Vascular Neurology Research Articles

Abstract WP47: Creation of a Pediatric Stroke Alert Protocol

Background: In 2021, our Comprehensive Stroke Center (CSC) in San Antonio (SA), Texas received 7 pediatric patients suffering from signs and symptoms of stroke. These patients ranged in age from 4-17 and approximately 57% were positive for an acute ischemic stroke (AIS). During the month of March, 2 patients were brought in via EMS and both MRIs were positive for AIS, prompting our stroke team to evaluate our adult processes. We concluded that an Emergency Department (ED) Pediatric Stroke Alert Protocol was needed in order for our hospital to have the capability to care for this patient population, and also appropriately triage and offer acute therapies to give these patients the best chance possible. Purpose: Develop an ED Pediatric Stroke Alert Protocol in order to provide rapid triage and advanced therapies if warranted. The ED Pediatric Stroke Alert protocol was developed with our same stroke alert time frame in mind, 0-6 hours, and with the age range of 2-17 years. Methods: An interdisciplinary team consisting of Vascular neurology, Pediatric Neurology, Pediatric Hematology/Oncology, Pediatric Critical Care nursing, Pediatric / Adult ED nursing & Faculty, Neuro Critical Care, Pharmacy, and our Stroke Team met to discuss how to implement a pediatric protocol. It was decided that modeling it after the Adult ED Stroke Alert Protocol would be best to limit confusion and triage errors. The Cincinnati Stroke Scale was used as the tool of choice in order for our ED team to identify stroke symptoms, also a time frame of less than 6 hours from onset of symptoms AND a blood glucose between 60 and 600. This would then prompt the activation of the Pedi ED Stroke Alert Protocol. Triage on the protocol includes inclusion and exclusion criteria for IV tPA, which was also tailored to the pediatric population with the help of Pediatric Hematology/Oncology. Results: The ED Pedi SA Protocol has since been revised to meet the needs of our changing pediatric stroke population. The CSC continues to treat pediatric patients and continues to develop other tools to meet the needs of this population. Conclusion: Our CSC has been categorized by EMS as one of the only CSCs in SA, Texas that is capable of providing complete stroke care to the pediatric population.

Retraction: Anterior Circulation Thrombectomy in Patients With Low National Institutes of Health Stroke Scale Score: Analysis of the National Inpatient Sample

The following article, published online on August 23, 2023 in Stroke: Vascular and Interventional Neurology , has been retracted by mutual agreement between the authors and the journal Editors. The retraction has been issued at the authors’ request. Patel et al Anterior Circulation Thrombectomy in Patients With Low National Institutes of Health Stroke Scale Score: Analysis of the National Inpatient Sample. Stroke: Vascular and Interventional Neurology . 2023, e000998. https://www.ahajournals.org/doi/10.1161/SVIN.123.000998 After publication, an error was discovered that pertains to the misclassification of two variables in the National Inpatient Sample. Specifically, the variables for endovascular therapy and intravenous thrombolysis were mistakenly switched. Given that this error significantly alters the original results and conclusions, the authors have requested to retract the article. The authors regret these errors and appreciate the opportunity to correct the published record. All parts of the article that were affected by the error have been corrected and republished online: https://www.ahajournals.org/doi/10.1161/SVIN.123.001283

Patterns of Care in the Diagnosis and Management of Intracranial Atherosclerosis‐Related Large‐Vessel Occlusion: The Rescue‐LVO Survey

Background We aimed to determine the current practice patterns among neurointerventional practitioners frequently involved in treating intracranial atherosclerosis‐related large‐vessel occlusion (ICAS‐LVO) during mechanical thrombectomy. Methods We conducted an international online survey of neurointerventionalist members of the Society of Vascular and Interventional Neurology and Society of Neurointerventional Surgery. The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. Results A total of 184 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 38.3% reported an incidence of 6% to 10% of ICAS‐LVO during mechanical thrombectomy. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis after multiple mechanical thrombectomy attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS)±angioplasty. However, in patients who achieved recanalization with a severe fixed focal stenosis, most (58%) recommended primary medical management. The preferred medication during acute RS was intravenous antiplatelet therapy (65%), and after acute RS, it was dual oral antiplatelet therapy (65%). Fear of hemorrhagic complications (74%) was the most compelling reason not to perform RS±angioplasty. Of respondents, 24% were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before mechanical thrombectomy treatment. Conclusions The findings of this survey highlight the variations in practice in the medical and endovascular management of ICAS‐LVO. In addition, it informs the situation of equipoise in the treatment decision in ICAS‐LVO, which can then be incorporated into the design of future randomized clinical trials.

The multidirectional effects of thrombin and the possibility of their control in neurology

The review presents the main physiological functions of thrombin. The procoagulant and anticoagulant activities of the key serine protease are discussed in both physiological and pathological conditions of hemostasis. The involvement of thrombin in atherogenesis, as well as its role as a mediator of vascular dysfunction and inflammation in both the peripheral and central nervous system, is highlighted. A pronounced imbalance between the pro- and anticoagulant systems leads to an increase in thrombin formation and creates conditions for the development of thrombosis. Tests that allow direct or indirect assessment of thrombin's functional activity are presented. The potential applications of direct thrombin inhibitors and direct blockers of thrombin PAR receptors in vascular neurology are also considered.

Ocular ischemic syndrome – case report and literature analysis

Abstract Introduction Ocular ischemic syndrome (OIS) is a rare condition associated with ocular hypoperfusion caused by carotid artery occlusive disease. This article describes the case of a patient who was admitted to the Department of Ophthalmology at UCK in Katowice, Poland, due to significant loss of visual acuity and pain in the right eye. Materials and Methods Retrosopective case report. Results Patient showed up in the ophthalmological emergency department complaining of significant loss of visual acuity and pain in the right eye persisting for 2 weeks. The patient had a history of type II diabetes mellitus, hypertension, status post ACS and PCI, and long-term nicotinism. Examination of the right eye revealed ocular irritation, mixed conjunctival injection, hyphema in the anterior chamber, iris neovascularization, and discrete central retinal fading. Additional examinations were performed, including an angioCT, which showed a long-standing obstruction of the right internal carotid artery, a ballooning thrombus in the lumen of the brachiocephalic trunk, and suspected critical stenosis of the left vertebral artery. A neurologist and vascular surgeon were consulted, and treatment was instituted to limit further complications from the underlying disease. The patient remains under close supervision of the vascular surgeon and neurologist. Conslusions OIS is a rare but potentially blinding condition and should be considered in the differential diagnosis of transient visual acuity reduction or vision loss.

Evaluation of Vascular Neurology Fellowship Websites in the U.S.

Due to the limitations of the Coronavirus disease pandemic, medical applicants have relied on remote means of information, such as a program's website, to decide where to apply. However, studies have shown that many residency and fellowship websites lack information. Vascular neurology fellowship websites have not yet been studied. This study evaluates the availability and accessibility of information on vascular neurology fellowship websites. From 2021 to 2022, a total of 109 U.S. vascular neurology fellowship programs from the Fellowship and Residency Electronic Interactive Database were investigated to determine whether they had websites. Each website was evaluated on the immediate availability of 34 different criteria, which were deemed important by past studies. These criteria were reviewed under four categories: program overview, application information, fellow life, and curriculum. The comprehensiveness of the information among these different categories were analyzed. Programs were grouped by geographic region and electronic residency application service (ERAS)-participation status and comparisons were made within these groups. There were 107 programs with websites (98%). ERAS-participating programs fulfilled more criteria on average than non-participating programs (P = 0.004). All websites provided information on general descriptions of their programs, but information on board exam pass rates, fellow testimonials, history of the fellowship program, responsibility progression, family and social events, parking availability, and application deadline were provided by less than 25% of websites. This study found that there was a large lack of information on vascular neurology fellowship websites, which could be improved to attract more applicants.

Large‐Vessel Occlusion Stroke Knowledge and Training for Stroke Severity Assessment Among Emergency Medical Services Personnel in the United States

BACKGROUND Prehospital identification of large‐vessel occlusion (LVO) stroke facilitates the development of a regional triage protocol that could lead to an improvement in intrahospital and interhospital workflows. This requires stroke education of emergency medical services (EMS) personnel to improve stroke recognition, severity assessment, and prenotification. However, the current state of EMS personnel's knowledge of LVO stroke, their training for stroke severity assessment, and their preferences for educational methods are unknown. We conducted a nationwide EMS survey across the United States to glean insights that can inform and customize future EMS educational efforts. METHODS The Society of Vascular and Interventional Neurology, in collaboration with EMS World , created an online questionnaire for EMS personnel. It included 12 multiple‐choice and free‐response questions designed to test participants’ clinical knowledge of LVO, knowledge of stroke center certification levels, prior LVO educational experiences, preferences for educational content delivery, and perspectives on prehospital hurdles to stroke care. All subscribers of EMS World received a survey link via email. RESULTS Of the 38 486 subscribers of EMS World , the survey email was opened by 1830, of whom 1107 completed the survey across all states in the United States, with a response rate of 2.9%. Most of the respondents identified themselves as paramedics/emergency medical technicians (91%). The number of patients with stroke that survey participants transported in the past year was <10 for 618 (56%). Only 285 (26%) participants answered both LVO knowledge questions correctly, and only 128 (12%) respondents correctly identified all types of stroke centers with thrombectomy capability. A total of 362 EMS personnel (33%) denied receiving training to perform LVO severity assessment. Respondents who received training to perform an LVO scale demonstrated nearly twice the prevalence of LVO knowledge (30.6% versus 15.7%; prevalence ratio, 1.94 [95% CI, 1.50–2.53]) than respondents who did not receive training. The top hurdle to prehospital LVO education was identified as the lack of standardized LVO training by 535 (48%) respondents. CONCLUSIONS EMS providers in the United States reported inadequate LVO training and demonstrated gaps in knowledge of LVO, stroke severity scales, and stroke center levels. Systematic efforts to enhance and standardize the educational content and delivery of LVO education are needed.

Indications for surgical evacuation of cerebellar intracerebral hemorrhage: consensus guidelines from the French Society of Neurosurgery (SFNC) and the French Society of Vascular Neurology (SFNV)

BackgroundCerebellar intracerebral hemorrhage (ICH) is associated with poor functional prognosis and high mortality. Surgical evacuation has been proposed to improve outcome. The purpose of this review was to determine the benefit of surgical evacuation of cerebellar ICH and to establish guidelines for when it should be performed. MethodThe writing committee comprised 9 members of the SFNV and the SFNC. Recommendations were established based on a literature review using the PICO questions. The American Heart Association (AHA) classification was used to define recommendation level. In case of insufficient evidence, expert opinions were provided. ResultsLevels of evidence were low to moderate, precluding definitive recommendations. Based on available data, surgical hematoma evacuation is not recommended to improve functional outcome (Class III; Level B NR). However, based on subgroup analysis, surgical evacuation may be considered in strictly selected patients (Class IIb; Level C-EO): hematoma volume 15−25 cm3, GCS 6-10, and no oral anticoagulation or antiplatelet therapy. Moreover, surgical evacuation is recommended to decrease risk of death (Class IIa; Level B NR) in patients with a hematoma volume >15 cm3 and GCS score <10. ConclusionThese guidelines were based on observational studies, limiting the level of evidence. However, except for strictly selected patients, surgical evacuation of cerebellar ICH was not associated with improved functional outcome, limiting indications. Data from RCTs are needed in this field.

Endovascular Treatment in Acute Basilar Artery Occlusion Stroke: A Brief Practice Update From the Society of Vascular and Interventional Neurology

Background The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee established the “Brief Practice Update” format to provide up‐to‐date recommendations on focused relevant clinical questions. In this Brief Practice Update, we review current evidence and provide recommendations for endovascular treatment (EVT) in patients with acute large‐vessel occlusion of the basilar artery. Methods The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee conducted a systematic review, including the recent randomized clinical trials of EVT for acute ischemic stroke attributable to basilar artery occlusion, and summarized relevant data to provide recommendations for clinical practice. The Guidelines and Practice Standards quality committee reviewed the findings to ensure adherence to the Society of Vascular and Interventional Neurology internal evidence evaluation guidelines before review by the Society of Vascular and Interventional Neurology board members for societal endorsement. Results Evidence favors EVT for basilar artery occlusion in comparison to medical management alone in patients with moderate to severe stroke. We formulated the level of evidence and the class of recommendation in the context of 5 clinical questions. Conclusions In this brief practice statement, we share general recommendations on EVT for acute ischemic stroke attributable to large‐vessel occlusion of the basilar artery. Recent randomized controlled trials, Basilar Artery Occlusion Chinese Endovascular (BAOCHE) trial and Endovascular Treatment for Acute Basilar‐Artery Occlusion (ATTENTION), and a meta‐analysis of all randomized controlled trials support EVT in patients with moderate to severe basilar artery occlusion stroke symptoms.

Abstract 112: When Cell Blood Count Matter, Hypereosinophilic Syndrome a Rare Cause of Ischemic Strokes

Introduction Hypereosinophilic syndrome (HES) is a rare hematological disorder defined by persistently elevated blood eosinophil count (&gt;1500/μL), associated with evidence of organ damage. It can occasionally present primarily with neurological conditions such as ischemic strokes, encephalopathy, or sensory neuropathy. Driving hypothesized mechanisms are hypercoagulability owing to eosinophil‐related endothelial damage or cardioembolism. We present an unusual case of ischemic strokes due to HES in the setting of Fip1‐like 1‐platelet‐derived growth factor receptor alpha (FIP1L1‐PDGFRA) mutation. Methods The patient was identified in routine clinical practice. Results 38 year‐old‐male with no significant medical history who was transferred to our institution for blurred vision, and dizziness. His initial National Institutes of Health Stroke Scale was 3 for bilateral leg weakness. The neurological exam was pertinent for paresis in his left arm and legs. Magnetic resonance imaging (MRI) of the brain demonstrated multiple acute infarcts in bilateral cortical and subcortical structures as shown in Figure 1. Computed tomography angiography (CTA) of the brain and neck did not show significant stenosis or occlusion. During admission, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) did not reveal any source for cardioembolism. Subsequently, he developed hyperactive delirium requiring anti‐psychotics. He was worked up for any infectious etiology because he continued to have a leukocytosis with an eosinophil count as high as 49%. Doppler of lower extremities showed deep vein thrombosis in the left femoral vein. Hematology evaluated the patient and, after performing a bone marrow biopsy, he was diagnosed with primary Hypereosinophilic syndrome (HES) in the setting of FIP1L1‐PDGFRA mutation. He was started on high‐dose methylprednisolone, hydroxyurea and later switched to Imatinib. A cardiac MRI was performed which was negative for eosinophilic myocarditis. The patient's mental status improved significantly after starting Imatinib and his anti‐psychotics were discontinued. In regards to secondary prevention, vascular neurology wanted antiplatelet monotherapy, however, the patient was started on Apixaban to treat his DVT. He was followed up in the stroke clinic 2 months after discharge, his modified Rankin score (mRS) was 1. Aspirin was recommended for secondary stroke prevention once hematology considers it safe to discontinue apixaban. Conclusion This case encourages the consideration of HES in patients with low cardiovascular risk factors who have infarcts following a cardioembolic or watershed pattern in brain imaging. Going back to the basics and reviewing simple laboratory tests like cell blood count can be the initial clue for diagnosis. Early recognition is crucial as immunosuppression is the most important treatment in the acute phase. While imatinib is the treatment of choice for FIP1L1‐PDGFRA mutation HES, patients continued to be at risk of stroke recurrence despite having normal eosinophil count as described by Rohmer et al.

Abstract 125: Amyloid Beta‐Related Angiitis: A Case Presentation

Introduction We detail the presentation and diagnostic workup of a woman who was ultimately diagnosed with Amyloid Beta‐Related Angiitis (ABRA), which can be a challenging condition to diagnose. Methods This is a case report which describes the presentation and workup that led to the diagnosis of ABRA. Results 64‐year‐old woman with history of hypertension, hypothyroidism, hyperlipidemia and diabetes mellitus presented to outside hospital with progressive encephalopathy and worsening expressive aphasia for three months who was transferred to our center for a left frontal lobe mass with vasogenic edema. MRI brain with and without gadolinium showed multiple small enhancing cerebral regions, diffuse swelling, and leptomeningeal enhancement. Lumbar puncture was within normal limits. Cytology and CA 19‐9, CEA, and alpha‐fetoprotein were all normal. CT thorax, abdomen, and pelvis with contrast did not reveal findings suspect for malignancy. Given diagnostic uncertainty, brain biopsy of the left frontal lesion was completed. Findings were consistent with amyloid beta deposition in the walls and concerning for an inflammatory angiitis, without features to suggest infectious or malignancy related process. Vasculitic labs were notable for positive ANA (1:160), speckled pattern, but were otherwise negative. She completed a five day course of methylprednisolone 1g IV with some improvement in encephalopathy and aphasia. She was started on a prednisone taper and cyclophosphamide and discharged to a skilled nursing facility with follow up with vascular neurology and neuroimmunology planned. Conclusion ABRA is a complication seen in cerebral amyloid angiopathy and is a rare cause of CNS vasculitis. This condition should be suspected in the appropriate clinical scenario, particularly given the improvement often noted with immunosuppression (1).

Abstract 231: Rescue Stenting for Failed Mechanical Thrombectomy in Acute Ischemic Stroke:An Analysis of the SVIN Registry

Introduction Mechanical thrombectomy (MT) often fails to achieve successful reperfusion in up to 20% of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) [1, 2]. Rescue strategies options, including balloon angioplasty alone, rescue stenting (RS) alone, or stent with balloon angioplasty, have shown promise in observational studies and meta‐analyses [3, 4]. We aimed to evaluate the association between RS with functional outcomes compared to medical management (MM) in anterior circulation LVO‐AIS patients who underwent failed MT. Methods This retrospective cohort study utilized prospectively collected data from the Society of Vascular and Interventional Neurology (SVIN) Registry, including adult patients with AIS who experienced a failed MT at 14 comprehensive stroke centers. A failed MT was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score of 0 to 2a after multiple attempts to clot retrieval. The patients were divided into two groups: those who received RS and those who only received MM. The primary efficacy outcome was the shift in the degree of disability, as measured by the modified Rankin Scale (mRS), at 90 days. Additional outcomes included functional independence (defined as a 90‐day mRS score of 0‐2), symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. These outcomes were assessed using uni‐ and multivariable logistic regression models. Results A total of 642 patients were included in the analysis. The RS group consisted of 294 (45.8%) patients, while the MM group comprised 348 (54.2%) patients. A mTICI score of 2b‐3 was achieved in 242/293 (82.6%) patients in the RS group. Compared to the MM group, the RS showed a favorable shift in the overall 90‐day mRS distribution (adjusted common odds ratio [OR]=1.97, 95% CI 1.36–2.85, p=&lt;0.001), higher rates of functional independence (RS: 30.7% vs. MM: 12%, adjusted OR [aOR]=2.39, 95% CI 1.34‐4.26, p=0.003), lower rates of sICH (RS: 2.7% vs. MM: 9%, aOR=0.32, 95% CI 0.14‐0.71, p=0.005), and lower 90‐day mortality (RS: 29.5% vs. MM: 49.7%, aOR=0.49, 95% CI 0.33‐0.74, p=&lt;0.001). Conclusion RS showed promising functional outcomes compared to MM. RS was associated with improved functional independence, reduced sICH rates, and lower 90‐day mortality. The RS group exhibited a favorable shift in the 90‐day mRS distribution, indicating better overall functional outcomes. These findings support RS as a potential rescue strategy for AIS patients with failed MT, with implications for clinical decision‐making. However, further prospective studies are needed to validate these observations and optimize outcomes.

Abstract 078: Managing Clopidogrel Resistance in Neurointervention: Surveying Current Approaches

Introduction Due to the variability in patient responses to clopidogrel, adjusting antiplatelet regimen based on platelet function testing has become a widespread practice to reduce thromboembolic complications in neurointervention. In the absence of standardized guideline, we aimed to explore the practice patterns related to clopidogrel resistance. Methods We conducted a survey targeting neurointerventionalists, comprising multiple‐choice questions and opportunities for free‐text responses when necessary. The survey was distributed via a professional society – the Society of Vascular and Interventional Neurology (SVIN) and two emailing lists – WovenEndoBridge and Neurointerventional Research Consortium. The data obtained from the responses were analyzed using descriptive statistics. Results A total of 133 neurointerventionalists representing 83 institutions within 24 countries responded to the survey. 62% of respondents tested for clopidogrel resistance prior to any neurovascular stent placements. 80% utilized VerifyNow point‐of‐care P2Y12 assay; other assays included multiplate analyzer, platelet function analyzer (PFA‐100), and CYP2C19 genotype assay. Respondents reported 25 different therapeutic thresholds, with the P2Y12 Reaction Units range between 60 and 180 most commonly used (16.4%). 61% reported they would switch to ticagrelor in the case of persistent resistance. On the other hand, when patients are supratherapeutic, 48% did not make any changes while 42% reduced clopidogrel dose. Finally, 93% felt that there was a lack of well‐established protocol for management of clopidogrel resistance. Conclusion Neurointerventional practice patterns around clopidogrel resistance remains heterogeneous. Our results underscore the need for evidence‐based guidance on anti‐thrombotic management during cerebrovascular stenting.

Abstract 056: Patterns of Care in the Management of Intracranial Atherosclerosis‐related Large Vessel Occlusion–the RESCUE‐LVO survey

Introduction Intracranial atherosclerosis‐related large vessel occlusion (ICAS‐LVO) is a common cause of failed mechanical thrombectomy (MT) in acute ischemic stroke (AIS) [1]. Treatment of ICAS‐LVO with rescue stenting and/or angioplasty has shown promising outcomes, but diagnosing ICAS‐LVO during MT can be challenging [2, 3]. There are uncertainties regarding optimal approaches, techniques, and timing for treating ICAS‐LVO. To understand current practice patterns and address these uncertainties, we conducted a survey among neurointerventional practitioners experienced in ICAS‐LVO management during MT. Methods We conducted an international online survey of neurointerventionalist members of the Society of Neurointerventional Surgery (SNIS) and the Society of Vascular and Interventional Neurology (SVIN). The 28‐question poll evaluated the preferences on diagnosis, treatment, and endovascular approach to ICAS‐LVO. Results 168 individual survey responses were obtained from practicing neurointerventional physicians. Overall, 40.6% reported an incidence of 6–10% of ICAS‐LVO during MT. Most neurointerventionalists (91%) diagnose ICAS‐LVO after a continued or recurrent occlusion or by the presence of fixed focal stenosis (FFS) after multiple MT attempts. Most respondents (86%) preferred acute treatment of ICAS‐LVO with rescue stenting (RS) +/‐ angioplasty. However, in patients who achieved recanalization with a severe FFS, the majority (44%) recommended maximal medical management only. The preferred medication during acute RS was intravenous antiplatelet therapy (69%), and after acute RS was dual oral antiplatelet therapy (58%). Fear of hemorrhagic complications (70%) was the most compelling reason not to perform RS +/‐ angioplasty. Twenty‐five percent of respondents were hesitant to randomize patients to acute RS versus medical therapy in a future randomized trial because of the lack of sensitive and specific biomarkers to diagnose ICAS‐LVO before MT treatment. Conclusion Our survey highlights the significant variability and uncertainty in the diagnosis and management of ICAS‐LVO during MT among neurointerventional practitioners. There is no equipoise regarding the optimal treatment strategy, and the fear of hemorrhagic complications associated with antithrombotic medications contributes to the variation in practice. Our survey underscores the need for future research and randomized clinical trials to address the uncertainties in the management of ICAS‐LVO during MT. Improved imaging biomarkers and consensus guidelines are essential to guide clinical decision‐making and optimize patient outcomes in this challenging population of AIS patients.

Abstract 004: Summary of MT2020+ Research Internship Progress from 2021 to 2023

Introduction Mission Thrombectomy, established in 2016 by the Society of Vascular and Interventional Neurology, aims to enhance global accessibility to mechanical thrombectomy surgery for strokes caused by large vessel occlusion in the brain. High school students interested in exposure to global health have limited access to get exposure in this rapidly expanding area of public health. The MT2020+ student internship was designed in collaboration with MT2020+ to provide such an experience to US High School students. Students designed and carried out projects to raise stroke awareness among other high school students and communities while studying the barriers to stroke treatment. We report on this novel internship program's methodology, results, and outcomes. Methods The MT2020+ internship program followed a comprehensive framework. Three phases were implemented: Phase A involved secondary research, stakeholder identification, and the formation of a detailed survey and interview questions. Stakeholders included neurologists, neuro‐interventionalists, neuro‐radiologists, and members of stroke societies. Countries in the region of interest were categorized into three groups based on stroke and COVID‐19 data. A survey template was created in Phase B, and stakeholders were contacted for data collection. Interviews were conducted to delve deeper into survey responses. Phase C focused on analyzing the collected data, articulating the key barriers, and generating a written report. Interns also developed interventions to address key barriers identified during the research. Results The first cohort (2020) comprised 8 interns who investigated barriers to stroke treatment across different regions. The interns received survey responses and conducted interviews with stakeholders. Their research covered the U.S. &amp; North America, Latin America, Europe, Africa, Asia, and Australia. The outcomes varied, with different levels of engagement. One student developed an app in Peru to address transportation, educational, and rehabilitation barriers. The second cohort (2021) had 2 interns who focused on Latin America and Asia, working on rehabilitation apps. The third cohort (2022) included 4 interns studying Asia, Australia/New Zealand, North America/US, and Latin America. Their interventions ranged from creating stroke awareness clubs to organizing virtual conferences. Conclusion The MT2020+ student internship provided a novel opportunity for high school students to get exposure to global health implementation. The student research in this internship has contributed valuable insights into stroke treatment barriers and raised awareness among high school students worldwide.

Abstract 121: Misdiagnosis in a case of pediatric stroke

Introduction Pediatric patients presenting with atypical stroke symptoms pose a diagnostic challenge, which often causes delays in management. Around a quarter of pediatric stroke patients will present with new onset seizures. We report this case to emphasize the importance of early consideration of ischemia as a differential diagnosis. We also want to emphasize the collaborative approach between pediatric and adult neurologists in challenging cases. Methods Case report Results A 15‐year‐old male presented to an outside hospital for new onset seizure. The patient later mentioned that he had difficulty writing the morning of the seizure. Initial blood work, CBC, CMP, urine analysis and toxicology were unremarkable. A second seizure occurred while in the ED. CT head revealed a questionable area of decreased attenuation in the left frontal lobe, felt to be artifact. Patient was transferred to our hospital for higher level of care. MRI of the brain showed gyriform signal abnormality within the left frontal lobe with restricted diffusion, no abnormal enhancement. Serum MOG, NMDA, LGI1, NMO antibodies were sent. LP was done and there was no evidence of infection. MRI of the C, T and L spine were unremarkable. CTA/CTV of the head was done and there was no evidence of vessel abnormalities or sinus thrombosis. Patient was started on high dose steroids for possible autoimmune etiology on hospital day 2. On Hospital Day 3, the case was re‐evaluated, and the possibility of infarction was proposed. The case was discussed with an adult vascular neurology attending physician, thus further imaging was obtained. CT Perfusion of Brain revealed a subacute left frontal infarct and possible dural AVF. A diagnostic cerebral angiography revealed enhanced capillary blush consistent with shunt in region of left peri‐Sylvian infarct. There was no evidence of other vascular malformations. A hypercoagulable panel was unremarkable. The patient was discharged on Hospital Day 6 on Vimpat and aspirin with outpatient follow‐up. Echo revealed a PFO on Valsalva maneuver. MRI spectroscopy revealed depressed creatine peak, low NAA and a high choline peak in the left frontal opercular T2 hyperintensity ‐ findings consistent with an evolving infarct with increased choline due to gliosis. He is planned for PFO closure and has not had further recurrent seizures. Conclusion According to Hollist et al., pediatric stroke incidence is 2.5‐13 per 100,000 children per year [1]. There are thousands of stroke misdiagnoses every year [2]. Stroke misdiagnosis is more likely in younger patients [2, 3]. 60% of pediatric stroke patients will end up with disability and half will have a decreased quality of life [4]. Misdiagnosis also results in misutilization of health care resources. Similar to our case, a collaborative approach between adult stroke neurologists and pediatric neurologists, where pediatric stroke neurologists are not available, helps avoid stroke misdiagnosis. As a result, this helps better patient outcomes and avoids preventable morbidity and mortality.

Abstract 269: Promoting Access to Vascular Neurology Services in Underserved Areas of Africa

Introduction Stroke is the most common manifestation of cerebrovascular disease, which requires prompt diagnosis and treatment. As one of the most prevalent causes of death, the third‐major source of illness, and the primary cause of long‐term disability, it is regarded as one of the most significant global health issues. To reduce the rising death and disability due to stroke in Africa, adequate vascular neurology services are crucial. There is little available data on how these services are accessed in African nations. The aim of this study is to outline the underlying reasons for Africa's lack of vascular neurology services as well as the measures required to improve access. Methods Data were collected by reviewing the literature from publications published between the years 2016 – 2023 from online databases including PubMed, Google Scholar and the World Health Organization website. Results Africa currently has some of the highest stroke indices in the world. Stroke is one of the major causes of dementia, disability, and mortality worldwide. The rise in the prevalence of stroke has been attributed to the shortage of vascular neurology services in underdeveloped African nations. Numerous initiatives have been initiated to expand access to these services in particular settings due to the various circumstances that have contributed to their restricted availability; nonetheless, more stroke care policies need to be implemented on a larger scale in order to improve outcomes. Conclusion In particular, for underserved areas, this study gives an overview of the difficulties and opportunities related to the availability of vascular neurology services in Africa. Although the accessibility of these services is still below the necessary levels, legislators, medical experts, and international organizations may collaborate to improve access and outcomes.

Abstract 226: Canadian Experience Facilitating a Hands‐on Neurointerventional Workshop for Neurology Trainees

Introduction Neurointerventional radiology is a growing field that has seen innumerable advances in recent years. Unlike the US, which has a sizeable presence of interventional neurologists[1], Canada has disproportionately fewer neurologists in the field of neurointervention. One of the barriers to neurology trainees entering the field of neurointerventional radiology is a lack of exposure during their training. To address this barrier, we conducted the first hands‐on neurointervention workshop focusing on neurology trainees during a Canadian national conference. Though this workshop was open to trainees from neurology, neuroradiology, and neurosurgery, it was conducted in association with the Canadian Stroke Consortium and therefore marketed towards neurology trainees. This pilot hands‐on workshop was the first of its kind in Canada targeting neurology trainees. Methods A 2‐hour workshop was conducted in June, 2023 during a Canadian national conference. The workshop included 3 stations: basic equipment orientation, overview of endovascular techniques for ischemic stroke, and an intracranial aneurysm treatment model treatment station. Participants had an opportunity to rotate through each station at least once. Each station was facilitated by a neurointerventionalist or fellow who demonstrated the techniques and devices to participants. Participants practiced handling wires and catheters, deploying stent‐retrievers, and deploying coils in an aneurysm model, among other essential neurointerventional skills. Participants were asked to voluntarily provide feedback via electronic survey. An electronic survey was emailed to participants, on a voluntary basis; responses were anonymized. Survey results were collected and analyzed using Google Forms. Results Twelve workshop participants consented to participate in the survey and seven completed the entire survey. Respondents were from multiple Canadian neurology residency programs, medical schools, and vascular neurology fellowship programs. Prior to the workshop, most respondents (71.4%) had little‐to‐no knowledge about interventional techniques. Only one respondent answered that their training program provides hands‐on neurointervention experience. Most respondents found the station on endovascular techniques for ischemic stroke to be the most helpful. Prior to the workshop, many respondents had not considered pursuing neurointerventional radiology training. At least one participant responded that they would more favorably consider pursuing neurointerventional radiology following the workshop. Conclusion Increasing neurology trainee exposure to neurointerventional radiology is essential for expanding the number of neurologists entering this field. Events at national and international conferences that provide hands‐on experience are one way to increase exposure. This workshop provided practical experience, particularly in endovascular therapy techniques. All participants had little to no exposure to neurointervention and all favorably rated the workshop. Based on this pilot project, further efforts are needed to incorporate neurointerventional radiology training into Canadian neurology training programs.

The prevalence of radiological cerebral amyloid angiopathy-related inflammation in patients with cerebral amyloid angiopathy

ObjectivesCerebral amyloid angiopathy (CAA) related inflammation (CAA-RI) is an autoimmune inflammatory condition occurring in patients with CAA. We aimed to determine the prevalence of radiological CAA-RI amongst patients with CAA and to describe their presenting clinical features. MethodsWe performed a retrospective review of electronic medical records across multiple centers within a single healthcare network. Patients who met radiological modified Boston 2.0 criteria for CAA and had white matter hyperintensity (WMH) were included. Scans were analyzed by a vascular neurologist and confirmed by a neuroradiologist blinded to clinical information for meeting criteria for possible or probable radiographic CAA-RI. ResultsOut of 1100 patients reviewed, 511 patients met radiological modified Boston criteria for CAA and 193 patients had WMH on MRI. A total of 55 (28.5 % of those with CAA and WMH, and 10.8 % of all CAA with or without WMH) patients had MRI brain imaging suggestive of possible or probable radiographic CAA-RI. The diagnosis of CAA-RI was reported in only 10 (18.2 %) patients initially while 20 (36.4 %) were diagnosed up to 74 months later (median 0, IQR 0-9 months). At the time of earliest probable CAA-RI findings on imaging, the most common concurrent findings were cognitive impairment (74.5 %), macro-hemorrhages (52.7 %), headache (30.9 %), seizures (14.5 %), and ischemic infarcts (14.5 %). Only 18 (32.7 %) patients were treated with immunosuppression. ConclusionsThe prevalence of radiographic CAA-RI was high, and most cases were unrecognized and untreated. Further studies are needed to assess if earlier detection and treatment of radiologic CAA-RI may halt disease progression and prevent cognitive decline in these patients.

Risk assessment of vascular complications following manual therapy and exercise for the cervical region: diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists framework (The Go4Safe project).

What is the diagnostic accuracy of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) framework to assess the risk of vascular complications in patients seeking physiotherapy care for neck pain and/or headache? Cross-sectional diagnostic accuracy study. One hundred and fifty patients seeking physiotherapy for neck pain and/or headache in primary care. Nineteen physiotherapists performed the index test according to the IFOMPT framework. Patients were classified as having a high, intermediate or low risk of vascular complications, following manual therapy and/or exercise, derived from the estimated risk of the presence of vascular pathology. The reference test was a consensus medical decision reached by a vascular neurologist and an interventional neurologist, with input from a neuroradiologist. The neurologists had access to clinical data and magnetic resonance imaging of the cervical spine, including an angiogram of the cervical arteries. Diagnostic accuracy measures were calculated for 'no contraindication' (ie, the low-risk category) and 'contraindication' (ie, the high-risk and intermediate-risk categories) for manual therapy and/or exercise. Sensitivity, specificity, predictive values, likelihood ratios and the area under the curve were calculated. Manual therapy and/or exercise were contraindicated in 54.7% of the patients. The sensitivity of the IFOMPT framework was low (0.50, 95% CI 0.39 to 0.61) and its specificity was moderate (0.63, 95% CI 0.51 to 0.75). The positive and negative likelihood ratios were weak at 1.36 (95% CI 0.93 to 1.99) and 0.79 (95% CI 0.60 to 1.05), respectively. The area under the curve was poor (0.57, 95% CI 0.49 to 0.65). The IFOMPT framework has poor diagnostic accuracy when compared with a reference standard consisting of a consensus medical decision.