Left Middle Cerebral Artery Research Articles

Protein misfolding: an additional player in the stroke-heart syndrome

Abstract Background Patients suffering from acute ischemic stroke experience an increased risk of major adverse cardiovascular events, introducing the term of stroke-heart syndrome (SHS). Beside common risk factors, the so-called brain-heart axis represents a relevant yet not fully understood biological matrix driving this multi-organ condition. Together with inflammatory and neurohormonal signals, protein misfolding appears as an additional component of this matrix. In fact, previous studies employing animal models of cerebral ischemia identified wrongly arranged toxic proteins (oligomers). In light of the spreading capabilities of such proteins, we questioned whether protein misfolding plays a role in the SHS. Purpose The purpose of this study is to investigate the occurrence of protein misfolding in the post-stroke cardiac dysfunction by assessing presence, origin, localization and routes of oligomers in the heart following an acute ischemic stroke. Its biological and physiological relevance are evaluated by in vivo and in vitro assessments of the myocardium. Methods Acute cerebral ischemic injury was induced in the mouse by left transient middle cerebral artery occlusion for 45 minutes followed by 48 hours of reperfusion in 3-4 month-old C57BL/6J wild type males. Sham operated littermate mice were used as controls. Forty-eight hours after acute cerebral ischemia, cardiac function was evaluated by electrocardiography and compared to pre-operative assessment. Organs were harvested after the abovementioned assessment for the localization and semi-quantification of oligomers in heart and lymph nodes. Furthermore, biological responses related to protein homeostasis in the myocardium were assessed on mRNA and protein levels. Results Our preliminary results show that acute ischemic stroke is associated with an increased presence of oligomers in the heart. In addition, higher levels of oligomers were detected in axillary lymph nodes isolated from stroke mice, suggesting a possible route of oligomers spreading (Fig 1A). Correlating with oligomers occurrence, molecular analyses showed significant upregulation of the inositol-requiring enzyme 1 (IRE1), and catalase at mRNA level (Fig 1B). On the other hand, the expression of the 78-kDa glucose-regulated protein (GRP78), and catalase significantly decreased at protein level, indicating impaired myocardial protein quality control and oxidative stress after acute ischemic stroke (Fig 1C). Stroke-induced cardiac dysfunction was presented by decreased heart weight to tibia length ratio as well as slower and irregular heart rhythm suggesting signs of arrhythmia (Fig 2). Conclusions Acute ischemic stroke is associated with an increased oligomers occurrence in the myocardium and ultimately correlates with altered cardiac resistance against proteotoxicity. Further experiments will be conducted in order to elucidate the role of oligomers as active players or bystanders in the stroke-heart syndrome.

Abstract 18886: Rare but Fatal: Thrombus Formation and Cerebral Infarction Following Atrial Fibrillation Ablation

Introduction: Atrial fibrillation (AF) ablation has become increasingly common as a first line treatment for young, healthy patients and recurrent AF. While the procedures are effective and safe with a mortality rate of <0.1%, it can be associated with fatal complications. Case Presentation: A 74-year-old male with a history of AF status post epicardial ablation, ascending and thoracic aortic aneurysm, hypertension, dilated cardiomyopathy, sick sinus syndrome and alcohol use presented with left hemiparesis and left sided facial droop. He had undergone radiofrequency ablation about 3 weeks prior. Initial evaluation for stroke with computed tomography (CT) of head and CT angiography (CTA) of head/neck was negative. He was intubated for airway protection. Upon insertion of the nasogastric tube, it had dark blood concerning for an upper gastrointestinal bleed. The hospital course was complicated by sinus bradycardia and severe hypotension requiring dopamine and norepinephrine infusions. Repeat CTA head/neck demonstrated new evolving infarcts in the left middle cerebral artery (MCA), left posterior cerebral artery and right MCA territories. During an esophagogastroduodenoscopy to rule out atrioesophageal fistula, patient had a vasovagal episode which resolved with epinephrine. Subsequent transesophageal echocardiogram (TEE) demonstrated an echogenic long protruding thrombus extending across the iatrogenic atrial septal defect from the right atrium to the posterior wall of the left atrium, attached near the ostium of the right lower pulmonary vein. Repeat CT head multiple new areas concerning for developing infarctions and pneumocephalus. Given his overall grim prognosis, the patient was transitioned to comfort care. Conclusions: As ablative procedures for management of AF become more prevalent, it is imperative to maintain a high clinical suspicion for rare but fatal complications which require prompt diagnosis and early aggressive management.

Cerebral Vasomotor Reactivity Testing in the Middle Cerebral Artery Using Transcranial Doppler to Assess Brain Dysregulation in Long-haul COVID Patients

Introduction: COVID-19 has wide-ranging physiological effects, with many patients complaining of persistent asthenia following recovery from the acute phase of the infection. The frequent term for this is “Long-Haul COVID.” While we have tools to measure effects on general physiology in human subjects, a metric for cerebral dysregulation is lacking. Cerebral blood flow is closely regulated in a healthy young person. Cerebral vasomotor reactivity (CVR) was used as a tool to assess this dysregulation. Methods: A transcranial Doppler (TCD) study for CVR was performed under the influence of Carbogen gas. A questionnaire collected prior to the procedure provided additional details on subjects’ demographics and COVID history. Cases and controls were recruited using the self-reported questionnaire. Statistics involved assessing the reproducibility of the test, as well as discovering differences between cases and control groups. Results: Cerebral vasomotor reactivity was assessed in 26 subjects (10 cases and 16 controls). Mean flow velocity in the left middle cerebral artery was analyzed at baseline, at peak Carbogen gas exposure, and in the hypercapnic phase. The reproducibility of the test was established within the longitudinal repeated measures data. The case and control groups were insignificant in difference at the base level but significant when controlled for confounders. Cerebral vasomotor reactivity was found to increase by 3.8 units in cases compared to controls. Confounders like body mass index, gender, and age were found significantly different between cases and controls. The number of COVID episodes and symptom severity was significant for CVR. Conclusion: This simple TCD bedside test was found to be effective in assessing CVR among all the subjects and was homogenous in its effect irrespective of baseline subject differences. As a preliminary test, the test showed differences among cases and control groups. The sample for the test lacked sufficient power and observations. A bigger sample size and a subsequent longitudinal follow-up may help better understand the use of CVR to screen high-risk populations for cerebrovascular anomalies.

Abstract 17085: An Unusual Case of Severe Hypertrophic Cardiomyopathy in a 23-Year-Old Systemic Lupus Erythematosus Patient on Hydroxychloroquine

A 23-year-old female with Systemic lupus erythematosus (SLE), lupus nephritis, antiphospholipid syndrome, venous thromboembolism, stroke, Libman-Sacks endocarditis, and hypertension presented with right upper and lower extremity weakness, right facial droop, and aphasia. Her home medications included hydroxychloroquine, mycophenolate, apixaban, and losartan. ECG showed normal sinus rhythm, left atrial enlargement, ST and T wave abnormalities in V5 and V6. Computed tomography angiography of the brain showed left middle cerebral artery occlusion. Transthoracic echocardiogram (TTE) showed left ventricular ejection fraction of 65%, severe left ventricular hypertrophy, moderate pericardial effusion, and moderately thickened mitral valve (MV) leaflets. Transesophageal echocardiogram showed large vegetations on atrial aspect of both MV leaflets concerning for Libman-Sacks endocarditis. We attempt to investigate the cause of this hypertrophic cardiomyopathy (HCM) in a young patient with SLE. Few reported cases of HCM in patients with SLE were medication induced. Tacrolimus has been observed to induced HCM in a Japanese patient with dermatomyositis. Hydroxychloroquine has been associated with myocardial thickening. Its use can lead to enlarged myocardiocytes with intracytoplasmic vacuoles consisting of concentric lamellar myelin figures in single membrane bound vesicles, curvilinear bodies, glycogen accumulation and fused mitochondria. Hydroxychloroquine use led to reversible inhibition of lysosomal enzyme activity. Cessation of medication use in both cases led to reduction in left ventricle thickness. These patients, like our own, has no family history of aortic valve stenosis, mitral valve prolapse, or HCM. However, this patient’s use of hydroxychloroquine to treat her SLE can be assumed to be a contributing factor to her HCM. This could suggest possible screening with ECG and TTE in patients taking hydroxychloroquine.

Abstract 14028: Stroke Location, White Matter Disconnections, and Neurodevelopmental Outcomes in Infants With Congenital Heart Disease

Objectives: Infants with congenital heart disease (CHD) are at risk for stroke, although associations with neurodevelopmental outcomes have varied. In adults with stroke, location and altered structural connectivity (disconnections) have been linked to neurologic symptoms. We assessed whether stroke (1) location and (2) white matter disconnections are related to neurodevelopment in infants with CHD. Methods: Infants underwent pre- and post-operative brain MRI in prospective studies at 3 centres (UBC, UCSF, SickKids) and completed 18-month neurodevelopmental assessments using Bayley Scales with separate motor and cognitive composites. Adverse outcomes were defined as composite score <85. Strokes were manually segmented. Voxel-wise lesion symptoms maps (VLSM) were used to assess relationships between lesion location and neurodevelopment. Disconnectomes were generated using stroke segmentations as seeds for tractography and diffusion MRI from healthy controls. Voxel-wise disconnectome-symptoms maps (VDSM) of associations between structural disconnections and neurodevelopment were developed. Results: 50 infants with strokes had neurodevelopmental outcomes data. Most strokes were small (<1/3 of arterial territory; n= 33) and in the left MCA territory (Fig 1A). However, strokes in the right basal ganglia and adjacent central white matter were most strongly associated with adverse motor and cognitive outcomes (Fig 1B). White matter disconnections extended beyond areas of injury (Fig 1C); these were extensive even in small strokes. Disconnections of tracts passing through the right basal ganglia were most strongly associated with adverse motor and cognitive outcomes (Fig 1D). Conclusions: Strokes involving the basal ganglia, particularly in the right hemisphere, were associated with worse motor and cognitive outcomes in infants with CHD. These data draw increasing attention to the right hemisphere in early-life stroke and neurodevelopment.

Abstract 213: Successful Mechanical Thrombectomy in Acute Stroke With Pre‐interventional Thrombolysis‐Induced Intracerebral Hemorrhage: Case Report

Introduction Intravenous thrombolytics (IVT) and mechanical thrombectomy (MT) have become the standards of care for treating patients with large vessel occlusion (LVO) acute ischemic strokes (AIS) [1‐4}. Intracerebral hemorrhage (ICH) is a main complication of IVT, with prevalence reported around 3.2% in a large multicentered meta‐analysis [2,6]. However, limited data remains about the safety and efficacy for patients to undergo MT with IVT associated pre‐interventional ICH as no randomized control trials or standard of care guidelines are available [2,4,5,7]. Methods NA Results 56‐yo male with history of alcohol abuse presented via EMS as a stroke alert with acute onset right hemiplegia, global aphasia, right facial droop, and leftward gaze preference two hours prior to arrival. RACE 10+ with NIHSS 24. No known history antiplatelet or anticoagulation use. Computerized Tomography (CT) Brain scan showed left middle cerebral artery (MCA) hyperdense sign with left insular cortical ribboning. CT angiography (CTA) showed near occlusive stenosis of the left carotid bulb with an acute thrombus within Supraclinoid Internal Carotid Artery (ICA) extending into the Left MCA and origin of Left Anterior Cerebral Artery (ACA). Patient was emergently administered IV‐tissue Plasminogen Activator (IV‐tPA) and taken for endovascular thrombectomy. During initial angiogram, after crossing the stenotic cervical bulb, the left Supraclinoid ICA and MCA occlusions were visualized. There was longitudinal partially occlusive thrombus extending from the M1 into the M2 divisions. No opacification of the inferior M2 branch was visualized, with perfusion deficit over the temporal, parietal and frontal regions. Additionally, extravasation of contrast was seen within the left basal ganglia region, concerning for hemorrhagic transformation from IV‐tPA. Reversal of IV‐tPA was initiated, and patient was given cryoprecipitate, platelets, and tranexamic acid. Decision to undergo MT was made secondary to severity of debilitating neurologic symptoms, age, and large perfusion deficit observed. He underwent single pass complete recanalization, TICI 2C using Stent retriever and aspiration. Left ICA stenting was not completed secondary to hemorrhagic transformation. Repeat CT Brain confirmed moderate left frontal lobe hemorrhage with vasogenic edema and 3mm left‐to‐right midline shift. No neurosurgical intervention required. Magnetic resonance imaging (MRI) Brain showed left cerebral hematoma with mass effect, acute infarct within left caudate nucleus, and minimal posterior cortical restricted diffusion without hemorrhagic conversion. Patient was monitored for 1 week with serial brain imaging. Patient was discharged on Aspirin 81 mg daily to inpatient rehabilitation with NIHSS 21, mRS 4 (0 prestroke). Today, in rehab he ambulates with walker with moderate expressive aphasia and right upper extremity weakness. Plan to follow‐up 2‐month post‐hospitalization for left ICA stenting. Conclusion While pre‐interventional IVT‐associated ICH in AIS with LVO are rare, few cases have been shown to have positive neurological outcomes [2,5,7]. We demonstrate a unique case of early identification of reperfusion hemorrhage on fluoroscopy with prompt reversal initiated. The decision to continue with MT based on downstream occlusion of basal ganglia hemorrhage not at further risk of expansion from reperfusion. The patient did well on follow‐up imaging despite the hemorrhage. Further randomized control clinical trials are required to establish best care guidelines, safety, and efficacy.

Abstract 044: Single‐Step Intracranial Angioplasty followed by Atlas Stent Deployment Through Mini Trek Rx Balloon

Introduction The current FDA approved intracranial stent delivery system requires a multi‐step deployment involving the use of exchange length microwire (ELW), typically 0.014‐inch 300 cm wire, to navigate the balloon catheter, which is then exchanged, after performing the angioplasty, over the ELW to a 0.017’ microcatheter that is used to deploy the intracranial stent. Herein, we describe a single‐step approach to deploy Neuroform Atlas stent (Stryker Neurovascular, Fremont, CA) which is a hybrid laser‐cut, nitinol self‐expanding stent without the need for ELW or lesion re‐access using MINI TREK RX (Abbott Vascular, Inc., Santa Clara, CA, USA) semi compliant balloon adapted from cardiovascular literature which showed a pre‐dilation angioplasty capability in coronary stenotic lesions. Methods We performed a retrospective review of prospectively maintained mechanical thrombectomy (MT) databases of 2 comprehensive stroke centers between November 2020, and May 2023. The inclusion criteria were consecutive large vessel occlusion stroke patients in whom single step MINI TREK RX balloon angioplasty followed by Neuroform Atlas intracranial stent deployment was performed without using ELW (Figure‐1). There was no restriction on time from last known well (TLKW) to MT. During the standard mechanical thrombectomy procedure, intracranial atherosclerotic disease/ significant stenotic lesion was suspected by immediate re‐occlusion/ persistent occlusion following at least 1 thrombectomy pass. This is followed by pursuing intracranial angioplasty and stent placement as a rescue recanalization measure. The primary outcome was successful reperfusion defined as a Modified Treatment in Cerebral Ischemia (mTICI) score of 2b or greater at the end of the procedure. Secondary outcomes included NIH Stroke Scale (NIHSS) at 24 hours, NIHSS at discharge, median modified Rankin Scale (mRS) score at discharge and at 90‐day follow‐up. Safety measures included rates of symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Results Among 9 patients who met our criteria, the median age was 63 (51‐69.5) years and 55.6% were females. Most patients had left middle cerebral artery‐ M1 occlusion (66.7%) and one third received thrombolytics (33.3%). All patients underwent the single‐step approach and achieved successful reperfusion (m TICI 2b‐3) with 2 median number of passes. The median NIHSS was reduced from 13.5 (8.5‐17.5) at baseline to 4 (1‐16.5) at discharge. In addition, median mRS was 1 (1‐3.5) at discharge and 3 (3‐4) at 90 days. None of the patients included in this series had sICH while only one patient with basilar artery occlusion underwent ventriculostomy during hospital stay and was sedated/intubated and died. Conclusion This preliminary experience showed technical feasibility and success of using single‐ step to deploy Neuroform Atlas stent after performing angioplasty using MINI TREK RX without the need for ELW or lesion re‐access. Prospective studies with larger sample size and long‐term clinical follow‐up are warranted to confirm these results.

Abstract 237: Thrombectomy is the Leading Treatment Modality for Symptomatic Sub‐Occlusive Lesions: a Nationwide StrokeNet Survey

Introduction Approximately 3% of all acute ischemic stroke are caused by sub‐occlusive thrombi in the proximal intracranial vasculature. There is a paucity of evidence regarding optimal treatment of this stroke etiology, with most evidence derived from retrospective case series preceding the advent of mechanical thrombectomy. We sought to survey the National Institute of Health StrokeNet to determine real‐world treatment patterns in experienced stroke centers. We hypothesized that most providers would choose mechanical thrombectomy (MT) over medical management (MM). Methods We conducted an email survey of all StrokeNet regional coordinating centers (RCCs). Each RCC principal investigator (PI) was asked to provide a name of a local stroke endovascular specialist most aligned with their region’s typical practice pattern. A subsequent survey was sent to each if the StrokeNet RCC PIs and their nominated interventionalists. Questions were based on a clinical vignette accompanied by CT angiogram displaying a sub‐occlusive lesion in the left middle cerebral artery (MCA) (Figure 1a). Subsequent questions kept the same basic vignette, changing only one historical, clinical, or radiographic variable at a time. Participants were asked to describe initial management for each scenario. If more than one initial treatment was selected, or if no treatment option was selected, applicants were asked to please explain. Results were gathered from each participant using Google Forms. Results Among 27 StrokeNet RCCs, 25 (93%) provided at least one response; responses were received from 43 of 54 (80%) physicians surveyed, including 26 stroke interventionalists. A total of 4 sites selected an alternate responder of the appropriate specialty if their PI or chosen representative was unable to respond. The majority (71.4%) of respondents treated patients with acute sub‐occlusive thrombus with MT (Figure 1b). MT alone, or MT with additional MM, comprised the majority of responses to clinical vignette variation questions[Moderate core (ASPECTS 6): 71.4% MT, 76.2% MT with MM; Last Known Normal 12‐hours prior with Favorable Advanced Imaging: 73.8% MT, 83% MT with MM; Last Known Normal 12‐hours prior without Advanced Imaging: 54.8% MT, 64.3% MT with MM; Severe hypertension (210/110mmHg): 50% MT, 69% MT with MM; Poor Collaterals: 71.4% MT, 78.6% MT with MM]. Only two scenarios, low baseline National Institutes of Health Stroke Score (NIHSS) and history of ipsilateral stenosis, led respondents to favor non‐thrombectomy approaches (Low NIHSS (3): 9.5% MT; History of Ipsilateral Stenosis: 30.9% MT, 47.6 MT with MM) (Figure1c‐d). Conclusion Despite limited evidence to support MT versus other treatment strategies, the majority of StrokeNet Regional Coordinating Center sites would use MT to treat acute strokes due to intracranial sub‐occlusive thrombi.

Abstract 127: Delayed Thrombectomy In A Patient With Recurrent MCA Strokes

Introduction Prior research has demonstrated mechanical thrombectomy (MT) to be a safe and effective treatment for stroke patients with a large vessel occlusion (LVO).1 However, MT has generally only been studied in a time window of less than 24 hours.2 To the best of the authors' knowledge, this case report is the first publication of a MT done months after the initial stroke event, in a patient with recurrent strokes and an evolving occlusion visualized in the middle cerebral artery (MCA). Methods The patient is a 55‐year‐old man with a past medical history of a left‐sided MCA stroke 2 months prior to current admission with multiple transient ischemic attacks (TIAs) on dual antiplatelet therapy (DAPT), with no persistent residual deficits. His first stroke was preceded by about 1 week of intermittent confusion and right arm tingling. MRI at the time showed an acute embolic infarct in left MCA territory, and a CTA showed a sub‐occlusive thrombus vs. atherosclerotic plaque in the superior branch of the left MCA. He was discharged on DAPT, but his prior symptoms began to recur on a weekly basis, lasting for a few minutes each time. The patient eventually presented on this admission to the ED with persistent dysarthria and word finding difficulties. Within 4 hours, his exam improved to an NIHSS of 0. An MRI without contrast showed a new acute punctate infarct in the posterior left lateral temporal cortex. CT angiogram showed a persistent left M2 occlusion which was confirmed by the diagnostic cerebral angiogram. CT Perfusion also showed a large penumbra in the same region. The decision was made to perform MT, and complete recanalization was achieved. On 2‐month follow‐up, the patient continues to report no new symptoms since the time of MT. Results The patient’s positive outcome thus far at 60 day follow up indicates that MT can prove safe and efficacious even in significantly delayed time windows. This also shows that the decision to proceed with MT ought not to depend on time interval and degree of collaterals alone, but also on the pattern of symptoms the patient is exhibiting. The recurrent TIAs and strokes our patient was having indicates that, although collaterals had formed in response to his sub‐occlusive thrombus in the MCA, they were still unable to provide full compensation for this lost blood flow, leading to the patient’s intermittent symptoms. Conclusion This report demonstrates that MT can be safely and effectively utilized even in significantly delayed time windows in patients with recurrent TIAs or strokes.

Abstract 188: Rescue Left Middle Cerebral Artery Stenting With Xience Skypoint Everolimus‐Eluting Stent: Technical Report

Introduction Drug‐eluting stent (DES) use in symptomatic intracranial atherosclerosis disease (ICAD) has been described in the literature using different guiding and distal access catheters. We describe a case of deployment of a Xience Skypoint everolimus‐eluting stent (EES) (Abbott Vascular, Abbott Park, Illinois) into a symptomatic stenosed left M1 segment using Armadillo catheter (Q'Apel, Fremont, CA) with a successful result. Methods Case report and review of literature Results 67‐year‐old woman with type II diabetes mellitus, hypertension, hyperlipidemia, and recent admission for transient ischemic attack (resolving right hemiparesis and mild dysnomia in the setting of severe left M1 segment stenosis with discharge on Aspirin, Clopidogrel and Atorvastatin), presented with recurrence of symptoms, and MRI brain showing left basal ganglia acute infarction. No tPA was given low NIHSS and resolution of symptoms. Patient’s aphasia and hemiparesis worsened with segmental hypoperfusion which resolved by maintaining high blood pressures with norepinephrine drip. Decision was made to deploy a drug eluting stent into the stenosed M1 segment. Through femoral access, a 7F long destination sheath was inserted to the left common carotid origin. A 7F Armadillo catheter was then inserted into the left internal carotid artery (ICA) terminus. ASAHI Prowater coronary guidewire was inserted over which Xience Skypoint EES deployment was attempted but was unsuccessful given difficulty traversing the ICA ophthalmic segment. Ultimately, Armadillo catheter was advanced over a Phenom catheter (Medtronic) with good access into the distal M1 segment. The Phenom intermediate catheter was then removed, and the 2.25 mm x 12 mm stent was introduced through the Prowater guidewire into the segment and inflated to a pressure of 8 atm, with restoration of blood flow. Postoperatively, SBP was lowered to prevent reperfusion injury. Patient’s exam stabilized with mild dysnomia and right hemiparesis without any elevated blood pressure requirements. At 5‐months follow‐up, patient’s exam was non‐focal with NIHSS 0 and repeat DSA showed no evidence of stent occlusion and patent M1 segment. Conclusion Xience Skypoint EES can be successful in treating symptomatic MCA stenosis refractory to maximal medical therapy with good long term results.

Abstract 216: Endovascular Thrombectomy +/‐ Thrombolytics In Patients With Cocaine‐Related Acute Ischemic Stroke

Introduction The safety of thrombolytic therapy in patients with cocaine‐related acute ischemic strokes (AIS) has been investigated, but the safety of endovascular thrombectomy in cocaine‐related AIS remains unknown (1‐2). Here, we report preliminary descriptive data on endovascular thrombectomy with or without thrombolytics performed in cocaine‐related ischemic strokes at our institution. Methods A retrospective chart review was performed at our comprehensive stroke center from June 2020 to May 2022 to identify AIS patients with cocaine‐positive urine toxicology screens on admission. Baseline demographics, urine toxicology, National Institute of Health Stroke Scale (NIHSS) scores, neuroimaging, Trial of ORG 10127 in Acute Stroke Treatment (TOAST) criteria, location of stroke, home medications, comorbidities, medical management, and outcomes including modified Rankin Score (mRS) were reported. Results A total of 74 AIS patients were identified to be cocaine‐positive. Of these patients, 14 underwent endovascular thrombectomy (EVT). Only 3 of these 14 patients received intravenous thrombolytics. Including the EVT group, 8 out of 74 AIS patients received thrombolytics. The mean age was found to be 61 years with 86% being male. The most common locations of large vessel occlusion were the M2 branch of the right middle cerebral artery (MCA) (40%), the M2 branch of the left MCA (33%), the M1 branch of the right MCA (13%), left internal carotid artery (7%), and A1 branch of the anterior cerebral artery (7%). Based on TOAST criteria, 64% of strokes were large artery atherosclerosis, 29% cardioembolic, and 7% cryptogenic stroke. The mean initial NIHSS was 14. Average mRS on admission was found to be < 1 and follow‐up mRS at 3 months was found to be 3. Conclusion Our data suggest that cocaine patients who underwent EVT on average had unfavorable functional outcomes defined as mRS > 2, on follow‐up mRS at 3 months. This study highlights the importance of future larger studies to investigate endovascular thrombectomy +/‐ thrombolytics in cocaine‐related AIS.

Abstract 198: Case Report: Thrombectomy using Zoom Reperfusion System In Pediatric Acute Ischemic Strokes

Introduction Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in mechanical thrombectomies in adults but has not been described in pediatrics to our knowledge. We present two cases of a 14‐year‐old boy with acute right middle cerebral artery (MCA) syndrome and a 10‐year‐old boy with acute left MCA syndrome who underwent mechanical thrombectomy using Zoom Reperfusion System safely with TICI 2B and 3 recanalization respectively. Methods Case report and review of literature Results Case 1: 14‐year‐old previously healthy boy presented to our facility for acute right MCA syndrome secondary to right supraclinoid internal carotid artery (ICA) occlusion. After receiving alteplase, patient was taken for mechanical thrombectomy. After femoral access was obtained, an 8‐French sheath was introduced into the right femoral artery through which a Zoom 88 catheter and 5‐French BERN catheter (Terumo) were coaxially advanced over a Terumo Glidewire into the right common carotid artery. Under roadmap guidance, the Zoom 88 catheter was parked at the lacerum ICA segment with BERN catheter and Glidewire then removed. Angiogram demonstrated complete occlusion of the ICA just past the origin of the ophthalmic artery. Via Zoom 88 catheter, a Zoom 71 catheter was then navigated to the face of clot over a velocity microcatheter (Penumbra) and synchro 2 wire system (Stryker) which was then removed. The vacuum manifold was then attached to Zoom 71 catheter and allowed to engage with the clot for 3 minutes prior to withdrawal into the Zoom 88 catheter. TICI 2B recanalization was achieved with sub‐occlusive thrombus within the proximal M1 segment. Retrieval of the sub‐occlusive thrombus in the M1 segment was performed with TREVO stentriever (Stryker). Procedure was complicated by vasospasm in the A1 and M2 segments which resolved with milrinone and verapamil infused through the Zoom 88 catheter. Case 2: 10‐year‐old with left hypoplastic heart syndrome presented to our facility for acute left MCA syndrome due to left ICA terminus occlusion. Mechanical thrombectomy was performed after receiving alteplase. Femoral artery access was obtained with a 8‐French sheath, through which Zoom 88 catheter and 5‐French select catheter (Penumbra) were advanced over Terumo Glidewire into the left common carotid artery. Under roadmap guidance, the Zoom 88 catheter was parked at the ophthalmic segment of ICA with select catheter and Glidewire then removed. Angiogram demonstrated complete occlusion at the ICA terminus. Zoom 71 catheter was introduced through Zoom 88 catheter and navigated to the face of clot at the ICA terminus over velocity microcatheter (Penumbra) and synchro wire system (Stryker) which was then removed. Zoom 71 was then attached to a vacuum manifold to engage with the clot for 90 seconds. TICI 2A recanalization after first pass was achieved with flow restoration in anterior cerebral artery but none in the MCA.TICI 3 recanalization was achieved after second pass. Conclusion The use of Zoom reperfusion system potentially proves to be safe for use in the pediatric age group with good recanalization results and no intraoperative or postoperative complications.

Abstract 212: Percutaneous Carotid access in Mechanical Thrombectomy ‐ a safe alternative to transfemoral approach

Introduction Emergent percutaneous carotid artery MER approach for acute ischemic large vessel strokes are rare given the risk of complications and seldom reported. Methods 75‐year‐old left‐handed functional male (mRs:0) with past medical history of HTN, HLD presented to ED after being found on the floor by his family with slurred speech, new onset right sided weakness, with a last known well of 17 hours. NIHSS on arrival was 14 for expressive aphasia, right visual field defect, right facial weakness, significant dysarthria, right hemiparesis, and sensory defect. CT Head demonstrated left MCA territory early ischemic changes. CTA head/neck demonstrated left M1 occlusion with large penumbra. Perfusion data demonstrated no area of core infarct with area of ischemic penumbra in the left MCA territory involving the left frontal, temporal and parietal lobes measuring 161 ml. ASPECT score 5‐6. The patient was deemed a candidate for mechanical endovascular thrombectomy (MER). The procedure was initiated via ultrasound‐guided right common femoral access. After multiple attempts using a wide range of techniques and wire/catheter combinations in order to establish left intracranial access and given extreme angulation/tortuosity/elongation in the proximal left common carotid artery, it was decided to proceed with the catheter position in the left common carotid or the left internal carotid artery that would allow for subsequent catheterization of the intracranial circulation for MER. Results Near complete revascularization with minimal distal thrombus material beyond endovascular reach corresponding to a TICI 2C degree of revascularization was achieved. Closure of the femoral puncture site was performed using an Angio seal femoral closure device. Surgical closure of the puncture site was performed by vascular surgery. The patient was eventually discharged to short term acute rehabilitation and continues to follow up outpatient with the Stroke clinic. Conclusion Older patients with ischemic stroke commonly have tortuous vessels or peripheral vascular disease. As a result, they may greatly benefit from emergent direct carotid access, as the trans‐femoral approach often poses challenges in accessing the thrombus. For patients with complex and unfavorable vascular anatomy for mechanical endo‐vascularization, direct percutaneous carotid puncture can be advantageous, effectively reducing the aforementioned difficulties. When opting for such an approach it is vital to factor in the aortic arch appearance and its branches.

Individualized Periprocedural and Intraprocedural Management for Coil Embolization of Unruptured Cerebral Aneurysm in a Patient with Severe Thrombocytopenia due to Liver Cirrhosis

A female patient in her early 60's with advanced liver cirrhosis and thrombocytopenia having a platelet count under 30,000/µL, visited an outpatient clinic. Computed tomography angiography revealed an unruptured aneurysm on the left middle cerebral artery bifurcation with 6.0 mm of maximal diameter. Endovascular coiling was planned, considering the patient's medical condition. Eight pints of platelet concentrate were transfused 6 hours before the procedure, and a platelet count of 57,000/ µL was achieved 3 hours before the procedure. No antiplatelet premedication and intraprocedural heparin was administered. A bail-out use of intra- or postoperative Tirofiban (Aggrastat®) was prepared for inadvertent thromboembolic events. The aneurysm was successfully occluded with no procedure-related event. The patient’s hospital course was uneventful, and she was discharged without complications. Despite the potential hemorrhagic risk caused by hemostatic failure in patients with cirrhosis, successful endovascular coiling can be performed with highly individualized management.

A Rare Case of Ischemic Optic Chiasmopathy Following Left Ventricular Dysfunction in a Patient with Coronary Artery Disease

We report a case of transient bitemporal hemianopia following a hypotensive episode in a patient of coronary artery disease (CAD). A 51-year-old male presented with anterior wall myocardial infarction (AWMI) and underwent percutaneous coronary artery intervention (PCI). On the second day post procedure, he developed an acute ischemic event following a cardioembolic infarct to the left middle cerebral artery (MCA) region. Over the next few days, the patient had persistent drop in blood pressure, during which he developed a transient bitemporal hemianopia, which improved after blood pressure correction, consistent with ischemic chiasmopathy. As such in literature, ischemic optic chiasmopathy is a very rare entity. This case report emphasizes that clinicians should consider that sustained hypotension associated with a cardiac event may lead to transient ischemic phenomenon such as the witnessed visual impairment due to hypoperfusion of the optic chiasm.

A clinical case of the Wada test in a patient with structural pharmacoresistant epilepsy

Wada test is an effective diagnostic method for determining the hemispheric localization of speech functions. The vast majority of epileptological centers use this technique in pre-surgical diagnosis in adult patients with medial temporal lobe epilepsy. According to international literature, the use of this test in the pediatric population is extremely rare due to the need for adequate contact with the patient. We present a clinical case of a patient with structural pharmacoresistant epilepsy caused by post-stroke changes in the left middle cerebral artery. Wada test was used as part of a pre-surgical examination to determine the lateralization of the patient’s speech function. The test results allowed determining the right hemisphere to be dominant in speech function. After the surgical intervention — transylviar periinsular functional hemispherectomy — the girl had no deterioration in speech functions, which confirmed the specificity and sensitivity of the Wada test in a child with impaired cognitive development.

Transradial intra-aortic catheter looping in the angioplasty of severe intracranial symptomatic arteriosclerotic diseases.

This study aims to investigate the effect and feasibility of intra-aortic catheter looping via transradial access in angioplasty for symptomatic intracranial severe (>70%) atherosclerotic stenosis or occlusion of large arteries (SISOLAs). Patients with SISOLAs who underwent transradial endovascular angioplasty using the catheter looping technique in the ascending aorta were retrospectively enrolled. The clinical data and treatment outcomes were analyzed. Fifteen patients aged 48-71 years were enrolled in this study. Left vertebrobasilar artery occlusion was present in 1 (6.7%) patient, severe left middle cerebral artery stenosis in 7 (46.7%) patients, severe left internal carotid artery (ICA) stenosis of the ophthalmic segment in 4 (26.7%) patients, severe left ICA stenosis of the cavernous segment in 2 (13.3%) patients, and severe right middle cerebral artery stenosis in 2 (13.3%) patients. The arterial stenosis ranged from 70 to 92% (mean 86%) before stenting. The looping of a guiding catheter in the ascending aorta via transradial access for angioplasty was successful in all patients (100%). The vertebral artery intracranial segment occlusion was successfully recanalized, while severe stenosis in the remaining 14 patients was successfully eliminated. After endovascular recanalization, the residual stenosis was reduced by 12-26% (median 18%). No puncture-related complications or surgical-related neurological complications occurred in these patients. In the follow-up angiography conducted on 10 (66.7%) patients after 6-25 months, no in-stent restenosis was detected. Intra-aortic guiding catheter looping via transradial access for endovascular angioplasty of SISOLAs is technically safe, feasible, and effective, especially when the transfemoral artery approach is difficult or impossible to undertake.

In vitro comparison of manual and robotic endovascular thrombectomy for acute ischemic stroke.

Robotic endovascular systems have the potential to reduce radiation exposure to physicians and expand timely neurointerventional access to patients in remote areas. The goal of the study was to determine the feasibility of robotic endovascular thrombectomy (EVT) in an in vitro model. In vitro procedures were conducted manually and robotically using the Corpath GRX robotic system in a human vascular simulator with an elastic ovine clot in the M1 segment of the left middle cerebral artery. Due to the limited device compatibility of the CorPath GRX, a simple technique with a stent retriever and guiding catheter without a balloon was used in the study. Seven robotic EVT and manual EVT were carried out in each group. Metrics including procedural time, success rate, and radiation dose were compared between the two groups. In robotic EVT, the mean total preparation and procedural time was 892 s, which was significantly longer than manual operation at 357 (p = 0.0001). There was no significant difference in the success rate between the two approaches (robotic: 28.6% vs. manual 42.9%, p = 0.577). The mean radiation exposure to operating physicians was significantly lower during robotic operation compared to manual operation (0.02 μSv vs. 0.22 μSv, p < 0.0001). Robotic EVT was feasible in our human vascular simulator with significantly reduced radiation exposure to the operating physicians, despite an increased length of procedure when compared to manual procedures. Future technological advancement is warranted for reducing procedural length using endovascular robotic techniques.

AGR - 1 A Case Study of Cognitive Reserve and Wernicke's Aphasia Status-Post Insular Stroke.

The case is an 88-year-old, woman, formerly a successful surgeon for decades, with Wernicke's aphasia due to dominant insular stroke. Our evaluation explored her deficits in the context of the heterogeneous presentations of insular strokes and how speech rehabilitation has impacted her language abilities given her cognitive reserve prior to her stroke. The patient sustained a left MCA embolic stroke in 2020. Neurodiagnostics revealed an infarct in the insula, dominant temporal, frontal, and parietal lobes. Baseline language assessment was completed. Results included moderate-severe receptive language impairment; intact fluency; deficits in writing and repetition; and significant paraphasias. Neuropsychological assessment demonstrated prominent deficits in repetition with paraphasias and irritability. Auditory learning, attention, and working memory were invalid due to deficits in repetition. She was diagnosed with mild vascular neurocognitive disorder and conduction aphasia. Despite comprehension having improved, the patient's paraphasias resemble the presentation of Wernicke's aphasia. Interestingly, there were some consistencies in paraphasic errors, such as consistently swapping certain words or letters, demonstrating diminished but not absent volition of speech. Story memory was the most effective measure of auditory memory given repetition deficits. Despite repetition deficits commonly localizing to the supramarginal gyrus, her repetition difficulty is likely related to language network disruption due to her insular infarct. Rehabilitation for comprehension was successful despite age at time of injury. Consistent with previous research, results suggest despite cognitive reserve, repetition is resistant to rehabilitation; however, in this case, paraphasic errors were also resistant. Rehabilitation should include a behavioral component for insular stroke patients.

FRI322 Lack Of Tumor Size Change With Long-term Cabergoline For Prolactinoma

Abstract Disclosure: S. Bendaram: None. V. Kantorovich: None. Introduction: Prolactinomas are the most common tumors of the pituitary gland and account for about 40% of all Pituitary adenomas, of which 10% are macroprolactinomas measuring &amp;gt;1 cm. Dopamine Agonists (DAs) normalize the prolactin levels and aid in shrinkage of the tumor size. We present two cases of Macroprolactinomas with biochemical response to DAs but no shrinkage in size as expected. Case 1: 75-year-old male with history of hypertension, left frontal MCA stroke with residual aphasia who underwent brain MRI for a recent TIA, was found to have a new 2.3 x 1.9 x 2.4 cm mass in the pituitary fossa invading the right cavernous sinus, concerning for a pituitary macroadenoma. Prolactin levels were 4152 ng/ml on dilution study, low testosterone with inappropriately normal LH/FSH. He denied any symptoms from compression, hyperprolactinemia or hypogonadism. After starting Cabergoline 0.25 mg biweekly, repeat levels in 2 weeks showed a decline in prolactin levels to 808.7 ng/ml. Visual Field (VF) testing was abnormal but was unreliable due to high fixation losses. Same dose of cabergoline was continued, with decline in prolactin further to 37.8 ng/ml, while a repeat MRI Brain showed no substantial change in the size of the mass. Cabergoline was doubled, and a repeat MRI still demonstrated same size of the mass, despite prolactin levels decreasing to below normal range. Case 2: 62-year-old male with history of macroprolactinoma for &amp;gt;3 years, but non-adherent to medications, who presented to his PCP with persistent occipital headaches, and was referred to Endocrinology due to repeat MRI brain revealing interval increase in the size of sellar and suprasellar mass measuring 2.2 x 2.2 x 2.9 cm in size consistent with macroadenoma with mass-effect on the optic chiasm and prechiasmatic optic nerves. Evaluation of pituitary panel revealed prolactin levels of 1352 ng/ml, low testosterone and LH, while the rest of the labs were normal. He was started on cabergoline 0.5 mg biweekly, and a repeat prolactin level after a single dose of cabergoline improved to 469 ng/ml. He was continued on the same dose with prolactin dropping to 2.6 ng/ml in 2 months, and further to 1.8 ng/dl after 10 months of treatment. Initial VF testing also demonstrated some degree of defect with compression of optic chiasm. Repeat MRI 3 months after initiation of cabergoline revealed interval decrease in size of macroadenoma to 2.1 cm in the largest dimension, which stayed the same on the recent imaging. Discussion: DAs like Cabergoline are first line therapy for prolactinomas. Fibrotic changes from long standing adenomas might be a possibility causing resistance to shrinkage of tumor, however it would be interesting to know if any specific molecular mechanisms that could be involved. In tumors with significant mass effect or those not responding to MT, Surgery is the preferred next step, and neurosurgery evaluation is necessary for further management. Presentation: Friday, June 16, 2023