bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 159: Computed Tomography Angiography Negative Spinal Artery Dissection
Authors: Ghani Mohammad R. , Roddy Eric , Liu Wei
Published: March 2024

Introduction

Vertebral artery dissection (VAD) is a relatively common cause of ischemic stroke, especially after chiropractic neck manipulation. VAD usually can be diagnosed by noninvasive imaging studies such as CT angiography (CTA) of the head and neck with suggestive findings of an arterial string sign, arterial stenosis, a double lumen sign, a pseudoaneurysm, or an occlusion. However, in rare situations, CTA may display normal arterial caliber except for very subtle signs such as abnormal dorsal thickening of the arterial wall against adjacent fat at the V3 segment of the vertebral artery. This is referred to as the "suboccipital rind sign." Here we wish to report such a case as identified at our institution.

Methods

Electronic charts of a patient with acute spinal shock and strokes were reviewed.

Results

The patient is a 36‐year‐old female with chronic neck pain, status‐post C5‐T1 spinal fusion who presented emergently with quadriparesis that following chiropractic neck manipulation. She felt a “pop” at the neck during the neck manipulation. She shortly thereafter began experiencing persistent neck pain associated with tingling sensations of both upper extremities on her drive home. She then noted transient right‐hand weakness as she was attempting to open a package. Her symptoms then temporarily resolved with rest, but after some time the paresthesia and neck pain reoccurred, worsened, and quickly progressed to quadriplegia. Brain MRI was negative for acute stroke. However, MRI of the cervical spine demonstrated acute cervical spinal cord ischemia in addition to post‐surgical changes. CTA head and neck reported normal arterial caliber. A diagnostic angiogram was performed that showed no evidence of arterial dissection but did demonstrate absence of the anterior spinal artery. Subsequently, CTA was further reviewed on thin slice revealing a “suboccipital rind sign" of the left V3 segment, suggesting left vertebral artery V3 segment dissection. Hypercoagulable workup was negative, and the patient was treated with anticoagulation.

Conclusion

Arterial dissection is usually readily diagnosable by CTA with high sensitivity. However, a study with normal caliber vessels in the reconstituted images does not always exclude an arterial dissection. To our knowledge there have been six reported vertebral dissection cases with a normal appearing lumen on CTA or conventional angiography. However, similar to our case, they displayed “suboccipital rind” signs on CTA thin cross‐section due to the thickening of the dissected artery on the V3 segment. The V3 segment has a horizontal course which runs parallel to the axially acquired imaging plane, which makes it difficult to appreciate the classic crescentic wall hematoma associated with arterial dissection. We hope that increased awareness of the typical location and appearance of the “suboccipital rind” sign on CTA may increase the detection rates of subtle arterial dissections in the setting normal‐appearing arterial lumens.
Abstract 170: Flow Diversion for Distal Aneurysms of the Posterior Circulation: A Multicenter Retrospective Study
Authors: Dibas Mahmoud , Vivanco‐Suarez Juan , Rodriguez‐Calienes Aaron , Hanel Ricardo A. , Toth Gabor , Galecio‐Castillo Milagros , Pereira Vitor M. , Altschul David , Alva Cristian , Fifi Johanna T. , Kan Peter T. , Puri Ajit S. , Wakhloo Ajay K. , Khandelwal Priyank , Farooqui Mudassir , Ortega‐Gutierrez Santiago
Published: March 2024

Introduction

Flow diversion (FD) has emerged as an effective treatment option for intracranial aneurysms (IAs). However, there is limited evidence regarding its safety and efficacy specifically for distal aneurysms of the posterior circulation including posterior inferior cerebellar artery (PICA), anterior inferior cerebellar artery (AICA), superior cerebellar artery (SCA), and the P2 and P3 segment of the posterior cerebral artery (PCA). This study aimed to investigate the outcomes of FD for these aneurysms.

Methods

A retrospective analysis of a multicentric observational registry was performed between 2014 and 2022. Patients harboring distal aneurysms of the posterior circulation including the PICA, AICA, SCA, and PCA P2‐3 treated with FD were included. Aneurysms characteristics and outcomes were calculated for the total series and a comparison was performed between fusiform/dissecting versus saccular aneurysms. The primary outcome was complete occlusion at last imaging follow up which was defined as per the Raymond Roy occlusion scale. Additional outcomes included the retreatment rate, and thromboembolic and hemorrhagic complications

Results

Overall, 36 patients with 36 aneurysms were treated with FD with a median age in years of 60.0 (interquartile range [IQR]: 52.8‐65.3 years). Of those, 13 were fusiform/dissecting while 23 were saccular IAs. Complete occlusion was achieved in 78.1% for all IAs at a median follow‐up of 14.0 months (IQR: 9.3‐48.6 months). There was no significant difference in rates of complete occlusion between fusiform/dissecting (91.7%) and saccular aneurysms (70%, p=0.151). Thromboembolic and hemorrhagic complications were observed in four cases (11.1%), and retreatment was required for four IAs (11.4%). There was no significant difference in rates of thromboembolic and hemorrhagic complications, or retreatment between fusiform/dissecting and saccular IAs

Conclusion

This study suggests the safety and efficacy of FD for distal aneurysms of the posterior circulation. Further larger‐scale studies are warranted to confirm these findings and to explore the long‐term safety and efficacy of FD in this specific aneurysm population.
Abstract 177: Clinical and Imaging Outcomes of Ophthalmic Aneurysm Flow Diversion with or without Adjunctive Coiling
Authors: Abdulrazzak Mohammad Ammar
Published: March 2024

Introduction

Flow diversion (FD) is commonly used for the treatment of aneurysms involving the ophthalmic segment of the carotid artery (COA). The origin of the ophthalmic artery (OA) in relation to the aneurysm sac can affect recurrence and complications. We studied the effects of COA treatment with FD alone or in combination with coil embolization, based on the origin of the ophthalmic artery in‐relation to the aneurysm sac.

Methods

Retrospective analysis of a prospectively collected tertiary center database. Based on the ophthalmic artery origin, four types of carotid ophthalmic aneurysms were previously described and implemented in this study: OA originates from Type A. directly from the aneurysm fundus, B. aneurysm neck, C. inner curve of the carotid siphon, and D. OA separate from the aneurysm. Imaging outcomes were aneurysm occlusion and OA patency at 1‐year, determined by Digital Subtraction Angiography (DSA) or MRA. Clinical outcome was treatment‐related visual complications.

Results

A total of 60 patients treated at our tertiary center between January 2017 and November 2019 were reviewed. 4 patients were lost to follow up. Clinical and angiographic data of 59 COAs treated with FD +/‐ coil embolization were available. FD alone was used in 44 (75%) aneurysms, the rest had adjunct coiling. Median age was 55. Ten (17%) patients were men. Thirty two aneurysms (55%) were Type D, 22 (37%) Type B, 5 (8%) Type A. No Type C aneurysms were identified. Overall complete occlusion rate was 82%; 94% vs 71% for adjunct coiling vs FD only, respectively. Residual filling was seen in 4 (12%) Type D aneurysms, 8 (35%) Type B aneurysms, and 1 (20%) Type A aneurysm. The ophthalmic artery was occluded at follow up in all but one patient in Type A aneurysm group (80%), 2 (7.1%) in Type D, and 6 (27%) in Type B. 6/15 (40%) of patients in the adjunct coiling group had transient and short‐lasting disturbing visual symptoms, vs 7/44 (16%) in the FD only group. No patient had long‐term visual complications. A total of 10 patients showed OA occlusion at follow up, 4 of them in the adjunct coiling group (26%). There was 1 patient (2%) with a non‐disabling stroke due to antiplatelet therapy interruption and in‐stent thrombosis.

Conclusion

Flow diversion appears safe and effective for COA treatment. Adjunct coil embolization increased COA occlusion 1 year after FD treatment without significant increase in long‐term visual complications. Adjunct coiling and ophthalmic artery origin location appear to have a significant effect on treatment result, and should be considered at treatment planning.
Abstract 191: Simulating Intracranial Stenosis: A Methodological Approach In An In‐Vitro Neurovascular Model
Authors: Tiberi Riccardo Daniel , Li Jiahui , Vargas Joan , Jablonska Magda , Cendrero Judith , Canals Pere , Molina Marc , Tomasello Alejandro , Ribo Marc
Published: March 2024

Introduction

Intracranial atherosclerotic disease (ICAD) induces the luminal narrowing of an intracranial vessel and represents one of the major causes of ischemic strokes [1, 2, 3, 4]. In vitro 3D printed models have gained popularity in the stroke research field as they are morphologically accurate and offer the possibility to simulate clinical scenarios for training purposes or device testing. Despite being a challenge for interventionalists, to date, clinically accurate ICAD in vitro models have not been developed. We aimed to develop a 3D printed ICAD model including realistic features to provide an optimal simulation phantom for research and training purposes.

Methods

Stereolithography 3D printing technique was used to create a resin neurovascular model based on vascular anatomies extracted from anonymized CTA images. The phantom includes the aortic arch, all supraoptic cervical arteries and a complete circle of Willis up to the M2‐MCA, A2‐ACA and P2‐PCA segments. 3% sodium alginate solution was cast into a stenosis mold and crosslinked in a 40% calcium chloride. The deformable gel constituted an 8mm long replaceable stenotic segment at the level of M1‐MCA simulating an atherosclerotic plaque with a 0.5mm internal diameter. A flow sensor (ME‐8PXL, Transonic) was used to measure the lesion flow rate before and after endovascular treatment was performed under fluoroscopy.

Results

The baseline angiographic run showed an irregular 80% stenosis at the level of M1‐MCA that generated a substantial delay of contrast arrival to the distal branches. After angioplasty (Gateway PTA Balloon Catheter 3.5x20mm, Boston Scientific) and stenting (Wingspan 2.5mmx15mm, Stryker) were performed the residual stenosis was <10% (Figure 1). An initial stenosis flow rate was registered with a value of 8.5 ± 5.33 mL/min. Following the completion of the endovascular procedure, the flow sensor detected a post‐procedural stenosis flow rate of 160 ± 3.45 mL/min.

Conclusion

The developed ICAD model is anatomically accurate and offers realistic physiological and procedural features. The phantom represents an ideal tool for training purposes and a platform to test different devices for the endovascular treatment of ICAD. The methodology and materials could be applied to simulate stenotic lesions at different levels in the cervical and intracranial arteries.
Abstract 194: Impact of Pre‐treatment Cerebral Microbleeds on the Outcomes of Endovascular Thrombectomy
Authors: Elfil Mohamed , Ghaith Hazem S. , Bayoumi Ahmed , Elmashad Ahmed , Aladawi Mohammad , Al‐Ani Mina , Najdawi Zaid , Al‐Mufti Fawaz
Published: March 2024

Introduction

Endovascular thrombectomy (EVT) is the gold standard treatment for patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), and there are several factors that can influence the outcomes of EVT in AIS‐LVO patients. We conducted this meta‐analysis to investigate the effect of cerebral microbleeds (CMBs) on the functional and safety outcomes of EVT in patients with AIS caused by LVO.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. We included observational studies that recruited AIS‐LVO patients, used susceptibility‐sensitive magnetic resonance imaging (MRI) to detect CMBs, and examined the association between them and predefined outcome events. The outcomes of interest included functional independence, revascularization success, and hemorrhagic adverse events. We conducted a meta‐analysis using the Mantel‐Haenszel method and calculated the risk ratios.

Results

Four studies involving 1,514 patients were included. A significant reduction in the likelihood of achieving a favorable functional outcome, as measured by the modified Rankin Scale (mRS), was observed in patients with CMBs (Risk Ratio (RR) 0.70, 95% Confidence Interval (CI): 0.53 ‐ 0.91, P=0.01). No significant differences were observed between the two groups in terms of successful revascularization (RR 0.93, 95% CI [0.74 to 1.17], P=0.51), mortality (RR 0.93, 95% CI [0.74 to 1.17], P=0.51), hemorrhagic transformation (RR 0.93, 95% CI [0.59 to 1.45], P=0.74), and parenchymal hematoma (RR 1.23, 95% CI [0.79 to 1.91], P=0.35).

Conclusion

The presence of CMBs significantly reduced the likelihood of achieving a favorable functional outcome after EVT in AIS‐LVO patients. However, CMBs did not impact the rates of successful revascularization, mortality, or the occurrence of various hemorrhagic complications. Future research should explore the mechanisms of this association and strategies to mitigate its impact.
Abstract 196: Navigation Orientation of the Angled Tip of the Zoom 71 catheter around the Carotid Siphon
Authors: Litao Miguel
Published: March 2024

Introduction

Aspiration thrombectomy has been one of the mainstays of treatment in stroke interventions. The Zoom71 (Z71) aspiration catheter is unique with its angled tip. This study describes the orientation of the angled tip as its navigated around the carotid siphon and its association with trackability.

Methods

Prospectively collected cases involving large vessel occlusions of the anterior circulation which were intervened upon using the Zoom71 aspiration catheter were retrospectively analyzed. 71 passes, among 50 patients, among 7 operators, were analyzed with respect to Zoom71 catheter tip orientation with respect to the following corners: “Corner 1”‐ posterior vertical to horizontal portion of cavernous segment, “Corner 2”‐ ophthalmic turn, and “Corner 3”‐ ICA terminus to M1. The catheter tip orientation Was described as “UP” vs “DOWN” with respect to the inner curve of each corner. We also took note of whether the tip was “caught up” in the aforementioned corners during navigation.

Results

There was no preferential angled tip orientation of the Z71 as its navigated around the carotid siphon: Corner 1 (posterior vertical to horizontal cavernous), 51% (N=36) UP vs 44% (N=31) DOWN, p= 0.54; Corner 2 (ophthalmic), 46.5%(N=33) UP vs 53.5% (N=38) DOWN, p= 0.55; Corner 3 (terminus to M1) 43.7%

(N=31) UP vs 46.5% (N=33) DOWN, p=0.63. It was not caught up in Corner 1. It got caught up in Corner 2 in 15.5% (N=11) of passes. The UP orientation at Corner 2‐ with Z71 angled tip pointing towards the ophthalmic (away from the inner curve), was associated with getting caught in 21% (7/33) of passes vs 10.5% (4/38) for the DOWN orientation though this was not statistically significant, p= 0.22. It got caught up in Corner 3 in 4.7% (N=3/64) of passes. The UP orientation at Corner 3 was associated with getting caught in 6.5% (2/31) of passes vs 3% (1/33) for the DOWN orientation, p=0.52. Usage of Z88 as guide catheter may be associated with Z71 getting caught up less in Corner 2 compared to other guide Catheters, 9.3% (4/43) for Z88 vs 25% (7/28) for “Others”, p= 0.07. This also applied to corner 3, 0% for Z88 vs 11.1% (3/24) for “Others”, p=0.038.

Conclusion

There is no preferential orientation of the angled tip of the Z71 as it navigates around the carotid siphon. The DOWN orientation may allow for better trackability around the ophthalmic turn. Usage of Z88 as guide catheter may help with Z71 trackability around the siphon.
Abstract 205: Efficacy and Safety of Mechanical Thrombectomy for Primary MeVO with Disabling Deficit
Authors: Yoshimoto Takeshi , Tanaka Kanta , Koge Junpei , Abe Siichiro , Kamogawa Naruhiko , Yoshie Tomohide , Imamura Hirotoshi , Kataoka Hiroharu , Toyoda Kazunori , Koga Masatoshi , Ihara Masafumi
Published: March 2024

Introduction

We aimed to evaluate the efficacy and safety of mechanical thrombectomy (MT) for medium vessel occlusion (MeVO) with the disabling deficit.

Methods

The study period was from January 2011 to December 2022. Inclusion criteria were 1) within 24 hours of stroke onset, 2) prestroke mRS score ≤1, 3) NIHSS score ≥4 or disabling deficit (complete hemianopia (≥2 on NIHSS), severe aphasia (≥2 on NIHSS), visual sensory extinction (≥1 on NIHSS), significant weakness with NIHSS subscore of paralysis ≥2), 4) MeVO (MCA distal M2, M3, ACA A1, A2, A3, PCA P1, P2, and P3). Outcomes were compared between the MT and standard medical treatment (SMT) groups. Outcome was defined as the favorable outcome (mRS score 0‐2 at 90 days), death within 90 days, and symptomatic intracranial hemorrhage (SICH).

Results

Of all, 192 patients (72 women, median age 78 years, median NIHSS score 11 points) were enrolled, and 76.6% (n=147) had distal M2 occlusion. Compared to the SMT group (n=153), the MT group (n=39) had a significantly larger median Tmax>10 sec volume (median 25 mL vs. 5 mL, P<0.01) and Tmax> 6‐sec volume (61 mL vs. 44 mL, P<0.01), while median NIHSS score (13 vs. 11, P=0.69) and intravenous thrombus (51.6％ vs. 55.3%, P=0.72) were significantly lower in the MT group. There were significantly more patients in the MT group with a favorable outcome (73.7% vs. 54.1%, adjusted odds ratio 2.59 95% confidence interval 1.07‐6.24), death within 90 days (7.9% vs. 3.1%), SICH (5.3% vs. 4.4%) were not significantly different. In subgroup analysis, MT was independently associated with age (<80 years; 1.33, 1.21‐15.57, P=0.222) and neurological severity (NIHSS ≥10 points; 2.79, 1.07‐7.24, P=0.870) for a favorable outcome.

Conclusion

In MeVO with disabling deficits, MT was independently associated with more favorable outcomes than the SMT group.
Abstract 209: Incidence and outcome of perforations during medium‐vessel occlusion compared to large‐vessel occlusion thrombectomy
Authors: Psychogios Marios
Published: March 2024

Introduction

Vessel perforation during thrombectomy is a severe complication and is hypothesized to be more frequent during MeVO thrombectomy. The aim of this study was to compare the incidence and outcome of patients with perforation during MeVO and LVO thrombectomy and to report on the procedural steps that led to perforation.

Methods

In this multicenter retrospective cohort study, data of consecutive patients with vessel perforation during thrombectomy between January 01, 2015 and September 30, 2022 were collected. The primary outcomes were independent functional outcome (i.e. modified Rankin Scale 0‐2) and all‐cause mortality at 90 days. Binomial test, chi‐squared test and t‐test for unpaired samples were used for statistical analysis.

Results

During 25,769 thrombectomies (5,124 MeVO, 20,645 LVO) in 25 stroke centers, perforation occurred in 335 patients (1.3%; mean age 72 years, 62% female). Perforation occurred more often in MeVO thrombectomy (2.4%) than in LVO thrombectomy (1.0%, p < 0.001). More MeVO than LVO patients with perforation achieved functional independence at three months (25.7% vs 10.9%; p=0.001). All‐cause mortality did not differ between groups (overall 51.6%). Navigation beyond the occlusion and retraction of stent‐retriever/aspiration catheter were the two most common procedural steps that led to perforation.

Conclusion

In our cohort, perforation was approximately twice as frequent in MeVO than in LVO thrombectomy. Efforts to optimize the procedure may focus on navigation beyond the occlusion site and retraction of stent‐retriever/aspiration catheter. Further research is necessary in order to identify thrombectomy candidates at high risk of intraprocedural perforation and to provide data on the effectiveness of endovascular countermeasures.
Abstract 215: A Sweet Indicator: HbA1C and Thrombectomy Outcomes in Hispanics
Authors: Khalil Zorain M. , Miller Samantha D. , Abualnadi Yazan D. , Desai Sohum K. , Sadiq Kaiser O. , Tekle Wondwossen G. , Hassan Ameer E.
Published: March 2024

Introduction

There is a higher prevalence of diabetes mellitus type 2 in Hispanics as compared to other ethnic groups in the United States. Diabetes is a risk factor for acute ischemic stroke and also a poor predictor of outcome for many interventional surgeries. We performed this retrospective cohort analysis to assess the impact of poorly controlled diabetes, defined as HbA1C of 9.0% or greater, on the functional and procedural outcomes of Hispanic patients with acute ischemic stroke undergoing mechanical thrombectomy.

Methods

We conducted a retrospective review of a prospectively maintained patient database at a large volume comprehensive stroke center. Patients included were of Hispanic origin presenting between 2012 and 2022 who underwent thrombectomy for acute ischemic stroke. Baseline patient demographics and clinical characteristics recorded include age, gender, HbA1C level, National Institutes of Health Stroke Scale (NIHSS) at admission, manual CT ASPECTS and stroke risk factors (hypertension, atrial fibrillation, coronary artery disease, congestive heart failure, LDL, smoking, history of stroke/TIAs). Patients were separated into two groups depending on the presence poorly controlled diabetes defined as an HbA1C of 9.0% or greater. Outcomes evaluated include modified Rankin scale at 3 months, symptomatic intracranial hemorrhage, mass effect, 90‐day mortality, and whether any stenting or angioplasty was required during mechanical thrombectomy.

Results

495 patients met the inclusion criteria out of which 69 had HbA1c of 9% or greater. Patients with poorly controlled diabetes were significantly younger (median age 63 vs 72, p <0.001), had a lower prevalence of atrial fibrillation (7.69% vs 29.8%, p <0.001) and a higher median LDL level (95.5 vs 72, p<0.001) compared to patients who did not have poorly controlled diabetes. Median NIHSS on admission was also lower in the poorly controlled diabetics group (13 vs 17, p = 0.02).

There was a statistically significant lower rate of functional independence (mRS 0‐2) at 90 days in patients with poorly controlled diabetes (30.6% vs 45.3%, p=0.05) after adjusting for age, NIHSS, and atrial fibrillation. Patients with poorly controlled diabetes also were more likely to require angioplasty (31.3% vs. 20.5%; p = 0.048) and stenting (28.4% vs. 18.1%; p = 0.049) during mechanical thrombectomy.

Conclusion

High HbA1c levels upon admission may be used to predict poor functional outcomes of thrombectomy and may also be associated with a greater chance of patients requiring angioplasty and/or stenting during thrombectomy. This can assist the physician in deciding if thrombectomy should be done on a patient with poorly controlled diabetes.
Abstract 217: Influence of CT Perfusion on Decision‐Making for Endovascular Thrombectomy in Distal Occlusions: A Multi‐center Analysis
Authors: Mehta Amol , Ballekere Anjan N. , Iyyangar Ananya S. , Abdelkhaleq Rania , Azeem Hussain , Le Ngoc M. , Sheth Sunil A.
Published: March 2024

Introduction

There is increasing interest in performing endovascular thrombectomy (EVT) for distal occlusions. Decision making for distal and medium vessel occlusions (DMVO) is variable and factors associated with undergoing the treatment at present remain incompletely characterized.

Methods

From our prospectively maintained multi‐center registry encompassing four comprehensive stroke centers in the greater Houston area, we identified patients with DMVO acute ischemic stroke (AIS). Patients with occlusions in and beyond the M2 segment, A2 segment, and P2 segment were included. The primary outcome was the likelihood of undergoing EVT, which was analyzed using multivariable logistic regression. We adjusted for time of day of presentation, NIHSS score, ASPECTS, and TPA administration, with the primary independent variable being whether CTP was used in the patient’s evaluation. Secondary outcomes included discharge modified Rankin Scale (mRS), dichotomized 0‐3 vs. 4‐6

Results

Among 269 patients with distal occlusions, the median age was 68 (IQR 18), median NIHSS score was 12 (IQR 11), 47.2% were female, and 39.4% received TPA. The most common occlusion locations were M2 (77.7%) followed by P2 (9.7%), and 12.6% comprised the remainder of the occlusions. 166 (61.7%) underwent CTP and 37.9% underwent EVT. Median infarct core on CTP was 18.8 cc and penumbra was 83.1 cc. In multivariable analysis, patients evaluated with CTP were less likely to undergo EVT (OR 0.56 [95% CI ‐1.11;‐0.02]). CTP usage was also associated with a non‐significant reduced likelihood of good discharge outcome (OR 0.59, [95% CI 0.33;1.02]).

Conclusion

In our multi‐center cohort, patients with DMVO screened with CTP were nearly 50% less likely to undergo EVT. While the modality may assist with occlusion detection, it may also influence whether treatment is offered.
Abstract 227: Combined Technique Versus Stent‐Retriever Alone: Angioarchitectural and Technical Analysis
Authors: Tarek Mohamed A. , Martins Pedro N. , Mohammaden Mahmoud H. , Monteiro Mateus Damiani , Grossberg Jonathan A. , Dolia Jay C. , Pabaney Aqueel , Nogueira Raul G. , Haussen Diogo C.
Published: March 2024

Introduction

Combined technique mechanical thrombectomy with contact aspiration with stent‐retriever has been shown to lead to comparable final reperfusion rates compared with stent retriever alone. We aimed to explore if anatomical and technical features could have interaction with the chances of reperfusion by each technique.

Methods

Retrospective analysis of a prospective mechanical thrombectomy (MT) database. Inclusion criteria: anterior circulation large vessel occlusion(LVO) due to carotid terminus or proximal MCA(M1) occlusion, first‐line stent‐retriever (SR) alone or combined technique (SR plus aspiration), and angiographic run with stent in place. The primary analysis was the interaction between clinical and angiographic characteristics and first‐line MT modality on first‐pass effect (FPE; first‐pass eTICI2c‐3). Secondary analyses aimed to evaluate predictors of FPE.

Results

A total of 150 patients were included in the analysis (SR alone,n=62 vs. combined technique, n=88). Demographics, vascular risk factors and NIHSS were comparable between groups. The SR group had higher IV‐tPA use (41.9%vs.26.1%,P=0.04), higher rates of FPE(64.5%vs.47.7%,P=0.04) but similar baseline ASPECTS, CTA collateral score, clot burden, as compared to the combined technique. Anatomical and technical variables (reperfusion channel, SR position in dominant MCA division, angle of interaction, diameter of stent proximal to clot, diameter of stent distal to clot, type of extracranial carotid or cavernous carotid tortuosity, clot length were comparable between both groups. None of the anatomical and technical factors were found to have an interaction with the modality (SR alone vs combined technique) on the chances of FPE (Pinteraction >0.05)(Figure). FPE was observed in 54.6% of the entire cohort. Multivariable analysis showed that use of IV‐tPA(OR 156.5,95%CI 4.59‐5334.8,P=0.005), lower angle of interaction (OR 0.94,95%CI 0.89‐0.99,P=0.03), presence of reperfusion channel (OR 145.8,95%CI 1.96‐108277.4),P=0.02), higher clot burden score (OR 8.17,95%CI 1.38 ‐48.21,P=0.02), type‐3 cavernous ICA tortuosity (OR 0.001,95%CI 0‐0.23,P=0.01) were independently associated FPE.

Conclusion

We could not identify any anatomical or technical features that predisposed to a benefit in adding catheter aspiration to SR thrombectomy. IV r‐TPA, clot burden score, presence of reperfusion channel, type of cavernous carotid tortuosity, and angle of interaction were found independently associated with FPE. Large sample studies are warranted.
Abstract 234: Antithrombotic use in Emergent Cervical Carotid Artery Stenting in Thrombectomy
Authors: Mahmoud Noor A.
Published: March 2024

Introduction

Current literature suggests a benefit in functional outcomes and reperfusion rates when carotid artery stenting (CAS) and mechanical thrombectomy (MT) are performed emergently. However, rates of symptomatic intracranial hemorrhages have been inconclusive. Antithrombotic protocols used in CAS and MT tend to be heterogenous among physicians. There is no standardized data on antithrombotic therapy use during CAS and MT procedures with less associated rates of symptomatic hemorrhagic transformation. We aimed to compare the efficacy and safety of antithrombotic use in patients requiring CAS and MT. Additionally, we sought to analyze clinical and mortality outcomes in CAS and MT retrospectively at our institution.

Methods

We searched for patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent‐retriever and/or aspiration devices in our institution between 2019‐2023. Clinicoangiographic and antithrombotic data were analyzed. Good clinical outcomes were a < 4 points of NIHSS at 24 hours, mRS (0‐3) at 90 days, and disposition to home or inpatient rehabilitation. Characteristics of hemorrhagic transformation (HT) according to the European Cooperative Acute Stroke Study (ECASS). Clinical, radiographic, and mortality outcomes were described.

Results

Twenty‐seven patients were treated. The mean age was 64 years, nine females: mean occlusion time 400 minutes, mean fluoro time 32 minutes. Fourteen patients received IV tissue‐type plasminogen (tPA) activator. The admission NIHSS score mean was 16. Stent placement was feasible in all cases. Thrombolysis in Cerebral Infarction score of 2B was achieved in 18 patients (66.7%); the rest had a TICI 3 score. Twelve patients had improved 4 NIHSS points between admission and 24 hours. Dual antiplatelet therapy with aspirin and clopidogrel was used in 15 patients before stenting. While six patients received aspirin and ticagrelor, and the rest received eptifibatide drip. Seven (26%) patients had symptomatic intracranial hemorrhages. Antithrombotic type of treatment had no significant association with bad outcomes (p‐value: 0.872), neither did IV tPA use (p‐value: 0.853). Fourteen patients had good clinical outcomes (mRS 0‐3) at discharge, while eight died. At 90 days follow‐up, the median mRS was 3.

Conclusion

Our analysis suggests no significant association between symptomatic hemorrhagic transformation with IV tPA or heterogenous antithrombotic use. Our retrospective study has several limitations, including sample size and heterogeneous pathology. Larger studies are needed to stratify symptomatic hemorrhages' high‐risk profile in CAS and MT.
Abstract 236: Effects of intravenous thrombolysis on thrombectomy outcomes: a systematic review and meta‐analysis
Authors: Tolba Hatem , Bilgin Cem , Ghozy Sherief , Kobeissi Hassan , Hassankhani Amir , Senol Yigit , Arul Santhosh , Kadrivel Ramanathan , Kallmes David
Published: March 2024

Introduction

Efficacy and safety of intravenous thrombolysis (IVT) in patients undergoing mechanical thrombectomy (MT) is still debatable. However, IVT's efficacy on stent retriever (SR) and aspiration thrombectomy (ASP) outcomes specifically remain unclear. In our meta‐analysis, we aimed to explore the effects of IVT on SR and ASP thrombectomy outcomes.

Methods

A systematic literature review was steered using Medline, Embase, Scopus, Web of Science, and Cochrane Center of Clinical Trials databases, according to PRISMA guidelines. Outcomes of interest included successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b), functional independence (modified Rankin Scale (mRS) ≤2), modified first pass efficacy (mFPE), symptomatic intracranial hemorrhage (sICH), and embolization to new territories (ENT).

Results

We included four randomized controlled trials with 1176 patients. SR and ASP had similar mTICI ≥2b, mFPE, and mRS 0‐2 rates whether they received IVT or not. SR without IVT was associated with a lower rate of mFPE compared with the SR+IVT (RR 0.85, 95% CI 0.74 to 0.97). Additionally, ASP without IVT resulted in a lower rate of mRS 0‐2 than the ASP+IVT (RR 0.78, 95% CI 0.60 to 1.01). Finally, bridging therapy did not increase sICH and ENT rates after ASP or SR thrombectomy.

Conclusion

Our analysis suggests that SR and ASP thrombectomy have equivalent efficacy and safety outcomes regardless of prior IVT administration. Moreover, our results indicate that administration of IVT before MT may improve certain outcomes based on the used first‐line MT technique.
Abstract 258: Comorbidities Associated with Exclusion from rtPA in Obese Ischemic Stroke Patients with History of Smoking
Authors: Brewer Philip C , Ojo Dami T , Garg Sahil , Broughton Philip X , Nathaniel Thomas I
Published: March 2024

Introduction

Recombinant tissue plasminogen activator (rtPA) is the only approved treatment for acute ischemic stroke (AIS) patients, however, only a minuscule percentage of patients receive rtPA [1, 2]. In some cases, the reason for patients' exclusion from rtPA is due to risk factors and comorbidities [1, 2]. Research has been conducted previously on rtPA exclusion in obese AIS patients as well as AIS patients with a history of smoking [3, 4, 5, 6]. However, little is known regarding the comorbidities associated with exclusion from rtPA in obese AIS patients with a history of smoking. ​

Therefore, a discussion surrounding these patients is warranted in order to better identify AIS patients who require special management in order to be eligible for rtPA. We hypothesize that the comorbidities associated with rtPA exclusion in obese AIS patients with a history of smoking will differ from comorbidities associated with rtPA exclusion in obese AIS patients or AIS patients with a history of smoking.

Methods

Retrospective data on demographic and clinical risk factors of obese AIS patients with a history of smoking was collected from a large stroke center from January 2010 to December 2016. Univariate analysis was used to differentiate between risk factors and demographics associated with exclusion and inclusion from rtPA. Variables in the univariate analysis were further analyzed using logistic regression. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each clinical risk factor were used to predict the increasing odds of an association of a specific clinical baseline risk factor with exclusion or inclusion from rtPA.

Results

In the adjusted analysis, Obese AIS patients with a history of smoking excluded from rtPA were more likely to present with CAS (OR = 0.069, 95% CI, 0.011‐0.442), diabetes (OR = 0.604, 95% CI, 0.366‐0.997), higher total cholesterol (OR = 0.975, 95% CI, 0.956‐0.995), history of drug and alcohol use (OR = 0.438, 95% CI, 0.232‐0.828). Higher NIHSS score (OR = 1.051, 95% CI, 1.017‐1.086), ambulation improvement (OR = 2.230, 95% CI, 1.423‐3.496), higher triglycerides (OR = 1.004, 95% CI, 1.001‐1.006), and higher HDL (OR = 1.028, 95% CI, 1.000‐1.057) were associated with Obese AIS patients that received rtPA.

Conclusion

Our findings reveal specific risk factors or comorbidities that contribute to the exclusion of Obese AIS patients with a history of smoking from rtPA. Specifically, a history of diabetes and higher total cholesterol were associated with rtPA exclusion in obese AIS patients with a history of smoking. These associations were not significantly correlated with rtPA exclusion in the populations of obese AIS patients or AIS patients with a history of smoking. These findings suggest the need to develop management strategies to improve the use of rtPA in obese AIS patients with a history of smoking.
Abstract 263: Cocaine Use and Acute Ischemic Stroke: Determining TOAST Etiology & Infarct Locations
Authors: Kothari Sachin , Desai Harsh , Behera Anit , Morsi Rami Z. , Carrion‐Penagos Julian , Smith Matthew , Coleman Elisheva , Kass‐Hout Tareq , Brorson James , Prabhakaran Shyam , Mendelson Scott J.
Published: March 2024

Introduction

Cocaine‐induced vasospasm of small vessels has long been proposed as a mechanism for ischemic stroke (1). However, there are limited studies to date that have classified cocaine‐related ischemic strokes under a subtype of the Trial of ORG 10127 in Acute Stroke Treatment (TOAST) criteria. This study aims to describe cocaine‐related ischemic strokes by TOAST criteria, treatment, and clinical outcome.

Methods

A retrospective review was performed to identify patients with acute ischemic stroke and a positive cocaine urine toxicology screen at our stroke center from June 2020 – May 2022. Baseline demographics, urine toxicology, National Institute of Health Stroke Scale (NIHSS) scores, neuroimaging, TOAST criteria, location of stroke, home medications, comorbidities, medical management, and in‐patient outcomes were collected. Data analysis was conducted on IBM SPSS Version 28.

Results

A total of 74 patients were identified to have a positive cocaine status on admission with a diagnosis of new strokes. The mean age was found to be age 60.8 years old with a majority male population at 73.0% (54/74). Seventy‐eight percent (58/74) were found to be cocaine positive on admission with the remaining endorsing a history of cocaine use. The most common category under the TOAST criteria was large artery atherosclerosis 39.2% (29/74). Among the cocaine‐positive cohort, 10.8% (8/74) of patients received thrombolytics. Most patients had intracranial atherosclerotic disease (46/74, 62.2%) on imaging and in the area of the stroke (41/74, 55.4%). Overall mortality was low (72/74, 97.3%) and modified Rankin score (mRS) at discharge was less than 3 for 59.5% (44/74) of patients.

Conclusion

Our data suggests that although cocaine may contribute to small vessel disease, cocaine‐related ischemic strokes may have a higher association with large artery atherosclerosis. This study highlights the importance of future larger studies to investigate atherosclerosis as a contributor to cocaine‐induced ischemic strokes.
Abstract 267: A Bibliometric Analysis of Tenecteplase Research Utilizing a Commonly Used Citation Index
Authors: Huang Brendan
Published: March 2024

Introduction

Tenecteplase is increasingly being used as a first‐line treatment for acute ischemic stroke after several randomized studies demonstrated its safety and efficacy, resulting in a massive increase in the number of published studies on this topic. Our aim was to investigate the most impactful authors and relevant journals that have been instrumental in validating this treatment, in hopes of identifying objective research trends that may assist scientists, health organizations, and funding agencies to collaborate and plan future avenues of research.

Methods

Using the search terms “Tenecteplase” and “Tenecteplase” AND “Stroke,” 2,683 and 1,150 references were queried, respectively, using the Abstract 20and citation database, Scopus. Scopus Citation Analysis was used to categorize the countries and authors who produced the most research. Metadata was retrieved and transferred to bibliographic visualization software, VOSviewer, for co‐authorship and co‐occurrence analyses to identify trends in tenecteplase research.

Results

Data visualization software identified three tenecteplase research clusters – myocardial infarction, pulmonary embolism, and acute ischemic stroke. Our bibliographic analysis graphically identified that ischemic stroke currently leads both myocardial infarction and pulmonary embolism in annual publications pertaining to tenecteplase therapy, and further pinpointed perfusion imaging and wake‐up strokes as the most relevant areas of study. The United States led all countries in tenecteplase publications, including exclusively stroke studies. The European Heart Journal led all journals in overall publications, while Stroke led all journals in stroke‐related studies.

Conclusion

Through the use of bibliographic analysis and data visualization, we identified major articles and journals that reflected and shaped the current landscape of tenecteplase; recognized authors who engaged in tenecteplase research as it progressed from cardiopulmonary disease to stroke; and postulated future avenues of research.
Abstract 278: Patterns of Mechanical Thrombectomy for Stroke Before and After the 2015 Pivotal Trials:5 Years Follow‐up
Authors: Chintaluru Yaswanth S , Atchaneeyasakul Kunakorn , Liaw Nicholas , Fukuda Keiko , Mendez Aldo , Kuybu Okkes , Desai Shasvat , Pinheiro Agostinho , Jadhav Ashutosh , Fitzgerald Kathryn C , Gross Bradley , Narayanan Sandra , Nogueira Raul , Lang Michael
Published: March 2024

Introduction

The 2015 American Heart Association Guidelines recommended mechanical thrombectomy with stent‐retriever devices. A prior published analysis of national trends after one year in mechanical thrombectomy use and outcomes for stroke before and after publication of the 2015 US guideline update showed improved functional outcomes and lower peri‐procedural mortality. We analyze the national trends in mechanical thrombectomy use and outcomes for stroke five years after publication of the US guideline update.

Methods

We analyzed the National Inpatient Sample from 2012‐2019. ICD‐9 and ICD‐10 codes identified Ischemic stroke and mechanical thrombectomy patients. Similar to the previous study, discharge to home was the primary efficacy outcome measure in this study since it strongly correlates with mild degree of disability at discharge and 3 months post‐stroke. Safety outcomes include in‐hospital medical complications and mortality. We utilized multivariate logistic regression to assess outcomes.

Results

From 2012‐2019, 4,003,405 individuals with a diagnosis of ischemic stroke were recorded, 103,605 (2.6%) of which were treated with mechanical thrombectomy, proportionally increased from 4,910/452,905 (1.1%) in 2012 to 26,365/552,780 (4.8%) in 2019. The proportion of endovascular thrombectomy performing hospitals nearly doubled during the study period from 2012 (295/4,378; 6.7%) to 2019 (582/4,568; 12.7%). Odds of a mild disability outcome increased from 16% to 20%, OR 0.65 (0.57, 0.74), while mortality decreased from 15% to 12%, OR 0.69 (0.61, 0.78). Compared with 2012‐2014, the 2015‐2019 cohort showed increased odds of ICH and shock while the odds of DVT, pulmonary embolism, pneumonia, and UTI were significantly lower. The presence of septicemia, shock, and cardiac arrest were unchanged.

Conclusion

The number of large vessel occlusion stroke patients receiving mechanical thrombectomy treatment in the United States is increasing rapidly each year after the 2015 US guideline update. As the use of mechanical thrombectomy expands, included patients have more medical complications at baseline, but experience fewer complications, peri‐procedural mortality and overall improved outcomes.
Abstract 282: Understanding Current Organizational Strategies to Support Physician Well‐Being in Stroke, Neurocritical Care, and Neurointerventional Practice
Authors: Kothari Sachin A. , Castonguay Alicia , Guerrero Waldo , Asif Kaiz S. , El‐Ghanem Mohammad , Kumar Ashish , Abraham Michael , Dumitrascu Oana , Ramos Romario , Pandya Dhruvil J.
Published: March 2024

Introduction

Burnout in medicine is an occupational hazard and has emerged as a pressing concern in recent years. Organizational changes can be impactful in countering burnout (1). The factors leading to burnout in medicine are multifaceted, encompassing organizational factors such as workload, inadequate support, and inefficient administrative systems. The purpose of this study is to investigate current organizational measures to support physician well‐being. This study was an initiative led by the SVIN wellness committee.

Methods

A 39‐question online survey investigating current organizational well‐being practices was distributed to physicians both nationally and internationally practicing stroke, neurocritical care, and interventional neurology. Data analysis was performed using Python, utilizing the libraries “pandas” and “sklearn”.

Results

This study analyzed burnout among 109 healthcare professionals, predominantly from the U.S. (93.6%) and Canada (6.4%). The majority were neurointerventional specialists (53.2%), aged 35‐44 years (52.3%), and male (62.4%). Burnout frequency was measured on a 0 (Never) to 4 (Every day) scale.

Using a Random Forest model, the study identified key burnout predictors from questions, which covered organizational leadership, wellness resources, compensation, and workload. The most influential predictors were: adequacy of compensation relative to specialty, workload, and stress (17.7% importance); leadership accountability for workforce wellbeing (9.1%); and establishment of wellness or burnout as a critical metric (7.5%). Other factors included provision of wellness screenings (7.1%), and dedication of resources toward professional well‐being (4.9%).

Conclusion

The study identifies compensation, leadership accountability, and wellness resources as key predictors of burnout among healthcare professionals. These findings highlight the need for targeted organizational strategies to enhance physician well‐being and mitigate burnout. Further research is warranted to validate and expand upon these findings.
The Status of Music in Islamic Law: Ibn Ḥajar al-Haytamī’s (d. 974/1567) Treatise Against Recreation in its Polemical Context
Authors: _ _
Published: March 2024

Kaff al-raʿāʿ ʿan muḥarramāt al-lahw wa-l-samāʿ is an influential treatise on the legal status of music and other recreational activities written by the Shāfiʿī Ibn Ḥajar al-Haytamī (d. 974/1567) in 958/1551. This article offers the first analysis of this “treatise against recreation”. Ibn Ḥajar al-Haytamī argues for the impermissibility of most musical activities on the basis of the Qurʾan and Hadith, the consensus of the ʿulamāʾ (particularly from his Shāfiʿī school), and the incompatibility of recreation (lahw) and piety. These arguments are forged in response to claims found in more permissive texts by the Ẓāhirīs Ibn Ḥazm (d. 456/1064) and Ibn al-Qaysarānī (d. 507/1113) and the Mālikī Muḥammad al-Shādhilī al-Tūnisī (d. 882/1477). I suggest that it is Ibn Ḥajar’s negative attitude to lahw that underlies his restrictive views on music, highlight the gendered element in this attitude, and observe that attitudes to recreation are not interchangeable with affiliation to Sufism.
Health, Religion, and Politics: Re-assessing the Role of Christian Missionaries in Colonial Assam
Authors: Jagriti  , Sengupta Madhumita
Published: March 2024

Most studies of Christian missionaries in British Assam have focused on their role in promoting Christianity or education, not to mention their contributions to the development and standardization of local languages. There has been a singular lack of studies concerning the immense contributions made by the missionaries in setting up a healthcare infrastructure in the region. This absence has further distorted the debate on whether the missionaries operated as independent agents or as auxiliaries of the state. This paper dwells on the medical work carried out by the missionaries in British Assam and contends that the missionaries fulfilled multiple roles and functions in the province. We argue that the significance of the work of the missionaries is enhanced by the utter neglect of healthcare by the colonial state in the frontier region.