Outcomes of Mechanical Thrombectomy for Ischemic Stroke in Nonagenarians: A 10-Year Institutional Experience.

BACKGROUND: Nonagenarians have been underrepresented in stroke trials that established endovascular treatment as the standard for acute ischemic stroke (AIS). Evidence remains inconclusive regarding the efficacy of thrombectomy in this population. OBJECTIVES: To report our experience with thrombectomy in nonagenarians with stroke, and to identify predictors of mortality. We further investigated the effects of first-pass reperfusion and the addition of intravenous thrombolysis (IVT) on achieving better outcomes. MATERIALS AND METHODS: Data was collected for consecutively treated patients at three affiliated comprehensive stroke centers from 2010 to 2021. We included patients ≥90 years-old with AIS secondary to large vessel occlusion. Bivariate analyses were performed using the Mann-Whitney U test for continuous variables, and χ2 and Fisher's exact tests, respectively, for nominal and ordinal variables. RESULTS: Thirty-two nonagenarians underwent thrombectomy, of whom 25 (81%) had prestroke mRS ≤2. Thrombectomies were performed using stents (2, 6.7%), aspiration (8, 26.7%), or a combination of both (20, 66.7%). Successful recanalization was achieved in 97%. Procedural complications occurred in 2 (6.3%) and intracranial hemorrhage in 3 (9.4%). Sixteen patients (50%) were discharged home or to rehabilitation, 9 (28.2%) to nursing home or hospice, and 7 (21.9%) died during hospitalization. Only 2 (6%) patients had mRS ≤2 at discharge. No independent predictors of in-hospital mortality were identified, and neither first-pass reperfusion nor the addition of IVT correlated with improvement in clinical outcome. CONCLUSIONS: Although thrombectomy is safe for nonagenarian stroke and can achieve excellent recanalization, high mortality and poor functional status remain high given the advanced age and frailty of this population.

Utility of Apical Lung Assessment on Computed Tomography Angiography as a COVID-19 Screen in Acute Stroke.

BACKGROUND AND PURPOSE: Evaluation of the lung apices using computed tomography angiography of the head and neck during acute ischemic stroke (AIS) can provide the first objective opportunity to screen for coronavirus disease 2019 (COVID-19). METHODS: We performed an analysis assessing the utility of apical lung exam on computed tomography angiography for COVID-19-specific lung findings in 57 patients presenting with AIS. We measured the diagnostic accuracy of apical lung assessment alone and in combination with patient-reported symptoms and incorporate both to propose a COVID-19 era AIS algorithm. RESULTS: Apical lung assessment when used in isolation, yielded a sensitivity of 0.67, specificity of 0.93, positive predictive value of 0.19, negative predictive value of 0.99, and accuracy of 0.92 for the diagnosis of COVID-19, in patients presenting to the hospital for AIS. When combined with self-reported clinical symptoms of cough or shortness of breath, sensitivity of apical lung assessment improved to 0.83. CONCLUSIONS: Apical lung assessment on computed tomography angiography is an accurate screening tool for COVID-19 and can serve as part of a combined screening approach in AIS.

Association of Serum Troponin Obtained During Stroke Codes with Cardioembolic Strokes.

BACKGROUND: Troponin is a marker of cardiac ischemia and is elevated in about 30% of stroke patients. We investigated if the elevation of troponin during an acute stroke code is associated with a cardioembolic source. METHODS: We performed a retrospective chart review of patients evaluated for acute strokes from July 2014 to March 2018. Patients included in the study were all given intravenous alteplase, had blood drawn for troponins during the acute stroke code and had confirmation of a new stroke on neuroimaging during hospitalization. Patients who were on dialysis or had a glomerular filtration rate of less than or equal to 40 ml/minutes on initial laboratory evaluation were excluded. Stroke etiology was classified into noncardioembolic (NCE) and cardioembolic (CE), according to Trial of Org 10172 in Acute Stroke Treatment criteria. The NCE group was compared with the CE group with respect to troponin levels. Troponin was considered as a dichotomous categorical variable, with a cut-off point at greater than or equal to.05 ng/ml. RESULTS: 144 patients met the inclusion criteria. In our cohort, 40.74% of patients in the CE group had troponin levels of greater than or equal to .05 ng/mL compared to 12.22% in NCE group. A troponin level of greater than or equal to.05 ng/ml obtained during a stroke code showed a significant difference between cardioembolic and noncardioembolic strokes (OR, 4.94; 95% CI, 2.15-11.35; P < .001), with high specificity (87.78%) but low sensitivity (40.74%) to exclude noncardioembolic stroke. CONCLUSIONS: A troponin level of greater than or equal to .05 ng/ml obtained during a stroke code showed a significant difference between CE and NCE strokes. This finding may have implications for clinical workup, and patients with admission troponin levels of greater than or equal to .05 ng/mL may need further clinical investigations to look for a cardioembolic source. A troponin level of greater than or equal to .05 ng/ml may prompt a more thorough search for a cardioembolic source in cases in which such a source is not identified on initial evaluation.

Symptomatic Intracerebral Hemorrhage after Intravenous Thrombolysis: Predictive Factors and Validation of Prediction Models.

OBJECTIVE: Thrombolytic therapy with intravenous alteplase (IV-rtPA) has a known risk of symptomatic intracerebral hemorrhage (sICH). We aim to identify factors with a significant association with the development of sICH post-IV-rtPA. We also aim to perform an external validation of sICH predicting scores in our patient population. MATERIAL AND METHODS: We performed a retrospective chart review of patients who received IV-rtPA at our tertiary care hospital. We excluded patients who underwent mechanical thrombectomy. We analyzed various factors recorded at presentation such as presenting mean arterial pressure (MAP), blood glucose, National Institutes of Health Stroke Scale (NIHSS) score, verify Aspirin, verify Plavix, age, sex, platelet count, international normalized ratio, prothrombin time, partial thromboplastin time, hemoglobin A1c, low-density lipoprotein, onset to treatment time, weight, sex, and early infarct signs on computed tomography (CT) head and compared them between sICH and non-sICH groups. For validation of sICH scores, we used documented variables to calculate the following scores for each patient: stroke prognostication using age and NIH stroke scale-100 (SPAN-100), DRAGON, CUCCHIARA, hemorrhage after thrombolysis (HAT), SEDAN, totaled health risks in vascular events, and safe implementation of thrombolysis in stroke-symptomatic intracerebral hemorrhage. RESULTS: sICH rate in our cohort of 89 patients was 5.62% according to the European-Australasian Cooperative Acute Stroke Study-II (ECASS-II) criteria and 7.86% according to the National Institute of Neurological Disorders and Stroke (NINDS) criteria. In the multivariate regression analysis, MAP (95% CI, .001-.01; P .002), blood glucose greater than or equal to 185 mg/dL (95% CI, .12-.45; P .001) and presence of early infarct signs (95% CI, .06-.25; P .002) had a significant association with the development of sICH with the ECASS-II definition of sICH post-IV-rtPA, whereas, only MAP (95% CI, 1.01-1.18; P .025) and verify Aspirin less than 500 (95% CI, .01-.80; P .032) had a significant association with the development of sICH with the NINDS definition of sICH post-IV-rtPA. Our study found that HAT (95% CI, .58-.96; P .044) and DRAGON (95% CI, .61-.96; P .012) scores had the highest area under the curve (AUC) with respect to ECASS-II and NINDS criteria of sICH, respectively. CONCLUSIONS: We found that presenting MAP, presence of early infarct signs on CT Head and blood glucose greater than or equal to 185 mg/dL upon a patient's presentation have a significant association with sICH post-IV-rtPA when the ECASS-II definition was used, while presenting MAP and verify Aspirin less than 500 upon a patient's presentation have a significant association with sICH post-IV-rtPA when the NINDS definition was used. Our study found that HAT and DRAGON scores had the highest AUC, and they were the most valid in predicting the development of sICH in our independent cohort. Patients with these risk factors should receive more intensive neurological monitoring.

A Rare Case of Posterior Circulation Stroke Caused by Bronchial Artery Embolization.

Bronchial artery embolization (BAE) is an effective treatment for massive hemoptysis. Stroke is a rare complication of BAE, with only a few cases reported in the literature. We report one such case. Posterior circulation strokes after BAE can be caused by connections between the vertebral arteries and the bronchial arteries (shunting between pulmonary and systemic circulations), backflow of embolization material from the bronchial or intercostal arteries to the subclavian artery or through backflow of emblospheres into the aortic lumen leading to subsequent embolization of the cerebral circulation. New-onset focal neurologic signs, change in mental status, or delay in recovery from anesthesia after BAE warrants brain imaging to rule out a stroke. Our case had a poor outcome, unlike the majority of previously reported cases.

Cerebral Cavernous Malformation Associated With Left Middle Cerebral Artery (MCA) Aneurysm and Bilateral Internal Carotid Artery (ICA) Dissections.

Cerebral cavernous malformations (CCMs) are the second most common type of cerebral vascular lesions. They are often associated with other vascular lesions, typically developmental venous anomalies. CCMs are not known to be associated with cerebral aneurysms and there is a paucity of literature on this occurrence. We report the case of a patient who presented with a focal seizure from a symptomatic CCM with acute hemorrhage and was incidentally found to have a cerebral aneurysm and bilateral internal carotid artery (ICA) dissections secondary to fibromuscular dysplasia. The presence of a cerebral aneurysm has clinical implications as these patients will need closer monitoring.

Association of blood pressure parameters post mechanical thrombectomy in anemic versus non-anemic patients and clinical outcomes.

INTRODUCTION: Higher blood pressure (BP) is considered to be detrimental in patients who undergo mechanical thrombectomy (MT), however, the impact of BP post-MT based on comorbidities like anemia has not been well studied. We aim to determine the association of 24-h post-MT BP parameters with clinical outcomes depending on their anemia status. METHODS: We conducted a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 1/2015 to 12/2020. Patients were dichotomized into anemic and non-anemic groups based on the World Health Organization's definition of anemia [hemoglobin < 12.0 g/dL in women and < 13.0 g/dL in men]. We performed a multivariable analysis with binary logistic regression with the 24-h post-MT BP parameters as predictors. The outcomes were functional dependence (3-month mRS 3-6), mortality, and an early neurological improvement. RESULTS: 220 patients met the inclusion criteria. 158 (71.82 %) patients had functional dependence at 3-months. In the multivariable analysis, the parameters of a higher mean SBP (132.9 ± 11.94 vs.126.52 ± 13.3; OR, 1.05; 95 % CI, 1.02-1.09; P 0.011), a higher mean MAP (93.35 ± 8.44 vs.89.69 ± 10.03; OR,1.06; 95 % CI, 1.01-1.11; P 0.029) and a higher maximum MAP (115.26 ± 11.73 vs.109.37 ± 12.51; OR,1.05; 95 % CI, 1.01-1.08; P 0.023)were significantly associated with functional dependence in non-anemic patients, while a lower mean DBP (65.53 ± 9.73 vs. 71.94 ± 10.16; OR, 0.92; 95 % CI, 0.86-0.98; P 0.007), lower mean MAP (85.7 ± 8.65 vs. 91.38 ± 10; OR, 0.93; 95 % CI, 0.86-0.99; P 0.02), a lower minimum DBP (49.27 ± 10.51 vs. 55.1 ± 11.23; OR, 0.93; 95 % CI, 0.88-0.99; P 0.019), a lower minimum MAP (68.96 ± 9.54 vs. 74.73 ± 10.47; OR, 0.93; 95 % CI, 0.87-0.99; P 0.023) were significantly associated with mortality in patients with anemia, and a lower minimum DBP (54.75 ± 10.42 vs. 59.69 ± 8.87; OR, 0.95; 95 % CI, 0.91-0.99; P 0.012) and a lower minimum MAP (71.92 ± 14.7 vs.75.67 ± 14.17; OR, 0.97; 95 % CI, 0.94-0.99; P 0.047) were significantly associated with an early neurological improvement in non-anemic patients. For patients with anemia, there was no association between 24-hour BP Parameters post-MT and functional dependence and early neurological improvement, and between 24-hour BP Parameters post-MT and mortality in non-anemic patients. CONCLUSION: In our study, higher BP parameters were associated with worse outcomes in patients without anemia, however, this effect was not found in patients with anemia. Certain lower BP parameters were associated with higher 3-month mortality in anemic patients; however, this effect was not found in non-anemic patients. Higher BP post-MT can potentially promote perfusion and thus is not associated with worse outcomes in anemic patients post-MT, whereas in non-anemic patients it may potentially lead to reperfusion injury While our study is limited because of size and its retrospective nature, the findings suggest that an individualized approach to tailor the target BP post-MT to a patient's risk factor profile and associated co-morbid conditions to achieve optimization of medical care post-MT and associated co-morbid conditions to achieve optimization of medical care post-MT.

Novel technique of stent placement via gateway balloon in intracranial atherosclerosis-associated large vessel occlusion.

BACKGROUND AND PURPOSE: Neuroform Atlas stent can be deployed directly via gateway balloon for angioplasty and stent placement without the need for exchange maneuver required for Wingspan stent use. We present our initial experience of this strategy in intracranial atherosclerosis-associated large vessel occlusions. METHODS: Patients were identified through mechanical thrombectomy (MT) database from January 2020 to June 2022 at our institutions. Due to reocclusion or impending occlusion, rescue angioplasty with stent placement was performed after initial standard MT. Primary outcomes were good angiographic recanalization with modified thrombolysis in cerebral infarction (mTICI) score of 2b-3, rate of intracranial hemorrhage (ICH), and favorable functional outcome at 3 months, that is, modified Rankin Scale (mRS) score of 0-3. RESULTS: We identified 22 patients treated using this technique. Among those, 11 were females with their average age at 66 years (range: 52-85). Initial median National Institute of Health Stroke Scale score was 11 (range: 5-30) and all patients received loading doses of aspirin and P2Y12 inhibitor. After performing submaximal angioplasty and Neuroform Atlas stent deployment through the gateway balloon, we achieved final mTICI of 2b-3 in 20 (90%) patients. One patient had ICH post-op that was asymptomatic. Eight (36%) patients had mRS of 0-3 at 90 days. CONCLUSION: Our preliminary experience suggests possible safety and feasibility of deploying Neuroform Atlas stent through a compatible Gateway balloon microcatheter without the need for ICH-associated microcatheter exchange. Further studies with long-term clinical and angiographic follow-up are warranted to corroborate our initial findings.

Association of 24-hour blood pressure parameters post-thrombectomy with functional outcomes according to collateral status.

INTRODUCTION: Elevation of blood pressure (BP) after mechanical thrombectomy (MT) can theoretically restore perfusion to the ischemic brain tissue, but it comes at a risk of causing reperfusion injury. We aim to determine the association of 24-h post-MT BP parameters with clinical outcomes depending on the pre-MT collateral status. METHODS: We performed a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 7/2014 to 12/2020. The patients were divided into good versus poor collateral groups depending on their collateral status. A board-certified neuroradiologist, who was blinded to the clinical outcomes, used collateral grading score of Miteff ≥3 to designate good collaterals on the pre-MT CT Angiogram. A binary logistic regression analysis was performed, controlling for baseline parameters, with the 24-h post-MT BP parameters as predictors. The outcomes were functional dependence [3-month mRS (3-6)] and mortality. RESULTS: A total of 220 met the inclusion criteria. In the multivariable analysis, for patients with poor collaterals, the parameters of higher mean SBP (131.7 ± 12.7 vs. 122.3 ± 14.2; OR, 1.06; 95% CI, 1.01-1.11; P 0.022), higher mean MAP (91.2 ± 8.2 vs. 86.1 ± 6.3; OR, 1.13; 95% CI, 1.03-1.23; P 0.015) and a higher maximum SBP (156.3 ± 13.7 vs. 145.3 ± 19.1; OR, 1.05; 95% CI, 1.01-1.1; P 0.019) were significantly associated with functional dependence at 3-months. For patients with good collaterals, the parameters of lower 24-h mean DBP (69.1 ± 11.1 vs. 73.8 ± 11 95% CI, OR, 0.96; 95% CI, 0.92-1; P 0.025) was significantly associated with higher mortality at 3-months. CONCLUSION: Our study demonstrates that there is a significant difference with respect to certain 24-h post-MT BP parameters in patients on clinical outcomes depending on their collateral status. In our study, some higher BP parameters were associated with worse outcomes in patients with a poor collateral profile, however, this effect was not replicated in patients with a good collateral profile.

Association of pre-mechanical thrombectomy collateral scores with functional outcomes in the early versus extended window for thrombectomy.

Introduction: Cerebral collateral circulation refers to the anastomoses that reroute the blood flow to the ischemic penumbra in the event of a large vessel occlusion (LVO). We aim to determine the utility of pre-mechanical-thrombectomy (MT) collateral scores in the early (<6 h from onset) versus extended (6-24 h from onset) window for MT with respect to a 3-month functional outcome, 3-month mortality, and early neurological improvement. Methods: We performed a retrospective chart review of patients who underwent MT for an anterior circulation LVO at a comprehensive stroke center from 7/2014 to 12/2020. A board-certified neuroradiologist, who was blinded to the clinical outcomes, used the collateral grading scales of Miteff (ordinal), Maas (ordinal), and modified-Tan (dichotomous) to designate collateral scores on the pre-MT CT Angiogram. The patients were divided into early (<6 h from onset) versus extended (6-24 h from onset) window groups depending on their timing of presentation to the emergency department. A regression analysis was performed, controlling for the baseline parameters, with the pre-MT collateral grading scores as predictors. The outcome measures were a good functional outcome (3-month mRS 0-2), mortality, and early neurological improvement. Results: A total of 220 patients met the inclusion criteria. In the overall cohort, the pre-MT scale of Maas was associated with a good functional outcome (OR, 0.58; 95% CI, 0.34-0.99; P 0.047) and mortality (OR, 0.55; 95% CI, 0.31-0.97; P 0.036). For the 162 patients who presented in the early window for MT, all of three pre-MT scales of Maas (OR, 0.39; 95% CI, 0.2-0.77; P 0.006), Miteff (OR, 0.43; 95% CI, 0.19-0.97; P 0.042) and modified-Tan (OR, 5.62; 95% CI, 1.16-27.37; P 0.033) were associated with a good functional outcome, whereas the Maas (OR, 0.48; 95% CI, 0.26-0.9; P 0.021) and the Miteff scale (OR, 0.4; 95% CI, 0.22-0.74; P 0.003) were associated with mortality. For the 58 patients who presented in the extended window for MT, none of the collateral grades were associated with functional outcome, mortality, or early neurological improvement. Conclusions: Our study demonstrates that while several collateral grades are helpful to predict outcomes in patients presenting in the early window, none of the pre-MT collateral scores were associated with outcomes in patients who presented in the extended window for MT. Thus, the current strategy of using perfusion imaging for the selection of patients for MT in the extended window should continue.

Interplay between anemia parameters and collateral status in patients who undergo mechanical thrombectomy.

INTRODUCTION: Anemia is associated with higher morbidity and mortality, but its association with acute ischemic stroke (AIS) is not well established. We aim to determine the association of five-day anemia parameters with clinical outcomes in patients with an AIS, depending on their pre-mechanical thrombectomy (MT) collateral status. METHODS: We performed a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 7/2014 to 12/2020. The patients were divided into good and poor collateral groups depending on their pre-MT collateral status. A blinded board-certified neuroradiologist used collateral grading scale of Maas ≥ 3 to designate good collaterals on the pre-MT CT Angiogram. A binary logistic regression analysis was performed, controlling for the baseline parameters, with the five-day anemia parameters as predictors. The outcomes were functional independence (mRS 0-2), mortality, and early neurological improvement. RESULTS: A total of 220 met the inclusion criteria. 94 (42.72 %) patients had good collaterals, while 126 (57.27 %) patients had poor collaterals. In the multivariable analysis, for patients with good collaterals, the higher values of five-day mean Hb (12.41 ± 1.87 vs 11.32 ± 1.95; OR, 0.72; 95 % CI, 0.54-0.95; P 0.018), five-day mean HCT (37.43 ± 5.1 vs 34.35 ± 5.5; OR, 0.89; 95 % CI, 0.81-0.98; P 0.018) and lower values of the difference between peak and trough values of Hb (1.75 ± 1.15 vs 2.41 ± 1.35; OR, 1.71; 95 % CI, 1.07-2.74; P 0.025) were associated with functional independence. For patients with poor collaterals, there was no association between five-day mean Hb, mean HCT parameters with functional independence, lower mortality, and early neurological improvement. CONCLUSION: Our study was suggestive of an association between higher mean values of Hb and HCT over a five-day period and good clinical outcomes in patients with good collaterals who undergo MT for an anterior circulation LVO. This association was not found in the poor collateral group.

Single Arm Access for Combined Transarterial and Transvenous Neurointerventional Procedures.

A concurrent arterial and venous access is routinely obtained for diagnosis and treatment of various neurovascular diseases. Traditionally, venous access is obtained by accessing the femoral vein or through direct internal jugular puncture. Although complication rates are low, life-threatening severe complications have been reported. Moreover, venous access can be challenging in large body habitus patients through these traditional routes. There is a growing trend of utilizing radial artery access for neuroendovascular procedures. Nevertheless, the use of upper limb veins in neurointerventional procedures is rare. We present 3 cases of the concurrent arterial and venous approach through the radial artery and cephalic or basilic vein of the forearm for diagnostic cerebral arteriography and venography. Radial access was obtained by using the standard technique, and venous access was obtained by cannulating cephalic or basilic vein using ultrasound guidance, and a 5F or 6F short sheath was placed. Venous angiography and catheterization of right and left internal jugular veins were then performed using a Simmons (SIM) 2 catheter alone or using 6F Envoy guide catheter coaxially over the SIM 2 catheter if an additional support for microcatheter was needed. Procedures were successfully completed with no adverse effects, and patients were discharged home the same day. We also describe the technique for the reformation of the SIM 2 catheter in the venous system for catheterization of right and left internal jugular veins through the arm access.

Association of anemia with functional outcomes in patients with mechanical thrombectomy.

INTRODUCTION: Anemia at presentation is associated with worse outcomes in patients with acute ischemic stroke (AIS). We aim to investigate the association of anemia parameters with functional dependence and mortality in patients who undergo mechanical thrombectomy (MT). METHODS: We performed a retrospective chart review of patients who underwent MT for an anterior circulation large vessel occlusion at a comprehensive stroke center from 1/2015-6/2020. Anemia was considered as a dichotomous categorical variable with a cutoff point of hemoglobin (Hb) < 12.0 g/dL in women and < 13.0 g/dL in men, as per the definition of the World Health Organization. Mean values of Hb and hematocrit (HCT) were obtained over the first five days of admission. Hemoglobin and HCT variability were measured using standard deviation (SD), and coefficient variability (CV) over the first five days of admission. Values of variance and difference (the difference between peak and trough of Hemoglobin or HCT) were also recorded. Multivariate logistic regression analyses were performed, including the predictor variables which were contributing significantly to the model (P < 0.05) in the univariate analysis, with 30-day functional dependence (mRS 3-6) (primary outcome) and 30-day mortality (secondary outcome) as the dependent variables. RESULTS: 188 patients met our inclusion criteria. Anemia on presentation, lower mean and minimum values of five-day Hb and HCT, and higher variability in five-day Hb and HCT parameters were associated with higher 3-month mortality. Men with lower mean and minimum values of five-day Hb and HCT had a significantly higher likelihood of functional dependence at 3-months. This finding was not replicated amongst women in our cohort. CONCLUSION: Our study demonstrated higher 3-mortality in patients with anemia and Hb variability. Our study also demonstrated a higher likelihood of functional dependence in patients amongst men with anemia.

Clinical impact of the first pass effect on clinical outcomes in patients with near or complete recanalization during mechanical thrombectomy for large vessel ischemic stroke.

BACKGROUND AND PURPOSE: The first pass effect has been reported as a mechanical thrombectomy (MT) success metric in patients with large vessel occlusive stroke. We aimed to compare the clinical and neuroimagign outcomes of patients who had favorable recanalization (mTICI 2c or mTICI 3) achieved in one pass versus those requiring multiple passes. METHODS: In this "real-world" multicenter study, patients with mTICI 2c or 3 recanalization were identified from three prospectively collected stroke databases from January 2016 to December 2019. Clinical outcomes were a favorable functional outcome at 90 days (modified Rankin Scale score 0-2), and the rate of symptomatic intracranial hemorrhage (ICH) any ICH, and 90-day mortality. RESULTS: Favorable recanalization was achieved in 390/664 (59%) of consecutive patients who underwent MT (age 71.2 ± 13.2 years, 188 [48.2%] women). This was achieved after a single thrombectomy pass (n = 290) or multiple thrombectomy passes (n = 100). The rate of favorable clinical outcome was higher (41% vs. 28 %, p = .02) in the first pass group with a continued trend on multivariate analysis that did not reaching statistical significance (OR 1.68 95% confidence interval [CI] 1.0-2.95, p = .07). Similarly, the odds of any ICH were significantly lower (OR 0.56 CI 0.32-0.97, p = .03). A similar trend of favorable clinical outcomes was noticed on subgroup analysis of patients with M1 occlusion (OR 1.81 CI 1.01-3.61, p = .08). CONCLUSION: The first-pass reperfusion was associated with a trend toward favorable clinical outcome and lower rates of ICH. These data suggest that the first-pass effect should be the mechanical thrombectomy procedure goal.

Cerebral Ischemia due to Aortic Arch Thrombosis Secondary to Iron Deficiency Anemia.

Thrombocytosis, hypercoagulable state, and hypoxia secondary to anemia are some of the mechanisms that are thought to cause strokes in patients with iron deficiency anemia (IDA). Several cases of middle-aged females with IDA who had embolic strokes due to aortic arch thrombosis have been reported. Majority of the cases were treated with anticoagulation. We report another case of embolic strokes in a patient with IDA treated with anticoagulation and iron replacement without recurrence of further episodes. We concluded that embolic phenomenon in middle-aged females with IDA warrants transesophageal echocardiogram with an evaluation of aortic arch.

A Rare Case of Cyclophosphamide-Induced Posterior Reversible Encephalopathy Syndrome in a Patient with Anti-GBM Vasculitis, and Review of Current Literature.

Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome of headache, altered mental status, and seizures with reversible mainly posterior leukoencephalopathy on neuroimaging. Precipitating factors for PRES are multifactorial and include autoregulatory failure due to changes in blood pressure, metabolic derangements, and cytotoxic medications. We report the second case of cyclophosphamide-induced PRES in a patient with anti-glomerular basement membrane (Anti-GBM) positive vasculitis. In the acute setting, PRES can be challenging to distinguish from cerebral venous sinus thrombosis or cerebral vasculitis based on clinical presentation. Neuroimaging with magnetic resonance imaging (MRI) of the brain along with a vessel imaging, can help reach the diagnosis.

Validation of ICH score in a large urban population.

OBJECTIVES: Hemorrhagic stroke cause around 10-20% of all strokes. ICH (Intracerebral Hemorrhage) score is a grading scale used to determine survival outcome after nontraumatic ICH at 30 days. It is a 6-point scale based on 5 independent variables, which are graded based on the weight of their association. These 5 variables are the Glasgow coma scale (GCS), ICH Volume, Intraventricular hemorrhage (IVH), Infratentorial origin and age. The aim of our study is to validate the ICH score in our population. MATERIALS AND METHODS: We conducted a retrospective chart review of 245 adult patients who presented with acute ICH to University Hospital, Newark between 1/1/2012 to 12/30/2015. GCS recorded in Emergency Department was used. Initial Computed tomography (CT) Head was used for calculating volume, IVH, and location origin, while ICH Volume was calculated using the ABC/2 method. The primary outcome was 30-day mortality. Patients with a hemorrhagic transformation of ischemic strokes or traumatic ICH were excluded. RESULTS: 245 patients met our inclusion criteria. 30-day mortality was 36%. ICH scores ranged from 0 to 5, and an increase in the ICH score was associated with an increase in 30-day mortality. 4 variables in the ICH score had a significant association with 30-day mortality: ICH Volume ≥30 ml (OR, 17.24; 95% CI, 8.33-35.66; P < 0.001), IVH (OR, 6.91; 95% CI, 3.72-12.85; P < 0.001), low GCS (P < 0.001) and infratentorial origin of bleed significant (OR, 2.17; 95% CI, 1.07-4.40; P 0.039). However, the association of age ≥ 80 years with respect to 30-day mortality wasn't statistically significant in our group (OR, 1.49; 95% CI, 0.70-3.17; P 0.325). CONCLUSIONS: Our study is one of the largest done at a single urban center to validate the ICH score. Age ≥ 80 years wasn't statistically significant with respect to 30-day mortality in our group. Restratification of the weight of individual variable in the ICH equation with modification of the ICH score can potentially more accurately establish mortality risk. Nevertheless, the overall prediction of mortality was accurate and reproducible in our study.