Asymptomatic Intracerebral Hemorrhage Research Articles

Intracerebral hemorrhage after deep brain stimulation surgery guided with microelectrode recording: analysis of 297 procedures

ObjectivesReport the incidence of symptomatic and asymptomatic intracerebral hemorrhage (ICH) in patients submitted to deep brain stimulation (DBS) guided with microelectrode recording (MER) with further analysis of potential risk factors, both inherent to the patient and related to the pathology and surgical technique. MethodsWe performed a retrospective observational study. 297 DBS procedures were concluded in 277 patients in a single hospital centre between January 2010 and December 2020. All surgeries were guided with MER. We analysed the incidence of symptomatic and asymptomatic ICH and its correlation to age, sex, diagnosis, hypertension and perioperative hypertension, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, and number of MER trajectories. ResultsThere were a total of 585 electrodes implanted in 277 patients. 16 ICH were observed, of which 6 were symptomatic and 10 asymptomatic, none of which incurred in permanent neurological deficit. The location of the hemorrhage varied between cortical and subcortical plans, always in relation with the trajectory or the final position of the electrode. The incidence of symptomatic ICH per lead-implantation was 1%, and the CT-scan demonstrated asymptomatic ICH in 1.7% more patients. Male patients or with hypertension are 2.7 and 2.2 times more likely to develop ICH, respectively. However, none of these characteristics has been shown to have a statistically significant association with the occurrence of ICH, as well as age, diagnosis, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, number of MER trajectories and perioperative hypertension. ConclusionsMER-guided DBS is a safe technique, with low incidence of ICH and no permanent deficits in our study. Hypertension and male sex seem to be risk factors for the development of ICH in this surgery. Nevertheless, no statistically significant factors were found for the occurrence of this complication.

Intracranial hemorrhage risk in patients with cerebral microbleeds after mechanical thrombectomy for acute ischemic stroke: asystematic review andmeta-analysis.

Background and purpose intracranial hemorrhage risk in patients with cerebral microbleeds (CMBs) after mechanical thrombectomy for acute ischemic stroke (AIS) was investigated. We searched PubMed and Embase from inception to 29 August 2023 for relevant studies, calculated pooled odds ratio (ORs) of intracerebral hemorrhage (ICH) subtypes in AIS patients with CMB presence, 1-4 or ≥ 5 CMBs versus CMB absence, and with different CMB locations after mechanical thrombectomy. ICH subtypes included any ICH, symptomatic and asymptomatic ICH, hemorrhage outside infarct (including subarachnoid hemorrhage), hemorrhagic infarction, and parenchymal hemorrhage after mechanical thrombectomy. Five eligible studies enrolling 2051 patients were included. No significant association was shown between CMB locations (lobar, deep, infratentorial or mixed) and ICH risk. CMB presence or 1-4 CMBs did not significantly increase the risk of any ICH, symptomatic or asymptomatic ICH, ICH outside infarct, subarachnoid hemorrhage, hemorrhagic infarction, or parenchymal hemorrhage. CMBs ≥ 5 increased the risk of any ICH (OR 2.58, 95% CI 1.16-5.72), parenchymal hemorrhage (OR 3.38, 95% CI 1.43-7.97) and parenchymal hemorrhage-2 (OR 5.33, 2.05-13.86), without increasing hemorrhagic infarction or parenchymal haemorrhage-1 risk. After adjusted for possible confounding factors, increases in CMB burden were associated with hemorrhagic complications but not with symptomatic ICH. In AIS patients who received mechanical thrombectomy, no association was shown between CMB location and ICH risk. ICH risk was not significantly increased by CMB presence or 1-4 CMBs. ICH risk in patients with ≥ 5 CMBs requires further study.

Asymptomatic Intracerebral Hemorrhage Following Endovascular Stroke Therapy Is Not Benign: A Systematic Review and Meta-Analysis.

Asymptomatic intracerebral hemorrhage (aICH) occurs in approximately 35% of patients with acute ischemic stroke after endovascular thrombectomy. Unlike symptomatic ICH, studies evaluating the effect of aICH on outcomes have been inconclusive. We performed a systematic review and meta-analysis to evaluate the long-term effects of postendovascular thrombectomy aICH. The meta-analysis protocol was submitted to the International Prospective Register of Systematic Reviews a priori. PubMed, Scopus, and Web of Science were searched from inception through September 2023, yielding 312 studies. Two authors independently reviewed all abstracts. Included studies contained adult patients with ischemic stroke undergoing endovascular thrombectomy with follow-up imaging assessment of ICH reporting comparative outcomes according to aICH versus no ICH. After screening, 60 papers were fully reviewed, and 10 studies fulfilled inclusion criteria (n=5723 patients total, 1932 with aICH). Meta-analysis was performed using Cochrane RevMan v5.4. Effects were estimated by a random-effects model to estimate summary odds ratio (OR) of the effect of aICH versus no ICH on primary outcomes of 90-day modified Rankin Scale 3 to 6 and mortality. The presence of aICH was associated with a higher odds of 90-day mRS 3 to 6 (OR, 2.17 [95% CI, 1.81-2.60], P<0.0001, I2 46% Q 19.15) and mortality (OR, 1.72 [95% CI, 1.17-2.53], P:0.005, I2 79% Q 27.59) compared with no ICH. This difference was maintained following subgroup analysis according to hemorrhage classification and recanalization status. The presence of aICH is associated with worse 90-day functional outcomes and higher mortality. Further studies to evaluate the factors predicting aICH and treatments aimed at reducing its occurrence are warranted.

Characteristics and predictors of stroke mimics in young patients in the norwegian tenecteplase stroke trial (NOR-TEST)

BackgroundSeveral studies have shown that stroke mimics occur more often among young patients. Our aims were to identify the common mimics in young patients under the age of 60 years who received thrombolysis, to analyze the risk of hemorrhage after treatment with thrombolysis, and to identify risk factors and clinical parameters that might identify mimics in this group.MethodsNorwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with acute ischemic stroke. Patients diagnosed with either acute cerebral ischemia or transient ischemic attack were categorized as stroke group, and patients with any diagnosis other than ischemic stroke or transient ischemic attack as mimics group. Patients were grouped post-hoc into young (< 60 years) and old (≥ 60 years). Logistic regression analyses were performed with mimics vs. stroke as dependent variable to identify predictors of mimics.ResultsOf the 1091 patients included in the trial, 211 patients (19.3%) were under the age of 60 years. Out of the 1091 patients, 434 (39.8%) were female, median age 77 years (18–99 years), and median NIHSS was 4. Sixty-nine patients (32.7%) out of the 211 patients under the age of 60 were diagnosed as mimic. Mimics were significantly more frequent among the young (OR = 3.3, 32.7% vs. 12.8%, p = < 0.001). The most frequent mimics diagnoses among patients under 60 years of age were migraine (11.8%), no definite diagnosis (11.4%) and peripheral vertigo (3.3%). Mimics were independently associated with age < 50 years (OR = 4.97, p = < 0.001), not currently working/studying (OR = 3.38, p = 0.002) and not having aphasia on admission (OR = 2.95, p = 0.025). None of the mimics under the age of 60 years had symptomatic or asymptomatic intracerebral hemorrhage as a complication to thrombolysis.ConclusionWe found significantly more mimics in the young, of which migraine was the most predominant diagnosis. Thrombolysis with alteplase or tenecteplase did not cause ICH in any mimics under 60 years.

Abstract 192: Throwing The Kitchen Sink At Tandem Occlusions: A Safety Analysis

Introduction The risk of tandem occlusion treatment in the setting of intravenous thrombolysis is unclear. Angioplasty and stenting typically require the administration of glycoprotein IIb/IIIa inhibitors and/or dual‐antiplatelets which may increase the risk of hemorrhage in the setting of recent thrombolysis administration. Methods We conducted a retrospective analysis of a prospectively maintained patient registry at a comprehensive stroke center. Patients who received thrombolysis and subsequently underwent endovascular therapy for acute ischemic stroke between 2012 and 2022 were included. Patients were separated into two groups depending on whether or not rescue angioplasty or stenting was performed. Per local practice patterns, patients who underwent angioplasty or stenting were immediately started on dual antiplatelets with or without a glycoprotein IIb/IIIa inhibitor bridge. Baseline demographics and clinical characteristics were compared. Outcomes of interest included symptomatic intracerebral hemorrhage (ICH), asymptomatic ICH, hemorrhagic transformation, mass effect and death. Analysis was completed using Chi Square and Fisher’s exact test for categorical variables and Mann‐Whitney U for continuous variables. Results Baseline demographics and clinical characteristics were compared between groups. Patients who underwent treatment of a tandem occlusion were on average younger (67 vs 73, p=0.08) and male (70.1% vs 55%, p=0.03). Median LDL was higher (94 vs 67, p=0.01) and there was a higher rate of diabetes (55.2% vs 40%, p=0.03) and lower rate of atrial fibrillation (12.1% vs 26.6%, p=0.01). Median NIHSS on admission was lower in the tandem occlusion group (15 vs 18, 0.02). Otherwise groups did not significantly differ in level of hemoglobin a1c or rates of hypertension, coronary artery disease, congestive heart failure, smoking status or prior stroke or transient ischemic attack. There was no significant different in hemorrhagic transformation (OR 1.02, 95% CI 0.49, 2.13), mass effect (OR 1.73, 95% CI 0.79, 3.79), symptomatic intracranial hemorrhage (OR 1.27, 95% CI (0.54, 2.99), asymptomatic intracerebral hemorrhage (OR 0.53, 95% CI 0.12, 2.43) or death (OR 0.55, 95% CI 0.24, 1.22) between groups. Limitations include a single center study and the retrospective nature of this analysis. Conclusion We did not find significant risk associated with the treatment of tandem occlusions in the setting of intravenous thrombolysis. Future prospective, multi‐center studies would be beneficial.

Intracerebral hemorrhage after deep brain stimulation surgery guided with microelectrode recording: analysis of 297 procedures

ObjectivesReport the incidence of symptomatic and asymptomatic intracerebral hemorrhage (ICH) in patients submitted to deep brain stimulation (DBS) guided with microelectrode recording (MER) with further analysis of potential risk factors, both inherent to the patient and related to the pathology and surgical technique. MethodsWe performed a retrospective observational study. 297 DBS procedures were concluded in 277 patients in a single hospital centre between January 2010 and December 2020. All surgeries were guided with MER. We analysed the incidence of symptomatic and asymptomatic ICH and its correlation to age, sex, diagnosis, hypertension and perioperative hypertension, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, and number of MER trajectories. ResultsThere were a total of 585 electrodes implanted in 277 patients. 16 ICH were observed, of which 6 were symptomatic and 10 asymptomatic, none of which incurred in permanent neurological deficit. The location of the hemorrhage varied between cortical and subcortical plans, always in relation with the trajectory or the final position of the electrode. The incidence of symptomatic ICH per lead-implantation was 1%, and the CT-scan demonstrated asymptomatic ICH in 1.7% more patients. Male patients or with hypertension are 2.7 and 2.2 times more likely to develop ICH, respectively. However, none of these characteristics has been shown to have a statistically significant association with the occurrence of ICH, as well as age, diagnosis, diabetes, dyslipidaemia, antiplatelet drugs, anatomic target, number of MER trajectories and perioperative hypertension. ConclusionsMER-guided DBS is a safe technique, with low incidence of ICH and no permanent deficits in our study. Hypertension and male sex seem to be risk factors for the development of ICH in this surgery. Nevertheless, no statistically significant factors were found for the occurrence of this complication.

Comparison of Effectiveness and Safety of Low-Dose Versus Standard-Dose Intravenous Recombinant Tissue Plasminogen Activator in Patients With Acute Ischemic Stroke: A Meta-Analysis.

The aim of the present meta-analysis is to compare the efficacy and safety of low-dose and standard-doserecombinant tissue plasminogen activators (r-tPA) in patients with acute ischemic stroke. The present meta-analysis was conducted according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE)guidelines. We conducted a systematic search in PubMed, Embase, and the Cochrane Library to identify studies published between January 1, 2010, and January 31, 2023, using the following terms: "stroke," "alteplase," "doses," "efficacy," "tissue plasminogen activator," "r-tPA," and "safety."Primary efficacyoutcomes included favorable outcomes (Modified Rankin Scale scores of 0-2), while secondary efficacy outcome was all-cause mortality at 90 days. Safety outcomes included asymptomatic intracerebral hemorrhage (ICH)and symptomatic ICH assessed using the National Institute of Neurological Disorders and Stroke (NINDS) study and the Safe Implementation of Thrombolysis in Stroke-Monitoring (SITS-MOST) study. We also compared parenchymal hematomas as safety outcome between the two groups defined by the authors themselves in their research.A totalof 16 studies were included in the present meta-analysis. The meta-analysis did not report any significant difference between low-dose and standard-dose r-tPA in terms of mortality, symptomatic intracranial hemorrhage (SICH), asymptomatic ICH, and parenchymal hematomas. However, the favorable outcome was significantly greater in patients receiving a standard dose of r-tPA.

Abstract WP150: Asymptomatic Intracranial Hemorrhage Following Endovascular Treatment Is Not Benign: A Systematic Review And Meta-analysis

Introduction: Asymptomatic intracerebral hemorrhage (aICH) occurs in ~40% of acute ischemic stroke patients after endovascular thrombectomy (EVT). Unlike symptomatic ICH, which is undoubtedly associated with worse outcomes, studies evaluating the association of aICH on long-term outcomes have been inconclusive. We performed a systematic review and meta-analysis to evaluate the long-term effects of post-EVT aICH. Methods: The meta-analysis protocol was submitted to PROSPERO a priori. PubMed, SCOPUS and Web of Science were searched from inception through April 2022 using database-specific searches with combination of keywords and controlled vocabulary. After deduplication, two authors independently reviewed all abstracts. Included studies contained adult AIS patients undergoing EVT with follow-up imaging assessment of ICH reporting comparative outcomes according to aICH vs no ICH . Meta-analysis was performed using Cochrane Review Manager v5.4. Summary effects were estimated by a fixed-effects model to estimate summary odds ratio (OR) of the effect of aICH vs no ICH on primary outcomes of 90-day modified Rankin score 3-6 and mortality. Results: Systematic review yielded 278 studies; 52 abstracts were fully reviewed ; 8 studies fulfilled inclusion criteria (n=4701 patients total; 1562 with aICH). aICH was associated with 90-day mRS 3-6 (OR 2.11 [95% CI 1.85-2.40]; Figure 1A) and higher mortality (OR 1.66 [95% CI 1.41-1.96]; Figure 1B) compared to no ICH. There was insufficient evidence of difference in 90-day mRS 3-6 when studies were grouped according to Heidelberg (n=2 studies; OR 2.37 [95% CI 0.92, 6.12]) vs ECASS (n=5 studies; OR 2.07 [95%CI 1.62, 2.64]) criteria for ICH. Meta-regression analysis adjusting for covariates will be presented Conclusion: aICH is associated with worse 90-day functional outcomes and higher mortality. Further studies to evaluate the factors predicting aICH and treatments aimed at reducing its occurrence are warranted.

Retrospective Evaluation of the Results of Low-Dose Intravenous Thrombolytic Therapy in Acute Ischemic Stroke.

This study aimed to investigate the clinical data of patients with acute ischemic stroke who received low-dose intravenous (IV) thrombolytic therapy (0.9 mg/kg; maximum 50 mg) for various reasons, compare the obtained results with those of patients who received standard-dose thrombolytic therapy, and discuss them in light of the literature. Patients who received IV thrombolytic therapy within 4.5 h of symptom onset between January 2015 and June 2018 were retrospectively reviewed. Patients were divided into the low-dose group (0.9 mg/kg; max. 50 mg) and the standard-dose group (0.9 mg/kg; max 90 mg) according to the thrombolytic therapy dose, after which demographic data and clinical results were analyzed. A total of 109 patients receiving thrombolytic therapy (19 patients in the low-dose group and 90 patients in the standard-dose group) were included in the study. There was no significant difference between the two groups in terms of good outcome rates (47.4% vs. 52.2%). There was no statistically significant difference in terms of symptomatic and asymptomatic intracerebral hemorrhage rates. Our study showed similar efficacy and safety for low-dose IV thrombolytic therapy compared with standard-dose IV thrombolytic therapy administered within 4.5 h of symptom onset in patients with acute ischemic stroke.

Large Head in Asymptomatic Child: A Subtle Presentation of Connective Tissue Disorder With Spontaneous Significant Intracerebral Bleed

Three years old boy with reassuring development had presented to the Pediatric Neurology clinic with a referral due to a large head. Occipito-frontal circumference was more than 97th centile with an unremarkable neurological examination. MRI brain exhibited an acute on chronic large right frontoparietal subdural hematoma with prominent mass effect. Consequentially, the hematoma was evacuated by the neurosurgeon. Postoperative recovery stayed satisfactory. Hematology workup showed normal coagulation and clotting factors levels. Whole exome sequencing (WES) study revealed heterozygous variant c.5187G>A p.(Trp1729*) in gene FBN1 - pathogenic for Marfan syndrome. However, this variant has not yet been reported in association with cerebral arteritis/intracerebral bleed. On follow-up, the child remained asymptomatic clinically with static head size. This drags us towards the fact that significant yet asymptomatic spontaneous intracerebral hemorrhage can be an infrequent presentation in pediatrics in regard to connective tissue disorders. Moreover, children with Marfan syndrome having variant c.5187G>A p.(Trp1729*) of gene FBN1 can have a rare presentation with cerebral arteritis or intracerebral bleed.

Asymptomatic Intracranial Hemorrhage Is Associated With Poor Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion

Asymptomatic Intracranial Hemorrhage Is Associated With Poor Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion

Predictors for intracerebral hemorrhage after intravenous or intraarterial recanalization in acute major cerebral artery occlusion in Korean patients

Objective To evaluate predictors for intracerebral hemorrhage (ICH) and 1-month mortality after intravenous (IV) or intraarterial (IA) recanalization therapy for major cerebral artery occlusion in Korean patients. Methods From 2011 to 2015, we prospectively gathered data from consecutive patients treated with IV/IA recanalization within 8 h of symptoms in a single center. The effects of demographic, clinical, laboratory, and radiological factors on ICH within 2 weeks were assessed, as well as 1-month mortality. Results From a total of 183 patients, symptomatic intracerebral hemorrhage (SICH) occurred in 32 patients (17.5%), and asymptomatic ICH occurred in 37 patients (20.2%). The mortality rate at 1 month in ICH patients was 37.7%. The international normalized ratio (INR) (OR, 4.9; 95% CI, 1.03–23.4; p = 0.046), glucose (OR, 1.119 per mmol/L; 95% CI, 1.015–1.233; p = 0.023), medium-volume infarct (15–69.9 mL) (OR, 2.62; 95% CI, 1.1–6.26; p = 0.03), large-volume infarct (≥70 mL) (OR, 5.54; 95% CI, 2.1–14.6; p = 0.001), and angioplasty or stenting (OR, 6.29; 95% CI, 1.71–23.22; p = 0.006) were predictors of any ICH. Hyperlipidemia or statin medication (OR, 4.17; 95% CI, 1.38–12.59; p = 0.011), INR (OR, 7.13; 95% CI, 0.94–54.22 p = 0.058), and large-volume infarct (≥70 mL) (OR, 7.96; 95% CI, 2.31–27.39; p = 0.001) were predictors of SICH. Hypertension (OR, 5.77; 95% CI, 1.43-23.3; p = 0.014), initial NIHSS score (OR, 1.09; 95% CI, 1.01–1.18; p = 0.27), and SICH (OR, 15.7; 95% CI, 4.04–61.08; p < 0.001) were predictors of 1-month mortality. Conclusion INR and glucose may be strong modifiable predictors of critical ICH leading to death after IV/IA recanalization therapy in acute cerebral artery occlusion.

Asymptomatic cerebral findings on 3-Tesla MRI in patients with severe carotid artery stenoses

Background and purposeSmall vessel diseases (SVDs) are often asymptomatic. However, SVDs significantly influence the prognosis in patients with large vessel diseases (LVDs). We investigated asymptomatic cerebral findings on 3-Tesla MRI in patients with severe carotid artery (CA) stenoses, compared to peoples without a past history of neurological disorders, including strokes. MethodsWe retrospectively analyzed the prevalences of various asymptomatic cerebral findings which were intracerebral hemorrhages (ICHs), cortical superficial siderosis, ventricular dilatation (Evans’ index) and SVDs including cerebral microbleeds (CMBs), lacunar infarctions (LIs), deep white matter hyperintensities (WMHs), periventricular hyperintensities (PVHs). The prevalence of each finding was compared using multivariate logistic regression models with adjustment for stroke risk factors. ResultsWe evaluated the findings in 54 patients with severe CA stenosis treated by stenting (CA stenosis group) and 200 adults with health screening tests of the brain and no past history of neurological disorders (control group). Multivariate analyses adjusted for age ≥ 65 years old, female gender, hypertension, hyperlipidemia, diabetes mellitus, alcohol consumption, and smoking index revealed that the prevalences of severe PVHs, severe deep WMHs, asymptomatic deep ICHs, and asymptomatic LIs were significantly higher in the CA stenosis group than the control group. However, there were no significant differences in the prevalences of CMBs, or the remaining asymptomatic findings described above. ConclusionsWith pathological differences between SVD and LVD, asymptomatic SVDs except CMBs and deep ICHs often co-exists severe CA stenosis as a presentative LVD.

144 Interstitial Laser Anterior Capsulotomy for Obsessive-compulsive Disorder: Lesion Size and Tractography Correlate with Outcome

INTRODUCTION: Anterior capsulotomy is a well-established treatment for refractory obsessive-compulsive disorder (OCD) and has been performed with radiofrequency ablation, stereotactic radiosurgery, and focused ultrasound. MRI-guided laser interstitial thermal therapy (LITT) allows creation of larger, more demarcated lesions with the safety conferred by real-time imaging of the ablation volume. METHODS: Patients with severe OCD refractory to pharmacotherapy and cognitive-behavioral therapy underwent bilateral anterior capsulotomy via LITT. The primary outcome was percent reduction in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score over time. Lesion size was measured on post-ablation MRI. Disconnection of the anterior limb of the internal capsule (ALIC) was assessed via individual and normative tractography. RESULTS: Eighteen patients underwent laser anterior capsulotomy. Median follow-up was 6 months (range 3-51 months). Time occupied by obsessions improved immediately (median Y-BOCS item 1 score 4 to 1, P = 0.0002). Mean (± standard deviation) decrease in Y-BOCS score at last follow-up was 46 ± 32% (16 ± 11 points; P = 0.0002). Sixty-one percent of patients were responders. One patient had an asymptomatic intracerebral hemorrhage. Reduction in Y-BOCS score was positively associated with ablation volume (P = 0.006). Individual tractography demonstrated durable ALIC disconnection. Normative tractography revealed a dorsal-ventral gradient, with disconnection of orbitofrontal streamlines most strongly associated with a positive response to surgery (P &lt; 0.0001). CONCLUSION: Laser anterior capsulotomy resulted in immediate, marked improvement in OCD symptom severity. Larger lesions can be created safely and permit greater disconnection of the prefrontal-subcortical pathways involved in OCD. The importance of greater disconnection is presumably related to variation in ALIC structure and the complex role of the PFC in OCD.

Intraarterial urokinase for thrombus migration after mechanical thrombectomy for large vessel ischemic stroke.

Achieving rapid and complete reperfusion is the ultimate purpose for ischemic stroke with large vessel occlusion (LVO). Although mechanical thrombectomy (MT) had been a proverbially important procedure, medium vessel occlusion (MeVO) with thrombus migration can sporadically occur after MT. Moreover, the safe and effective approach for such had been unknown. We reported thrombolysis with intraarterial urokinase for MeVO with thrombus migration after MT. We included 122 patients who were treated by MT with LVO stroke at our institution between April 2019 and March 2021. Of 26 patients (21.3%) who developed MeVO with thrombus migration after MT, 11 (9.0%) underwent additional MT (MT group) and 15 (12.3%) received intraarterial urokinase (UK group). The procedure time; angiographically modified Treatment in Cerebral Ischemia Scale (mTICI); functional independence, which was defined as modified Rankin Scale 0-2, on day 30 or upon discharge; and symptomatic and asymptomatic intracerebral hemorrhage (ICH) were compared between the UK and MT groups. The procedure time, mTICI, and asymptomatic ICH did not significantly differ between the groups. In the UK group, 8 of 15 (53.3%) patients obtained functional independence, and the functional independence rate was significantly higher in the UK group than in the MT group (p < 0.05). Symptomatic ICH did not occur in the UK group, and its incidence was significantly smaller than that in the MT group (p < 0.05). The results of this study suggest that intraarterial urokinase for MeVO with thrombus migration after MT may safely improve angiographic reperfusion.

Familiarization with Contact Aspiration using Non-Penetrating of the Thrombus (CANP) Technique as the Initial Procedure for Acute Ischemic Stroke

ObjectivesThis study aimed to prove the safety and efficacy of the contact aspiration using non-penetrating of thrombus (CANP) technique for the initial procedure for acute ischemic stroke and to increase operator familiarization with the technical aspects of the CANP technique. Materials and MethodsA total of 103 patients with large-vessel stroke who were treated using thrombectomy alone at our institution between April 2019 and March 2021 were included in this study. CANP technique was performed using a large lumen catheter (inner diameter, ≥0.060 in.) without penetrating a thrombus. Results of the CANP technique, including the procedure time; first-pass effect (FPE); angiographical recanalization; functional independence; thrombus migration; and intracerebral hemorrhage (ICH) were compared with combined technique. ResultsA total of 77 patients (74.8%) were scheduled to undergo the CANP technique for initial procedure, and 50 (64.9%) attempted the CANP technique. Of 50 patients with CANP technique, 33 (66.0%) achieved angiographically good recanalization using CANP technique alone. FPE was achieved in 31 patients (62.0%) in CANP technique group; the rate of FPE was significantly higher (p = 0.008). Asymptomatic ICH were significantly smaller in the CANP technique group (p = 0.008). The median interval of only the CANP technique was 20 (IQR, 16–29.5) min for groin puncture to final recanalization, and was significantly faster (p < 0.001). ConclusionsCANP technique was safe with low risk of hemorrhagic complication and effective for the initial procedure of acute ischemic stroke.

First pass effect vs multiple passes complete reperfusion: A retrospective study.

First pass effect (FPE) is defined as achieving modified treatment in cerebral infarction (mTICI) grade 2c/3 reperfusion from the first pass and is associated with more favorable outcomes. We aimed to compare FPE and non-FPE using a large database and further compare first-pass mTICI 2b with multiple passes mTICI 3. A retrospective cohort study of acute ischemic stroke patients who received mechanical thrombectomy at a high-volume center was performed. Baseline characteristics and outcomes including rates of discharge and 90-day functional independence (modified Rankin Scale ≤2), mortality, symptomatic, and asymptomatic intracerebral hemorrhage were compared. Of the 637 patients included, 294 achieved FPE; 161 patients had multiple passes mTICI 3 and 36 had first pass mTICI 2b. Propensity-score matching resulted in 211 matched pairs for FPE vs non-FPE, and 30 matched pairs for multiple passes mTICI 3 vs first pass mTICI 2b. The FPE group had significantly more instances of discharge (33.6% vs 19.4%, p = 0.001) and 90-day functional independence (51.7% vs 40.8%, p = 0.032), and lower rates of mortality (18.0% vs 27.5%, p = 0.027) compared to non-FPE. There was no significant difference between first pass mTICI 2b and multiple passes mTICI 3 concerning any studied outcomes. First pass mTICI 2c/3 is safer and is associated with higher rates of functional independence. We did not observe a significant difference between first pass mTICI 2b and multiple passes mTICI 3. The limitations of this study prevent us from drawing conclusions related to the difference between them and calls for future large-scale studies to explore that further.

Symptomatic and asymptomatic intracerebral hemorrhages detected by magnetic resonance imaging after catheter ablation of atrial fibrillation.

Symptomatic intracerebral hemorrhages (ICHs) are a rare complication after atrial fibrillation (AF) catheter ablation, while the incidence of asymptomatic ICHs detected by magnetic resonance (MR) imaging remains unclear. This study aimed to investigate the incidence, characteristics, and predictors of new-onset ICHs on MR imaging after AF ablation. We retrospectively studied 1257 consecutive AF ablation procedures in 1201 patients who underwent MR imaging on the day after the procedure. Repeat MR imaging within 3months post-ablation was available in 352 procedures. Old ICHs on the initial MR imaging were observed in 28 procedures (2.2%). Post-ablation new ICHs were observed in 14 procedures (4.0%), including one symptomatic (0.3%) and 13 (3.7%) asymptomatic ICHs. One patient had a new ICH on the initial MR imaging, while the remaining 13 had such on the repeat MR imaging. A univariate analysis revealed that a previous ischemic stroke or transient ischemic attack (TIA) and the CHA2DS2-VASc score were positive predictors of new ICHs (odds ratios, 5.502 and 1.435; P = 0.004 and 0.044). The lesion diameter did not significantly differ between the old and new ICHs (median, 6.1mm vs. 8.0mm, P = 0.281), while the predominant location differed (lobar areas, 22.6% vs. 53.3%; cerebellum, 22.6% vs. 20.0%; others, 54.8% vs. 26.7%; P = 0.026). A few asymptomatic ICHs may occur after AF ablation. Most of the post-ablation new ICHs occurred a few days or later after the procedure. A previous ischemic stroke/TIA and the CHA2DS2-VASc score may be risk factors for post-ablation ICHs.

A Case for the Non-Neurologist Telestroke Provider.

Introduction: Telestroke networks have effectively increased the number of ischemic stroke patients who have access to acute stroke therapy. However, the availability of a dedicated group of stroke subspecialists is not always feasible. We hypothesize that rates of tPA recommendation, sensitivity of final diagnosis, and post-tPA hemorrhagic complications do not differ significantly between neurologists and an emergency-medicine physician during telestroke consultations.Methods: Retrospective review of all telestroke consults performed at a comprehensive stroke center over 1 year. Statistical analysis: Chi squared test.Results: Three hundred and three consults were performed among 6 spoke sites. 16% (48/303) were completed by the emergency medicine physician; 25% (76/303) were performed by non-stroke-trained neurologists, and 59% (179/303) were completed by a board-certified Vascular Neurologist. Overall rate of tPA recommendation was 40% (104/255), 38% (18/48), 41% (73/179), and 41% (31/76) among the all neurology-trained, emergency medicine-trained, stroke neurology-trained and other neurology- trained provider groups, respectively (p = 0.427). Sensitivity of final stroke diagnosis was 77% (14/18) and 72% (75/104) in the emergency-medicine trained and neurology-trained provider groups (p = 0.777) No symptomatic hemorrhagic complications following the administration of tPA via telestroke consultation occurred in any group over this time period. One asymptomatic intracerebral hemorrhage was observed (0.96% or 1/104) in the neurology-trained provider group.Discussion/Conclusion: Our results did not illustrate any statistically significant difference between care provided by an emergency medicine-trained physician and neurologists during telestroke consultation. While our study is limited by its relatively low numbers, it suggests that identifying a non-neurologist provider who has requisite clinical experience with acute stroke patients can safely and appropriately provide telestroke consultation. The lack of formerly trained neurologists, therefore, may not need to serve as an impediment to building an effective telestroke network. Future efforts should be focused on illuminating all strategies that facilitate sustainable telestroke implementation.

Abstract P502: Significance of Asymptomatic Hemorrhage After Mechanical Thrombectomy: A Post-Hoc Analysis of the Best Study

Introduction: Intracerebral hemorrhage (ICH) occurs in 20-30% of the stroke patients undergoing endovascular therapy (EVT). However, there is conflicting evidence regarding the effect of asymptomatic ICH (aICH) on post-EVT outcomes. Methods: In this post-hoc analysis of our multi-center, prospective, “Blood Pressure after Endovascular Therapy (BEST)” study, we determined the rates of patients with aICH and symptomatic ICH (sICH; any ICH associated with ≥4 points deterioration in the baseline NIH Stroke scale). Their associations with a primary outcome of 90-day modified Rankin Scores (mRS) 0-2 vs 3-6 and early neurological recovery (ENR; NIHSS of 0-1 or ≥8-point improvement at 24 hours from baseline) was determined using univariable and multivariable logistic regression models (adjusted for age, NIH stroke scale, ASPECT score, age, thrombolytic administration, and successful recanalization defined as mTICI ≥2b). Results: Of 485 patients included in BEST at 12 comprehensive stroke centers across the US, 446 patients had a 90-day follow-up available. Of these, 92 (20.6%) developed aICH and 18 (4%) developed sICH. The aICH was not associated with worse 90-day outcome or lower ENR (OR 1.19 [0.74-1.88], p=0.45, aOR 1.19 [0.69-2.06], p= 0.53 for 90-day mRS 3-6; OR 0.77 [0.48-1.23], p=0.30, aOR 0.72 [0.43-1.22] for ENR).A higher proportion of patients with aICH had mTICI ≥2b compared to those without any ICH (97%vs 87%, p=0.01, Table). The aICH was not associated with 90-day outcome or ENR in patients with mTICI ≥2b (OR 1.28 [0.79-2.08], p=0.32 for 90-day mRS 3-6; OR 0.89 [0.69-1.12], p=0.14 for ENR). Conclusion: We found insufficient evidence that aICH associated with worse outcomes in EVT-treated patients, including those with successful recanalization. Interestingly, aICH was more frequent in patients with successful recanalization. Further validation of our findings in other large cohort studies of EVT-treated patients is warranted.