bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP115: Interventional Therapy for Brain AVMs Before and After ARUBA
Authors: Sussman Eric , Teo Mario , Iyer Aditya , Ho Allen , Pendharkar Arjun , Dodd Robert , Steinberg Gary
Published: March 2022

Introduction:
The ARUBA Trial (2014) concluded that medical management alone is superior to medical management plus interventional therapy in the management of unruptured brain arteriovenous malformations (bAVMs). This sparked considerable controversy among involved healthcare providers.

Hypothesis:
We hypothesize that the publication of ARUBA impacted the volume and type of bAVMs treated in a large tertiary care center.

Methods:
This was a retrospective review of a prospectively maintained database of bAVMs treated at Stanford Hospital and Clinics from January 2012 through July 2015. The study period was divided into three phases: the ‘pre-ARUBA phase’, consisting of the 17 months prior to the presentation of ARUBA Trial Results at the XXII European Stroke Conference (ESC) (Jan 1, 2012 - May 31, 2013), the ‘transition phase’, consisting of the 8 months between ESC XXII and the ARUBA publication in Lancet (June 1, 2013 - Feb 15, 2014), and the ‘post-ARUBA phase’, or the 17 months following the Lancet publication (Feb 16, 2014 - July 31, 2015).

Results:
Thirty patients were treated in the ‘pre-ARUBA phase’ (1.8/month), 23 in the ‘transition phase’ (2.7/month) and 37 in the ‘post-ARUBA phase’ (2.2/month). The percentage of treated bAVMs that were not ruptured at the time of presentation was 40%, 57%, and 46% in these study phases, respectively (chi-square statistic=5.96, p=0.05), and the mean S-M for each phase was 2.6, 3.0 and 2.4, respectively. The percentage of patients undergoing surgery as a component of their treatment regimen was 60% in both the pre- and post-ARUBA phases, whereas the percentage undergoing CyberKnife radiosurgery was 23% and 22%, respectively. There is no difference in the percentage of patients treated with each modality in the pre- and post-ARUBA phases (chi-square statistic=0.41, p=0.94).

Conclusions:
The volume and type (ruptured vs. unruptured, S-M Grade) of bAVMs treated at one large neurosurgery referral center has been relatively unchanged in the period of time leading up to and following ARUBA. Furthermore, there has been no change in the frequency of the various treatment modalities throughout the period in study. Additional research is necessary to more thoroughly characterize the impact of ARUBA on the treatment patterns of bAVMS.
Abstract WMP14: Increased Diffusion Heterogeneity After Acute Ischemic Stroke is Associated With Salvageable Tissue
Authors: Wu Ona , Lauer Arne , Boulouis Gregoire , Cloonan Lisa , Etherton Mark , Cohen Abigail S , Cougo-Pinto Pedro T , Mott Katherine , Copen William A , Rost Natalia S
Published: March 2022

Background:
Diffusion kurtosis MRI (DKI) may be more sensitive to microstructural changes in acute ischemic stroke (AIS), compared to diffusion weighted MRI (DWI). We investigated differences in diffusion kurtosis metrics related to time and tissue outcome.

Methods:
DKI from AIS patients enrolled in a prospective serial MRI study were analyzed (N=18). Mean kurtosis (MK), axial kurtosis (AK), radial kurtosis (RK), mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD) and fractional anisotropy (FA) maps were calculated. Follow-up (FU) FLAIR infarct volumes were defined as “final.” Abnormal perfusion was defined as tissue with Tmax values greater than 6 seconds. All maps were co-registered to one another. DWI and DKI were compared (nonparametric Spearman’s correlation analysis) in the following regions: Core (abnormal acute DWI and FU), Growth (normal acute DWI, abnormal FU), and Salvaged (normal acute DWI, abnormal acute perfusion, normal FU).

Results:
Patient characteristics were: mean±SD age 66±10 years, median [IQR] admission NIHSS score 6 [3-11], time-to-acute MRI 6.2±2.1 h, time-to-FU MRI 3.0±1.3 days, acute DWI lesion 4.9 [0.8-21.1] cm3 and FU lesion 12.9 [1.8-54.7] cm3. Significant correlations were found between time-to-MRI and diffusivity and kurtosis metrics, but differed depending on tissue outcome (Table).

Discussion:
The significant inverse correlation between FA and RK and time-to-MRI in salvaged tissue suggests renormalization of transient ischemia-induced increases in FA and RK tissue with otherwise preserved cytoarchitecture. One possible mechanism underlying this could be that hyperacute ischemia-induced cellular swelling increases tortuosity of water diffusion paths, imposing direction-dependent restrictions upon diffusion. Coupled with changes in DWI, DKI may provide further insight into tissue evolution after AIS and therefore improve identification of potentially salvageable tissue.
Abstract WMP17: Severe CT Perfusion Bolus Delays Predict Infarct Growth Despite Reperfusion
Authors: Christensen Soren , Tsai Jenny , Kemp Stephanie , Mishra Nishant , Kim Sun , Mlynash Michael , Federau Christian , Bammer Roland , Frankel Michael , Dehkharghani Seena , Devlin Thomas , Yavagal Dileep , Straka Matus , Zaharchuk Greg , Akhtar Naveed , Haussen Diogo , Marks Michael , Jovin Tudor , Nogueira Raul , Albers Greg , Lansberg Maarten
Published: March 2022

Introduction:
Prior studies based on MR data have shown that large perfusion lesions with long perfusion delays (Tmax>10s) are associated with poor functional and imaging outcomes. It is uncertain if the same associations exist for patients imaged with CT perfusion (CTP).

Hypothesis:
Patients with large volumes (>100mL) of tissue with a Tmax delay exceeding 10s (malignant Tmax profile) on CTP exhibit more infarct growth and have larger infarct outcomes than patients without this profile.

Methods:
The CRISP study is a multi-center NIH-sponsored prospective cohort study designed to evaluate if the presence of a CTP mismatch pattern is associated with a favorable response to reperfusion. All patients underwent CTP prior to endovascular therapy, early follow-up MRI (<36 hours from baseline CTP), and MRI at day 5. Infarct growth was calculated as the difference between the infarct core volume on baseline CTP (tissue with rCBF<30%) and the day 5 FLAIR. Reperfusion was defined as >50% resolution of the Tmax>6s lesion between baseline and early follow-up, or TICI 2b or 3 reperfusion by angiography in the absence of an early follow up scan. The volumes were compared using Wilcoxons rank-sum test, we report median, [IQR].

Results:
Baseline mismatch profile, reperfusion status and day 5 MRI were available in 109/201 patients, of whom 99 reperfused. Among patients with reperfusion, those with a malignant Tmax profile (n=24) had more infarct growth than patients without a malignant profile (n=75) (90,[49-116] vs 43,[18-81] mL, p=0.006). Patients with malignant profile also had larger final infarct volumes (110,[61-155] vs 48,[21-99] mL, p=0.001). Both the time from stroke onset and from baseline CTP to intravascular therapy were balanced between the two Tmax profile groups (p=0.32 and 0.53). Of the 10 patients without reperfusion, only 1 had malignant Tmax profile and no comparisons we performed in this group.

Conclusion:
A Tmax>10s lesion of 100 mL or more on CTP is associated with more than doubling of both infarct growth and final infarct volume despite successful reperfusion. While this does not exclude potential benefit from intraarterial thrombectomy, it suggests that the beneficial effect of reperfusion may be attenuated among patients with a malignant CTP profile.
Abstract WMP2: A New Device to Prevent Embolization in New Territories During Mechanical Thrombectomy
Authors: Piotin Michel , Redjem Hocine , Ciccio Gabriele , Smajda Stanislas , Blanc Raphaël
Published: March 2022

Introduction:
Embolic events can occur in up to 12% of cases of stent retriever thrombectomy and are associated with a 2-fold increase in mortality compared with cases without embolic complications. The COVER embolization protection device (Lazarus Effect, Campbell, California, USA) is a novel nitinol-braided mesh device that surrounds stent retriever (SR) devices and thrombus during thrombectomy to mitigate clot fragmentation and embolization.

Hypothesis:
Our goal was to evaluate the performance of this new COVER device in mechanical thrombectomy procedures for ischemic stroke therapy.

Methods:
We investigated the use of the Lazarus COVER device in combination with SR for mechanical thrombectomy. We report our initial experience including rates of target vessel recanalization and embolization in new territories (ENT). An independent core lab reviewed case images and films and adjudicated safety and efficacy endpoints. Thrombectomy procedures were initiated per standard approach. Once the SR was in place, the delivery microcatheter was removed. The Lazarus COVER device rapid exchange catheter was then delivered over the stent retriever pusher wire and advanced to the proximal end of the SR. The SR and Lazarus COVER were then pulled back as a system.

Results:
In a total of 20 patients, 20 thrombectomy procedures were performed from March through June 2015. Large vessel occlusions concerned 9 M1, 8 M2, 2 M1/M2 and 1 tandem (ICA + M1). Five operators in 20 cases and 35 total deployments with SR devices deployed the Lazarus COVER device successfully. There were no device-related complications, adverse events or serious adverse events. A TICI 2b/3 was obtained in 95% of cases (19/20), TICI 2a in 1 case. Neither ENT nor angiographic vascular damage occurred. Three-month mRS was obtained in 15/20 patients to date (mean: mRS 2, range:0-6).

Conclusions:
Application of the Lazarus COVER device when performing acute stroke thrombectomy with SR is feasible, appears to be safe, and may result in good successful recanalization rates with less embolic events.
Abstract WMP21: Which is a Better Predictor of Functional Outcome, TICI Score or Perfusion Imaging?
Authors: Spokoyny Ilana , Mlynash Michael , Federau Christian E , Kemp Stephanie M , Lansberg Maarten G , Marks Michael P , Albers Gregory W
Published: March 2022

Background:
DEFUSE 2 demonstrated that patients with Target mismatch on MRI had favorable clinical response to reperfusion. This study compares the accuracy of early follow-up perfusion imaging vs. end of procedure angiographic TICI scores for predicting functional outcome.

Methods:
Prospectively enrolled ischemic stroke patients underwent a baseline MRI followed by endovascular therapy within 12 hours of symptom onset. Patients with the Target mismatch profile, with both end of procedure TICI score and early follow-up perfusion imaging were included. Reperfusion was defined as % reduction in perfusion lesion (Tmax >6s) volume between baseline and early follow-up. Discordance between TICI and perfusion imaging was defined as TICI 0-2a with >50% reperfusion or TICI 2b-3 with <50% reperfusion.

Results:
66 patients were included; 12 (18%) TICI 0-1, 19 (29%) TICI 2A, 23 (35%) TICI 2B, and 12 (18%) TICI 3. More favorable TICI scores were associated with greater reperfusion (p<0.001), but 33% had discordance between TICI and reperfusion imaging: 55% of TICI 0-2a patients and 14% of TICI 2b-3 patients. MRI reperfusion ≥90% had a more favorable mRS distribution than 50-90% (p=0.001) or <50% (p=0.004). TICI 2b-3 scores had a more favorable mRS distribution than TICI 2a (p=0.032) or TICI 0-1 (p=0.010) (Figure). mRS 0-2 was achieved in 72% with >90% MRI reperfusion vs 60% of TICI 2b-3 (p=0.42). The sensitivity of reperfusion ≥90% for predicting mRS 0-2 was not significantly different from TICI 2b-3 (0.58 vs. 0.68) p=0.45; but specificity was higher for reperfusion (0.80 vs. 0.60) p=0.039.

Conclusions:
While there is a strong association between end of procedure TICI and MRI reperfusion, one third of the DEFUSE 2 patients had discordant results. This may be due to additional reperfusion following the procedure, or subsequent thromboembolism. Reperfusion ≥90% on perfusion imaging had a higher specificity than a TICI 2b-3 score for predicting good outcome in Target mismatch patients.
Abstract WMP3: Grade 2 or Partial Collaterals in IMS III: Half Full or Half Empty?
Authors: Liebeskind David S , Hill Michael D , Jovin Tudor G , Menon Bijoy K , Nogueira Raul G , Zaidat Osama O , Scalzo Fabien , Demchuk Andrew M , Carrozzella Janice , von Kummer Ruediger , Khatri Pooja , Goyal Mayank , Yan Bernard , Foster Lydia D , Yeatts Sharon D , Palesch Yuko Y , Broderick Joseph P , Tomsick Thomas A , Yoo Albert J ,   for the IMS III Investigators
Published: March 2022

Background:
Most ischemic stroke patients have at least partial collateral filling of the ischemic territory or grade 2 collaterals, yet the temporal delay or limited spatial extent may vary considerably. We investigated the clinical implications of grade 2 (partial) versus grade 3 (complete) collaterals in the IMS III trial.

Methods:
The angiography core lab in IMS III prospectively evaluated collateral circulation utilizing the ASITN/SIR definitions of grades 2 and 3. The clinical features, serial imaging findings, revascularization results and outcomes were contrasted.

Results:
Of 203 M1 or intracranial ICA occlusions, ASITN/SIR collateral grades could be scored in 161 (79%) cases, including grade 0 or none (n=7), grade 1 or marginal (n=23), grade 2 or partial (n=62), grade 3 or complete but delayed (n=62) and grade 4 or early and complete (n=7) collaterals. History of hypertension (p=0.02) was more common in those with partial collaterals, whereas age, sex and other co-morbidities were similar. Initial stroke severity defined by baseline NIHSS was worse in those with partial versus complete collaterals (median 19 IQR 16-21 vs. median 17 IQR 13-20; p=0.02). Baseline ASPECTS was lower in partial versus complete collaterals (median 7 IQR 5-9 vs. median 8 IQR 7-10; p=0.04). Successful reperfusion (mTICI 2B-3) was markedly less frequent (16% vs. 44%, p<0.001), despite equivalent recanalization of primary vessel occlusions (AOL 2-3) (49% vs. 54%, p=0.34). ASPECTS at 24 hours was much lower in partial versus complete collaterals (median 3 IQR 1-5 vs. median 6 IQR 3-7; p<0.001), with greater ASPECTS decline (median 4 IQR 2-5 vs. median 2 IQR 1-4; p=0.002) even after successful reperfusion (median 3.5 IQR 1-4.5 vs. median 2 IQR 1-4; p=0.22). 90-day mRS was notably worse in those with partial collaterals (median 4 IQR 3-6 vs. median 2 IQR 1-4; p<0.001) with fewer good clinical outcomes (12% mRS 0-2 vs. 32%, p<0.001) and greater mortality (19% vs. 5%, p=0.003).

Conclusions:
Grade 2 or partial collaterals have radically distinct imaging and clinical implications in the setting of endovascular stroke therapy.
Abstract WMP46: Histone Deacetylase Inhibitor, Sodium Butyrate, Exhibits Neuroprotective Effects in a Stroke Model of Middle-Aged Female Rats
Authors: Park Min Jung , Sohrabji Farida
Published: March 2022

Background and Purpose:
Sodium butyrate (NaB) is recognized as a HDAC inhibitor exhibiting anti-inflammatory and neuroprotective effects in a rat ischemic model of stroke as well as a myocardial ischemia model. Although clinical evidence show that older women are at higher risk for stroke occurrence and greater stroke severity, no studies have evaluated the effectiveness of the HDAC inhibitor either in females or in aged animals. Additionally, few studies have used this treatment at a time point > 6 h following stroke, thus the effectiveness of delayed NaB administration is not well understood. Our present study specifically tested the HDAC’s neuroprotective effect on middle-aged female rats after ischemic damage.

Methods:
Middle-aged Sprague-Dawley female rats (9-11 months old, constant diestrus) were used for all experiments. Middle cerebral artery occlusion (MCAo) was induced by intracerebral injection of endothelin-1 (600 pmol). Rats were treated with NaB (300 mg/kg, i.p.) at 6 h and 30 h following ET-1 injection. Animals were sacrificed at 5 days after MCAo. Brains were quickly removed and sectioned coronally at 2-mm thickness. The sections were immersed in 2% 2,3,5-triphenyltetrazolium chloride in DPBS for 30 min at 37°C and processed for imaging. Serum and brain lysates were also collected for biochemical analyses.

Results:
Treatment with NaB, a fatty acid HDAC inhibitor, by i.p. injection 6 h after MCAo followed by another injection 30 h later reduced brain infarction determined at 5 day. The effect was consistent both in cortex and striatum with an approximately 40% and 60% decrease, respectively, in infarct volume (n=6-7; p<0.01). The protective effects of NaB against MCAo were associated with the anti-inflammatory effect of this HDAC inhibitor. Specifically, NaB treatment significantly suppressed MCAo-induced increase of IL-1beta, IL-17A, and IL-18 in brain lysates from the ischemic hemisphere. No significant alterations were observed in cytokines and chemokines in circulating serum level at 5 day post MCAo.

Conclusions:
These findings support the HDAC inhibitor, NaB, exhibits neuroprotective effects against MCAo-induced brain damage. This is also the first report that NaB treatment post-stroke is neuroprotective in older female rats.
Abstract WMP48: Delayed Intravenous Administration of Drag Reducing Polymers Improves Brain Microcirculation and Neurologic Outcome After Permanent Middle Cerebral Artery Occlusion in Rats
Authors: Bragina Olga A , Wu Jun , Yang Yirong , Kameneva Marina V , Nemoto Edwin M , Bragin Denis E
Published: March 2022

Introduction:
Tissue plasminogen activator is used in only 5% of stroke patients because therapeutic window is short (∼3 hr) due to risk of hemorrhage. Rheological modulation of blood flow by nanomolar concentrations of drag-reducing polymers (DRP) improved hemodynamics and survival in animal models of the ischemic myocardium and limb. We previously showed that DRP applied early at 30 min after permanent middle cerebral artery occlusion (pMCAO) restored microvascular perfusion and improved neurologic outcome. We hypothesized that DRP applied after 3 hr delay would be effective in improving recovery.

Methods:
DRP or saline (control) were i.v. injected 3 hours after pMCAO in rats. Evaluation of the acute DRP effects (5 hours after pMCAO) on microvascular perfusion, hypoxia (NADH) and blood brain barrier (BBB) was done by in-vivo 2-photon laser scanning microscopy (2PLSM) and followed by brain perfusion for Fluoro-Jade staining for neurodegeneration. Cerebral infarction and perfusion were evaluated by MRI at 24 hours, 1 and 3 weeks after pMCAO. Motor function was evaluated by Rotarod test at 1, 2 and 3 weeks after pMCAO.

Results:
DRP compared to saline, applied after 3 hours following pMCAO, improved impaired microvascular circulation in the penumbra of the parietal cortex (Δ=33 %), reducing hypoxia (Δ=27 %) and BBB damage (Δ=42 %) thereby protecting neurons from neurodegeneration (Fluoro-Jade, Δ=36 %) (n=4, p<0.05). After prolonged recovery, DRP solution compared to saline reduced infarct expansion (Δ=23 %) and increased cerebral blood flow (Δ=31 %) in the penumbra at 24 hours, 1 and 3 weeks after pMCAO as measured by MRI (n=6, p<0.05). Rotarod tests showed that DRP treated rats performed better than saline treated (Δ=35 %) at 1, 2 and 3 weeks after the pMCAO (n=6, p<0.05).

Conclusions:
Rheological enhancement of cerebral microcirculation by DRP improved neurologic outcome after permanent MCAO without reperfusion even with delayed application after stroke onset. Potential DRP mechanisms involve improved collateral flow and anti-inflammatory effects of the increased shear stress with enhanced microcirculatory flow. DRP may be an effective therapy for ischemic stroke even without reperfusion and after delayed administration following the stroke onset.
Abstract WMP54: Cerebrovascular Accidents in Patients With a Left Ventricular Assist Device
Authors: Miyazaki Yuichi , Seguchi Osamu , Tanaka Tomotaka , Hata Hiroki , Hayakawa Mikito , Kajimoto Katsufumi , Yamagami Hiroshi , Yanase Masanobu , Nagatuka Kazuyuki , Takahashi Jun C , Fujita Tomoyuki , Nakatani Takeshi , Minematsu Kazuo , Toyoda Kazunori
Published: March 2022

Background:
Cerebrovascular accidents (CVAs), including ischemic stroke, transient ischemic attack, and intracranial hemorrhage, are major and devastating complications of left ventricular assist devices (LVADs). However, little is known about their incidence and risk factors.

Materials and methods:
We retrospectively reviewed the medical records of 75 consecutive cases supported with a LVAD (mean age of 39 years, 60 men, paracorporeal pulsatile-flow LVAD in 31, implantable centrifugal-flow in 18, and implantable axial-flow in 26) in our institution between December 2009 and June 2014. The incidence rate of CVAs was estimated as events per patient-year, and baseline characteristics (age, sex, etiologies of heart failure, comorbid diseases, and types of LVAD) were assessed to determine their contribution to the incidences of total, ischemic and hemorrhagic CVAs.

Results:
During 113.7 patient-years of observation, a total of 59 CVA events (26 hemorrhagic and 33 ischemic) were identified in 31 cases, yielding an incidence rate of 0.52 events per patient-year. Univariate negative binomial regression (NBR) analysis demonstrated that patients with an axial-flow LVAD had significantly lower incidence of total CVAs [incidence rate ratio (IRR) 0.29, 95% confidence interval (CI) 0.10 - 0.88, p=0.03] and subsignificantly of both of ischemic (0.30, 0.05 - 1.69, p=0.17) and hemorrhagic CVAs (0.29, 0.08 - 1.02, p=0.05) than those with a paracorporeal LVAD (reference), whereas those with a centrifugal-flow LVAD did not. Patients with diabetes had a significantly higher incidence of total CVAs (IRR 2.39, 95% CI 1.03 - 5.57, p=0.04) and ischemic CVAs (4.01, 1.31 - 12.2, p=0.02) than those without diabetes but not of hemorrhagic CVAs (1.41, 0.54 - 3.66, p=0.48). Results of multivariate NBR analysis were similar with those of univariate analysis.

Conclusion:
Among patients on LVAD support, CVA occurred at a rate of 0.52 events per patient-year. Axial-flow LVADs reduced the incidence of CVAs, regardless of ischemic or hemorrhagic subtype, compared with paracorporeal LVADs. Diabetes was associated with an increased risk of CVAs, but the influence was different between ischemic and hemorrhagic CVAs.
Abstract WMP55: Racial Disparities in Stroke Recovery: a Meta-analysis
Authors: Chhatbar Pratik Y , Lee Hamin , Ovbiagele Bruce , Lackland Daniel T , Adams Robert J , Feng Wuwei
Published: March 2022

Introduction:
While it is well known that Blacks have a higher risk of death after an index stroke compared to their White counterparts, the influence of Black race on recovery after a stroke is unclear.

Objective:
To qualitatively and quantitatively examine the association of Black vs. White race on stroke recovery utilizing a systematic review and meta-analysis.

Methods:
We searched PubMed for cohort studies that investigated racial variation issues in stroke motor recovery between January 1970 and July 2015, in which outcome was measured by Functional Independence Measures (FIM) scale. Change scores (the difference score between discharge and admission) or endpoint scores (at the time of discharge) were compared between Whites and Blacks by calculating standardized mean differences (Hedge’s
g
) to derive a summary effect size. Random Effects model was used to account for data heterogeneity.

Results:
We identified six studies (4 studies with changes scores and 4 studies with endpoint scores available) with a total 151,361 subjects. Overall, there was no difference between blacks vs. Whites (Hedge’s
g
= 0.02, 95% CI = [-0.08, 0.13],
p
= 0.89) if endpoint scores were used, but Whites seemed to show a non-significant pattern of greater improvement than Blacks during the inpatient hospital rehabilitation (FIM change scores, Hedge’s
g
= 0.12, 95% CI = [-0.05, 0.30],
p
= 0.17). This qualitative discrepancy maybe explained by the difference in admission score between the two groups (Hedge’s
g
= 0.16, 95% CI = [-0.01, 0.34],
p
= 0.06). Better FIM change scores in Whites maybe explained by longer stays in hospital (Hedge’s
g
= 0.13, 95% CI = [0.00, 0.25],
p
= 0.06).

Conclusions:
This analysis identifies a significant evidence gap for racial disparities in stroke recovery. Additional studies to assess change scores are needed to address these gaps.
Abstract WMP58: Burden and Distribution of Cerebral Microbleeds Predict Long-Term Mortality in Lacunar Stroke Patients
Authors: Song Tae-Jin , Kim Jinkwon , Song Dongbeom , Nam Hyo Suk , Kim Young Dae , Kim Yong-Jae , Heo Ji Hoe
Published: March 2022

Background and Purpose:
Cerebral microbleeds (CMBs) are frequently observed in patients with lacunar infarction. CMBs are associated with an increased risk of mortality in stroke patients with nonvalvular atrial fibrillation and in the elderly population. We investigated the association of CMBs with long-term mortality in patients with lacunar infarction according to characteristics of CMBs.

Methods:
This was a retrospective hospital-based observational study. This study included 315 patients with first-ever lacunar infarction who underwent brain gradient-recalled echo imaging. The mortality data were obtained from the Korean National Statistical Office. By using a Cox regression analysis, we investigated the relationship between CMB characteristics and all-cause, ischemic stroke, and hemorrhagic stroke mortality.

Results:
CMBs were noted in 17.5% of patients (55/315). During a follow-up of 4.8 median years (interquartile range, 3.4-6.2 years), 43 patients (13.7%) died (ischemic stroke, 8; hemorrhagic stroke, 3). In multivariate analysis (age, sex p < 0.1 in univariate), the presence of multiple (≥4) CMBs was an independent predictor for all-cause (hazard ratio [HR], 6.02), ischemic stroke (HR, 15.44), and hemorrhagic stroke (HR, 16.56) mortality. Considering CMB location, strictly lobar CMBs were independently related to hemorrhagic stroke mortality (HR, 101.22)(Tables and Figures).

Conclusions:
The presence, multiplicity, and distribution of CMBs were predictive of long-term mortality in acute lacunar infarction. The detection and evaluation of CMBs are of value in predicting long-term prognosis in patients with lacunar infarction.
Abstract WMP70: Accuracy of Emergency Dispatcher Stroke Recognition When Employing a Stroke Screening Tool: A Systematic Review
Authors: Oostema John A , Carle Trevor , Talia Nadine , Reeves Mathew
Published: March 2022

Introduction:
Emergency dispatchers are usually the first contact point for stroke patients accessing the healthcare system. Dispatcher stroke recognition is associated with better paramedic stroke recognition and faster emergency medical services (EMS) response time, but stroke is often unrecognized during the initial call. We conducted a systematic review to quantify the accuracy of emergency dispatcher stroke recognition when employing stroke screening tools.

Methods:
We conducted a comprehensive search Medline, EMBASE, CINAHL, and Cochrane databases to identify studies of dispatcher stroke recognition accuracy using a stroke screening tools such as the Medical Priority Dispatch System (MDPS) or Face Arm Speech Time (FAST) mnemonic. Studies were included if they reported dispatcher sensitivity or positive predictive value (PVP) using hospital stroke/TIA diagnosis as the gold standard. Study quality was assessed using QUADAS 2. Two independent reviewers determined study eligibility, assessed quality, and abstracted data.

Results:
We identified 1450 abstracts; seven cohort studies met inclusion criteria. Stroke screening tools included MPDS (n=4), FAST (n=2), and a novel screening algorithm (n=1). The sensitivity of dispatcher stroke recognition (5 studies, range 41-83%) and PPV (7 studies, range 42% -68%) were variable. Specificity was high (3 studies, 95-99%). No screening tool demonstrated superiority. Included studies had moderate risk of bias and dramatically variable stroke prevalence (range 3-68%).

Conclusion:
Published reports of screening tools utilized by emergency dispatchers demonstrate suboptimal sensitivity and PPV. More research is needed to identify the causes of poor dispatcher stroke recognition and to improve stroke screening tools.
Abstract WMP74: Admission Volume Depletion is Associated With Poor Outcome in Acute Ischemic Stroke
Authors: Shiue Harn , Albright Karen C , Sands Kara A , Sisson April , Shahripour Reza B , Lyerly Michael , Arora Kanika , Gadpaille Alissa , Khawaja Ayaz , Jones Benjamin A , Gropen Toby
Published: March 2022

Background:
Few large studies exist on volume depletion and its association with outcomes in acute ischemic stroke (AIS) patients. A common marker of volume status is the calculated blood urea nitrogen (BUN) to serum creatinine (SCr) ratio. We examined the association between admission volume depletion (BUN/SCr > 15) and discharge outcome in AIS patients.

Methods:
Consecutive patients (March 2014 - April 2015) who presented with AIS to our Comprehensive Stroke Center (CSC) were retrospectively analyzed. Demographics, medical history, imaging, initial lab values, stroke severity (NIHSS), and discharge disposition were recorded. Patients with BUN/SCr <= 15 and > 15 were compared and good outcome defined as discharge home. We performed logistic regression adjusting for admission NIHSS and age.

Results:
We identified 776 patients who met inclusion criteria. Patients with BUN/SCr >15, were older (median 61 vs. 68, p<0.001), more often female (43.5 vs. 59.6%, p<0.001), and had atrial fibrillation (9 vs. 16%, p=0.004). Greater proportions presented with a hyperdense artery sign (7.1 vs. 12.9%, p=0.010) and developed an in-hospital UTI (2.8 vs. 5.9%, p=0.034). Volume depleted patients had increased LOS (3 vs. 4 days, p=0.049) and higher in-hospital mortality (6.2 vs. 12.6%, p=0.003) with fewer discharged home (57.7 vs. 44.9%, p=0.001). A BUN/SCr >15 was associated with lower odds of good outcome at discharge (OR=0.57, 0.42 - 0.78; p< 0.001), this relationship persisted after adjusting for known predictors (OR=0.70, 0.49 -1.00; p=0.055).

Conclusions:
After controlling for age and NIHSS, volume depletion in AIS patients estimated by BUN/SCr ratio was associated with poor discharge outcome, complicated hospital course, increased LOS, and in-hospital mortality. This simple ratio can be used in the early evaluation and treatment of AIS. However, multi-center prospective studies are needed to determine if volume correction is confounding this association.
Abstract WMP76: Increased Systolic Blood Pressure Variability is Associated With Symptomatic Intracerebral Hemorrhage After Endovascular Treatment for Stroke
Authors: Bennett Alicia , Wilder Michael , Majersik Jennifer , Ansari Safdar , de Havenon Adam
Published: March 2022

Introduction:
Hemorrhagic transformation is a serious complication of endovascular treatment (IAT) for acute ischemic stroke. Increased systolic blood pressure variability (SBPV) is associated with symptomatic intracerebral hemorrhage (sICH) after intravenous rt-PA, however the association with IAT is unknown.

Hypothesis:
Increased SBPV will be associated with sICH after IAT for acute ischemic stroke.

Methods:
We retrospectively reviewed ischemic stroke patients from 2005-2013 who received IAT at a single center. SBPV was measured by standard deviation (SD) and coefficient of variation (CV) for all readings documented within 48 hours of hospital arrival (7,117 readings). A multivariable ordinal logistic regression model with the dichotomous outcome of sICH was used.

Results:
There were 156 patients identified, 49% male, mean age 64±15 years, and mean presenting NIHSS 16±8. Only 13/156 patients were treated with second-generation retrievable stent devices. sICH was identified in 18/156 patients (11.5%). Mean blood pressure was not significant at 24 or 48 hours. After controlling for potential confounders, a one quartile increase of SBP SD or CV was associated with a 1.8 to 2.3 fold increased risk of sICH (see Table and Figure).

Conclusions:
In acute ischemic stroke patients who undergo IAT, increased SBPV in the first 24 and 48 hours is associated with an approximately 80% increased risk of sICH. This association warrants prospective investigation, particularly in populations with predominant use of new generation stentrievers.
Abstract WMP87: Inflammatory Response in Cerebrospinal Fluid is Triggered by Large Volume Intraventricular Hemorrhage
Authors: Khader Eliyas Javed , Fam Maged D , John Sayona , Stadnik Agnieszka , Jesselson Michael , Zhang Lingjiao , Wu Meijing , McBee Nichol , Lane Karen , Ziai Wendy , Hanley Daniel , Awad Issam
Published: March 2022

Introduction:
Cerebrospinal fluid (CSF) pleocytosis has been consistently observed with intraventricular hemorrhage (IVH) in small case series. Its extent, time course, and relation to IVH volume and infection have never been studied in a large cohort with systematic data collection.

Hypothesis:
Inflammatory response in CSF follows a predictable pattern after IVH, and is more enhanced in cases with higher IVH volume and infection

Method:
We analyzed prospectively collected samples from 500 patients enrolled in the Clot Lysis Evaluation of Accelerated Resolution (CLEAR) phase III trial. Patients with obstructive IVH requiring external ventricular drainage (EVD) were randomized to receive thrombolytic or placebo injections via EVD. We analyzed 12,291 data points including daily peripheral WBC and RBC counts, CSF RBC, WBC and neutrophil count, protein and glucose. Corrected WBCs (coWBC) reflecting true inflammatory response in the CSF was calculated by controlling for RBC/WBC ratio in a contemporaneous blood sample of the patient. Consecutive values were adjusted to the date of ictus (day 0) and analyzed on days 1-9. Median daily values were chronologically plotted to define the temporal pattern for each parameter. Similar analyses were repeated after stratification based on IVH volume, time to EVD insertion, and presence of culture positive ventriculitis (14 cases, 3%)

Result:
CSF protein gradually declined with later clearance of RBCs after IVH. There was a surge in coWBC at days 3-5. All parameters of inflammatory response, and most notably the coWBC peak, were greater with larger volume of IVH. Subgroup analyses defined a threshold for significant inflammatory response with initial IVH volume 27mls (P=0.006). Bacterial ventriculitis resulted in significantly higher coWBCs (P<0.001) and neutrophils (P=0.01), but only in cases with low volume IVH (<27ml)

Conclusion:
Inflammation is an integral response to IVH and is more pronounced with large IVH volume. Bacterial ventriculitis is associated with CSF leukocytosis exceeding the aseptic inflammatory response, notably in lower volume bleeds. These results form a basis for future correlation with treatment rendered, rate of IVH clearance and clinical outcome, with upcoming unblinding of the trial.
Abstract WMP88: Perihematomal Edema Expansion Rate Predicts Functional Outcome in Deep Intracerebral Hemorrhage
Authors: Grunwald Zachary , Urday Sebastian , Beslow Lauren A , Vashkevich Anastasia , Ayres Alison , Greenberg Steven M , Goldstein Joshua N , Battey Thomas W , Simard J M , Rosand Jonathan , Kimberly W T , Sheth Kevin N
Published: March 2022

Introduction:
Perihematomal edema (PHE) expansion rate may be an independent predictor of poor functional outcome following spontaneous intracerebral hemorrhage (ICH). We examined whether this association varies by ICH location.

Hypothesis:
The effect size of PHE expansion rate on mortality and poor functional outcome will be greater for deep ICH compared to lobar ICH.

Methods:
Subjects (n=139) were retrospectively identified from a prospective ICH cohort enrolled from 2000-2013. Inclusion criteria: ≥18 years of age, spontaneous supratentorial ICH, and known time of onset. Exclusion criteria: infratentorial or primary intraventricular hemorrhage, subsequent surgery, trauma, or warfarin-related ICH. ICH, PHE, and intraventricular hemorrhage (IVH) volumes were measured from CT scans. PHE expansion rates were calculated from serial PHE volume measurements. Logistic regression assessed the association between PHE expansion rate and mortality or poor functional outcome (modified Rankin Scale >2) at 90 days. Odds ratios are per 0.04 mL/h.

Results:
PHE expansion rate from baseline to 24 hours (PHE24) predicts mortality for deep (p=0.03, OR 1.13[1.02-1.26]) and lobar ICH (p=0.02, OR 1.03[1.00-1.06]) in unadjusted regression, and in models adjusted for age (Deep: p=0.02; Lobar: p=0.03), blood pressure (Deep: p=0.02; Lobar: p=0.04), IVH volume (Deep: p=0.02; Lobar: p=0.05), Glasgow Coma Scale (Deep: p=0.03; Lobar: p=0.02), or time to baseline CT (Deep: p=0.05; Lobar: p=0.05). PHE24 also predicts mortality for lobar ICH adjusting for ICH volume (p=0.05, OR 1.03[1-1.06]). A significant interaction exists between ICH location and PHE expansion rate from baseline to 72 hours (PHE72) in models predicting mRS>2 (p=0.04). PHE72 predicts mRS>2 for deep but not lobar ICH (p-values not shown) in models that are unadjusted (p=0.02, OR 4.04[1.25-13.04]) or adjusted for ICH volume (p=0.02, OR 4.3[1.25-14.98]), age (p=0.03, OR 5.4[1.21-24.11]), blood pressure (p=0.05, OR 3.28[1.02-10.57]), IVH volume (p=0.02, OR 4.59[1.28-16.41]), GCS (p=0.02, OR 4.19[1.2-14.55]), or time to first CT (p=0.03, OR 4.02[1.19-13.56]).

Conclusion:
PHE72 predicts poor functional outcomes exclusively after deep ICH, whereas PHE24 predicts mortality for deep and lobar ICH.
Abstract WMP90: Florbetapir PET to Diagnose Cerebral Amyloid Angiopathy
Authors: Gurol M. Edip , Becker J. Alex , Riley Grace A , Fotiadis Panagiotis , Schwab Kristin M , Johnson Keith A , Greenberg Steven M
Published: March 2022

Introduction:
Previous studies showed that Pittsburgh Compound B (PiB) labels vascular amyloid characteristic of cerebral amyloid angiopathy (CAA) on PET scans; PiB is not approved for clinical use, however.

Hypothesis:
We hypothesized that Florbetapir, an FDA-approved PET tracer, can detect amyloid in CAA and help distinguish CAA-related intracerebral hemorrhage (ICH) from hypertensive ICH (HTN-ICH).

Methods:
We prospectively enrolled non-demented survivors of primary ICH related to probable CAA (per Boston Criteria, n=10) and HTN-ICH (n=9). All patients underwent Florbetapir-PET, multimodal MRI, and additional PiB-PET for the CAA patients. Amyloid burden was assessed quantitatively using parametric maps and also visually, classified as positive or negative. Spatial correlations between Florbetapir and PiB retention were used to test vascular amyloid binding in CAA. We have tested the diagnostic value of Florbetapir by comparing global and occipital mean Florbetapir retention (standard uptake value ratio, SUVR) as well as Florbetapir positive/negative status between CAA and HTN-ICH groups.

Results:
The CAA and HTN-ICH groups had similar age (66.9 vs 67.1), sex and white matter hyperintensity volumes (31ml vs 30ml, all p>0.8). Florbetapir uptake and PiB retention strongly correlated in CAA patients both globally within cerebral cortex (r=0.96, p<0.001) and regionally in occipital, frontal, temporal, parietal cortices (all r>0.8, all p
<
0.01). Mean global cortical Florbetapir uptake was significantly higher in CAA than HTN-ICH (SUVR: 1.41±0.16 vs 1.16±0.08, p=0.001) as was mean occipital SUVR (1.44±0.12 vs 1.17±0.08, p<0.001), remaining independent after correcting for global SUVR (p=0.02). Visual rating for Florbetapir positive/negative demonstrated perfect interrater agreement (k=1) between two trained neurologists blinded to all other information and was positive for all 10 CAA patients vs 1 of 9 HTN-ICH patients (sensitivity 100%, specificity 89%).

Conclusions:
Florbetapir, like PiB, appears to label vascular amyloid in patients with CAA-related ICH. Data using the approved Florbetapir binary visual reading method suggest sufficient sensitivity and specificity for diagnostic use in appropriate clinical settings.
Abstract WMP94: Perihematomal Edema and Functional Outcomes in Intracerebral Hemorrhage: Influence of Hematoma Volume and Location
Authors: Murthy Santosh , Moradiya Yogesh , Dawson Jesse , Lees Kennedy , Hanley Daniel , Ziai Wendy
Published: March 2022

Background and Purpose:
Perihematomal edema is associated with poor outcomes following intracerebral hemorrhage (ICH). Perihematomal edema evolves in the early period after ICH, providing a therapeutic target and window for intervention. We studied the effect of perihematomal edema volume expansion in the first 72 hours (iPHE) and its relationship with functional outcomes.

Methods:
We used data contained in the Virtual International Stroke Trials Archive. We included patients who presented within six-hours of symptom onset, had baseline clinical, radiological and laboratory data, and further computed tomographic scan data at 72 hours and 90-day functional outcomes. We calculated iPHE and used logistic regression analysis to assess relationships with outcome. We adjusted for confounding variables and the primary outcome measure poor day-90 outcome (defined as modified Rankin Scale score of ≥ 3. We performed subgroup analyses by location and volume of ICH.

Results:
We included 596 patients with ICH. Median baseline hematoma volume was 15.0 mL (IQR: 7.9- 29.2) and median baseline perihematomal edema volume of 8.7 mL (IQR: 4.5- 15.5). Hematoma expansion occured in 122 (34.9%) patients. Median iPHE was 14.7 mL (IQR: 6.6-30.3). The odds of a poor outcome were greater with increasing iPHE (OR: 1.78, CI: 1.12- 2.64 per mL increase). Subgroup analyses showed iPHE was only related to poor functional outcomes in basal ganglia and small (<30 mL) ICH.

Conclusion:
Absolute increase in PHE over 72 hours was associated with worse functional outcomes following ICH, particularly with basal ganglia ICH and hematomas <30 mL.
Abstract WMP99: Major Causes of Stroke in Children With Congenital and Acquired Heart Disease
Authors: Elbers Jorina , Lee Esther J , Yarlagadda Vamsi V , Lo Clara , Hanisch Debra , Lin Aileen , Almond Christopher S , Shin Andrew Y
Published: March 2022

Introduction:
Heart disease is the leading cause of stroke in children; however, little is known about the distribution of cardiac conditions associated with stroke.

Hypothesis:
We assessed the hypothesis that patients requiring cardiac surgery, catheterization, or mechanical support account for the majority of strokes in children with heart disease.

Methods:
All patients admitted to Lucile Packard Children’s Hospital at Stanford were included. A new diagnosis of stroke was identified using hospital data. Descriptive statistics were used to evaluate the characteristics of the population and tabulate common causes of stroke and stroke sub-types.

Results:
Between September 1, 2009 and February 1, 2014, a total of 36 patients with congenital or acquired heart disease had a new diagnosis of stroke. The median age was 4.18 years (IQR 0.32 - 10.6 years); 64% were male. Overall, 50% of strokes were arterial ischemic, 17% hemorrhagic and 25% had both ischemic and hemorrhagic components. Transient ischemic attacks accounted for the remaining 8%. Patients on mechanical support accounted for the majority of strokes (33%; ECMO 22%, ventricular assist device 11%) followed by left-sided cardiac catheterization (22%). Single-ventricle palliation procedures (Norwood or Glenn) accounted for 11% and septal defect repair 8%. Associated cardiac conditions included cardiomyopathy (28%), single-ventricle physiology (28%), septal defects (14%), myo/endocarditis (11%), heart transplantation (6%), and left-sided valvular disease (5%). Overall, 47.2% of patients were receiving anticoagulant therapy at the time of their stroke. Among those patients, 32% with arterial ischemic strokes and 60% with hemorrhagic strokes were within goal anticoagulation levels.

Conclusions:
Mechanical circulatory support, cardiac catheterizations and single-ventricle palliation procedures account for two-thirds of strokes observed in patients with cardiac disease. Many strokes occur in patients receiving anticoagulant therapy in accordance with contemporary anticoagulation guidelines. Re-evaluation of these guidelines and studies to reduce the risk of strokes in vulnerable sub-groups of cardiac patients is warranted.
Abstract WP10: Peri-procedural Heparin Use in Stent-retriever Thrombectomy
Authors: Haussen Diogo C , Nogueira Raul G , Liebeskind David S , Smith Wade , Lutsep Helmi , Jovin Tudor , Xiang Bin , Nogueira Raul G
Published: March 2022

Background and Objectives:
The use of periprocedural heparin has been reported safe and potentially beneficial during thrombectomy with older generation devices. We aim to investigate the impact of heparin in the era of stent-retrievers.

Methods:
A TREVO2 trial post-hoc analysis was performed aiming to compare baseline characteristics and clinical outcomes between patients who received [HEP(+)] versus patients that did not receive periprocedural heparin [HEP(-)].

Results:
Out of 173 patients treated in the trial, 58 received a mean 3999 units of periprocedural heparin (n=42 received only pre-procedural bolus for a mean of 2952 units). Baseline characteristics amongst HEP(+) and HEP(-) were similar, with the exception of lower NIHSS (17±5 vs 18±6; p=0.04), IV t-PA use (37 vs 64%; p<0.01), and higher baseline ASPECTS (7.6±1.3 vs 7.1±1.7; p=0.02) in the HEP(+) patients. Occlusion site varied amongst HEP(+) and HEP(-) groups: vertebrobasilar 10 vs 5%; ICA 8 vs 21%; MCA-M1 70 vs 55%; MCA-M2 10 vs 17%; p=0.04, respectively. Time from symptom-onset to puncture was similar, while procedure duration was longer in HEP(+) patients (98±47 vs 82±42min; p<0.01). TICI2b-3 reperfusion rate was comparable (65 vs 62%; p=0.74), as well as embolization to unaffected territory, and access-site complications. Hemorrhagic changes were similar (ECASS HI1/HI2 27 vs 24%; p=0.71 and PH1/PH2 22 vs 25%; p=0.85). Good outcome (mRS0-2) and mortality at 90-days were 40 vs 25% (p=0.07) and 29 vs 27% (p=0.85), respectively. Multivariate logistic regression for good outcome identified the following independent predictors: use of heparin bolus (OR:5.30; 95%CI 1.70-0.16.48; p<0.001), intubation (OR:0.10; 95%CI 0.03-0.33; p<0.001), TICI2b-3 reperfusion (OR:6.56; 95%CI 2.29-18.83; p<0.001), diabetes mellitus (OR:0.11; 95%CI 0.03-0.39; p<0.001), NIHSS (OR:0.84; 95%CI 0.75-0.93; p<0.001), stent-retriever device (OR:3.54; 95%CI 1.28-9.03; p<0.001), time from symptom-onset to puncture (OR:0.64; 95%CI 0.45-0.89; p<0.001), and CHF (OR:0.23; 95%CI 0.06-0.83; p<0.001).

Conclusions:
The use of periprocedural heparin in stent-retriever thrombectomy is safe and may have a positive impact on outcomes.