bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.