVDs) enables analysis of the CNS inflammatory profile. We hypothesize that hemorrhagic stroke patients with a more proinflammatory CSF profile will have worse outcomes at discharge.

Methods:
Using cytometric bead array, we measured a panel of cytokines in CSF and blood samples collected from hemorrhagic stroke patients between day 0 and 7 after symptom onset. Ventricular CSF was collected from control patients undergoing shunt placement for normal pressure hydrocephalus. C-C motif chemokine ligand 2 (CCL2), interleukin-6 (IL-6), interleukin-8 (IL-8), granulocyte-colony stimulating factor (G-CSF), and vascular endothelial growth factor (VEGF) were all detectable within the CSF at this time point. All cytokine concentrations were log transformed given non-normal distributions. Using univariate and multivariate analyses, we examined the relationship between discharge outcomes using Modified Rankin Score (mRS) and CSF cytokine levels.

Results:
CSF was collected from 25 intracerebral hemorrhage (ICH) patients, 54 subarachnoid hemorrhage (SAH) patients, and 25 controls. Hemorrhagic stroke patients showed higher IL-8, IL-6, CCL2, and G-CSF compared to plasma samples and control CSF (all p< 0.01). In ICH patients, higher CSF VEGF was associated with a worse discharge mRS (mRS 5-6 vs 0-4) (p=0.029). In SAH patients, there was a trend towards an association between higher CSF IL-6, IL-8, and G-CSF and worse discharge mRS (p= 0.056, 0.087, and 0.071 respectively). In multivariate analyses looking at each cytokine with discharge mRS, adjusted for age, sex, and ICH volume, log IL-8 in CSF was associated with higher discharge mRS in ICH patients (p=0.012).

Conclusion:
Our data show that CSF cytokine levels are higher in the first 7 days post-hemorrhagic stroke than in controls or plasma. In ICH, elevated CSF VEGF and IL-8 are both associated with worse outcome at discharge. These findings provide the rationale for investigation into the relationship between CSF cytokines and outcome in hemorrhagic stroke, which can lead to discovery of therapeutic targets for improving outcome in this devastating condition.
Abstract TP197: Trends In Stroke Mortality due to Hypertension Among Older Adults In The United States From 1999-2020
Authors: Shahid Ahmad , Latif Fakhar , Meer Komail , Shaikh Abdul Wassay , Mubbashir Ayesha , Usmani Taimur Faheem , Ahmed Huda , Nasir Muhammad Moiz , Shaikh Naeemuddin , KUMAR MUKESH
Published: January 2025

Background:
Hypertension (HTN)-induced stroke is a leading cause of mortality among older adults in the United States. Analyzing trends and disparities in HTN-associated stroke mortality is essential for guiding targeted interventions and informing policy decisions.

Objectives:
This study aims to evaluate HTN-associated stroke mortality trends in adults aged ≥65 years, with a focus on demographic and geographic variations, using comprehensive nationwide death certificate data.

Methods:
We analyzed death certificate data from the CDC WONDER database spanning 1999 to 2020 to assess HTN-related stroke mortality. Stroke cases were identified as the underlying cause of death (UCD) using specific ICD-10 codes: I60.x, I61.x, I63.x, I64, I69.0, I69.1, I69.3, and I69.4. HTN and its subtypes were identified as a contributing cause of death using ICD-10 codes I10, I11.x, I12.x, I13.x, and I15.x. AAMRs per 100,000 were calculated, and stratified by age, sex, and geographic region. Temporal trends were assessed using the Joinpoint Regression Program to determine annual percentage changes (APCs). Subgroup analysis based on race/ethnicity was excluded due to data suppression by the CDC.

Results:
Between 1999 and 2020, notable disparities in hypertension-related stroke mortality emerged. In nationwide analysis, the AAMRs demonstrated considerable fluctuation, beginning at 79.1 in 2000, declining to 51.2 by 2019, and then increasing to 54.8 in 2020. The APC for the entire study period was -2.32, indicating a general gradual decline in mortality rates. Gender-based analysis revealed females experienced a higher mean AAMR (62.9) than males (54.7). Despite higher mean AAMR, females had more pronounced decline in mortality rate than males (APC female: -2.47 vs male: -1.84). Regional disparities were also pronounced, with Western region exhibiting the highest mean AAMR (73.4), followed by Southern (60.9), Midwestern (58.6), and Northeastern (47.7) regions. Additionally, urban-rural differences were evident, as non-metropolitan areas had a higher mean AAMR (66.1) than metropolitan areas (59.1).

Conclusion:
This study highlights a significant decrease in HTN-related stroke mortality over two decades, yet disparities remain. Females, South region, and rural areas continue to face higher rates, emphasizing the need for targeted healthcare interventions. The COVID-19 pandemic further underscores the importance of strengthening healthcare systems to address these disparities.
Abstract TP198: Alpha-Delta Ratio as an Acute Marker of Intracerebral Hemorrhage on Sub-galeal EEG
Authors: Cummins Daniel , Bose Javin , Kalagara Roshini , Waziri Allen , Dangayach Neha , Kellner Christopher
Published: January 2025

Background:
Spontaneous intracerebral hemorrhage (ICH) remains one of the most devastating forms of stroke, leaving many patients unresponsive with disorders of consciousness. However, there remain few options for continuous brain monitoring for ICH. While EEG markers such as decreased alpha-delta power ratio may indicate ischemic stroke, similar EEG markers of ICH have yet to be explored. Sub-galeal EEG is a promising method for robust continuous brain monitoring, which may have relevance for detecting new ischemic or hemorrhagic events in ICH patients. We therefore aimed to evaluate electrophysiologic features of ICH on sub-galeal EEG.

Methods:
Consecutive patients at one center with ICH who underwent minimally-invasive surgical ICH evacuation received bilateral sub-galeal EEG for continuous brain monitoring. To explore markers of ICH, electrophysiologic features on sub-galeal EEG were compared between hemorrhagic and non-hemorrhagic hemispheres.

Results:
Six patients with ICH who underwent minimally-invasive surgical evacuation were implanted with sub-galeal EEG intraoperatively. Patient age was on average 66.0±7.5 years, National Institutes of Health Stroke Scale at presentation was 19.6±4.0, and ICH volume was 54.0±42.4mL. In five patients, significant reductions in alpha-delta power ratio (power between 8-13Hz relative to power from 2-4Hz) were seen in the hemorrhagic hemisphere compared to the non-hemorrhagic hemisphere. Decreased alpha-delta ratio was seen both with lobar cortical ICH and with basal ganglia ICH. In one of the six patients, higher alpha-delta ratio was seen on the side of left-sided hemorrhage in the context of bilateral epileptiform Lateralized Rhythmic Delta Activity (LRDA) unique to this patient.

Conclusions:
In patients at elevated risk of ICH or with ICH, sub-galeal EEG may be an effective method of continuous brain monitoring. In addition to ischemic stroke, decreased alpha-delta ratio on EEG may be seen in hemorrhagic stroke.
Abstract TP200: Association Between Hematoma Evacuation and Risk of Subsequent Ischemic Stroke and Coronary Ischemic Events by Hematoma Location: A MISTIE III and ATACH-2 Analysis
Authors: Ziai Wendy , Murthy Santosh , Qureshi Adnan , Awad Issam , Hanley Daniel
Published: January 2025

Background:
Nontraumatic intracerebral hemorrhage (ICH) especially in deep locations is independently associated with a long-term increased risk of major arterial ischemic events. Minimally invasive surgery (MIS) has not been shown to improve outcomes for deep ICH. Whether ischemic events modify the effect of MIS on outcomes for deep ICH has not been studied.

Methods:
We pooled individual patient data from the MISTIE III (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase 3) and the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) trials. The exposure was ICH location (deep vs. lobar). The outcome was a symptomatic, clinically overt ischemic stroke or coronary ischemic event, adjudicated centrally within each trial. We evaluated the association between ICH location and risk of an ischemic event using Cox regression analyses after adjustment for demographics, vascular comorbidities, and ICH characteristics. We used logistic regression to assess whether ischemic events modified the effect of MIS with end of treatment volume (EOT) <15mL on modified Rankin scale (mRS) 0-3 at one year in MISTIE III.

Results:
Of 1470 patients with ICH, mean age was 61.7 (SD, 12.8) years, and 574 (38.3%) were female. The median hematoma volume was 17.3 mL (interquartile range, 7.2–35.7) and 1186 (80.7%) were deep. During a median follow-up of 110 days (iqr 110-365), a total of 70 ischemic events occurred, 60 (5.0% cumulative incidence) in patients with deep ICH and 10 in patients with lobar ICH (cumulative incidence 3.2%). In adjusted analysis, deep ICH location, but not MIS was associated with increased risk of ischemic events (hazard ratio, 2.1 [95% CI, 1.07–4.3]). In the full MISTIE cohort, in patients without ischemic events during follow-up, MIS with EOT<15 mL was significantly associated with favorable one year outcome (OR 1.90 (95% CI: 1.16-3.12; Pinteraction = 0.04). There was no effect modification for deep location (Pinteraction = 0.13) and for lobar ICH, achieving EOT<15 with MIS was associated with good outcome regardless of ischemic events in adjusted analyses.

Conclusions:
In a heterogeneous cohort of patients with ICH, deep ICH location was associated with increased risk of ischemic events over the short term, but this appears to have low impact on one-year outcomes with successful surgery and does not help to explain worse outcomes of deep (vs. lobar) ICH with MIS.
Abstract TP208: Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: An Updated Meta-Analysis of 6405 Patients
Authors: Jeswani Bijay , Syed Saif , Desouki Mariam , Onwujiogu Queeneth , Kauser Hena , Cicani Laura , Abdelaziz Ahmed
Published: January 2025

Background:
Traumatic acute subdural hematoma (tSDH) is a life-threatening condition and frequently requires surgical evacuation via craniotomy (bone flap) or decompressive craniectomy (no bone flap). However, there are controversial data regarding this setting. We aimed to give a comprehensive assessment of craniotomy versus decompressive craniectomy in patients with tSDH.

Methods:
We systematically searched PubMed, OVID, Cochrane Library, Scopus, and Web of Science for eligible comparative studies from inception until April 2024. The primary outcome of interest was the rating of the Glasgow Coma Scale (GCS). Other studied outcomes are all-cause mortality, and rate of residual SDH. STATA 18MP was used to analyze the data using the Der-Simonian Leir random effect model.

Results:
A total of 16 studies comprising 6405 patients (3963 in the craniotomy, and 2442 in the craniectomy), with a mean age ranging from 34.4 to 68.9 years, and a mean follow-up of 9 months. Craniotomy was associated with a lower risk of all-cause mortality (OR: 0.74, 95% CI: 0.56 to 0.99, p= 0.004; I2= 80.66, p <0.001). Moreover, for patients with GCS scores of 13-15, there were significantly higher rates in the craniotomy group compared to the craniectomy group (OR: 1.64, 95% CI: 1.13 to 2.36, p= 0.001; I2= 0.00, p= 0.75); however, there was no significant difference in patients with the most severe GCS scores of 3-8 or those with GCS scores of 9-12.

Conclusion:
Craniotomy was associated with better clinical presentation and postoperative outcomes compared to craniectomy for patients with acute SDH. However, the results are powered by the observational data, and further large-volume RCTs are warranted.
Abstract TP213: Dolichoectasia and Its Impact on Clinical Outcomes in Patients with Spontaneous Intracerebral Hemorrhage
Authors: Cadena Tejada Angel , Lopez-Navarro Edgar , Tom Rebecca , Gutierrez Jose , Roh David
Published: January 2025

Introduction:
Dolichoectasia (DE), a condition marked by dilation and tortuosity of intracranial arteries, is related to an increased risk of strokes. While the association between DE and ischemic stroke is well established, the relationship with hemorrhagic stroke remains less clear. We investigated the presence of dolichoectasia in patients with intracerebral hemorrhage (ICH) and examine its impact on clinical outcomes.

Methods:
We studied adult spontaneous ICH A retrospective study of patients aged consecutively admitted to an academic medical center between 2012 and 2023 with available hospitalization vascular imaging (CTA and/or MRA). DE was primarily assessed as a composite assessment based on artery arterial diameter cutoffs by either CTA or MRA imaging modality seen either in anterior or posterior circulations. Multivariable logistic regression models assessed DE’s association with poor discharge ICH outcomes (modified Rankin Scale 4-6) after adjusting for relevant covariates. Separate models explored relationships of DE with ICH characteristics (volume, location), and exploratory analyses were performed defining DE based on vascular location.

Results:
Of 373 of 860 patients met the inclusion criteria for meeting criteria for analyses, 56.1% were male, mean age was 66, and 29.8% were white. DE was present in 20% of the cohort. Patients with DE were more likely older, white patients. In our regression models, we identified that DE was associated with decreased odds of poor discharge ICH outcomes (adjusted OR 0.49, 95%CI: 0.26-0.92,
p
=0.03). In exploratory analyses, we did not identify relationships of DE (as a composite assessment) with ICH volume. However, when assessing DE based on anatomical location, we identified that posterior circulation DE was associated with deep ICH location (95%CI: 1.04-4.98, p=0.04). No interactions of age, sex, race, with DE’s association with outcomes were seen.

Conclusion:
We identified a high prevalence of DE in our cohort of ICH patients. Furthermore, we identified that the presence of DE was associated with decreased odds of poor ICH outcomes. Further work is warranted to clarify the role of this vasculopathy in ICH pathogenesis and outcomes, especially to identify if flow-related changes mediate the observed improved outcomes.
Abstract TP227: Bone Marrow Mesenchymal Stem Cell-derived Migrasomes can Enhance the Proliferation of Thymic Epithelial Cells Following Infarction and Prevents Stroke-Induced Immunosuppression
Authors: Yi Haotong , Hu Mengyan , Cai Wei , Lu Zhengqi
Published: January 2025

Introduction:
Stroke-induced immunosuppression (SIIS) can lead to increased susceptibility to infections, which ultimately affects functional outcomes and increases mortality rates. Our previous studies suggest that Bone Marrow Mesenchymal Stem Cell (BM-MSCs) protect against SIIS and prevent post-stroke pneumonia.In this study, we propose that BM-MSCs have the potential to repair thymic atrophy after infarction, thereby offering protection against SIIS.

Methods:
We conducted a 60-minute transient middle cerebral artery occlusion (tMCAO) on male C57BL/6J mice. Two hours after the tMCAO, separate injections of PBS , BM-MSCs , and GFP-TSPAN4-labeled migrasomes derived from BM-MSCs were administered.The thymuses of the infarcted mice were subsequently collected at 3, 7, and 14 days post-tMCAO for RNA sequencing, and immunofluorescence staining. Liquid chromatography tandem mass spectrometry (LC-MS/MS) was performed to profile the proteome of migrasomes.

Result:
We found that in tMCAO mice, the mortality rate decreased and thymic weight was restored after injection of BM-MSCs. Cellular mechanism studies using bulk RNA sequencing revealed that BM-MSC treatment downregulates senesence of thymic cells and enhances cell proliferation. Immunofluorescence analysis indicated that after stroke, thymic medullary epithelial cells (TECs) exhibited remarkable senescence, especially those in the medulla. BM-MSC treatment reversed the senesence of thymic cells. Interestingly, we found that BM-MSCs do not directly enter the thymus, while migrasomes derived from BM-MSCs, which are newly discovered organelle that produced during cellular migration, could cross the blood-thymus barrier, reaching and interacting with TECs. Proteomic analysis of BM-MSC-derived migrasomes revealed that Peptidyl-prolyl cis-trans isomerase (Pin1) was packed in the organelle. Pin1 is a vital cell cycle protein that promotes cell proliferation and division. Based on these findings, we hypothesize that migrasomes derived from BM-MSCs may transfer Pin1 protein to TECs, potentially reversing cellular aging.

Conclusions:
BM-MSCs have the potential to reverse thymic atrophy after infarction and protect against the senscence of TECs. Notably, migrasomes derived from BM-MSCs can cross the blood-thymus barrier and transfer the Pin1 protein to TECs. Based on these findings, we propose that BM-MSC-derived migrasomes can restore thymic atrophy and prevent SIIS.
Abstract TP237: Efficacy And Safety Of Mechanical Thrombectomy In Medium Vessel Occlusion Ischemic Stroke Patients On Low-Dose Aspirin
Authors: Salim Hamza , Koneru Manisha , Pulli Benjamin , Abushehab Nimer , Lakhani Dhairya , Musmar Basel , Faizy Tobias , Heit Jeremy , Wintermark Max , Guenego Adrien , Dmytriw Adam , Yedavalli Vivek
Published: January 2025

Introduction:
Acute ischemic stroke (AIS) from distal medium vessel occlusion (DMVO) presents unique treatment challenges. Mechanical thrombectomy (MT) is emerging as a viable option for these patients, yet the role of pre-stroke aspirin treatment is unclear. This study evaluates the impact of pre-stroke low-dose aspirin on outcomes in DMVO patients undergoing MT.

Methods:
We conducted a multinational, multicenter, propensity score-weighted analysis within the Multicenter Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy (MAD-MT) registry. Patients with AIS due to DMVO, treated with MT, were included. We compared outcomes between patients on pre-stroke low-dose aspirin (75-100 mg) and those not on antiplatelet therapy. The primary outcome was functional independence at 90 days (mRS 0-2). Secondary outcomes included excellent functional outcome at 90 days (mRS 0-1), mortality, and day-one post-MT NIHSS score. Safety outcomes focused on hemorrhagic complications, including symptomatic intracerebral hemorrhage (sICH).

Results:
Among 1,354 patients, 150 were on pre-stroke low-dose aspirin. Aspirin use was associated with significantly better functional outcomes (mRS 0-2: OR = 2.12, 95% CI, 1.29 to 3.49; mRS 0-1: OR = 1.87, 95% CI, 1.12 to 3.14;) and lower 90-day mortality (OR = 0.53, 95% CI, 0.30 to 0.95). The aspirin group had lower NIHSS scores on day one (β = -2.0, 95% CI, -3.3 to -0.70). The rate of sICH was not significantly different between the groups (OR = 0.98, 95% CI, 0.56 to 1.72).

Conclusions:
Pre-stroke low-dose aspirin was associated with improved functional outcomes and reduced mortality in patients with DMVO undergoing MT, without a significant increase in sICH. These findings suggest that low-dose aspirin may be safe and associated with more frequent excellent outcomes for this patient population. Further prospective studies are needed to validate these results and assess long-term outcomes.
Abstract TP243: Treatment time metrics following implementation of the Viz.ai artificial intelligence intracranial occlusion-detection and communication platform: A multicenter analysis
Authors: Siegler James , Frost Emma , Penckofer Mary , Aroor Sushanth , Fraser Justin , Paul Alexandra , Krishnaiah Balaji , Essibayi Muhammed , Jovin Tudor , Thon Jesse , Khalife Jane
Published: January 2025

Introduction:
Delays in endovascular therapy for acute large vessel occlusion (LVO) stroke can contribute significantly to disability following successful recanalization. The implementation of an automated intelligence LVO detection and interdisciplinary communication platform can shorten times to treatment.

Methods:
We conducted a multicenter retrospective observational cohort study of consecutive adults with acute occlusion of the internal carotid, proximal middle cerebral, or basilar artery. Hub-and-spoke networks implementing Viz.ai queried electronic medical records 6 months prior to and 6 months following implementation of Viz.ai. Patients were included if they had a National Institutes of Stroke Scale (NIHSS) score ≥6, pre-stroke modified Rankin Scale 0-1, and presented within 24 hours of last known well (or unknown). The primary outcome was time from initial hospital contact to arterial puncture, which was compared between study periods using descriptive statistics, regression with robust standard errors clustered by site, and adjusted inverse probability of treatment weighting (IPTW) in which probability weights were used to reduce imbalance between study periods in a causal inference model. The model was adjusted for age, NIHSS, sex, comorbidities, overnight arrival, hub versus spoke arrival, academic quarter, and pre-stroke modified Rankin Scale which was imputed when missing using chained equations as an ordinal covariate.

Results:
Of the 474 included patients across 7 sites (n=215 post-Viz, 45.4%), the median age was 67 years (interquartile range [IQR] 57-77) and median NIHSS was 17 (IQR 11-22). Using descriptive statistics, there was a trend toward a shorter time from hospital contact to puncture during the post-Viz period (median 103min, IQR 68-146, vs. 106min, IQR 76-169, p=0.10). In unadjusted regression with robust errors, clustered by site, the trend persisted (β -26.3, 95% confidence interval [CI], -53.7 to 1.3, p=0.058). In the adjusted IPTW model, arrival during the post-Viz period was associated with a shorter adjusted average treatment effect (time difference) of 31 minutes (95% CI, 14 to 48 minutes, p<0.001) when compared to arrival during the pre-Viz period.

Conclusions:
Implementation of the Viz.ai platform led to a significant decrease in time to arterial puncture for patients with acute LVO. The degree to which these changes contributed to better clinical outcomes is being explored in subsequent analyses.
Abstract TP247: Iatrogenic Cervical Artery Dissections during Endovascular Interventions
Authors: Xeros Helena , Bucak Bilal , Oushy Soliman , Lanzino Giuseppe , Keser Zafer
Published: January 2025

Introduction:
Iatrogenic cervical artery dissection (CeAD) may result from various procedures such as procedural and diagnostic angiography. Due to the rarity of iatrogenic CeAD, existing literature on management and outcomes is limited. This observational cohort study investigates clinical approaches and long-term outcomes of iatrogenic CeAD after endovascular interventions.

Methods:
We conducted a retrospective chart review to analyze patients who underwent endovascular treatments at the Mayo Clinic from 1998 to 2021. We focused on patients with iatrogenic CeAD resulting from interventions. Pertinent patient factors were extracted. Descriptive statistics highlighted the relationship between treatments and long-term clinical outcomes.

Results:
Between 1998 and 2021, 21,191 patients underwent catheter cerebral angiography. Among them, 32 had iatrogenic CeAD (30 identified as white, 23 women, median age 59 [range 40.5–92.9]). Common comorbidities included hypertension (62.5%), smoking (56.3%), and hyperlipidemia (46.9%). Of the 32 patients, 9(28.1%) had dissection with diagnostic angiograms, 6(18.8%) endovascular thrombectomy, 15(46.9%) aneurysm treatment, and 2(6.3%) angioplasty with or without stenting. The location of dissections was dependent upon the intervention: 17(53.1%) had internal carotid artery dissection, 13(40.6%) vertebral artery dissection, and 2(6.3%) common carotid dissection. One patient was symptomatic with neck pain. All dissections were diagnosed by cerebral angiography during the same session as the initial intervention. Only 4(12.5%) were treated with hyperacute stenting. Following diagnosis, 30(93.7%) were placed on antithrombotic therapy, including aspirin alone (34.4%) or dual antiplatelet therapy with aspirin and clopidogrel (37.5%). The median duration of acute treatment was 3 months. The median duration of imaging follow up was 1022 days. Follow-up imaging showed an excellent radiological course, with complete or nearly complete dissection remodeling.

Conclusions:
Iatrogenic CeAD with endovascular interventions is rare and typically benign. Most cases are managed medically without significant clinical complications or long-term negative outcomes. Single or dual antiplatelet therapies remain preferred treatments, in line with current trends. Key factors influencing clinical decision-making include location, occlusion rate, pseudoaneurysm formation, intracranial extension, distal collateral circulation, and ischemia.
Abstract TP251: The Use of Hydrophilic-Coated Introducer Sheaths for Reducing Radial Artery Spasm During Transradial Procedures: A Systematic Review and Meta-Analysis
Authors: Hukamdad Mishaal , Adachi Kaho , Soliman Youssef , Ezzeldin Rime , Ezzeldin Mohamad
Published: January 2025

Background:
Transradial access has become increasingly favored over the traditional transfemoral approach for neurointerventional procedures, however radial artery spasm (RAS) and radial artery occlusion (RAO) pose challenges to this approach. RAS is one of the most common complications associated with the transradial approach that can impede procedural success and cause significant pain to patients. A promising strategy to mitigate RAS is the use of hydrophilic-coated (HC) introducer sheaths. The lubricious surface facilitates smoother insertion and manipulation within the radial artery, potentially reducing friction that contributes to RAS. Prior studies have reported conflicting results regarding the utility of HC sheaths in reducing the risk of RAS. Thus, the clinical benefit of HC sheaths is not fully understood.

Objective:
The purpose of this study is to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing HC introducer sheaths with non-coated (NC) introducer sheaths during transradial procedures and their impact on RAS, RAO, periprocedural pain, and complications.

Methods:
PubMed, Embase, and Cochrane Library were searched for RCTs utilizing HC sheaths in their intervention arm and NC sheaths in their control arm in patients undergoing a transradial procedure. Outcomes included incidence of RAS, RAO, pain/discomfort during the procedure, pseudoaneurysm, and hematoma. RevMan 5.4 software was used to calculate pooled risk ratios and mean differences with 95% confidence intervals.

Results:
Seven RCTs were included in this study. HC sheaths were associated with a significant reduction in the risk of RAS and periprocedural pain/discomfort compared to NC sheaths (RR = 0.38, 95% CI [0.24, 0.60], I
2
= 19% and RR = 0.45, 95% CI [0.34, 0.60], I
2
= 14%, respectively). The use of HC sheaths had no significant effect on the risk of RAO, hematoma, or pseudoaneurysm.

Conclusion:
The use of HC sheaths is associated with a reduced risk of RAS and periprocedural pain/discomfort compared to NC sheaths with no significant effect on RAO, procedure duration, hematoma, or pseudoaneurysm. HC sheaths improve the overall patient experience and reduce the risk of spasm. These findings may provide valuable insights for neurointerventionalists seeking to optimize transradial techniques and improve patient care.
Abstract TP259: Acute Ischemic Stroke Patient Factors Associated with Poor Outcomes in Patients with Favorable Collaterals and Successful Thrombectomy
Authors: Kesten Jamie , Mlynash Michael , Yuen Nicole , Seners Pierre , Wouters Anke , Schwartz Maya , Lansberg Maarten , Albers Gregory , Heit Jeremy
Published: January 2025

Background:
Endovascular treatment (EVT) is an effective treatment for acute ischemic stroke in anterior large vessel occlusions. Despite successful reperfusion, many patients still have unfavorable outcomes even in the presence of favorable arterial collaterals. We determined patient characteristics, treatment details and imaging characteristics associated with favorable outcome in patients with good collaterals who had successful EVT.

Methods:
In a post hoc analysis of the prospective CRISP 2 study, we identified patients with successful reperfusion following EVT (TICI 2b-3) and good collaterals (Tan ≥2). These patients were dichotomized into favorable (mRS 0-2) and unfavorable outcome (mRS 3-6) groups. Multivariate analyses were performed to identify clinical, imaging, and treatment predictors of favorable outcome.

Results:
92 patients were included, and 31 patients (33.7%) had favorable outcomes. There were no differences in the number of females (16 patients [52%] versus 33 patients [54%]; p=0.821) or age (71 years, [IQR 56-79] versus 68 years [IQR 57-79]; p=0.859) in favorable versus unfavorable groups, respectively. Favorable outcome patients had lower pre-treatment mRS (p<0.001), more frequent administration of intravenous thrombolysis (52% versus 23%; p=0.006), shorter EVT procedure times (27 min (IQR 23-40) versus 46 min (IQR 27-64), and lower NIHSS before EVT (12 [IQR 9-15] versus 16 [IQR 12-20]; p=0.006). There were no differences in the frequency of TICI 3 rates (48% vs. 38%; p=0.325) or first pass effect between the two groups (61% vs. 57%; p=0.719). In a multivariable regression analysis, intravenous thrombolysis administration (OR 3.27 [95% CI: 1.04-10.33]; p = 0.043) and EVT procedure time (OR for every 5 min 0.98 [95% CI: 0.81-0.98]; p = 0.022) were modifiable predictors of favorable outcomes. Lower pre-stroke mRS also predicted favorable outcomes (p = 0.03).

Conclusions:
Among patients with good collaterals and successful reperfusion following EVT, favorable outcomes were associated with lower baseline mRS, intravenous thrombolysis administration, and shorter EVT procedure times.
Abstract TP262: Fibrocartilaginous embolism: a rare cause of ischemic myelopathy
Authors: Hillhouse Kelsey , Britt Erin , Rose Lydia , Taylor Charlotte , Thompson James , Davis Lamar
Published: January 2025

Introduction:
Fibrocartilaginous embolism (FCE) is a rare etiology of spinal cord infarction that occurs when nucleus pulposus material from intervertebral discs spontaneously embolizes into a spinal artery. Younger patients are at higher risk because arterial vascularization of the nucleus pulposus is present from early life through adolescence after which it regresses.

Methods:
Case report

Results:
An 11yo F presented with sudden onset back pain and lower extremity sensory disturbances following an ATV ride that quickly evolved into an ascending paralysis with associated urinary retention. Exam showed 4/5 strength in proximal UEs, 2/5 grip strength on the right, and 0/5 strength in LEs with associated areflexia and decreased sensation to light touch and pinprick but preserved vibratory sense. CSF studies were unremarkable with no albuminocytologic dissociation or lymphocytic pleocytosis. EMG/NCS revealed absent F-waves consistent with possible early demyelinating polyradiculopathy. She was started on IVIG given concern for AIDP. Extensive work-up including TSH, ESR, CRP, B1, B12, heavy metals, C. jejuni Ag, stool cx, blood cx, ANCA vasculitis panel, RMSF and Arbovirus Abs, and AchR and MuSK Abs was unremarkable. MRI revealed diffusion restriction in the cervicothoracic cord without enhancement (
Fig 1
). She had no improvement of her symptoms after completing 5 days of IVIG. She also developed long-tract signs including +Babinski on the left and LE spasticity. Repeat imaging 4 days from prior revealed adjacent vertebral body with area of T2 hyperintensity concerning for bony infarct (
Fig 2
). Given her rapid onset of symptoms, lack of improvement after treatment with IVIG, and development of long-tract signs, she was given a diagnosis of spinal cord infarction. FCE was deemed the etiology given the presence of adjacent bony infarct suggesting embolic phenomenon and the lack of evidence of CNS inflammation, infection, or other etiology. Repeat EMG/NCS showed evidence of severe reduction in the amplitudes of the compound motor action potentials which can be seen in compromise of the motor neuron population due to spinal cord infarction (
Fig 3
). She was discharged to inpatient rehab.

Conclusion:
This report alerts clinicians to FCE as a rare etiology of ischemic myelopathy that should be considered in patients who present with sudden, painful onset followed by “stroke-in-evolution” pattern of progression that may resemble the ascending paralysis seen in AIDP.
Abstract TP264: Blood pressure trends during first forty-eight hours post arterial ischemic stroke in children with cardiac disease
Authors: Quesnel Elya , Guerguerian Anne-Marie , Chin Norbert , Linds Alexandra , Sheng Min , Pulcine Elizabeth , Moharir Mahendranath , deVeber Gabrielle , Dlamini Nomazulu
Published: January 2025

Introduction:
Children with cardiac diseases are at an increased risk to develop ischemic stroke that can lead to lifelong neurological deficits. Blood pressure is an important modifiable factor associated with poor neurological outcomes. However, there lacks sufficient evidence to provide patient specific blood pressure guidelines post pediatric ischemic stroke.

Objective:
We evaluated blood pressure mean and changes in pediatric patients with cardiac diseases within the first 48hours cardiac critical care unit (CCCU) after an arterial ischemic stroke.

Method:
We conducted a retrospective study of children diagnosed with acute arterial ischemic stroke admitted to the CCCU. We reviewed data on demographics, clinical outcome, radiologic, hemodynamic parameters, and medication. Ischemic lesion volume size was obtained from Diffusion-Weighted Imaging by a full-trained neuroradiologist. Blood pressure percentile was obtained based on age, sex, and the 50
th
height range. We contrasted the blood pressure with age and admission year matched CCCU controls without a history of stroke. We used linear regression to model blood pressure trends, t-test to compare continuous data, and chi square analyses to compare discrete data points.

Results:
Twenty-nine stroke patients (34% female, median age 2.1 years and range 17 years) were included. The majority of patients aged up to 3 years-old, presented with congenital heart defects (69%). Older patients presented more often with acquired heart disease (40%). Blood pressure means and trends differed by age, cardiac disease, and neurological outcomes. Younger patients and those with congenital heart defects had higher blood pressure compared to controls. Older patients or those with acquired heart diseases tended to have lower systolic blood pressure and higher diastolic blood pressure than their control. A third of patients with neurological deficits presented with an average blood pressure greater than the 95
th
percentile, while patients with normal neurological status at discharge all had an average blood pressure inferior to the 50
th
percentile. Higher blood pressure was associated with worst neurological outcomes, and larger ischemic brain volume size.

Conclusion:
Patients with cardiac disease have age and cardiac anomaly specific blood pressure after an acute ischemic stroke. Further research into these differences and blood pressure management in this group is crucial to lessening the burden of stroke on this at risk population.
Abstract TP272: Transthoracic Echocardiographic Findings in Cryptogenic stroke: Prevalence and Comparisons to other Subtypes of Ischemic Stroke
Authors: Nabavizadeh Pooneh , Stanton Robert , Sucharew Heidi , Merkler Alexander , Sharma Richa , De Los Rios La Rosa Felipe , Mackey Jason , Ferioli Simona , Mistry Eva , Demel Stacie , Coleman Elisheva , Jasne Adam , Slavin Sabreena , Walsh Kyle , Star Michael , Haverbusch Mary , Woo Daniel , Robinson David , Khatrip Pooja , Kissela Brett , Kleindorfer Dawn
Published: January 2025

Background:
Certain findings on transthoracic echocardiography (TTE) are associated with a recognized cardioembolic stroke mechanism but less is known about the prevalence of those findings in other subtypes, especially cryptogenic stroke patients. We sought to describe the prevalence of these abnormalities reported on TTE in stroke patients in a large, population-based stroke study and compare the findings specifically of cryptogenic stroke patients to those with the other identified subtypes.

Methods:
In 2015, the Greater Cincinnati/Northern Kentucky Stroke Study identified all stroke cases in the 5-county area surrounding Cincinnati by ICD 9/10 codes. Potential cases were abstracted by trained study nurses and physician adjudicated, which included assigning ischemic stroke etiology based on our epidemiologic criteria. TTE reports were reviewed. Demographic information, medical history, stroke subtype and prespecified TTE features were collected for each patient and compared across stroke subtype groups. We performed a pair-wise post hoc comparison to the cryptogenic group if a difference was found amongst the groups based on the omnibus test.

Results:
In 2015, there were 2481 ischemic strokes among patients 18 years or older in our 5-county area. Of these, 677 (27%) were cardioembolic, 312 (13%) large artery atherosclerotic (LAA), 419 (17%) small vessel, 154 (6%) other etiology and 919 (37%) cryptogenic. Of these ischemic stroke events, there were 1503 (61%) with TTE reports available. The severity for diastolic dysfunction, left atrial (LA) dilation, left ventricular hypertrophy and valvular abnormalities were not included in the data analysis. Cardioembolic strokes had significantly higher proportions of LA dilation, mitral and aortic regurgitation, greater LA size and area, and lower left ventricular ejection fraction (LVEF) compared to cryptogenic patients. LAA patients had a higher LA size and lower LVEF compared to cryptogenic patients. The only difference found between cryptogenic and small vessel patients was higher LA size in the latter group.

Conclusion:
In a large population-based study, TTE findings in cryptogenic stroke patients were less similar to cardioembolic stroke and more similar to other subtypes. While our findings suggest it is less likely to have echocardiographic findings concerning for cardioembolic stroke in the cryptogenic population, further studies on novel and comprehensive cardiac markers are needed to confirm this.