Cerebral tau pathology in cerebral amyloid angiopathy

Tau, a hallmark of Alzheimer's disease, is poorly characterized in cerebral amyloid angiopathy. We aimed to assess the clinico-radiological correlations between tau positron emission tomography scans and cerebral amyloid angiopathy. We assessed cerebral amyloid and hyperphosphorylated tau in patients with probable cerebral amyloid angiopathy (n = 31) and hypertensive small vessel disease (n = 27) using 11C-Pittsburgh compound B and 18F-T807 positron emission tomography. Multivariable regression models were employed to assess radio-clinical features related to cerebral tau pathology in cerebral amyloid angiopathy. Cerebral amyloid angiopathy exhibited a higher cerebral tau burden in the inferior temporal lobe [1.25 (1.17-1.42) versus 1.08 (1.05-1.22), P < 0.001] and all Braak stage regions of interest (P < 0.05) than hypertensive small vessel disease, although the differences were attenuated after age adjustment. Cerebral tau pathology was significantly associated with cerebral amyloid angiopathy-related vascular markers, including cortical superficial siderosis (β = 0.12, 95% confidence interval 0.04-0.21) and cerebral amyloid angiopathy score (β = 0.12, 95% confidence interval 0.03-0.21) after adjustment for age, ApoE4 status and whole cortex amyloid load. Tau pathology correlated significantly with cognitive score (Spearman's ρ=-0.56, P = 0.001) and hippocampal volume (-0.49, P = 0.007), even after adjustment. In conclusion, tau pathology is more frequent in sporadic cerebral amyloid angiopathy than in hypertensive small vessel disease. Cerebral amyloid angiopathy-related vascular pathologies, especially cortical superficial siderosis, are potential markers of cerebral tau pathology suggestive of concomitant Alzheimer's disease.

Aldosteronism is associated with more severe cerebral small vessel disease in hypertensive intracerebral hemorrhage

Primary aldosteronism is associated with various types of cardiovascular and cerebrovascular damage independently of hypertension. Although chronic hypertension and related cerebral arteriosclerosis are the main risk factors for intracerebral hemorrhage, the effects of aldosteronism remain poorly understood. We enrolled 90 survivors of hypertensive intracerebral hemorrhage, 21 of them with aldosteronism and 69 with essential hypertension as controls in this study. Clinical parameters and neuroimaging markers of cerebral small vessel disease were recorded, and its correlations with aldosteronism were investigated. Our results showed that the aldosteronism group (55.2 ± 9.7 years, male 47.6%) had similar hypertension severity but exhibited a higher cerebral microbleed count (interquartile range) (8.5 [2.0‒25.8] vs 3 [1.0‒6.0], P = 0.005) and higher severity of dilated perivascular space in the basal ganglia (severe perivascular space [number >20], 52.4% vs. 24.6%, P = 0.029; large perivascular space [>3 mm], 52.4% vs. 20.3%, P = 0.010), compared to those with essential hypertension (53.8 ± 11.7 years, male 73.9%). In multivariate models, aldosteronism remained an independent predictor of a higher (>10) microbleed count (odds ratio = 8.60, P = 0.004), severe perivascular space (odds ratio = 4.00, P = 0.038); the aldosterone-to-renin ratio was associated with dilated perivascular space (P = 0.043) and large perivascular space (P = 0.008). In conclusions, survivors of intracerebral hemorrhage with aldosteronism showed a tendency towards more severe hypertensive arteriopathy than the essential hypertension counterparts independently of blood pressure; aldosteronism may contribute to dilated perivascular space around the deep perforating arteries. Aldosteronism is associated with more severe cerebral small vessel disease in hypertensive intracerebral hemorrhage.

Differences in lobar microbleed topography in cerebral amyloid angiopathy and hypertensive arteriopathy

Lobar cerebral microbleeds are a characteristic neuroimaging finding in cerebral amyloid angiopathy (CAA) but can also be found in hypertensive arteriolosclerosis. We aimed to investigate whether CAA is more associated with intracortical lobar microbleeds than hypertensive arteriosclerosis. Ninety-one survivors of spontaneous intracerebral hemorrhage with at least one lobar microbleed were included and underwent brain MRI and amyloid PET. We categorized lobar microbleeds as intracortical, juxtacortical, or subcortical. We assessed the associations between the lobar microbleed categories and microangiopathy subtypes or cerebral amyloid load based on the Pittsburgh Compound-B PET standardized uptake value ratio (SUVR). Patients with CAA had a higher prevalence of intracortical lobar microbleeds (80.0% vs. 50.8%, P = 0.011) and lower prevalence of subcortical lobar microbleeds (13.3% vs. 60.1%, P < 0.001) than patients with hypertensive arteriolosclerosis. Strictly intracortical/juxtacortical lobar microbleeds were associated with CAA (OR 18.9 [1.9-191.4], P = 0.013), while the presence of subcortical lobar microbleeds was associated with hypertensive arteriolosclerosis (OR 10.9 [1.8-68.1], P = 0.010). Amyloid retention was higher in patients with strictly intracortical/juxtacortical CMBs than those without (SUVR = 1.15 [1.05-1.52] vs. 1.08 [1.02-1.19], P = 0.039). Amyloid retention positively correlated with the number of intracortical lobar microbleeds (P < 0.001) and negatively correlated with the number of subcortical lobar microbleeds (P = 0.018). CAA and cortical amyloid deposition are more strongly associated with strictly intracortical/juxtacortical microbleeds than subcortical lobar microbleeds. Categorization of lobar microbleeds based on anatomical location may help differentiate the underlying microangiopathy and potentially improve the accuracy of current neuroimaging criteria for cerebral small vessel disease.

Outcome of endovascular thrombectomy in patients with end-stage renal disease undergoing dialysis

BACKGROUND

Patients with end-stage renal disease (ESRD) are often excluded from clinical trials of endovascular thrombectomy (EVT). This study investigated the outcome in these patients.

METHODS

From September 2014 to July 2021, all patients undergoing EVT for anterior circulation stroke in two stroke centers in Taiwan were included. They were divided into no renal dysfunction (non-RD, estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2), RD (eGFR <60 mL/min/1.73 m2 but no dialysis), and ESRD undergoing dialysis (ESRD-dialysis). The clinical features and outcomes were compared.

RESULTS

Of 482 patients included, there were 20 ESRD-dialysis, 110 RD, and 352 non-RD patients. The Alberta Stroke Program Early CT Score (ASPECTS), National Institutes of Health Stroke Scale (NIHSS), use of intravenous thrombolysis, EVT-related time metrics, and successful recanalization rates were comparable among the three groups. However, the ESRD-dialysis patients had more symptomatic intracerebral hemorrhage (ICH, 15% vs 3.6% vs 3.7%), more contrast-induced encephalopathy (15% vs 1.8% vs 0.9%), and a higher mortality at 90 days (35% vs 18% vs 11%) than the other groups. Multivariable analysis revealed that ESRD-dialysis was associated with a less favorable outcome (OR 0.21, 95% CI 0.04 to 0.77) and more severe disability or mortality (modified Rankin Scale 5 or 6; OR 13.1, 95% CI 3.93 to 48.1) at 90 days. In the ESRD-dialysis group, the patients with premorbid functional dependence had a significantly higher mortality than those without (75% vs 8.3%; P=0.004).

CONCLUSION

ESRD-dialysis patients were associated with symptomatic ICH and less favorable outcome at 90 days. Patients with premorbid functional dependency had an excessively high mortality.

Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience

BACKGROUND/PURPOSE

A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community.

METHODS

Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3 h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6 h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time.

RESULTS

We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p < 0.001) and IVT (15.34% vs. 21.58%, p = 0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23 min, p < 0.001), longer door-to-CT time (median 10 vs 11 min, p < 0.001), longer DTN time (median 53 vs 54.5 min, p < 0.001) but shorter DTP time (median 141 vs 139.5 min, p < 0.001).

CONCLUSION

The prehospital bypass strategy with G-FAST showed benefits for stroke patients.

Association of Ferroptosis with Severity and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Thrombectomy: A Case-control Study

Ferroptosis, an iron-dependent form of cell death, is characterized by intracellular accumulation of iron and reactive oxygen species-induced lipid peroxidation. Animal experiments have shown the important roles of ferroptosis in ischemic stroke, but the evidence in human stroke is insufficient. This prospective study evaluated the associations between plasma ferroptosis biomarkers at hyperacute stage and long-term outcomes in patients with acute ischemic stroke undergoing endovascular thrombectomy (EVT). The plasma samples were collected immediately before and after EVT (T1 and T2) and at 24 h (T3) for the 126 stroke patients and once for the 50 stroke-free control subjects. Compared with controls, stroke patients had higher 4-hydroxynonenal (4-HNE) levels at T1 and T2 while lower homocysteine and soluble transferrin receptor (sTfR) levels at T3. In stroke patients, higher National Institutes of Health Stroke Scale scores at admission were correlated with higher 4-HNE and lower sTfR levels. Lower Alberta Stroke Program Early CT (ASPECT) scores and larger infarct core volumes on CT perfusion before EVT were correlated with higher 4-HNE and homocysteine levels. After adjusting for significant parameters, homocysteine levels at T2 were significantly associated with poor functional outcome and mortality at 3 months. In the receiver operating characteristic (ROC) models, adding homocysteine levels at T2 and hemoglobin levels to the reference model for predicting poor functional outcome significantly increased the area under the ROC curve. In summary, this study provides evidence that ferroptosis is associated with stroke severity and outcomes in patients with acute ischemic stroke undergoing EVT.

Detection of Amyotrophic Lateral Sclerosis (ALS) Comorbidity Trajectories Based on Principal Tree Model Analytics

The multifaceted nature and swift progression of Amyotrophic Lateral Sclerosis (ALS) pose considerable challenges to our understanding of its evolution and interplay with comorbid conditions. This study seeks to elucidate the temporal dynamics of ALS progression and its interaction with associated diseases. We employed a principal tree-based model to decipher patterns within clinical data derived from a population-based database in Taiwan. The disease progression was portrayed as branched trajectories, each path representing a series of distinct stages. Each stage embodied the cumulative occurrence of co-existing diseases, depicted as nodes on the tree, with edges symbolizing potential transitions between these linked nodes. Our model identified eight distinct ALS patient trajectories, unveiling unique patterns of disease associations at various stages of progression. These patterns may suggest underlying disease mechanisms or risk factors. This research re-conceptualizes ALS progression as a migration through diverse stages, instead of the perspective of a sequence of isolated events. This new approach illuminates patterns of disease association across different progression phases. The insights obtained from this study hold the potential to inform doctors regarding the development of personalized treatment strategies, ultimately enhancing patient prognosis and quality of life.

Interaction between cerebral small vessel disease, blood pressure, and remote ischemic lesions in acute spontaneous intracerebral hemorrhage

BACKGROUND

Acute blood pressure (BP) reduction is the first-line treatment for acute spontaneous intracerebral hemorrhage (ICH); however, recent research suggests that intensive BP reduction along with cerebral small vessel disease (cSVD) is a risk factor for remote DWI lesions (RDWILs). We aimed to delineate the interplay between cSVD and BP reduction therapy on the risk of RDWILs.

METHODS

We enrolled 303 patients who underwent brain magnetic resonance imaging within 7 days after acute spontaneous ICH. RDWILs were categorized as occurring in borderzone (BZ) or non-BZ areas. We examined the effect of cSVD, acute BP reduction, and their interaction on RDWILs.

RESULTS

RDWILs were observed in 34 (11%) patients (59.8 ± 10.3-years-old, 24% male). RDWILs were associated with a larger acute weighted average mean arterial pressure (MAP) reduction in the initial 24 h after ICH onset and a higher total cerebral microbleed (CMB) count. Intensive MAP changes (odds ratio (OR) per 10 mmHg 1.76, 95% confidence interval (CI) 1.03-3.20), total CMBs burden (OR per 10 CMBs 1.21, 95% CI 1.08-1.39), and presence of lobar CMBs (OR 7.33, 95% CI 1.59-55.6) were risk factors for RDWILs at BZ, but not at non-BZ. Furthermore, a significant interaction was observed between lobar CMBs and MAP reduction on increased risk of RDWILs at BZ (p = 0.030).

CONCLUSION

cSVD modulates the effect of acute BP reduction on the risk of RDWILs. Patients with extensive microangiopathy have a higher risk of developing cerebral ischemic changes in BZ during unstable hemodynamic status.

Association between modifiable vascular risk factors and rapid progression of postradiation carotid artery stenosis

BACKGROUND

Postradiotherapy carotid vasculopathy is a clinically relevant complication in patients with head and neck cancer receiving radiotherapy. In this study, we investigated the factors associated with the development and progression of carotid artery stenosis (CAS) in such patients.

METHODS

Patients who received radiotherapy for head and neck cancers between October 2011 and May 2019 at a medical center in Taiwan were eligible for inclusion in this study. This study included patients who underwent two consecutive carotid duplex examinations within an interval of 1 to 3 years. The factors associated with ≥50% CAS at baseline and follow-up were analyzed.

RESULTS

In total, 694 patients (mean age, 57.8 ± 9.9 years; men, 75.2%; nasopharyngeal cancer, 73.3%) were included. The mean interval between radiotherapy and carotid duplex examination was 9.9 ± 5.9 years. At baseline, 103 patients had ≥50% CAS, which was significantly associated with tobacco smoking, hypercholesterolemia, and a prolonged interval between radiotherapy and carotid duplex examination. A total of 586 patients did not have CAS at baseline; of them, 68 developed ≥50% CAS during follow-up. Hypertension and hypercholesterolemia were identified as independent risk factors for CAS progression.

CONCLUSION

Modifiable vascular risk factors, such as hypertension and hypercholesterolemia, appear to be significantly associated with the rapid progression of postradiotherapy CAS in patients with head and neck cancer.

Brain-derived neurotrophic factor contributes to neurogenesis after intracerebral hemorrhage: a rodent model and human study

Background and purpose

Intracerebral hemorrhage (ICH) enhances neurogenesis in the subventricular zone (SVZ); however, the mechanism is not fully understood. We investigated the role of brain-derived neurotrophic factor (BDNF) in post-ICH neurogenesis in a rodent model and in patients with ICH using cerebrospinal fluid (CSF).

Methods

A rat model of ICH was constructed via stereotaxic injection of collagenase into the left striatum. Patients with ICH receiving an external ventricular drain were prospectively enrolled. CSF was collected from rats and patients at different post-ICH times. Primary cultured rat neural stem cells (NSCs) were treated with CSF with or without BDNF-neutralized antibody. Immunohistochemistry and immunocytochemistry were used to detect NSC proliferation and differentiation. The BDNF concentration in CSF was quantified using enzyme-linked immunosorbent assays (ELISA).

Results

In the rat model of ICH, the percentage of proliferating NSCs and neuroblasts in SVZ was elevated in bilateral hemispheres. The cultured rat NSCs treated with CSF from both rats and patients showed an increased capacity for proliferation and differentiation toward neuroblasts. BDNF concentration was higher in CSF collected from rats and patients with ICH than in controls. Blocking BDNF decreased the above-noted promotion of proliferation and differentiation of cultured NSCs by CSF treatment. In patients with ICH, the BDNF concentration in CSF and the neurogenesis-promoting capacity of post-ICH CSF correlated positively with ICH volume.

Conclusion

BDNF in CSF contributes to post-ICH neurogenesis, including NSC proliferation and differentiation toward neuroblasts in a rat model and patients with ICH.

Impact of direct oral anticoagulant concentration on clinical outcomes in Asian patients with atrial fibrillation

A real-world association between direct oral anticoagulant (DOAC) concentration and clinical outcomes among Asian patients with atrial fibrillation (AF) is reported herein. Patients with AF aged ≥20 years who used DOAC for ≥3 days were enrolled. Trough and peak DOAC concentrations were measured and compared to the expected range reported in clinical trials. The Cox proportional hazard model was used to investigate the association between concentration and outcomes. From January 2016 to July 2022, a total of 859 patients were enrolled. Among them, 22.5%, 24.7%, 36.4%, and 16.4% were on dabigatran, rivaroxaban, apixaban, and edoxaban, respectively. Compared to clinical trials, the proportion of DOAC concentrations higher or lower than the expected range were 9.0% and 14.6% for trough, respectively, and 20.9% and 12.1% for peak, respectively. The average follow-up duration was 2.4±1.6 years. The incidence of stroke and systemic thromboembolism (SSE) was 1.31 per 100-person years, and low trough concentration predicted SSE (hazard ratio [HR]=2.78 [1.20, 6.46]). The incidence of major bleeding was 1.64 per 100-person years, and high trough was associated with major bleeding (HR=2.63 [1.09, 6.39]). The association between peak concentration and SSE or major bleeding was non-significant. Off label under dosing (odds ratio [OR]=2.69 [1.70, 4.26]), once daily DOAC dosing (OR=3.22 [2.07, 5.01]), and high creatinine clearance (OR=1.02 [1.01, 1.03]) caused low trough concentration. Contrarily, congestive heart failure was significantly associated with high trough concentration (OR=1.71 [1.01, 2.92]). In conclusion, trough DOAC concentration measurements should be considered among patients at risk of out-of-expected range DOAC concentrations.

Diagnostic Challenges of Neuromuscular Disorders after Whole Exome Sequencing

BACKGROUND

Whole-exome sequencing (WES) facilitates the diagnosis of hereditary neuromuscular disorders. To achieve an accurate diagnosis, physicians should interpret the genetic report carefully along with clinical information and examinations. We described our experience with (1) clinical validation in patients with variants found using WES and (2) a diagnostic approach for those with negative findings from WES.

METHODS

WES was performed on patients with the clinical impression of hereditary neuromuscular disorders. Information on clinical manifestations, neurological examination, electrodiagnostic studies, histopathology of muscle and nerve, and laboratory tests were collected.

RESULTS

Forty-one patients (Male/Female: 18/23, age of onset: 34.5±15.9) accepted WES and were categorized into four scenarios: (1) patients with a positive WES result, (2) patients with an inconclusive WES result but supporting clinical data, (3) negative findings from WES, but a final diagnosis after further work-up, and (4) undetermined etiology from WES and in further work-ups. The yield rate of the initial WES was 63.4% (26/41). Among these, seventeen patients had positive WES result, while the other nine patients had inconclusive WES result but supporting clinical data. Notably, in the fifteen patients with equivocal or negative findings from WES, four patients (26.7%) achieved a diagnosis after further workup: tumor-induced osteomalacia, metabolic myopathy with pathogenic variants in mitochondrial DNA, microsatellite expansion disease, and vasculitis-related neuropathy. The etiologies remained undetermined in eleven patients (myopathy: 7, neuropathy: 4) after WES and further workup.

CONCLUSIONS

It is essential to design genotype-guided molecular studies to correlate the identified variants with their clinical features. For patients who had negative findings from WES, acquired diseases, mitochondrial DNA disorders and microsatellite expansion diseases should be considered.

Association of temporalis muscle thickness with functional outcomes in patients undergoing endovascular thrombectomy

INTRODUCTION

Temporalis muscle thickness (TMT) is a surrogate marker for sarcopenia. This study investigated the association of TMT with clinical outcomes in patients receiving endovascular thrombectomy (EVT) for stroke involving acute large vessel occlusion (LVO).

MATERIAL AND METHODS

We enrolled consecutive patients who had undergone EVT between September 2014 and December 2021 at three thrombectomy-capable institutes. TMT was measured through preprocedural computerized tomography angiography. The clinical variables affecting TMT were investigated. The associations between TMT and clinical functional outcomes, defined using the modified Rankin scale, were also studied.

RESULTS

A total of 657 patients were included (mean age: 72.0 ± 12.7 years; male: 52.1%). The mean TMT was 6.35 ± 1.84 mm. Younger age, male sex, higher body mass index, and premorbid functional independence were associated with larger TMT in both univariate and multivariate linear regression (P <.05). Ordinal logistic regression revealed that TMT was associated with better clinical outcomes at 90 days (P_trend = 0.047); multivariate logistic regression indicated that larger TMT was an independent predictor (adjusted odds ratio: 1.14, 95% confidence interval: 1.03-1.27, P = 0.02) of favorable functional independence (modified Rankin scale score: 0-2). The effect was stronger in older patients (≥80 years) than younger patients, as revealed by interaction modeling analysis (P_interaction = 0.06).

CONCLUSION

TMT is associated with age, sex, body mass index, and premorbid functional status. Larger TMT is associated with better outcomes after EVT. The effects of TMT are more pronounced in older adults, indicating that sarcopenia may have influence on stroke outcomes.

Cerebral Venous Reflux and Cerebral Amyloid Angiopathy: An Magnetic Resonance Imaging/Positron Emission Tomography Study

BACKGROUND

Cerebral venous outflow alterations contribute to central nervous system pathology in aging and neurodegenerative disorders and are potentially linked to underlying cerebral microangiopathy. We investigated whether cerebral venous reflux (CVR) is more closely associated with cerebral amyloid angiopathy (CAA) than hypertensive microangiopathy in intracerebral hemorrhage (ICH) survivors.

METHODS

This cross-sectional study included 122 patients of spontaneous ICH with magnetic resonance and positron emission tomography imaging studies (2014-2022) in Taiwan. The presence of CVR was defined as abnormal signal intensity in the dural venous sinus or internal jugular vein on magnetic resonance angiography. Cerebral amyloid load was measured using the Pittsburgh compound B standardized uptake value ratio. Clinical and imaging characteristics associated with CVR were evaluated in univariable and multivariable analyses. In the subset of patients with CAA, we applied univariable and multivariable linear regression analyses to evaluate the association between CVR and cerebral amyloid retention.

RESULTS

Compared with patients without CVR (n=84, 64.5±12.1 years), patients with CVR (n=38, 69.4±11.5 years) were significantly more likely to have CAA-ICH (53.7% versus 19.8%; P<0.001) and had a higher cerebral amyloid load (standardized uptake value ratio [interquartile range], 1.28 [1.12-1.60] versus 1.06 [1.00-1.14]; P<0.001). In a multivariable model, CVR was independently associated with CAA-ICH (odds ratio, 4.81 [95% CI, 1.74-13.27]; P=0.002) after adjustment for age, sex and conventional small vessel disease markers. In CAA-ICH, higher PiB retention was observed in patients with CVR than patients without CVR (standardized uptake value ratio [interquartile range], 1.34 [1.08-1.56] versus 1.09 [1.01-1.26]; P<0.001). In multivariable analysis after adjustment for potential confounders, the presence of CVR was independently associated with a higher amyloid load (standardized β=0.40; P=0.001).

CONCLUSIONS

In spontaneous ICH, CVR is associated with CAA and a higher amyloid burden. Our results suggest venous drainage dysfunction potentially plays a role in CAA and cerebral amyloid deposition.

Abstract 163: Cerebral Amyloid Deposition Predicts Long-term Cognitive Decline In Intracerebral Hemorrhage Survivors

Background: To investigate the role of cerebral amyloid deposition for long-term cognitive outcomes in spontaneous intracerebral hemorrhage (ICH) survivors.

Methods: Patients experiencing an ICH without over dementia were included (n = 68). Each patient received the brain MRI and Pittsburgh Compound B (PiB) PET at baseline, and the cognitive function was followed up using Mini-mental Status Examination (MMSE) and clinical dementia rating (CDR) with an overall median of 3.8 years. The association between follow-up cognitive outcomes and neuroimaging markers was explored using multivariable Cox regression models. Positive amyloid scan was defined as global PiB standardized uptake value ratio > 1.2.

Results: Patients with PiB(+) were older (72.1 ± 7.8 vs. 59.9 ± 11.7, p = 0.002) and were more frequently associated with probable CAA (54.5% vs. 8.8%, p=0.001) than patients with PiB(-). PiB(+) was associated with a higher risk of dementia conversion (32.9 vs. 4.0 per 100-person-years, HR=16.4 [3.5-75.5], p <0.001) and cognitive decline (defined as MMSE decline≥ 2, 58.8 vs.9.9 per 100-person-years, HR=6.1 [2.0-18.8], p=0.002) compared to PiB(-). Higher lobar microbleed number and the presence of lacune were also associated with cognitive worsening (both p<0.005). In the cox models, PiB(+) was an independent predictor of dementia conversion (HR=12.3 [2.9-52.6], p=0.001) or cognitive decline (HR=7.9 [2.4-26.0], p=0.001) after adjustment for age, sex, educational years, lobar microbleeds and lacune. In the subgroup of patients who were non-CAA (n=57), PiB(+) remained an independent predictor of cognitive worsening (both p<0.005).

Conclusions: We demonstrate the strong association between positive amyloid scan and long-term cognitive change in ICH survivors, suggesting cerebral amyloid deposition as an important driving factor for cognitive impairment in hemorrhagic small vessel disease.

Development and Validation of a Risk Score for Predicting Ischemic Stroke After Transient Ischemic Attack

BACKGROUND

A risk stratification scale is essential to identify high-risk patients who had transient ischemic attack (TIA) to prevent subsequent permanent disability caused by ischemic stroke.

OBJECTIVE

This study aimed to develop and validate a scoring system to predict acute ischemic stroke within 90 days after TIA in an emergency department (ED).

METHODS

We retrospectively analyzed the data of patients with TIA in a stroke registry between January 2011 and September 2018. Characteristics, medication history, electrocardiogram (ECG), and imaging findings were collected. Univariable and multivariable stepwise logistic regression analyses were performed to create an integer point system. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration. Youden's Index was also used to determine the best cutoff value.

RESULTS

A total of 557 patients were included, and the occurrence rate of acute ischemic stroke within 90 days after TIA was 5.03%. After multivariable analysis, a new integer point system was created-MESH (Medication Electrocardiogram Stenosis Hypodense) score-which contained medication history (antiplatelet medication taken before admission, 1 point), right bundle branch block on electrocardiogram (1 point), intracranial stenosis ≥ 50% (1 point), and size of the hypodense area on computed tomography (diameter ≥ 4 cm, 2 points). The MESH score showed adequate discrimination (AUC = 0.78) and calibration (HL test = 0.78). The best cutoff value was 2 points, with a sensitivity of 60.71% and specificity of 81.66%.

CONCLUSIONS

The MESH score indicated improved accuracy for TIA risk stratification in the ED setting.

Serum amyloid A predicts poor functional outcome in patients with ischemic stroke receiving endovascular thrombectomy: a case control study

BACKGROUND

Post-stroke inflammation contributes to poor outcomes, but its impact on patients with stroke receiving endovascular thrombectomy (EVT) remains unknown.

METHODS

We enrolled adult patients with stroke who received EVT, with blood sampling immediately before (T1) and after EVT (T2), and at 24 hours after EVT (T3). Non-stroke controls and patients with non-EVT stroke were also enrolled. The medical information, image findings and levels of serum amyloid A (SAA) and C-reactive protein (CRP) were analyzed to clarify the association with poor functional outcome (modified Rankin Scale 4-6) at 3 months after stroke.

RESULTS

A total of 93 patients with stroke receiving EVT, 51 non-stroke controls, and 64 with non-EVT stroke were enrolled in this study. The SAA and CRP levels at T1 to T3 in patients with stroke receiving EVT were higher compared with those in controls (all p<0.001), and their levels at T3 were significantly higher than those at T1 (both p<0.0001) while similar to those in patients with non-EVT stroke. The SAA levels at the three time points were significantly associated with poor functional outcome (p=0.003 to 0.009). Furthermore, adding SAA level at T3 significantly improved the basic prediction model for 3-month poor functional outcome by receiver operating characteristic (ROC) analysis (areas under ROC curves from 0.803 to 0.878, p=0.03).

CONCLUSIONS

Our findings demonstrate that plasma levels of SAA at an early stage are significant predictors for poor functional outcomes at 3 months in patients with stroke receiving EVT, indicating the substantial role of systemic inflammation in shaping stroke outcomes following EVT.

Improvement After Celecoxib Treatment in Patients with Thalamic Hemorrhage - A Case Report

PURPOSE

Perihematomal edema of intracerebral hemorrhage (ICH) is caused by a hematoma-induced inflammatory reaction, which usually contributes to delayed deterioration of neurological function and poor outcomes. Celecoxib is a commonly used nonsteroidal anti-inflammatory drug that selectively inhibits cyclooxygenase-2. High-dose celecoxib (400 mg twice daily) for 14 days has been shown to reduce perihematomal edema and hematoma enlargement in patients with ICH, but without improvement in long-term functional outcome, which may be confounded by the heterogeneity of hematoma location. Low-dose celecoxib may be an effective management for symptoms caused by perihematomal edema in patients with ICH, particularly those involving the thalamus.

CASE REPORT

We reported two patients with acute thalamic ICH; a common symptom between the two was delayed onset of drowsiness caused by perihematomal edema involving the thalamus. Their consciousness improved after low-dose celecoxib (200 mg once daily) administration for 3 and 2 days in case A and B, respectively. Furthermore, other symptoms that concomitantly improved included poor appetite caused by perihematomal edema involving the left hypothalamus in case A, and limb weakness caused by perihematomal edema of the internal capsule in case B.

CONCLUSION

These cases revealed that low-dose celecoxib may be an effective management for symptoms caused by perihematomal edema in patients with ICH, particularly those involving the thalamus.

Concomitant Sympathetic and Parasympathetic Dysfunction after Acute Ischemic Stroke

PURPOSE

Autonomic dysfunction is an underrecognized complication of acute ischemic stroke. The cortical regulation of sympathetic activation is predominantly lateralized to the right hemisphere and parasympathetic activation to the left hemisphere. However, prior evidence is lacking regarding ischemic lesions in unilateral hemisphere that concomitantly cause sympathetic and parasympathetic dysfunction.

CASE REPORT

We present the case of a 73-year-old woman with acute ischemic stroke in the left middle cerebral artery territory, whose neurological symptoms improved significantly after thrombolysis and endovascular thrombectomy. She presented residual scattered small infarctions involving the left insula and lateral parietal cortex. However, she experienced obvious autonomic symptoms that included orthostatic hypotension, which is indicative of sympathetic dysfunction, and micturition difficulty with exaggerated reflex tachycardia, indicative of parasympathetic dysfunction. The sympathetic and parasympathetic functions sequentially resolved on days 10 and 20 after stroke onset, respectively.

CONCLUSION

The case revealed insight into the phenomenon and recovery course of concurrent sympathetic and parasympathetic dysfunction associated with ischemic lesions in the left hemisphere.

Posterior Limb of Internal Capsule Infarct Predicts Functional Outcome in Acute Terminal Internal Carotid Artery Occlusion After Thrombectomy

PURPOSES

This study investigated the impact of posterior limb of internal capsule (PLIC) infarct on outcomes of acute internal carotid artery (ICA) occlusion after endovascular thrombectomy (EVT) and the diagnostic accuracy of pretreatment noncontrast computerized tomography (NCCT) and computerized tomography angiography (CTA) findings.

METHODS

Patients who underwent EVT for acute ICA occlusion between September 2014 and August 2020 were included in the study. The patients were dichotomized as PLIC infarct or spared. The risk factors for PLIC infarct were investigated, and the association between infarct patterns and clinical outcomes were assessed using logistic regression analysis. Pretreatment NCCT and CTA findings, including PLIC hypodensity, choroid plexus enhancement (CPE), and posterior cerebral artery (PCA) flow status, were calculated for diagnosis of PLIC infarct.

RESULTS

Among 72 patients, the mean age was 70.9 years, and the mean stroke scale was 19.4. PLIC infarct was identified in 15 patients (20.8%). PLIC infarct was associated with worse 90-day functional outcome (P = 0.01, shift test). Lack of CPE is the only independent predictor of PLIC infarct (odds ratio: 127.48, P = 0.001). Lack of CPE and impaired PCA flow produce greater diagnostic accuracy for PLIC infarct than does NCCT hypodensity (area under the receiver operating characteristics curve: 0.85 and 0.76, P = 0.0005 and 0.02, respectively).

CONCLUSIONS

In acute ICA occlusion, PLIC infarct is an independent risk factor for worse clinical outcome at 90 days. The lack of CPE was associated with PLIC infarct, and pretreatment CTA can be useful for early diagnosis.

Postoperative vascular event prediction using angiography and ultrasonography in patients with Moyamoya disease

OBJECTIVE

Indirect revascularization surgery reduce the risk of recurrent vascular events in patients with moyamoya disease (MMD), but the roles of postoperative angiography and ultrasonography in predicting these events remain unclear.

METHODS

This prospective study enrolled patients with MMD who would undergo their first unilateral indirect revascularization surgery. They received preoperative and postoperative ultrasound examination at 1, 3, and 6 months and conventional cerebral angiography. On ultrasonography, postoperative emerging flow (PEF) in an intracranial artery was defined as emerging flow postoperatively with absence of flow preoperatively. Predictors of vascular event frequency reduction were identified from angiographic and ultrasonographic parameters.

RESULTS

In total, 52 patients (including 24 pediatric and 24 male patients), who underwent 52 preoperative and 82 postoperative ultrasound examinations, were enrolled. Significant postoperative changes were noted in all the ultrasonographic parameters of ipsilateral superficial temporal artery (STA) and the end-diastolic velocity and flow volume in contralateral STA. During a median follow-up of 5.3 years, indirect revascularization surgery significantly reduced the occurrence of ipsilateral vascular events. Predictors of vascular event frequency reduction included Matsushima grade A or B on the ipsilateral side on angiography (odds ratio [OR] = 22.00, P = 0.002) and lower resistance index (RI) in ipsilateral STA (OR = 0.0001, P = 0.012) but no PEF pattern in ipsilateral middle cerebral artery (OR = 0.14, P = 0.029) on ultrasonography performed within 6 months.

CONCLUSIONS

Reduction of long-term vascular event frequency probably can be predicted through postoperative angiography and ultrasonography within 6 months after indirect revascularization surgery.

Cerebral Venous Reflux and Dilated Basal Ganglia Perivascular Space in Hypertensive Intracerebral Hemorrhage

Background and Purpose Cerebral venous flow alterations potentially contribute to age-related white matter changes, but their role in small vessel disease has not been investigated.Methods This study included 297 patients with hypertensive intracerebral hemorrhages (ICH) who underwent magnetic resonance imaging. Cerebral venous reflux (CVR) was defined as the presence of abnormal signal intensity in the dural venous sinuses or internal jugular vein on time-of-flight angiography. We investigated the association between CVR, dilated perivascular spaces (PVS), and recurrent stroke risk.Results CVR was observed in 38 (12.8%) patients. Compared to patients without CVR those with CVR were more likely to have high grade (>20 in the number) dilated PVS in the basal ganglia (60.5% vs. 35.1%; adjusted odds ratio [aOR], 2.64; 95% confidence interval [CI], 1.25 to 5.60; <i>P</i>=0.011) and large PVS (>3 mm in diameter) (50.0% vs. 18.5%; aOR, 3.87; 95% CI, 1.85 to 8.09; <i>P</i><0.001). During a median follow-up of 18 months, patients with CVR had a higher recurrent stroke rate (13.6%/year vs. 6.2%/year; aOR, 2.53; 95% CI, 1.09 to 5.84; <i>P</i>=0.03) than those without CVR.Conclusions CVR may contribute to the formation of enlarged PVS and increase the risk of recurrent stroke in patients with hypertensive ICH.

Effectiveness of Standard-Dose vs. Low-Dose Alteplase for Acute Ischemic Stroke Within 3-4.5 h

Background

The efficacy and safety of intravenous alteplase administered 3–4.5 h after acute ischemic stroke have been demonstrated. However, whether responses differ between low-dose and standard-dose alteplase during this time window and whether certain subgroups benefit more remain unknown.

Patients and Methods

The current analysis was based on a multicenter matched-cohort study conducted in Taiwan. The treatment group comprised 378 patients receiving intravenous alteplase 3–4.5 h after stroke onset, and the control group comprised 378 age- and sex-matched patients who did not receive alteplase treatment during the same period. Standard- and low-dose alteplase was administered to patients at the physician's discretion.

Results

Overall, patients receiving alteplase exhibited more favorable outcomes than did controls [34.0 vs. 22.7%; odds ratio (OR): 1.75, 95% confidence interval (CI): 1.27–1.42], and the effectiveness was consistent in all subgroups. Although patients in the standard-dose group (n = 182) were younger than those in the low-dose (n = 192) group, the proportions of patients with favorable outcomes (36.3 vs. 31.8%; OR: 1.22, 95% CI: 0.80–1.88) and symptomatic hemorrhage (2.8 vs 4.2%; OR: 0.65, 95% CI: 0.21–2.02) were consistently comparable in a covariate-adjusted model and an age-matched cohort. In the subgroup analysis, patients with cardioembolism, atrial fibrillation, and hypercholesterolemia were more likely to achieve favorable outcomes after receiving standard-dose than low-dose alteplase.

Conclusion

In the 3–4.5 h time window, the effectiveness and safety of standard-dose and low-dose alteplase may be comparable. A standard dose may be selected for patients with cardioembolism, atrial fibrillation, or hypercholesterolemia.

Abstract 118: Cerebral Venous Reflux And Dilated Basal Ganglia Perivascular Space In Hypertensive Small Vessel Disease

Background: Cerebral venous flow alterations have been considered as a contributor in white matter ischemia and cognitive impairment, but their role in small vessel disease has never been investigated.

Method: 297 patients with spontaneous hypertensive intracerebral hemorrhage who underwent brain MRI were included. Presence of cerebral venous reflux (CVR) was defined as abnormal signal intensity in the dural venous sinus (cavernous, inferior petrosal, sigmoid or transverse sinus) or internal jugular vein using MR angiography (Figure). Dilated basal ganglia (BG) perivascular spaces (PVS) was defined as the number of PVS >20 or any PVS with size > 3mm in short axis (L-PVS). The association between CVR and dilated BG-PVS were evaluated in univariate and multivariable models. Stroke recurrence was also analyzed in cox regression model.

Results: Compared to patients without CVR, patients with CVR (n=37, 12,5%) had similar demographics, but showed a trend toward more severe SVD markers including microbleeds, white matter hyperintensities and lacunes. In addition, presence of CVR is significantly associated with dilated BG-PVS (BG-PVS > 20, 62.2% vs. 34.6%, P = 0.002; L-PVS, 48.6% vs. 18.8%, P < 0.001). In multivariable model, the presence of CVR remained independently associated with dilated BG-PVS (odds ratio 4.03 [1.68-9.68], p=0.002) after adjustment for age and other SVD markers. In cox model, CVR predicts higher risk of stroke recurrence independent of conventional SVD markers (odds ratio 2.32 [1.00-5.34], P = 0.049).

Conclusion: We demonstrated a close relationship between CVR and dilated BG PVS, suggesting the potential role of venous drainage dysfunction in the formation of enlargement of PVS in hypertensive SVD.

Capping Protein Regulator and Myosin 1 Linker 3 (CARMIL3) as a Molecular Signature of Ischemic Neurons in the DWI-T2 Mismatch Areas After Stroke

Ischemic stroke with a mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) or T2-weighted images indicates onset within 4.5 h, but the pathological substrates in the DWI-T2 mismatch and T2(+) areas remain elusive. In this study, proteomics was used to explore (1) the protein expression profiles in the T2(+), mismatch, and contralateral areas, and (2) the protein with the highest expression in the T2(+) area in the brains of male Sprague-Dawley rats within 4.5 h after middle cerebral artery occlusion (MCAO). The expression of the candidate protein was further validated in (1) rat brain subjected to MCAO, (2) rat primary cortical neuronal culture with oxygen-glucose deprivation (OGD), and (3) infarcted human brain tissues. This study showed that apoptosis was observed in the T2(+) and mismatch regions and necroptosis in the T2(+) region of rat brains after MCAO. We identified capping protein regulator and myosin 1 linker 3 (CARMIL3) as the candidate molecule in the T2(+) and mismatch areas, exclusively in neurons, predominantly in the cytoplasm, and most abundant in the mismatch area. The CARMIL3(+) neurons and neurites in the mismatch and T2(+) areas were larger than those in the control area, and associated with (1) increased expression of sulfonylurea receptor 1 (SUR1), indicating edema, (2) accumulation of p62, indicating impaired autophagy, and (3) increase in 8-hydroxy-2′-deoxyguanosine (8-OHdG), indicating oxidative stress. The increased expression of CARMIL3 was validated in a cell model of cortical neurons after OGD and in infarcted human brain tissues. In conclusion, this study shows that the mismatch and T2(+) areas within 4.5 h after ischemia are characterized by upregulated expression of CARMIL3 in neurons, particularly the mismatch area, which is associated with neuronal edema, impaired autophagy, and oxidative stress, indicating that CARMIL3 serves as a molecular signature of brain ischemia.

Incidence of stroke among patients with polycystic kidney disease in Taiwan: a retrospective population-based cohort study using National Health Insurance Database

BACKGROUND

Few studies documented incidence rates of different types of stroke among patients with polycystic kidney disease (PKD).

MATERIALS AND METHODS

We conducted a retrospective cohort study based on the National Health Insurance (NHI) Database of Taiwan. The PKD cohort comprised patients aged≥20 years diagnosed with PKD using inpatient claims from 1998 to 2011, excluding prior stroke. The reference cohort was established by inpatients without PKD using 1:4 frequency-matched with age, gender, and baseline comorbidities. The two cohorts were followed-up until stroke hospitalization, death, withdrawal from the NHI program, or the end of 2012. To account for competing risks of death, we used multivariable competing risks regression models to estimate sub-distribution hazard ratio (SHR) adjusted for age, gender, baseline comorbidities and end stage renal disease.

RESULTS

7837 PKD patients and 31211 reference subjects were followed up through 2012. A total of 955 cases of stroke were identified in the PKD cohort, including 441 ischemic stroke (IS), 289 intracranial hemorrhage (ICH), 73 subarachnoid hemorrhage (SAH) and 232 other stroke. The incidence rates of overall stroke, IS, ICH, and SAH were 21.3, 10.2, 6.8, and 1.7 per 1000 person-years, respectively. The SHR for overall stroke was 1.39 [95% confidence interval (CI) 1.28-1.50]. SAH had the highest SHR, 4.55 [95% CI 3.26-6.37], followed by ICH (1.84), other stroke (1.24), and IS (1.22).

CONCLUSIONS

This study illustrated the incidence rates of stroke among inpatient of PKD. The PKD patients had a significantly increased risk of all kinds of stroke after adjusting baseline comorbidities.

Plasma soluble TREM2 is associated with white matter lesions independent of amyloid and tau

Cerebral small vessel disease is one of the most common causes of cognitive decline and stroke. While several lines of evidence have established a relationship between inflammation and cerebrovascular pathology, the mechanistic link has not yet been elucidated. Recent studies suggest activation of immune mediators, including the soluble form of triggering receptor expressed on myeloid cells 2 (TREM2), may be critical regulators. In this study, we compared the plasma levels of soluble TREM2 and its correlations with neuroimaging markers and cerebral amyloid load in ten patients with Alzheimer's disease and 66 survivors of spontaneous intracerebral haemorrhage with cerebral amyloid angiopathy or hypertensive small vessel disease, two of the most common types of sporadic small vessel disease. We performed brain MRI and 11C-Pittsburgh compound B PET for all participants to evaluate radiological small vessel disease markers and cerebral amyloid burden, and 18F-T807 PET in a subgroup of patients to evaluate cortical tau pathology. Plasma soluble TREM2 levels were comparable between patients with Alzheimer's disease and small vessel disease (P=0.690). In patients with small vessel disease, plasma soluble TREM2 was significantly associated with white matter hyperintensity volume (P<0.001), but not with cerebral amyloid load. Among patients with Alzheimer's disease and cerebral amyloid angiopathy, plasma soluble TREM2 was independently associated with a tau-positive scan (P=0.001) and white matter hyperintensity volume (P=0.013), but not amyloid load (P=0.221). Our results indicate plasma soluble TREM2 is associated with white matter hyperintensity independent of amyloid and tau pathology. These findings highlight the potential utility of plasma soluble TREM2 as a strong predictive marker for small vessel disease-related white matter injury and hold clinical implications for targeting the innate immune response when treating this disease.

Expanding resources of endovascular thrombectomy: An optimization model

BACKGROUND/PURPOSE

Recently optimized models for selecting the locations of hospitals capable of providing endovascular thrombectomy (EVT) did not consider the accuracy of the prehospital stroke scale assessment and possibility of secondary transport. Our study aimed to propose a new model for selecting existing hospitals with intravenous thrombolysis capability to become EVT-capable hospitals.

METHODS

A sequential order was provided to upgrade hospitals providing intravenous thrombolysis, using a mixed integer programming model based on current medical resource allocation. In addition, we drafted a centralized plan to redistribute existing EVT resources by redetermining locations of EVT-capable hospitals. Using historical data of 7679 on-scene patients with suspected stroke, the model was implemented to determine the hospital that maximizes the number of patients receiving EVT treatment within call-to-definitive-treatment time.

RESULTS

All suspected stroke patients were sent to EVT-capable hospitals directly under the current medical resource allocation model. After upgrading one additional hospital to become an EVT-capable hospital, the percentage of patients receiving definitive treatment within the standard call-to-definitive-treatment time was elevated from 68.82% to 72.97%. In the model, assuming that there is no hospital providing EVT, all patients suspected of stroke will be sent to EVT-capable hospitals directly after upgrading three or more hospitals to be able to provide treatment.

CONCLUSION

All patients eligible for acute stroke treatment are sent to EVT-capable hospitals in the simulation under the current medical resource allocation model. This model can be utilized to provide insights for capacity redistribution in other regions.

Arterial Spin Labeling Imaging Assessment of Cerebrovascular Reactivity in Hypertensive Small Vessel Disease

Objective: Cerebrovascular reactivity (CVR) represents the phenomenon where cerebral vessels dilate or constrict in response to vasoactive stimuli. CVR impairment may contribute to brain injury due to cerebral small vessel disease (SVD). We aimed to determine the CVR in hypertensive intracerebral hemorrhage (ICH) and to identify its vascular dysfunction.

Methods: A total of 21 patients with spontaneous hypertensive ICH (strictly deep or mixed deep and lobar hemorrhages, mean age 62.5 ± 11.3 years) and 10 control subjects (mean age 66.1 ± 6.0 years) were enrolled for CVR measurement at least 3 months after the symptomatic ICH event. Each participant underwent a brain MRI study, and CVR was calculated as the cerebral blood flow (CBF) reduction using arterial spin labeling (ASL) between baseline and 10 min after an intravenous dipyridamole injection (0.57 mg/kg). Traditional MRI markers for SVD were also evaluated, including cerebral microbleed, white matter hyperintensity, lacune, and MRI-visible enlarged perivascular space, which were used to determine the total small vessel disease score.

Results: Compared to control subjects, hypertensive ICH patients showed reduced CVR in the basal ganglia (CBF reduction 22.4 ± 22.7% vs. 41.7 ± 18.3, p = 0.026), the frontal lobe (15.1 ± 11.9 vs. 26.6 ± 9.9, p = 0.013), and the temporal lobe (14.7 ± 11.1 vs. 26.2 ± 10.0, p = 0.010). These differences remained significant in multivariable models after adjusting for age and sex. Within ICH groups, the CBF reduction in the basal ganglia was significantly correlated with the total small vessel disease score (R = 0.58, p = 0.006), but not with individual MRI markers.

Conclusion: Patients with advanced hypertensive SVD demonstrated impaired vasoconstriction after dipyridamole challenge in the basal ganglia and the frontal and temporal lobes. Our findings provide safe approaches for whole-brain CVR mapping in SVD and identify a potential physiological basis for vascular dysfunction in hypertensive SVD.

Update of Intravenous Thrombolytic Therapy in Acute Ischemic Stroke

Upon acute ischemic stroke, rapid recanalization of the occluded cerebral vessel via intravenous thrombolytic therapy (IVT) is crucial to achieve good functional outcome. The time window of IVT with recombinant tissue plasminogen activator (rt-PA) has been extended from post-stroke 3 to 4.5 hours. In patients with cerebral penumbra identified using cerebral perfusion imaging, IVT is still beneficial within 4.5 to 9 hours after onset of stroke. For those without clear stroke onset time, DWI-FLAIR mismatch by brain MRI indicates hyperacute infarct and IVT is indicative. For patients with large cerebral vessel occlusion, endovascular thrombectomy (EVT) alone is likely non-inferior to bridging therapy (IVT followed by EVT) and this issue is still under investigation. Serial studies have provided the evidence of safety and risk of IVT in specific groups of patients, such as elderly, anticoagulant users, and those having cerebral microbleeds or seizure. Tenecteplase has higher fibrin selectivity than rt-PA and large clinical trials have demonstrated its great potential for stroke therapy. Future clinical trials are mandatory for therapeutic optimization of IVT, especially in bridging therapy, specific groups of patients, and new thrombolytic agents. Keywords: Acute Ischemic Stroke, Cerebral Infarction, Recombinant Tissue Plasminogen Activator, Tenecteplase, Thrombolytic Therapy.

Autoantibody of NRIP, a novel AChR-interacting protein, plays a detrimental role in myasthenia gravis

BACKGROUND

Nuclear receptor interaction protein (NRIP) co-localizes with acetylcholine receptor (AChR) at the neuromuscular junction (NMJ), and NRIP deficiency causes aberrant NMJ architecture. However, the normal physiological and pathophysiological roles of NRIP in NMJ are still unclear.

METHODS

We investigated the co-localization and interaction of NRIP with AChR-associated proteins using immunofluorescence and immunoprecipitation assay, respectively. The binding affinity of AChR-associated proteins was analysed in muscle-restricted NRIP knockout mice and NRIP knockout muscle cells (C2C12). We further collected the sera from 43 patients with myasthenia gravis (MG), an NMJ disorder. The existence and features of anti-NRIP autoantibody in sera were studied using Western blot and epitope mapping.

RESULTS

NRIP co-localized with AChR, rapsyn and α-actinin 2 (ACTN2) in gastrocnemius muscles of mice; and α-bungarotoxin (BTX) pull-down assay revealed NRIP with rapsyn and ACTN2 in complexes from muscle tissues and cells. NRIP directly binds with α subunit of AChR (AChRα) in vitro and in vivo to affect the binding affinity of AChR with rapsyn and rapsyn with ACTN2. In 43 patients with MG (age, 58.4 ± 14.5 years; female, 55.8%), we detected six of them (14.0%) having anti-NRIP autoantibody. The presence of anti-NRIP autoantibody correlated with a more severe type of MG when AChR autoantibody existed (P = 0.011). The higher the titre of anti-NRIP autoantibody, the more severe MG severity (P = 0.032). The main immunogenic region is likely on the IQ motif of NRIP. We also showed the IgG subclass of anti-NRIP autoantibody mainly to be IgG1.

CONCLUSIONS

NRIP is a novel AChRα binding protein and involves structural NMJ formation, which acts as a scaffold to stabilize AChR-rapsyn-ACTN2 complexes. Anti-NRIP autoantibody is a novel autoantibody in MG and plays a detrimental role in MG with the coexistence of anti-AChR autoantibody.

Centrum Semiovale Perivascular Space and Amyloid Deposition in Spontaneous Intracerebral Hemorrhage

[Figure: see text].

Determinants for Control of Status Epilepticus in Patients with Anti-N-Methyl-D-Aspartate Receptor Encephalitis

BACKGROUND

Treatment guideline for status epilepticus (SE) specifically in patients with anti-N-methyl- D-aspartate receptor (anti-NMDAR) encephalitis is insufficient. This study aimed to clarify the determinants for the control of SE in adult patients with anti-NMDAR encephalitis.

METHODS

Medical records of all patients with anti-NMDAR encephalitis hospitalized between Jan. 2010 and Sep. 2019 were analyzed for the time sequence of seizures and treatments, and antiepileptic drug (AED) regimens related to SE. The outcomes were control of SE and seizures, and the discharge score of modified Rankin Scale (mRS).

RESULTS

All eight patients had seizures and seven (87.5%) suffered from SE which lasted for 3.6 ± 3.9 days. Five patients (71.4%) had SE earlier than using IT, whose SE was controlled by AEDs alone (n = 4) or combined with teratomas resection (n = 1). Another two patients suffered from SE after receiving IT, and one of them had SE only for 1 hour. Moreover, all SE patients received increased types and dosages of AEDs at SE end. A shorter duration of refractory SE was associated with its later occurrence after seizure onset (p = 0.005) and longer duration of AEDs use before SE (p = 0.026). All cases achieved seizure freedom after receiving AEDs and IT.

CONCLUSIONS

In these patients with anti-NMDAR encephalitis, all the SE which occurred before initiating IT was successfully controlled by AEDs alone or combined with teratoma resection, and later onset of refractory SE was associated with a shorter SE duration.

Abstract 39: Acute Blood Pressure Dysregulation Increases the Risk of Border Zone Ischemic Lesions in Hypertensive Intracerebral Hemorrhage

Background: Intensive blood pressure (BP) reduction is regarded as the gold standard therapy for acute intracerebral hemorrhage (ICH), but its associations to cerebral hypoperfusion and ischemic lesions have been suspected. This study aims to investigate the impact of acute BP reduction on the development of acute ischemic lesions (AILs) at border zone (BZ) areas in patients with hypertensive ICH.

Methods: We enrolled patients with acute hypertensive ICH (hemorrhagic lesions restricted to deep region [Strictly deep-ICH] or located in mixed lobar and deep areas [Mixed-ICH]) who received brain MRI within 7 days after ICH onset. BZ AILs were defined as lesions locating at BZ areas that were hyperintense on DWI sequence and hypointense on ADC series (figure). Acute SBP change was the difference between the initial SBP and the SBP recorded at 24 hours after ICH onset.

Results: Of the 274 enrolled patients (62.5 ± 12.7 years old, 65% male), 11 subjects had BZ AILs. Compared to patients without BZ AILs, patients with lesions had wider amount of acute SBP reduction (71.7 ± 33.6 vs. 43.0 ± 32.2 mmHg, P = 0.023), more lobar and deep microbleeds (MB) and larger white matter hyperintensity volume (all p < 0.05). Using ROC curve analysis, acute SBP drop at more than 54mmHg was linked to the occurrence of AILs (sensitivity 82%, specificity 64%, P = 0.002). In multiple logistic regression model, acute SBP decline at above 54mmHg (OR 11.45, 95%CI 2.06 - 63.49, P = 0.005) and higher deep MB burden ( P = 0.032) raised the risk of AILs after adjustment for age, sex, and image markers of cerebral small vessel disease. In subgroup analysis, larger acute SBP drop remained to be an independent risk factor for development of AILs in patients with Mixed-ICH ( P = 0.008), but not in patients with strictly deep-ICH ( P = 0.715).

Conclusion: Acute SBP change in hypertensive ICH, especially in Mixed-ICH, increases the risk of AILs at BZ areas, showing widespread microangiopathy that is vulnerable to rapid BP dysregulation to ischemia.

Angiographic early hyperemia in the middle cerebral artery territory after thrombectomy is associated with favorable clinical outcome in anterior circulation stroke

OBJECTIVES

Angiographic cortical early hyperemia (EH) is frequently observed after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke. The aim of the study is to investigate the relationship between EH and clinical outcomes.

METHODS

Between January 2015 and September 2018, consecutive patients who underwent EVT for anterior circulation LVO stroke with optimal recanalization (modified thrombolysis in cerebral infarction 2b or 3) were included. Angiographic studies after immediate reperfusion were used for analysis for cortical EH sign. Clinical functional outcomes were evaluated with the modified Rankin Scale (mRS) at 90 days. Safety outcomes, including mortality and intracerebral hemorrhage, were assessed. The association of EH between clinical functional and safety outcomes was analyzed.

RESULTS

A total of 143 patients were analyzed (mean age: 71 years; median National Institutes of Health Stroke Scale score: 18). A positive EH sign was observed in 88 (62%) patients. Good functional outcome at 90 days was significantly different between the EH⁺ and EH^- groups (p = .0157). Intracerebral hemorrhage and mortality did not differ between groups. In multivariate logistic regression analysis, EH was an independent predictor for good clinical outcome (mRS ≤ 2, odds ratio: 3.49, p = .0034) in addition to young age.

CONCLUSION

Results revealed that the presence of EH is associated with better clinical outcome at 90 days, but not associated with increased hemorrhagic complication. These findings with clinically relevant implications require further validation.

KEY POINTS

• Angiographic cortical hyperemia is a common finding immediately after endovascular thrombectomy. • Presence of cortical hyperemia is an independent prognostic factor for good clinical outcome. • Hemorrhagic complication is not associated with cortical hyperemia.

External validation of prehospital stroke scales for emergent large vessel occlusion

BACKGROUND

It is suggested that a prehospital scale should be utilized to identify patients with emergent large vessel occlusion (ELVO). We aimed to perform external validation of nine ELVO scales.

METHODS

This single center retrospective observational study included patients with ischemic stroke visiting the emergency department (ED) within 6 h of symptom onset. Participants were excluded if individual items of the National Institute of Health Stroke Scale scores were not recorded or they did not receive brain computed tomography angiography or magnetic resonance imaging before intravenous thrombolysis or endovascular thrombectomy, and within 24 h of ED admission. The first definition of ELVO was emergent occlusion of the internal carotid artery (ICA) and middle cerebral artery segment 1 (M1). The second definition was emergent occlusion of ICA, M1, basilar artery, middle cerebral artery segment 2, anterior cerebral artery segment 1, and posterior cerebral artery segment 1. Area under the receiver operating characteristic curve (AUROC) was constructed to examine discrimination. The sensitivity, specificity, positive predictive value, and negative predictive value of the nine scales under the two ELVO definitions were calculated.

RESULTS

A total of 1231 patients were included in the study. No significant differences were observed in the AUROC under the two ELVO definitions. However, sensitivity values of these scales were largely different, ranging from 44.56% to 93.68% under the first ELVO definition. The sensitivity values among scales were also different under the second ELVO definition.

CONCLUSION

Stakeholders in the community should choose suitable scales according to their own system conditions.

Long-Term Vascular Outcomes in Patients With Mixed Location Intracerebral Hemorrhage and Microbleeds

OBJECTIVE

To determine whether mixed location intracerebral hemorrhages/microbleeds (mixed ICH) is a risk factor for vascular unfavorable outcome compared to cerebral amyloid angiopathy-related ICH (CAA-ICH) or strictly deep hypertensive ICH/microbleeds (HTN-ICH).

METHODS

A total of 300 patients with spontaneous ICH were included. Clinical data, neuroimaging markers, and follow-up outcomes (recurrent ICH, ischemic stroke, and vascular death) were compared among mixed ICH (n = 148), CAA-ICH (n = 32), and HTN-ICH (n = 120). The association between follow-up events and neuroimaging markers was explored using multivariable Cox regression models.

RESULTS

Patients with mixed ICH were older (65.6 ± 12.1 years vs 58.1 ± 13.3 years, p < 0.001) than patients with HTN-ICH, but younger than patients with CAA-ICH (73.3 ± 13.8 years, p = 0.001). Compared to CAA-ICH, mixed ICH had similar incidence of vascular events (all p > 0.05). Compared to HTN-ICH, mixed ICH is associated with higher ICH recurrence (hazard ratio [HR] 3.0, 95% confidence interval [CI] 1.2-7.7), more ischemic stroke (HR 8.2, 95% CI 1.0-65.8), and vascular composite outcome (HR 3.5, 95% CI 1.5-8.2) after adjustment for age and sex. In patients with mixed ICH, the presence of cortical superficial siderosis (cSS) is associated the development of ICH recurrence (HR 4.8, 95% CI 1.0-23.2), ischemic stroke (HR 8.8, 95% CI 1.7-45.5), and vascular composite outcome (HR 6.2, 95% CI 1.9-20.2). The association between cSS and ischemic stroke (p = 0.01) or vascular composite outcome (p = 0.003) remained significant after further adjustment for other radiologic markers.

CONCLUSIONS

Mixed ICH harbors higher risk of unfavorable vascular outcome than HTN-ICH. Presence of cSS in mixed ICH independently predicts vascular event, suggesting the contribution of detrimental effect due to coexisting CAA.

Fibrin and Platelet-Rich Composition in Retrieved Thrombi Hallmarks Stroke With Active Cancer

BACKGROUND AND PURPOSE

We aim to investigate whether histopathologic examination of thrombi retrieved from acute ischemic stroke patients undergoing endovascular treatment could distinguish cancer-related stroke from other etiologies.

METHODS

Thrombi from patients undergoing endovascular treatment were analyzed. The etiology of stroke was divided into cardioembolism, large artery atherosclerosis, and active cancer groups. All selected thrombi were subjected to hematoxylin and eosin staining. The percentages of fibrin/platelets, red blood cells, and white blood cells within a thrombus were quantified.

RESULTS

One-hundred fifty-two patients (active cancer, 19; cardioembolism, 107; large artery atherosclerosis, 26) were included. Thrombi from the active cancer group exhibited a higher fibrin/platelet composition than did those from the cardioembolism and large artery atherosclerosis groups (median, 85.7% versus 43.9% and 42.5%; P<0.001). Fibrin/platelet composition was the only independent factor (odds ratio, 1.05 [95% CI, 1.02-1.08]) in differentiating cancer-related stroke from stroke caused by cardioembolism and large artery atherosclerosis. A fibrin/platelet proportion of ≥65% accurately predicted cancer-related stroke (area under the curve, 0.84; P<0.001).

CONCLUSIONS

In thrombi retrieved from patients undergoing endovascular treatment, a high fibrin/platelet composition was a probable indicator of cancer-related stroke.

Contrast-Induced Encephalopathy After Endovascular Thrombectomy for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Contrast-induced encephalopathy (CIE) is a rare and underrecognized complication after endovascular thrombectomy (EVT) for acute ischemic stroke. This study investigated the incidence and risk factors of CIE in patients who underwent EVT.

METHODS

Consecutive patients with acute ischemic stroke who received EVT between September 2014 and December 2019 at 2 medical centers were included. CIE was diagnosed on clinical criteria of neurological deterioration or delayed improvement within 24 hours after the procedure that was unexplained by the infarct or hemorrhagic transformation and radiological criterion of edematous change extending beyond the infarct core accompanied by contrast staining.

RESULTS

Of 421 patients with acute ischemic stroke who received EVT, 7 (1.7%) developed CIE. The manifestations included worsening of focal neurological signs, coma, and seizure. Patients with CIE were more likely to experience contrast-induced acute kidney injury than were those without CIE, but the volume of contrast medium was comparable between the two groups. The independent risk factors for CIE included renal dysfunction (defined as an estimated glomerular filtration rate <45 mL/min per 1.73 m²; odds ratio, 5.77 [95% CI, 1.37-24.3]; P=0.02) and history of stroke (odds ratio, 4.96 [95% CI, 1.15-21.3]; P=0.03). Patients with CIE were less likely to achieve favorable functional outcomes (odds ratio, 0.09 [95% CI, 0.01-0.87]; P=0.04).

CONCLUSIONS

CIE should be suspected in patients with clinical worsening after EVT accompanied by imaging evidence of contrast staining and edematous changes, especially in patients with renal dysfunction or history of stroke.

Prediction of mTICI 3 recanalization and clinical outcomes in endovascular thrombectomy for acute ischemic stroke: a retrospective study in the Taiwan registry

PURPOSE

Early recanalization for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) by endovascular thrombectomy (EVT) is strongly related to improved functional outcomes. With data obtained from the Taiwan registry, the factors associated with mTICI 3 recanalization and clinical outcomes in EVT are investigated.

METHODS

From January 2014 to September 2016, 108 patients who underwent EVT for AIS due to LVO in 11 medical centers throughout Taiwan were included. Complete recanalization is defined as achieving modified thrombolysis in cerebral infarction (mTICI) grade 3. Good clinical outcomes are defined by the modified Rankin scale (mRS) 0-2 at 3 months after EVT. Clinical and imaging parameters for predicting mTICI 3 recanalization and good clinical outcomes are analyzed.

RESULTS

Of the 108 patients who received EVT, 54 (50%) patients had mTICI 3 recanalization. Having received aspiration only and the use of IV-tPA are shown to be significant predictors for mTICI 3 recanalization with odds ratios of 2.61 and 2.53 respectively. Forty-six (42.6%) patients experienced good 3-month clinical outcomes (mRS 0-2). Pretreatment collateral statuses, NIHSS scores, time lapses between symptoms to needle, and the occurrence of hemorrhage at 24 h are all significant predictors for good outcomes with odds ratios of 2.88, 0.91, 0.99, and 0.31 respectively.

CONCLUSIONS

Prediction of mTICI 3 recanalization and clinical outcomes offer valuable clinical information for treatment planning in EVT.

Early recurrence of ischemic stroke in patients receiving endovascular thrombectomy

BACKGROUND/PURPOSE

Endovascular thrombectomy (EVT) is effective in treating acute ischemic stroke associated with large vessel occlusion. Early recurrence of ischemic stroke (ERIS) after EVT, however, is a devastating event and could worsen the condition of patient. Current study aimed to investigate the prevalence and risk factors of ERIS after EVT.

METHODS

The medical records of all patients receiving EVT at a single medical center were reviewed and analyzed. ERIS was defined as presentation of newly developed neurological deficits in previously recanalized vascular territory or another vascular territory that was not initially involved within 30 days of the index stroke.

RESULTS

From January 2015 to September 2018, a total of 200 patients (71.6 ± 12.3 years, male 49%) had received EVT and 17 patients (8.5%) developed ERIS. Presence of valvular heart disease was the only clinical factor associated with ERIS (OR: 4.26, 95% CI: 1.16-17.7). Patients with ERIS had significantly worse modified Rankin scale at 3 months (common OR: 3.11, 95% CI: 1.18-8.73) and were independently associated with mortality (OR: 7.73, 95% CI: 2.00-30.6). Ten of 17 patients with ERIS had received repeated EVT and all achieved good recanalization without procedure-related complications or symptomatic intracerebral hemorrhage.

CONCLUSION

ERIS in patients receiving EVT was not rare, especially in those with valvular heart disease, and was associated with worse outcome. Nevertheless, they could be safely treated by repeated EVT.

NPGPx-Mediated Adaptation to Oxidative Stress Protects Motor Neurons from Degeneration in Aging by Directly Modulating O-GlcNAcase

Amyotrophic lateral sclerosis (ALS), the most common motor neuron disease, usually occurs in middle-aged people. However, the molecular basis of age-related cumulative stress in ALS pathogenesis remains elusive. Here, we found that mice deficient in NPGPx (GPx7), an oxidative stress sensor, develop ALS-like phenotypes, including paralysis, muscle denervation, and motor neurons loss. Unlike normal spinal motor neurons that exhibit elevated O-GlcNAcylation against age-dependent oxidative stress, NPGPx-deficient spinal motor neurons fail to boost O-GlcNAcylation and exacerbate ROS accumulation, leading to cell death. Mechanistically, stress-activated NPGPx inhibits O-GlcNAcase (OGA) through disulfide bonding to fine-tune global O-GlcNAcylation. Pharmacological inhibition of OGA rescues spinal motor neuron loss in aged NPGPx-deficient mice. Furthermore, expression of NPGPx in ALS patients is significantly lower than in unaffected adults. These results suggest that NPGPx modulates O-GlcNAcylation by inhibiting OGA to cope with age-dependent oxidative stress and protect motor neurons from degeneration, providing a potential therapeutic axis for ALS.

Diagnosis and Treatment for embolic stroke of undetermined source: Consensus statement from the Taiwan stroke society and Taiwan society of cardiology

Cryptogenic stroke comprises about one-quarter of ischemic strokes with high recurrence rate; however, studies specifically investigating the features and treatment of this stroke subtype are rare. The concept of 'embolic stroke of undetermined source' (ESUS) may facilitate the development of a standardized approach to diagnose cryptogenic stroke and improve clinical trials. Since recent large randomized control trials failed to demonstrate a reduction in stroke recurrence with anticoagulants, anti-platelet agents remain the first-line treatment for ESUS patients. Nevertheless, patients with high risk of stroke recurrence (e.g., those with repeated embolic infarcts despite aspirin treatment) require a more extensive survey of stroke etiology, including cardiac imaging and prolonged cardiac rhythm monitoring. Anticoagulant treatments may still benefit some subgroups of high-risk ESUS patients, such as those with multiple infarcts at different arterial territories without aortic atheroma, the elderly, or patients with high CHA₂D₂-VASc or HOVAC scores, atrial cardiopathy or patent foramen ovale. Several important ESUS clinical trials are ongoing, and the results are anticipated. With rapid progress in our understanding of ESUS pathophysiology, new subcategorizations of ESUS and assignment of optimal treatments for each ESUS subgroup are expected in the near future.

Renal Function-Dependent Associations of Statins with Outcomes of Ischemic Stroke

Aim: Chronic kidney disease (CKD) is associated with unfavorable outcomes in patients with ischemic stroke. One major metabolic derangement of CKD is dyslipidemia, which can be managed by statins. This study aimed to investigate whether the association of statins with post-stroke outcomes would be affected by renal function.

Methods: We evaluated the association of statin therapy at discharge with 3-month outcomes according to the estimated glomerular filtration rate (eGFR) of 50,092 patients with acute ischemic stroke from the Taiwan Stroke Registry from August 2006 to May 2016. The outcomes were mortality, functional outcome as modified Rankin Scale (mRS), and recurrent ischemic stroke at 3 months after index stroke.

Results: Statin therapy at discharge was associated with lower risks of mortality (adjusted hazard ratio [aHR], 0.41; 95% confidence interval [CI], 0.34 to 0.50) and unfavorable functional outcomes (mRS 3–5; aHR, 0.80; 95% CI, 0.76 to 0.84) in ischemic stroke patients. After stratification by eGFR, the lower risk of mortality associated with statins was limited to patients with an eGFR above 15 mL/min/1.73 m². Using statins at discharge was correlated with a lower risk of unfavorable functional outcomes in patients with an eGFR of 60–89 mL/min/1.73 m². Statin therapy in patients with an eGFR of 60–89 mL/min/1.73 m² may be associated with a higher risk of recurrent ischemic stroke compared with nonusers (aHR, 1.29; 95% CI, 1.07 to 1.57).

Conclusions: In patients with acute ischemic stroke, the associations of statins with mortality and functional outcomes was dependent on eGFR.

Generation of a human induced pluripotent stem cell (iPSC) line (IBMS-iPSC-048-05) from a patient with ALS and parkinsonism having a hexanucleotide repeat expansion mutation in C9orf72 gene

A hexanucleotide repeat expansion in chromosome 9 open reading frame 72 (C9orf72) gene causes a heterogeneous neurodegenerative disorder that includes amyotrophic lateral sclerosis (ALS), frontotemporal degeneration (FTD), and parkinsonism. Here, we used the Sendai virus delivery system to generate induced pluripotent stem cells (iPSCs) from peripheral blood mononuclear cells of a male patient with an increased hexanucleotide repeat expansion in C9orf72. The resulting iPSCs exhibited pluripotency, confirmed by immunofluorescent staining for pluripotency markers, and differentiated into three germ layers in vivo. This cellular model will provide a useful platform for further pathophysiological studies of C9orf72-related neurodegeneration.

Factors for recurrent stroke among Asian patients with non-valvular atrial fibrillation under non-vitamin K antagonist oral anticoagulant therapy

BACKGROUND/PURPOSE

Atrial fibrillation (AF) patients with a history of ischemic stroke or transient ischemic attack (TIA) carry excessive risk of recurrent stroke. Real-world data for the Asian population is scarce. This study aimed to investigate the thromboembolism and major bleeding risk of non-vitamin K antagonist oral anticoagulant (NOAC) therapy among Asian patients, and to identify the risk factors of recurrent stroke.

METHODS

This retrospective study recruited AF patients aged over 20 years, who had a previous stoke or TIA, and received NOAC therapy. Thromboembolic events were recurrent ischemic stroke or TIA, and the major bleeding events were classified according to the PLATO (Platelet Inhibition and Patient Outcomes) criteria.

RESULTS

A total of 361 patients (61.2% male) were enrolled for data analysis. The incidence rate for recurrent ischemic stroke or TIA was 3.6 (95% CI = 2.5 to 5.5) per 100 person-years, and 0.9 (95% CI = 0.4 to 1.7) per 100 person-years for major bleeding. Patients with recurrent ischemic stroke or TIA were more likely to have malignancy (hazard ratio [HR] for malignancy = 4.4, 95% CI = 1.9 to 10.3, p = 0.001) and concomitantly take enzyme inducing antiepileptic drugs (EIAED, HR = 8.1, 95% CI = 2.7 to 24.1, p < 0.001).

CONCLUSION

Atrial fibrillation patients with underlying malignancy or concurrently use of EIAED may have increased risk of treatment failure in secondary stroke prevention.

Abstract WP417: Relevance of Lobar Cerebral Microbleeds in Patients With Deep Intracerebral Hemorrhage

Background: Markers of cerebral small vessel disease (cSVD) severity and prognosis in strictly lobar or strictly deep intracerebral hemorrhages (ICH)/cerebral microbleeds (CMB) are well defined but data are scarce for mixed-location ICH/CMB. We aimed to compare neuroimaging features and outcomes between deep ICH patients with and without lobar CMBs.

Methods: Patients with first-ever deep ICH from a prospectively maintained single-center registry were analyzed. Demographics, risk factors and neuroimaging markers of cSVD including CMBs, cortical superficial siderosis, enlarged perivascular spaces (EPVS), white matter hyperintensity volumes (WMH) and brain atrophy scores (range 0-15) were compared between deep ICH patients with lobar CMBs and those without lobar CMBs. The follow-up data were analyzed for ICH recurrence, ischemic stroke (IS) and all-cause mortality.

Results: Of 208 patients, 98 (47.1%) had lobar CMBs. Patients with L-CMBs were older (65.3±12.1 vs. 57.4±12.5, p<0.001) and more likely to be hypertensive (98% vs. 90.9%, p=0.037) than those without L-CMBs. Deep CMBs (83.7% vs 56.4%, p<0.001), lacunes (53.1% vs 31.8%, p=0.003) and severe basal ganglia EPVS (40.8% vs 17.3%, p<0.001) were more common in patients with L-CMBs. Patients with L-CMBs had higher volumes of WMH (17.4 ml [IQR 9-38] vs 4.8 ml [IQR 1-13], p<0.001) and atrophy scores (4 [IQR 2-7] vs 3 [IQR 0-6], p=0.007) as compared to patients without L-CMBs. During a median follow-up of 21 months, the ICH recurrence rate was similar between groups (p=0.2), but higher incident IS (3.0 vs 0.0 per 1000-person-months, p=0.016) and all-cause mortality (4.9 vs 1.5 per 1000-person-months, p=0.026) were observed in patients with L-CMBs. In a cox regression model, the presence of lobar CMBs was independently associated with a composite outcome measure (ICH/IS/mortality) after adjusting for age, hypertension, WMH volume, lacune, BG-EPVS and atrophy scores (odds ratio: 2.9, 95%CI:1.01-8.4 p=0.046).

Conclusions: Presence of lobar CMBs in patients with deep ICH is associated with parenchymal markers of more severe cSVD and poor prognosis, suggesting a more advanced vasculopathy compared to patients with strictly deep ICH.

Abstract WMP107: Outcomes in Mixed Location Intracerebral Hemorrhage and Microbleeds

Objective: Patients with mixed location intracerebral hemorrhages/microbleeds (Mixed-ICH) have predominantly hypertensive vasculopathy rather than cerebral amyloid angiopathy (CAA), but the long-term outcomes in Mixed-ICH is unknown. In this study, we aimed to determine whether Mixed-ICH is a risk factor for vascular unfavorable outcome compared to CAA-ICH or strictly deep hypertensive intracerebral hemorrhage/microbleeds (HTN-ICH).

Methods: 305 consecutive ICH patients were included. Clinical data, neuroimaging markers and follow-up outcomes (recurrent ICH, ischemic stroke and vascular death) were compared between Mixed-ICH (n=151), CAA-ICH (n=33) and HTN-ICH (n=121). The association between follow-up events and neuroimaging markers were explored using multivariable Cox regression models.

Results: Mixed-ICH patients were older (65.9±12.4 vs 58.1±13.2, p<0.001) than HTN-ICH, but younger than CAA-ICH patients (73.8 ± 13.9, p=0.001). The survival curves of follow-up outcomes were shown in the Figure. Compared to CAA-ICH, Mixed-ICH has similar incidence of vascular event (all P>0.05). Compared to HTN-ICH, Mixed-ICH is associated with higher ICH recurrence (hazard ratio [HR]=3.0 [1.2-7.7], p=0.021), more ischemic stroke (HR=8.2 [1.0-65.8], p=0.048), and vascular composite outcome (HR=3.5 [1.5-8.2], p=0.003) after adjustment for age and sex. In patients of Mixed-ICH, the presence of cortical superficial siderosis (cSS) is associated the development of ICH recurrence (p=0.048), ischemic stroke (p=0.009), and vascular composite outcome (p=0.008). The association between cSS and vascular composite outcome remains significant after further adjustment for microbleed number, lacune and WMH volume (p=0.019).

Conclusions: Mixed-ICH harbors higher risk of unfavorable vascular outcome than HTN-ICH. Presence of cSS in Mixed-ICH independently predicts vascular event, suggesting the contribution of detrimental effect due to coexisting CAA.

Abstract TP342: Asymptomatic Striatocapsular Slit-Like Hemorrhage as a Severity Marker in Patients With Hypertensive Intracerebral Hemorrhage/Microbleeds

Background: Concomitant asymptomatic striatocapsular slit-like hemorrhage (SSH) is occasionally found in patients of hypertensive intracerebral hemorrhage (ICH), but was seldom reported. The correlation between hypertension severity and cerebral hemorrhagic pattern has not been well investigated, either. In this study, we described the clinico-radiological features of previous asymptomatic SSH in ICH patients with hypertensive angiopathy.

Methods: 246 patients with strictly deep or mixed deep and lobar ICH/CMBs were included. SSH was defined as hypointense lesions involving the lateral aspect of lentiform nucleus or external capsule in slit shape (>1.5cm) on susceptibility-weighted imaging without history of associated symptoms (Figure 1). Demographics and neuroimaging markers were compared between patients with SSH and those without. The association between SSH and left ventricular hypertrophy (LVH) or proteinuria was investigated in univariable and multivariable logistic regression models.

Results: Patients with SSH (n=24, 10%) and without SSH (n=222, 90%) had comparable age (62.0 ± 12.6 vs. 62.3 ± 13.5, p=0.912) and vascular risk factor profiles (all p>0.05). SSH was associated with more common lobar CMBs (79.2% vs 48.2%, p=0.005), lacunes (75% vs. 41.4%, p=0.002) and higher white matter hyperintensity (WMH) volumes (12.0 [7.7-26.8] vs. 8.7 [4.3-16.1] mL, p=0.016) on MRI, as well as more frequent LVH (50.0% vs. 20.3%, p=0.004) and proteinuria (41.7% vs. 19.4%, p=0.018). In multivariable analyses, SSH remains independently associated with LVH (Odds ratio 2.8 [1.1-7.3], p=0.033) and proteinuria (Odds ratio 2.6 [1.0-6.6], p=0.041) after adjustment for age, sex, CMBs, lacune and WMH volume.

Conclusions: Asymptomatic SSH is associated with more severe cerebral small vessel disease-related change on brain MRI, and hypertensive cardiac and renal injury, suggesting a more advanced stage of chronic hypertension.