bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP47: Low Sensitivity Of Widely Used Emergency Dispatch Algorithm For Thrombectomy Patients - Implications For Mobile Stroke Units
Authors: Haliem Ahmed , Menezes Candice M , churilov leonid , Smith Karen L , Delardes Belinda , Coote Skye , Easton Damien , Langenberg Francesca , Beharry James , Yogendrakumar Vignan , Weir Louise C , Mitchell Peter J , Donnan Geoffrey A , Davis Stephen , Campbell Bruce , Zhao Henry ,   Melbourne Stroke Unit consortium
Published: February 2023

Introduction:
Widely used emergency dispatch algorithms such as the Advanced Medical Priority Dispatch System (AMPDS) have limited diagnostic accuracy for prehospital diagnosis of stroke. With advent of mobile stroke units (MSU), this inaccuracy prevents optimal dispatch to patients who may benefit. Expedited endovascular thrombectomy (EVT) is a major contributor to net benefit of MSUs. We assessed the accuracy of AMPDS for recognizing stroke in thrombectomy patients in the Australian state of Victoria.

Methods:
We included consecutive patients accepted for EVT (direct and secondary transfer) to The Royal Melbourne Hospital from 2007-2021 in whom linked AMPDS dispatch codes could be obtained from Ambulance Victoria. The primary outcome was the proportion of cases dispatched as stroke vs non-stroke with subgroup analyses of the effect of baseline clinical severity, metropolitan vs rural dispatch and time to thrombectomy. Chi square and Mann Whitney tests were used as appropriate.

Results:
A total of n=618 patients were included with baseline NIHSS 16 (IQR 10-20). Of these, only 62% (95% CI 58-66) were initially dispatched as suspected stroke, with the most common non-stroke diagnoses being “Unconscious/Fainting” (19.2%) and “Falls” (6.9%). Those with a higher baseline severity (NIHSS ≥10) were less likely to be classified as stroke than those with lower severity (59% vs 76%, p<0.001), while no difference was found between metropolitan and rural patients (p=0.066). Overall, no significant time differences were found between stroke and non-stroke dispatches for ambulance dispatch to arterial access (median 208 vs 216 min, p=0.593) or hospital arrival to arterial access (median 42 vs 42 min, p=0.851). However, only 32 patients were treated on the MSU, which commenced operation November 2017.

Conclusions:
Almost 40% of thrombectomy patients did not receive an initial AMPDS dispatch of suspected stroke and those with higher baseline severity were more likely to be misclassified. Although time to thrombectomy was not significantly different between stroke vs non-stroke dispatches, MSU treatment was under-represented. Our findings have implications for emergency medical services and particularly mobile stroke units which rely on accurate stroke dispatch.
Abstract WMP64: Increased Risk Of Adverse Outcomes With Methocarbamol Versus Cyclobenzaprine Use In Medication Naïve Acute Stroke Patients
Authors: Simmonds Kent P , Atem Folefac , Welch Babu G , Ifejika Nneka L
Published: February 2023

Introduction:
Methocarbamol and Cyclobenzaprine are often used interchangeably as muscle relaxants for acute stroke patients. There is limited data comparing medication side effect profiles within this hemodynamically vulnerable population.

Methods:
Electronic medical records from 65 health care organizations (Aug 2002-Jul 2022) were used to identify a cohort of medication naïve acute stroke patients (ICD-10 codes I61-I63) who received Methocarbamol or Cyclobenzaprine. A 1:1 matched propensity score was used to adjust for baseline demographic and comorbidity differences. Outcomes included the 30-day relative risk (RR) and risk difference (RD) for: falls, sedation/fatigue, bradycardia, hypotension, seizure, urinary retention, and death. Sensitivity analysis focused on 30-day risk among patients aged > 65 years.

Results:
Prior to matching, the final cohort consisted of 34,865 stroke patients who received Methocarbamol (n=20,150) or Cyclobenzaprine (n=14,715). A total of 13,667 pairs were matched, all baseline covariates were well balanced. In the adjusted analyses, Methocarbamol (vs. Cyclobenzaprine) use during the acute stroke period was associated with a 44% increased risk of fall (RR: 1.44; 95% CI: 1.31-1.50) sedation/fatigue (RR: 1.54 95% CI: 1.44-1.65), bradycardia (RR: 1.32; 95% CI: 1.19-1.44), hypotension (RR: 1.29 95% CI: 1.20-1.38), and seizure (RR: 1.32 95%CI: 1.24-1.40). Results were not affected by age as adverse event risks were similar among patients aged >65.

Conclusions:
Compared to Cyclobenzaprine, Methocarbamol use was associated with increased 30-day risk of a range of adverse outcomes across the age spectrum for acute stroke patients.
Abstract WMP65: Association Between Heart Failure And Collateral Flow In Large Vessel Occlusive Ischemic Stroke
Authors: Godasi Raja , Badi Mohammed , Anisetti Bhrugun , Mateti Nihas , Salem Amr , Barrett Kevin M , Eidelman Benjamin H , Huang Josephine F , Meschia James F , Williams Lindsy N , English Stephen , Lin Michelle P
Published: February 2023

Introduction:
Collateral circulation plays a crucial role in determining the extent of brain tissue ischemia and functional outcome in large vessel occlusive (LVO) stroke. Heart failure (HF) is known to cause cerebral hypoperfusion, yet the relationship between HF and robustness of collateral flow has not been well described. Here we hypothesized that HF is associated with poor collateral flow and functional outcome in patients presenting with LVO treated with mechanical thrombectomy (MT).

Methods:
A single center retrospective study of patients presenting with LVO ischemic stroke who underwent MT between 2012-2020 was done. Single-phase CTA of head prior to MT was used to assess collateral status with poor status defined as ≤ 50% filling and good status as >50% filling. Classification of HF by left ventricular ejection fraction (LVEF) on echocardiogram was used where HF with reduced ejection fraction (HFrEF) had LVEF ≤40%, HF with preserved EF (HFpEF) had LVEF ≥50% with evidence of structural heart disease, and no HF was LVEF≥50% without structural heart disease. Functional outcome was modified Rankin scale (mRS) at 90 days with scores of 0-2 representing good outcome and 3-6 representing poor outcome. Multivariable logistic regression analyses were performed to evaluate the association between HF and poor collaterals after adjusting for vascular risk factors.

Results:
We identified 235 patients, mean age was 69 ±15 years, median NIHSS was 18, and 45.5% had HF (HFrEF 12.8%, HFmrEF 4.7%, HFpEF 28.1%) while 54.5% had no HF. Poor collaterals were seen in 47.7%, and those with HF were likely to have poor collaterals compared to those without HF (56.1% vs 35.1%, P=.001). There was a dose-dependent relationship between severity of HF and poor collaterals: adjusted odds of poor collaterals were 1.63 and 2.45 in HFpEF and HFrEF, compared to those without HF (trend p=.018). Patients with poor collaterals were likely to have poor outcome at 3 months compared to those with good collaterals (75.0% vs 57.8%; p=.015).

Conclusion:
Patients with HFrEF were twice as likely to have poor collaterals. This study demonstrated a likely mechanism for poor outcomes seen in ischemic stroke with HF, future studies may explore whether optimization of HF may augment collaterals to improve outcomes.
Abstract WMP7: Bridging Thrombolysis For Large Vessel Occlusion: Who Benefits Most? Analysis Of A Prospective Endovascular Therapy Registry
Authors: Sedghi Annahita , Barlinn Jessica , Pallesen Lars-Peder , Puetz Volker , Barlinn Kristian , Siepmann Timo
Published: February 2023

Introduction:
Recent meta-analytic evidence supported efficacy and safety of bridging intravenous thrombolysis (IVT) prior to endovascular therapy (EVT) for large vessel occlusion (LVO) but large confirmatory trials are still lacking and optimal candidates for treatment have been a topic of contention lately.

Objectives:
We aimed to determine a cut-off in treatment times that allows identification of those who would benefit most from bridging IVT.

Methods:
We analyzed prospectively collected data from consecutive LVO patients who underwent EVT at a tertiary stroke center in Germany from 01/2017 to 12/2021. Patients underwent detailed cardiovascular phenotyping, repeated cranial imaging, and received standardized multidisciplinary stroke unit care. Functional outcome was assessed via modified Rankin scale three months after discharge. Ordinary ridge regression models were built to assess the impact of treatment time cut-offs on functional outcome with adjustment for age, sex, cardiovascular risk factors, baseline NIHSS, cerebrovascular territory, ASPECT score, stroke etiology and carotid artery stenting.

Results:
Out of 935 patients who had undergone EVT, 170 received bridging IVT (median age 74 [63-82, IQR], 52.4% females), fulfilled our criteria and were included in our analysis. Overall, onset-to-recanalization time but not onset-to-needle time was associated with functional outcome (β1=0.36, 95%CI [0.14,0.58], p=0.001 vs. p=ns). However, those who received EVT with a time delay longer than 190 minutes additionally displayed an association of onset-to-needle time and functional outcome (β1=0.64, 95%CI [0.25,1.04], p=0.02 vs. β2= 2.96, 95%CI [1.32,4.60], p=0.016).

Conclusions:
Our data indicates that the beneficial effect of swift bridging IVT on functional outcome is most pronounced in cases where initiation of subsequent EVT is substantially delayed.
Abstract WMP72: Acute Ischemic Stroke In Asians In A Large Integrated Health Care Delivery System
Authors: Nguyen-Huynh Mai N , Alexander Janet , Go Alan S , Zrelak Patricia A , Lee Catherine , Jaffe Marc , Chen Yi-Fen Irene , Klingman Jeffrey
Published: February 2023

Background:
Stroke is a major problem in Asia where more than half of the world population resides. Asian Americans are among the fastest growing racial-ethnic groups in the US, yet the incidence of stroke subtypes, stroke risk factors and outcomes have been largely unstudied in Asian Americans. We assessed acute stroke alert presentations in Asians compared to whites in a large integrated health care delivery system.

Methods:
In 2016, Kaiser Permanente Northern California launched a standardized telestroke program for 21 certified stroke centers to include immediate video evaluation by a teleneurologist. Non-cancelled stroke alerts included those patients who were potential candidates for further workup for acute ischemic stroke treatment. We evaluated all non-cancelled stroke alerts evaluated by Telestroke in 2019. Assessment included demographics, mode of arrival, initial NIHSS, neuroimaging results, IV thrombolytic, door-to-needle (DTN) time, large vessel occlusion (LVO), thrombectomy referral, and discharge disposition.

Results:
We identified 427 Asian and 1262 White patients with potential acute ischemic stroke. Compared with whites, Asians were younger, just as likely to arrive via EMS and arrived quicker from their last known well time, but presented with more severe NIHSS, were more likely to have bleeding on the initial head CT, and less likely to receive IV thrombolytic within 30 minutes from ED arrival (Table). Asians had less detected LVO, but those with LVO were transferred out for thrombectomy faster compared with whites. There were less stroke mimics in Asians presenting with stroke alerts, and no difference in inpatient mortality compared with whites.

Conclusions:
Several differences existed between Asian and white patients evaluated by Telestroke as non-cancelled stroke alerts. Further research is needed to understand these differences and assess outcomes for Asians as well as major Asian subgroups presenting with acute ischemic stroke.
Abstract WMP80: Multimodal CT Imaging Of Ischemic Stroke Thrombi Identifies Scale-Invariant Radiomic Features
Authors: Santo Briana , M J Sarayi S M , Monteiro Andre , Siddiqui Adnan H , Tutino Vincent
Published: February 2023

Background:
Paired analysis of ischemic stroke clot histology and pre-treatment CT imaging could identify digital indicators of treatment outcome or stroke etiology. Yet, differences in scale limit our ability to interpret the biology of the clot from pre-treatment images.

Hypothesis:
Radiomic analysis of resected clots on microCT has the potential to identify important, biologically-interpretable features that are correlated among pre-treatment imaging modalities (CTA, nCCT) and post-treatment histopathology.

Methods:
We performed multimodal CT imaging of 10 stroke clots retrieved by mechanical thrombectomy (example in top of Figure). Clots were manually segmented from co-registered, pre-treatment CTA and nCCT images. For the same cases, portions of resected clots were stained with iodine, imaged on a ScanCo microCT 100 (4.9 μm resolution), and segmented using adaptive intensity thresholding. Radiomic texture features (
n
=93 for each modality, 279 total) were extracted from the images using PyRadiomics. Pearson correlation analysis was used to test associations between CTA (or nCCT) and microCT radiomics. Statistical significance was considered at
R
≥0.7 and
q
<0.05, after multiple testing correction.

Results:
18 features were significantly correlated between CTA and microCT, and 5 features were significantly correlated between nCCT and microCT (bottom of Figure). Cluster Prominence (
R
=0.96,
q
<0.001) and Cluster Shade (
R
=0.92,
q
<0.001) on CTA and microCT exhibited near-perfect positive correlation. When comparing microCT and nCCT, FOS Energy (
R
=0.90,
q
<0.001) and Total Energy (
R
=0.90,
q
<0.001) had high positive correlation. Our findings suggest that RBC density (reflected in brighter pixels) and heterogeneity of clot constituents (reflected in pixel intensity) are scale-invariant clot attributes detectable on CT.

Conclusion:
Scale-invariant radiomic features can help bridge the gap between pre-treatment imaging and clot pathobiology.
Abstract WMP88: Endovascular Versus Medical Treatment For Chronic Occlusion Of The Internal Carotid Artery: Systematic Review And Meta-analysis
Authors: Ortega-Gutierrez Santiago , Galecio-Castillo Milagros , Zevallos Mau Cynthia , Rodriguez Calienes Aaron , Vivanco-Suarez Juan , Samaniego Edgar A , Farooqui Mudassir , Derdeyn Colin P
Published: February 2023

Introduction:
Chronic occlusion of the ICA (COICA) is an important cause of ischemic strokes. Evidence has showed that medical management (MM) alone is not sufficient for prevention of ischemic events. Carotid occlusion endovascular revascularization & stenting (COERS) is a promising technique, yet its safety and superiority to MM remain unclear.

Objective:
To pool and compare rates of safety and efficacy outcomes of COERS versus MM of COICA.

Methods:
We conducted a systematic search in Embase, Medline, and Web of Science for studies reporting short and long-term outcomes of symptomatic COICA patients who received MM and/or COERS. Main efficacy outcomes were successful recanalization and long-term recurrence of ischemic events. Safety outcomes for COERS were periprocedural (<30 days) events. We performed a meta-analysis of proportions for MM and COERS groups, using GLMM transformation and a random-effects model.

Results:
11 studies contained data of COICA patients undergoing COERS, 3 studies of patients who received only MM, and 2 studies compared both arms; they provided data for 513 and 313 patients in the COERS and MM groups, respectively. The pooled recanalization rate after treatment with COERS was 75% (95% CI 0.67-0.82, PI 0.49-0.94, I
2
64%). Recurrence rates of ischemic events at long-term follow-up were 19% (95% CI 0.15-0.25, PI 0.11-0.32, I
2
25%) with MM, and 11% (95% CI 0.07-0.19, PI 0.02-0.42, I
2
2%) after COERS; comparison meta-analysis showed a similar non-significant trend (MM:24% vs. COERS:13%, OR 0.52, 95% CI 0.17-1.59, I
2
0%). The rate of periprocedural events in the COERS group were 2.3% (95% CI 0.012-0.045, I
2
0%) for stroke/TIA, and 2.1% (95% CI 0.011-0.038, I
2
0%) for any ICH.

Conclusion:
COERS is a feasible technique and a safe strategy for maximizing secondary stroke prevention for the treatment of symptomatic COICA. Still, further prospective trials to better define safety and efficacy boundaries are needed before starting a RCT.
Abstract WMP90: Is Endovascular Thrombectomy More Effective Than IV-tPA For Distal Vessel Occlusions? Propensity Score-matched Analysis From K-net Registry
Authors: Yoshie Tomohide , Ueda Toshihiro , Takeuchi Masataka , Morimoto Masafumi , Tsuboi Yoshifumi , Yamamoto Ryoo , Kaku Shogo , Ayabe Junichi , Akiyama Takekazu , Ishima Daisuke , Hasegawa Yasuhiro ,   K-NET Registry Investigators
Published: February 2023

Background and Purpose:
The benefit of endovascular thrombectomy (EVT) for acute ischemic stroke due to primary distal vessel occlusions is unclear. We assessed whether outcome of acute ischemic stroke patients treated with EVT for primary distal vessel occlusions was better than intravenous tissue-type plasminogen activator (IV-tPA) alone.

Materials and Methods:
We investigated data from K-NET Registry, which is a prospective, multicenter, observational registry of acute ischemic stroke patients treated with EVT or IV t-PA in Kanagawa, Japan. We evaluated the patients who had primally distal vessel occlusion and were treated with EVT (with or without IV-tPA) or IV tPA alone. Distal vessel occlusion was defined as middle cerebral artery M2-M3, anterior cerebral artery or posterior cerebral artery occlusion. Propensity score-matched analysis was conducted to compare outcomes between EVT and IV-tPA alone. Primary outcome was good outcome at 90 days, defined as mRS of 0 to 2 or not worsening compared to pre-stroke mRS. Safety outcome was the occurrence of all hemorrhage and symptomatic hemorrhage.

Results:
703 patients with distal vessel occlusion (MCA M2, 436 cases, M3, 167 cases, ACA 48 cases, PCA 52 cases) were included in this study. 461 cases were treated with EVT and 242 were IV-tPA alone. Propensity-score matching paired 110 patients with EVT and 110 patients with IV-tPA. There were no significant differences in good clinical outcome (EVT 65.4%, IV-tAP 60.0%), all hemorrhage (EVT 15.4%, IV-tAP 11.8%) and symptomatic hemorrhage (EVT 4.5%, IV-tAP 1.8%). Dividing EVT group into EVT with IV-tPA and EVT alone, there were no significant differences in outcomes compared to IV-tPA alone.

Conclusions:
The benefit of EVT for acute primary distal vessel occlusions was similar as IV-tPA alone. Although IV-tPA is a first line treatment for primary distal vessel occlusions, EVT is a feasible treatment for patients who have contraindication to IV-tPA.
Abstract WP105: Diffusion Restriction In The Splenium: A Comparative Study Of Cytotoxic Lesions Of The Corpus Callosum (CLOCCs) Versus Vascular Lesions
Authors: Stamm Brian , Chrenka Ella , Lineback Christina , Tang Mengxuan , Jia Dan Tong , Sorond Farzaneh A , Sabayan Behnam
Published: February 2023

Introduction:
Diffusion restriction within the splenium of the corpus callosum poses a clinical challenge. Whereas cytotoxic lesions of the corpus callosum (CLOCC) have broad differential diagnoses and often favorable prognosis, vascular splenial lesions may require acute stroke evaluation and initiation of secondary stroke prevention. Differentiating these lesions is of clinical significance; however, no prior studies have compared them. We sought to compare the clinical and radiological characteristics and outcomes between vascular splenial lesions and CLOCCs.

Methods:
This was a retrospective cohort study using more than 10 years of clinical data (1/1/2009 to 8/1/2020). Patients with diffusion restriction in the splenium of the corpus callosum, either due to a vascular etiology or CLOCC, were included. Baseline, clinical, and radiologic characteristics and outcomes (including discharge medications and in-hospital mortality rates) were ascertained and compared between the two groups.

Results:
There were 124 vascular and 31 CLOCC cases. Vascular patients were older than CLOCC patients (64.1 vs 34.6, p<0.001) and more frequently had: >1 vascular risk factor (91.1% vs 45.2%, p<.001); were taking antiplatelet (p<0.001) and statin medications (p<0.001) on admission; had elevated LDL (p=.027) and A1c (p<.001); and had echocardiogram abnormalities (p=.001). CLOCCs more commonly had midline splenial involvement (p<.001) and only splenium affected (p<.001), whereas vascular cases had more multifocal areas of other diffusion restriction (p=.002). The rate of in-hospital mortality was significantly higher in patients with vascular pathologies (p=.043).

Conclusions:
In this large and long-term retrospective study, vascular and CLOCC splenial lesions had distinct baseline, clinical, and radiological characteristics and outcomes. Accurately differentiating these lesions is important for appropriate secondary stroke complications and prevention.
Abstract WP13: Value Of Stress Hyperglycemia Ratio In Predicting The Prognosis Of Patients With Acute Ischemic Stroke:a Subgroup Analysis Of The Rescue Bt Clinical Trial
Authors: Peng Zhouzhou , Song Jiaxing , Li Linyu , Guo Changwei , Yang Jie , Kong Weilin , Huang Jiacheng , Yue Chengsong , Hu Jinrong , Liu Shuai , Tian Yan , Yang Dahong , Liu Xiang , Zi Wenjie , Li Fengli , Yang Qingwu
Published: February 2023

Objective:
This study aimed to evaluate the correlation between the stress hyperglycemia and clinical outcomes after large vessel occlusion stroke (LVO) at 90 days.

Methods:
The RESCUE BT trial was a multicenter, randomized, double-blind, placebo-controlled clinical trial, consisting of 948 patients from 55 centers in China. In this subgroup study, 542 consecutive stroke patients with glucose or glycated hemoglobin values were included. Stress hyperglycemia was evaluated both as a tri-categorical variable (≤1.07 vs 1.08-1.29 vs ≥1.30) and a continuous variable. The primary outcome was favorable functional outcome (modified Rankin Scale [mRS] ≤ 2) at 90 days. The secondary outcome contained excellent functional outcome (modified Rankin Scale [mRS] ≤ 1) and safety outcomes such as 90-day mortality and intracranial hemorrhage.

Results:
542 patients were included. Compared to patients with the lowest tertiles of stress hyperglycemia, calculated as glucose/GA ratio, the highest tertiles of stress hyperglycemia was obviously associated with a higher rate of poor functional outcome at 90-day (modified Rankin Scale [mRS] score 3-6) after adjusted for potential covariates (adjusted hazard ratio, 0.44; 95% confidence interval, 0.28-0.69, P < 0.001). This result was also consistent in the excellent clinical outcome of 90-day mRS score 2-6 (adjusted hazard ratio, 0.48; 95% confidence interval, 0.29-0.79, P =0.004).

Conclusion:
In patients with acute ischemic stroke, lower stress hyperglycemia, as measured by glucose/GA ratio, was more likely to have favorable outcome at 90-day.

Trial registration
Chinese Clinical Trial Registry Identifier: ChiCTR-IOR-17014167, December 27, 2017.
Abstract WP131: Association Between Intercellular Adhesion Molecule-1 And Intracerebral Hemorrhage: A Post-hoc Analysis Of The Fast Trial
Authors: Witsch Jens , Roh David J , Oh Stephanie E , Iadecola Costantino , Diaz-Arrastia Ramon , Kasner Scott E , Mayer Stephan A , Murthy Santosh B
Published: February 2023

Introduction:
Neutrophil-mediated inflammation in the acute phase of intracerebral hemorrhage (ICH) worsens outcome in pre-clinical studies. Intercellular adhesion molecule-1 (ICAM-1), an inducible ligand for integrins and cell-cell adhesion molecules, is critical for neutrophil extravasation. We aimed to determine whether serum levels of ICAM-1 are associated with worse outcomes after ICH.

Methods:
We conducted a post-hoc analysis of the randomized controlled FAST (Factor-VII-for-Acute-Hemorrhagic-Stroke-Treatment) trial. The study exposure was serum level of ICAM-1, ascertained at admission. The co-primary outcomes were mortality, and death or major disability (modified Rankin Score 4-6) at 90 days. Secondary radiological outcomes were baseline ICH volume, perihematomal edema volume (PHE), and hematoma expansion at 24 hours (ICH volume increase of ≥33% or 6mL). Multivariable linear and logistic regression analyses, adjusted for age, sex, baseline ICH volume, ICH location, and trial treatment arm, were used to test for associations between ICAM-1 and outcomes.

Results:
Of 841 patients, we included 507 (60%) with complete data (mean age 64 years, 37% women). Hematoma expansion occurred in 169 (34%), while 242 (48%) had a poor outcome. In multivariable analyses, ICAM-1 was associated with mortality (OR, 1.02; 95% confidence interval, CI, 1.01-1.05; p=0.02) and poor outcome (OR, 1.02; CI, 1.01-1.04; p=0.04). In multivariable analyses of radiological outcomes, ICAM-1 was associated with hematoma expansion (OR, 1.03, CI, 1.01-1.07) and baseline PHE (beta, 0.02; SE, 0.001, p=0.01), but was not associated with baseline ICH volume.

Conclusions:
In this post-hoc analysis of the FAST trial in patients with ICH, admission serum levels of ICAM-1 were associated with hematoma expansion, PHE, and poor outcome. These findings highlight the need to further explore the role of early inflammatory biomarkers in prognostication and as potential therapeutic targets.
Abstract WP135: Trends In The Incidence Of Spontaneous Cervical Artery Dissection
Authors: Griffin Kim J , Harmsen William S , Brown Robert D , Mandrekar Jay , Keser Zafer
Published: February 2023

Background:
Arterial dissection represents a rare but significant cause of ischemic stroke. We hypothesized that the detection rate of arterial dissections has increased in recent decades.

Objective:
To determine the incidence of cervical artery dissection in a defined population.

Methods:
We identified Olmsted County, Minnesota residents diagnosed with carotid artery or vertebral artery dissection between 2002 and 2020 using the Rochester Epidemiology Project database. Patients who had suffered major trauma, were under 18 years of age or had intracranial artery dissections were excluded. Virtually all Olmsted County residents receive their medical care within the participating health systems, leading to a high likelihood of complete case ascertainment. We assessed longitudinal trends by dividing the data into 5-year time windows, with the last being a 4-year interval. Incidence rates were adjusted for age and sex.

Results:
In a 19-year period from 2002 through 2020, 127 patients with a diagnosis of cervical artery dissection were identified. There were 64 females (50.4%) and 63 males (49.6%). The average age at diagnosis was 51.2 years (SD 15.7). There were 63 internal carotid artery dissections (ICAD), 60 vertebral artery dissections (VAD), and three common carotid artery dissections (CCAD) identified. One patient had ICAD and VAD at diagnosis. The overall incidence rate of detection for cervical artery dissection, adjusted for age and sex, was 4.9 per 100,000 person-years (py) (95% CI, 4.0 to 5.7). The incidence rate of ICAD was 2.5 per 100,000 py (95% CI, 1.8 to 3.1). The incidence rate of VAD was 2.3 per 100,000 py (95% CI, 1.7 to 2.9). The incidence rate of CAD gradually increased over time from 2.3 per 100,000 py (95% CI, 1.1 to 3.5) in 2002-2006 to 9.4 per 100,000 py (95% CI, 6.9 to 11.8) in 2017-2020, a 4.2-fold increase.

Conclusion:
The incidence of detection rate of cervical artery dissection increased over four-fold in the last 19 years. This can potentially be attributed to increased usage of non-invasive angiographic imaging.
Abstract WP138: Intracranial Artery Stenosis In Relation To Blood Pressure Components
Authors: Patil Dhrumil , Gutierrez Jose , Mena Luis , Reinier Leendertz , Chávez Carlos , Silva Egle , Lee Joseph , Terwilliger Joseph , Bos Daniel , Melgarejo Jesus , Maestre Gladys , Zhang Zhenyu
Published: February 2023

Introduction:
Vascular aging is characterized by structural and functional changes in blood vessels that lead to reduced perfusion pressure to distal organs and high blood pressure (BP). Cerebrovascular aging is strongly associated with high BP, however, systemic BP is constituted by the steady and pulsatile components. We aimed this study to investigate the association of intracranial artery stenosis in relation to the steady and pulsatile components of the systemic BP - such association remains undocumented.

Methods:
We used cross-sectional data from 292 participants from the Maracaibo Aging Study who underwent ambulatory BP monitoring, magnetic resonance angiography, and MRI between 2011 to 2016. The stenosis of eleven intracranial arteries was measured using magnetic resonance angiography scans and encompassed the right and left sides of the anterior (ACA), middle (MCA), posterior (PCA) cerebral arteries, and internal carotid arteries (ICA), vertebral arteries, and the basilar artery. The steady BP component included the 24-hour mean arterial pressure (MAP) while the pulsatile component included the 24-hour pulse pressure (PP). We performed multivariable logistic regression models to assess the association between intracranial artery stenosis and BP components. Models were accounted for age, sex, head circumference, years of education, body mass index, total and high-density cholesterol ratio, creatinine, diabetes mellitus, and antihypertensive treatments.

Results:
Mean age was 57.5±11 years, 75% women. After adjustment for confounders, 24-hour pulse pressure was associated (P≤ 0.020) with the stenosis of ICA (Odds ratios [OR], 2.00 per every 5 mmHg of PP; 95% confidence interval [CI], 1.49-2.69), ACA (OR, 1.50; 95% CI, 1.23-1.84), MCA (OR, 1.46; 95%, CI, 1.21-1.77), PCA (OR, 1.55; 95% CI, 1.26-1.91), basilar artery (OR, 1.28; 95% CI, 1.03-1.59) and vertebral arteries (OR, 1.42; 95% CI, 1.14-1.78). The ORs of ICA, ACA, MCA, PCA, basilar artery, and vertebral arteries in relation to high 24-hour MAP levels (P≤ 0.040) ranged from 1.27 (95% CI, 1.00-1.61) to 1.48 (95% CI, 1.15 - 1.91).

Conclusion:
Elevated levels in the steady and pulsatile components of the systemic BP are associated with intracranial artery stenosis.
Abstract WP142: Risk Of New Ischemic Events In Patients With Symptomatic Internal Carotid Artery Stenosis While Awaiting Carotid Artery Stent Placement
Authors: Bains Navpreet K , Nunna Ravi , Jaura Attiya , French Brandi R , siddiq Farhan , Gomez Camilo R , Qureshi Adnan I
Published: February 2023

Introduction:
Although there is emphasis on performing carotid artery stent placement (CAS) within two weeks after index event of transient ischemic attack (TIA) or minor stroke in patients with cervical internal carotid artery (ICA) stenosis, the risk and characteristics of recurrent cerebral ischemic events while waiting for CAS are not well defined.

Method:
We analyzed patients admitted to our institution over a 45-month period with symptomatic cervical ICA stenosis. All patients were initiated on daily aspirin and clopidogrel 75mg on the day of admission. We identified any new cerebral ischemic events that occurred between index event and CAS and categorized them as TIA, and minor or major ischemic strokes. We calculated the risk of new ipsilateral cerebral ischemic events between index ischemic event and CAS.

Results:
The mean age of 150 patients analyzed was 67 years (range: 46-94 years; 106 were men); and 94 and 56 patients had ≥ 70% and 50-69% stenosis, respectively. The mean and median time intervals between index event and CAS performance were 25 and 6 days, respectively. A total of 6 new cerebral ischemic events (5 TIAs and 1 major stroke) were observed over 3,776 patient days of observation. The risk of new ipsilateral cerebral ischemic events between index ischemic event and CAS performance was 1.6 per 1000 patient days of observation.

Conclucion:
We identified a low risk of new ipsilateral cerebral ischemic events in patients with ≥ 50% ICA stenosis while waiting for CAS presumably due to early initiation of dual antiplatelets.
Abstract WP150: Asymptomatic Intracranial Hemorrhage Following Endovascular Treatment Is Not Benign: A Systematic Review And Meta-analysis
Authors: Harker Pablo , Aziz Yasmin , Vranic Justin , Chulluncuy-Rivas Roberto , Previtera Melissa , Khatri Vivek , Yaghi Shadi , De Havenon Adam H , Tsivgoulis Georgios K , Khatri Pooja , Mistry Eva
Published: February 2023

Introduction:
Asymptomatic intracerebral hemorrhage (aICH) occurs in ~40% of acute ischemic stroke patients after endovascular thrombectomy (EVT). Unlike symptomatic ICH, which is undoubtedly associated with worse outcomes, studies evaluating the association of aICH on long-term outcomes have been inconclusive. We performed a systematic review and meta-analysis to evaluate the long-term effects of post-EVT aICH.

Methods:
The meta-analysis protocol was submitted to PROSPERO a priori. PubMed, SCOPUS and Web of Science were searched from inception through April 2022 using database-specific searches with combination of keywords and controlled vocabulary. After deduplication, two authors independently reviewed all abstracts. Included studies contained adult AIS patients undergoing EVT with follow-up imaging assessment of ICH reporting comparative outcomes according to aICH vs no ICH . Meta-analysis was performed using Cochrane Review Manager v5.4. Summary effects were estimated by a fixed-effects model to estimate summary odds ratio (OR) of the effect of aICH vs no ICH on primary outcomes of 90-day modified Rankin score 3-6 and mortality.

Results:
Systematic review yielded 278 studies; 52 abstracts were fully reviewed ; 8 studies fulfilled inclusion criteria (n=4701 patients total; 1562 with aICH). aICH was associated with 90-day mRS 3-6 (OR 2.11 [95% CI 1.85-2.40]; Figure 1A) and higher mortality (OR 1.66 [95% CI 1.41-1.96]; Figure 1B) compared to no ICH. There was insufficient evidence of difference in 90-day mRS 3-6 when studies were grouped according to Heidelberg (n=2 studies; OR 2.37 [95% CI 0.92, 6.12]) vs ECASS (n=5 studies; OR 2.07 [95%CI 1.62, 2.64]) criteria for ICH. Meta-regression analysis adjusting for covariates will be presented

Conclusion:
aICH is associated with worse 90-day functional outcomes and higher mortality. Further studies to evaluate the factors predicting aICH and treatments aimed at reducing its occurrence are warranted.
Abstract WP151: DISPARI-TICI: Determining If Stroke Patients Assessed For Revascularization Show Ethnic Disparities In TICI Scores Or Complications
Authors: Torres Dolores , Meyer Dawn M , Van Orden Kimberlee , Poynor Briana , Alwood Benjamin T , Hailey Lovella S , Meyer Brett C , Agrawal Kunal
Published: February 2023

Introduction:
There is limited data on ethnic disparities in endovascular therapy (EVT) Thrombolysis In Cerebral Infarction (TICI) revascularization scores and EVT complications. The goal of this study was to compare disparities in TICI scores and complications in Hispanic versus Non-Hispanic ethnicities.

Methods:
We retrospectively examined prospectively collected data from an IRB-approved stroke registry at two academic Comprehensive Stroke Centers (CSC). We included acute ischemic stroke (AIS) patients with large vessel occlusion within 24 hours of last known well that underwent EVT between 1/1/2013-6/30/2022. Favorable outcome was defined as TICI 2b-3. Complications of symptomatic intracranial hemorrhage (sICH), life-threatening or serious systemic hemorrhage, or other serious complication were collected within 36 hours of EVT and compared between Hispanic or Non-Hispanic subjects. Data was analyzed using Chi-squared and was adjusted for baseline NIHSS, blood glucose, and age. A p-value of <0.05 was significant.

Results:
A total of 411 patients who met study criteria were identified. In Hispanics versus Non-Hispanics, the mean age was 69 vs 70 years, 44.6% vs 48.3% patients were female, and median initial NIHSS was 17 vs 16. The rate of Hispanics in this sample was 29.4% (n=121). There were no differences in baseline characteristics or in patients receiving IV rt-PA prior to EVT between Hispanic and Non-Hispanics (72.6% vs 65.5%; p=0.17). The overall rate of favorable TICI outcome was 93.7% (n=385/411). There was no difference in favorable TICI scores in Hispanic versus Non-Hispanics (96.7% vs 92.4%; p=0.12). Complication rates were also not significantly different in Hispanics versus Non-Hispanics for: sICH (5.8% vs 2.4%; p=0.09), other serious complications (1.7% vs 2.1%; p=0.78), and life-threatening systemic hemorrhage (0.8% vs 0.7%; p=0.88).

Conclusion:
There were no differences in TICI outcome or complication rates in Hispanic versus Non-Hispanic patients in these 2 academic CSCs. The use of consistent protocols and pathways at a CSC likely contribute to consistent EVT treatment between ethnicities. Further studies must examine EVT outcomes within various ethnicities and races in multiple stroke centers around the country.
Abstract WP157: Prognostic Impact Of Pulse Pressure At Admission On Functional Outcomes Post-thrombectomy For Acute Ischemic Stroke
Authors: Ahmadi Sabrena M , Avila Stephen D , Simpkins Alexis N
Published: February 2023

Introduction:
Prior studies showed that pulse pressure (PP) correlates with cerebral collateral status, but the prognostic impact of widened PP on thrombectomy outcomes following acute ischemic stroke (AIS) is unclear. We hypothesized that patients with AIS undergoing thrombectomy with a presenting PP of > 60 on admission would be less likely to have successful revascularization and have worse functional outcomes.

Methods:
Patients treated with a thrombectomy from our institutional retrospective stroke database between 2018 to 2022 were included. Patient demographics and post-thrombectomy outcomes were analyzed using nonparametric t-tests and Chi-Square analysis, with variables <0.20 p-value being included in regression analysis.

Results:
Of the 134 AIS patients, 60% had a PP > 60. Patients with PP > 60 were older [age 77 (interquartile range (IQR) 68-87) vs 67 (IQR (57-78), p< 0.0001]. There was no difference in the distribution of sex [male 53% vs 52%, p=0.94], M1 occlusion [56% vs 58%, p=0.78], time from last known well to arterial access [306 min (IQR 155-764) vs 242 min (IQR 155-583), p=0.61], NIHSS [17 (IQR 10-23) vs 18 (IQR 11-22), p=0.90], thrombolysis [40% vs 40%, p=0.97], in patients with PP > 60 vs those with a PP ≤ 60 respectively. Discharge mRS was 4 (IQR 4-5) in patients with PP > 60 vs 4 (IQR 4-4) in patients with PP ≤ 60, p=0.02. In this study, 40% lacked a discharge mRS, and no significance was found on 90-day mRS [PP > 60 4 (IQR 2-5) vs 3 (IQR 3-4) PP ≤ 60]. A trend of more patients with PP ≤ 60 having TICI2B/TICI3 was found [75% vs 87%, p=0.06]. In regression analysis, patients with PP > 60 were less likely to have TICI2b/TICI3 after controlling for age [OR 0.23 (95% CI 0.06 - 0.70), p=0.02], but no significant association was found with discharge mRS.

Conclusions:
The impact of PP on collateral flow in AIS and functional outcome should be studied further in larger AIS cohorts.
Abstract WP163: Relationship Between Three-dimensional Arterial Tortuosity And Difficulty Of Guide Catheter Access During Endovascular Reperfusion Therapy
Authors: Maekawa Kota , Ohara Nobuyuki , Junji Takasugi , Nakazawa Shinsaku , Kawamoto Michi , Ohta Tsuyoshi , Sakai Nobuyuki
Published: February 2023

Introduction:
Few studies have investigated the tortuosity of great vessels only in the longitudinal direction during endovascular reperfusion therapy. This study evaluated the tortuosity of the great vessels in the perpendicular and longitudinal directions by using novel reference line and how it affects procedural difficulty.

Methods:
We retrospectively reviewed the medical records of 294 patients with large vessel occlusion. Features of the anatomy of the ipsilateral great vessels were investigated by preintervention CT angiography. The reference line used to evaluate tortuosity was defined as a line from the origin of each ipsilateral great vessel to the entrance of the external auditory canal (AE-line). Coronal and sagittal angles were calculated using the AE-line and the most curved point of each ipsilateral great vessel. The right side of the reference line was negative and the left side was positive, and similarly, the ventral side of the reference line was negative and the dorsal side of the reference line was positive. Patients were divided into three groups with a threshold of -20° and 20° based on sagittal and coronal angles on the both sides, and finally into nine groups. (Figure) Reference group was set to Group 5. Procedural difficulty was determined by whether or not the internal carotid artery could be accessed within 10 min.

Results:
On the left side, compared with the reference group, the odds ratio [OR] (95% confidence interval [CI]) for the procedural difficulty in the Group 9 was 9.020 (2.85-28.5; p<0.001). On the right side, the ORs (95% CI) for the procedural difficulty in the Group 2, Group 3, and Group 9 were 21.700 (2.200-215.000; p=0.008), 29.000 (1.770-475.000; p=0.018), and 65.200 (8.010-532.000; p<0.001), respectively.

Conclusion:
There was a strong correlation between difficulty in guide catheter placement in the internal carotid artery and three-dimensional tortuosity when using the AE-line as a reference.
Abstract WP167: Pregnancy And Neonatal Outcomes After A Stroke In An Integrated Healthcare System.
Authors: Ajani Zahra , Taleb Shayandokht , Gaffney Denise , Ly An , Sangha Navdeep S
Published: February 2023

Background:
Stroke in women of childbearing age is not only disabling but also has lifelong consequences for family planning. There are no large studies on maternal and fetal outcomes in patients with a history of stroke.

Methods:
We retrospectively collected data from January 2004 to December 2021 on women aged 18-50 years, who had a pregnancy following their cerebrovascular event (CVE) using ICD-10 codes to identify the eligible subjects. Demographic data including maternal age, race, gestational age, mode of delivery, associated medical conditions were collected.

Results:
219 patients were included in this cohort with a mean age of 29.1±6.2 at the time of CVE, and a median time between CVE and delivery of 34 months (IQR:13-65). 17 (7.8%) had history of factor V Leiden, Protein C deficiency or lupus associated hypercoagulable state. The initial CVE was identified as acute ischemic stroke in 77 (35.2%), transient ischemic attack (TIA) in 64 (29.2%), subarachnoid hemorrhage in 46 (21%), intracerebral hemorrhage in 23 (10.5%), and cerebral venous thrombosis in 9 (4.2%). The maternal adverse events were seen in 38 (17.3%) patients: 29 (13.2%) with HELLP Syndrome/eclampsia/pre-eclampsia, and 9 (4.1%) with recurrent TIA/stroke within 1 year after pregnancy. The rate of maternal adverse events decreased 5 years after the index stroke (Figure 1A). Patients with a history of stroke were at higher risk of having preterm delivery 38 (17.4%) than the general population. 27 (12.3%) of newborn infants had 1min Apgar<7 while 6 (2.7%) had 5 min Apgar<7. The rate of neonatal poor outcomes (preterm birth or Apgar<7) decreased over time (Figure 1B).

Conclusion:
The rate of maternal and neonatal adverse events are high in the first 5 years after the CVE and begin to decline thereafter.
Abstract WP171: Impact Of Pre-stroke Sulfonylurea Use On Functional Outcomes In The SHINE Trial
Authors: Streib Christopher D , Bruno Askiel , Durkalski Valerie , Pauls Qi , Staugaitis Abbey , Annam Saketh , Bentho Oladi , Lakshminarayan Kamakshi , Meurer William J
Published: February 2023

Background:
Pharmacological and clinical evidence suggest that sulfonylurea (SU) medications may improve acute ischemic stroke (AIS) outcomes. The SHINE trial studied intensive vs standard blood sugar management in patients presenting with AIS and hyperglycemia. We investigated whether pre-existing SU use impacted functional outcomes in SHINE.

Methods:
SHINE data collection forms were reviewed to identify AIS patients taking SUs at the time of study enrollment. Our primary outcome compared the adjusted 90-day utility weighted modified Rankin Scale (UW-mRS) score in the SU and non-SU cohorts. The UW-mRS score was adjusted for age, baseline NIHSS, baseline glucose, and reperfusion therapy. Pre-specified analyses of the 90-day UW-mRS scores assessed for heterogeneity of SU effect across the following subgroups: age, stroke severity, reperfusion therapy, type of SU, and SHINE study arm.

Results:
In total, 1066 SHINE subjects with a final diagnosis of AIS were included (SU=248 [23.3%], non-SU=818 [76.7%]). Baseline demographics were generally similar (Table 1). Calculated 90-day mean UW-mRS score were higher in the non-SU group compared to the SU group: mean 0.617 ± 0.012 versus mean 0.566 ± 0.022 (Diff 0.051, 95% CI 0.001-0.1) without heterogeneity of treatment effect (Figure 1).

Conclusion:
Contrary to our hypothesis and published literature, our retrospective analysis of the SHINE trial demonstrated better functional outcomes in the non-SU cohort. This may be due to selection bias with inadequate controlling for baseline risk factors present in the SU cohort. Definitive prospective studies are required.
Abstract WP176: Prior TIAs Among Patients With Ischemic Stroke In The Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS)
Authors: Madsen Tracy E , Khoury Jane C , Haverbusch Mary , Adeoye Opeolu M , Coleman Elisheva R , De Los Rios La Rosa Felipe , Demel Stacie L , Ferioli Simona , Flaherty Matthew L , Jasne Adam , Khatri Pooja , Mackey Jason , Martini Sharyl R , Mistry Eva , Slavin Sabreena , Star Michael , Walsh Kyle B , Woo Daniel , Broderick Joseph P , Kissela Brett M , Kleindorfer Dawn O
Published: February 2023

Background:
TIAs serve as an opportunity to identify and modify risk factors and to prevent future events. Given known epidemiologic differences in strokes by race and sex, our objective was to investigate the rates of prior TIAs among those with incident ischemic stroke (IS) in the GCNKSS.

Methods:
We included all physician adjudicated, incident IS among adults age ≥20 years in the GCNKSS, a population-based stroke surveillance study in a 5-county region of southern Ohio/ northern Kentucky, in 2005, 2010, and 2015. We calculated the frequency of cases in which a TIA (sudden onset of focal neurologic symptoms lasting ≤ 24 hours) was documented in the 365 days prior to IS. Frequencies and proportions of prior TIA were compared by sex, race, and age, and location at which patients sought care for their TIA was described. Finally, multivariable logistic regression was performed to investigate demographic and clinical predictors of cases in which TIA preceded stroke; covariates were chosen a priori.

Results:
We included 5310 IS events; mean age was 69.7 (SD 14.8) years, 54.7% were female, and 20.4% were Black. A total of 351 patients (6.6%) had a documented TIA the year preceding their IS. Overall, 42.2% did not seek care for their TIA, 21.6% called 911 and/or came to the ED, 6.0% saw a PCP, and 6.6% sought other care. In 22.5% of cases, location of care was unknown. In adjusted results, older age, female sex, history of hypertension, and CAD were associated with having had a prior TIA, while Black race was not. NIHSS was inversely associated with prior TIA (Table). Prior TIAs were similar between study years.

Conclusions:
We conservatively estimate that ≥ 6% of patients with first-ever IS had a TIA in the preceding year, though underreporting is likely. Many patients did not report seeking care for the TIA, suggesting missed opportunities for risk factor modification. Further research is needed to understand the implications of sex and race differences in frequencies of prior TIA.