Presence Of Intracerebral Hemorrhage Research Articles

Hospital admissions of spontaneous subarachnoid hemorrhage during the COVID-19 pandemic: Southeastern Turkey experience

Objective: This study aimed to determine if the coronavirus disease 2019 (COVID-19) pandemic had any impact on admission patterns for subarachnoid hemorrhage (SAH) during 1st and 2nd waves and in-between in a tertiary institution in southeastern Turkey. Methods: Three periods were determined during the pandemic: First and second peaks (April 1-May 1, 2020 and November 18-December 18, 2020, respectively) and the slowdown period (July 5-August 4, 2020) where the daily new cases hit its lowest. We retrospectively collected data of the patients with SAH who were admitted to our institution within these periods during 2020 (the pandemic) and 2019 (the year before the pandemic). Demographic data, time between symptom onset and admission, Glasgow Coma Scale (GCS), Fisher score, World Federation of Neurosurgical Societies (WFNS), presence of intracerebral hemorrhage, intraventricular hemorrhage, hydrocephalus, type of SAH (aneurysmal vs non-aneurysmal) were recorded and compared between the pandemic and pre-pandemic periods. Results: The number of admissions in first peak, slowdown, and second peak during the pandemic was 11, 15, and 17, respectively. They did not differ significantly from corresponding periods in 2019 (17, 7, and 10, respectively) (all P>0.05). The mean time from onset to admission to hospital was similar between pandemic and 2019 (ranging between 0.40-2.00 days in 2020 compared to ranging between 1.12-2.29 days in 2019). The rate of cases with worse neurological condition on admission turned out to be lower during the first peak of the pandemic compared to previous year (9.1% vs 29.4%, P=0.029), but showed no difference in the remaining two periods. The incidence of accompanying pathologies (intracerebral hemorrhage, intraventricular hemorrhage, and hydrocephalus) was also similar between the periods in 2020 and their counterparts in 2019. Rate of non-aneurysmal cases ranged between 11.1%-45.5% in 2020 compared to 10.0%-57.1% in 2019 (all P>0.05). Conclusion: The study showed that hospital admission patterns for SAH was not affected by COVID-19 pandemic in the southeastern Turkey, unlike other reports. This may be due to different behavioral characteristics of the study population and capability of health care system to cope with high number of patient admissions.

Vaccine-induced thrombotic thrombocytopenia (VITT): first report from India

BackgroundVaccine-induced thrombotic thrombocytopenia (VITT) is a rare but devastating adverse event following adenoviral vector-based vaccinations for COVID-19, resulting in thrombosis, especially of the cerebral and splanchnic vasculature. Despite the progress in laboratory techniques for early diagnosis, VITT remains a clinical diagnosis supplemented by coagulation studies. We report on VITT for the first time from India.CaseWe describe cortical venous sinus thrombosis and intracerebral bleed associated with severe thrombocytopenia in two young men who had no other contributory cause besides a recent ChAdOx1 nCoV-19 vaccination. The diagnosis was supported with PF-4 antibodies in one patient. The second patient’s test could not be processed to technical limitations. Both patients were treated with IVIG at 1 g/kg for 2 days and anticoagulation (Apixaban). One patient fully recovered with no residual deficits, and the other is under treatment and recovering.ConclusionVITT can cause devastating fatality and morbidity in otherwise healthy patients via potential immune-mediated effects. Clinicians should have a high suspicion index and treat VITT in the appropriate setting even if the PF-4 antibody testing by ELISA is unavailable or delayed. Though counterintuitive, clinicians must not delay the administration of non-heparin anticoagulation, IVIG and restrict platelet transfusion even in the presence of intracerebral haemorrhage.

Determinants of hyponatremia following a traumatic brain injury.

Hyponatremia is common in patients with central nervous system disease. It may prolong hospitalization and increase morbidity and mortality. However, the incidence and risks factors remain largely unknown in traumatic brain injury (TBI). The objectives of this study are to characterize hyponatremia in TBI patients and find its main risk factors. All patients admitted with a diagnosis of acute TBI over a 1-year period were included, except patients with known chronic hyponatremia, those who died within 72h, and those receiving hyperosmolar therapy to treat their intracranial hypertension. Sodium levels throughout hospitalization were collected. Post-traumatic hyponatremia was defined as follows: borderline (1-2 points below normal and 1-2days duration) and significant (more than 2 points below normal and/or more than 2days duration). Demographic data, GCS, mechanism of injury, and CT findings were collected. These factors were correlated to the incidence of hyponatremia. Hyponatremia was found in 29% of the 283 included patients and was significant in 2/3 of the cases. Significant hyponatremia had a narrower peak, between 7 and 11days, while borderline hyponatremia started earlier and was more distributed in time. Factors associated with hyponatremia were greater age (p = 0.004), worse ISS (p = 0.017), worse Marshall Grade on CT (p = 0.007), and a diffuse pattern of injury on CT (p < 0.001). Significant hyponatremia was associated with: a diffuse pattern of injury on CT (p = 0.032), the presence of intracerebral hemorrhage (p = 0.027), and multiple lesions on CT (p = 0.043). Post-traumatic hyponatremia is common and can lead to serious consequences in TBI patients. Adequate monitoring and treatment are therefore important. Older patients and those with more significant injury on CT are more at risk.

Predictors of mortality in thrombotic thrombocytopenia after adenoviral COVID-19 vaccination: the FAPIC score.

AimsThe clinical manifestation and outcomes of thrombosis with thrombocytopenia syndrome (TTS) after adenoviral COVID-19 vaccine administration are largely unknown due to the rare nature of the disease. We aimed to analyse the clinical presentation, treatment modalities, outcomes, and prognostic factors of adenoviral TTS, as well as identify predictors for mortality.Methods and ResultsPubMed, Scopus, Embase, and Web of Science databases were searched and the resulting articles were reviewed. A total of 6 case series and 13 case reports (64 patients) of TTS after ChAdOx1 nCoV-19 vaccination were included. We performed a pooled analysis and developed a novel scoring system to predict mortality. The overall mortality of TTS after ChAdOx1 nCoV-19 vaccination was 35.9% (23/64). In our analysis, age ≤60 years, platelet count <25 × 103/µL, fibrinogen <150 mg/dL, the presence of intracerebral haemorrhage (ICH), and the presence of cerebral venous thrombosis (CVT) were significantly associated with death and were selected as predictors for mortality (1 point each). We named this novel scoring system FAPIC (fibrinogen, age, platelet count, ICH, and CVT), and the C-statistic for the FAPIC score was 0.837 (95% CI 0.732–0.942). Expected mortality increased with each point increase in the FAPIC score, at 2.08, 6.66, 19.31, 44.54, 72.94, and 90.05% with FAPIC scores 0, 1, 2, 3, 4, and 5, respectively. The FAPIC scoring model was internally validated through cross-validation and bootstrapping, then externally validated on a panel of TTS patients after Ad26.COV2.S administration.ConclusionsFibrinogen levels, age, platelet count, and the presence of ICH and CVT were significantly associated with mortality in patients with TTS, and the FAPIC score comprising these risk factors could predict mortality. The FAPIC score could be used in the clinical setting to recognize TTS patients at high risk of adverse outcomes and provide early intensive interventions including intravenous immunoglobulins and non-heparin anticoagulants.

Surgical Treatment of Cerebral Aneurysms in the Acute Period of Subarachnoid Hemorrhage: Long-Term Result

Surgical Treatment of Cerebral Aneurysms in the Acute Period of Subarachnoid Hemorrhage: Long-Term Result

Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) as a radiographic marker of clinically relevant intracranial hypertension and unfavorable outcome after subarachnoid hemorrhage.

The severity of early brain edema (EBE) after aneurysm rupture was reported to be strongly associated with the risk of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Using the recently developed Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), we analyzed the predictors of EBE and its impact on complications related to intracranial pressure (ICP) increase after SAH and on poor outcome. All consecutive SAH cases treated between January 2003 and June 2016 with assessable SEBES were included (n=745). Data on demographic characteristics, medical history, initial severity of SAH, need for conservative ICP treatment and decompressive craniectomy, occurrence of cerebral infarctions and unfavorable outcome at 6months (modified Rankin scale score>2) were collected. Univariable and multivariable analyses were performed. Younger age (<55years; adjusted odds ratio [aOR]3.16, 95% confidence interval [CI]2.28-4.38), female sex (aOR1.64, 95% CI1.16-2.31), poor initial clinical condition (World Federation of Neurosurgical Societies score4-5; aOR1.74, 95% CI1.23-2.46), presence of intracerebral hemorrhage (aOR1.63, 95% CI1.12-2.36), hypothyroidism (aOR0.60, 95% CI0.37-0.98) and renal comorbidity (aOR0.29, 95% CI0.11-0.78) were independently associated with SEBES (scores 3-4). There was an independent association between SEBES3-4 and the need for conservative ICP treatment (aOR2.43, 95% CI1.73-3.42), decompressive craniectomy (aOR2.68, 95% CI 1.84-3.89), development of cerebral infarcts (aOR2.24, 95% CI1.53-3.29) and unfavorable outcome (aOR1.48, 95% CI1.0-2.17). SEBES is a reliable predictor of ICP-related complications and poor outcome of SAH. Our findings highlight the need for further research of the impact of patients' demographic characteristics and comorbidities on the severity of EBE after SAH.

Microbubble-mediated sonothrombolysis with BR38 of a venous full blood thrombus in a rat embolic stroke model.

BackgroundEarly recanalization of an occluded vessel is associated with a better clinical outcome in acute ischemic stroke. Intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA) is only available in a minority of patients and often fails to reopen the occluded vessel. Mechanical recanalization is more effective in this matter but only available for selected patients when a thrombectomy centre can be reached. Therefore, sonothrombolysis might represent an alternative or complementary approach. Here, we tested microbubble-mediated sonothrombolysis (mmSTL) in a thromboembolic stroke model for middle cerebral artery occlusion (MCAO) in rats.MethodsSixty-seven male Wistar rats underwent MCAO using an autologous full blood thrombus and were randomly assigned to four groups receiving rt-PA, mmSTL, a combination of both, or a placebo. Diagnostic workup included neurological examination, assessment of infarct size, and presence of intracerebral haemorrhage by magnetic resonance imaging (MRI) and presence of microbleedings in histological staining.ResultsNeurological examination revealed no differences between the treatment groups. In all treatment groups, there was a reduction in infarct size 24 hours after MCAO as compared to the placebo (P≤0.05), but there were no differences between the active treatment groups (P>0.05) (placebo 0.75±0.10 cm3; mmSTL 0.43±0.07 cm3; rt-PA 0.4±0.07 cm3; mmSTL + rt-PA 0.27±0.08 cm3). Histological staining displayed intracerebral microbleedings in all animals. The frequency of gross bleeding detected by MRI did not differ between the groups (placebo 3; mmSTL 4; rt-PA 2; mmSTL + rt-PA 2; P>0.05) and was not associated with worse performance in clinical testing (P>0.05). There were no statistical differences in the mortality between the groups (P>0.05).ConclusionsOur study showed the efficacy and safety of mmSTL with or without rt-PA in an embolic rat stroke model using a continuous full blood thrombus. Sonothrombolysis might be useful for patients who need to be transported to a thrombectomy centre or for those with distal vessel occlusion.

Abstract P442: The Association of Amyloid and Tau Burden With Centrum Semiovale Perivascular Spaces in Cerebral Amyloid Angiopathy

Background: The mechanisms linking cerebral amyloid angiopathy (CAA) to enlarged perivascular spaces in centrum semiovale (CSO-EPVS) and whether other Alzheimer’s Disease (AD) pathologies might affect CSO-EPVS are unclear. We hypothesized that amyloid but not tau load would independently correlate with CSO-EPVS in CAA. Methods: Fifty prospectively enrolled nondemented probable CAA patients underwent high-resolution structural MRI, Pittsburgh compound B (PiB, for amyloid), and 18 F-flortaucipir (FTP, for tau) PET imaging. Microbleeds (all lobar, LMB) were counted and white matter hyperintensity volume (WMH) was quantified. CSO-EPVS were counted on T 2 -MRI sequence and graded using a previously validated scale (range 0-4). A multivariate ordinal regression model was used to assess the independent associations between CSO-EPVS and mean cortical amyloid as well as tau deposition, after adjusting for relevant covariates. Results: Patients had a mean age of 69.3±7.2. Age, sex, presence of hypertension, intracerebral hemorrhage (ICH), LMB counts, and WMH were not associated with CSO-EPVS grades (p&gt;0.2 for all comparisons). Higher PiB uptake significantly correlated with increased CSO-EPVS (rho=0.45, p=0.001). Higher FTP showed a trend for correlation with CSO-EPVS (rho=0.26, p=0.069). In an ordinal regression model with CSO-EPVS grade as the dependent variable and both amyloid and tau levels included as predictors along with covariates presented above, the association of CSO-EPVS remained significant with higher PiB uptake (β=3.97, 95%CI 1.1-6.8, p=0.007) but not with FTP uptake (p=0.167). Conclusion: Results of this study suggest that CSO-EPVS is independently associated with amyloid but not with tau deposition in CAA. CSO-EPVS was not associated with age or classical vascular risk factors or presence of ICH. Our results support the view that vascular amyloid but not other AD pathologies such as tau might contribute to EPVS in patients with CAA.

Abstract 6: The Effect of Vascular Amyloid on White Matter Disease is Mediated by Vascular Dysfunction in Cerebral Amyloid Angiopathy

Background: Cerebral amyloid angiopathy (CAA) is associated with white matter hyperintensities (WMH) but the physiopathological mechanisms remain unclear. We hypothesized that the relationship between vascular amyloid load and WMH is mediated by vascular dysfunction. Methods: The study cohort included 38 non-demented probable CAA patients who underwent advanced multimodal structural and functional MRI (fMRI) and amyloid PET scans. White matter hyperintensity volume was quantified using FreeSurfer and expressed as a percent of total intracranial volume (pWMHv). Time-to-peak [TTP] of blood oxygen level-dependent [BOLD] response to visual stimulation using fMRI was used as an established measure of vascular dysfunction. Mean cortical Pittsburg Compound B uptake representing amyloid load was calculated. A bootstrapping procedure was used to test the mediation hypothesis adjusting for age, sex, and presence of intracerebral hemorrhage (ICH). Results: Of 38 patients with CAA (mean age 70±7.1, 86.8% male), 25 (65.8%) had ICH, while the remaining 13 patients (34.2%) presented with multiple strictly cortical microbleeds. Higher amyloid load correlated with prolonged TTP response (r=0.373, p=0.021) and higher pWMHv (r=0.337, p=0.039), and prolonged TTP response correlated with higher pWMHv (r=0.485, p=0.002). Amyloid load no longer predicted pWMHv (p=0.254) after controlling for TTP. In the bootstrapping model, TTP response had a significant indirect effect (ab=0.977, 95% CI: 0.15-2.42), showing that the association between amyloid load and pWMHv is mediated by TTP. Discussion: Our findings confirm the hypothesis that the effect of vascular amyloid load on the extent of white matter disease is mediated by vascular dysfunction in patients with CAA. Amyloid lowering strategies might prevent pathophysiological processes leading to vascular dysfunction, therefore limiting ischemic brain injury.

Complex intracranial vascular complications caused by essential thrombocythemia: a critical case report

BackgroundEssential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by elevated and dysfunctional platelets. ET can result in systemic thrombotic and hemorrhagic complications, and it’s a rare cause of stroke. The coexistence of multiple vascular lesions has seldom been reported in patients with essential thrombocythemia.Case presentationA young woman presented with isolated and persistent vertigo and vomiting. The CT scan indicated a hyperdense lesion in the right cerebellar hemisphere. No signs of cerebral artery malformation were observed in the CT angiography (CTA). Besides, the blood tests indicated an increase in platelet and white blood cell counts. The patient then suddenly developed a transient unconsciousness with left horizontal nystagmus when staring to the right. The subsequent cranial magnetic resonance imaging (MRI) scans indicated a diffuse and acute infarction of the pons and hemorrhage in the bilateral cerebellums. Further digital subtraction angiography (DSA) revealed a progressive and critical intracranial vertebral arterial occlusion. The patient’s clinical condition stabilized after cytoreductive therapy with interferon-α (IFN-α), even though endovascular and antiplatelet treatments were restricted because of the simultaneous presence of intracerebral hemorrhage (ICH) and ischemic stroke. A JAK2 V617F mutation was later detected through genetic testing, further confirming the diagnosis of ET. The patient was treated with a continuous regimen of IFN-α, and an antiplatelet treatment (aspirin) was added after ICH. The 1-year follow-up indicated normal platelet levels and no additional stroke event.ConclusionsThis case demonstrates that ET can be a rare cause of the cerebrovascular disease (CVD), even though the coexistence of ischemic and hemorrhagic complications. Underlying hematological system diseases should be taken into account when abnormal hemogram and CVD are concurrent in a patient. An early multidisciplinary diagnosis and intervention could significantly improve patient’s prognosis.

Utility of the Hijdra Sum Score in Predicting Risk of Aneurysm in Patients With Subarachnoid Hemorrhage: A Single-Center Experience With 550 Patients.

Subarachnoid hemorrhage (SAH) is most commonly caused by a ruptured vascular lesion. A significant number of patients presenting with SAH have no identifiable cause despite extensive cerebrovascular imaging at presentation. Significant neurological morbidity or mortality can result from misdiagnosis of aneurysm. To generate a model to assist in predicting the risk of aneurysm in this patient population. We conducted a retrospective study of all patients aged≥18 yr admitted to a single center from March 2008 to March 2018 with nontraumatic SAH (n=550). Patient information was compared between those with and without aneurysm to identify potential predictors. Odds ratios obtained from a logistic regression model were converted into scores which were summed and tested for predictive ability. Female sex, higher modified Fisher or Hijdra score, nonperimesencephalic location, presence of intracerebral hemorrhage, World Federation of Neurosurgical Societies (WFNS) score≥3, need for cerebrospinal fluid diversion on admission, and history of tobacco use were all entered into multivariable analysis. Greater modified Fisher, greater Hijdra score, WFNS≥3, and hydrocephalus present on admission were significantly associated with the presence of an aneurysm. A model based on the Hijdra score and SAH location was generated and validated. We show for the first time that the Hijdra score, in addition to other factors, may assist in identifying patients at risk for aneurysm on cerebrovascular imaging. A simple scoring tool based on patient sex, SAH location, and SAH burden can assist in predicting the presence of an aneurysm in patients with nontraumatic SAH.

Abstract WP65: Clinical and Radiographic Characterization of Cerebral Hyperdensities on Post-thrombectomy Conventional Non-contrast Ct Brain: Differentiating Between Contrast Staining and Post-thrombectomy Hemorrhage

Background: Post-interventional cerebral hyperdensities (PCHD) are present 31.2 to 87.5% of the time on post-thrombectomy (PT) CT. It can be difficult for radiologists to differentiate if PCHD represents intracerebral hemorrhage (ICH) or contrast staining using conventional CT. The ability to accurately determine the etiology of PCHD may be important for a patient’s outcome. Methods: We retrospectively investigated clinical risk factors, imaging findings, and interventional technique of patients who had a thrombectomy from 2011-2017 (n=238) at a Comprehensive Stroke Center. 112 patients with anterior circulation infarcts and immediate PT CTs as well as either a PT MRI or follow-up CT within 48 hours were included. Two experienced neuroradiologists interpreted all imaging. Baseline demographics and imaging characteristics were collected. The presence of ICH was determined by dephasing on gradient echo or by its persistence &gt; 2 days on repeat CT. Chi-square and Fisher’s exact tests were used for statistical significance, and logistic regression to determine risk estimates. Results: 84% of patients had PCHD, of which 56% had ICH. Patients had similar demographics (ICH: median age 69, 47.5% female; non-ICH: median age 71, 42.5% female). Higher pre-thrombectomy ASPECTS score (OR 0.62, p &lt; 0.05) decreased the risk of ICH, and higher Hounsfield units (HU) of PCHD both on immediate (OR 1.04, p &lt; 0.05) and intermediate (OR 1.1, p &lt; 0.0005) PT CT increased the risk of ICH. PCHDs in the deep grey matter (OR 2.84, p &lt; 0.05) and demonstrating a confluent pattern (OR 3.9 p &lt; 0.05) increased the likelihood of ICH. 10% increase risk of ICH was seen for every HU increase in density on PT CT at 24 or 48 hours. A 50% decrease in ICH was observed for each unit increase of the pre-thrombectomy ASPECTS score. ROC revealed the optimal cut-off for predicted probability as 0.64, sensitivity 70.2% and specificity 69.2%. The AUC for the predicted model was 0.84 (95%CI= (0.75- 0.92, p &lt;0.0001). Conclusion: Several imaging characteristics of PCHDs and ASPECTS score can help differentiate between the PT ICH and contrast staining. Application of these variables to patients in the immediate PT period may change clinical management.

Abstract TP155: Predictive Values of Glasgow Coma Scale and National Institutes of Health Stroke Scale Scores in Determining 3-Month Outcomes of Patients With Intracerebral Hemorrhage

Background: Intracerebral hemorrhage (ICH) is associated, with high rates of mortality, and long-term disability. We investigated the predictive values of the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) in the prognosis of mortality and functional outcome in patients with ICH. Methods: A total of 1000 patients recruited in a clinical trial with acute were assessed using GCS and NIHSS at admission. Then, the receiver operating characteristic (ROC) curves were established, and the area under the curves of these 2 scoring systems was compared. The primary outcome was death or disability (modified Rankin scale (mRS) score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments. Results: The area under the curve of GCS and NIHSS was 0.660 (95% confidence interval: 0.593-0.727) and 0.708 (95% confidence interval: 0.640-0.755), respectively, for predicting disability among survivors. The area under the curve was 0.655 (95% confidence interval: 0.621-0.688) and 0.788 (95% confidence interval: 0.759-0.817), respectively for prediction of 3-months death or disability among all patients with ICH. The GCS predicted 3-month disability among survivors with a sensitivity of 68.7% and a specificity of 57.7%, and the NIHSS predicted 3-month disability with a sensitivity of 74.6% and a specificity of 62.3%. The GCS predicted 3-month death or disability among all patients with a sensitivity of 60.5% and a specificity of 66.5%, and the NIHSS predicted 3-month death or disability with a sensitivity of 80.1% and a specificity of 66.8%. NIHSS (P&lt;0.0001) and GCS (P=0.0002) scores had a statistically significant predictive value for the presence of intracerebral hemorrhage among survivors. Among all patients, NIHSS (P&lt;0.0001) and GCS (P&lt;0.0001) scores also had statistically significant predictive value for identifying patients at risk for death or disability at three months. Conclusions: GCS and NIHSS scales have good predictive values for the prognosis of patients with ICH as regards of mortality and disability. The NIHSS is more accurate than the GCS in predicting death or disability in patients with ICH.

Management of Tandem Cervical Internal Carotid Artery Stenosis and Large Vessel Occlusion During Acute Stroke: A Single Institution's Initial Experience

Abstract INTRODUCTION Thrombectomy for large vessel occlusion (LVO) has become a well-established treatment for acute stroke. Management of tandem internal carotid artery (ICA) stenosis in thrombectomy patients can be challenging, as no formal treatment algorithm exists for this unique pathology. We present a single institution's experience with the acute treatment of ICA stenosis during or after thrombectomy with either carotid artery stent (CAS) or carotid endarterectomy (CEA). METHODS A retrospective analysis was performed on all patients who underwent thrombectomy with tandem ICA stenosis at our institution. All demographic, stroke presentation, stroke treatment, cervical carotid stenosis treatment, and follow-up data were analyzed for these patients. RESULTS From 2015 to 2018, 31 patients with tandem ICA stenosis underwent thrombectomy for LVO. Of these patients, 26 had a CAS placed, 25 of which were done at time of thrombectomy, and 1 placed 5 d after thrombectomy. CAS patients were placed on antiplatelet therapy after stent placement. Of the 25 patients who had CAS placed at time of thrombectomy, 5 patients had a symptomatic ICH, 4 of which did not survive the hospitalization. Two additional CAS patients did not survive hospitalization. There were 5 patients who had a CEA performed during the same hospital stay, ranging from 1 to 10 d post-thrombectomy. Patients who underwent CEA had a smaller area of infarct and a shorter thrombectomy procedure time when compared to the CAS patients, and all CEA patients survived hospitalization, with good outcomes. CONCLUSION CAS placement for tandem ICA stenosis at time of thrombectomy may be less safe than previously published. Early, but not simultaneous, intervention on cervical ICA stenosis after thrombectomy allows for the assessment of infarct volume, patient recovery, and the presence of intracerebral hemorrhage, and thus provides the opportunity to appropriately select patients who would benefit from treatment of the carotid stenosis with either CAS or CEA.

Prognostic variables and outcome in relation to different bleeding patterns in arteriovenous malformations.

Subarachnoid hemorrhage as bleeding pattern occurs rarely in ruptured arteriovenous malformations (AVM). The aim of the present study is to evaluate different bleeding patterns in hemorrhages due to an AVM and their impact on outcome in terms of risk and treatment stratification. We evaluated 158 patients with ruptured AVMs who were admitted to our neurosurgical department from 2002 to 2017. We compared different bleeding patterns, such as intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or both (ICH + SAH) and evaluated predictive variables for outcome in the last follow-up. ICH was found in 48.7% of patients, isolated SAH in 20.9% of patients, and both in 30.4% of patients. The mean parenchymal blood volume was 34.5cm3. 38.6% of the patients had AVM-associated aneurysms, mostly located pre-nidal (77%). AVMs with ruptured aneurysms often resulted in ICH with SAH component (p < 0.001) and SAH pattern occurred more often infratentorial (p = 0.003). In a multivariate logistic regression model, poor clinical state on admission (WFNS IV-V) (p < 0.01), eloquence, infratentorial location (p = 0.05), and presence of ICH with SAH component (p = 0.02) were the most relevant predictors of a poor outcome after AVM rupture. Bleeding pattern in AVM hemorrhage depends on angioarchitectural and hemodynamic features and SAH component predicts outcome negatively. AVM-associated pre-nidal aneurysms may harbor a higher risk for rupture and SAH pattern when located infratentorial. Treatment decisions and risk stratifications should be considered in view of these findings.

Abstract 103: Cortical tau Pathology in Cerebral Amyloid Angiopathy

Introduction: Cerebral amyloid angiopathy (CAA), a condition related to Alzheimer’s Disease, causes ischemic and hemorrhagic brain injury and contributes to cognitive impairment. Vascular amyloid, the hallmark of CAA, can be detected using amyloid PET imaging. We used selective tau imaging to understand the degree and associations of tau aggregation and deposition in patients with CAA. Methods: Thirty-four patients with probable CAA but without cognitive impairment were prospectively enrolled. Selective tau imaging was performed using PET tracer flortaucipir (FTP) and amyloid imaging was obtained with Pittsburgh Compound B PET. Global and region of interest based (ROI) standardized uptake value ratios (SUVR) were calculated from PET acquisitions. High resolution multimodal MRIs were obtained for each patient and markers of CAA-related structural injury were quantified. Results: The mean age ( + SD) of the patients was 69 + 6, 38% were female. Thirteen patients (38%) enrolled without intracerebral hemorrhage (ICH). Mean cortical FTP uptake was 1.18 + 0.11 (tau load, in SUVR). Five patients were tau positive based on FTP SUVR &gt; 1.28 from a posterior cingulate cortex ROI, a previously validated method. Mean global cortical FTP uptake correlated with cortical amyloid load (r=0.37, p=0.04), centrum semiovale perivascular spaces (cs-PVS, r=0.49, p=0.004), extent of cortical superficial siderosis (cSS, r=0.44, p=0.01), and showed a trend for correlation with extent of leukoaraiosis (r=0.33, p=0.059). The associations with amyloid load and cs-PVS remained significant in multivariable models. Cortical FTP uptake was not associated with age, sex, vascular risk factors, presence of ICH or any of the CAA-related focal lesions (cerebral microbleeds, microinfarcts, lacunes), all p&gt;0.2. Conclusions: Our results show that many patients with CAA have some degree of cortical tau deposition, but severe tau positivity was not frequent (15%) in this cognitively normal CAA cohort, considering that 30% of healthy older adults were positive in other studies. The associations of cortical tau with brain amyloid and CAA-specific markers of global brain injury suggest that vascular amyloid might trigger tau deposition which, in turn, might increase parenchymal damage.

Aneurysm rebleeding before therapy: a predictable disaster?

OBJECTIVECurrent guidelines for subarachnoid hemorrhage (SAH) include early aneurysm treatment within 72 hours after ictus. However, aneurysm rebleeding remains a crucial complication of SAH. The aim of this study was to identify independent predictors allowing early stratification of SAH patients for rebleeding risk.METHODSAll patients admitted to the authors' institution with ruptured aneurysms during a 14-year period were eligible for this retrospective study. Demographic and radiographic parameters, aneurysm characteristics, medical history, and medications as well as baseline parameters at admission (blood pressure and laboratory parameters) were evaluated in univariate and multivariate analyses. A novel risk score was created using independent risk factors.RESULTSData from 984 cases could be included into the final analysis. Aneurysm rebleeding occurred in 58 cases (5.9%), and in 48 of these cases (82.8%) rerupture occurred within 24 hours after SAH. Of over 30 tested associations, preexisting arterial hypertension (p = 0.02; adjusted odds ratio [aOR] 2.56, 1 score point), aneurysm location at the basilar artery (p = 0.001, aOR 4.5, 2 score points), sac size ≥ 9 mm (p = 0.04, aOR 1.9, 1 score point), presence of intracerebral hemorrhage (p = 0.001, aOR 4.29, 2 score points), and acute hydrocephalus (p < 0.001, aOR 6.27, 3 score points) independently predicted aneurysm rebleeding. A score built upon these parameters (0-9 points) showed a good diagnostic accuracy (p < 0.001, area under the curve 0.780) for rebleeding prediction.CONCLUSIONSCertain patient-, aneurysm-, and SAH-specific parameters can reliably predict aneurysm rerupture. A score developed according to these parameters might help to identify individuals that would profit from immediate aneurysm occlusion.

Abstract WP63: Global Cerebral Edema is Associated With Worse Outcomes in Patients With Cerebral Venous Sinus Thrombosis

Background and Purpose: Obstruction of venous drainage may lead to venous hypertension, edema, infarction or intracerebral hemorrhage (ICH) in patients with cerebral venous thrombosis (CVST). While the presence of ICH and infarction are associated with worse outcomes, the independent effect of edema remains unknown. We aimed to evaluate the impact of the characteristics of brain edema on functional outcomes as measured by the modified Rankin Scale (mRS) at discharge. Methods: We retrospectively reviewed all patients who presented to the University of Iowa Health Care with CVST between 2004-2014. All patients received standard of care management per available AHA/ASA recommendations. Edema was categorized as focal vasogenic, focal cytotoxic or global cerebral edema (GCE). Vasogenic edema was described as hyperintensity on FLAIR MRI sequences around the location of venous clot while cytotoxic edema was noted when hyperintensities were visualized around the location of ICH/ venous infarction on FLAIR or DWI respectively. GCE was scored when bilateral finger-like extensions into gray white junction and effacement of gyri/sulci were seen on CT scans as described by Claassen et al. Edema scorer was blinded to outcome measures. Multiple regressions were conducted on mRS outcome to test hypotheses of interest. A p value ≤ 0.05 was set as statistically significant. Results: 115 patients met inclusion criteria, 76 women, mean age 42. A total of 30(26%) had venous infarction, 34(30%)ICH , 57(50%) had cerebral edema(20% vasogenic, 35% cytotoxic and 32% GCE). The three edema types together explained 22% variance in discharge mRS (p&lt;.001). The effect of GCE remained significant (p=.001) when adjusting for age, presence/absence of ICH and infarct. The 95%CIs for discharge mRS among those with GCE [2.89-4.17] compared to those without GCE [1.44-2.12]. Vasogenic and cytotoxic edema did not contribute significantly to prediction in multivariate analyses. Conclusions: Characterization of early cerebral edema might contribute to a better prognostication of high risk patients after CVTS. GCE in particular forecast an unfavorable outcome. Further understanding of its pathogenesis may represent a new therapeutic window for refractory patients to standard therapies.

Cerebral Microbleeds, Hypertension, and Intracerebral Hemorrhage in Cerebral Autosomal-Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy.

Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common genetic cause of stroke. In addition to ischemic stroke, CADASIL predisposes to development of cerebral microbleeds (CMB). CMB and hypertension are known to be associated with intracerebral hemorrhage (ICH). The purpose of this study was to analyze the relationships among CMB, hypertension, and ICH in CADASIL. We enrolled 94 genetically confirmed CADASIL patients from 76 unrelated families at Jeju National University Hospital (Korea) between March 2012 and February 2015. We analyzed CMB presence, number, and distribution on susceptibility-weighted imaging MRI using the microbleed anatomical rating scale. Multiple logistic regression was used to determine factors associated with the presence of CMB and ICH. CMB were observed in 62 patients (66%), median number of CMB per patient was 4 (range 0-121). Twenty-two ICHs were found in 16 patients (17%). There was incongruence between the most common site of CMB (thalamus) and that of ICH (basal ganglia). Hypertension was independently associated with the presence of CMB (multiple regression OR, 2.71; 95% CI 1.02-7.18, p < 0.05), and CMB ≥ 9 (highest third) was significantly associated with the presence of ICH (multiple regression OR = 9.50, 95% CI 1.08-83.71, p < 0.05). In this CADASIL sample, presence of hypertension was independently associated with CMB presence, and CMB burden was independently associated with ICH. Incongruence of sites for CMB and ICH is currently unexplained and requires further study.

Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol.

Rationale Multimodal imaging, including computed tomography angiography and computed tomography perfusion imaging, yields additional information on intracranial vessels and brain perfusion and can differentiate between ischemic core and penumbra which may affect patient selection for intravenous thrombolysis. Hypothesis The use of multimodal imaging will increase the number of patients receiving intravenous thrombolysis and lead to better treatment outcomes. Sample size 400 patients. Methods and design PRACTISE is a prospective, multicenter, randomized, controlled trial in which patients presenting within 4.5 h of symptom onset are randomized to either the current evidence-based imaging (NCCT alone) or additional multimodal computed tomography imaging (NCCT + computed tomography angiography + computed tomography perfusion). Clinical decisions on intravenous recombinant tissue plasminogen activator are documented. Total imaging time in both arms and time to initiation of treatment delivery in those treated with intravenous recombinant tissue plasminogen activator, is recorded. Follow-up will include brain imaging at 24 h to document infarct size, the presence of edema and the presence of intra-cerebral hemorrhage. Clinical evaluations include NIHSS score at baseline, 24 h and day 7 ± 2, and mRS at day 90 to define functional outcomes. Study outcomes The primary outcome is the proportion of patients receiving intravenous recombinant tissue plasminogen activator. Secondary end-points evaluate times to decision-making, comparison of different image processing software and clinical outcomes at three months. Discussion Multimodal computed tomography is a widely available tool for patient selection for revascularization therapy, but it is currently unknown whether the use of additional imaging in all stroke patients is beneficial. The study opened for recruitment in March 2015 and will provide data on the value of multimodal imaging in treatment decisions for acute stroke.