MCA Territory Research Articles

Abstract TP11: CTA Collateral Status and Final Infarct Distribution Following Thrombectomy in Stroke Patients With Large Vessel Occlusion

Aim: The angiographic collateral status is a major predictor of final infarct volume in patients with large vessel occlusion (LVO). In this study, we assessed the effects of collateral status on final infarct lesion distribution after thrombectomy. Methods: Acute ischemic stroke patients with occluded terminal ICA and/or MCA M1 segment who underwent thrombectomy and had a follow up MRI within a week were included. The angiographic collateral status was evaluated on pre-thrombectomy CTA and graded according to Miteff et al. (Brain 2009;132(8):2231-8). The final infarct lesion was segmented on DWI; and using voxel-wise general linear model, we determined the correlation of final infarct volume with post-thrombectomy TICI (thrombolysis in cerebral infarction) score, and collateral status - as a covariate. Results: Among 106 patients with terminal ICA and/or MCA M1 occlusion in analysis, final infarct volume had a significant correlation with TICI reperfusion score (rho=0.384, p<0.001), CTA collaterals (rho=0.221, p=0.023), and TICIxCollaterals interaction term (rho=0.446, p<0.001). Voxel-wise analysis (Figure) showed that better reperfusion after thrombectomy (i.e. higher TICI) was associated with preservation of MCA territory cortex and deep white matter (green). The voxel-wise interaction analysis of TICI and CTA collateral status showed that poor collateral status is associated with infarction of the MCA-PCA border zone (red). Alternatively, good collaterals may preserve the peripheral edges of the MCA territory and MCA-ACA border zone (blue). Conclusion: A successful thrombectomy in LVO stroke patients can preserve the cortical and deep white matter of MCA territory - including eloquent speech and motor regions - while CTA collateral status mainly determines the fate of the MCA-PCA border zone. On the other hand, lentiform nuclei tend to infarct despite successful reperfusion and good CTA collateral status.

Abstract TP252: Extended Window TPA is Safe at Community Emergency Departments via Telestroke

Introduction: Recent studies support tPA for acute ischemic stroke (AIS) patients presenting beyond 4.5 hours from last known well (LKW), if established infarct is not evident on advanced imaging. Many community hospitals, where AIS patients may be managed via telestroke (TS), lack advanced imaging capability and hesitate to administer off-label tPA. In our TS network, physicians adhere to an extended window tPA (EW) protocol also used in the hub emergency room; eligibility includes NIHSS≤25, <1/3 MCA territory hypodensity on CT brain, and off-label tPA consent. Here, we characterize patients receiving EW via TS and investigate safety. Methods: We identified 1,150 AIS patients who received tPA via TS (9/2015-12/2018). We compared baseline characteristics between patients who received EW (arrival >4.5 hrs) and those who received standard window tPA (SW, arrival ≤4.5 hrs). We explored clinical outcomes and describe incidence of adverse effects from tPA. Results: Forty patients received EW, with median ASPECTS of 9 (Q1-Q3: 9-10). Median LKW to arrival time was 491 mins with EW and 66 mins with SW (p<0.0001, Table 1). EW led to few tPA complications; symptomatic intracranial hemorrhage incidence was 2%. EW was given for more severe stroke than SW (median NIHSS 10 vs 7, p=0.011). Both groups had comparable baseline characteristics, except a higher rate of tobacco use with EW. EW patients had longer length of stay (median 5 vs 3, p=0.023) and were more likely to be discharged to rehab than home (OR: 2.05 (1.01 4.15), p=0.046), however a small number of EW patients precludes in-depth comparative outcomes analysis. Conclusions: Our data suggest that EW is safe via TS for select patients with favorable CT, in settings that may lack advanced imaging capability. A specified mismatch between NIHSS and acute ischemia on plain CT is not part of our EW protocol, however EW is more likely given for severe stroke in our TS network. Small sample size warrants further study on clinical outcomes.

Abstract WP188: Community-Based Outpatient Stroke Rehabilitation Program Achieves Excellent Outcomes Including Return to Work, Driving, Stroke Knowledge, and Other Rehabilitation Outcomes

Background: Return to driving and employment are goals for many stroke survivors. There are few reports of patient centered outcomes including return to employment, driving, self-efficacy, functional outcomes, stroke knowledge or characteristics of survivors who achieve these goals. Methods: Prospective observational study of stroke patients treated in an interdisciplinary outpatient rehabilitation program addressing physical, cognitive, communicative, risk factor/stroke knowledge, self-efficacy, psychosocial, driving and vocational issues. Results: 190 consecutive patients(117 men, 73 women, average age 62(18-90), 66 aphasic) with baseline modified Rankin Scores of 5(1%); 4(25%); 3(56%); 2(15%); 1(3%), and average NIHSS score of 6(range 0-18) were treated between 12/2011-7/2019. 136 Patients suffered ischemic strokes and 54 had hemorrhages. Locations were: 65 left, 69 right, 26 bilateral hemisphere, 30 brainstem. 41% had MCA territory strokes. Of 104 patients working pre-stroke, 50% returned to work and an additional 7% were work capable upon completion of program. 95% of patients driving pre-stroke could not drive on admission. After training, 43%(67/157) returned to driving. Patients had improvements in all 9 domains of Stroke Impact Scale with SIS total score improving an average of 23%. Patients received an average of 33 physical therapy visits with average percent improvement of 72% and 41% on 6” walk and Berg Balance scores. Average percent improvement in Stroke Self Efficacy Scores was 29%. After individualized cardiovascular risk, stroke and medication education sessions with the Nurse Practitioner based on AHA guidelines and Life’s Simple 7’s curriculum, stroke and risk factor knowledge quiz scores improved an average of 29%. Average length of stay was 5(range .5-24) months. Multiple other demographic and outcome measures are collected. Conclusions: Outcome data show a community-based team rehabilitation program can successfully combine CV/stroke education with rehabilitation services to maximize patient centered outcomes including return to work, driving, overall stroke recovery, physical functioning, stroke knowledge, and self-efficacy for many types of stroke survivors with moderate to severe disability.

A Study of Prevalence and Predictors of Acute Ischemic CVA Patients Admitted to Manipal Teaching Hospital, Pokhara, Nepal

Background: According to the World Health Organization (WHO), 15 million people suffer stroke worldwide each year. Of these, 5 million die, and another 5 million are left permanently disabled.
 Materials and methods: A retrospective hospital based observational study was carried out in patients with ischemic CVA. Modified Ranking Scale (MRS) on the follow up on 30 days after discharge was obtained. MRS 0-2 was categorized and good outcome and MRS 3-6 was categorized as poor outcome.
 Results: Out of 56 patients studied 33.9 % were less than 60 years of age and 63.1% were greater than 60 years of age. Male to female ratio was 1.55. MCA territory infarct was the most common with the frequency of 76.8%. There was significant association of HTN, DM, coronary artery disease and other factors as well with the outcome of the patients.
 Conclusion: On regards to clinic-social demographic parameters there was statistical significance between the gender of the patient, history of systemic hypertension, history of diabetes mellitus and coronary artery disease and outcome of the patient in 30 days follow up.

Surgical decision-making depending solely on the radiological volume of the ischemic brain can be misleading in the management of patients with malignant stroke

Recent studies suggest that a total ischemic brain tissue volume >300 cm3 observed on CT is a significant indicator of an unfavorable outcome with a sensitivity of 100% after DC in patients with malignant ischemic stroke. In this article, we reported a 61-year-old male patient with poor preoperative clinical status and most predictive factors pointed to an unfavorable outcome who nonetheless demonstrated an acceptable functional recovery after DC. On cranial computer tomography, CT angiography, and diffusion MRI, his cortical and subcortical MCA and anterior cerebral artery (ACA) vascular territories showed infarctions that extended toward the basal ganglion. The volume of the ischemic cerebral tissue was calculated using ROI (region of interest) manager tool of OsiriX® DICOM image processing software (Pixmeo SARL, Bernex, Switzerland) and found to be 411 cm3. Decompressive craniectomy decision-making depending solely on the radiological volume of the ischemic brain can be misleading in the management of patients with malignant ischemic stroke.

Development of a Routinely Applicable Imaging Protocol for Fast and Precise Middle Cerebral Artery Occlusion Assessment and Perfusion Deficit Measure in an Ovine Stroke Model: A Case Study.

Temporary middle cerebral artery occlusion (MCAO) in sheep allows modeling of acute large vessel occlusion stroke and subsequent vessel recanalization. However, rapid and precise imaging-based assessment of vessel occlusion and the resulting perfusion deficit during MCAO still represents an experimental challenge. Here, we tested feasibility and suitability of a strategy for MCAO verification and perfusion deficit assessment. We also compared the extent of the initial perfusion deficit and subsequent lesion size for different MCAO durations. The rete mirabile prevents reliable vascular imaging investigation of middle cerebral artery filling status. Hence, computed tomography perfusion imaging was chosen for indirect confirmation of MCAO. Follow-up infarct size evaluation by diffusion-weighted magnetic resonance imaging revealed fluctuating results, with no apparent relationship of lesion size with MCAO at occlusion times below 4 h, potentially related to the variable collateralization of the MCA territory. This underlines the need for intra-ischemic perfusion assessment and future studies focusing on the correlation between perfusion deficit, MCAO duration, and final infarct volume. Temporary MCAO and intra-ischemic perfusion imaging nevertheless has the potential to be applied for the simulation of novel recanalization therapies, particularly those that aim for a fast reperfusion effect in combination with mechanical thrombectomy in a clinically realistic scenario.

Middle Cerebral Artery Plaque Hyperintensity on T2-Weighted Vessel Wall Imaging Is Associated with Ischemic Stroke.

Vessel wall imaging can identify intracranial atherosclerotic plaque and give clues about its components. We aimed to investigate whether the plaque hyperintensity in the middle cerebral artery on T2-weighted vessel wall imaging is associated with ischemic stroke. We retrospectively reviewed our institutional vessel wall MR imaging data base. Patients with an acute ischemic stroke within 7-day onset in the MCA territory were enrolled. Patients with stroke and stenotic MCA plaque (stenosis degree, ≥50%) were included for analysis. Ipsilateral MCA plaque was defined as symptomatic, and contralateral plaque, as asymptomatic. Plaque was manually delineated on T2-weighted vessel wall imaging. The plaque signal was normalized to the ipsilateral muscle signal. The thresholds and volume of normalized plaque signal were investigated using logistic regression and receiver operating characteristic analysis to determine the association between normalized plaque signal and stroke. One hundred eight stenotic MCAs were analyzed (from 88 patients, 66 men; mean age, 58 ± 15 years), including 72 symptomatic and 36 asymptomatic MCA plaques. Symptomatic MCA plaque showed larger plaque hyperintensity volume compared with asymptomatic MCA plaque. The logistic regression model incorporating stenosis degree, remodeling ratio, and normalized plaque signal 1.3-1.4 (OR, 6.25; 95% CI, 1.90-20.57) had a higher area under curve in differentiating symptomatic/asymptomatic MCA plaque, compared with a model with only stenosis degree and remodeling ratio (area under curve, 0.884 versus 0.806; P =.008). The MCA plaque hyperintensity on T2-weighted vessel wall imaging is independently associated with ischemic stroke and adds value to symptomatic MCA plaque classification. Measuring the normalized signal intensity may serve as a practical and integrative approach to the analysis of intracranial atherosclerotic plaque.

Infarct Pattern in Patients with Varying Degrees of Internal Carotid Artery Stenosis

Background: Internal carotid artery (ICA) is one of the commonest site stenosis in patients with ischemic stroke. There is difference in the distribution of stenosis among different sites of cerebral infarct.Volume and severity of cerebral infarct may also depend on the degree of stenosis. To plan efficient evaluation and treatment of individual patient of ischemic stroke, the responsible clinician must be familiar with the relative probability of finding occlusive lesions at various sites within the vascular tree. Objective: The objective of this study was to evaluate the angiographic pattern of ICA stenosis among different types of cerebral infarct. Materials and Methods: We evaluated 53 ischemic stroke patients from indoor, outdoor, stroke and neuro intervention clinic, BSMMU. CT scan and/ or MRI of brain were done to each patient to confirm the diagnosis. After vascular imaging, the degree of stenosis was measured by the NASCET formula. Results: Cervical segment of ICA was most commonly [n=45(84.9%)] encountered site of stenosis and total occlusion of ICA was always observed in cervical segment. Among patients with moderate stenosis (n=15) of ICA, 6(40.0%) presented with subcortical infarction, 4(26.7%) presented with lacunar infarction and 5(33.0%) presented with territorial infarction. In case of severe stenosis (n=23), territorial, lacunar and watershed infarct were 9(39.1%), 8(34.8%) and 2(8.7%) respectively. Whereas total occlusion (n=15) of ICA presented as either territorial infarction [n=11(73.3%)] or watershed infarction [n= 4(26.7%)]. These differences between severity of stenosis and subtype of infarct were also significant (p-value = 0.003).A total of 25 patients presented with territorial infarction, mostly MCA territory [n=23(92%)]. Conclusion: With increasing severity of stenosis, the infarct burden rises. ICA stenosis of e”70% mainly presented as territorial infarction whereas, watershed infarct was an indicator of severe stenosis. Bangladesh Journal of Neuroscience 2019; Vol. 35 (2): 69-77

Worsening clinical features in a patient with right middle cerebral artery territory stroke

We describe a case with acute ischemic stroke in the right MCA territory. He developed secondary deterioration for which no obvious cause could be found. He underwent FDG-PET for evaluating carotid plaque inflammation as part of a research study, which revealed considerable hypometabolism in the left cerebellar hemisphere-responsible for the neurological deterioration. This phenomenon is often called ‘crossed cerebellar diaschisis. Various imaging findings are presented.

Abstract WP162: Automatic Detection of Middle Cerebral Artery Plaque on T2-weighted Vessel Wall Imaging

Background: Intracranial vessel wall imaging (VWI) has been reported to be an efficient approach for evaluating ICAD, yet the reliability of intracranial plaque identification may vary depending on the experience of institutions or readers. We aim to automatically detect middle cerebral artery plaque on T2-weighted VWI using machine learning algorithms and thus reduce inter-reader variability. Methods: Patients were selected from our institutional vessel wall imaging database if they had acute stroke in the MCA territory on diffusion-weighted imaging (DWI) and MCA plaque seen on VWI, or if they had no history of stroke or transient ischemic attack and no plaque seen on VWI. Bilateral MCAs of all patients were analyzed individually. The cross-sectional images of MCA were graded into a scale of 1-3 based on the confidence of the reader regarding the presence of plaque in the cross-sections: Grade 1, the plaque is not present, used as control group; Grade 2, the plaque may or may not present, not included in further analysis; Grade 3, the plaque is present, used as plaque group. Cross-sections with insufficient image quality result from motion artifacts or with non-cross-sectional images of MCA were excluded. The annotated vessel regions on T2-weighted images were used as input to a classification algorithm based on a nonlinear spectral regression algorithm. The model was evaluated under a crossvalidation in order to predict the presence of plaque in the vessel (Grade 1 versus Grade 3). Results: A total of 104 patients with stroke and 27 controls were included, leading to 453 slices with plaque and 246 slices for the control group. After a 3-fold crossvalidation, the model reached an accuracy of 87.2% in detecting correctly the presence of plaque in the vessel regions. Conclusion: Our experiments demonstrate that a nonlinear machine learning approach can achieve high performance in detecting presence of plaque in the vessel, which is the first step in further analysis of plaque-related parameters and more objective diagnoses.

Abstract TP470: The Value of Perfusion Ct as a Prognostic Factor After Mechanical Thrombectomy in Anterior Circulation

Introduction: Mechanical thrombectomy is recommended as first line treatment for large vessel occlusion(LVO) patients. Mechanical thrombectomy is performed based on the ASPECT score to achieve recanalization of the blood vessels at a faster rate. However, in patients with ASPECT score of 6 or more, the infarction volume on the diffusion MRI can occur throughout the MCA territory, resulting in hemorrhage after the thrombectomy and low cost effectiveness. Therefore, we conducted a study to determine whether recanalization was faster and whether perfusion CT could be used as a predictor of prognosis. Method and Material: We retrospectively studied patients who had recanalization therapy with LVO of anterior circulation at our hospital from 2011 to 2015. The cerebrovascular accident(CVA) protocol was activated when LVO was suspected, and non-enhance CT, perfusion CT, and CT angiography were performed. The CVA CT scan takes a 7 minutes. In these patients, 10 areas such as ASPECT score were designated and scores were given to the lowered areas of CBF, MTT, and CBV compared with the contralateral side, and scoring was performed at 10 points. EMR and imaging study of patients with ASPECT score of 7 or more were confirmed. We checked NIHSS at admission, mRS at discharge, and mRS at 90 days after discharge. Results: In total, 94 patients met the inclusion criteria of this study. After recanalization, TICI G 2b and 3 were achieved 80 patients (85.10%). Of the total patients, 71 patients (75.53%) had a CBV score of 4points or less and 23 patients (24.47%) had a score of 5points or more. In patients with CBV 4 points or less, good outcome(mRS 0 ~ 2) was 34 patients (47.88%). In patients with CBV 5 points or more, good outcome(mRS 0 ~ 2) was 6 patients(26.08%). The mortality rate was 7.04%(5patients) in patient with CBV 4points or less, but there were 30.43%(7patients) in patients with CBV 5points or more. Conclusion: Mechanical thrombectomy showed better prognosis in LVO patients with CBV score of 4 points or less. But there is showed higher mortality rate in patients with CBV score of 5 points or more. Perfusion CT can be helpful in predicting the prognosis of the patient.

Abstract WP312: Application of the e-NIHSS at a Tertiary Care Stroke Center: Experience and Results

Background and Purpose: Stroke is a time sensitive emergency with proper identification and rapid evaluation critical. The National Institutes of Health Stroke Scale (NIHSS) is used to quantify stroke severity. The NIHSS favors detection of signs and symptoms indicative of anterior circulation strokes, especially MCA territory. Capturing signs and symptoms associated with posterior circulation strokes is limited in the present NIHSS. Methods: This prospective study explored if the e-NIHSS utilized by stroke nurse responders correlated with the diagnosis of posterior circulation stroke determined by the neurologist based on clinical and radiographic findings. A secondary objective was to determine ease of use, including time for completion, of the expanded items on the NIHSS. Results: In 40 assessments, there were no positive findings using the e-NIHSS; in these 40 cases, the CT or MRI was negative for acute stroke. In 4 cases, positive e-NIHSS findings (3 - CN XII: tongue turns to one side and 1- Trunk Ataxia: falls back to one side) were noted but imaging was negative for acute stroke. In 5 patients, tongue (N=4) and trunk ataxia (N=1) were positively assessed with resulting positive imaging for anterior circulation stroke. Nine patients were diagnosed with a posterior circulation stroke based on imaging with 3 having trunk ataxia identified by nurse stroke responders. Subjective findings included complaints of nausea/vomiting, dizziness, lightheadedness, and/or headache. Sensitivity was calculated at 33%, specificity 82%, positive predictive value 25%, negative predictive value 87%, and 74% accuracy. Conclusions: Findings are limited to small sample size (N=96) and low incidence of posterior circulation strokes. The additional 6 e-NIHSS items are easy to assess except standing the patient was found to be challenging physically and timewise. Assessment of soft palate paralysis was not specific to posterior circulation. Trunk ataxia, falling to one side when sitting up, identified posterior circulation compromise.

Abstract TMP43: Fluoxetine May Enhance Visual Recovery After Acute Ischemic Stroke by Cortical Remapping of the Blind Visual Field

Post-stroke homonymous hemianopia is disabling and complete spontaneous recovery is rare (12.5%). Other than acute revascularization, no proven treatments are available to enhance recovery. Compensatory training may lead to modest functional improvements, but does not restore native function. As such, therapies effective beyond the acute stage are desperately needed. In this phase IIa single-center, double-blinded, randomized, placebo-controlled pilot clinical trial, we tested whether fluoxetine (FLX) enhances visual recovery after an ischemic stroke by facilitating cortical remapping as measured by fMRI. We randomized 10 consecutive adults in a 1:1 ratio to 90 days of FLX 20 mg daily vs placebo within 5 days of a stroke in the PCA ( n = 9) or MCA ( n = 1) territory causing an isolated homonymous field defect. Only one subject was treated with tPA. The primary outcome measure was percent improvement in perimetric mean deviation (PMD) as measured by automated Humphrey perimetry at 6 months. Eight subjects completed the study. Intention-to-treat analysis of the primary outcome measure showed a non-significant benefit of FLX ( n = 4) over placebo (70.5 ± 21.1% vs 30.1 ± 23.5%; one-tailed t -test, p = 0.12). Complete recovery occurred more frequently than expected in both groups (75% vs 25%), but was significantly greater than 12.5% only in the FLX group ( p = 0.007 vs p = 0.41). Percent improvement in PMD significantly correlated with scores on the 25-item Visual Functioning Questionnaire, a vision-targeted measure of health-related quality of life ( r 2 = 0.74; p = 0.012). Subjects in both groups who fully recovered showed fMRI evidence of cortical remapping by expansion and shifting of the center of their ipsilesional V1 receptive fields. In those with partial recovery, fMRI showed no cortical remapping, but a return of function in normal retinotopic locations, possibly due to recovery of “stunned” tissue. In conclusion, these results illustrate the feasibility of our approach, suggest a trend in favor of FLX, and have the potential to inform the design of a multi-center trial. Our fMRI analysis raises testable hypotheses about post-stroke recovery and suggests that FLX may improve outcomes by enabling the same kind of plasticity that underlies spontaneous recovery.

Abstract WP19: How Many Patients With Acute Ischemic Stroke Are Eligible to Apply Dawn and Defuse 3 Mismatch Criteria? Results From a Prospective Stroke Center Datebase

Background: Recent clinical trials have proven efficacy of endovascular therapy (EVT) for anterior circulation large vessel occlusion (acLVO). The DAWN and DEFUSE 3 trials have selected patients for EVT beyond 6h from symptom onset. We sought to determine how many patients of our center would qualify to apply advanced DAWN or DEFUSE 3 imaging criteria based on clinical symptoms and imaging with non-contrast CT (NCCT) and CT angiography (CTA). Methods: We prospectively registered consecutive ischemic stroke patients who were screened for EVT eligibility between 01/2016 and 12/2017. Of these patients, we identified those who fulfilled DAWN (age ≥18years, pre-morbid mRS score ≤1 , NIHSS score ≥10, onset-to-CT time 6-24 hours) and DEFUSE 3 (age 18- 90 years, pre-morbid mRS score ≤2, NIHSS score ≥6, onset-to-CT time 6-16 hours) inclusion criteria, respectively. Of these, we identified patients with acLVO on CTA and early ischemic changes in ≤1/3 of the middle cerebral artery territory (DAWN) or NCCT-ASPECTS >6 (DEFUSE-3), respectively. Results: Among 1011 patients who presented during the study period, 362 patients (36%) had an onset-to-CT time between 6-24 hours and 244 patients (24%) between 6-16 hours. Among the 6-24 hours cohort, 62 patients had an NIHSS score ≥10. Of these, 30 patients had acLVO of whom 13 patients had early ischemic changes ≤1/3 of the MCA territory on NCCT. Among the 6-16 hours cohort, 69 patients had an NIHSS score ≥6. Of these, 33 patients had acLVO of whom 18 patients had a NCCT-ASPECTS >6. Despite early ischemic changes in ≤1/3 of the MCA territory in 320 patients presenting >6 hours from symptom onset, no acute vascular imaging was performed in 108 patients. Overall, 19 patients (2% of the complete cohort) fulfilled clinical and imaging criteria utilized in DAWN or DEFUSE-3 trials. Of these, only 10 patients (1% of the complete cohort) received additional perfusion CT of whom 7 patients eventually underwent EVT. Conclusions: Only a minority (2%) of patients in our cohort would have qualified to apply advance imaging criteria based on DAWN or DEFUSE-3 trials for EVT beyond 6 hours from stroke onset. However, the positive results of these trials may have an impact on future assessment of EVT eligibility in patients presenting at a later time window.

Abstract TP509: Patterns of Injury in Children With Perinatal Arterial Ischemic Stroke and Infantile Spasms

Perinatal arterial ischemic stroke (AIS) occurs in 1 in 4000 live births and is the most common stroke in children. Consequences include seizures and a spectrum of cognitive and motor disability. Infantile spasms (IS) is an epileptic encephalopathy of infancy with an incidence of 2 in 10,000 live births. Approximately 5% of IS is caused by perinatal AIS. Patterns of ischemic injury that may predispose infants to IS and predict treatment response have not yet been identified. This retrospective case series of infants with AIS and IS provides detailed descriptions of ischemic distribution, seizure presentation, treatment and outcomes. Inclusion criteria were: term birth, ischemic stroke or encephalomalacia in an arterial distribution identified or presumed to have occurred in the perinatal period, a diagnosis of infantile spasms. Patients with a watershed pattern of injury were excluded. The modified pediatric ASPECTS was used to qualify and quantify the type and distribution of stroke. Areas of injury were identified on MRI and scored from T2/Flair or DWI sequences. Eleven patients with AIS and IS were identified. Of nine who fit inclusion criteria, all had MCA territory involvement with 6/9 having basal ganglia injury. Five had ischemia identified retrospectively after developing IS and four presented as neonates. The highest ASPECTS (bilateral deep MCA) was associated with the worst outcome in motor function and epilepsy control. However, the second-highest ASPECTS (unilateral MCA, bilateral ACA) had mild motor deficits and no seizure recurrence after IS resolution. The three lowest ASPECTS (<10) involved unilateral cortical MCA strokes sparing the deep structures, and also had the best motor outcome and seizure control. The co-occurrence of perinatal AIS and IS often results in significant neurologic disability. Although there was no defined pattern of regional homogeneity, there was a trend towards basal ganglia injury with progression of epilepsy after IS. This study highlights that size of ischemic injury may be less important than location as a predictor of motor outcome and seizure intractability. Future research will focus on identifying areas of injury that may confer increased risk of IS compared to stroke patients who remain seizure-free.

Abstract NS5: Is the Extended Time Window Approach Safe in Pediatric AIS? Lessons Learned From 3 Cases

Background: Pediatric stroke is a rare but important cause of mortality and morbidity in this population. Endovascular therapy up to 24 hours after symptoms onset is beneficial in adults LVO acute ischemic stroke (AIS), but no safety or efficacy data of this approach is available for patients <18. Methods and Results: We present three pediatric AIS cases (age 15-17) treated at GUH and WVU with endovascular techniques using extended time-window with selection based on perfusion criteria. Case 1 : 17 year old patient with history of Ebstein’s anomaly presented the day after a cardiac catheterization procedure with right hemiparesis and aphasia (NIHSS = 22). CTP identified left proximal ICA occlusion (ASPECTS score 7). Using the Penumbra device successful clot retrieval was achieved at 9:19 hours from onset. She was found to have a venous clot and right-to-left shunt from an atrial septal defect. 3 months mRS was 1. Case 2 : 17 y.o. female with 2 weeks history of intermittent right arm numbness presented with left hemiparesis and hemi-sensory loss (NIHSS 12). ER arrival time was 18:43 hours from the onset of sensory symptoms. CTP demonstrated complete right M1 occlusion secondary to right sub-clavian thrombus (ASPECTS score 8). Using the Solitaire stent retriever, recanalization was obtained at 20:05 hours after clinical onset. 3 months mRS was 1. Case 3 : 15 y.o female with Down syndrome, recently started on BCP woke up with right hemiparesis and aphasia (NIHSS = 22). MR perfusion demonstrated a distal M1/M2 clot with a large mismatch in the left MCA territory. Using a stent retriever device complete recanalization was obtained at 14:46 hours from the last time she was well. On the day of discharge her NIHSS was 7. Complete recanalization (TICI 3) was obtained in all three patients. No complications were observed during or following the procedure. NIHSS before and after the procedure improved by 11-to-17 points. Conclusions: A controlled study regarding endovascular approach in pediatric stroke is unlikely to occur. Therefore, case series must be reported in order to understand the safety of this approach. Strict patient selection and a team approach involving multiple pediatric and adult expertise are needed for a pediatric AIS response that includes endovascular intervention.

Abstract TMP38: Dysregulated Post-Stroke Immune Response is Associated With Cerebral Volume Loss in the Contralateral Non-Ischemic Hemisphere

Background: There is delicate homeostatic balance between the central nervous system and immune system. Cerebral insults, like ischemia, trigger an immune-depressive state to suppress a potential immune response directed against the neuroglial tissue; however, this supposedly protective reaction inadvertently creates an infection-prone state in the peri-stroke setting. In this study, we assessed the magnitude of cerebral volume loss in the unaffected contralateral hemisphere following stroke, and determined its relationship with the intimate cascades of inflammation, immune-depression and infection. Methods: The change in contralateral hemisphere volume was determined by voxel-based morphometry on admission and follow-up MRI’s in a consecutive series of 50 patients with ischemic stroke involving the MCA territory. Information related to clinical features, infectious complications, and markers of inflammation (erythrocyte sedimentation rate, neutrophil/lymphocyte ratio, C-reactive protein) and immunodepression (plasma high mobility group box 1 protein level; HMGB-1) were prospectively collected. Results: The contralateral hemisphere volume decreased by a median (interquartile range) of 2.80% (0.70-5.64) after a follow-up duration of 101 (63-123) days (p<0.001); the monthly volume reduction was 0.82% (0.18-1.79). Old age, stroke severity, neutrophil/lymphocyte ratio, and development of infections during hospitalization were significantly associated with monthly volume loss (p<0.05). Stroke severity (NIHSS score or infarct volume) and inflammation related parameters (neutrophil/lymphocyte ratio or systemic infections) remained independently and positively associated with monthly volume loss when assessed in multivariate regression models, while plasma HMGB-1 levels were inversely related to this loss. Conclusions: Cerebral tissue damage following stroke is not limited to the ischemic hemisphere. Apart from stroke severity, a pro-inflammatory state and an impaired immune-depressive response contribute to cerebral volume loss in the non-ischemic hemisphere.

Abstract TP181: Community Based Outpatient Stroke Rehabilitation Program Achieve Excellent Outcomes Including Return to Work, Driving, Stroke Education Knowledge, and Other Rehabilitation Outcomes

Background: Return to driving and employment are goals for many stroke survivors. There are few reports of patient centered outcomes including return to employment, driving, self efficacy, functional outcomes, stroke knowledge or characteristics of patients who achieve these goals. Methods: Prospective observational study of stroke patients treated in an interdisciplinary outpatient rehabilitation program addressing physical, cognitive, communicative, risk factors/stroke knowledge, self efficacy, psychosocial, driving and vocational issues. Results: 168 consecutive patients(104 men, 64 women, average age 62(18-90),61 aphasic)with baseline modified Rankin Scores of 5( 1%); 4(27%); 3(55%); 2(13%); 1(4%), and average NIHSS score of 6(range 0-16) were treated between 12/2011-7/2018. 116 patients suffered ischemic strokes(53 Left, 63 right, 24 bilateral hemisphere, 28 brainstem) and 52 had hemorrhages. 41% of patients had MCA territory strokes. Of 91 patients working pre-stroke, (47%) returned to work and and an additional 6% were work capable upon completion of program. 96% of patients driving pre-stroke could not drive at time of admission. After training, 45%(65/143) returned to driving. Patients had improvement in all 9 domains of Stroke Impact Scale with SIS total score improving an average of 26%. Patients received an average of 33 physical therapy visits with average percent improvement of 70% and 76% on 6 " walk and Berg Balance scores. Average Stroke Self Efficacy Scores improved from 74% to 82%. After individualized cardiovascular/stroke, and medication education sessions with the Nurse Practitioner based on AHA guidelines and Life's Simple 7's curriculum, Stroke Knowledge Quiz and risk factor knowledge scores improved 13% and 18%. Average length of stay was 5(range .5-20) months. Multiple other demographic and outcome measures are collected. Conclusions: Outcome data show a community-based team rehabilitation program can successfully combine cardiovascular education and rehabilitation services to maximize patient centered outcomes including return to work, driving, overall stroke recovery, physical functioning, stroke knowledge, and self efficacy for many types of stroke survivors with moderate to severe disability.

Abstract 48: Digital Brain Maps of 1018 Acute Supratentorial Large Artery Atherosclerotic Infarction

Background: Current territorial maps are difficult to interpret because of highly variable territorial boundaries noted, thus complicating the assessment of stroke mechanism . Objective: To offer further knowledge on the variable anatomy of cerebral artery territory by providing terriorial maps of the anterior, middle, and posterior cerebral arteries (ACA, MCA, and PCA, respectively). Methods and Results: Digital maps of supratentorial infarcts were generated using diffusion-weighted MRIs of 1160 acute (<1w) stroke patients (67.0±13.3 years old, 53.7% male) recruited consecutively from 11 academic stroke centers in Korea. All had supratentorial infarction due to significant stenosis or occlusion of one of the three large supratentorial arteries, but with patent intracranial/extracranial carotid arteries. The three vascular territories were mapped individually by affected vessel, generating three datasets for which infarct frequency is defined for each voxel in the dataset. By mapping these three vascular territories collectively, we generated datasets showing the certainty index (CI) to reflect the likelihood of a voxel being a member of a specific vascular territory, calculated as either ACA, MCA, or PCA infarct frequency / total infarct frequency in that voxel. We defined border-zone maps using relative frequencies or CI differences. The volume of the MCA territory (54.1% of the supratentorial parenchymal brain volume) was about 3-fold bigger than the volumes of the ACA (13.3%) and PCA territories (13.8%). Quantitative studies using the maps showed that the medial frontal gyrus, superior frontal gyrus, and anterior cingulate were involved mostly in ACA infarcts, whereas the middle frontal gyrus and caudate were involved mostly by MCA infarcts. The PCA infarct territory was smaller and narrower than traditionally shown. Infarct territories in posterior upper brain regions were complex with a z-axis dependent order of involvement. The width of overlapping border-zones was relatively narrow in the anterior boundary of the MCA territory compared with its posterior boundary. Conclusion: The new topographic brain atlas can be used in clinical care and research to objectively define the supratentorial arterial territories and their borders.

A case of bilateral internal carotid artery complete occlusion

Complete bilateral intracranial internal carotid artery occlusion is a rare disease with grave prognosis. It may cause recurrent stroke and extensive disability. We discuss a case of 62-year-old man who presented with sudden onset right sided hemiplegia, and GCS 7/15. CT scan revealed acute ischemic infarct in left MCA territory with mass effect and compression over the left lateral and third ventricle. Cerebral angiography showed bilateral intracranial internal carotid artery and middle cerebral artery occlusion. We present the case in view of wide range of presentation which depends on collateral formation and lack of specific guidelines for management.