bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP193: Endovascular Thrombectomy for DAWN- and DEFUSE 3 Ineligible Acute Ischemic Stroke Patients: A Systematic Review and Meta-Analysis
Authors: Elfil Mohamed , Morsi Samah M , Ghozy Sherief , Tolba Hatem , Kadirvel Ram , Kallmes David F
Published: February 2024

Background:
The current evidence supports the benefits of endovascular treatment (EVT) in acute ischemic stroke (AIS) with large vessel occlusion (LVO). The DAWN and DEFUSE-3 trials expanded the EVT window up to 24 hours. A few real-world studies explored EVT outcomes in DAWN/DEFUSE-3 ineligible (NDND) patients.

Methods:
This meta-analysis investigated EVT outcomes in patients with late-window anterior circulation LVO, including both DAWN/DEFUSE-3 eligible (DD) and NDND patients. Nine studies were included, focusing on study characteristics, risk of bias, and outcomes.

Results:
Baseline characteristics showed comparable age, gender, comorbidities, NIHSS score, and ASPECTS between DD and NDND patients. NDND patients exhibited larger infarct volumes and higher atrial fibrillation rate. Successful reperfusion rates (TICI 2b-3) were comparable between the two groups (OR= 0.86; 95% CI= 0.40, 1.84; p = 0.689), with significant heterogeneity (I
2
= 73%; P = 0.002). Functional independence (90-day mRS score 0-2) was not significantly different between the two groups (OR= 1.12; 95% CI= 0.77, 1.63; p = 0.552) with notable heterogeneity (I
2
= 46%, p = 0.063). Symptomatic intracranial hemorrhage (sICH) rate was lower in the DD group as compared to NDND patients (OR= 0.49; 95% CI= 0.25, 0.93; p = 0.029) with no heterogeneity (I
2
= 0%, p = 0.552). 90-day mortality was lower in the DD group than in the NDND group (OR= 0.55; 95%-CI= 0.37, 0.82; p = 0.004) with no significant heterogeneity (I
2
= 0%, p = 0.536).

Conclusion:
While this meta-analysis showed comparable rates of functional independence between DD and NDND patients, the potential bias introduced by the higher rates of sICH and mortality in the latter group should prompt great care when offering EVT to NDND patients. Less restricted EVT eligibility criteria might yield positive outcomes in real-world practice in specific patients. However, increased risks of sICH and mortality in NDND patients warrant further investigation to optimize the risk-benefit balance in expanding EVT eligibility criteria.
Abstract WP200: Endovascular Therapy for Isolated Carotid Occlusion in the Neck
Authors: Hansen Katrine F , Jensen Jonas , Simonsen Claus Z
Published: February 2024

Background and Study Purpose:
Existing guidelines on endovascular treatment (EVT) of acute ischemic stroke do not include isolated cervical internal carotid artery occlusions (CICAO). These occlusions are still treated, but the effect remains unclear. This study aimed to compare the baseline characteristics and treatment outcomes between patients with isolated CICAO and patients who underwent EVT due to occlusions mentioned in guidelines.

Methods:
A retrospective study was conducted on 1162 patients who underwent EVT due to ischemic stroke at Aarhus University Hospital between June 2017 and June 2022. Univariate analysis of outcomes and baseline characteristics were compared between patients with isolated CICAO and tandem occlusions or isolated CICAO and occlusion of the middle cerebral artery (M1)/intracerebral internal carotid artery (ICA-T).

Results:
731 patients were eligible for inclusion. Patients with isolated CICAO were more likely male (67.8% vs 50.9%, p-value = 0.0009) and active smokers (42.2% vs 26.4%, p = 0.0016) compared to patients with M1/ICA-T occlusions where atrial fibrillation (35.5% vs. 23.5%, p = 0.0158) and an equal sex distribution was more frequently seen. The groups showed similar favorable outcomes and mortality. Notably, a statistically significant difference in mortality between patients with isolated CICAO (precent) and M1/ICA-T occlusions (percent) could not be excluded (p = 0.0584).

Conclusion:
Patients with isolated CICAO and M1/ICA-T occlusions seem to differ in sex, smoking status, and atrial fibrillation. This study did not find any differences between isolated CICAO and tandem occlusions. EVT appears beneficial in patients with isolated CICAO, however randomized-controlled trials are necessary to examine and compare the effect between occlusion sites.
Abstract WP225: Changes in Hemoglobin Levels During Vascular Events in Moyamoya Arteriopathy
Authors: Kubica Marcelina , Xu Yu Qing , Gatti John R , Burton Noah , Sun Lisa R
Published: February 2024

Background:
Anemia is a well-established risk factor for stroke in many populations. Recent data suggest that in patients with moyamoya arteriopathy (MMA), decrease in hemoglobin is associated with perioperative stroke. Evaluating the role of anemia in stroke pathogenesis outside of the perioperative period in MMA could aid in risk stratification and stroke prevention.

Hypothesis:
We hypothesized that patients with MMA have lower hemoglobin levels in the setting of vascular events compared to their pre-event baseline.

Methods:
In this retrospective self-controlled case series, we abstracted demographic and clinical data from patients < 40 years old with MMA cared for in our institution’s pediatric or young adult stroke clinics between 2003 and 2023. Laboratory data for each vascular event (stroke or TIA) were collected. The most recent laboratory data preceding events were also collected (baseline). Perioperative events (those occurring ≤7 days after revascularization) were excluded. Pre- and post-revascularization events were analyzed together and separately. Paired T-tests were used to compare baseline and vascular event hemoglobin values.

Results:
Eighty-nine (89) participants met inclusion criteria. There were 32 vascular events with corresponding baseline data available. There was no significant difference in hemoglobin between event and baseline values (11.2 v 11.3 g/dL, p = 0.87). However, among only pre-surgical events (n=20), hemoglobin was lower during events compared to baseline (10.4 v 11.5 g/dL, p=0.03). For events that occurred >7 days post-revascularization (n=12), hemoglobin was higher during events compared with baseline (12.6 v 10.9 g/dL, p=0.008).

Conclusions:
In our cohort of children and young adults with MMA, hemoglobin was lower than baseline during presurgical vascular events and higher than baseline during post-revascularization vascular events. Though further exploration with multivariate models is necessary, these preliminary data suggest that while anemia and dehydration may both increase the risk of stroke in MMA, the relative contributions of these stroke risk factors differ based on surgical status.
Abstract WP234: Intracranial Vasculopathy Patterns of
RNF213
R4810K Carriers: Does Anatomical Difference Make a Clinical Difference?
Authors: Ha Jiyeon , Yang Wookjin , Jeong Han-Yeong , Lee Eung-Joon , Chung Matthew , Kim Jeong-Min , Jung Keun-Hwa , Lee Seung-Hoon
Published: February 2024

Introduction:
The 2021 revised diagnostic criteria of Moyamoya’s disease (MMD) of Japan more emphasize terminal ICA involvement than 2012 version. Accordingly, there is still ambiguity about whether MCA steno-occlusion with intact ICA qualifies as MMD. Also, basal collateral is mandated in both versions, while its specificity and sensitivity for MMD remain uncertain. Although the discovery of RNF 213
R4810K
variant gave hope for further insight into MMD, its diagnostic role is limited by scarce data on associated vasculopathy pattern.

Methods:
Patients with intracranial vasculopathy tested for RNF213 genotype between September 2017 and 2022 and positive for R4810K were included. They were classified by two anatomical features of vasculopathy in the latest angiographic image: 1) steno-occlusive degree of ICA and MCA, 2) laterality. The resulting classification composes 3 main and 6 subgroups: A) No involvement. B) MCA involvement and intact ICA, bilaterally (B1) or unilaterally (B2). C) ICA involvement, bilaterally (C1), unilaterally (C2), or unilaterally with contralateral MCA involvement (C3). Their demographic and clinical factors were compared, and fulfillment for MMD by 2012 and 2021 criteria was assessed.

Results:
Among 240 eligible patients, 84 (35.9%) and 33 (14.1%) did not meet 2021 and 2012 criteria. Notably, though group B showed high basal collateral prevalence of over 80%, all (100%) and 25 (36.8%) of them did not fulfill 2021 and 2012 criteria by ICA and MCA parameters. This group showed no significant contrast in demographic, conventional stroke risk factors and hemorrhagic or ischemic stroke prevalence from those with ICA involvement.

Conclusions:
Despite their clinical and demographic similarities, a notable number of
RNF213
R4810K carriers do not meet MMD criteria due to anatomical features, mainly when ICA involvement is absent. Revising the criteria of MMD to incorporate
RNF213
R4810K positivity should be considered to address its weakness.
Abstract WP24: Safety of Tenecteplase vs Alteplase in Telestroke: A Large Multistate Experience (STAT)
Authors: Figurelle Morgan , Corti Sandro J , Collins Oleg , Gao Lan , Avila Amanda , Sevilis Theresa
Published: February 2024

Background:
Prompt treatment with IV thrombolytics (IVT) in acute ischemic stroke (AIS) patients is critical for improved recovery and survival. Recently, hospital systems are switching to the IVT tenecteplase (TNK) instead of the FDA approved alteplase (tPA) for treatment. Multiple studies and meta-analyses evaluating the efficacy and safety of TNK demonstrate similar or superior outcomes when compared to tPA. TNK is not FDA approved for treatment leading to hesitation and attention on the complications profile including intracranial hemorrhage (ICH) rates.

Methods:
AIS consults seen in the ED by TeleSpecialists, LLC at 220 facilities (26 states) from January 1, 2022 to May 31, 2023 were extracted from the TeleCare by TeleSpecialists
TM
database. The encounters were reviewed for IVT candidate, door to needle (DTN) time, IVT used, advanced imaging, LVO, complication occurrence, complication type, symptomatic ICH, and ECASS II ICH score. Comparison of complications was performed between the two groups by IVT: TNK or tPA. Comparison of continuous variables was performed by student’s t-test for normally distributed data, and the Mann-Whitney test for nonnormally distributed data. Pearson's Chi-square test was employed for comparisons of categorical variables.

Results:
A total of 2305 TNK patients and 3337 tPA patients were extracted. DTN times were faster (37 min vs 42 min, p < 0.0001) and more total complications were seen in the TNK group (87 vs 80, p =0.0035). In nonLVO IVT patients, TNK group had more complications (57 vs 47, p 0.0078), specifically ICH (48 vs 35, p= 0.0036). In LVO IVT patients, TNK group did not have a statistically significant difference in ICH (21 vs 18, p =0.07). In IVT patients not accepted for NIR, TNK group had more complications (77 vs 69, p=0.005), specifically ICH (63 vs 51, p=0.0026). In IVT patients accepted for NIR, no significant differences were observed. There were no statistically significant differences in symptomatic ICH between groups.

Conclusions:
TNK group was found to have significantly more complications including ICH compared to tPA group driven by non-LVO patients. Closer analysis of potential for increased risk to non-LOV patients is warranted based on this data from the largest simultaneously collected data.
Abstract WP241: Migraine Associated Risk of Stroke Score
Authors: McCain Caylee , Parrish Michael , Rosamond Wayne D , Sengupta Sweta , Spinale Francis G , Sen Souvik
Published: February 2024

Background:
Migraine with aura is a risk factor for ischemic stroke. We refined the migraine with aura risk score (MARS) to create the migraine associated risk of stroke score (MARS Plus) making it applicable to migraine with and without aura. The expanded risk score includes vascular risk factors, migraine characteristics, and medications used in migraine patients.

Methods:
We prospectively evaluated participants in Atherosclerosis Risk in Communities Cohort (ARIC) with history of migraine. In this population, we tested the association of potential risk factors for ischemic stroke using a Cox proportional-hazards model. The coefficient of each variable was divided by the lowest β value and rounded to the nearest integer. The sum of the weighted score of the reported risk factors was found and was categorized into two prognostic groups.

Results:
We assessed migraine characteristics (aura, migraine frequency and duration) and medications (ergot alkaloids, triptans, hormone replacement therapy, sympathomimetics and steroids) in addition to traditional risk factors. Based on the points derived from the significant factors we assigned age≥65 =2, non-white race=2, hypertension=3, diabetes=4, body mass index ≥30 =2, coronary artery disease =2, atrial fibrillation =3, alcohol use=1, steroids=3 and presence of aura=2 to total 24 points. Cut-off of MARS Plus ≥5 was considered high risk for ischemic stroke based on receiver operating characteristic (ROC) curve and Youden’s index (Figure). Of the 1485 migraineurs, 112 had an ischemic stroke. MARS Plus ≥5 revealed a hazard ratio of 4.29 (95% CI 2.86-6.45) as shown in the Kaplan-Meier Survival Curve.

Conclusion:
The new MARS Plus is used to predict ischemic stroke in patients with migraine with and without aura. This new risk score, in addition to generalizability, includes factors such as migraine characteristics and medications that may increase stroke risk.
Abstract WP244: Myocardial Infarction Risk Following Stroke and Cervical Artery Dissection: Multi-State Inpatient Sample Analysis
Authors: Strelecky Lukas , Shu Liqi , Salehi Omran Setareh , Goldstein Eric , Nguyen Thanh , Siegler James E , Khan Farhan , Stretz Christoph , Furie Karen L , Yaghi Shadi
Published: February 2024

Introduction:
Cervical artery dissection (CAD) and acute ischemic stroke (AIS) are key health challenges. We utilized a multi-state database to examine myocardial infarction (MI) risk post stroke or CAD to estimate cardiovascular complication risk.

Method:
We analyzed State Inpatient Database from New York (2011-2017) and Florida (2011-2019). Adult patients with no head or neck trauma were separated into 4 groups based on diagnoses of AIS, CAD, concurrent AIS and CAD, or a reference group of transient ischemic attack, transient global amnesia, or migraine. Diagnosis identification was based on ICD-9 and ICD-10 CM codes. One-year MI risk was evaluated using Kaplan-Meier survival analysis, parametric accelerated failure time survival analysis, and additional Inverse Probability of Treatment Weighting (IPTW) analysis.

Results:
827,761 patients were included (mean age 62.7 years, 61.58% female). Among all patients, 19,755 (2.39%) had MI within one-year: 1.4% of the reference group, 3.4% of the AIS group, 1.5% of the CAD group, and 1.8% of concurrent AIS and CAD group. Compared to the reference group, patients with AIS alone and patients with concurrent CAD and AIS had higher MI risk (hazard ratio [HR] 4.91, 95% CI 4.63-5.21, P < 0.001; HR 1.67, 95% CI 1.02-2.73, P = 0.04, respectively), while patients with CAD alone had no elevated risk (HR 1.17, 95% CI 0.66-2.06, P = 0.60) (Figure). After IPTW adjustment for age, diabetes, heart failure, coronary artery disease and hyperlipidemia, patients with AIS alone still had the highest risk for MI (adjusted HR [aHR] 1.87, 95% CI 1.75-1.99, P < 0.001), followed by patients with concurrent CAD and AIS (aHR 1.26, 95% CI 1.05-1.5, P = 0.012), while patients with CAD had nonsignificant risk (aHR 1.142, 95% CI 0.82-1.58, P = 0.42).

Conclusion:
This analysis reveals stroke patients are nearly two-fold more likely to have subsequent MI compared to those with CAD. These findings merit validation and may impact clinical evaluation and patient care.
Abstract WP250: The Changing Impact of Neighborhood Socioeconomic Status on Stroke Incidence in the BASIC Project
Authors: Becker Christopher J , Delhey Leanna , Kwicklis Madeline , Shi Xu , Case Erin , Morgenstern Lewis B , Lisabeth Lynda D
Published: February 2024

Background:
Poverty is associated with increased stroke risk, but it is unclear how this has changed over time. We sought to evaluate temporal trends in stroke incidence by neighborhood socioeconomic status (nSES) in a south Texas community.

Methods:
Within the BASIC project, we identified all first-ever ischemic and hemorrhagic strokes among Mexican American or non-Hispanic White persons, age >45, from 2010-2021, geocoded to census tract by patient home address (n=4,137). Using 5 year rolling average annual data from the American Community Survey, a composite nSES score was assigned to each census tract, reflecting aggregate neighborhood income, wealth, education, and occupation (range -1.60, 1.95; lower=poorer). For each year, the nSES percentile of each tract was determined. Incidence rates were estimated using Poisson regression, with annual population estimates as offsets, including a quadratic term for time to account for nonlinear trends. The model included annual nSES percentile, age, sex, ethnicity, and nSES-time and ethnicity-time interactions.

Results:
Incidence rates for high vs low nSES neighborhoods for the 45-65-year age group are shown in the Figure. Incidence rate ratios for nSES changed over time (p<0.01 for interaction) in a u-shaped fashion, with no association present in 2010, a significant association in 2015 (RR for 90th vs 10th percentile nSES=0.59, 95% CI=0.49-0.70), and no association in 2021 (Figure).

Conclusions:
The gap in stroke incidence between the richest and poorest neighborhoods peaked in 2015 and was no longer present in 2021, due to declining rates in low nSES neighborhoods. Future work should explore the causes underlying these trends.
Abstract WP256: Evaluating the State-by-State Burden of Stroke and the Effectiveness of Stroke Prevention Efforts in the United States: A Cross-Sectional Study
Authors: Chen Alex , Oh Seok Y , Chavda Purva , Arora Rohan
Published: February 2024

Background:
Assessing the economic impact of stroke and the potential for prevention through policy and programs raises questions about progress and underscores the importance of state-level data for targeted public health resource allocation. In this study, the National Inpatient Sample Database was utilized to examine the proportion of hospital admissions attributed to stroke between two distinct time intervals: 2008-2010 and 2016-2020.

Methods:
A retrospective cross-sectional study was performed using nationwide inpatient sample and ischemic and hemorrhagic stroke was identified using MSD-RGC codes of 62, 64-71, and total admissions associated with any medical conditions were extracted. The average percentages of AIS, ICH, other unspecified stroke types, and the total stroke admissions for each year were compared for each state. Univariate analysis was made using chi-square and Cochran Armitage trend test. P<0.05 was considered as statistical significant.

Results:
By state, there is a nationwide trend of decreasing percentage of AIS stroke admission and increasing percentage of ICH type of stroke among all four regions in the United States. These may account for the total increase in stroke burden and hospital utilization. Among all states, comparing the two periods of time, the greatest reduction rate of AIS was noticed in Maryland (0.78% vs. 0.35%, P< 0.0001). The greatest increment in ICH was noticed in South Carolina (1.41 vs 1.84%, P< 0.0001), and in total stroke was noticed in Washington state (1.76% vs 2.28%, increased by 0.51%,
P
< 0.0001; Figure 1).

Conclusions:
The findings of our study indicate a significant decrease in the proportion of admissions for AIS across the entire country, accompanied by a corresponding rise in admissions for ICH. Further investigation is warranted to ascertain the underlying causes that have led to the rise in the proportion of ICH cases necessitating hospitaizations.
Abstract WP259: Headache and Hypertension and Early Postpartum State: A Proposed Clinical Triad for Maternal Stroke Risk Prediction
Authors: Valdes Eduard , Bourscheid Raeann , Woolcock Helen , van Wingerden Anne-Sophie , Haghighi Noora , Booker Whitney , Bello Natalie A , Prabhakaran Shyam , Holl Jane , Shields Andrea , Miller Eliza C
Published: February 2024

Background:
Stroke is a major cause of maternal morbidity and mortality, but delays in diagnosis are common. We hypothesize that in individuals who are pregnant or within 1 year postpartum (PP), the triad of early PP state (first 6 weeks after delivery), elevated blood pressure (BP), and headache is associated with higher stroke risk.

Methods:
We conducted a single-institution case-control study. Cases had a maternal stroke (ischemic, hemorrhagic, subarachnoid hemorrhage, or cerebral venous thrombosis) during pregnancy or PP, identified from a stroke registry. Controls were pregnant or PP but without any stroke and admitted for any reason, identified from a cohort of individuals with a high proportion of hypertensive disorders of pregnancy (HDP), a known maternal stroke risk factor. We created multivariable logistic regression models with stepwise backward elimination to evaluate the association between maternal stroke and the triad of (1) early PP; (2) systolic BP ≥140 or diastolic ≥90 mmHg; and (3) headache.

Results:
We identified 60 cases and 113 controls. Population characteristics are shown in the Table. Cases had a higher proportion of preexisting headache disorders and controls a had higher proportion of HDP. Adjusting for race, HDP, and headache disorder history, stroke risk was higher in those presenting to acute care with the proposed triad than in those without these features (adjusted odds ratio 13.6, 95% confidence interval 3.8-48.5, p<0.0001). In a predictive model, the triad exhibited excellent discrimination between cases and controls (AUC 0.82, sensitivity 30%, specificity 98%, positive predictive value 90%).

Conclusions:
In a high risk, diverse maternal population delivering at an urban academic medical center, the triad of early PP state, elevated BP, and headache was associated with a more than 13-fold higher risk of stroke. Patients presenting for acute care with this triad could potentially benefit from a comprehensive stroke evaluation.
Abstract WP268: Transcarotid Arterial Revascularization of Symptomatic Internal Carotid Artery Disease: A Systematic Review and Meta-Analysis
Authors: Ghannam Malik , Almajali Mohammad , Al Qudah Abdullah , Khasiyev Farid , Dibas Mahmoud , Ghazaleh Dana , Roeder Hannah , Henninger Nils , de Havenon Adam H , Derdeyn Colin P , Leira Enrique C , Chaturvedi Seemant , Yaghi Shadi
Published: February 2024

Introduction:
TCAR is an interventional therapy for symptomatic ICA disease. Currently, the utilization of TCAR is contentious due to limited evidence. We conducted a comprehensive systematic review and meta-analysis utilizing existing studies to evaluate the postoperative outcomes and complications of TCAR as compared to CAS and CEA for patients with symptomatic ICA disease.

Methods:
A systematic review was conducted, spanning from January 2000 to February 2023, encompassing studies that employed TCAR for the treatment of symptomatic ICA disease. The primary outcomes included 30-day combined stroke and transient ischemic attack (TIA), myocardial infarction (MI), and mortality. This was explained in Figure 1.

Results:
A total of seven studies involving 24,246 patients were analyzed. Compared to CAS, TCAR was associated with a similar rate of stroke and TIA (OR:0.77,95%CI:0.33-1.82), and MI (OR:1.29,95%CI:0.83-2.01) but lower mortality (OR:0.42,95%CI:0.22-0.81). In patients, ≥80 years, the rate of stroke and TIA was lower with TCAR compared to CAS (OR:0.47,95%CI:0.35-0.65). When compared to CEA, TCAR was associated with a higher rate of stroke and TIA (OR:1.26,95%CI:1.03-1.54) but without differing rates of MI (OR:0.9,95%CI:0.64-1.38), and mortality (OR:1.35,95%CI:0.87-2.10). this was explained in figure 2.

Conclusions:
Although CEA has traditionally been considered superior to stenting for symptomatic carotid stenosis, TCAR may have some advantages over CAS, particularly in the elderly population (≥80 years). Prospective randomized trials comparing the three modalities are needed.
Abstract WP271: Marijuana Use and Stroke: A Systematic Review and Meta-Analysis
Authors: Kurra Nithin , Gandrakota Nikhila , Jillella Dinesh
Published: February 2024

Introduction:
The prevalence of stroke among young adults has been on the rise, along with a similar rising trend in marijuana use. Ischemic strokes, intracerebral hemorrhage (ICH), reversible cerebral vasoconstriction syndrome (RCVS), and subarachnoid hemorrhage (SAH) are among the commonly reported neurovascular events associated with marijuana use. We attempted to systematically review the literature and find an association between marijuana use and stroke.

Methods:
We searched data from PubMed/Medline, SCOPUS and studies that met the inclusion criteria were selected and Review Manager 5.4.1 was used for statistical analysis of data. Twenty six studies with a total of 13,550 patients were selected of which 11 were included in the meta analysis.

Results:
The pooled odds of cannabis use in ischemic stroke patients was statistically significant at 1.16 (95% CI: 1.07-1.25). Among patients with undefined stroke, pooled odds of cannabis use were 0.86 (0.43, 1.72). Meta-analysis for the SAH subgroup could not be done due to varying outcome measures. Overall, upon combining all the subgroups, the odds of cannabis use among stroke patients was not significant (OR: 0.96; 0.77,1.20, I2-100%). High heterogeneity might be the pooling of studies with different stroke types and individual study variations.

Conclusions:
Cannabis use was significantly associated with ischemic stroke although this significance was not maintained among other stroke subgroups and with overall analysis. Further research should be done to assess the association of dose, chronicity and frequency of cannabis on stroke to further delineate the true association.
Abstract WP276: Large Artery Atherosclerosis and Young Stroke
Authors: Patel Himanshu A , Heshmati Keyvan , Ryan Kathleen A , Yarbrough Karen L , Mixon Lakeisha M , Williams Devin E , Kittner Steven J , Cronin Carolyn A
Published: February 2024

Introduction:
It is known that past the age of 35, the prevalence of large artery atherosclerosis (LAA) related strokes increases with a cardiovascular risk factor (CVRF) profile beginning to resemble that of elderly patients. However, LAA-related strokes still only account for <10% of all young strokes over the age of 35. Further, there is limited data regarding the location, intracranial or extracranial, of LAA in this patient population.

Methods:
We conducted a retrospective review of stroke patients between the ages of 18 to 50 years presenting to our Young Stroke Center between April 2022 through August 2023. For each case, data including basic demographics and medical history were collected, and stroke etiology was determined by a vascular neurologist. Patients with LAA as the stoke etiology were compared to all non-LAA stroke etiologies. The two groups were analyzed with respect to baseline demographics and CVRFs. Analysis was performed with logistic regression adjusting for age, sex, and race.

Results:
Of 179 patients in the registry, 15 patients had LAA compared with 164 patients with non-LAA as their stroke etiology. Only one patient had extracranial carotid stenosis, with the rest of the LAA patients having intracranial atherosclerotic disease. There was a significant difference in age at time of stroke (42.9 ± 5.0 vs. 38.2 ± 8.0 years; OR [95% CI]: 1.11 [1.01-1.21]) between LAA and non-LAA groups, respectively. There was no significant difference in sex (66.7% vs. 62.8% female) and race (46.7% vs. 54.9% Black). A significantly larger proportion of patients with LAA had baseline CVRFs including hypertension (80.0% vs. 44.5%; 5.0 [1.2-20.3]), dyslipidemia (66.7% vs. 31.7%; 4.3 [1.3-14.1]), and obesity (33.3% vs. 12.2%; 5.6 [1.5-20.7]). There was also a trend toward increased rates of smoking (40.0% vs. 20.7%; 2.82 [0.9-9.0]) and diabetes (26.7% vs. 18.9%; 1.3 [0.3-4.7]).

Conclusion:
In the young stroke population, stroke due to LAA is more likely due to intracranial disease rather than extracranial disease and is associated with traditional CVRFs including hypertension, dyslipidemia, and obesity. These findings reinforce the importance of early intervention of modifiable risk factors for primary prevention of stroke in the young.
Abstract WP281: Investigating the Incidence of Stroke in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis
Authors: Suresh Vinay , Gupta Shiva , Dhakal Bishal , Dey Debankur , Shah Aditya , DINKAR PRATEEK KUMAR , Ramana Dabbara V , Gurav Jaiprakash , Shah Sanaya , Murtaza Aqsa , Moideen sheriff Serin , Jaiswal Vikash
Published: February 2024

Background:
Chronic obstructive pulmonary disorder (COPD) is a progressive respiratory disorder ranking third in global mortality. It often correlates with new cardiovascular incidents including stroke, affecting both management and prognostic considerations. The precise relationship between the incidence of stroke and COPD remains unclear. We performed a meta-analysis to determine the incidence of stroke in COPD patients.

Methods:
The PubMed and EMBASE databases were searched using predefined search terms encompassing COPD, emphysema, chronic bronchitis, and stroke related terms. The search timeline included the earliest available date until April 2023, including studies that investigated stroke occurrence in COPD patients. The analysis was conducted using CMA v.3 and R (Version: 4.3.1). The number of patients with COPD and stroke in each study were extracted and analyzed. A random-effects model was employed to calculate the incidence, pooled odds ratio (OR), and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I^2 statistic. The prediction interval was calculated to explain the distribution of the true effects.

Results:
A total of 33 studies matched our inclusion criteria, with a total of 865521 COPD patients. The weighted mean age of the population was 60.46 years, and 98739 of them had an incident of stroke in their lifetime. From the pooled analysis of all 33 included studies, using the random effects model, the incidence of stroke was 7.6% (Proportion, 0.076; 95% CI, 0.060 - 0.095, I2=99%). The prediction interval was calculated to be 0.02-0.27. Our analysis also showed a pooled odds ratio of 1.355 (95% CI:1.281-1.432, I2=99.96%) using the random effects model.

Conclusion:
We report a 7.6% incidence of stroke in COPD patients, and an increase in the odds of stroke in individuals with COPD. The cardiovascular health of such patients should be adequately monitored to mitigate the risk of stroke.
Abstract WP284: Assessment of Stroke Risk Following Hysterectomy: A Meta Analysis of Prospective Studies
Authors: Javed Binish , Suresh Vinay , Dey Debankur , Jena Rahul , Agrawal Vibhor
Published: February 2024

Background:
Hysterectomy is one of the most prevalent gynecological procedures in the United States. The risk of stroke following hysterectomy remains unclear. While some studies suggest a possible increase in stroke risk, others have shown inconsistent results.

Aim:
This meta-analysis aims to evaluate the risk of stroke following hysterectomy procedures.

Methods:
We systematically searched PubMed, Embase and Google Scholar to identify studies that evaluated the occurrence of stroke in hysterectomized patients using database-specific queries via combination of controlled vocabulary from the earliest available data to July, 2023. HRs (hazard ratios) and 95% CI were extracted from the included studies. The analysis was conducted using R (4.3.1). Extracted hazard ratios were log transformed, including their confidence intervals. The combined effect size was computed using the inverse variance pooling method. The random-effects models were utilized to assess the overall effect. I2 statistic evaluated the statistical heterogeneity, and the DerSimonian-Laird estimator quantified the between-study variance.

Results:
A total of 6 cohort studies were included, which evaluated the risk of stroke with a total of 772707 patients, out of which 138188 patients (17.88%) underwent hysterectomy procedures. The pooled aHR of hysterectomised patients was 1.21 (95% CI: 1.05-1.40; p < 0.01). Significant heterogeneity was noted in the outcome (I2 = 82%). 2 studies that reported the data for each stroke subtype yielded a pooled aHR 0.98 (95% CI: 0.89-1.09; I2 = 67%; p = 0.08) for hemorrhagic stroke while a pooled aHR = 0.98; 95% CI: 0.89-1.20; I2 = 0%; p = 0.66) for ischemic stroke.

Conclusion:
Our analysis reveals an elevated stroke risk post-hysterectomy. While more prospective studies are required to strengthen the evidence for the same, this meta-analysis underscores monitoring for stroke risk factors in hysterectomised patients.
Abstract WP288: Epidemiological Analysis of Incidence, Treatment, Mortality and Costs of Cerebrovascular Diseases in Brazil Between 2017 and 2022
Authors: Goulart Thiago O , Perdoná Gleici S , Monteiro Rosane A , Marazzi Thire B , Camilo Millene , Pontes-Neto Octavio M
Published: February 2024

Background:
Cerebrovascular diseases (CVD) represent a Global Health concern, being the first cause of disability worldwide and second cause of mortality (first in Brazil). Despite that, detailed data from Brazil was scarce and this study found alarming results.

Aims:
The study aims to analyze incidence, mortality, treatment, procedures and costs related to the three most common cerebrovascular diseases: Subarachnoid Hemorrhage (SAH), Intracerebral Hemorrhage (ICH) and Ischemic Stroke in Brazil.

Methods:
This is an epidemiological study. Data was obtained through DataSUS, a public database. For the search, we utilized the CID-10 notification system from I60 until I64, including admissions, deaths, treatments and costs related to each CID-10.

Results:
Between 2017 and 2022, 1,283,435 CVD cases were notified (SAH=4,7%; ICH= 8.8%; and ischemic stroke=86.5%). 52.4% were Male and 47.6% were Female. Mortality percentages were: SAH=20.2%, ICH=25.3%, Ischemic Stroke=15.3%. Rates of Thrombolysis were alarming, but with an increasing tendency: 22969 were performed, from 1.6% in 2017 to 2.3% in 2022 of all ischemic strokes. 8290 aneurysms embolizations were performed (13.5% of all SAH cases). 4.9% of SAH cases were treated with neurosurgical clipping, demonstrating a decrease tendency after 2020, as well other procedures, such as Craniectomy and Angioplastia. Yearly costs related to these diseases increased steeply, from R$ 360,710,749.92 in 2017 to R$ 537,511,793.62 in 2022 (around US$107,502,358.00).

Conclusions:
This study has found increasing incidence and costs associated with low rates of thrombolysis and procedures in Brazil The results can direct Public Health policies in developing countries, and similar research in other low- and middle-income-countries are encouraged.
Abstract WP297: Time-Dependent Effects of Drag-Reducing Polymers Administration on Permanent Middle Cerebral Artery Occlusion Injury in Rats
Authors: Bragina Olga , Wu Jun , Peng Zefeng , Atochin Dmitriy N , Nemoto Edwin M , Yang Yirong , Bragin Denis E
Published: February 2024

Introduction:
Current treatments for ischemic stroke are not focused directly on cerebral microcirculation. We previously showed that 2 μg/ml of drag-reducing polymers (DRPs) restore cerebral microcirculation and oxygenation in rats subjected to permanent middle cerebral artery occlusion (pMCAO). Here we evaluated the dependence of DRPs efficiency on stroke outcome from the time of application.

Methods:
DRPs (2 μg/ml) or saline was i.v. injected 0.5, 3, and 6 hrs after filament pMCAO in rats (n=10/group). In-vivo 2-photon laser scanning microscopy (2PLSM) was used to assess the acute effects of DRPs on cerebral microcirculation, hypoxia (NADH), and blood-brain barrier (BBB). Cerebral infarction, blood flow (CBF), and neurological outcomes were evaluated by magnetic resonance imaging (MRI) and behavioral testing, respectively, at 24 hours, 1 and 3 weeks after pMCAO. Differences between groups were determined using a two-way analysis of variance for multiple comparisons and posthoc testing with the statistical significance level set at p<0.05.

Results:
In vivo 2PLSM showed that pMCAO progressively decreased cerebral microcirculation leading to hypoxia and BBB disruption (p<0.05 from baseline). DRPs (0.5-6 hrs) increased near-wall blood flow velocity and flow rate in arterioles, leading to an increase in the number of erythrocytes entering capillaries, capillary perfusion and oxygenation while protecting BBB compared to saline (p<0.05). MRI demonstrated reduced infarct expansion (T2) and mitigated CBF disturbances (arterial spin labeling) in all DRPs-treated groups compared to saline (p<0.05). Neurobehavioral testing revealed more preserved neurological function in all DRPs groups than in the saline group (p<0.05). The obtained results showed that DRPs efficacy reduces with the time of application from 0.5 h to 6 hours after pMCAO but remains significant (p<0.05).

Conclusions:
DRPs (effectively restore cerebral microcirculation after pMCAO reducing tissue hypoxia and BBB damage, leading to reduced infarct size and improved neurological outcome in a time-dependent manner. DRPs can be used as a new effective adjunct therapy for ischemic stroke even without reperfusion and after delayed administration following the stroke onset.
Abstract WP303: Hypertension Disrupts the Relationship Between Pial Collateral Flow and Tissue Oxygenation During Ischemic Stroke
Authors: Hunt Ryan D , Cipolla Marilyn J
Published: February 2024

Introduction:
Chronic hypertension decreases collateral blood flow through leptomeningeal anastomoses (LMAs) during ischemic stroke, which has been linked to worsened stroke outcome. Given the important relationship between LMA flow, tissue oxygenation and cortical cerebral blood flow (CBF), we characterized the interplay between CBF and tissue oxygenation during the sub-acute progression of ischemia in normotensive Wistar (n=6) and spontaneously hypertensive rats (SHR, n=5).

Methods:
Transient middle cerebral artery occlusion was used to induce ischemia for 2 hours. Relative change in LMA flow, normalized to initial drop after occlusion, was measured via surface laser Doppler; tissue oxygenation and change in parenchymal CBF were measured using a combined laser Doppler-oxygen sensor placed in the expected cortical peri-infarct region. Recording was done at 400Hz, and data analyzed in 20 second blocks over the first hour of ischemia. Data reported as mean ± SEM, statistical comparisons done via Mann-Whitney tests.

Results:
CBF through LMAs was significantly higher in Wistars compared to SHR at 60 min of occlusion (156±18% vs 80±4% p<0.05). Pial LMA flow strongly correlated with tissue CBF (Wistar: r=0.91, SHR: r=0.75), which was also greater in Wistars at 60 min compared to SHR (80±14% vs.19±3%, p<0.05). Tissue oxygenation initially dropped below 10mmHg in all animals, increasing in Wistars over the course of ischemia to 22.8±0.34 mmHg at 60 min. However, oxygenation did not recover in SHR (5.9±0.23 mmHg). The relationship between CBF and oxygenation was strongly correlated in Wistar rats with both LMA (r=0.88) and tissue CBF (r=0.88). However, in SHR, oxygenation had an inverse relationship with CBF (LMA: r=
-
0.56, tissue CBF r=
-
0.37).

Conclusion:
Under normotensive conditions the relationship between CBF and oxygenation had a strong, linear relationship. However, this relationship was disrupted by chronic hypertension, with LMA and tissue CBF increasing without an increase in tissue oxygenation. This uncoupling was potentially due to cerebrovascular dysfunction and metabolic dysregulation due to chronic hypertension. These findings could be an important consideration for the development of stroke therapeutics in hypertensive patients.
Abstract WP313: Towards Molecular Profiling of Transient Ischemic Attack Mimics for Triage
Authors: Carmona Paulina , Lenz Garreck , Jickling Glen , Knepp Bodie , Amini Hajar , Hull Heather , Albers Gregory W , George Paul , Cucchiara Brett L , PENN ANDREW , RANGARAJU Srikant , Nahab Fadi B , Bruce Beau , Sharp Frank R , Stamova Boryana , Ander Bradley
Published: February 2024

Peripheral blood gene expression profiles can distinguish ischemic stroke from intracerebral hemorrhage and controls. However, it can be difficult to clinically distinguish “mimics” of transient ischemic attacks (TIA) and minor strokes from true TIAs and minor strokes. Even with imaging this can be a challenging differential diagnosis in the ED and other acute settings. Hence, there is a need for defining a molecular profile from blood that could guide triage of TIA mimics to reduce ED burden. This multi-site project collected peripheral blood from the participants and generated gene-level data from RNA sequencing. The cohort was composed of patients with a) TIA mimic presentation (n= 142 TIA mimics: an acute onset of neurological symptoms lasting <24h, that can be explained by some identifiable process other than cerebral ischemia including migraine, seizure, peripheral vestibular disease, brain tumors, syncope, root or peripheral nerve disease, and others); b) patients with transient ischemic attacks (n= 181 TIA: acute onset of neurological symptoms and signs that last <24h with a likely underlying cause of either large vessel atherosclerosis or cardioembolic origin but with a negative brain DWI-MRI); c) controls (n= 172 VRFC: no acute brain event, usually with one or more vascular risk factors including diabetes, hypertension or hypercholesterolemia). Differential expression (DE) analyses (fold change >
Abstract WP322: GluN2A-NMDAR Mediated Increased Neuronal Prostaglandin E2 Release and Microglial Activation Exacerbates Ischemic Brain Injury Under Hyperhomocysteinemic Condition
Authors: Seelig Sarah , Paramasivam Prabu , Paul Surojit , Poddar Ranjana
Published: February 2024

Hyperhomocysteinemia (Hhcy), a metabolic disorder is recognized as a risk factor for ischemic stroke. However, the impact of Hhcy on stroke outcome is not known. Using a rodent model of experimental stroke, we recently showed that predisposition to Hhcy exacerbates ischemic brain injury. The findings also showed that Hhcy triggers GluN2A subunit containing NMDA receptor (GluN2A-NMDAR) stimulation that act in conjunction with ischemia-induced pathways involving GluN2B subunit containing NMDAR (GluN2B-NMDAR) stimulation to enhance stroke pathology. The current study evaluated whether GluN2A-NMDAR-mediated increased expression of cyclooxygenase-2 (COX-2) and excessive release of the pro-inflammatory mediator prostaglandin E2 (PGE2) from neurons results in increased microglial activation and exacerbated ischemic brain injury.

HHcy was induced by implantation of Alzet pumps with L-homocysteine in adult male Wistar rats. Cerebral ischemia was induced by middle cerebral artery occlusion (60 min) in control and Hhcy rats. In a subset of Hhcy rats, NVP-AAM077, a pharmacological inhibitor of GluN2A-NMDAR was injected intravenously at the onset of stroke. At specified times following reperfusion, brain tissues were processed for FluroJade staining, immunoblotting with COX2 antibody, immunohistochemistry with COX2/NeuN and Iba1 antibodies, prostaglandin E2 (PGE2) assay and RT-PCR.

FluroJade staining shows an early onset and exacerbation of ischemic injury in Hhcy rats. This involves increased expression of COX-2 in neurons, release of PGE2, and a shift in microglial morphology from ramified state to active amoeboid state, 6h after reperfusion. Administration of NVP-AAM077 attenuates the increase in COX2 expression and PGE2 levels as well as microglial activation.

The findings demonstrate that an early onset of neuroinflammatory response mediated through GluN2A-NMDAR stimulation could contribute to the exacerbation of ischemic brain injury under Hhcy conditions. As GluN2A-NMDAR stimulation is primarily involved in promoting synaptic plasticity, neuronal growth, and survival, establishing their role in promoting neuroinflammatory response could lead to a paradigm shift in our understanding of the consequences of NMDAR signaling.
Abstract WP39: Stroke Risk Factor and Prevention Considerations in Women Veterans
Authors: Colsch Renee , Onweni-Eze Maureen , Byrd Elizabeth , reardon erin , OLNEY CHRISTINE , Damush Teresa , Hadidi Niloufar
Published: February 2024

Background:
Stroke is a significant health burden for Veterans and the fifth leading cause of death for women. Beyond traditional stroke risk factors, female sex hormones and pregnancy exposures are risk factors for women. Compared to civilian women, women Veterans have significant multimorbid physical and mental health conditions contributing to their stroke risk. Stroke risk factors specific to women Veterans have not been elucidated.

Purpose:
This scoping review aimed to summarize evidence on the stroke risk factors specific to United States women Veterans.

Methods:
The search strategy was run across six databases: MEDLINE and EMBASE via Ovid, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. A total of 1,218 records were uploaded to Covidence for screening. Criteria for included studies were peer-reviewed primary research and articles written in English about women Veterans and cardiovascular disease and stroke risk factors. No restrictions were placed on publication date.

Results:
Seventeen articles met inclusion criteria. Cohorts were 30 years and older. Data originated from national and individual Veterans Affairs studies. When comparing White Veterans and civilian counterparts, Black Veterans had a higher incidence of stroke; stroke incidence was higher in Veterans with post-traumatic stress disorder with insomnia, restless leg syndrome, traumatic brain injury, constipation with laxative use, egg consumption, frailty, and systemic sclerosis. Women Veterans, starting at age 30, had steadily increasing positive association with stroke risk indicating a need to screen earlier than recommended 45 years of age.

Conclusions:
Research is needed on stroke risk factors specific to the female sex as they connect to Veteran exposures (chemical, physical, and environmental). Nurses play a crucial role in interdisciplinary collaboration to recognize and support risk factor reduction for stroke prevention. The knowledge gained from this scoping review helps identify and treat women Veteran's specific stroke risk factors. This, in turn, can reduce the incidence of stroke and help reach equitable sex-specific care that women Veterans need.