bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 057: Recent Trends and Outcomes of Hospital Transfer for Endovascular Stroke Treatment in U.S.
Authors: Abbasi Mohammad H. , Warach Steven , Saber Hamidreza
Published: March 2024

Introduction

Optimal triage strategies for patients suspected of acute ischemic stroke due to large vessel occlusion remains debated. Whereas secondary analyses from randomized trials have demonstrated no differences in thrombectomy outcomes in transferred vs direct presentation strokes (1‐2), several registry based cohorts reported worse functional outcomes in those with transferred presentation mode (3‐4). We explored the US national claims database to explore trends in presentation (transferred vs direct presentation) and their outcomes for EVT hospitalizations using a nationally representative sample.

Methods

National Inpatient Sample database was retrospectively explored from 2016 to 2020 for stroke hospitalizations with EVT. Outcomes were compared for EVT hospitalizations with direct vs transferred presentation at discharge. Outcomes included favorable discharge disposition (home without assistance); in‐hospital mortality; and radiographic intracranial hemorrhage (ICH).

Results

Among 100,865 admissions with EVT, 32,685 (32.4%) presented following hospital transfer for thrombectomy. The utilization of EVT in US nearly doubled during between 2017 to 2020, and the proportion of in‐hospital transfer for EVT remained unchanged during this period. White race, higher baseline NIHSS, hospital size and status (urban teaching vs rural), and hospital location were independent predictors of transferred status for EVT. Transferred status was significantly associated with a lower likelihood of achieving favorable outcome (OR: 0.80, CI: [0.72, 0.89], P<0.001) and a higher likelihood of ICH (1.18 [1.07, 1.31], P=0.001), whereas no differences were observed in early mortality following transferred vs direct presentation mode (1.07 [0.93, 1.23], P=0.33).

Conclusion

Nearly one in 3 EVTs in US is performed in patients presenting following transfer from another acute care hospital. Transferred presentation status was associated with worse clinical outcomes following EVT in a real‐world setting. Future studies are needed to determine the optimal triage strategies for patients suspected of harboring large vessel occlusion strokes.
Abstract 061: Identification of Proteins Predictive of Post‐Thrombectomy Outcome Based on an Appalachian vs. Non‐Appalachian Cohort
Authors: Maglinger Benton
Published: March 2024

Introduction

The Appalachia region of North America is known to have significant health disparities, specifically, worse risk factors and outcomes for stroke. Appalachians are more likely to have comorbidities related to stroke, such as diabetes, obesity, and tobacco use, and are often less likely to have stroke interventions such as mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO). As our Comprehensive Stroke Center directly serves stroke subjects from both Appalachian and non‐Appalachian areas, we set out to identify proteomic biomarkers predictive of stroke outcomes specific to subjects residing in Appalachia.

Methods

Eighty‐one subjects met inclusion criteria for this study. These subjects underwent MT for ELVO, and during the procedure, carotid arterial blood samples were acquired and subsequently sent for proteomic analysis. Samples were processed in accordance with the Blood And Clot Thrombectomy Registry And Collaboration (BACTRAC; clinicaltrials.gov; NCT 03153683). Statistical analyses were utilized to examine whether relationships between protein expression and outcomes differed by Appalachian status for functional outcomes (NIH Stroke Scale; NIHSS and Modified Rankin Score; mRS), cognitive outcomes (Montreal Cognitive Assessment; MoCA), and mortality.

Results

No significant differences were found in demographic data nor co‐morbidities when comparing Appalachia to non‐Appalachia subjects. However, time from stroke onset to treatment (last known normal) was significantly longer in patients from Appalachia, so this datapoint was entered as a co‐variate in all predictive models. A comprehensive analysis of 184 cardiometabolic and inflammatory proteins revealed seven Appalachia‐specific proteins predictive of NIHSS, fourteen predictive of MoCA, six predictive of mRS, and seven proteins related to mortality. Specifically, within the Appalachian group, the protein multiple epidermal growth factor‐like domains protein 9 (MEGF9) was positively correlated to discharge NIHSS, elevated levels of the proteins coagulation factor XI (F11) and mannose binding protein (MBL2) were found to have an increased likelihood of worse mRS, but there were no proteins identified from the Appalachian cohort that were predictive of worse MoCA score, nor worse mortality.

Conclusion

Appalachia is an underserved population with significantly worse health disparities, specifically related to ischemic stroke. Our study found that patients who presented from Appalachian regions have a different proteomic response at time of MT when compared to otherwise similar subjects presenting from non‐Appalachian communities. These differentially expressed proteins could be used as prognostic biomarkers as well as novel therapies targeted at an underserved population. Lastly, expression differences may be in part related to environmental exposures, such as coal pollution, which will require additional studies moving forward.
Abstract 063: Emergent versus delayed carotid artery stenting in tandem occlusion strokes treated with thrombectomy
Authors: Seblani Nader El , Kalra Saurabh , Ortega‐Gutierrez Santiago , Kalra Deepak , Nagaraja Nandakumar
Published: March 2024

Introduction

It is controversial when to pursue carotid artery stenting (CAS) after acute tandem occlusion (TO) strokes treated with endovascular thrombectomy (EVT). We conducted a retrospective observational study to evaluate the clinical and safety outcomes of emergent versus delayed CAS in the first week of EVT.

Methods

In this retrospective cohort study, using 2016‐19 Nationwide Readmissions Database, we identified patients with acute ischemic stroke who had EVT for anterior circulation large vessel occlusions (LVOs) and CAS up to 7 days of EVT. CAS performed on day ‐1, 0 or 1 day after admission was considered as emergent CAS. CAS performed 2‐7 days after EVT was defined as delayed CAS. The primary clinical outcomes were all‐cause mortality during same admission. Secondary safety outcomes included intracranial hemorrhage (ICH), seizures, gastric tube (G‐tube) insertion, > 24‐hours mechanical ventilation, tracheostomy, length of stay (LOS), and discharge location (home vs. others). Multivariate logistic regression analysis was used to compare outcomes in emergent CAS group in comparison to delayed CAS group. Age, sex, hypertension, diabetes mellitus, hyperlipidemia, and use of thromobolytics were considered as covariates.

Results

We identified total of 1990 hospitalizations meeting the study inclusion criteria (mean age: 67 years ± standard deviation:12 years, female 612 (31%). Of these, 1745 (87%) had undergone emergent CAS with EVT and 245 (13%) had delayed CAS (2‐7 days) pos‐EVT. Baseline characteristics were similar between the two cohorts. Delayed CAS cohort had significantly less mortality rates [6 vs 13%; OR 0.43, 95% CI 0.24‐0.78], less ICH [20 vs 30%; OR 0.6, 95% CI 0.43‐0.82¬¬], less cerebral edema [16 vs 23%; OR 0.65, 95% CI 0.44‐0.96], and less mechanical ventilation for >24‐hours [11 vs 18%; OR 0.54, 95% CI 0.34‐0.85]. There was no significant difference between the two treatment groups for tracheostomy, G‐tube placements, new‐onset seizure, and mean LOS.

Conclusion

Delaying CAS for 2‐7 days after EVT might be a safer approach for endovascular revascularization in anterior circulation LVO strokes secondary to tandem lesions.
Abstract 068: Basilar artery bifurcation anatomy as a determinant of recanalization and stroke outcome
Authors: Abbasi Mohammad Hossein , Eltatawy Ali , Messé Steven R. , Mowla Ashkan , Prestigiacomo Charles J. , Smith Matthew S. , Rosso Michela , Kasner Scott E. , Shirani Peyman
Published: March 2024

Introduction

Background: Thrombectomy improves outcomes in patients with basilar artery (BA) occlusion [1,2]. We hypothesized that the anatomic configuration of the BA bifurcation, classified as T‐ or Y‐shaped, may impact the outcome. Specifically, we expected that a T‐shaped BA would involve more deep penetrating arteries of the midbrain and thalamus, leading to greater disability or death [3,4].

Methods

In this 2‐center retrospective cohort study over seven years, we included patients with stroke due to distal BA occlusion and performed blinded classification of their BA anatomy as either T‐ or Y‐shaped [Figure 1]. The primary outcomes were favorable functional status at 90 days (modified Rankin Scale 0 – 2) and successful reperfusion (TICI scores 2B or 3).

Results

70 patients (mean age 66 years, 36% women) were included. 38 had T‐ and 32 had Y‐shaped bifurcations. Baseline characteristics were similar for both groups, including demographics, treatment time, baseline NIHSS, THRIVE score, posterior circulation collateral score, and presence of tandem occlusion. Comparing the T‐ to the Y‐ shape, there was no difference in the likelihood of successful reperfusion (1.09 [0.52–2.27], p=1.00) nor 90‐day favorable mRS (0‐2) score (RR: 0.68 [0.37–1.27]; p=0.18). Similarly, mortality at 30 and 90 days were not significantly affected by the type of bifurcation.

Conclusion

The configuration of the basilar artery does not significantly impact reperfusion success or stroke outcome.
Abstract 077: Readmission Rates and Etiologies among Patients with Subarachnoid Hemorrhage: A Nationwide United States Analysis
Authors: Laswi Ibrahim , Arabi Maryam , Al‐Najjar Yousef , Dargham Soha , Jerdi Salman Al , Khalil Charbel Abi
Published: March 2024

Introduction

Subarachnoid Hemorrhage (SAH) is the leading cause of morbidity and mortality in stroke patients, associated with severe neurological, infectious, and thromboembolic complications. Identifying clinical predictors linked to hospital readmissions after a SAH allows for the determination of patients with higher risks of complications, opening an avenue for prevention and improved quality of care.

Methods

The Nationwide Readmission Database (NRD) was used to extract patients with SAH (ICD‐10 code: I60.x) from 2016‐2019. The difference in days between the index admission and the readmission was used to identify patients who were readmitted within 30 and 90 days. The primary diagnosis of the readmission was used to identify the etiology of readmission. Data was weighted to allow for representative nationwide estimates.

Results

We identified 68,726 patients with SAH, with a mean age of 60.47 years, and 57.86% being female. Overall, 7.79% (n=5354) were readmitted within 30 days and 12.04% (n=8525) were readmitted within 90 days. The rate of 30‐day readmission was overall stable (7.34% in 2016 and 7.70% in 2019; p=0.42), but the 90‐day readmission rate slightly increased from 11.69% in 2016 to 12.47% in 2019 (p=0.04). Around 62% of 90‐day readmissions occurred within the first 30 days. Patients readmitted within 30 days were more likely to be older (mean age = 61.92 vs 60.99 years; p<0.001) and male (43.96% vs 41.74%; p=0.002) compared to those not requiring readmission. They had a higher prevalence of diabetes (23.38% vs 18.82%), hypertension (74.34% vs 70.12%), obesity (13.95% vs 12.25%), dyslipidemia (38.17% vs 33.02%), smoking (39.30% vs 37.43%), prior TIA/ischemic stroke (22.60% vs 20.39%), coronary artery disease (15.03%), DVT (6.06% vs 3.51%), peripheral vascular disease (14.24% vs 11.09%), chronic renal failure (13.34% vs 9.35%), and heart failure (10.57% vs 7.75%) (p<0.001 for all). The most common etiologies of 30‐ and 90‐day readmission were cardiovascular (42.53% and 40.79%), neurological (12.34% and 11.50%), and infectious (8.41% and 8.21%).

Conclusion

The annual rate of 90‐day readmission, but not 30‐day readmission, increased from 2016 to 2019. Readmitted patients both within 30 and 90 days were more likely to have a higher prevalence of vascular risk factors and related comorbidities.. The most common cause of 30‐ and 90‐day readmission is cardiovascular diseases followed by neurological and infectious conditions. Further studies are required to offer risk stratification and prevention strategies for readmission among patients with Subarachnoid Hemorrhage.
Abstract 078: Managing Clopidogrel Resistance in Neurointervention: Surveying Current Approaches
Authors: Kim Hyun Woo , Bach Ivo , Martinez‐Gutierrez Juan Carlos , Dmytriw Adam , Zeineddine Hussein , D'Amato Salvatore , Sheth Sunil
Published: March 2024

Introduction

Due to the variability in patient responses to clopidogrel, adjusting antiplatelet regimen based on platelet function testing has become a widespread practice to reduce thromboembolic complications in neurointervention. In the absence of standardized guideline, we aimed to explore the practice patterns related to clopidogrel resistance.

Methods

We conducted a survey targeting neurointerventionalists, comprising multiple‐choice questions and opportunities for free‐text responses when necessary. The survey was distributed via a professional society – the Society of Vascular and Interventional Neurology (SVIN) and two emailing lists – WovenEndoBridge and Neurointerventional Research Consortium. The data obtained from the responses were analyzed using descriptive statistics.

Results

A total of 133 neurointerventionalists representing 83 institutions within 24 countries responded to the survey. 62% of respondents tested for clopidogrel resistance prior to any neurovascular stent placements. 80% utilized VerifyNow point‐of‐care P2Y12 assay; other assays included multiplate analyzer, platelet function analyzer (PFA‐100), and CYP2C19 genotype assay. Respondents reported 25 different therapeutic thresholds, with the P2Y12 Reaction Units range between 60 and 180 most commonly used (16.4%). 61% reported they would switch to ticagrelor in the case of persistent resistance. On the other hand, when patients are supratherapeutic, 48% did not make any changes while 42% reduced clopidogrel dose. Finally, 93% felt that there was a lack of well‐established protocol for management of clopidogrel resistance.

Conclusion

Neurointerventional practice patterns around clopidogrel resistance remains heterogeneous. Our results underscore the need for evidence‐based guidance on anti‐thrombotic management during cerebrovascular stenting.
Abstract 080: Continuous Automated Stroke Screening Software for Early Detection of Neurological Impairment
Authors: Eskian Mahsa , Sharashidze Vera , Heit Jeremy J. , Taghdiri Foad , Masoud Hesham , Gould Grahame
Published: March 2024

Introduction

Stroke is the second leading cause of death worldwide leaving up to 50 % of Survivor chronically disabled after their event. Early diagnosis and treatment can significantly lower mortality and morbidity, significantly reducing the economic burden of long‐term disability. Due to the painless nature of most stroke events, many lack the stimulus to seek emergency assistance, further compounded by a symptomatology of deficit resulting in being unaware of the symptoms or lacking the ability to call for help when needed. A continuous automated stroke screening software tool was developed to address these pitfalls in prehospital care, allowing for the early detection of neurological impairment and the release of a medical emergency alert to facilitate emergency medical care.

Methods

Python version 3.11.3, NumPy, OpenCV, and mediapipe were used for facial and hand land marking with mathematical models employed to detect eye gaze direction, facial symmetry, eyelid closure and left or right hand detection.

Results

We were able to demonstrate consistent performance of the final software to continuously detect the eye gaze deviation, or center in real time video capturing (Figure‐1). Software is also capable of detecting lower facial palsy through facial symmetry recognition of smiling to demonstrate a right or left sided palsy (Figure‐2). The ability to blink can be detected to differentiate motor neuron palsy and used as a measure of mental status demonstration of the ability to follow a simple midline command (Figure‐3). Detection of lateralizing hand presentation to the camera allows the software to be used in detecting hemi‐neglect, and antigravity muscle strength in upper extremity. (Figure 1‐3).

Conclusion

Our developed automated stroke screening software can be used for continuous, physician independent, monitoring of neurologic patients and the detection of acute deficits and emergency alert to facilitate early care. The software is designed for use in medical emergency alert systems, tele stroke assessments, and remote surveillance of the neurological examination in intensive care unit or patients in isolation. Here we present the initial software development and capability, we are currently studying our detection models on patients with neurological deficits in varied practice settings.
Abstract 081: Clinical Presentation and Treatment of 26 Spinal Epidural Arteriovenous Fistulas: A Single Center Experience
Authors: Beaman Charles , Molaie Amir , Ghochani Yasmin , Fukuda Keiko , Peterson Catherine , Kaneko Naoki , Nour May , Szeder Viktor , Colby Geoffrey , Tateshima Satoshi , Jahan Reza , Duckwiler Gary
Published: March 2024

Introduction

Spinal epidural arteriovenous fistulas (SEAVFs) are rarely diagnosed vascular malformations that can cause spinal cord compression and congestive myelopathy.

Methods

This is a single center, retrospective case series of patients with SEAVF who underwent observation or treatment at UCLA medical center from 1993 to 2023.

Results

A total of 26 patients were found to have a SEAVF at UCLA from 1993 to 2023. The median age at treatment was 59 years (range 4 months to 91 years). 16 of 26 patients (55.2%) were male. 12 were located in the cervical spine, 2 in the thoracic spine, 11 in the lumbar spine, and 1 in the sacral spine. Sacral, lumbar, and thoracic SEAVFs demonstrated a strong male predominance (12 of 14, 85.7%), while cervical SEAVFs were more common in women (8 of 12, 66.7%). The median duration of symptoms prior to treatment was 6.5 months (range 1 day to 8 years). Possible triggers included prior spinal surgery (n=3), turning neck (n=1), trauma to the neck (n=1), lifting a heavy box (n=1), prolonged period of bending over (n=1). The remaining patients did not have any particular trigger. All patients with lumbar and thoracic SEAVFs (except the 3‐month‐old) demonstrated flow voids and cord edema. Patients with cervical SEAVF did not demonstrate cord edema and only 5 of 12 explicitly mentioned flow voids. 22 patients were treated strictly endovascularly, 1 patient endovascularly and then surgically, 1 patient surgically, and 2 patients refused treatment. No patients treated endovascularly experienced complications. 19 of 23 patients (82.6%) treated endovascularly received complete cure after the first treatment. 1 patient had a successful subsequent embolization 2 days later. Of the 3 other incomplete treatments, one patient received subsequent successful surgery, one patient was a 3‐month‐old patient with Parkes‐Weber syndrome who subsequently died of other medical issues, and one was lost to follow‐up. One patient underwent surgical treatment alone due to the feeding arteries being too small to catheterize and unfortunately experienced a failed surgery on the first attempt and developed a surgical site infection after the second successful attempt at treatment. Onyx was used in 10 cases (9 of 10 successful). 2 cases treated with NBCA were unsuccessful. Cervical and Sacral SEAVFs were treated successfully (mostly prior to 2006) with coils and/or detachable balloons.

Conclusion

SEAVF is a rare disease that can be treated effectively and safely with endovascular embolization in most cases. Pre‐operative MRI demonstrated abnormalities in all cases. We found a strong male predominance in our cohort.
Abstract 092: Vasospasm as a Consequence of IVIg Usage for GBS.
Authors: Welsh Connor D
Published: March 2024

Introduction

The relationship between Intravenous Immunoglobulin (IVIg) and cerebrovascular vasospasm is poorly and incompletely understood. Some case reports have identified IVIg as potential therapy for vasospasm, while others have implicated it as a causative agent in primarily coronary artery vasospasm and the development of atypical angina. This case illustrates a situation in which a patient with Guillain‐Barre Syndrome (GBS) was started on IVIg and developed subsequent vasospasm with cerebral infarcts requiring intra‐arterial therapy.

Methods

Case Report

Results

Our patient is a 62 year old female with a history of cervicothoracic subdural hematoma status postevacuation with left leg weakness, hypertension, known right ICA aneurysm, and chronic left ICA occlusion who presented as a transfer from an outside facility where she initially presented with progressive back pain, lower extremity weakness, areflexia and dysautonomia. MRI brain initially demonstrated posterior‐predominant T2 hyperintensities affecting subcortial white tracts suggestive of PRES. Lumbar puncture demonstrated cytoalbuminologic dissociation supporting a superimposed GBS. IVIg was initiated, however the patient's mentation and examination declined. Repeat MRI demonstrates bilateral, posterior‐predominant acute multifocal ischemic infarcts. Vessel imaging demonstrated vasospasm of the basilar and bilateral anterior Circle of Willis. Oral Verapamil was initiated. Digital Subtraction Angiography confirmed these findings; intra‐arterial verapamil was utilized with significant improvement in the patient's examination.

Conclusion

IVIg has only a weak association with coronary artery vasospasm, however is heavily implicated in the onset of this patient's diffuse vasospastic ischemic disease. Prompt identification and aggressive initiation of treatment is essential in minimizing the burden of ischemic stroke and optimizing outcomes for these complex patients.
Abstract 102: Pseudo‐Internuclear Ophthalmoplegia in a Patient with an Acute Globus Pallidus Infarct: A Case Report
Authors: Idris Anas
Published: March 2024

Introduction

Internuclear ophthalmoplegia (INO) is an ocular movement disorder typically due to a lesion in the medial longitudinal fasciculus (MLF). Rarely, similar ocular movement abnormalities can be observed in the absence of an MLF lesion. This case report aims to highlight a potential association between acute globus pallidus (GP) infarct and an ocular movement abnormality resembling INO.

Methods

N/A

Results

Case Presentation: A 72‐year‐old male with a medical history significant for chronic myeloid leukemia, prostate cancer, type 2 diabetes mellitus, hypertension, prior stroke, and heart failure presented with dizziness. Examination revealed right INO, skew deviation with right hypertropia, left lower extremity weakness, left upper extremity dysmetria, right facial weakness (prior deficit), and ataxic gait. MRI of brain confirmed an acute lacunar infarct in the right globus pallidus with no apparent brainstem or cerebellar lesion. The patient was started on dual antiplatelet therapy and discharged with home rehabilitation services to improve his balance. Discussion: The patient presented with pseudo‐INO in the setting of an acute globus pallidus infarct. This case introduces the idea that ocular motor abnormalities resembling INO could occur due to a GP lesion, which was not previously reported. The basal ganglia control saccadic eye movements by means of their connection to the superior colliculus (SC). GP was shown to have a role in this connection which may provide a plausible explanation for this observation. Another possible explanation can be based on the concept of diaschisis, where a lesion in a specific area of the brain (GP in this case) can lead to deficits or impairments in various functions associated with that region (the SC and its pathway for controlling saccadic eye movement).

Conclusion

This case emphasizes that slow adducting saccades and associated nystagmus is not always INO.
Abstract 104: Fetal Posterior Cerebral Artery (PCA) Occlusion from Occluded Cavernous ICA Stent
Authors: Kahriman Aydan , Borchert William , Blenden Adam , Masoud Hesham
Published: March 2024

Introduction

Posterior Cerebral Artery (PCA) is a medium vessel occlusion (MVO) which is 5‐10% of all acute ischemic events. Safety and efficacy of mechanical thrombectomy in posterior circulation MVO is unclear compared to medical treatment only (1). There is concern that fragility of distal, smaller vessels may have an increased risk of procedural complications (e.g., arterial dissection and or perforations). More people are getting flow divertors over the years and rate of flow diverter of ICA occlusion is 0.05%‐0.08% (2). Here we present a case of embolic fetal PCA stroke with ICA stent occlusion.

Methods

We report a case of fetal origin posterior cerebral artery occlusion from ICA with literature search of Pubmed.

Results

77 years old female with left cavernous‐ICA stent presented from a rehab facility with complaints of word finding difficulty, confusion, right hemiparesis, right sided neglect, and visual disturbance. In the emergency department (ED), her NIHSS was 28. ED presentation was 2.5 hrs after the last known well (LKW). Of note, patient had a with left cavernous‐ICA stent placement a month before the presentation and was noncompliant to antiplatelets. CT head was negative for intracranial bleeding and ASPECT score was 7. CT angiography head and neck was obtained, showing new complete interval occlusion of the intracranial extradural left ICA with reconstitution of distal branches through anterior communicating artery. Patient received IV thrombolytics, intubated for airway protection and was transferred to a comprehensive stroke center for possible mechanical thrombectomy. Time of the arrival was approximately 6 hours after the LKW, reexamination was hindered by the sedation and intubation but was concerning for possible PCA occlusion rather than ICA occlusion. As the localization of ischemic area was unclear, CT perfusion (CTP) was obtained. CTP showed 27 ml penumbra without core infarct in left PCA territory. As fetal origin of left PCA from ICA is occluded, without ability to access through occluded stent, noted risk of left ICA complications with attempts to recanalize stent for noted PCA hypoperfusion outweigh the benefits. With the exam improvement post thrombolytics administration and small penumbra, mechanical thrombectomy was not indicated.

Conclusion

In acute large vessel occlusion, utility of CT perfusion (CTP) usually recommended after 6 hours from last well known. In this case, patient presented within the 6 hours but the reexamination post thrombolytics was not localizing to suggest large vessel occlusion (LVO) and the territory at risk was unclear. We described a left intracranial ICA flow diversion occlusion without anterior circulation ischemia and left PCA ischemia demonstrated. In this case, CTP was employed to differentiate the territory at risk for triage to appropriate intervention, to differentiate the LVO vs MVO.
Abstract 106: CHANTER Syndrome: A Case Report Of A 59 Year Old Man With Positive Outcome
Authors: Elsayed Sherif , Al‐Ani Mina , Balabhadra Anvesh , Elmashad Ahmed
Published: March 2024

Introduction

Cerebellar, Hippocampal, and Basal Nuclei Transient Edema with Restricted Diffusion (CHANTER) syndrome was first described in 2019 [1] as a pattern of radiographic findings that are distinct from ischemic, anoxic, or toxic brain injury. Pathophysiology is still uncertain, but some proposed theories include a primary metabolic etiology or a mitochondrial failure of gray matter. Clinically, patients typically present with altered level of consciousness. Radiographically, diffusion weighted imaging shows restriction in the bilateral hippocampi, bilateral cerebelli, and basal nuclei. The cerebral cortex, thalamus, and subcortical white matter are usually spared. Despite the morbid clinical picture on presenation, positive outcomes were reported with early intervention. We describe a case of CHANTER syndrome in a 59 year old man with history of illicit substance abuse.

Methods

Case report with electronic medical record review.

Results

59‐year‐old man with history of illicit substance abuse including cocaine, opioid, and phencyclidine presented to the hospital after being found down at a drug store. Patient did not respond to Naloxone and was eventually intubated due to respiratory compromise. Non‐contrast CT head showed hypoattenuation of the bilateral cerebellar hemispheres with mild effacement of the fourth ventricle. MRI brain showed diffusion signal abnormalities with corresponding T2 FLAIR hyperintensities in the bilateral cerebellar hemispheres, bilateral hippocampi, and bilateral basal ganglia with some involvement of the left occipital lobe suggestive of CHANTER syndrome. As vasogenic edema worsened, hydrocephalus ensued requiring administration of hypertonic saline and eventual external ventricular drain (EVD) insertion in the neurocritical care unit. Despite initial improvement in his level of consciousness after the EVD insertion, his intracranial pressure (ICP) continued to increase and midazolam and ketamine infusion drips were added. A fine balance between lowering the ICP and avoiding respiratory suppresion with sedating infusions was maintained. Consecutive MRI brain images over the course of the following 4 weeks of his stay showed decrease of the abnormal diffusion weighted imaging signal along with improvement in his overall mental status and eventual discharge 12 weeks from his initial presentation.

Conclusion

This case further strengthens the relationship between CHANTER syndrome and illicit substance use as a likely etiology along with other cases in the literature. Aggressive management in the neurocritical care to control vasogenic edema and avoid ICP elevation is essential to give patients the highest chance of recovery. Clinical improvement At least partial reversal of the radiographic findings of CHANTER syndrome can be attained with treatment, however, unclear if complete reversal is possible.
Abstract 108: Artery Of Percheron Infarctions (AOP): A Tale of Two Outcomes
Authors: Beck Eric N. , Cabrera Nynoshka M. Bassatt , Ngo Melanie , Elwan Sherif , Wee Claribel D.
Published: March 2024

Introduction

The AOP is a rare anatomic variant in which a solitary arterial trunk arises from the proximal segment of the posterior cerebral artery (PCA) and supplies the bilateral paramedian thalami and rostral midbrain. Occlusion may result in variable bilateral thalamic and midbrain infarcts. The clinical presentation is most commonly lethargy and somnolence thought to lack other localizing features. Often the diagnosis and treatment of stroke is delayed.

Methods

Here we present two cases of likely AOP infarcts which highlight the importance of considering this diagnosis on the differential of acute lethargy as timely treatment can lead to a significant difference in morbidity and mortality.

Results

Case 1: A 68‐year‐old male was initially admitted to an outside hospital with acute lethargy. He was transferred to our institution where he was found to be somnolent and required repeated stimulation to participate with interview. On further exam he was noted to have left ptosis, anisocoria, restricted left supra‐ and add‐ duction, and dysarthria. CT angiogram (CTA) showed no large vessel occlusion (LVO) or significant stenosis. Magnetic resonance imaging (MRI) demonstrated acute infarcts in the medial thalami and subthalamic nuclei bilaterally and uppermost portion of the midbrain. He was out of the window for IV thrombolytic. He was ultimately discharged to inpatient rehab with a persistent CN III palsy. Case 2: A 71‐year‐old female was evaluated emergently via telestroke for acute lethargy and was found to additionally have vertical diplopia, right facial palsy, and subsequent bilateral numbness of the face, arms, and legs. NIHSS 10 for LOC questions (1), facial palsy (2), motor drift (1 pt for each limb), sensory loss (1), aphasia (1), and dysarthria (1). She was treated with IV tenecteplase 179 minutes after the last known well and ultimately had complete symptom resolution. CTA was negative for LVO or significant stenosis. MRI brain demonstrated acute infarcts in the medial thalami bilaterally.

Conclusion

Here we present two cases of acute onset lethargy. MRI Brain revealed relatively symmetric restricted diffusion in the bilateral thalami of both patients suggesting the presence of an AOP variant. In contrast to the first case, signs of a posterior circulation infarct were quickly recognized in the second patient and IV thrombolytic administration resulted in return to baseline. In both cases there were subtle neurologic findings that suggested midbrain involvement – ptosis, restricted ductions, anisocoria. A high level of suspicion for bilateral thalamic infarct and potential AOP variant should be maintained in cases of acute lethargy. Careful neurologic exam often reveals other signs suggestive of posterior circulation infarct and timely therapeutics can significantly improve morbidity and mortality.
Abstract 119: VP‐shunting for IIH complicated by CVST, Dural AV Fistula and Status Epilepticus ‐ Endovascular Perspective
Authors: Choudhury Omar
Published: March 2024

Introduction

Cerebral venous sinus thrombosis (CVST) presents diagnostic challenges, especially in its overlap with idiopathic intracranial hypertension (IIH). Timely neuroimaging using MRI and MRV is crucial to avoid misdiagnosing CVST as IIH [1]. VP shunts, although beneficial in IIH, have significant failure rates and potential complications [2]. Few cases in the literature report occurrence of CVST or worsening of CVST after VP‐shunt placement [3]. The close relationship between CVST and dural AVF further complicates the clinical picture [4]. Endovascular intervention may present challenges with respect to chronic CVST, which can be mistaken for IIH.

Methods

We report a rare case of a 73‐year‐old woman with a past medical history of diabetes, hypertension, and hyperlipidemia who presented with confusion, disorientation, and lethargy. Comprehensive neurological evaluation, neuroimaging, lumbar puncture, EEG monitoring and treatment interventions, including VP shunt placement, cerebral angiogram, onyx embolization, and systemic anticoagulation, were performed.

Results

The patient initially presented with symptoms of progressive headaches, transient visual obscurations, and papilledema, suggestive of IIH. After lumbar puncture revealed elevated opening pressures, she underwent VP shunt placement. Her postoperative period was complicated by status epilepticus, extensive venous sinus thrombosis, and multiple dural AV fistulas. A cerebral angiogram showed a left occipital AV fistula, treated with onyx embolization. Repeat imaging indicated dural over‐shunting, yet this was negated upon Neurosurgical evaluation. A subsequent diagnostic cerebral angiogram was unable to clear the chronic CVST, but the patient responded positively to systemic anticoagulation and seizure management.

Conclusion

This case underscores the need for caution when considering VP shunting in patients with elevated intracranial pressure symptoms. Our findings emphasize the importance of an early MRV to rule out CVST and determine the appropriate treatment approach. Iatrogenic progression of CVST, VP shunt over‐drainage, and status epilepticus are serious complications that can arise from a misdiagnosis of IIH. Additionally, this case offers an endovascular perspective on patients who have chronic CVST, which can be misdiagnosed as IIH. Endovascular interventions including onyx AV fistula embolization and angiographic evaluation of the patient provided significant diagnostic and therapeutic benefits, and ultimately the patient was discharged with improved mentation.
Abstract 128: Endovascular Thrombectomy for Severe Cerebral Venous Thrombosis: A Comprehensive Meta‐analysis Assessing Safety and Efficacy
Authors: Tolba Hatem , Ghozy Sherief , Orscelik Atakan , Abdelghaffar Mariam , Kobeissi Hassan , Ghaith Hazem , Abbas Alzahraa , Kadirvel Ramanathan , Brinjikji Waleed , Kallmes David
Published: March 2024

Introduction

Cerebral sinus venous thrombosis (CSVT) has traditionally been treated medically with systemic anticoagulation. Recent advances in endovascular therapy (EVT) may represent an alternative treatment to medical therapy for CSVT. We conducted a systematic review and meta‐analysis to evaluate the use of EVT for CSVT.

Methods

We conducted a systematic literature review using PubMed, Embase, Scopus, and Web of Science. We included studies that reported outcomes following EVT for CSVT. The primary outcome of interest was rate of modified Rankin Scale (mRS) 0‐2. Secondary outcomes of interest were rates of complete, partial, and failed recanalization, mortality, and new or expansion of hematoma. We calculated pooled rates (%) and their corresponding 95% confidence intervals (CI).

Results

Thirty‐eight studies with 682 patients were included. Rate of mRS 0‐2 was 82.6% (95% CI, 75.3%‐88.0%). Rate of complete recanalization was 60.9% (95% CI, 49.1%‐71.5%), rate of partial recanalization was 34.2% (95% CI, 24.1%‐45.9%), and rate of failed recanalization was 5.4% (95% CI, 3.1%‐9.2%). Rate of mortality was 6.7% (95% CI, 4.1%‐10.8%) and rate of new or expansion of hematoma was 5.1% (2.9%‐8.8%).

Conclusion

In this systematic review and meta‐analysis, EVT for CSVT was associated with favorable rates of mRS 0‐2 and recanalization. Furthermore, EVT was associated with a promising safety profile. Future prospective, comparative studies are warranted to assess EVT for CSVT.
Abstract 130: Endovascular Therapy for Cerebral Venous Sinus Thrombosis: A Systematic Review of 267 patients
Authors: Sultany Abdullah , Qudah Abdullah M. Al , Kakamyradov Guvanch , Doheim Mohamed F.
Published: March 2024

Introduction

Cerebral venous sinus thrombosis (CVST) is a rare form of stroke that usually affects young females especially during pregnancy and the postpartum period. Several risk factors can contribute to the development of cerebral venous sinus thrombosis including hypercoagulable states, dehydration, infections, head or neck injuries, cancer, and some rheumatological diseases (1). The symptoms of cerebral venous sinus thrombosis can vary depending on the location and extent of the clot. Common signs and symptoms may include severe headaches, visual disturbances, seizures, focal neurological deficits, altered mental status, and in severe cases, coma. The initial treatment for CVST is systemic anticoagulation (2‐3). However, endovascular treatment (EVT) of CVST is typically reserved for cases associated with significant thrombus burden and lack of clinical improvement or worsening of symptoms despite systemic anticoagulation therapy without current conclusive evidence of its benefit. The aim of this study is to evaluate the evidence of EVT in patients with CVST.

Methods

A systemic literature search was conducted via PubMed to identify relevant studies. Only studies with sample sizes larger than 10 were included. We excluded small case series, meta‐analyses, systematic reviews, and studies that lack the main outcomes of interest. Our main outcomes included functional outcome defined as modified Rankin Scale score (mRS 0‐3), mortality, new or expanded ICH and recanalization rates.

Results

We finally included 10 studies (4‐13) in our qualitative synthesis. Only one study was a small, randomized clinical trial while the rest were observational studies. In our included studies, 267 patients underwent EVT for CVST. Among them, the median age was ranging from 12 to 75 and 162 (60 %) of patients were females. Patients were followed up for a mean ranging from 3 to 12 months. Recanalization was observed in 161 patients, out of which 111 were complete recanalization (68.9%) and 50 were partial recanalization (31.1%). Good functional outcome defined as mRS 0‐3 was achieved in a total of 181 patients. Additionally, 26 (9.7%) patients had a new onset or expanded ICH while 26 patients had died (9.7%).

Conclusion

EVT for CVST was associated with improved clinical outcomes with acceptable safety profile in severe cases. There is a lack of evidence from large randomized clinical trials so more prospective studies are needed to confirm these results.
Abstract 139: Super Distal Access using the Vecta46 Intermediate Catheter in Embolization of the MMA for cSDH
Authors: Meyer Benjamen M. , Khan Muhammad W. , Campos Jessica K. , Laghari Fahad A. , Zarrin David A. , de Beaufort Jonathan C. Collard , Amin Gizal , Golshani Kiarash , Beaty Narlin B. , Bender Matthew T. , Lin Li‐Mei P. , Colby Geoffrey P. , Coon Alexander L.
Published: March 2024

Introduction

There is increasing literature to support the efficacy of middle meningeal artery (MMA) embolization in the treatment of chronic subdural hematomas (cSDH). Techniques for optimal embolization of the MMA are yet to be elucidated. We hypothesized utilization of a novel 046” intermediate catheter within the proximal MMA trunk carry procedural advantages for multiple pedicle embolizations and ease of navigation to distal MMA vasculature.

Methods

We retrospectively reviewed and analyzed a prospectively maintained IRB‐approved database of the senior authors.

Results

Twenty‐one (21) consecutive cases of Vecta46 utilization with MMA embolization were identified (2023), in patients 69±13 years (range 49‐83 years), 4 (19%) women. Four (19%) patients were on antiplatelet/anticoagulants. At presentation, recurrent cSDH in 9 patients (43%) were previously managed with burr holes (n=2, 22%), craniotomy (n=3, 33%), or without drainage (n=4, 44%). Average admission cSDH thickness was 8.8±1.6mm, midline shift of 3±0.7mm. Access was performed through a 5‐ or 6‐French arteriotomy. Both anterior and posterior MMA branches were embolized in 16 (76%) cases, and adjunctive coiling of the proximal MMA trunk was performed in all cases. Vecta46 was successfully placed in the proximal MMA trunk in all cases. There were no vessel irregularities, vasospasm, or dissection noted along the course of the MMA Vecta46 placement. No immediate procedural complications were noted and all cases achieved complete distal MMA occlusion.

Figure 1: (A) Ophthalmic (black) and petrous (white) collaterals off the anterior and posterior MMA branches, respectively. (B) Contralateral (green) and falx (orange) penetration of the MMA branches. (C) Proximal coiling of the anterior and posterior MMA branches (black).

Conclusion

The Vecta46 intermediate catheter is a powerful tool for MMA embolization that allows the safe and effective placement of an intermediate catheter in the proximal MMA trunk. This allows for simple catheter exchange for multiple liquid embolic pedicle embolizations and significant support for navigating microcatheters to distal MMA branches.
Abstract 151: Age‐Related Increases in Carotid Artery Calcification: Insights from NaF PET/CT Imaging
Authors: Teichner Eric M. , Subtirelu Robert C. , Werner Tom , Alavi Abass
Published: March 2024

Introduction

Atherosclerosis, the hardening and narrowing of the arteries, occurs due to the buildup of plaque on the inner walls of the arteries which can result in reduced blood flow to the organs and tissues. Risk factors such as smoking, chronic kidney disease, and aging can contribute to plaque formation. The gradual loss of elasticity in arterial walls and the presence of other risk factors, such as high blood pressure and diabetes, contribute to the increased risk of cardiovascular disease (CVD) observed in aging populations. Early detection through sensitive and specific imaging methods is important for the detection and treatment of CVD. 18F‐Sodium Fluoride positron emission tomography/computerized tomography (NaF‐PET/CT) can be utilized to detect and quantify molecular calcification and therefore early atherosclerosis in patients with CVD. Research has shown a positive correlation between NaF uptake in the common carotid arteries/thoracic aorta and cardiovascular/thromboembolic risk. This study aims to assess the effect of aging on NaF uptake in the left common carotid artery (LCC) in subjects with known cardiovascular risk factors.

Methods

In total, 36 subjects (mean age 55.4 ± 12.3 years, 50% males) with known cardiovascular risk factors underwent FDG‐PET/CT. Participants were recruited from a group of patients with chest pain syndromes who were referred for coronary CT angiography. Individuals who were not taking any blood pressure medications and who had a greater than 1% increased risk of fatal CVD, estimated by the systematic coronary risk evaluation tool, were eligible for inclusion into the at‐risk for CVD group. NaF PET/CT was performed 90 min after the intravenous injection of 2.2 MBq of NaF/kg. NaF uptake in the LCC was quantitatively assessed by measuring the blood‐pool‐corrected maximum standardized uptake value (SUVmean) on each axial slice. Pearson’s R was calculated and evaluated for significance in all variables. The threshold for significance was set at P < 0.05.

Results

A significant association between age in patients with cardiovascular risk factors and NaF uptake in the LCC artery was found. Age positively correlated with NaF uptake (r=0.472, p= 0.004) across all 36 patients.

Conclusion

Our results demonstrate that NaF uptake increases in the LCC with age in subjects with known cardiovascular risk factors. The strong association between age and calcification of the carotid arteries within a population of individuals with unfavorable cardiovascular and thromboembolic risk profiles demonstrates the potential of NaF PET/CT. NaF PET/CT may allow physicians to evaluate effectiveness of treatment and determine a patient's risk for CVD. However, additional trials are needed to further evaluate the associations found in this study and determine relevance in a clinical setting.