bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 153: Pre‐procedural 3D visualization of deep‐learning vascular segmentation enhances identification of difficult femoral access in thrombectomy
Authors: Canals Pere , Requena Manuel , García‐Tornel Álvaro , Molina Marc , Tomasello Alejandro , Li Jiahui , Balocco Simone , Díaz Oliver , Ribó Marc
Published: March 2024

Introduction

Difficult or impossible femoral access remains a significant burden for mechanical thrombectomy (MT) in stroke, affecting between 4.4% (impossible) to ∼10% of cases (time to first angiography [T1A] > 30 min) [1]. Visualization of CT angiography (CTA) or MR angiography are the only available diagnostic tools for neurointerventionalists (NIs) to qualitatively assess catheterization difficulty ahead of intervention. Visualization of 3D segmentation of the head‐and‐neck arteries from CTA may provide enhanced spatial information for catheter access difficulty assessment to the occlusion site, as well as large vessel occlusion (LVO) localization or carotid stenosis detection.

Methods

Three observers (2 expert NIs and 1 medical image engineer) assessed a sample of patients with anterior circulation stroke rating LVO location, femoral access difficulty according to a Likert scale (0 to 5) and assessment of radial access compared to femoral (easier or not). Raters were asked to answer the same form for each case twice, once after visualizing only the CTA and again after visualizing a deep‐learning, automated 3D segmentation of the head‐and‐neck arteries from CTA [2]. Cases were randomly sampled and blind to raters for both assessments. Likert scale values were normalized and averaged across observers, and correlation to T1A was studied. LVO localization accuracy and time needed for the analysis was also assessed.

Results

The final sample included N = 117 cases, where 22.98% presented difficult or impossible access. LVO location prevalence was 13/15/45/27% for extracranial ICA (eICA)/TICA/M1/M2, and 49/51% for right/left. Averaged Likert values presented significant linear correlation for both segmentation and CTA visualization, but this was much stronger in the former (R: 0.58 vs 0.30, p<0.001). Three‐dimensional visualization of segmented vessels allowed for an enhanced detection of difficult or impossible femoral access (ROC‐AUC: 0.85 vs 0.66). LVO detection was also superior after segmentation visualization (mean accuracy across observers: 0.81 vs 0.72) and time needed for assessment was on average 2.3 times shorter (44 s vs 100 s). In difficult or impossible patients, radial access was considered easier in 74% (63‐89%) of cases when visualizing the segmentation compared to 42% (35‐48%) when inspecting the CTA.

Conclusion

Visualization of deep‐learning 3D arterial segmentation resulted in enhanced difficult or impossible femoral access for MT, LVO detection and faster analysis over traditional pre‐procedural CTA inspection. Adding this visualization to the current workflow could enhance difficult access detection ahead of intervention.
Abstract 162: Indirect Carotid Cavernous Fistula with Oculomotor Nerve Palsy Secondary to Trauma
Authors: Iqbal Zahid
Published: March 2024

Introduction

Intriguing and uncommon, we present a fascinating case of carotid‐cavernous fistula (CCF) following ocular trauma. Delving into medical nuances and outcomes, this reported case offers valuable insights for clinicians and researchers in the field of ophthalmology and interventional Neurology.

Methods

An elderly patient presented to the emergency department with diplopia and left eyelid ptosis two weeks after left ocular trauma. The patient had exotropia and hypotropia with restricted movement in all directions but mostly during adduction and infraduction which led to the diagnosis of oculomotor nerve palsy. Computer Tomography (CT) head was obtained which showed mild left proptosis with the prominence of the optic nerve sheath complex, CT angiography revealed asymmetric prominence of the left ophthalmic veins and enlarged left cavernous sinus with outward convex borders. CT face and mandible with IV contrast did not show any bony deformity. The patient underwent cerebral angiography that showed an indirect type 4 cavernous‐carotid fistula.

Results

A precise incidence of CCF fistula has not been reported so far in the literature but it is estimated to be present in 0.2 % of patients presenting with traumatic brain injury with an increased incidence of 4 % with basilar skull fractures. They can occur spontaneously or following closed skull injury, skull base fractures, or iatrogenically after craniotomies, endoscopic transsphenoidal or sinus surgery, and endovascular procedures. They can be classified based on angiographic arterial architecture (direct or indirect), hemodynamics (high flow or low flow), and etiology (spontaneous or traumatic). Type A are direct fistulas, whereas types B, C, and D are indirect fistulas.

Direct CCFs often present with pulsatile exophthalmos, orbital bruit, chemosis, diplopia, ocular redness, orbital pain, swelling, swishing or buzzing sounds, headache, or vision loss. Indirect low‐flow CCFs may be asymptomatic and insidious in onset and mostly present with chemosis and conjunctival injection.

Conclusion

Indirect carotid‐cavernous fistula rarely occurs secondary to a head trauma without any bony deformity and it's even rare to have an oculomotor nerve palsy on presentation, it should be considered as an etiology when evaluating patients for ocular nerve palsies.
Abstract 165: Subarachnoid Hemorrhage Related to Thoracic Spinal Cord Stimulator Placement
Authors: Arthur Melinda C. , Tandon Adesh , Lebovitz Jonathon , Wright Paul
Published: March 2024

Introduction

Spinal cord stimulators (SCS) offer safe and effective pain relief. Precise lead placement is critical. Indications for lead placement include chronic pain, failed back surgery syndrome and complex regional pain syndrome (1). Hardware related complications include lead fracture and lead migration into the subdural space. Complications can also include spinal cord injury, nerve root damage or lack of desired pain control (2). We present a case of subarachnoid hemorrhage (SAH) due to SCS lead migration into the subdural space.

Methods

An 81‐year‐old female patient with a past medical history of heart failure, atrial fibrillation and a mechanical mitral valve, presents with a severe headache and right hemiparesis. The patient was anticoagulated with a warfarin to heparin bridge. One week prior to presentation, the patient underwent SCS placement for chronic lower back pain due to post herpetic neuralgia. She was also found to have 8/10 pain on palpation of the lumbar spine and loss of sensation in the right lower extremity. An urgent CT brain revealed a SAH in the bilateral occipital lobes, right sylvian fissure and right temporal lobe. CT angiogram was also performed and did not reveal any evidence of a cerebral aneurysm. CT of the thoracic spine revealed neurostimulator lead migration into the subdural space. Neurosurgery was consulted and subsequently removed the SCS. The patient’s hemiparesis resolved, and CT brain showed no progression of the hemorrhage. MRI brain showed no infarct.

Results

We propose that the combined risk of anticoagulation and lead migration into the subdural space led to the development of SAH.

Conclusion

In cases of a SAH, where a cerebral aneurysm or arteriovenous malformation have been excluded, other sources should be considered. We report a novel case of SAH following SCS placement.
Abstract 174: Treatment of Unruptured Saccular Aneurysms with PED: A Systematic Review and Meta‐Analysis of Long‐Term Outcomes
Authors: Zermeno Jorge A. Rios , Ghaith Abdel Karim , Greco Elena , Michaelides Loizos , Ruiz Omar R. Ortega , Faisal Umme H. , Tawk Rabih G.
Published: March 2024

Introduction

The Pipeline Embolization Device (PED) is commonly used for intracranial aneurysm treatment. While its effectiveness for certain types of aneurysms is well‐established, its efficacy for saccular aneurysms remains debatable. This review and meta‐analysis aimed to assess the long‐term outcomes of PED treatment for unruptured intracranial aneurysms (UIA).

Methods

A systematic review and meta‐analysis were conducted following PRISMA guidelines. Studies with at least one year of follow‐up after PED treatment for saccular aneurysms were included. The primary endpoint was angiographic complete aneurysm occlusion at long‐term (≥ 12 mo.) follow‐up. Secondary outcomes included long‐term complications. We conducted a meta‐regression analysis to explore the potential sources of heterogeneity across studies.

Results

Eleven studies on 594 patients with 726 aneurysms were included, of which 5% were previously treated. The mean age was 55.7 years, and 78.3% were women. The mean aneurysm size was 7.72 mm, 8.95% were treated with more than one device, and 2.9% had adjunct coiling. The long‐term complete occlusion rate was 81% (CI 95%: 72% to 88%, p<0.01). Regarding long‐term complications, the rate of symptomatic ischemic stroke was 1% (CI 95%: 0% to 4%, p=0.07), the rate of delayed rupture was 1% (95%, CI 0% to 3%, p=0.02), and the rate of intracranial hemorrhage was 3% (CI 95%: 1% to 6%, p=0.81). The meta‐regression analysis revealed a decreasing trend per year for aneurysmal occlusion, ischemic stroke rate, and aneurysmal rupture rate over time and an increasing trend for ICH over time.

Conclusion

PED demonstrates high long‐term occlusion and low complication rates, suggesting it is a safe and effective treatment option for unruptured intracranial saccular aneurysms. However, studies with greater than 5‐10 years of follow‐up are needed to evaluate the clinical and radiographical outcomes of incompletely occluded aneurysms Additionally, as newer devices exhibit reduced thrombogenic profiles and ICH rates increase over time, reevaluation of antiplatelet therapy's role, including dosage and DAPT, is warranted.
Abstract 176: Management of Unruptured Intracranial Aneurysms in SubArachnoid Hemorrhage
Authors: Lingam Sivani , Samiee Tara , Galate Vince , Panchananam Vivek , Leconte Caitlin , Fry Lane , Paul Meirah , Abraham Michael G.
Published: March 2024

Introduction

Subarachnoid hemorrhage (SAH) has an estimated prevalence of 7.9 per 100,000 person yearsi. It is primarily caused by the rupture of intracranial aneurysms, leading to severe consequences and a 60% 6‐month mortality rateii. The management of UIAs in SAH cases poses a unique dilemma due to the potential increased risk of rupture, especially when the exact source of SAH remains ambiguous in the presence of multiple UIAs. Although tools like the PHASES scoreiii and the Unruptured Intracranial Aneurysms Treatment Score (UIATS)iv help guide aneurysm management, they are not tailored specifically to the scenario of UIAs in SAH. Thus, there is a need to study and comprehend the management strategies and outcomes of these cases. We reviewed the management and outcomes of UIAs in SAH at our institution in the past 10 years.

Methods

A retrospective review of all patients presenting between July 2013 and July 2023 with SAH and one concomitant UIA at our institution were analyzed.

Results

A total of 79 patients with confirmed UIA on angiography met inclusion criteria. Of these, 20 patients (25.3%) with UIAs were intervened on, as opposed to 59 (74.7%) that were not. UIAs >7 mm in diameter were found in 6 patients, and of these, 5 patients received intervention. 45.6% of the patients had a Hunt Hess Score of ≥3, and of these, 27.8% were intervened on. 72.2% of the patients had a Modified Fisher score >2, and of these, only 22.8% of the UIAs were intervened on. 58.2% of patients had a PHASES score >3, and of these, 34.7% were intervened on. Of the patients that were intervened on, 80% had a PHASES score >3. There was no significant difference in the UIATS score between the two groups. 34.9% of patients were noted to have the UIA in the same vascular territory as the SAH and of these 36.3% were intervened on. Current use of blood thinning medication, personal history of SAH or UIA, hypertension history, age, nor gender significantly affected the rate of UIA intervention

Conclusion

The majority of the UIAs in SAH were not intervened on, and the PHASES score and the UIATS score did not correlate with the decision on intervention. Of the ones that were intervened on, most of them were in the same vascular territory as the SAH. The decision to intervene appears to be on a case‐by‐case basis.
Abstract 181: Technical success of the WEB‐17 system for intracranial aneurysms: Summary of the early experience
Authors: Elrefaei Amro , Ghozy Sherief , Motawei Ahmed Sallam , Kobeissi Hassan , Moussalem Charbel , Kallmes David F. , Kadirvel Ramanathan
Published: March 2024

Introduction

Background: The Woven Endo‐Bridge (WEB) device is an intrasaccular device being used to secure intracranial aneurysms through the endovascular approach. The WEB is commonly used for wide‐neck aneurysms. There are no comprehensive studies to assess the low‐profile device WEB 17 so far. Although, some single studies have reported their early experience using the device. We plan to provide a comprehensive assessment of the early center experience using the WEB 17 device to secure intracranial aneurysms.

Objective: To provide an overview of the early‐center experience of the 0.017‐inch endovascular Woven EndoBridge device (WEB‐17) device.

Methods

A systematic review and meta‐analysis were conducted following the PRISMA recommendations. On April 15, 2023, we searched for eligible papers in Pubmed, Web of Science (ISI), Scopus, and Embase databases. The meta‐analysis was done using R software version 4.3.0. and the "meta" package. Pooled prevalence (%) and their corresponding 95% confidence intervals (CI), random‐effects model based and the generalized linear mixed models (GLMMs) method. On the presence of multiple follow‐up points, we included the last available in the analysis. Complete occlusion was defined as Raymond–Roy occlusion classification (RROC) class I, and adequate occlusion was defined as RROC class I or II.

Results

Seven studies were finally included following the double‐reviewer screening of the retrieved literature. The patients' mean age ranged from 52.5±13.8 to 62.0±9.5 years, and 71.0% were females. The mean follow‐up duration ranged from 6±2.25 months to 11.6±4. Technical success was achieved in 98.34% (95% CI= 96.72‐99.17) of the cases, while adjunctive devices were used in 4.97% (95% CI= 1.60‐14.39) of them (Figure 1). The complete occlusion rate was 72.54% (95% CI= 63.44‐80.08) (Figure 2), while the adequate occlusion rate was 94.41 (95% CI= 88.17‐97.46) (Figure 3). There was no significant heterogeneity in all pooled outcomes.

Conclusion

The early experience of the device shows an efficacy profile comparable with the currently available devices in treating intracranial aneurysms.
Abstract 187: Nontraditional Lipid Indices and Intracranial Atherosclerotic Stenosis Burden
Authors: Park Jong‐Ho
Published: March 2024

Introduction

Expert consensus guidelines recommend low‐density lipoprotein cholesterol (LDL‐C) as the primary serum lipid target for recurrent stroke risk reduction. Nontraditional lipid variables including triglycerides/high‐density lipoprotein cholesterol (HDL‐C) ratio and total cholesterol/HDL‐C ratio are linked to a vascular risk as a residual risk factor. Since intracranial atherosclerotic stenosis (ICAS)‐related stroke is prevalent in Asian population, we evaluated the relationship between lipid indices and ICAS burden.

Methods

We analyzed consecutively enrolled 1220 patients with acute ischemic stroke from March 2009 to May February 2013, who underwent brain MRI and MRA. ICAS was defined as >/=50% stenosis and quantified by presence, >/=2, and >/=3. Study patients were divided into four groups according to level of nontraditional lipid variables: triglycerides/HDL‐C, total cholesterol/HDL‐C ratio, and low‐density lipoprotein cholesterol (LDL‐C)/HDL‐C ratio, and non‐HDL‐C. Independent associations of 4 lipid variables with ICAS were assessed.

Results

Table shows multivariable adjusted odds of ICAS by Increasing strata of each lipid indices. Compared with the lowest triglycerides/HDL‐C quartile, stepwise relationships were observed between increasing quartiles and the presence of ICAS (adjusted OR 1.04, 95% CI 0.68–1.58; 1.06, 0.69–1.62; and 1.80, 1.17–2.77), ICAS >/=2 (1.32, 0.83–2.09; 1.32, 0.82–2.11; and 1.72, 1.07–2.74), and ICAS >/=3 (2.49, 1.32–4.69; 2.98, 1.58–5.63; and 3.18, 1.67–6.04). Compared with the lowest total cholesterol/HDL‐C ratio, stepwise relationships were observed with ICAS >/=2 (1.51, 0.90–2.54; 1.56, 0.90–2.68; and 2.03, 1.00–3.74), and ICAS >/=3 (1.67, 0.84–3.33; 2.22, 1.10–4.51; and 2.63, 1.20–5.77). Relationships between LDL‐C/HDL‐C ratio and ICAS burden showed similar pattern to findings from total cholesterol/HDL‐C. Association between non‐HDL‐C and ICAS was not significant.

Conclusion

Among four lipid indices, elevated triglycerides/HDL‐C is more likely associated with ICAS burden. HDL‐C might exert as a crucial role for developing ICAS.
Abstract 202: Early Experience with the Aristotle Colossus 035” Micro‐Guidewire for Mechanical Thrombectomy: Experience in 6 Cases
Authors: Meyer Benjamen M. , Khan Muhammad W. , Campos Jessica K. , Laghari Fahad , Zarrin David A. , de Beaufort Jonathan C. Collard , Amin Gizal , Golshani Kiarash , Beaty Narlin , Bender Matthew T. , Colby Geoffrey P. , Lin Li‐Mei , Coon Alexander L.
Published: March 2024

Introduction

Recent literature continues to demonstrate the successful role large‐bore aspiration catheters have in thrombus ingestion during mechanical thrombectomy. However, the ledge gap, or step off, between the catheter and the microwire can make navigating to distal vasculature difficult. A new 035” micro‐guidewire reduces the step off for 035” aspiration catheters (Aristotle 35 Colossus Guidewire, Scientia Vascular, West Vale City, UT) while maintaining torquability and softness. We report here our early experience in 6 mechanical thrombectomy cases.

Methods

We reviewed and analyzed a prospectively maintained database of the senior authors to identify cases utilizing a 035” micro‐guidewire with 035” aspiration catheters in mechanical thrombectomy.

Results

Six consecutive cases of 035” microwire use for mechanical thrombectomy were identified. Four (67%) patients were female with an average age of 77±5.3 years (range 56‐97). Average presenting NIHSS was 11±3. Thrombus locations included 50% (n=3) in the M2, 33% (n=2) in the M1, and 17% (n=1) in the P1. Radial access was performed in 1 case (17%), with remaining via femoral access (n=5, 83%). An 088” ID aspiration catheter was navigated to at least the M1 segment in all anterior circulation cases and the basilar in the posterior circulation case. The 035” wire was placed proximal to the occlusion in all cases allowing coaxial 035” and 071” catheter aspiration passes. The average number of passes was 2±0.3. TICI 2C/3 was achieved in 83% of cases (5/6) and 2b in the remaining case. There were no catheter‐related dissections, perforations, or hemorrhagic complications noted for the cases.

Figure 1. (A) AP angiography demonstrating a thrombus in the right M2 superior division (white). (B) 035” (yellow), 071” (orange), and 088” (red) aspiration catheters over the Colossus 35 micro‐guidewire (black) at the level of the thrombus without crossing it.

Conclusion

The Colossus 035” micro‐guidewire may offer advantages over its narrower counterparts by reducing ledge effect and the need to cross the thrombus. Further comparative studies against currently available microwires are needed in various anatomies to confirm this perceived performance advantage.
Abstract 204: On Old Dogs and New Tricks: Connecticut Perfusion Predicts Hemorrhagic Transformation After Thrombectomy
Authors: Abualnadi Yazan D. , Miller Samantha , Khalil Zorain M. , Desai Sohum K. , Sadiq Kaiser O. , Tekle Wondwossen G. , Hassan Ameer E.
Published: March 2024

Introduction

Hemorrhagic transformation is a major complication of large vessel occlusion (LVO) recanalization after mechanical thrombectomy in acute ischemic stroke. We investigated whether computed tomography perfusion (CTP) derived hypoperfusion index ratio correlates with the rate of hemorrhagic transformation.

Methods

We conducted a retrospective cohort analysis of a prospectively maintained patient database. Included patients underwent mechanical thrombectomy for large vessel ischemic stroke from January 2019 to December 2022. Patients were separated into 2 groups depending on whether or not hemorrhagic transformation developed. Hypoperfusion index ratio on admission CTP was determined using VizAI software. Data were analyzed using Chi‐square and Mann‐Whitney U tests.

Results

Among the 289 patients included (median age, 72.5; 41.5% female), 55 (19%) had hemorrhagic transformation. Patients with hemorrhagic transformation had a significantly higher hypoperfusion index ratio (median, 0 vs 0.2; P= 0.004) compared with those with no hemorrhagic transformation. Multivariable analysis showed that for every 0.1 increase in the hypoperfusion index ratio, there was a significant 4.64‐fold increase in hemorrhagic transformation (OR 4.64; 95% CI 1.40 to 15.18; p=0.011).

Conclusion

In patients with LVO who underwent mechanical thrombectomy, a higher hypoperfusion index ratio on admission CTP was associated with an increased rate of hemorrhagic transformation. This suggests that the hypoperfusion index ratio could be used as a predictor for hemorrhagic transformation after mechanical thrombectomy.
Abstract 214: Predictors of Mechanical Thrombectomy Success and Failure: A Preliminary Analysis
Authors: Johnson‐Black Phoebe , Mukarram Faisal , Molaie Amir , Ghochani Yasmin , Saver Jeffrey , Szeder Viktor
Published: March 2024

Introduction

Mechanical thrombectomy (MT) is now the standard of care in treatment of large vessel occlusion (LVO) in acute ischemic stroke (AIS). However, a significant minority of patients do not achieve successful recanalization. Previous case series’ have reported failed recanalization at a rate of approximately 12% (1). In the present study, we investigated clinical and procedural characteristics predictive of MT success and failure.

Methods

We conducted a retrospective analysis of MT patients with LVO presenting to our academic comprehensive stroke center from 2015‐2020. Recanalization failure was defined as TICI 0‐2a and success as TICI 2b‐3. We compared all 49 consecutive failure cases to a random selection of 85 successful MT cases. Demographic, clinical, procedural, and outcome data were compared between the two groups.

Results

In this cohort, there was no statistically significant difference in sex, pre‐stroke modified Rankin score (mRS), admission National Institutes of Health Stroke Scale (NIHSS), door‐to‐groin time, thrombolytic use, or site of occlusion between the two groups. In the success group, patients were older (76 vs 61, p=0.003), and had a higher average number of atherosclerotic risk factors (p=0.002). There was a higher proportion of embolic stroke of undetermined source (ESUS) in the success group compared with the failure group (8.5% vs 0%, p=0.039). A higher proportion of failure cases were due to large artery atherosclerosis (30.6% vs 19.5%, p=0.12) and cardioembolism (55.1% vs 67.1%, p=0.27), though neither of these differences were statistically significant. Stent‐retrieval alone (SR) was a more common first pass technique in failed than in successful MT (14.3% vs 0%, p=0.001).

Conclusion

This study investigated clinical and procedural factors associated with successful and failed recanalization in MT. In this cohort, stent‐retrieval alone as a first pass technique was more commonly associated with failed MT. Stroke etiology was associated with rates of failure, with a significantly higher proportion of ESUS in successful cases and a trend toward a higher proportion of large vessel atherosclerosis and cardioembolism in failed MT.
Abstract 216: Endovascular Thrombectomy +/‐ Thrombolytics In Patients With Cocaine‐Related Acute Ischemic Stroke
Authors: Kothari Sachin A. , Desai Harsh , Morsi Rami Z. , Carrion‐Penagos Julian , Smith Matthew , Coleman Elisheva , Kass‐Hout Tareq , Brorson James , Prabhakaran Shyam , Mendelson Scott
Published: March 2024

Introduction

The safety of thrombolytic therapy in patients with cocaine‐related acute ischemic strokes (AIS) has been investigated, but the safety of endovascular thrombectomy in cocaine‐related AIS remains unknown (1‐2). Here, we report preliminary descriptive data on endovascular thrombectomy with or without thrombolytics performed in cocaine‐related ischemic strokes at our institution.

Methods

A retrospective chart review was performed at our comprehensive stroke center from June 2020 to May 2022 to identify AIS patients with cocaine‐positive urine toxicology screens on admission. Baseline demographics, urine toxicology, National Institute of Health Stroke Scale (NIHSS) scores, neuroimaging, Trial of ORG 10127 in Acute Stroke Treatment (TOAST) criteria, location of stroke, home medications, comorbidities, medical management, and outcomes including modified Rankin Score (mRS) were reported.

Results

A total of 74 AIS patients were identified to be cocaine‐positive. Of these patients, 14 underwent endovascular thrombectomy (EVT). Only 3 of these 14 patients received intravenous thrombolytics. Including the EVT group, 8 out of 74 AIS patients received thrombolytics. The mean age was found to be 61 years with 86% being male. The most common locations of large vessel occlusion were the M2 branch of the right middle cerebral artery (MCA) (40%), the M2 branch of the left MCA (33%), the M1 branch of the right MCA (13%), left internal carotid artery (7%), and A1 branch of the anterior cerebral artery (7%). Based on TOAST criteria, 64% of strokes were large artery atherosclerosis, 29% cardioembolic, and 7% cryptogenic stroke. The mean initial NIHSS was 14. Average mRS on admission was found to be < 1 and follow‐up mRS at 3 months was found to be 3.

Conclusion

Our data suggest that cocaine patients who underwent EVT on average had unfavorable functional outcomes defined as mRS > 2, on follow‐up mRS at 3 months. This study highlights the importance of future larger studies to investigate endovascular thrombectomy +/‐ thrombolytics in cocaine‐related AIS.
Abstract 228: Suboptimal Door‐to‐Puncture Times: Challenges Faced in the Stroke Alert Workflow
Authors: Chakales Pressley A. , Khalid Fatima C. , Dolia Jaydevsinh N. , Tarek Mohamed A. , Haussen Diogo C.
Published: March 2024

Introduction

Advances in stroke care have led to more patients eligible for thrombectomy. With these advances, it has become imperative to create a seamless workflow for thrombectomy candidates to ensure rapid door‐to‐puncture times and, ultimately, improve patient outcomes. We sought to determine what barriers are causing delays in patients’ door‐to‐puncture time.

Methods

A survey was distributed to all members of the Neurology PGY2, PGY3, PGY4 classes and vascular fellows at our single‐center, Comprehensive Stroke Center. The survey allowed participants to freely respond to questions regarding obstacles they encountered that led to delays in door‐to‐puncture times. All survey responses were anonymized.

Results

The survey was sent to 32 participants, with 26 responses. Of the 26 responses, 11 respondents (42%) noted that obtaining IV access for CTA/CTP scans was a significant cause of delay. Other responses included lack of availability of family for collateral (23%), CT scanner availability (15%), and length of time to decide if the patient is a thrombectomy candidate (15%).

Conclusion

The goal of this study was to collect data from the individuals involved in the direct care of acute stroke patients who are thrombectomy candidates. We used their experience to determine which points in the stroke alert workflow led to delays in door‐to‐puncture time. Our survey showed the most consistent delay is obtaining proper IV access for CTA and CTP imaging. This information was valuable and has led to the creation of a coalition between the neurology and emergency medicine departments, nursing, and CT technologists to create a “CODE IV” protocol to be implemented into the stroke alert workflow. We aim to report the change in door‐to‐puncture time after the implementation of this new protocol.
Abstract 229: Recanalization Rate in Mechanical Thrombectomy in Patients With Elevated LDL‐C Levels
Authors: Gao Xiaoyi , Christopher Kara , Rodriguez Wilson , Gordon Weston , Linares Guillermo
Published: March 2024

Introduction

A high level of low‐density lipoprotein ‐ cholesterol (LDL‐C) is a known risk factor for ischemic stroke1. However, the impact of LDL‐C on stroke outcomes after mechanical thrombectomy (MT) is unclear. Interestingly, previous studies have shown conflicting evidence. Some studies showed higher LDL‐C early in the course of stroke is associated with a favorable post‐MT outcome and a lower risk of hemorrhage2,3 whereas others showed higher LDL‐C is associated with a higher risk of hemorrhagic transformation4. In this study, we aim to examine the relationship between LDL‐C level and post‐MT functional outcome. We also aim to investigate whether LDL‐C levels affect MT recanalization rate.

Methods

We reviewed the records of 223 patients who received MT at our institution from 2018‐2023. We collected data on baseline characteristics and demographics, functional outcomes at discharge and 90 days, and procedural information including final thrombolysis in cerebral infarction (TICI) grade. Univariate analysis included chi‐square and Mann‐Whitney U tests. Multivariable logistic regression models were fitted to determine the odds of the outcomes while adjusting for age, race, and gender.

Results

Of the patients who received MT, 69 (31.9%) had elevated LDL‐C levels of 100 or higher. Patients with elevated LDL were 47% less likely to achieve TICI 3 status after adjustment for age, race, and gender (aOR =0.53, 95%CI = 0.30‐0.95, p=0.03). There were no statistically significant differences in 90‐day modified Rankin Scale (mRS), or discharge mRS. However, only 81.2% of patients with an elevated LDL‐C had an unfavorable mRS (>=3) at discharge compared with 87.0% of those with a normal LDL‐C level (<100).

Conclusion

In our cohort, elevated LDL‐C level was significantly associated with poor recanalization rate in MT. Patients with elevated LDL‐C levels more frequently had favorable functional outcomes (mRS<3) after MT even though this effect was not statistically significant in our study. To our knowledge, no studies have examined the relationship between LDL‐C and MT recanalization rate. This association we observed might explain the relationship between good functional outcomes and elevated LDL‐C levels found in our study and the previous studies. Previous literature demonstrated that the composition of thrombus can have an impact on the efficacy of MT5. Whether LDL‐C level is involved in this mechanism is yet unknown. Future research on the pathophysiological mechanisms underlying this observation is warranted.
Abstract 230: Endovascular therapy for large core ischemic strokes: Meta‐analysis of randomized clinical trials
Authors: Abbasi Mohammad Hossein , Shoamanesh Ashkan , Liebeskind David S. , Warach Steven , Saber Hamidreza
Published: March 2024

Introduction

Background: Patients with acute strokes with large infarct size are traditionally excluded from endovascular therapies, as like as clinical care. However, questions remain with respect to the safety and efficacy of EVT in these patients.

Methods

We conducted a meta‐analysis based on pooled data from SELECT 2 trial [1], ANGEL‐ASPECT trial [2], RESCUE Japan [3], and HERMES study [4]. We explored the efficacy of EVT for large infarcts to achieve a favorable 90‐day modified Rankin Scale. Also, we compared favorable outcomes following EVT in those with a core infarct at baseline of more than 70 ml, delayed thrombectomy of more than 6 hours, older than 75 years, and those who received concomitant IV thrombolysis. We also examined the pooled rate of hemorrhagic transformation following EVT in large core strokes.

Results

This meta‐analysis showed a statistically significant higher rate of favorable outcome in subjects with extremely large infarct size who undergone EVT compared to those who were managed by medical therapy alone (RR: 1.41, 95% CI: [1.05‐1.98], p: 0.03). In the subgroups of patients with core size > 70ml (RR: 1.51, 95% CI: [1.23‐1.87]), late window presentation (LKN to randomization ≥ 6 hours), (RR: 1.53, 95% CI: [1.27‐1.84]), or those 75 or older than 75 years old (RR: 1.43, 95% CI: [1.12‐1.84]), EVT was associated with higher rates of favorable 90‐day mRS score of 0‐3 compared to medical therapy alone. However, EVT was not associated with better outcomes in those who received IV thrombolysis (RR: 1.37, 95% CI: [0.93‐2.01]. Based on pooled data from SELECT‐2, ANGEL‐ASPECT, and RESCUE Japan trials, the overall rate of early symptomatic hemorrhagic transformation among cases with ASPECT 0‐5 in the thrombectomy group was not significantly higher compared to patients who were managed non‐surgically (OR 1.75, 95% CI: [0.89‐3.47]).

Conclusion

Endovascular therapy is a reasonable option for the management of large infarcts. EVT results in favorable outcome by a delayed thrombectomy for a large core infarct and in older patients.
Abstract 235: General Anesthesia vs. Non‐General Anesthesia in Endovascular Treatment for Patients with Acute Ischemic Stroke
Authors: Doheim Mohamed F. , Sultany Abdullah , Al‐Bayati Alhamza R. , Nogueira Raul
Published: March 2024

Introduction

Current evidence supports endovascular therapy (EVT) for eligible patients with acute ischemic stroke in the anterior and posterior circulation. However, there is no consensus regarding the choice of anesthetic approach during EVT and early reported studies were observational with potential biases and confounding. Therefore, we sought to build concrete evidence from randomized clinical trials (RCTs) comparing the general anesthesia (GA) vs. non‐GA via a systematic review and meta‐analysis approach.

Methods

Data from inception to June 2023 were reviewed and only RCTs comparing the GA vs. non‐GA were included. We then pooled data for the main procedural, safety, and efficacy outcomes with odds ratios (ORs) and 95% CI for dichotomous data and mean difference (MD) with 95% CI for continuous data under random effect model.

Results

Eight RCTs were included in the final analysis (n=1203) with seven of them reporting data for the anterior circulation (n=1116) and one for the posterior circulation (n=87). Regarding efficacy outcomes, pooled results revealed non‐statistically significant difference between GA and non‐GA for functional independence at 90 days defined as modified Rankin Score scale of 0‐2 (OR = 1.17, 95% CI: 0.88–1.56, P= 0.28; I2 = 26%, Figure A) and the results of the anterior circulation subgroup showed non‐statistically significant difference (OR = 1.22, 95% CI: 0.90–1.67, P= 0.2; I2 = 31%) and the difference was not also evident for posterior circulation (48.8% vs 54.5%; RR, 0.89; 95% CI, 0.58‐1.38; adjusted OR, 0.91; 95% CI, 0.37‐2.22). Successful recanalization, defined as Thrombolysis in Cerebral Infarction score of 2b‐3, showed a statistically significant results favoring GA over non‐GA (OR = 1.94, 95% CI: 1.42–2.63, P=0.0001; I2 = 0%, Figure B) and this continued to show statistically significant in both anterior and posterior circulation subgroups. Onset to reperfusion time was not statistically significant between GA and non‐GA (MD, ‐2.59; 95% CI: ‐22.38 to 17.21, P= 0.8; I2=24%, Figure C). Regarding safety outcomes, there were no statistically significant differences in intracranial hemorrhage (OR = 0.95, 95% CI: 0.67–1.35, p = 0.79; I2 =0%, Figure D) or mortality (OR = 0.95, 95% CI: 0.71–1.29, p = 0.76; I2 =0%, Figure E). However, GA showed a higher risk of hypotension compared to non‐GA (OR = 6.05, 95% CI: 3.25–11.25, P=0.00001; I2 =69%, Figure F). Sensitivity analysis by leave one out removing Ren et al (5) showed homogenous results (OR = 8.43, 95% CI: 5.85–12.16, P=0.00001; I2 =0%)

Conclusion

In this study‐level meta‐analysis, GA resulted in higher rates of successful reperfusion as compared to non‐GA despite being associated with higher rates of hypotension. Since many of the included studies were small and single center, more studies are warranted to support these findings.
Abstract 244: Effect of Actuation Frequency on Clot Integration with the Tigertriever Device: An In Vitro Study
Authors: Dashti Nakisa , Gopal Megha , Serna Rowan J , Fiorella David , Sadasivan Chander
Published: March 2024

Introduction

Mechanical thrombectomy has been widely recognized as the preferred treatment for large vessel occlusion strokes. The Tigertriever stent‐retriever (Rapid Medical, Yokneam, Israel) is a novel operator‐adjustable device that can be actively expanded and contracted by the operator [1], which allows for several actuation‐related parameters to be optimized to potentially improve device efficacy. These parameters – such as amplitude and frequency of the actuation cycle, and rate of expansion and contraction – have not yet been evaluated in correlation with device success. We conducted a benchtop study to evaluate the effect of actuation frequency on clot integration within the stent.

Methods

A Tigertriever 17 device was deployed within a biological thrombus analog (2.5 cm length) placed in a straight silicone tube (2.4 mm diameter). The device was actuated between the maximally contracted and maximally expanded states with three different frequencies: Passive (one‐time opening, n=6), Slow (20 seconds/cycle, n=6), and Fast (5 seconds/cycle, n=7). A flat‐detector CT scan was acquired, the clot and stent wires were segmented, and the boundaries of the clot and stent wires were calculated on each axial slice (Figure 1A). The intersection between the stent and clot boundaries throughout the volume was defined as the volume of clot integrated within the stent. The clot integration factor (CIF, ratio of integrated clot volume to total clot volume) was then statistically compared between the three frequencies as an estimate of clot capture efficiency.

Results

The CIF was significantly higher (23% increase, p=0.01) with the Fast actuation as compared to the Passive and Slow actuations, with a post‐hoc test showing no difference (p>0.05) between the Passive and Slow actuation frequency (Figure 1B).

Conclusion

The unique malleability of the Tigertriever stent‐retriever (Rapid Medical) presents an opportunity to better understand actuation parameters that can maximize thrombus capture. Results indicate that faster actuation frequencies may result in improved clot integration with the Tigertriever device. These results are concordant with a previous clinical study [1] that found repetitive‐expansion‐contraction was more successful than single unsheathing (which corresponds to our Passive group). It is possible that the greater acceleration of the stent mesh wires in the Fast actuation frequency resulted in increased radial forces that improved clot integration. This effect must be further validated in an in vitro setting more representative of physiological conditions, as well as eventual clinical evaluation.
Abstract 249: In‐silico Versus In‐Vitro Evaluation of a New Stent‐Retriever Design: A Novel Approach to Pre‐clinical Development
Authors: Bridio Sara M. , Konduri Praneeta , Desai Shashvat M. , Terreros Nerea Arrarte , Luraghi Giulia , Atchaneeyasakul Kunakorn , Fregona Virginia , Matas Jose F. Rodriguez , Berti Francesca , Yavagal Dileep R. , Yoo Albert , Majoie Charles B. , Jadhav Ashutosh P. , Marquering Henk A. , Migliavacca Francesco
Published: March 2024

Introduction

In‐vitro evaluation (analysis in a bench top flow model) is the gold standard and a regulatory requirement for pre‐clinical investigation of devices being developed for endovascular thrombectomy (EVT). In‐silico evaluation (computer simulated analysis in a virtual stroke model) has the potential to test and optimize large number of stent‐retriever design variations in a relatively time and cost‐effective manner. Further, new design concepts can be tested across multiple anatomical scenarios. We aim to validate the utility of in‐silico evaluation when compared with in‐vitro evaluation for the SuperNova Stent‐retriever.

Methods

In‐silico analysis was performed using a virtual thrombectomy model, built using data from a fine‐grained finite‐element model, to estimate the probability of successful recanalization and emboli in new/distal territory. Neurovascular anatomy of the virtual model was built based on digital subtraction angiography of an in‐vitro model (Sim Agility, Mentice, Inc). Gravity Medical Technology’s SuperNova Stent‐retriever was the device under investigation‐ physical device for in‐vitro analysis and virtual replica for in‐silico analysis (built using finite element analysis incorporating various physical metrics of the stent‐retriever). Experiments performed for in‐vitro analysis were replicated for in‐silico analysis. Multiple thrombectomy scenarios were defined and validation analysis was performed. Data was analyzed using SPSS 23 (IBM, Armonk, NY)

Results

We defined multiple thrombectomy scenarios including 1 cm red blood clot in M1 artery, 2 cm bifurcation M1‐M2 red blood clot (Y‐shaped clot), 1 cm white blood clot in M1 artery, and 1 cm white blood clot in superior M2 artery. The figure below demonstrates a pictorial representation of the first scenario‐ 1 cm red blood clot in M1 artery followed by mechanical thrombectomy simulation using the SuperNova stent‐retriever. Per our in‐vitro analysis (10 thrombectomy experiments), the rate of first pass effect and the rate of complete recanalization after a maximum of 3 passes using SuperNova stent‐retriever was 50% and 90%, respectively. Complete data from in‐silico analysis is being generated and will be presented at the conference. Preliminary data suggests high degree of concordance.

Conclusion

In‐silico analysis has the potential to improve and expedite pre‐clinical thrombectomy device development. Further studies are required to better understand the scope and potential of this technology.
Abstract 260: TCD Bubble test as a Screening tool for detection of Patent Foramen Ovale in Stroke
Authors: PK Danish Ahammed , Alapatt Paul , Raj Aiswarya , VV Ashraf , Mattummal Shafeed
Published: March 2024

Introduction

Introduction & Objectives: Transcranial Doppler (TCD) ultrasound provides rapid, noninvasive, real‐time measures of cerebrovascular function. Patent Foramen Ovale (PFO) is fourfold more common in Young Stroke Patients <55 years of age, as opposed to age‐matched controls. The PFO test with TCD, often called a “TCD bubble test,” involves the intravenous injection of micro‐bubbles (air mixed with saline), which can be detected by a TCD system in the Middle Cerebral artery (MCA). The TCD Bubble test, hence, can be used as a screening test in the evaluation of Embolic Stroke Of Undetermined Source.

Methods

A retrospective observational study was carried out at Aster MIMS Hospital, Kozhikode, where 63 patients with Young stroke were evaluated between April 2021 and October 2022. Along with routine stroke workup, including Transthoracic Echocardiography, TCD bubble tests were performed to detect Right to left shunt. Further, Transesophageal Echocardiography was done to look for Patent Foramen Ovale in TCD Bubble test positive patients.

Results

TCD Bubble test was detected to be positive in 36 patients and negative in 27 patients. Transesophageal Echocardiography performed in TCD Positive patients confirmed PFO in 35 out of 36 patients. Transthoracic echocardiography, however, could detect PFO only in 10 patients.

Conclusion

TCD Bubble test can be employed as a screening tool in the evaluation of young stroke to detect Patent Foramen Ovale with efficacy similar to TEE.
Abstract 264: Enhancing Stroke Care: Neurology Residents' Clinical Prediction of Large Vessel Occlusions for Faster Endovascular Activation
Authors: Heshmati Keyvan , Hernandez Maria , Shahani Jai , Vulkanov Volodymyr , Khandelwal Priyank , Aroor Sushanth
Published: March 2024

Introduction

Large vessel occlusions (LVO) account for approximately 15 to 30% of acute ischemic strokes, necessitating rapid clinical recognition to facilitate timely endovascular team activation and reduce door‐to‐reperfusion time for mechanical thrombectomy (MT). Existing clinical LVO scales, such as RACE, FASTED, and VAN, designed for utilization by Emergency Medical Services (EMS), lack reliability and have not been widely adopted for pre‐activation of endovascular teams. Typically, endovascular team activation occurs after LVO confirmation through neuroimaging, highlighting the need for improved methods to identify LVO during early assessments by neurologists.

Methods

A prospective observational study was conducted at University Hospital, involving all stroke codes activated by the Emergency Department (ED) or EMS. Neurology residents responding to the codes performed initial assessments, encompassing patient history, physical examination, and NIH Stroke Scale (NIHSS) evaluations. Based on the onset and severity of symptoms, presence of cortical signs, and NIHSS scores, patients were classified into four categories: A) probable LVO and stroke, B) possible LVO and stroke, C) not LVO but probable stroke, and D) probable stroke mimic. All assessments were completed before CT scanning.

Results

Over a ten‐month period, 159 stroke codes were evaluated by neurology residents. Among these, 27 patients were diagnosed with LVO, while 132 patients had no LVO. The neurology residents classified 18 patients into the probable stroke group, demonstrating a sensitivity of 48%, specificity of 96%, a positive predictive value (PPV) of 72%, and a negative predictive value (NPV) of 90%. Combining the probable and possible stroke groups, the residents identified 34 patients with a sensitivity of 74%, specificity of 89%, a PPV of 5%, and an NPV of 94%. Regrettably, seven patients with LVO were misclassified as either stroke mimics or non‐LVO strokes. Among these cases, five patients presented with low NIHSS scores, two had LVO in the posterior circulation, and one developed an in‐stent thrombus.

Conclusion

Our study revealed that neurology residents' ability to predict LVO was comparable to other LVO prediction scales in terms of sensitivity and specificity, but significantly improved in PPV. With a PPV exceeding 70%, the clinical prediction of LVO by neurology residents proves to be a valuable tool for activating the endovascular team promptly. This approach holds promise for enhancing stroke care in both the emergency department and pre‐hospital ambulance‐based settings. Nevertheless, larger studies are warranted to validate and further refine these findings. Implementing the neurology residents' clinical judgment in LVO identification can potentially optimize patient outcomes and treatment timelines in acute ischemic strokes.