bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP7: The Healthy Octogenarian Profile (HOPE): A Simple Indicator of Elderly Stroke Patients that may Benefit from Endovascular Intervention
Authors: Urra Xabier , San Román Luis , Jovin Tudor G
Published: July 2021

Background:
Octogenarian stroke patients are frequent and they are often excluded from acute revascularization procedures, in particular endovascular interventions, because older age is a poor prognostic factor after stroke and the benefit from interventions is debated. We studied which baseline, peri- and postprocedural factors determine the response to endovascular treatment in octogenarians with acute stroke.

Methods:
We first studied a highly homogeneous cohort of 32 octogenarian patients with M1 occlusion treated with endovascular procedures in a comprehensive stroke center. We collected information on history of vascular risk factors as well as a general measure of health, the healthy octogenarian profile (HOPE), defined as absence of any vascular risk factor or known vascular disease. We also measured admission NIHSS score, systolic blood pressure and glucose levels, previous treatment with IV tPA, time to treatment, successful revascularization (TICI2b-3), symptomatic hemorrhage, final infarct volume on MRI and favorable 3-month functional outcome (mRS≤2). The variables associated with outcome were validated in an independent cohort of 34 octogenarians with anterior circulation stroke treated with endovascular procedures in another comprehensive stroke center.

Results:
HOPE, history of hypertension and successful recanalization were associated to favorable outcome in univariate analysis. In adjusted models, HOPE remained strongly associated to better outcome (n=8; unadjusted OR=40,p=0.003; adjusted OR=38.9,p=0.02). In the validation cohort, HOPE remained associated to favorable outcome while history of hypertension was not. HOPE remained associated to outcome in adjusted models (n=5; unadjusted OR=9.4,p=0.035; adjusted OR=16,p=0.022). Hemorrhagic complication rate and final infarct volume were not significantly associated to outcome in any of the cohorts.

Conclusions:
General health at baseline rather than procedural factors or radiological outcome measures determines the outcome in elderly patients treated with endovascular procedures. Around 20% of octogenarians have the healthy octogenarian profile (HOPE), which identifies patients likely to benefit from endovascular interventions.
Abstract TP70: Safety of IV tPA Administration with CT Evidence of Prior Infarction
Authors: Houston J. Thomas , Albright Karen C , Boehme Amelia K , Lyerly Michael J , Shahripour Reza Bavarsad , Palazzo Paola , Alvi Muhammad , Rawal Pawan V , Kapoor Niren , Sisson April , Shiue Harn , Alexandrov Anne W , Alexandrov Andrei V
Published: July 2021

Background:
Prior stroke within 3 months excludes patients from thrombolysis, however patients may have CT evidence of prior infarct often of unknown time of origin. We aimed to determine if the presence of a previous infarct on pre-treatment head CT is a predictor of hemorrhagic complications following administration of IV tPA.

Methods:
We retrospectively analyzed the database of consecutive patients treated with IV tPA at our institution from 2009-2011. Pre-treatment CTs were reviewed without knowledge of subsequent hemorrhagic transformation (HT) for evidence of any prior infarct. Further independent review determined if any HT was present on repeat CT or MRI. Symptomatic ICH (sICH) was defined as the presence of parenchymal hematoma (PH-1 or PH-2) and neurological deterioration by ≥ 4 points within 36 hours.

Results:
Of 212 IV tPA treated patients, 72 (34%) had evidence of prior infarct on pre-treatment CT. Any HT was found in 16%, sICH occurred in 2.4% of the total population, and both events never occurred in the areas of prior infarcts. Patients with prior infarcts on CT were older (median age 72 vs 65; p=0.001), were more likely to have a history of hypertension (85% vs 71%; p=0.024), were on antiplatelet agents prior to admission (49% vs 31%; p=0.007) and had higher pre-treatment NIHSS scores (median 10 vs 7; p=0.023). Patients with prior infarcts on CT did not experience more HT (p=0.3956) nor sICH (p=0.2207), even after stratifying for prior lacunar or cortical stroke appearances (p=0.301). More patients with prior infarcts on CT had microbleeds on follow-up MRI (25% vs 11%; p=0.033), and patients with prior infarcts and microbleeds experienced more HT (63% vs. 10%; p<0.0001) but did not have more sICH (p=0.4784).

Conclusions:
Visualization of prior infarcts on pre-treatment CT does not predict an increased risk of sICH and should not be viewed as a contraindication for systemic tPA treatment after clinically evident strokes within 3 months were excluded. A subgroup of patients with prior infarcts and subsequently discovered cerebral microbleeds show a propensity to develop asymptomatic HT.
Abstract TP76: Medium-Term Angiographic Follow-up and Packing Density Analysis in a Series of 67 Consecutive Intracranial Aneurysms Treated Endovascularly with a Single Coil
Authors: Delgado Almandoz Josser E , Crandall Benjamin M , Fease Jennifer L , Kadkhodayan Yasha , Scholz Jill M , Anderson Ruth E , Tubman David E
Published: July 2021

Purpose:
To determine the medium-term angiographic outcome and packing density threshold for complete aneurysm occlusion at follow-up in a series of cerebral aneurysms treated with a single coil.

Methods:
We retrospectively identified all cerebral aneurysms treated with a single coil at our institution from July 1997 until September 2011. We recorded aneurysm dimensions, neck size, packing density, and follow-up catheter or MR angiograms to determine the angiographic outcome at last follow-up according to the Raymond scale. We then performed receiver operating characteristic (ROC) analysis of the likelihood of complete aneurysm occlusion at follow-up to determine the packing density maximum operating point (MOP).

Results:
Eighty-one aneurysms in 79 patients were treated with a single coil at our institution during the study period. Sixty-four patients were female (81%) and mean age was 53 years (range 23-87 years). Mean maximum aneurysm dimension was 2.8mm (range 1.6-4.8mm), and mean dome-to-neck ratio was 1.3 (median 1.3, range 0.8-1.9). Mean aneurysm packing density was 35.3% (median 32.8%, range 10.2-94.3%). Three patients with ruptured aneurysms died during the hospitalization (7.7%), and follow-up angiographic examinations were performed in 65 patients with 67 aneurysms (85.9%). Mean time to last angiographic follow-up was 26.4 months (range 4-102 months). Complete aneurysm occlusion at last follow-up was present in 46 aneurysms (68.7%), a neck remnant in 16 aneurysms (23.9%) and sac recanalization in 5 aneurysms (7.4%). ROC analysis of the likelihood of complete aneurysm occlusion at last follow-up yielded a packing density MOP of >36.3%, with a specificity of 85.7%, sensitivity of 47.8%, and an area under the curve of 0.61 (95%CI 0.49-0.73). There was a statistically-significant difference in the likelihood of complete aneurysm occlusion at last follow-up between the 25 aneurysms with a packing density >36.3% (88%), and the 42 aneurysms with a packing density ≤36.3% (57.1%, OR 5.5 [95%CI 1.4-21.3], p-value 0.009).

Conclusion:
Achieving a packing density >36.3% predicts a significantly higher likelihood (88%) of complete aneurysm occlusion at medium-term angiographic follow-up in cerebral aneurysms treated with a single coil.
Abstract TP80: Incidence And Risk Factors For The Growth And Rupture Of Unruptured Cerebral Aneurysms. Results Of Annual Radiologic Follow Up Study.
Authors: Matsumoto Katsumi , Tsuruzono Kouichirou , Sasaki Manabu , Yoshimura Noriyasu , Yoshimine Toshiki , Oshino Satoru
Published: July 2021

Background:
The recent trend of the treatment of unruptured cerebral aneurysms(UIAs) is going to be conservative. Their natural history of rupture and growth is still unkown. We present the results of annual radiological follow-up study in UIAs.

Method:
In recent 12 years, we have found 121patients with 148 unruptured cerebral aneurysms were followed annually using 3D-CTA or MRA. Mean follow-up period was 5.5 year. Several factors influencing rupture or growth were statistically examined.

Results:
Among 121 patients, 9 ruptured and 11 showed growth of UIAs. Annual rupture rate was 1.3% per year and annual growth rate was 1.6% per year. Aneurysm size was the sole factor influencing rupture(P<0.001), whereas female sex and multiplicity were major factors influencing aneurysm growth(P<0.05). Under size 3mm, annual growth rate was 3.0% whereas annual rupture rate was 0.7%. In 4-6mm, growth rate was 1.6% and rupture rate was 1.6%. In 7-9mm, growth rate was 0 and rupture rate was 5.8%. In over 10mm, growth rate was 2.9% and rupture rate was 11.6%. Within 1 year, rupture occurred in 4 cases, and growth was found in 1 case.

Conclusions:
By annual radiological examination, growth of UIAs was noted more frequently than aneurysm rupture. Especially UIAs under 3mm, growth was 4 times higher than rupture, radiological follow up is effective for aneurysm rupture. Within 1 year, initially found UIAs should be carefully followed in a short interval.
Abstract TP82: The Growth of Small, Asymptomatic, Unruptured Intracranial Aneurysms with no History of SAH -Different Risk Factors Associated with Single and Multiple Aneurysms
Authors: Chien Aichi , Liang Feng , Sayre James , Salamon Noriko , Villablanca Pablo , Vinuela Fernando
Published: July 2021

Introduction:
The International Study on Unruptured Intracranial Aneurysms suggests that small (<7mm), asymptomatic, unruptured intracranial aneurysms (UIA) in patients with no history of subarachnoid hemorrhage (SAH) should be managed conservatively. Recent research has independently shown considerable variation in the rupture risk of small UIA. As enlargement may indicate increased risk of rupture, the factors related to UIA growth may also influence rupture risk. Information about small UIA growth is limited and heterogeneous due to limited follow-up data.

Hypothesis:
Growth factors for small UIA vary between subset groups.

Methods:
A retrospective study was performed based on a total of 508 patients diagnosed with UIA from 2005-2010 in our center. 235 patients with asymptomatic, small UIA and no history of SAH were monitored with high resolution 3D CTA. Patient medical history and aneurysm characteristics (size, growth, location and multiplicity) were analyzed. Multiple logistic regression analysis and the Hosmer-Lemeshow statistic were used to identify the factors associated with growth. The Student’s t-test was applied to compare the aneurysm growth rate between subset groups.

Results:
A total of 319 UIA were included with follow-up durations of 29.2 20.0 months. 42 UIA increased in size during the follow-up. 5 UIA grew to become ≥ 7 mm (within 38.2±18.3 months). A trend of higher growth rates was found in single aneurysms than in multiple aneurysms (P=0.07). History of stroke was the only factor associated with single aneurysm growth (P=0.03). The number of aneurysms (P=0.014), aneurysms located within the posterior circulation (P=0.023), and patient history of transient ischemic attack (P=0.032) were related to multiple aneurysm growth.

Conclusion:
We found that multiple small aneurysms were more likely to grow, especially those at posterior circulation. Although single aneurysms have a lower risk of growth, a trend of higher growth rates was found.
Abstract TP90: Effect of Smoking on Morphological Variables for Ruptured and Unruptured Intracranial Aneurysms
Authors: Lin Ning , Ho Allen L , Day Arthur L , Du Rose
Published: July 2021

Introduction:
Management of unruptured intracranial aneurysms remains controversial in neurosurgery. The contribution of morphological parameters has been gradually included in the treatment paradigm. Smoking is associated with increased risk of cerebral aneurysm formation and rupture, but the effect of smoking on morphological features of an aneurysm is unclear. We present a large sample of aneurysms that were assessed using morphological variables to investigate how smoking status affects the parameters associated with aneurysm rupture.

Methods:
Pre-operative CT angiograms (CTA) were evaluated with 3D Slicer© to generate three-dimensional models of the aneurysms and surrounding vascular architecture. Morphological parameters examined in each model included aneurysm volume, size, aspect ratio, aneurysm angle, flow angle, size ratio, and parent-daughter angle. Univariate and multivariate statistical analyses were performed to determine statistical significance.

Results:
From 2006-2010, 114 ruptured and 89 unruptured aneurysms were treated in a single institution, including 72 anterior communicating artery aneurysms, 79 middle cerebral artery aneurysms, and 52 internal carotid artery aneurysms. Ruptured aneurysms were associated with greater aspect ratio and size ratio, larger aneurysm angle, and smaller parent-daughter angle (p<0.05). While no difference in aneurysm angle and parent-daughter angle was observed based on smoking status, ruptured aneurysms in smokers are more likely to be smaller in size, have narrower neck diameters, and possess larger aspect ratios (p<0.05) when compared to ruptured aneurysms in nonsmokers. Multivariate logistic regression revealed aspect ratio was the strongest parameter associated with aneurysm rupture in patients who smoke after adjusting for demographic and other clinical risk factors.

Conclusion:
Aspect ratio, aneurysm angle, and parent-daughter angle have a greater association with aneurysm rupture than size. Smoking status does not affect parameters related to the vascular architecture (i.e. aneurysm angle and parent-daughter angle), but is associated with increased aspect ratio and smaller size in ruptured aneurysms.
Abstract TP97: Improved Long-Term Outcome after Transient Cerebral Ischemia in Aquaporin-4 Knockout Mice
Authors: Fukuda Andrew M , Hirt Lorenz , Ambadipudi Kamalakar , Verkman Alan S , Binder Devin K , Obenaus Andre , Badaut Jerome
Published: July 2021

Introduction:
Aquaporin-4 (AQP4) is an abundant aquaporin in brain that has been hypothesized to play a central role in edema formation. Furthermore, AQP4 downregulation has been correlated with connexin 43 (Cx43) downregulation, a gap junction protein important for ion and water transport through astrocyte networks. AQP4 deletion in mice was shown to be beneficial at 24 hours after permanent occlusion of the middle cerebral artery (MCAO). However, the long-term consequences of AQP4 deletion on behavior, edema, and tissue properties after stroke have not been studied.

Objective:
Following transient MCAO, behavior, lesion volumes, blood brain barrier (BBB) integrity, neuroinflammation, and astrocyte network properties with Cx43 expressions were assessed for 14 days in wild type (WT) and AQP4
-/-
mice.

Methods:
Transient (30-min) filament MCAO was performed on AQP4
-/-
(n=5) and WT (n=8) mice on a CD1 genetic background. Behavioral outcomes were assessed by rotarod, beam balance, and foot fault tests from 1 to 14 days (d) post injury. Temporal magnetic resonance imaging (MRI) was undertaken to assess lesion volume. Mice were transcardially perfused at 15 d and the brains were extracted and frozen to perform immunohistochemical analysis for IgG, AQP4, Cx43, and glial fibrillary acidic protein (GFAP).

Results:
MRI showed significantly smaller lesion volume in AQP4
-/-
at 1, 3, 7, and 14d. AQP4
-/-
mice also had improved motor function recovery with 54% and 75% decreased number of foot-faults than WT mice respectively at 1 and 3 d; and 60% increased time spent on the rotarod compared to WT over the 14 days after stroke onset. AQP4
-/-
mice had reduced IgG extravasation and Cx43 expression but increased GFAP staining compared to WT at 14d, suggesting, respectively, less BBB disruption and modified astrocyte network properties combined with altered neuroinflammation fates.

Conclusion:
AQP4 deletion resulted in improved long-term functional recovery associated with decreased lesion volumes and improved BBB integrity. Although more work must be done, the beneficial outcomes in AQP4
-/-
may partly be due to decreased Cx43 as well, resulting in not only decreased edema formation through AQP4, but also in decreased spread of edema through the astrocyte network.
Abstract WMP29: Single-Center Experience with The Pipeline Embolization Device: The Treatment of Smaller Secondary Aneurysms
Authors: Raychaudhuri Ratul , Kureshi Inam , Ollenschleger Martin , Ohki Stephen , Spiegel Gary
Published: July 2021

The Pipeline embolization device is a flow diverting stent that is now available as an FDA approved treatment for giant wide-neck cavernous and supraclinoid aneurysms. This revolutionary device has made it possible to safely treat large wide necked aneurysms with excellent results. There is limited information on the impact of Pipeline on smaller secondary aneurysms. We present single center data regarding Pipeline’s efficacy in the treatment of these aneurysms.

Methods:
Since August 2012, 24 patients have been electively treated utilizing the Pipeline Embolization Device (PED) (Covidien, Mansfield, MA) at Hartford Hospital. Of these patients, 17 patients have had follow up angiograms and 9 (52%) had smaller secondary aneurysms that was covered by the Pipeline stent. For each patient where angiographic follow-up was available, the degree of secondary aneurysm occlusion was assessed utilizing the Raymond criteria.

Results:
All procedures were successfully completed and a total of 41 PEDS were implanted. No intraprocedural complications were present. During the clinical follow-up period, no major complications resulted. One patient developed a partial CN III and IV neuropathy secondary to thrombosis of a large cavernous aneurysm 4 days following treatment. The results of 6 month follow-up angiography demonstrated that out of a total of 9 cases, 8 cases (89%) with smaller secondary aneurysms resolved and 1 case (11%) improved significantly. In all cases where the smaller secondary aneurysm was occluded, the larger primary aneurysm was also occluded. The single case of significant improvement demonstrated that the primary aneurysm had also significantly decreased in size.

Conclusion:
Smaller secondary aneurysms are adequately treated by Pipeline stenting. In all cases, the primary aneurysm either improved significantly or totally occluded along with the secondary aneurysms. This suggests that the Pipeline device, in addition to treating large wide-necked aneurysms, can effectively treat smaller associated aneurysms without the need for additional endovascular coiling.

Key Words:
Pipeline embolization device, giant wide-neck cavernous and supraclinoid aneurysm, secondary aneurysms
Abstract WMP30: Risk Analysis Of Growth And Rupture In Unruptured Intreacranial Aneurysms : Single Institutional Cohort Study
Authors: Murayama Yuichi , Ishibashi Toshihiro , Takao Hiroyuki , Yuki Ichiro , Arakawa Hideki , Irie Koreaki
Published: July 2021

Introduction:
Risk of growth and rupture in unruptured intracranial saccular aneurysm (UIA) are still unclear.

Hypothesis:
Gowth and risk of UIA may be correlated and they were evaluated our single center large cohort.

Methods:
Between January 2003 and March 2011, a total of 2122 patients with 2756 UIA were referred to our institution. 1403 patients with 2037 UIAs were assigned for conservative management. The mean follow up duration was 6201 aneurysm-years. Bi-annual three-dimensional computed tomography angiography (3D CTA) was performed and aneurysm growth was evaluated using 3D workstation. The aneurysm growth was defined as size increase more than 1mm.

Results:
During observation, 14.6% aneurysms increased their size. Female and male growth rate were 16% and 11% respectively. 130 patients stopped observation and therapeutic intervention was performed due to increase their size or anxiety. During observation 50 UIAs ruptured resulting in a 0.8% rupture rate per year. Aneurysm growth, IC-pcom aneurysms, posterior circulation, female, and SAH associated multiple aneurysms were risk factor for aneurysm rupture. Growing aneurysm was 10 times higher relative risk of rupture compare to stable aneurysm. No aneurysm demonstrated reduction of their size after rupture.

Conclusions:
Risk of Aneurysm growth and rupture may be correlated. Risk of rupture of UIAs was similar that was reported before but even small aneurysms can be rupture during observation. Growing UIAs should be considered to treat as soon as possible even in small size.
Abstract WMP49: The Impact of Age vs. Age-Related Comorbidities on White Matter Hyperintensity Volume
Authors: King Kevin S , Peshock Ronald M , McColl Roderick M , Ayers Colby , Das Sandeep R
Published: July 2021

Introduction:
White matter hyperintensity (WMH) at MRIis a marker of cerebral microvascular disease and confers risk for cognitive impairment. The strongest determinant of WMH volume is age, but the extent to which this is explained by age related abnormalities comorbidities is unclear. Using data from the large, multi-ethnic Dallas Heart Study (DHS), we compared age related differences in WMH volume in the overall DHS cohort to a subset without obesity, diabetes, or hypertension.

Methods:
Automated WMH volumes for 2,011 DHS participants were acquired from 3T MRI. The impact of aging on WMH volume independent of comorbidities was quantified in a subset of 218 DHS participants without obesity, diabetes, or hypertension. The impact of comorbidities in the overall cohort was then quantified by subtracting the mean age-specific WMH volumes of the healthy group from the overall cohort and evaluating the association of these normalized values with age using linear regression. To assess the possibility of a threshold effect, data were modeled using cubic splines.

Results:
In the healthy cohort, WMH volume was correlated with age (p<0.001) with modest explanatory power (r
2
=0.12). The explanatory power of age in the overall cohort was higher (r
2
=0.22) and since a spline fit showed a threshold effect at age 55 (p<0.001), the analysis was stratified at that point. Using normalized data, there was no association between age and WMH volumes prior to age 55 (p=0.3), while WMH volume increased with age after that point (p<0.001), see attached figure.

Conclusions:
In this large, multi-ethnic cohort, after accounting for the modest baseline association between age and WMH volume seen in healthy subjects, we characterize the relation between age and WMH volume that reflects the impact of comorbid obesity, hypertension, and diabetes. The observed threshold effect suggests that these comorbidites have little impact on WMH volume prior to age 55, but likely play a significant role above that age.
Abstract WMP54: ABO Blood Type and Incident Stroke in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study
Authors: Zakai Neil A , Judd Suzanne E , McClure Leslie A , Kissela Brett M , Howard George , Cushman Mary
Published: July 2021

Background:
Non-O blood type is associated with higher procoagulant proteins and potentially stroke. Prior studies may overestimate the association due to lack of control for race and stroke risk factors as there are known racial differences in blood type, conventional stroke risk factors, and stroke risk.

Methods:
REGARDS recruited 30,239 participants in their homes between 2003-07 from the continental US; 55% were female, 41% were black, and 56% lived in the southeast (by design). Using a case-cohort design, 553 participants with incident stroke and 991 participants without baseline stroke were genotyped to determine blood type. Cox proportional hazard models adjusting for race and Framingham or ARIC stroke risk factors were used to determine the association of blood type with incident stroke.

Results:
Blacks had a higher frequency of blood type B (17% vs. 10%) and AB (5% vs. 2%) and a lower frequency of blood type O (31% vs. 42%) than whites (p <0.001) (Table). Except for diabetes (OR 4.1 95% CI 2.1, 7.9) and higher systolic blood pressure (7.5 mm hg higher, p = 0.01) for blood type AB vs. O, stroke risk factors did not differ by blood type. Over 4.5 years of follow-up, neither blood types A or B were associated with incident stroke accounting for race and traditional stroke risk factors (Table). Blood type AB was associated with a marginally increased risk of stroke after adjusting for race and Framingham (HR 1.8; 95% CI 1.0, 3.4) or ARIC (HR 1.8; 95% CI 1.0, 3.3) stroke risk factors (Table).

Discussion:
Blood type AB is associated with an increased risk of stroke which is not mediated by conventional stroke risk factors. This association could relate to increased factor VIII or von Willebrand factor in individuals with non-O blood type but this does not explain the unique association of blood type AB with stroke. Whether blood type should be incorporated into clinical stroke risk models is unknown.
Abstract WMP6: Delayed Device Access to the Occluded Target Vessel Predicts Worse Recanalization Rates and Poor Outcomes in Endovascular Therapy for Acute Stroke
Authors: Ribo Marc , Jankowitz Brian , Zaidi Syed , Jumaa Mouhammad , Oakley Jennifer , Jovin Tudor
Published: July 2021

During embolectomy for acute stroke, transfemoral access to occluded vessel may be technically difficult. We aim to study the impact of difficult catheter access to target artery.

Methods:
Single center review of anterior circulation stroke patients enrolled in prospective trials/registries (MR Rescue, MERCI, DEFUSE) requiring recording of time from groin puncture to first device deployment(Tdep). Patients were divided according to Tdep quartiles (Q): patients in Q4 were considered as difficult access. We recorded recanalization (TICI≥2a), complete recanalization (TICI≥2b), infarct volume(24h DWI), day 5 NIHSS, and favorable outcome (3 months mRS≤2).

Results:
We included 196 patients, mean age 66±14, median NIHSS 16(IQR:12-21). Overall outcomes were: median Tdep 52 min (36-77), recanalization 89.1%, complete recanalization 59.4%, favorable outcome 43.8%. We observed a positive correlation between Tdep and day 5 NIHSS (r=0.27; p=0.01) or 3 months mRS (r=0.26; p<0.01). Patients with difficult access (Q4: Tdep>77 min) had similar baseline NIHSS (16 Vs 17 p=0.58), time from symptom to procedure start (433 Vs 371min; p=0.28) and occlusion location (ICA/M1/M2: 46.7/42.2/11.1% Vs 39.1/54.3/6.5%; p=0.31). However, patients in Q4 had: longer IA procedures (153 vs 112 min;p<0.01), lower complete recanalization (41% Vs 66%;p<0.01), larger infarcts (87 Vs 53cc; p<0.01), higher day 5 NIHSS (15 Vs 9;p<0.01), and less favorable outcome (29.2% Vs 49%; p=0.02). After adjusting by age and time to reperfusion, a regression model identified admission NIHSS (OR% 1.12: 95%CI 1.02-1.21; p<0.01), age (OR% 1.03: 95%CI 1.01-1.06; p=0.01) and Tdep (OR% 1.02 95%CI 1.01-1.03; p=0.01) as independent predictors of poor outcome. In univariate analysis age>69, male gender and left hemisphere stroke were associated with difficult access. The combined presence of the 3 factors increased by 3.5 fold the likelihood of difficult access (OR:3.55 95%CI 1.5-8.6: p<0.01)

Conclusion:
Delayed device access to target occluded artery independently predicts poor outcome. Identification of difficult access using clinical scores or imaging may lead to alternative strategies; brachial, radial or cervical approaches that could result in shortened procedural times and improved outcomes
Abstract WMP70: HIF-1alpha Sumoylation Provides Neuroprotection in Ischemic Stroke
Authors: Yan Jingqi , Shi Honglian
Published: July 2021

Hypoxia-inducible factor 1 (HIF-1) is a transcriptional factor that regulates the cellular adaptive response to hypoxia and has been suggested as a potent therapeutic target in stroke. To find new post-transpational modification pathways of HIF-1 in ischemic brain, we determined SUMOylation of HIF-1α protein in ischemic brain of a rat middle cerebral artery occlusion (MCAO) stroke model. The results demonstrated that SUMOylation of HIF-1α by SUMO1 was increased in the ischemic brain. Immunostaining images showed that HIF-1α co-localized with SUMO1 in the neuron nucleus of the ischemic brain. Inhibition of HIF-1α SUMOylation by Ubc9 siRNA reduced HIF-1α protein level in primary neurons during hypoxia. Furthermore, ischemia-induced neuron death was increased by the Ubc9 siRNA. The results, for the first time, demonstrate that HIF-1α is directly SUMOylated in the ischemic brain. HIF-1α SUMOylation is important for HIF-1α stability and neuron survival during ischemia. These results complement the knowledge about HIF-1 regulation in ischemic brain and shed new light on the role of HIF-1 as a stroke therapeutic target.
Abstract WP1: Recanalization Therapy For Acute Symptomatic Occlusion Of The Intracranial Cerebral Arteries In Korea
Authors: Jang Min Uk , Kang Jihoon , Kim Beom-Joon , Hong Jeong-Ho , Han Moon-Ku , Jang Myung-Suk , Yang Mi-Hwa , Lee Byung-Chul , Yu Kyung-Ho , Cho Yong-Jin , Hong Keun-Sik , Park Jong-Moo , Kang Kyusik , Cha Jae Kwan , Kim Dae-Hyun , Park Tai Hwan , Park Sang-Soon , Lee Kyung Bok , Lee Soo Joo , Ko Youngchai , Lee Jun , Kim Joon-Tae , Cho Ki-Hyun , Lee JiSung , Bae Hee-Joon
Published: July 2021

Background:
Despite its clinical importance in the Koreans, the status of recanalization therapy for acute occlusion of the intracranial cerebral arteries has not been reported yet.

Methods:
Using a nationwide stroke registry, a consecutive series of 642 patients with symptomatic occlusion of intracranial arteries were identified among 3028 who were hospitalized within 12 h of stroke onset at 10 participating centers between 2010 and 2011. Demographics, clinical characteristics, clinical outcomes, and type of recanalization therapy were described.

Results:
The mean age was 68.6 years (57.2% males, median baseline NIHSS 12). MCA was most commonly affected vessel (65.1%), followed by intracranial ICA (15.3%), PCA (14.2%), basilar artery (11.1%), and ACA (5.1%). Recanalization therapy was applied in 307 patients (47.8%); intravenous thrombolysis only (IVT) in 45.9%, and endovascular treatment (ET) in 54.1%. Intravenous thrombolysis treatment preceded ET in 69.9%. Doses of tPA were 0.6mg/kg in 22.3% and 0.9mg/kg in 77.7%. Recanalization therapy according to occluded vessels and onset-to-arrival time is described in the Table. Recanalization by IAT as seen on angiography was complete (thrombolysis in cerebral infarction [TICI] grade 3) in 29.5% and partial (TICI grade 2A or 2B) in 50.6%. Solitaire were applied to 48.8% of patients with ET and recanalization rate was 86.4%, and Penumbra were applied to 15.1% and recanalization rate (TICI grade 2A~3) was 76.0%. Favorable outcome (modified Rankin Scale, 0-2) was achieved in 39.4% of those with IVT and in 35.4% of those with ET, and symptomatic hemorrhagic transformation occurred in 8.5% and 12.0%, respectively.

Conclusion:
This study shows that a considerable proportion of patients with symptomatic occlusion of intracranial cerebral arteries are treated by endovascular approach. Efficacy and safety of endovascular approach in this setting should be tested by randomized clinical trials.
Abstract WP140: Concurrent Anterior Cerebral Artery Involvement Is Predictive of Mortality In Severe Middle Cerebral Artery Ischemic Stroke
Authors: Walcott Brian P , Miller Jennifer C , Kwon Churl S , Sheth Sameer A , Hiller Marc R , Cronin Carolyn A , Schwamm Lee H , Simard J Marc , Kimberly William T , Sheth Kevin N
Published: July 2021

Background:
Severe middle cerebral artery (MCA) stroke is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient specific variables may be associated with outcomes. We also sought to describe under-recognized outcomes.

Methods:
A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009-2011. 127 patients were first identified by NIHSS score ≥ 15 and then screened for initial infarct volume ≥ 60 mL3. Malignant edema was defined as the development of midline brain shift of ≥ 5 mm in the first 5 days. The only exclusion criterion was enrollment in any experimental trial. 6 patients were censored from secondary analysis given that therapeutic treatment was not pursued. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes. Significance was predefined at p≤0.05 (two-tailed).

Results:
46 patients (29 female, 17 male; mean age 57.3±1.5) met study criteria. The mortality rate was 28% (n=13). Univariate predictors of mortality included infarct volume, intracranial pressure (ICP) crisis, and concurrent anterior cerebral artery (ACA) involvement. In a multivariate analysis, only concurrent ACA involvement was associated with mortality (OR 9.78, 95% CI 1.15, 82.8, p=0.04). Univariate predictors of tracheostomy were decompressive craniectomy (DC) and admission GCS score. In multivariate analysis, only admission GCS score was significant (OR 0.59, 95% CI 0.37, 0.94, p=0.03). Infarct volume, elevated peak serum sodium level, hyperosmolar therapy, and ICP crisis independently predicted the development of malignant edema, whereas only infarct volume remained significant in multivariate analysis (OR 1.02, 95% CI 1.00, 1.04, p=0.05). In the malignant edema subgroup (n=23, 58%), 4 died (17%), 7 underwent DC (30%), 7 underwent tracheostomy (30%), and 15 underwent gastrostomy (65%).

Conclusion:
Adverse outcomes after severe stroke are common. ACA involvement predicts mortality in severe MCA stroke. Knowledge of outcomes and their predictors is necessary for optimal care and future study.
Abstract WP145: Medtronic Driver® Balloon-mounted Coronary Stent System In Endovascular Neurointervention: Off-label Clinical Experience At A Tertiary Referral Medical Center
Authors: Manjila Sunil , Jung Richard S , Kim Benny S , Hsu Daniel P , Blackham Kristine , Tarr Robert W , Sunshine Jeffrey L
Published: July 2021

Background:
Balloon-mounted coronary stents have been employed in the endovascular management of ischemic cerebrovascular disease, where rapid and precise stenting with angioplasty may be performed in a patient with minimal or no sedation. The Medtronic Driver® balloon-mounted stent is known to have excellent trackability and deliverability, making it a viable tool in the armamentarium of the neurointerventional surgeon.

Methods:
Retrospective review of 46 patients who underwent endovascular revascularization utilizing Medtronic Driver® stent from 2003-2011. Characteristics analyzed were patient demographics, lesion location, etiology of vascular lesion, degree of stenosis, extent of revascularization, short-term complications, and clinical outcome.

Results:
Out of 46 patients with 51 Driver® stents studied, 21 were female and age of patients ranged from 37 to 91 years. The treatment data comprised of 22 internal carotid artery stents (19 patients) 1 common carotid artery stent, 25 vertebal artery stents (20 patients), and 3 basilar artery stents. 18 out of 51 stents were intracranial, including 7 ICA, 3 basilar and 8 vertebral artery. Extracranial stents comprised of 1 CCA, 15 ICA and 17 vertebral artery stents. Etiology of lesion included 41 stroke or TIA with symptomatic stenosis, 1 instent restenosis, and 4 dissections. Angiographically 5 patients had occluded vessels, 5 had <70% stenosis and 36 patients had 70-99% stenosis. The Driver® stent dimensions ranged from 3 mm x 9 mm to 4mm x 24 mm. Driver® stent placement failed in 2 cases and 4 patients developed instent-restenosis; two were stent occlusions in the same patient. Multiple Driver stents were used in 5 patients. 3 patients had symptomatic post-stenting hemorrhagic conversion and

4 deaths from non-procedure medical complications.

Conclusion:
This study presents the largest single institution review of the Medtronic Driver® balloon- mounted coronary stent for use in neurointervention. The authors have demonstrated technical feasibility of the stent system and satisfactory revascularization in a variety of clinical indications.This device allows quick revascularization by performing stent-angioplasty together, and providing access for distal clot removal.
Abstract WP155: The Safety And Efficacy Of Carotid Artery Stenting In A High Grade Stenosis More Than 80% Under Proximal Protection With Flow-reversal System.
Authors: Yako Rie , Masuo Osamu , Matsumoto Hiroyuki , Nakao Naoyuki , Terada Tomoaki , Tsuura Mitsuharu , Ooura Yoshinori
Published: July 2021

Background:
Different embolic protection devices in carotid artery stenting(CAS) have been developed to prevent procedural cerebral embolization. Proximal flow reverse protection has theoretically advantages from the view point of prevention of distal embolism, compared with distal protection. On the other hand, there is a disadvantage that this system is complexity.

Purpose:
we evaluated the safety and efficacy of proximal reverse flow protection for CAS in patients with high-grade stenosis.

Methods:
Distal protection has mainly been used as protection device in our institute. In case that there was high possibility of distal embolism, proximal reverse flow protection has been used. These cases treated with proximal flow reverse protection were included in this study. A total of 75 patients(71 men, mean age 71.9 years) with a high grade stenosis≧80% were treated between September 2003 and March 2012. 72% (n=54) of the patients were symptomatic.The primary endpoint was death and stroke rate at 30 days. The outcome was also compared to data from 386 patients with a high-grade stenosis who were treated under only distal protection device in the same period.

Results:
The procedure was technically successful in all cases. In 2 cases out of proximal reverse flow protection group, intracerebral hemorrhage was occurred. However, there was no ischemic complication. In distal protection group, the incidence of complication occurred in 11 cases (7 ischemic, 4 otheres). The stroke/death rate at 30 days was 2.6% (n=2) in proximal reverse flow protection group compared to 2.8% (n=11) in the distal protection group. There was no significant difference. However, the incidence of ischemic complication in the proximal reverse flow protection group tended to be lower than that of distal protection group.

Conclusion:
In selected patients with large atherosclerotic plaques, the clinical results of CAS with proximal reverse flow protection is safe and feasible. Especially, the incidence of ischemic stroke was lower than that of distal protection.
Abstract WP170: Long Time Follow Up Of Patients With Moyamoya Disease Treated By Multiple Burr Hole Surgery
Authors: Uchihashi Yoshito , Hosoda Kohkichi , Kawaguchi Tetsuro , Nakamura Mitsugu , Kohmura Eiji
Published: July 2021

Background
The best revascularization surgery and its long term result for Moyamoya disease (MMD) remains unclear. From the 1980’s we have been performed Multiple Burr Hole Operation (MBHO, see figure). We report on the incidence of stroke in the long-term follow up.

Materials and Methods
This study includes 46 patients with MMD treated in Hyogo Brain and Heart Center, Japan. There were 29 female and 17 male patients with a mean age of 40 years. The initial symptom was cerebral ischemia in 29 patients, hemorrhage in 15, and other in 2, respectively. The average follow-up period was 10.8 years. Evaluation of cerebral hemodynamics was performed in 32 cases. Revascularization surgery was performed in 39 patients. Among them, 31 cases were treated with MBHO. 7 cases were followed without any surgical procedures.

Results
12 patients (26%) suffered recurrent strokes in the follow-up period. The recurrent rate of stroke after diagnosis of MMD was 3.0% /patient-year. In the patients with initial ischemic presentation, MBHO provided similar stroke prevention comparing with direct surgery (27% vs. 25%). Poor CBF and Cerebral Vasoriactivity (CVR) were the statistically significant risk factors for recurrent stroke (OR=11, see figure, p=0.04).

Discussion/Conclusion
MBHO could provid similar long-term results compared with direct bypass in patients with ischemic MMD. Evaluation of cerebral hemodynamics may predict future strokes. MBHO revealed to be a useful method as it is less invasive and can be easily done, performed in any place, and added to any other revascularization surgery.
Abstract WP173: The Texas Awareness Puppet Experience Leads to Improved Public Awareness of Stroke Symptoms and Response
Authors: SHARKEY SONYA M
Published: July 2021

Background and Purpose:
Stroke treatment rates have been hindered by under recognition of stroke symptoms, delayed presentation and lack of utilization of Emergency Medical Services (EMS). The community is the first link in the chain of survival in Brain Attack. With an increasing trend of multi-generational homes in Texas, education of children on stroke symptoms and the importance of calling 9-1-1 is a prime opportunity for increasing community awareness. The Texas Awareness Puppet Experience (TAPE) is a pilot program seeking to increase the permanence of stroke community education through the use of a multisensory puppet experience. The purpose of this pilot study was to determine the efficacy of the TAPE program in improving community awareness of stroke across a variety of age groups.

Methods:
TAPE was guided by Piaget’s Cognitive Development Theory in an effort to educate all age groups. Audiences watch a brief eight minute puppet show on stroke awareness that incorporates local EMS response with a paramedic arriving to the scene. The experience concludes with a hands-on activity of puppet-making. A pre-survey and post-survey was used to assess cognitive improvement related to stroke location, symptoms, and activation of EMS. The survey consisted of one demographic question (age) and three stroke questions with graphics. Chi-square was used to assess for statistical significance in stroke location and symptoms while Fisher’s Exact was used for activation of EMS.

Results:
The post-survey showed statistically significant improvement in all three stroke questions. When comparing the pre-surveys (n=97) with the post-surveys (n=96), the greatest improvement occurred in identification of stroke as occurring in the brain (59.8% pre-survey vs. 91.7% post-survey, p<0.001). The correct identification of stroke symptoms improved from 73.2% to 96.7% (p<0.001) while the need to notify EMS increased from 90.7% to 100% (p=0.003).

Conclusions:
The Texas Awareness Puppet Experience (TAPE) proved to be a beneficial tool when educating the community on stroke awareness. TAPE is effective in educating all age groups on the location of stroke, symptoms, and the need for immediate activation of EMS.
Abstract WP197: Race (Black-White) and Sex Divergences in the Relationship of Childhood Cardiovascular Risk Factors to Arterial Stiffness in Adulthood: The Bogalusa Heart Study
Authors: Li Shengxu , Chen Wei , Fernandez Camilo , Srinivasan Sathanur R , Berenson Gerald S
Published: July 2021

Arterial stiffness is an important risk factor for cardiovascular diseases including stroke. It has been established that childhood cardiovascular (CV) risk factors are predictive of adulthood arterial stiffness as measured by pulse wave velocity. Limited information is available on this relationship such as race- and sex-specific differential effects. This aspect was examined in a black-white, longitudinal cohort of 786 adults (28% blacks, 42% men) aged 23-44 years who were examined as both children (age<18 years) and adults (age≥18 years) for traditional CV risk factors with an average follow-up period of 24.2 years. Multiple childhood measurements were averaged and standardized to age-specific z-scores. Brachial-ankle pulse wave velocity (baPWV) measured by an automatic oscillometric technique was used as an index of arterial stiffness in adults. Systolic blood pressure in childhood was predictive of baPWA in adults (P=0.002) in the total cohort. However, nominally significant (P<0.05) childhood predictors of adult baPWV included body mass index (BMI), low-density lipoprotein cholesterol (LDL-C) and systolic blood pressure in white men; systolic blood pressure in white women; and BMI in black women. For race difference, childhood LDL-C tended to show a stronger effect on baPWA in adults in whites than in blacks (P=0.04). For sex difference, BMI tended to be a stronger predictor and LDL-C a weaker predictor in women than in men (P=0.0002 and P=0.003, respectively). Such differences persisted even after adjustment for adulthood risk factors (P<0.05 in all cases). In conclusion, the predictability of childhood CV risk factors for increased arterial stiffness in adulthood varies by race and sex, and this observation indicates that arterial stiffening is different in blacks vs whites and in men vs women.
Abstract WP2: Intracranial Stenting with the use of the Wingspan Intracranial Stent for Patients Presenting with Acute Stroke Symptoms and Critical Intracranial Arterial Stenosis.
Authors: Padidar Arash , Taghavi Pejman , Malek Reza , Tolley Ursula , Catalli Linda , Guisado Raul
Published: July 2021

Introduction:
Patients with pre-existing severe intracranial arterial stenosis are at increased risk of re-current stroke. The treatment modalities for patients presenting with acute stroke symptoms are limited due to risk of re-occlusion after thrombolysis. Following re-canalization of an occluded stenotic vessel, stenting can prevent re-occlusion. Currently the only FDA approved stent specifically indicated for intracranial stenosis is the wingspan stent which is listed as a Humanitarian Use Device (HUD). With the efficacy and safety of intracranial stenting still in question we present a 3 year retrospective review of a community based hospitals outcomes with stenting in an acute stroke setting.

Methods:
Between 2009-2012 our group treated 47 patients with intracranial stenosis presenting with acute ischemic stroke. These patients had failure of intravenous thrombolysis or had contraindications for its use, had symptomatic intracranial stenosis or tandem lesions, had evidence of salvageable tissue determined by CT perfusion scanning and had an acute infarct not exceeding 1/3 of the affected vascular territory. All patients were treated within 12 hours of the acute event and received the Wingspan intracranial stent after successful thrombolysis. Fifteen patients had posterior circulation stenosis and 32 patients had anterior circulation stenosis.

Results:
The 30 day post-procedural stroke rate was 12.8%, with a total early mortality rate of 8.4% (Table). The 35 patients with no complications had an average of 4 points improvement in NIHSS post procedure (Figure). Of these patients 15 were discharged home, 10 discharged to acute rehabilitation facilities, and 10 were transferred to nursing homes.

Conclusion:
Intracranial stenting using the Wingspan device results in significant clinical improvement in patients with acutely symptomatic intracranial stenosis, with acceptable mortality and low rate of symptomatic intracranial hemorrhage.