Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.lba7
Farah Fourcand, Sean Scarpiello, Abdallah O Amireh, Thomas Snyder, Shrinjay Vyas, Rudra Joshi, I. Dubinsky, Brigitte Percival, H. Zacharatos, S. Mehta, J. Kirmani
Acute ischemic stroke (AIS) from arterial occlusions are treated with emergent endovascular thrombectomy (EVT) when clinically appropriate. Clinical outcomes of EVT in medium vessel occlusion (MVO) compared to large vessel occlusion (LVO) have neither been well established nor compared to alternate medical management. Our aim was to evaluate outcomes of patients with AIS secondary to MVO undergoing EVT. We conducted a retrospective chart review of patients presenting to our comprehensive stroke center with MVO‐associated AIS undergoing EVT or aggressive intra‐arterial thrombolytic treatment with concurrent administration of IV eptifibatide. We assessed occlusion site, NIHSS (presentation, 7 day or discharge, 3 months), modified Rankin Scale (baseline, 90‐day), and intracranial hemorrhage (ICH) rate. MVO was defined as occlusion of pure M2 middle cerebral artery without M1 segment involvement, anterior cerebral artery A1 segment or more distal, and posterior cerebral artery P1 segment or more distal. Mann‐Whitney U test, Fisher exact test statistic, and T‐test statistic were used for analysis. Social science statistics software was used for data analysis. From August 2020 to December 2021, out of 175 patients who underwent EVT, 50 had MVO (n = 33 M2 occlusion, n = 12 M3 occlusion, n = 1 for P1, P2, A1, A2, A3 each). Twelve subjects with MVO received aggressive medical management with concurrent IV eptifibatide. Subjects between arms were similar at baseline (median NIHSS 11 [95% CI 10.75, 14.32]; mean age 71.5 [95% CI 69.24, 73.77]; male 48.39% [n = 30]). The difference between initial NIHSS and discharge NIHSS was statistically significant in the EVT arm (Z‐Score = 4.03; p‐value < .00001) but not in the medical arm (Z‐score = 1.96; p‐value 0.05). Hemorrhagic transformation occurred in 28% (n = 14) of EVT arm and 16.67% (n = 2) of medical arm. This was not statistically significant (Fisher value: 0.71). Median 90 day mRS was 1 (95% CI [0.89, 2.11]). The difference between 90 day mRS was not significantly different (Z‐score = ‐1.20; p‐value 0.23). In our patient cohort, endovascular therapy was safe in medium vessel occlusion and may have more favorable clinical outcomes as illustrated by higher delta NIHSS in the endovascular thrombectomy group. Larger, prospective studies are needed to validate our results.
{"title":"Abstract Number: LBA7 Outcomes of Endovascular Thrombectomy Versus Medical Treatment in Ischemic Strokes Secondary to Medium Vessel Occlusion","authors":"Farah Fourcand, Sean Scarpiello, Abdallah O Amireh, Thomas Snyder, Shrinjay Vyas, Rudra Joshi, I. Dubinsky, Brigitte Percival, H. Zacharatos, S. Mehta, J. Kirmani","doi":"10.1161/svin.03.suppl_1.lba7","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.lba7","url":null,"abstract":"\u0000 \u0000 Acute ischemic stroke (AIS) from arterial occlusions are treated with emergent endovascular thrombectomy (EVT) when clinically appropriate. Clinical outcomes of EVT in medium vessel occlusion (MVO) compared to large vessel occlusion (LVO) have neither been well established nor compared to alternate medical management. Our aim was to evaluate outcomes of patients with AIS secondary to MVO undergoing EVT.\u0000 \u0000 \u0000 \u0000 We conducted a retrospective chart review of patients presenting to our comprehensive stroke center with MVO‐associated AIS undergoing EVT or aggressive intra‐arterial thrombolytic treatment with concurrent administration of IV eptifibatide. We assessed occlusion site, NIHSS (presentation, 7 day or discharge, 3 months), modified Rankin Scale (baseline, 90‐day), and intracranial hemorrhage (ICH) rate. MVO was defined as occlusion of pure M2 middle cerebral artery without M1 segment involvement, anterior cerebral artery A1 segment or more distal, and posterior cerebral artery P1 segment or more distal. Mann‐Whitney U test, Fisher exact test statistic, and T‐test statistic were used for analysis. Social science statistics software was used for data analysis.\u0000 \u0000 \u0000 \u0000 From August 2020 to December 2021, out of 175 patients who underwent EVT, 50 had MVO (n = 33 M2 occlusion, n = 12 M3 occlusion, n = 1 for P1, P2, A1, A2, A3 each). Twelve subjects with MVO received aggressive medical management with concurrent IV eptifibatide. Subjects between arms were similar at baseline (median NIHSS 11 [95% CI 10.75, 14.32]; mean age 71.5 [95% CI 69.24, 73.77]; male 48.39% [n = 30]). The difference between initial NIHSS and discharge NIHSS was statistically significant in the EVT arm (Z‐Score = 4.03; p‐value < .00001) but not in the medical arm (Z‐score = 1.96; p‐value 0.05). Hemorrhagic transformation occurred in 28% (n = 14) of EVT arm and 16.67% (n = 2) of medical arm. This was not statistically significant (Fisher value: 0.71). Median 90 day mRS was 1 (95% CI [0.89, 2.11]). The difference between 90 day mRS was not significantly different (Z‐score = ‐1.20; p‐value 0.23).\u0000 \u0000 \u0000 \u0000 In our patient cohort, endovascular therapy was safe in medium vessel occlusion and may have more favorable clinical outcomes as illustrated by higher delta NIHSS in the endovascular thrombectomy group. Larger, prospective studies are needed to validate our results.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47165947","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.228
Omar Choudhury, Ammar Jumah, H. A. Nour
Dolichoectasia; “dolichos'' and “ectasia” respectively meaning elongation and distention of blood vessels is a process by which arteries undergo deterioration of the tunica intima or tunica media, resulting in smooth muscle atrophy.1 It can be atherosclerotic, non‐atherosclerotic, and dissection‐related. Prolonged hypertension resulting in breakdown and remodeling of collagen‐elastin meshwork produces the atherosclerotic subtype, though hyperlipidemia also plays a role. The incidence is approximately 3%, higher in males.2 Vessels commonly affected by dolichoectasia are in the vertebrobasilar system but the internal carotid arteries are also at risk. Vertebrobasilar dolichoectasia (VBDE) is radiographically defined by basilar artery diameter > 4.5 mm, though it is sometimes overlooked due to healthy variations in basilar tortuosity and diameter. Smoker’s criteria includes artery diameter, laterality, and bifurcation height.3 Neurovascular compression often occurs, but high‐risk complications of VBDE such as hemorrhagic or ischemic stroke, TIA, brainstem compression, hydrocephalus, or subarachnoid hemorrhage are also possible.4 We present two cases of ventriculomegaly in the setting of VBDE. Case Report Case #1: A 40 year‐old man with history of hypertension, gout, anal fissures, and bicuspid aortic valve presented to the hospital for intermittent visual obscuration for 2 weeks. He described it as a “Polaroid picture: starting dark and slowly developing” featuring positional exacerbation with Valsalva, leaning forward, and laying flat. Examination revealed bilateral papilledema, right eye ptosis, and right 6th nerve palsy. CT head showed hydrocephalus. CTA and CTV were negative. MRI brain with contrast showed dilated lateral ventricles (left > right) and anterior third ventricle lacking significant transependymal CSF flow. The distal basilar was tortuous extending towards the mid‐portion of the third ventricle (Figure 1). A precipitating factor was thought to be an epidural for anal fissure surgery 2 months prior. Initially treated with acetazolamide, the patient later underwent endoscopic third ventriculostomy (ETV). One‐year follow‐up showed significant improvement of papilledema with minimal residual visual field deficits. Case #2: A 71 year‐old man with history of atrial fibrillation presented to the Neurology clinic for memory loss. It started with misplacing belongings, complicated by an episode of getting lost while driving to a familiar location. Examination showed 1/5 word recall at 5 minutes and mild impairment of serial sevens and abstract thinking. MRI brain revealed dilatation of the lateral and third ventricles out of proportion to the sulci and fourth ventricle, dolichoectatic basilar artery up to 8 mm with superior displacement of nearby structures and effacement of the anterior third ventricle. Repeat MRI with CSF flow one month later showed unchanged ventricular dilatation favored secondary to volume loss without
{"title":"Abstract Number ‐ 228: Two Cases of Vertebrobasilar Dolichoectasia +/‐ Obstructive Hydrocephalus","authors":"Omar Choudhury, Ammar Jumah, H. A. Nour","doi":"10.1161/svin.03.suppl_1.228","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.228","url":null,"abstract":"\u0000 \u0000 Dolichoectasia; “dolichos'' and “ectasia” respectively meaning elongation and distention of blood vessels is a process by which arteries undergo deterioration of the tunica intima or tunica media, resulting in smooth muscle atrophy.1 It can be atherosclerotic, non‐atherosclerotic, and dissection‐related. Prolonged hypertension resulting in breakdown and remodeling of collagen‐elastin meshwork produces the atherosclerotic subtype, though hyperlipidemia also plays a role. The incidence is approximately 3%, higher in males.2 Vessels commonly affected by dolichoectasia are in the vertebrobasilar system but the internal carotid arteries are also at risk. Vertebrobasilar dolichoectasia (VBDE) is radiographically defined by basilar artery diameter > 4.5 mm, though it is sometimes overlooked due to healthy variations in basilar tortuosity and diameter. Smoker’s criteria includes artery diameter, laterality, and bifurcation height.3 Neurovascular compression often occurs, but high‐risk complications of VBDE such as hemorrhagic or ischemic stroke, TIA, brainstem compression, hydrocephalus, or subarachnoid hemorrhage are also possible.4 We present two cases of ventriculomegaly in the setting of VBDE.\u0000 \u0000 \u0000 \u0000 Case Report\u0000 \u0000 \u0000 \u0000 Case #1: A 40 year‐old man with history of hypertension, gout, anal fissures, and bicuspid aortic valve presented to the hospital for intermittent visual obscuration for 2 weeks. He described it as a “Polaroid picture: starting dark and slowly developing” featuring positional exacerbation with Valsalva, leaning forward, and laying flat. Examination revealed bilateral papilledema, right eye ptosis, and right 6th nerve palsy. CT head showed hydrocephalus. CTA and CTV were negative. MRI brain with contrast showed dilated lateral ventricles (left > right) and anterior third ventricle lacking significant transependymal CSF flow. The distal basilar was tortuous extending towards the mid‐portion of the third ventricle (Figure 1). A precipitating factor was thought to be an epidural for anal fissure surgery 2 months prior. Initially treated with acetazolamide, the patient later underwent endoscopic third ventriculostomy (ETV). One‐year follow‐up showed significant improvement of papilledema with minimal residual visual field deficits. Case #2: A 71 year‐old man with history of atrial fibrillation presented to the Neurology clinic for memory loss. It started with misplacing belongings, complicated by an episode of getting lost while driving to a familiar location. Examination showed 1/5 word recall at 5 minutes and mild impairment of serial sevens and abstract thinking. MRI brain revealed dilatation of the lateral and third ventricles out of proportion to the sulci and fourth ventricle, dolichoectatic basilar artery up to 8 mm with superior displacement of nearby structures and effacement of the anterior third ventricle. Repeat MRI with CSF flow one month later showed unchanged ventricular dilatation favored secondary to volume loss without","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49370681","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.lba19
Farah Fourcand, S. Sahito, ChHassan Ali, E. Marandi, Joshua Haimi, I. Dubinsky, Yong-Bum Song, S. Mehta, N. Tabibzadeh, Nancy E Gadallah, Spozhmy Panezai, J. Kirmani
Intravenous tenecteplase (TNK) is currently being used as a thrombolytic agent in acute ischemic stroke (AIS) and has has been shown to be non‐inferior to intravenous alteplase according to recent studies. Intracranial hemorrhage (ICH) as a complication of alteplase is approximately at 6%. The aim of our study was to determine the rate of significant ICH in patients receiving TNK indicated for AIS in a real world setting. A network‐wide (3 CSCs, 6 PSCs), multicenter retrospective chart review of patients receiving TNK from February 2020 to January 2022 was performed using the Get With The Guidelines database. TNK bolus dose of 0.25mg/kg was used according to a network‐wide policy. ICH was categorized using ECASS‐3 criteria. Fisher exact test statistic was used to determine if a significant association existed between the presence of ICH and baseline ASPECTS score, endovascular treatment (EVT), and IV eptifibatide use. A benchmark less than 2% PH‐2 incidence was set based on historical alteplase related PH‐2 rates within our network. Social science statistics software was used for data analysis. Out of 180 patients who received TNK, 25 subjects (13.89%) developed hemorrhagic transformation. Mean age was 71.88 (95% CI 65.54, 78.22). Forty‐eight percent of subjects were female. Median ASPECTS score was 8 (95% CI 7.54, 8.78). Median 90 day mRS was 3 (95% CI 2.1, 3.9). Hemorrhagic transformation was classified as HI‐1 in 5% (n = 9), HI‐2 in 1.7% (n = 3), PH‐1 in 3.8% (n = 7), and PH‐2 in 3.3% (n = 6) subjects. No significant difference between subjects with other subtypes versus PH‐2 was identified when adjusting for ASPECTS score > = 7 versus < 7 (Fisher value = 1), EVT versus no EVT (Fisher value = 0.65), or use of IV eptifibatide (Fisher value = 0.06). Tenecteplase is associated with higher rates of PH‐2 intracranial hemorrhage when compared with our benchmark rates of alteplase‐related PH‐2. This study is significantly limited by small sample size, retrospective nature, and uncontrolled variables. Larger, prospective studies are needed to validate our results.
静脉注射替萘普酶（TNK）目前被用作急性缺血性中风（AIS）的溶栓剂，根据最近的研究，它已被证明不劣于静脉注射阿替普酶。作为阿替普酶并发症的颅内出血（ICH）约占6%。我们研究的目的是确定在现实世界中接受TNK治疗的AIS患者的显著ICH发生率。使用Get With the Guidelines数据库对2020年2月至2022年1月接受TNK治疗的患者进行了全网络（3个CSC，6个PSC）、多中心回顾性图表审查。根据全网络政策，TNK剂量为0.25mg/kg。ICH采用ECASS‐3标准进行分类。Fisher精确检验统计量用于确定ICH的存在与基线ASPECTS评分、血管内治疗（EVT）和静脉注射依非巴特之间是否存在显著关联。根据我们网络中与阿替普酶相关的PH-2发病率，设定了低于2%的PH-2发生率基准。社会科学统计软件用于数据分析。在180名接受TNK治疗的患者中，25名受试者（13.89%）出现出血性转化。平均年龄为71.88岁（95%CI 65.54，78.22）。48%的受试者为女性。ASPECTS评分中位数为8（95%CI 7.54，8.78）。90天平均mRS中位数为3（95%CI 2.1，3.9）。出血性转化分为HI-1（5%，n=9）、HI-2（1.7%，n=3）、PH-1（3.8%，n=7）和PH-2（3.3%，n=6）。当调整ASPECTS评分>=7与<7（Fisher值=1）、EVT与无EVT（Fisher值=0.65）、，或静脉注射依非巴特（Fisher值=0.06）。与阿替普酶相关的PH-2的基准发生率相比，替萘普酶与较高的PH-2颅内出血率相关。本研究受到样本量小、回顾性和非受控变量的显著限制。需要更大规模的前瞻性研究来验证我们的结果。
{"title":"Abstract Number: LBA19 Network‐Wide Incidence of Intracranial Hemorrhage in Patients with Acute Ischemic Stroke Receiving Tenecteplase","authors":"Farah Fourcand, S. Sahito, ChHassan Ali, E. Marandi, Joshua Haimi, I. Dubinsky, Yong-Bum Song, S. Mehta, N. Tabibzadeh, Nancy E Gadallah, Spozhmy Panezai, J. Kirmani","doi":"10.1161/svin.03.suppl_1.lba19","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.lba19","url":null,"abstract":"\u0000 \u0000 Intravenous tenecteplase (TNK) is currently being used as a thrombolytic agent in acute ischemic stroke (AIS) and has has been shown to be non‐inferior to intravenous alteplase according to recent studies. Intracranial hemorrhage (ICH) as a complication of alteplase is approximately at 6%. The aim of our study was to determine the rate of significant ICH in patients receiving TNK indicated for AIS in a real world setting.\u0000 \u0000 \u0000 \u0000 A network‐wide (3 CSCs, 6 PSCs), multicenter retrospective chart review of patients receiving TNK from February 2020 to January 2022 was performed using the Get With The Guidelines database. TNK bolus dose of 0.25mg/kg was used according to a network‐wide policy. ICH was categorized using ECASS‐3 criteria. Fisher exact test statistic was used to determine if a significant association existed between the presence of ICH and baseline ASPECTS score, endovascular treatment (EVT), and IV eptifibatide use. A benchmark less than 2% PH‐2 incidence was set based on historical alteplase related PH‐2 rates within our network. Social science statistics software was used for data analysis.\u0000 \u0000 \u0000 \u0000 Out of 180 patients who received TNK, 25 subjects (13.89%) developed hemorrhagic transformation. Mean age was 71.88 (95% CI 65.54, 78.22). Forty‐eight percent of subjects were female. Median ASPECTS score was 8 (95% CI 7.54, 8.78). Median 90 day mRS was 3 (95% CI 2.1, 3.9). Hemorrhagic transformation was classified as HI‐1 in 5% (n = 9), HI‐2 in 1.7% (n = 3), PH‐1 in 3.8% (n = 7), and PH‐2 in 3.3% (n = 6) subjects. No significant difference between subjects with other subtypes versus PH‐2 was identified when adjusting for ASPECTS score > = 7 versus < 7 (Fisher value = 1), EVT versus no EVT (Fisher value = 0.65), or use of IV eptifibatide (Fisher value = 0.06).\u0000 \u0000 \u0000 \u0000 Tenecteplase is associated with higher rates of PH‐2 intracranial hemorrhage when compared with our benchmark rates of alteplase‐related PH‐2. This study is significantly limited by small sample size, retrospective nature, and uncontrolled variables. Larger, prospective studies are needed to validate our results.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49462505","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.050
Hend Abdelhamid, N. Bhatt, L. S. Viana, Felipe M Ferreira, R. Nogueira, A. Al-Bayati, J. Grossberg, Jason W. Allen, D. Haussen
Carotid Web (CaW) represents an important and overlooked etiology for ischemic stroke and has been associated with high rates of stroke recurrence. Computed tomography angiography (CTA) has been shown to have comparable performance to digital subtraction angiography (DSA) and has been suggested to be the non‐invasive imaging of choice for CaW detection. However, misdiagnosis has been demonstrated to be common even in specialized centers. We evaluated the impact of adding CTA multiplane reconstruction (MPR) andthree‐dimensional maximum intensity projection (3D MIP) reformat on the diagnostic performance of CTA in CaW detection. After exclusion of patients aged >65 years old and patients with no available/poor quality CTA,CaW cases (n = 31 consecutive patients leading to 31 ipsilateral carotids to the stroke derived from out prospective CaW database), as well as two other groups: 1)carotid atherosclerosis (n = 27consecutivepatients from out carotid stenting database leading to 27 carotids contralateral to the index lesion) and 2) consecutive normal carotid cases (n = 49 patients with normal carotids extracted from the electronic medical records for patients imaged due to suspected blunt cerebrovascular trauma) were included. All CTA images were deidentified and reviewed independently by three stroke neurologists to record the diagnosis and level of diagnostic certainty (in form of a scale (1[lowest]‐to‐5[highest]) after evaluating the CTA axial plane alone, then after sagittal and coronal planes (MPR) reconstructions, and then after evaluation of3D MIP reformatted images.The analyses were made for the total number of observations for all readers (93 CaWs, 81 atherosclerosis cases and 147 normal carotids). On reviewing CTA axial projection alone, raters correctly diagnosed 44.1% of CaW, 87.7% of carotid atherosclerosis and 83% of normal carotid images. Sagittal and coronal MPR significantly increased the rate of accurate CaW diagnosis (76.3%‐Table 1) The certainty level for CaW diagnosis was lower when compared to atherosclerosis as well as normal carotid using the CTA axial projection alone (3.0[3.0‐4.0] vs 4.0[3.0‐5.0];p< 0.001 and vs 4.0[3.0‐5.0];p< 0.001) as well as after adding sagittal/coronal MPR (4.0[3.0‐5.0] vs 5.0[4.0‐5.0],p = 0.01; and vs 4.0[4.0‐5.0],p< 0.001). The certainty level became similar between CaW and atherosclerosis as well as normal carotids with the addition of 3D MIP (5.0[5.0‐5.0] vs 5.0[4.5‐5.0], p = 0.61; and vs 5.0[5.0‐5.0],p = 0.15) respectively. Inter‐rater agreement in CaW detection increased from k = 0.46(0.35‐0.57);p< 0.05usingaxial section to k = 0.80(0.69‐0.91);p< 0.05 with MPR. Axial projection alone had lower sensitivity in CaW detection (AUC = 0.69(0.62‐0.76),sensitivity = 44%,specificity = 95%,p< 0.05) compared to MPR (AUC = 0.86(0.80‐0.91),sensitivity = 76%,specificity = 96%,p< 0.05). Misdiagnosed CaW cases, after using all planes with 3D MIP (n = 23/93), were older (56[46‐61] vs 52[46‐57] y
{"title":"Abstract Number ‐ 50: Multiplane Reconstruction Modifies The Diagnostic Performance Of CTA Imaging In Carotid Web Cases","authors":"Hend Abdelhamid, N. Bhatt, L. S. Viana, Felipe M Ferreira, R. Nogueira, A. Al-Bayati, J. Grossberg, Jason W. Allen, D. Haussen","doi":"10.1161/svin.03.suppl_1.050","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.050","url":null,"abstract":"\u0000 \u0000 Carotid Web (CaW) represents an important and overlooked etiology for ischemic stroke and has been associated with high rates of stroke recurrence. Computed tomography angiography (CTA) has been shown to have comparable performance to digital subtraction angiography (DSA) and has been suggested to be the non‐invasive imaging of choice for CaW detection. However, misdiagnosis has been demonstrated to be common even in specialized centers. We evaluated the impact of adding CTA multiplane reconstruction (MPR) andthree‐dimensional maximum intensity projection (3D MIP) reformat on the diagnostic performance of CTA in CaW detection.\u0000 \u0000 \u0000 \u0000 After exclusion of patients aged >65 years old and patients with no available/poor quality CTA,CaW cases (n = 31 consecutive patients leading to 31 ipsilateral carotids to the stroke derived from out prospective CaW database), as well as two other groups: 1)carotid atherosclerosis (n = 27consecutivepatients from out carotid stenting database leading to 27 carotids contralateral to the index lesion) and 2) consecutive normal carotid cases (n = 49 patients with normal carotids extracted from the electronic medical records for patients imaged due to suspected blunt cerebrovascular trauma) were included. All CTA images were deidentified and reviewed independently by three stroke neurologists to record the diagnosis and level of diagnostic certainty (in form of a scale (1[lowest]‐to‐5[highest]) after evaluating the CTA axial plane alone, then after sagittal and coronal planes (MPR) reconstructions, and then after evaluation of3D MIP reformatted images.The analyses were made for the total number of observations for all readers (93 CaWs, 81 atherosclerosis cases and 147 normal carotids).\u0000 \u0000 \u0000 \u0000 On reviewing CTA axial projection alone, raters correctly diagnosed 44.1% of CaW, 87.7% of carotid atherosclerosis and 83% of normal carotid images. Sagittal and coronal MPR significantly increased the rate of accurate CaW diagnosis (76.3%‐Table 1) The certainty level for CaW diagnosis was lower when compared to atherosclerosis as well as normal carotid using the CTA axial projection alone (3.0[3.0‐4.0] vs 4.0[3.0‐5.0];p< 0.001 and vs 4.0[3.0‐5.0];p< 0.001) as well as after adding sagittal/coronal MPR (4.0[3.0‐5.0] vs 5.0[4.0‐5.0],p = 0.01; and vs 4.0[4.0‐5.0],p< 0.001). The certainty level became similar between CaW and atherosclerosis as well as normal carotids with the addition of 3D MIP (5.0[5.0‐5.0] vs 5.0[4.5‐5.0], p = 0.61; and vs 5.0[5.0‐5.0],p = 0.15) respectively. Inter‐rater agreement in CaW detection increased from k = 0.46(0.35‐0.57);p< 0.05usingaxial section to k = 0.80(0.69‐0.91);p< 0.05 with MPR. Axial projection alone had lower sensitivity in CaW detection (AUC = 0.69(0.62‐0.76),sensitivity = 44%,specificity = 95%,p< 0.05) compared to MPR (AUC = 0.86(0.80‐0.91),sensitivity = 76%,specificity = 96%,p< 0.05). Misdiagnosed CaW cases, after using all planes with 3D MIP (n = 23/93), were older (56[46‐61] vs 52[46‐57] y","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49506781","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.155
Romil Singh, Chris T Hackett, H. Saini, R. Cerejo, K. Malhotra, R. Williamson
Prior studies have demonstrated that CT perfusion (CTP) may be used to select patients for mechanical stroke thrombectomy (MST) with acute ischemic stroke owing to major artery obstruction in the anterior circulation for up to 24 hours. There is limited data on CTP selection of elderly patients aged ≥ 90 years old. We aimed to examine whether selecting nonagenarians with CT perfusion (CTP) imaging would allow for better outcomes. Specifically we aimed to examine hypoperfusion intensity ratio (HIR) and early infarct growth rate (EIGR) to optimize MST selection of nonagenarians. This is a single center retrospective study from a large academic medical center. Patients included were at least 90 years old, presented with an anterior circulation acute ischemic stroke due to large vessel occlusion (LVO) and were treated with mechanical stroke thrombectomy (MST) between January 2018 and April 2022. Patients without CT perfusion (CTP) imaging prior to MST and without complete data were excluded. HIR was defined as time to maximum (Tmax 10 seconds/ Tmax 6 seconds). EIGR was defined as (relative cerebral blood flow < 30% / last known well to CTP). Primary outcome was modified Rankin Scale (mRS) at 90 days, analyzed using an ordinal regression analysis and adjusted for baseline mRS, NIHSS, and possible confounding variables identified in univariate analyses. Secondary outcomes were: excellent reperfusion (TICI ≥ 2C), procedural complications of MST and symptomatic intracranial hemorrhage (sICH). The secondary outcomes were analyzed using binomial logistic regressions in two blocks where confounding variables were entered first, followed by variables of interest: HIR and EIGR. During the study epoch 70 nonagenarians were treated with MST. After exclusions, 59 nonagenarians were analyzed in the study. Despite selecting patients with CTP, 35 (59.3%) of patients reached mortality at 90 days. Additionally, only 9 (15.3%) patients achieved mRS of 0 – 2 or baseline mRS (if baseline mRS > 2) at 90 days. HIR was found to be correlated with 90 day mRS (shift to next worse mRS), adjusted odds ratio (aOR) = 14.41 [95%CI 1.16, 179.11] p = 0.04, but not EIGR, aOR = 0.98 [95%CI 0.90, 1.06], p = 0.58. Neither HIR nor EIGR were not associated with excellent reperfusion, p = 0.38 and p = 0.88, respectively. Patients with higher EIGR were more likely to experience proceduralcomplications, aOR = 1.16 [95%CI 1.03, 1.31], p = 0.01, but there was no difference in HIR, p = 0.28. Lastly, there were no differences in HIR or EIGR and sICH, p = 0.07 and p = 0.68, respectively. Very elderly patients aged 90 years or older experienced high rates of mortality and low proportions of good outcomes at 90 days. Nonagenarians with better collaterals as measured by HIR may have better outcomes at 90 days. Additionally, nonagenarians with faster growing ischemic cores may be more likely to experience complications during MST.
{"title":"Abstract Number ‐ 155: CT Perfusion May Optimize Selection Of Elderly Patients For Mechanical Stroke Thrombectomy","authors":"Romil Singh, Chris T Hackett, H. Saini, R. Cerejo, K. Malhotra, R. Williamson","doi":"10.1161/svin.03.suppl_1.155","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.155","url":null,"abstract":"\u0000 \u0000 Prior studies have demonstrated that CT perfusion (CTP) may be used to select patients for mechanical stroke thrombectomy (MST) with acute ischemic stroke owing to major artery obstruction in the anterior circulation for up to 24 hours. There is limited data on CTP selection of elderly patients aged ≥ 90 years old. We aimed to examine whether selecting nonagenarians with CT perfusion (CTP) imaging would allow for better outcomes. Specifically we aimed to examine hypoperfusion intensity ratio (HIR) and early infarct growth rate (EIGR) to optimize MST selection of nonagenarians.\u0000 \u0000 \u0000 \u0000 This is a single center retrospective study from a large academic medical center. Patients included were at least 90 years old, presented with an anterior circulation acute ischemic stroke due to large vessel occlusion (LVO) and were treated with mechanical stroke thrombectomy (MST) between January 2018 and April 2022. Patients without CT perfusion (CTP) imaging prior to MST and without complete data were excluded. HIR was defined as time to maximum (Tmax 10 seconds/ Tmax 6 seconds). EIGR was defined as (relative cerebral blood flow < 30% / last known well to CTP). Primary outcome was modified Rankin Scale (mRS) at 90 days, analyzed using an ordinal regression analysis and adjusted for baseline mRS, NIHSS, and possible confounding variables identified in univariate analyses. Secondary outcomes were: excellent reperfusion (TICI ≥ 2C), procedural complications of MST and symptomatic intracranial hemorrhage (sICH). The secondary outcomes were analyzed using binomial logistic regressions in two blocks where confounding variables were entered first, followed by variables of interest: HIR and EIGR.\u0000 \u0000 \u0000 \u0000 During the study epoch 70 nonagenarians were treated with MST. After exclusions, 59 nonagenarians were analyzed in the study. Despite selecting patients with CTP, 35 (59.3%) of patients reached mortality at 90 days. Additionally, only 9 (15.3%) patients achieved mRS of 0 – 2 or baseline mRS (if baseline mRS > 2) at 90 days. HIR was found to be correlated with 90 day mRS (shift to next worse mRS), adjusted odds ratio (aOR) = 14.41 [95%CI 1.16, 179.11] p = 0.04, but not EIGR, aOR = 0.98 [95%CI 0.90, 1.06], p = 0.58. Neither HIR nor EIGR were not associated with excellent reperfusion, p = 0.38 and p = 0.88, respectively. Patients with higher EIGR were more likely to experience proceduralcomplications, aOR = 1.16 [95%CI 1.03, 1.31], p = 0.01, but there was no difference in HIR, p = 0.28. Lastly, there were no differences in HIR or EIGR and sICH, p = 0.07 and p = 0.68, respectively.\u0000 \u0000 \u0000 \u0000 Very elderly patients aged 90 years or older experienced high rates of mortality and low proportions of good outcomes at 90 days. Nonagenarians with better collaterals as measured by HIR may have better outcomes at 90 days. Additionally, nonagenarians with faster growing ischemic cores may be more likely to experience complications during MST.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48436594","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.lba23
A. Mowla, S. Abdollahifard, Saman Sizdahkhani, K. Khatibi
Infective endocarditis (IE) often presents as an acute ischemic stroke (AIS) secondary to a thromboembolic event leading to large vessel occlusion (LVO). These patients are at significant risk for intracerebral hemorrhage when given intravenous thrombolytics (IT) and are therefore better candidates for mechanical thrombectomy (MT). Current reports in the literature are divided on the safety of MT in this setting and no randomized control studies exist. With the advent of modern thrombectomy devices, we believe MT might be safe in this patient population. Here we report a patient with IE who presented with LVO stroke (MCA syndrome) and underwent MT leading to first‐pass Thrombolysis inCerebral Infarction (TICI) score of 3 revascularization. In addition to presenting our case, we did a comprehensive review of the current literature on this topic. A thirty‐year‐old female with a history of cocaine abuse presented with acute onset left hemiplegia, dysarthria, and rightward gaze deviation. NIHSS was 19 and she presented 90 minutes from her last known well time . Computed Tomography (CT) head and CT perfusion imaging demonstrated a large MCA distribution stroke, an AlbertaStrokeProgram Early CT Score (ASPECTS) of 10, with significant perfusion mismatch of right MCA territory. CT angiography (CTA) confirmed a proximal large vessel occlusion (LVO) at the proximal M1. On initial assessment, the patient was febrile with a temperature of 40 degrees Celsius with a high clinical suspicion for IE; therefore, intravenous thrombolytic was not administered. MT was performed with one pull of stent retrieval under aspiration led to a successful opening of the vessel with TICI score of 3. Positive cocaine on urine toxicology was noted as well as, two sets of gram‐positive blood cultures which later resulted in Staph Aureus, oxacillin susceptible, unremarkable transthoracic echo, but with TEE demonstrating vegetative thickening within atrial aspects of both anterior andposterior mitral valve leaflets(Figure1). On hospital day two, magnetic resonance imaging of the brain shows small acute infarct with no bleed. The patient underwent a mitral valve replacement on hospital day nine. The patient was discharged to rehabilitation facilities with an NIHSS of two for mild left facial droop and mild left arm weakness; her degree of disability was measured as a modified Rankin Scale (mRS) one at 3 months. In case IE is suspected, giving IV tPA (tissue‐type plasminogen activator) is contraindicated as it increases the chance of hemorrhagic complications and when LVO is confirmed in the setting of AIS, MT might be safe and effective to be considered .
{"title":"Abstract Number: LBA23 Endovascular treatment of large vessel occlusion stroke caused by infective endocarditis","authors":"A. Mowla, S. Abdollahifard, Saman Sizdahkhani, K. Khatibi","doi":"10.1161/svin.03.suppl_1.lba23","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.lba23","url":null,"abstract":"\u0000 \u0000 Infective endocarditis (IE) often presents as an acute ischemic stroke (AIS) secondary to a thromboembolic event leading to large vessel occlusion (LVO). These patients are at significant risk for intracerebral hemorrhage when given intravenous thrombolytics (IT) and are therefore better candidates for mechanical thrombectomy (MT). Current reports in the literature are divided on the safety of MT in this setting and no randomized control studies exist. With the advent of modern thrombectomy devices, we believe MT might be safe in this patient population.\u0000 \u0000 \u0000 \u0000 Here we report a patient with IE who presented with LVO stroke (MCA syndrome) and underwent MT leading to first‐pass Thrombolysis inCerebral Infarction (TICI) score of 3 revascularization. In addition to presenting our case, we did a comprehensive review of the current literature on this topic.\u0000 \u0000 \u0000 \u0000 A thirty‐year‐old female with a history of cocaine abuse presented with acute onset left hemiplegia, dysarthria, and rightward gaze deviation. NIHSS was 19 and she presented 90 minutes from her last known well time . Computed Tomography (CT) head and CT perfusion imaging demonstrated a large MCA distribution stroke, an AlbertaStrokeProgram Early CT Score (ASPECTS) of 10, with significant perfusion mismatch of right MCA territory. CT angiography (CTA) confirmed a proximal large vessel occlusion (LVO) at the proximal M1. On initial assessment, the patient was febrile with a temperature of 40 degrees Celsius with a high clinical suspicion for IE; therefore, intravenous thrombolytic was not administered. MT was performed with one pull of stent retrieval under aspiration led to a successful opening of the vessel with TICI score of 3. Positive cocaine on urine toxicology was noted as well as, two sets of gram‐positive blood cultures which later resulted in Staph Aureus, oxacillin susceptible, unremarkable transthoracic echo, but with TEE demonstrating vegetative thickening within atrial aspects of both anterior andposterior mitral valve leaflets(Figure1). On hospital day two, magnetic resonance imaging of the brain shows small acute infarct with no bleed. The patient underwent a mitral valve replacement on hospital day nine. The patient was discharged to rehabilitation facilities with an NIHSS of two for mild left facial droop and mild left arm weakness; her degree of disability was measured as a modified Rankin Scale (mRS) one at 3 months.\u0000 \u0000 \u0000 \u0000 In case IE is suspected, giving IV tPA (tissue‐type plasminogen activator) is contraindicated as it increases the chance of hemorrhagic complications and when LVO is confirmed in the setting of AIS, MT might be safe and effective to be considered .\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41470619","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.096
J. Singer, Fawaz Al Mufti, S. Tateshima
Results of systematic reviews and studies evaluating treatment effects of cerebrovascular interventions on the prevalence of post‐stroke cognitive impairment vary likely due to heterogeneity in populations, sample size, variable treatment effect, and time and methods of cognitive examination. Like thrombolytic therapy, endovascular therapy (EVT) in large vessel occlusion (LVO) stroke is strongly associated with successful reperfusion, reduced mortality, and good clinical outcomes. Nevertheless, the effect of successful reperfusion after EVT on cognitive function remains unexplored. Four hundred (400) patients aged 18–75 will be enrolled in the USA and outside USA clinical centers. The primary endpoint will be the association between successful reperfusion, defined as eTICI ≥ 2b50, and cognitive benefit, defined as delta Montreal Cognitive Assessment (MoCA) from 4 days to 180 days post‐EVT or MoCA ≥ 26 at 180 days post‐EVT. Secondary endpoints will include first pass successful revascularization, reduction in hypoperfusion volumes within 24 h, functional evaluations (NIHSS, mRS), MoCA and cognitive battery evaluations, and QOLs at various timepoints, baseline to 180 days post‐EVT. The correlation between cognitive function and stroke characteristics, imaging variables, functional ability, and demographic and socio‐behavioral factors will be explored. Safety endpoints will include all‐cause mortality, symptomatic intracranial hemorrhage within 24 h, and device‐related serious adverse events. Key inclusion criteria are per instructions for use (IFU) and pre‐stroke mRS ≤1. Key exclusion criteria are per IFU, prior hemorrhage or stroke within 3 months, and pre‐existing cognitive impairment and/or dementia. More study details including the statistical analysis plan and study status will be discussed. COGNITIVE is a very first multi‐center, post‐market, prospective, single‐arm EVT study to evaluate whether successful reperfusion with the Tigertriever device is associated with cognitive benefit in subjects with LVO. The study is a superiority design to evaluate whether Tigertriever treatment significantly reduces cognitive impairment.
{"title":"Abstract Number ‐ 96: The COGNITIVE study: Cognition and Imaging with Tigertriever","authors":"J. Singer, Fawaz Al Mufti, S. Tateshima","doi":"10.1161/svin.03.suppl_1.096","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.096","url":null,"abstract":"\u0000 \u0000 Results of systematic reviews and studies evaluating treatment effects of cerebrovascular interventions on the prevalence of post‐stroke cognitive impairment vary likely due to heterogeneity in populations, sample size, variable treatment effect, and time and methods of cognitive examination. Like thrombolytic therapy, endovascular therapy (EVT) in large vessel occlusion (LVO) stroke is strongly associated with successful reperfusion, reduced mortality, and good clinical outcomes. Nevertheless, the effect of successful reperfusion after EVT on cognitive function remains unexplored.\u0000 \u0000 \u0000 \u0000 Four hundred (400) patients aged 18–75 will be enrolled in the USA and outside USA clinical centers. The primary endpoint will be the association between successful reperfusion, defined as eTICI ≥ 2b50, and cognitive benefit, defined as delta Montreal Cognitive Assessment (MoCA) from 4 days to 180 days post‐EVT or MoCA ≥ 26 at 180 days post‐EVT. Secondary endpoints will include first pass successful revascularization, reduction in hypoperfusion volumes within 24 h, functional evaluations (NIHSS, mRS), MoCA and cognitive battery evaluations, and QOLs at various timepoints, baseline to 180 days post‐EVT. The correlation between cognitive function and stroke characteristics, imaging variables, functional ability, and demographic and socio‐behavioral factors will be explored. Safety endpoints will include all‐cause mortality, symptomatic intracranial hemorrhage within 24 h, and device‐related serious adverse events. Key inclusion criteria are per instructions for use (IFU) and pre‐stroke mRS ≤1. Key exclusion criteria are per IFU, prior hemorrhage or stroke within 3 months, and pre‐existing cognitive impairment and/or dementia.\u0000 \u0000 \u0000 \u0000 More study details including the statistical analysis plan and study status will be discussed.\u0000 \u0000 \u0000 \u0000 COGNITIVE is a very first multi‐center, post‐market, prospective, single‐arm EVT study to evaluate whether successful reperfusion with the Tigertriever device is associated with cognitive benefit in subjects with LVO. The study is a superiority design to evaluate whether Tigertriever treatment significantly reduces cognitive impairment.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48715427","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.243
Ammar Jumah, H. A. Nour, O. Intikhab, Omar Choudhury, Karam Gagi, Michael Fana, H. Alhajala, Mohammad Alkhoujah, O. Alsrouji, Katie A. Latack, L. Schultz, Lara Eltous, Megan Walsh, A. Chebl, H. Marin, Daniel J. Miller
Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e., < 50% stenosis) might be underestimated, and further investigation is mandated to describe the association between high‐risk plaque features and ESUS. This was a retrospective observational study. Using the stroke registry of our hospital’s system between June 20th 2016 and June 20th 2021. We reviewed data for patients diagnosed with ESUS according to previously published definition criteria. Using computed tomography angiography (CTA), we analyzed laterality of high‐risk plaque features in relation to the stroke side, and then we identified the incidence of recurrent stroke events. Out of 1779 patients with cryptogenic ischemic stroke, only 152 met the inclusion criteria for ESUS. We Compared high‐risk plaque features ipsilateral to stroke side as to contralaterally. There were significantly more ulcerations defined as >1 mm depression (19.08% vs 5.26%, p< .0001), plaque thickness >3 mm (19.08% vs 7.24%, p = 0.001), and plaque length >1cm (13.16% vs 5.92%, p = 0.0218).Also, there was a significant difference in stenosis of ipsilateral to stroke when compared contralaterally, especially for stenoses of 10–30% and 31–49% (17.76% vs 10.53% and 5.26% vs 2.63%, respectively. p = 0.0327). There was also a significant difference in plaque component; both components (soft and calcified) and only soft plaque (42.76% vs 23.68% and 17.76% vs 9.21%, respectively. p< .0001) were more prevalent ipsilaterally. In total, 17patients were found to have a recurrent stroke event, 8 patients had an ipsilateral stroke to the index event, 7 had a bilateral and 2 had a contralateral event. ESUS is more commonly found ipsilateral to high‐risk plaque features. Qualitative assessment of plaque features using CTA could be easily implemented in clinical practice. The small number of our sample is definitely a limitation. Further large and multicenter studies aiming to form precise prediction models and scoring systems are needed to help guide treatment with carotid artery stenting or carotid endarterectomy versus maximizing medical therapy.
颈内动脉粥样硬化性病变是缺血性卒中和短暂性脑缺血发作的主要原因之一。轻度至中度狭窄(即狭窄< 50%)的卒中风险可能被低估，需要进一步研究来描述高风险斑块特征与ESUS之间的关系。这是一项回顾性观察性研究。使用2016年6月20日至2021年6月20日期间我院系统的卒中登记。我们回顾了根据先前公布的定义标准诊断为ESUS的患者的数据。使用计算机断层血管造影(CTA)，我们分析了与卒中侧相关的高风险斑块特征的侧边性，然后我们确定了卒中复发事件的发生率。在1779例隐源性缺血性卒中患者中，只有152例符合ESUS的纳入标准。我们比较了同侧卒中侧和对侧的高风险斑块特征。溃疡定义为> 1mm凹陷(19.08% vs 5.26%， p< 0.0001)，斑块厚度> 3mm (19.08% vs 7.24%， p = 0.001)，斑块长度>1cm (13.16% vs 5.92%， p = 0.0218)。与对侧相比，同侧与卒中的狭窄也有显著差异，特别是10-30%和31-49%的狭窄(分别为17.76%对10.53%和5.26%对2.63%)。p = 0.0327)。斑块成分也有显著差异;两种成分(软质和钙化)和只有软质斑块(分别为42.76%对23.68%和17.76%对9.21%)。P < 0.0001)在同侧更为普遍。总共有17例患者发生卒中复发，8例患者发生同侧卒中至指数事件，7例患者发生双侧卒中，2例患者发生对侧卒中。ESUS更常见于高风险斑块特征的同侧。应用CTA对斑块特征进行定性评价在临床实践中较为方便。我们的样品数量少，这肯定是一个限制。需要进一步的大型和多中心研究，旨在形成精确的预测模型和评分系统，以帮助指导颈动脉支架置入或颈动脉内膜切除术的治疗，而不是最大化的药物治疗。
{"title":"Abstract Number ‐ 243: The Non‐stenosing Carotid Artery Plaque in Embolic Stroke of Undetermined Source: A Retrospective Study","authors":"Ammar Jumah, H. A. Nour, O. Intikhab, Omar Choudhury, Karam Gagi, Michael Fana, H. Alhajala, Mohammad Alkhoujah, O. Alsrouji, Katie A. Latack, L. Schultz, Lara Eltous, Megan Walsh, A. Chebl, H. Marin, Daniel J. Miller","doi":"10.1161/svin.03.suppl_1.243","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.243","url":null,"abstract":"\u0000 \u0000 Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e., < 50% stenosis) might be underestimated, and further investigation is mandated to describe the association between high‐risk plaque features and ESUS.\u0000 \u0000 \u0000 \u0000 This was a retrospective observational study. Using the stroke registry of our hospital’s system between June 20th 2016 and June 20th 2021. We reviewed data for patients diagnosed with ESUS according to previously published definition criteria. Using computed tomography angiography (CTA), we analyzed laterality of high‐risk plaque features in relation to the stroke side, and then we identified the incidence of recurrent stroke events.\u0000 \u0000 \u0000 \u0000 Out of 1779 patients with cryptogenic ischemic stroke, only 152 met the inclusion criteria for ESUS. We Compared high‐risk plaque features ipsilateral to stroke side as to contralaterally. There were significantly more ulcerations defined as >1 mm depression (19.08% vs 5.26%, p< .0001), plaque thickness >3 mm (19.08% vs 7.24%, p = 0.001), and plaque length >1cm (13.16% vs 5.92%, p = 0.0218).Also, there was a significant difference in stenosis of ipsilateral to stroke when compared contralaterally, especially for stenoses of 10–30% and 31–49% (17.76% vs 10.53% and 5.26% vs 2.63%, respectively. p = 0.0327). There was also a significant difference in plaque component; both components (soft and calcified) and only soft plaque (42.76% vs 23.68% and 17.76% vs 9.21%, respectively. p< .0001) were more prevalent ipsilaterally. In total, 17patients were found to have a recurrent stroke event, 8 patients had an ipsilateral stroke to the index event, 7 had a bilateral and 2 had a contralateral event.\u0000 \u0000 \u0000 \u0000 ESUS is more commonly found ipsilateral to high‐risk plaque features. Qualitative assessment of plaque features using CTA could be easily implemented in clinical practice. The small number of our sample is definitely a limitation. Further large and multicenter studies aiming to form precise prediction models and scoring systems are needed to help guide treatment with carotid artery stenting or carotid endarterectomy versus maximizing medical therapy.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42263964","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.lba17
A. Mowla, Banafsheh Shakibajahromi, S. Shahjouei, R. Zand
SARS‐CoV‐2 infection may be associated with uncommon complications such as intracerebral hemorrhage (ICH), with a high mortality rate. We compared a series of hospitalized ICH cases infected with SARS‐CoV‐2 with a non‐SARS‐CoV‐2 infected control group and evaluated if the SARS‐CoV‐2 infection is a predictor of mortality in ICH patients. In a multinational retrospective study, 63 cases of ICH in SARS‐CoV‐2 infected patients admitted to 13 tertiary centers from the beginning of the pandemic were collected. We compared the clinical and radiological characteristics and in‐hospital mortality of these patients with a control group of non‐SARS‐CoV‐2 infected ICH patients of a previous cohort from the country where the majority of cases were recruited. Among 63 ICH patients with SARS‐CoV‐2 infection, 23 (36.5%) were women. Compared to the non‐SARS‐CoV‐2 infected control group, in SARS‐CoV‐2 infected patients, ICH occurred at a younger age (61.4± 18.1 years versus 66.8± 16.2 years, P = 0.044). These patients had higher median ICH scores ([3 (IQR 2–4)] versus [2 (IQR 1–3)], P = 0.025), a more frequent history of diabetes (34% versus 16%, P = 0.007), and lower platelet counts (177.8± 77.8 × 109/L versus 240.5± 79.3 × 109/L, P< 0.001). The in‐hospital mortality was not significantly different between cases and controls (65% versus 62%, P = 0.658) in univariate analysis; however, SARS‐CoV‐2 infection was significantly associated with in‐hospital mortality (aOR = 4.3, 95% CI: 1.28‐14.52) in multivariable analysis adjusting for potential confounders. Infection with SARS‐CoV‐2 may be associated with increased odds of in‐hospital mortality in ICH patients.
{"title":"Abstract Number: LBA17 SARS‐CoV‐2 Infection Might be a Predictor of Mortality in Intracerebral Hemorrhage","authors":"A. Mowla, Banafsheh Shakibajahromi, S. Shahjouei, R. Zand","doi":"10.1161/svin.03.suppl_1.lba17","DOIUrl":"https://doi.org/10.1161/svin.03.suppl_1.lba17","url":null,"abstract":"\u0000 \u0000 SARS‐CoV‐2 infection may be associated with uncommon complications such as intracerebral hemorrhage (ICH), with a high mortality rate. We compared a series of hospitalized ICH cases infected with SARS‐CoV‐2 with a non‐SARS‐CoV‐2 infected control group and evaluated if the SARS‐CoV‐2 infection is a predictor of mortality in ICH patients.\u0000 \u0000 \u0000 \u0000 In a multinational retrospective study, 63 cases of ICH in SARS‐CoV‐2 infected patients admitted to 13 tertiary centers from the beginning of the pandemic were collected. We compared the clinical and radiological characteristics and in‐hospital mortality of these patients with a control group of non‐SARS‐CoV‐2 infected ICH patients of a previous cohort from the country where the majority of cases were recruited.\u0000 \u0000 \u0000 \u0000 Among 63 ICH patients with SARS‐CoV‐2 infection, 23 (36.5%) were women. Compared to the non‐SARS‐CoV‐2 infected control group, in SARS‐CoV‐2 infected patients, ICH occurred at a younger age (61.4± 18.1 years versus 66.8± 16.2 years, P = 0.044). These patients had higher median ICH scores ([3 (IQR 2–4)] versus [2 (IQR 1–3)], P = 0.025), a more frequent history of diabetes (34% versus 16%, P = 0.007), and lower platelet counts (177.8± 77.8 × 109/L versus 240.5± 79.3 × 109/L, P< 0.001). The in‐hospital mortality was not significantly different between cases and controls (65% versus 62%, P = 0.658) in univariate analysis; however, SARS‐CoV‐2 infection was significantly associated with in‐hospital mortality (aOR = 4.3, 95% CI: 1.28‐14.52) in multivariable analysis adjusting for potential confounders.\u0000 \u0000 \u0000 \u0000 Infection with SARS‐CoV‐2 may be associated with increased odds of in‐hospital mortality in ICH patients.\u0000","PeriodicalId":74875,"journal":{"name":"Stroke (Hoboken, N.J.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42290928","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-03-01DOI: 10.1161/svin.03.suppl_1.213
Aaisha Mozumder, A. Luo, D. Ramaswamy, Shadman Sakib Mozumder, F. Kaddouh
Symptomatic cerebral vasospasm and delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage leads to significant morbidity and mortality. Intrathecal (IT) nicardipine has been shown to improve outcome and reduce DCIin retrospective cohort studies1. Ecological validity of such reported conclusions may be a real‐world test of the efficacy of the proposed treatment.We sought to study our limited experience with this treatment modality in our cohort, in order to potentially inform our practice in treating vasospasm. Retrospective case series of all patients who received IT nicardipine for the treatment of cerebral vasospasm from 2016 to 2021 at our University Hospital. Demographics, risk factors, clinical course and outcomes were analyzed. In addition to standard of care treatments and interventions, 12 patients received intrathecal nicardipine during the study period. IT nicardipine was given at doses of 2 mg every 8 hrs. Linear regression was conducted and found that IT nicardipine was associated with a reduction of the mean cerebral blood flow velocity of 16% on average. Among 12 patients, 5 patients had in‐hospital mortality; 4 out of these 5 patients developed in‐hospital DCI. Age (p 0.017), history of hypertension(HTN) (p 0.0007) were significant predictors for in‐hospital mortality. 6 patients developed DCI: mFisher scale (p 0.03), admission GCS (p 0.000998), vasopressor requirement to maintain target pressure (p 0.04) were significant predictors for developing DCI. Only 1 patient was diagnosed with bacterial ventriculitis (positive CSF culture). 80% (n = 5) patients had a favorable functional outcome (mRS≤2) at 90 days. Our experience does not conform to the reported outcomes in a much larger patient cohort1. Nonetheless, the choice of this treatment on a case‐by‐case basis somewhat has led to rendering it as a salvage treatment at our center. In our cohort we found significant mortality rate, with age and HTN as predictive factors for in‐hospital mortality, and mFisher scale, admission GCS and vasopressor usage as predictors for DCI development. These results can be difficult to interpret, especially that the use of IT nicardipine was in only few selected patients with initial comorbidities potentially confounding the high mortality and morbidity in our cohort. Intrathecal nicardipine treatment without a well‐vetted protocol with clear inclusion and exclusion criteria can potentially misinform the practice style and lead to early abandonment of this promising therapy as part of our armamentarium. Thus, it is important to develop a standardized protocol with participation of all stakeholders of neurosurgery, neurocritical care, vascular neurology, pharmacy, and patient/family input before deploying in clinical practice on institutional level. Such protocols allow for a pilot study and more contextual prospective assessment of outcomes.
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