Background: Insertable cardiac monitoring (ICM) detects atrial fibrillation (AF) in substantial proportions of cryptogenic stroke, non-cryptogenic ischemic stroke without known AF, and non-stroke patients who are at risk of underlying AF. Given differences in patient characteristics across studies, there may be differences in AF detection rates on ICM across these subgroups that have not been identified. We investigate whether AF detection rates on ICM are higher in cryptogenic stroke or TIA (C-IS/TIA) patients compared to individuals with non-cryptogenic stroke or without stroke when accounting for differences in study populations. Methods: This is an individual-participant data (IPD) meta-analysis of prospective studies and randomized controlled trials (RCTs) of ICM in C-IS/TIA, non-cryptogenic ischemic stroke, and non-stroke patients. Multi-level multivariable logistic regression models were used to test whether C-IS/TIA is associated with increased AF detection relative to other categories. We performed multiple imputation to derive values for variables with <20% missing data and Rubin’s rules to estimate adjusted odds ratios (aOR) by combining 100 post-imputation datasets. The primary outcome was detection of AF. The attributable risk was derived by application of Bayes Theorem. Results: Two RCTs and 12 prospective studies were included with a total of 1562 C-IS/TIA patients and 474 non C-IS/TIA. In adjusted multi-level logistic regression analyses, AF detection was higher in C-IS/TIA patients (aOR 1.90; 95%CI 1.18-3.06, p=0.009), indicating that 47% of AF detected in C-IS/TIA may be pathogenic. Limiting the comparator group to ischemic stroke or history of stroke yielded similar results (aOR 2.83 95% CI 1.47-5.44, p = 0.002). Days to AF detection was significantly shorter in C-IS/TIA patients (median 65 vs. 169, p<0.001). Conclusion: In this IPD meta-analysis of patients undergoing ICM, AF detection was higher in C-IS/TIA patients, with shorter time to AF detection compared to non-cryptogenic/non-stroke individuals. These findings suggest that nearly 50% of the AF detected in patients with C-IS/TIA may be pathogenic.

BACKGROUND:Insertable cardiac monitoring (ICM) detects atrial fibrillation (AF) in substantial proportions of cryptogenic stroke, noncryptogenic ischemic stroke without known AF, and nonstroke patients who are at risk of underlying AF. Given differences in patient characteristics across studies, there may be differences in AF detection rates on ICM across these subgroups that have not been identified. We investigate whether AF detection rates on ICM are higher in cryptogenic stroke or transient ischemic attack (C-IS/TIA) patients compared with individuals with noncryptogenic stroke or without stroke, when accounting for differences in study populations. METHODS:This is an individual-participant data meta-analysis of prospective studies and randomized controlled trials of ICM in C-IS/TIA, noncryptogenic ischemic stroke, and nonstroke patients. Multilevel multivariable logistic regression models were used to test whether C-IS/TIA is associated with increased AF detection relative to other categories. We performed multiple imputation to derive values for variables with <20% missing data and used Rubin's rules to estimate adjusted odds ratios by combining 100 postimputation data sets. The primary outcome was detection of AF. The attributable risk was derived by application of Bayes' Theorem. RESULTS:Two randomized controlled trials and 12 prospective studies were included with a total of 1562 C-IS/TIA patients and 474 non-C-IS/TIA patients. In adjusted multilevel logistic regression analyses, AF detection was higher in C-IS/TIA patients (adjusted odds ratio, 1.90 [95% CI, 1.18-3.06]; P=0.009), indicating that 47% of AF detected in C-IS/TIA is pathogenic. Limiting the comparator group to ischemic stroke or history of stroke yielded similar results (adjusted odds ratio, 2.83 [95% CI, 1.47-5.44]; P=0.002). Days to AF detection were significantly shorter in C-IS/TIA patients (median 65 versus 169; P<0.001). CONCLUSIONS:In this individual-participant data meta-analysis of patients undergoing ICM, AF detection was higher in C-IS/TIA patients, with shorter time to AF detection compared with noncryptogenic/nonstroke individuals. These findings suggest that some of the AF detected in patients with C-IS/TIA may be pathogenic.

Background: The term embolic stroke of undetermined source (ESUS) encompasses a substantial but heterogeneous population of patients with ischemic stroke, underscoring the importance of identifying personalized treatment strategies. In subgroups of patients randomized in ESUS trials, we evaluated the effectiveness of anticoagulation compared to antiplatelet therapy in secondary ischemic stroke prevention. Methods: A study-level meta-analysis was conducted of randomized controlled trials of patients with ESUS, comparing anticoagulation to antiplatelet therapy. The primary efficacy outcome was recurrent ischemic stroke and safety outcomes were major bleeding and death. Subgroups assessed were age, sex, presence of patent foramen ovale (PFO), left atrial enlargement (LAE), and atrial cardiopathy. Pooled relative risks (RRs) were meta-analyzed. Cochrane Risk of Bias Tool 2.0 (RoB 2) was used for risk of bias assessment. Results: A total of seven randomized controlled trials involving 14,804 patients were analyzed, with 7,406 patients treated with anticoagulation, and 7,398 treated with antiplatelet therapy. Compared with antiplatelet therapy, anticoagulation was associated with a similar rate of recurrent ischemic stroke (RR 0.91, 95% CI 0.80-1.05; I2 = 0%). In ESUS with PFO, anticoagulation was associated with significantly lower risk of ischemic stroke (RR 0.59, 95% CI 0.35-0.98; I2 = 0%). Heterogeneity was present in those with LAE: antiplatelet therapy was superior in trials allowing cardiac monitoring after randomization (RR 6.65, 95% CI 1.26-35.08; I2 = 0%), but anticoagulation was superior in trials prohibiting cardiac monitoring after randomization (RR 0.25 95% CI 0.07-0.89). Subgroups based on age, sex, or presence of atrial cardiopathy did not benefit from anticoagulation over antiplatelet therapy. Conclusions: In this meta-analysis, an empiric anticoagulation approach is not beneficial for patients with ESUS. This finding highlights the importance of an individualized treatment strategy. Such a strategy should include prolonged cardiac monitoring for atrial fibrillation, particularly in patients with moderate to severe LAE. Anticoagulation treatment showed promise in patients with medically treated PFO. Other subgroups did not benefit from anticoagulation therapy. Large prospective studies within ESUS subgroups are needed to validate our findings.

Introduction: Atrial Fibrillation (AF) is detected in nearly 30% of patients undergoing cardiac monitoring after ischemic stroke. Studies investigating predictors of AF showed mixed results. In this study, we aim to identify predictors of AF on insertable cardiac monitors (ICMs) and compare rates between cryptogenic stroke patients and controls. Methods: The ANT icoagulation A nd St R oke Re C urrence in A T rial F I brillation Dete C ted A fter Stroke (ANTARCTICA) study is an individual patient data meta-analysis of prospective observational studies of cryptogenic ischemic stroke and control patients (non-cryptogenic ischemic stroke and non-ischemic stroke) who underwent an ICM implantation. The search included prospective observational studies and randomized controlled trials of patients with non-cardioembolic ischemic stroke or transient ischemic attack or non-ischemic stroke controls who underwent prolonged cardiac monitoring with an ICM after the index event. We performed multiple imputations to derive missing covariates such as left atrial volume index. We used multivariable multi-level logistic regression models to identify clinical, imaging, and echocardiographic factors associated with AF detection. We compared AF rates and charecterisctis between cryptogenic stroke and controls. Results: We identified 14 studies (2 RCTs and 12 observational) that included 2036 patients (1562 cryptogenic stroke and 474 non-cryptogenic stroke and non stroke controls); AF was detected in 30.7% of cryptogenic stroke patients and 29.1% of non-cryptogenic stroke patients. In multivariable logistic regression analyses, factors associated with AF were age (OR per year increase 1.05 95% CI 1.04-1.06), left atrial volume index (OR per unit increase 1.03 95% CI 1.02-1.05), and cryptogenic stroke (adjusted OR 1.89, 95% CI 1.20-2.98, p = 0.006). When compared to controls, the time to AF detection was significantly shorter in cryptogenic stroke (median 65 days vs. 169 days, p < 0.001) and AF duration was non-significantly longer (median 90 minutes vs. 120 minutes, p = 0.144). Results remained unchanged when the control group was limited to patients with non-cryptogenic ischemic stroke. Conclusions: In this large, individual patient data meta-analysis of patients undergoing ICM, there is increased detection and burden of AF after cryptogenic stroke compared to controls, suggesting a likely pathogenicity of device-detected AF in cryptogenic stroke.

BACKGROUND AND OBJECTIVES:The term "embolic stroke of undetermined source" (ESUS) encompasses a substantial but heterogeneous population of patients with ischemic stroke, underscoring the importance of identifying personalized treatment strategies. In subgroups of patients randomized in ESUS trials, we evaluated the effectiveness of anticoagulation compared with antiplatelet therapy in secondary ischemic stroke prevention. METHODS:A study-level meta-analysis was conducted on randomized controlled trials of patients with ESUS, comparing anticoagulation with antiplatelet therapy. The primary efficacy outcome was recurrent ischemic stroke, and safety outcomes were major bleeding and death. Subgroups assessed were age, sex, presence of patent foramen ovale (PFO), left atrial enlargement (LAE), and atrial cardiopathy. Pooled risk ratios (RRs) were meta-analyzed. Cochrane Risk of Bias Tool 2.0 was used for risk-of-bias assessment. RESULTS:A total of 7 randomized controlled trials involving 14,804 patients were analyzed, with 7,406 patients treated with anticoagulation and 7,398 treated with antiplatelet therapy. Compared with antiplatelet therapy, anticoagulation was associated with a similar rate of recurrent ischemic stroke (RR 0.91, 95% CI 0.80-1.05; I2 = 0%). In ESUS with PFO, anticoagulation was associated with significantly lower risk of ischemic stroke (RR 0.59, 95% CI 0.35-0.98; I2 = 0%). Heterogeneity was present in those with LAE: antiplatelet therapy was superior in trials allowing cardiac monitoring after randomization (RR 6.65, 95% CI 1.26-35.08; I2 = 0%), but anticoagulation was superior in trials prohibiting cardiac monitoring after randomization (RR 0.25 95% CI 0.07-0.89). Subgroups based on age, sex, or presence of atrial cardiopathy did not benefit from anticoagulation over antiplatelet therapy. DISCUSSION:In this meta-analysis, an empiric anticoagulation approach is not beneficial for patients with ESUS. This finding highlights the importance of an individualized treatment strategy. Such a strategy should include prolonged cardiac monitoring for atrial fibrillation, particularly in patients with moderate-to-severe LAE. Anticoagulation treatment showed promise in patients with medically treated PFO. Other subgroups did not benefit from anticoagulation therapy. Large prospective studies within ESUS subgroups are needed to validate our findings.

Background: Patent foramen ovale (PFO)-associated stroke is diagnosed more frequently in young patients with infrequent vascular risk factors and embolic appearing infarcts. The risk of paradoxical embolism (RoPE) score is used to identify PFO-associated stroke. Patients with symptomatic carotid artery web (CaW) share a very similar risk profile and these lesions are frequently overlooked. In this study, we evaluate the RoPE score profile in patients with suspected symptomatic CaW. Methods: Retrospective analysis of prospectively collected data of patients with symptomatic CaW as the presumed cause of stroke presenting to 2 comprehensive stroke centers from 2014 to 2021. CaW was diagnosed using computed tomography angiography (CTA) of the neck & head. Shunt study was done using a transthoracic, transesophageal, and/or transcranial-Doppler with bubbles. RoPE score >= 7 was considered high. Results: Seventy-five patients had stroke from a symptomatic ipsilateral CaW. Mean age was 49.7 +/- 11.2 years and 74.7 % were females. Median RoPE score was 7 [5-8], and 52.0 % had a high RoPE score. PFO was detected in 13.3 % of the patients and 20.5 % within the high RoPE score group. Ten percent of the cases would have been misclassified as PFO-associated strokes based on RoPE score. Conclusion: High RoPE scores were observed in the majority of patients with CaW-attributed stroke, and it should not be used to differentiate CaW- versus PFO-associated stroke. Careful extracranial internal carotid artery evaluation for CaW is warranted in cryptogenic strokes, including in PFO positive patients before defining stroke etiology.

Background Recent randomized clinical trials have demonstrated that endovascular therapy for basilar artery occlusion is safe and potentially effective, predominantly in the non‐White population. The aim of this study was to identify predictors of good functional outcome in posterior circulation strokes in US population after mechanical thrombectomy from the TRACK (Trevo Stent‐Retriever Acute Stroke) and the NASA (North American Solitaire Stent Retriever Acute Stroke) registries from North America. Methods Patient‐level data from the TRACK and NASA registries were pooled, and patients with posterior circulation stroke were included in this analysis. Patients were dichotomized into those with 90‐day good functional outcome (modified Rankin scale [mRS] score 0–2) and poor functional outcome (mRS score ≥3). Baseline and procedural data were compared between the 2 cohorts. Multivariate logistic regression was performed to identify predictors of functional outcome. P < 0.05 was considered significant. Results Of 119 posterior stroke patients (99 [83.2%] basilar artery, 16 [13.4%] vertebral artery, and 4 [3.4%] posterior cerebral artery), 110 patients had 90‐day mRS data available on follow‐up. Good functional outcome was observed in 44 patients (40%). Patients with mRS score 0–2 were less likely to have hypertension (61.4% versus 83.3%; P = 0.01), hyperlipidemia (38.6% versus 62.1%; P = 0.016), and diabetes (18.2% versus 36.4%; P = 0.040). Patients with mRS score 0–2 had a lower mean presentation National Institutes of Health Stroke Scale score (15.2±9.95 versus 22.6±9.50; P < 0.001) and more likelihood of achieving Thrombolysis in Cerebral Infarction 3 (79.5% versus 42.2%; P < 0.001). There was no difference between 2 cohorts in time to puncture, use of balloon guide catheter, use of general anesthesia, and number of passes. On multivariate analysis, higher presentation National Institutes of Health Stroke Scale and hypertension were associated with worse functional outcomes. Complete recanalization and the receipt of intravenous tissue‐type plasminogen activator were associated with higher odds of achieving good functional outcomes. Conclusion In this pooled analysis of the NASA and TRACK registries, patients with posterior circulation stroke achieving good outcomes were more likely to have lower presentation National Institutes of Health Stroke Scale and fewer comorbidities. Use of intravenous tissue‐type plasminogen activator, hypertension, final Thrombolysis in Cerebral Infarction 3, and lower baseline National Institutes of Health Stroke Scale score were independent predictors of functional outcome.

Background: Evaluating patients with ascending sensorimotor deficits has a broad differential diagnosis at initial presentation which can be further narrowed upon neurologic examination but may represent a diagnostic and therapeutic dilemma in light of findings raising suspicion for multiple possible etiologies. Data Collection: In this case, a 29-year-old patient presented with ascending bilateral lower extremity sensory loss, paresthesias, and weakness which progressed to the inability to ambulate. Conclusions: This case highlights the diagnostic approach to patients with bilateral lower extremity sensorimotor deficits, discusses the development of a comprehensive differential diagnosis, and further evaluates the most likely etiologies. Furthermore, this case reviews complexities related to clinical reasoning in the setting of diagnostic uncertainty, particularly when the neurologic structures affected portend high risk for severe disability and early treatment may improve outcome.

Background: Carotid free-floating-thrombus(CFT)is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by contrast. Unfortunately, there is no clear consensus among experts on the ideal treatment for CFT. Methods: Retrospective analysis of acute ischemic stroke(AIS)patients diagnosed with internal carotid CFT on CTA between January2015-March2023.We aimed to compare two treatment regimens: antiplatelet(APT) and anticoagulation(ACT) in the treatment of CFT. APT regimens included the use of dual or single APT (aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin+/-aspirin. Patients that underwent thrombectomy were excluded. Results: During study time there were 8252 AIS patients, of which 137(1.6%) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.4years + 12.8;p<0.01) (Table 1) .Other demographic variables were similar between groups. Complete CFT resolution by repeat imaging was comparable between groups at 30 days (58.8vs31.6%;p=0.1) and at latest follow-up (70.8vs50%;p=0.1) on ACT vs APT, respectively. There were similar rates of any ICH (13.5vs27.6%;p=0.5), PH1/2, independence at discharge and similar hospital length of stay between APT and ACT groups, respectively ( Table 1 ). Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5vs55.2%;p<0.001).The rate of recurrent AIS was comparable among APT and ACT at 30 days (0vs3.4%;p=0.1,respectively).Sensitivity analysis comparing DAPT to exclusive ACT lead to similar results. Conclusion: Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed with APT vs ACT. Larger prospective studies are needed.

Background and ObjectivesThe term "embolic stroke of undetermined source" (ESUS) encompasses a substantial but heterogeneous population of patients with ischemic stroke, underscoring the importance of identifying personalized treatment strategies. In subgroups of patients randomized in ESUS trials, we evaluated the effectiveness of anticoagulation compared with antiplatelet therapy in secondary ischemic stroke prevention.MethodsA study-level meta-analysis was conducted on randomized controlled trials of patients with ESUS, comparing anticoagulation with antiplatelet therapy. The primary efficacy outcome was recurrent ischemic stroke, and safety outcomes were major bleeding and death. Subgroups assessed were age, sex, presence of patent foramen ovale (PFO), left atrial enlargement (LAE), and atrial cardiopathy. Pooled risk ratios (RRs) were meta-analyzed. Cochrane Risk of Bias Tool 2.0 was used for risk-of-bias assessment.ResultsA total of 7 randomized controlled trials involving 14,804 patients were analyzed, with 7,406 patients treated with anticoagulation and 7,398 treated with antiplatelet therapy. Compared with antiplatelet therapy, anticoagulation was associated with a similar rate of recurrent ischemic stroke (RR 0.91, 95% CI 0.80-1.05; I2 = 0%). In ESUS with PFO, anticoagulation was associated with significantly lower risk of ischemic stroke (RR 0.59, 95% CI 0.35-0.98; I2 = 0%). Heterogeneity was present in those with LAE: antiplatelet therapy was superior in trials allowing cardiac monitoring after randomization (RR 6.65, 95% CI 1.26-35.08; I2 = 0%), but anticoagulation was superior in trials prohibiting cardiac monitoring after randomization (RR 0.25 95% CI 0.07-0.89). Subgroups based on age, sex, or presence of atrial cardiopathy did not benefit from anticoagulation over antiplatelet therapy.DiscussionIn this meta-analysis, an empiric anticoagulation approach is not beneficial for patients with ESUS. This finding highlights the importance of an individualized treatment strategy. Such a strategy should include prolonged cardiac monitoring for atrial fibrillation, particularly in patients with moderate-to-severe LAE. Anticoagulation treatment showed promise in patients with medically treated PFO. Other subgroups did not benefit from anticoagulation therapy. Large prospective studies within ESUS subgroups are needed to validate our findings.

BACKGROUND: Carotid free-floating thrombus (CFT) is a rare cause of stroke describing an intraluminal thrombus that is loosely associated with the arterial wall and manifesting as a filling defect fully surrounded by flow on vascular imaging. Unfortunately, there is no clear consensus among experts on the ideal treatment for this pathology. METHODS: Retrospective analysis of acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients diagnosed with CFT on computed tomography angiogram (CTA) between January 2015-March 2023. We aimed to compare two treatment regimens: anticoagulation (ACT) and antiplatelet (APT) in the treatment of CFT. APT regimens included the use of dual or single antiplatelets (DAPT or SAPT; aspirin, clopidogrel and ticagrelor) and ACT regimens included the use of direct oral anticoagulants, warfarin, heparin or low molecular weight heparin +/- ASA. Patients that underwent mechanical thrombectomy were excluded. RESULTS: During study time there were 8252 acute ischemic stroke hospitalizations, of which 135 (1.63 %) patients were diagnosed with CFT. Sixty-six patients were included in our analysis. Patients assigned to APT were older (60.41years +/- 12.82;p < 0.01). Other demographic variables were similar between ACT and APT groups. Complete CFT resolution on repeat vascular imaging was numerically higher at 30 days (58.8 vs 31.6 %, respectively; p = 0.1) and at latest follow-up (70.8 vs 50 %; p = 0.1) on ACT vs APT, respectively without reaching statistical significance. Similarly, there was numerically higher rates of any ICH with ACT compared to APT but it did not achieve statistical significance (27.6 % vs 13.5 %; p = 0.5). There were similar rates of PH1/2 hemorrhagic transformation, independence at discharge and similar hospital length of stay between ACT and APT groups. Patients assigned to APT were more likely to be discharged on their assigned treatment compared to those assigned to ACT (86.5 vs 55.2 %; p < 0.001). The rate of 30-day recurrent stroke was comparable among ACT and APT at 30 days (3.4 vs 0 %; p = 0.1, respectively). Subgroup analysis comparing exclusive ACT vs Dual APT lead to similar results. CONCLUSION: Our study showed comparable efficacy and safety outcomes in CFT patients who were exclusively managed medically with ACT vs APT. Larger prospective studies are needed.

Vascular diseases are among the most common disorders that neurologists treat on a daily basis. Ischemic stroke is generally what comes to mind on mention of vascular disorders. However, the term is inclusive of multiple other pathologies. This chapter allows readers to appreciate the breadth of this field by exploring various types of vascular lesions. In addition to ischemic strokes, we will discuss cases of hemorrhagic strokes, vascular malformations, and other uncommon vascular entities such as dynamic occlusions and rare genetic disorders.

Introduction PFO‐associated stroke is more common in young patients (<60 years) with less vascular risk factors, and with an infarct pattern consistent with embolic phenomena. These features are included in the Risk of Paradoxical Embolization (RoPE) score in which a high score (≥ 7) indicates a high likelihood of a symptomatic PFO. However, carotid artery webs (CaW) have been reported in patients with the same profile in which a PFO might be detected. In this study, we calculated RoPE score for patients with symptomatic CaW related strokes to identify how many of these patients would have been potentially misclassified as having a PFO‐associated stroke. Methods Patients presenting with ESUS and ipsilateral symptomatic CaW were included. Stroke work up was completed including cervicocranial vascular imaging that was reviewed by a neuroradiologist and an interventional neurologist. Shunt study was done with a TTE, TEE, and/or TCD, all with a bubble study. RoPE score of ≥ 7 was considered high. Results A total of 75 patients fulfilled the inclusion criteria of having an ipsilateral symptomatic CaW as the etiology of ESUS with no competing etiologies aside from PFO. The baseline characteristics are described in the table. The rates of vascular risk factors were generally low which is reflected by a high median RoPE score of 7 [IQR 5‐8], with 52% (n = 39) of patients having a score of ≥ 7. Ten patients (13%) had a PFO, of which 3 had high‐risk features. There was no significant difference in median RoPE score between patients with and without PFO (8 [6‐8] vs 6 [5‐8], p = 0.238), nor in the rate of patients with high RoPE score (78% vs 44%, p = 0.06). Recurrence happened in 16% (n = 12) of the patients and was always ipsilateral to the symptomatic CaW. No significant difference was detected in the rates of recurrence between high vs low RoPE scores (20.5% vs 11.1%, p = 0.351). Patients with a PFO had higher rates of recurrence compared to those without a PFO (40%, n = 4 vs 12.3%, n = 8, p = 0.048); however, none of the PFO patients with a recurrent stroke had a high‐risk PFO. A superimposed thrombus was seen on the CaW in 12.2% (n = 9) and was more commonly seen in patients who had recurrence (36%, n = 4 vs 8%, n = 5, p = 0.024). Conclusions Patients with ESUS from a presumably symptomatic CaW‐related stroke have high RoPE scores. The recurrence rates were high in this population and were always ipsilateral to the side of the CaW including in the PFO population. The PFO is likely incidental in this population despite having a high RoPE score. Neurologists should carefully evaluate the cervical vasculature before concluding that a PFO is stroke‐related and committing patients to PFO treatment.

Objective: NA Background: Longitudinally extensive transverse myelitis (LETM) is caused by a myriad of etiologies. We present a case of Neuromyelitis Optica Spectrum Disorder (NMOSD)-related myelitis, initially seronegative, masquerading as VZV-related myelitis. Design/Methods: A case report. Results: A woman in her sixties reported a one-month history of bilateral lower extremity paresthesias and weakness. Days prior, she felt tingling on her back with eruption of a painful rash, and was diagnosed with varicella zoster (VZV). She had transient improvement, before worsening 2 months later with involvement of the arms and signs of myelopathy on exam. MR imaging revealed a long segment T2 hyperintense cord expansion extending from the medulla throughout the thoracic spine with additional hyperintensities in the conus medullaris with patchy enhancement. Work up was significant for lymphocytic-predominant CSF pleocytosis with elevated protein and IgG index. Serum VZV IgG was positive with negative IgM. CSF VZV PCR was negative. Aquaporin-4 antibody was negative. Testing for other causes of myelopathy was unrevealing. She was treated with IV Acyclovir, IV pulse steroids, and subsequently plasma exchange. She improved without further immunomodulation. Three months later, she had another attack and imaging showed new occipital enhancing lesion consistent with demyelination. At this visit, aquaporin-4 antibodies returned positive with a titer of 1:100. She received IV steroids and started rituximab. The patient was diagnosed with LETM from NMOSD. Due to symptom severity, she underwent plasma exchange despite a potential alternative etiology. VZV myelitis and her history of shingles were likely a red herring in the setting of her positive NMO testing. This emphasizes the importance of rechecking antibodies for high clinical suspicion, as the results can drastically influence management and outcome. In the presence of unconfirmed alternative etiologies, neurologists should have low threshold for aggressively treating inflammatory myelitis, using intravenous immunoglobulin or plasma exchange if indicated. Conclusions: NA Disclosure: Dr. Alshaer has nothing to disclose. Dr. Cavanagh has nothing to disclose. Dr. Antzoulatos has nothing to disclose.

Introduction: Carotid Web (CaW) is an underrecognized etiology for ischemic stroke. This entity has been shown to be amenable to endovascular stenting, similar to carotid atherosclerotic stenosis (CAS). We aimed to assess procedural characteristics of stenting for CaW as compared to CAS. Methods: We retrospectively analyzed a cohort of patients at a single comprehensive stroke center from October 2014 to March 2021 who had undergone endovascular stent placement for symptomatic CAS or CaW. Patients who received other intervention (e.g. thrombectomy, aneurysm repair) on the same day as stent placement were excluded. Baseline patient characteristics, procedural data, periprocedural complications, and follow-up statistics were analyzed. Results: In total, 105 patients underwent stent placement status post ischemic stroke or transient ischemic attack; 79 patients had CAS and 26 patients had CaW. Patients with CAS were older on average (CAS 63 vs CAS 53.5 years, p < 0.001 ) and less likely to be female (OR 0.116; 95% CI 0.041 to 0.326, p <0.001). CAS patients were more likely to have vascular risk factors such as hypertension, hyperlipidemia, and Diabetes ( Table ). Radiation, need for angioplasty, and filter time were significantly lower in CaW procedures. No significant difference was found between the two pathologies in periprocedural complications such as hypotension, need for vasopressors, or bradycardia. However, post-procedural restenosis only occurred in CAS stents. Conclusion: Stenting for CaW is comparable to stenting for CAS in terms of vasovagal side effects, but associated with lower filter times, lower radiation dose, lower need for angioplasty, and lower rates of restenosis.

Background and purpose: Screening scales are recommended to assist field-based triage of acute stroke patients to designated stroke centers. Cincinnati prehospital stroke scale (CPSS) is a commonly used prehospital stroke screening tool and has been validated to identify large vessel occlusion (LVO). This study addresses the impact of county-based CPSS implementation to triage suspected LVO patients to a comprehensive stroke center (CSC). Materials and methods: Dekalb County in Atlanta, Georgia, implemented CPSS-based protocol with score of 3 and last seen normal time < 24 h mandating transfer to the nearest CSC if the added bypass time was <15 min. Frequency of stroke codes, LVO, IV-tPA use, and thrombectomy treatment were compared six months before and after protocol change (November 1, 2020). Results: During the study period, 907 stroke patients presented to the CSC by EMS, including 289 (32%) with CPSS score 3. There was an increase in monthly ischemic stroke volume (pre-16 +/- 2 vs.19 +/- 3 p = 0.03), LVO (pre-4.3 +/- 1.7 vs. post 7.0 +/- 2.4; p = 0.03), EVT (pre-15% vs. post-30%; p = 0.001), without significant increase in stroke mimic volume or delay in mean time from last seen normal to IVtPA (pre-165 +/- 66, post-158 +/- 49 min; p = 0.35). CPSS score 3 was associated with increased likelihood of LVO diagnosis (OR 8.5, 95% CI 5.0-14.4; p = 0.001) and decreased the likelihood of stroke mimics (OR 0.66, 95% CI 0.50-0.88; p = 0.004). Conclusion: CPSS is a quick, easy to implement, and reliable prehospital severity scale for EMS to triage LVO to CSC without delaying IV-tPA treatment or signifi-stroke mimics.

HomeStroke: Vascular and Interventional NeurologyAhead of PrintVascular Imaging Follow‐Up in Carotid Webs: Is There Vascular Remodeling? Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessLetterPDF/EPUBVascular Imaging Follow‐Up in Carotid Webs: Is There Vascular Remodeling? Sitara Koneru, MD, Raul G. Nogueira, MD, David Landzberg, MD, Ehizele Osehobo, MD, Qasem AlShaer, MD, Alhamza Al‐Bayati, MD, Fadi Nahab, MD and Diogo C. Haussen, MD Sitara KoneruSitara Koneru , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, , Raul G. NogueiraRaul G. Nogueira , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, , David LandzbergDavid Landzberg , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, , Ehizele OsehoboEhizele Osehobo , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, , Qasem AlShaerQasem AlShaer , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, , Alhamza Al‐BayatiAlhamza Al‐Bayati , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, , Fadi NahabFadi Nahab , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, and Diogo C. HaussenDiogo C. Haussen *Correspondence to: Diogo C. Haussen, MD, Emory University Hospital/Grady Memorial Hospital, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0003-1884-2196 , Emory University Hospital/Grady Memorial Hospital, , Atlanta, , GA, Originally published21 Oct 2022https://doi.org/10.1161/SVIN.122.000559Stroke: Vascular and Interventional Neurology. 2022;0:e000559Carotid web (CaW) is a shelf‐like fibrotic projection at the carotid bulb and constitutes an underrecognized cause of ischemic stroke. The histological natural history of these lesions has not been investigated. Conversely, carotid atherosclerotic lesions have been extensively documented to undergo dynamic processes at the cellular and molecular levels, leading to both positive and negative remodeling.1 Considering that 3‐dimensional volumetric measurements on computed tomography angiography (CTA) for CaW size quantification have been demonstrated to be highly reproducible,2 we aimed to evaluate if CaW is a static or dynamic entity on delayed vascular imaging based on lesion volume.This was a retrospective analysis of patients diagnosed with CaW between September 2014 and June 2021 at our comprehensive stroke center. Patients who had at least 2 good‐quality CTAs that were at least 6 months apart were included (cases with superimposed thrombus were excluded). CaWs were quantified with 3‐dimensional measurements using Horos software (New York, NY) via volumetric analysis of freehand‐delineated CaW borders on thin cuts of axial CTA (Figure 1A). North American symptomatic carotid endarterectomy trial criteria were used to evaluate the degree of stenosis.3Download figureDownload PowerPointFigure 1. Measurement methodology and temporal trends in lesion volume. A, Representative sections of 3‐dimensional volumetric measurement. B, Volumetric measurements for all lesions on initial and follow‐up computed tomography angiography. CaW indicates carotid web.A total of 20 CaW lesions in 17 patients were included. The median imaging follow‐up window was 16 months (interquartile range [IQR], 12–21 months; range, 6–58 months). Median patient age was 44 years, 75% were women, 30% had hypertension, 30% had hyperlipidemia, 20% had diabetes, 0% had atrial fibrillation, and 10% were active smokers. Of the included CaWs, 75% were symptomatic, whereas 25% were asymptomatic.Median volume of CaW on initial CTA (8.27 mm3; IQR; 4.5–11.6 mm3; range, 2.2–30.4 mm3) was comparable with the median volume of CaW on the most recent CTA (8.44 mm3; IQR, 4.5–11.6 mm3; range, 2.3–29.4 mm3; P<0.001; Figure 1B). The CaW volumetric measurement correlation between the initial and most recent CTA was near perfect (rs=−0.99; P<0.001). The median change in measured volume of CaW between the first and last CTA was −0.03 mm3 (IQR, −0.6 to 0.4 mm3; range, −1 to 0.8 mm3). Median degree of stenosis was 8.1% (IQR, 4.5%–17.1%; range, 0.4%–31.2%).The duration of follow‐up imaging was not correlated with change in CaW volume (Kendall τb=0.06; P=0.72). The initial CaW volume was not found to be correlated to the degree of stenosis (τb=−0.04; P=0.80).In atherosclerotic disease, the progression of carotid total plaque area has been shown to be a strong predictor of clinical outcomes.4, 5 In a large cohort of patients followed annually with carotid total plaque measurements, about 63% had progression (defined as an increase by 5 mm2 from baseline), 28% had regression (decrease by 5 mm2), and 16% had no change.4 The natural history of fibromuscular dysplasia lesions is not well established. The median change in CaW volume in our cohort of patients was −0.03 mm3, suggesting a stable condition. Although there are limitations to this study, including the small number of patients with relatively short lengths of follow‐up, we showed that webs appear to be a relatively static lesion. Considering that favorable remodeling was not observed, long‐term medical therapy may have to be considered for protection.Nonstandard Abbreviations and AcronymsCaWcarotid webCTAcomputed tomography angiographyAcknowledgmentsS.K. was involved in the conception and design of the study, acquisition and analysis of data, and drafted a significant proportion of the article and figures. R.G.N. was involved with the conception and design of the study and revised the article for intellectual content. D.L. was involved with acquisition and analysis of data and revised the article for intellectual content. E.O. was involved with acquisition and analysis of data and revised the article for intellectual content. Q.A. was involved with acquisition and analysis of data and revised the article for intellectual content. A.A.B was involved in the conception and design of the study and revised the article for intellectual content. F.N. was involved in the conception and design of the study and revised the article for intellectual content. D.C.H. was involved in the conception and design of the study and revised the article for intellectual content.Footnotes*Correspondence to: Diogo C. Haussen, MD, Emory University Hospital/Grady Memorial Hospital, 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303. E‐mail: diogo.[email protected]eduThis work was presented at the Society of Vascular and Interventional Neurology Annual Meeting, November 16‐19, 2021.REFERENCES1 Peeters W, Hellings WE, de Kleijn DP, de Vries JP, Moll FL, Vink A, Pasterkamp G. Carotid atherosclerotic plaques stabilize after stroke: insights into the natural process of atherosclerotic plaque stabilization. Arterioscler Thromb Vasc Biol. 2009; 29:128‐133.LinkGoogle Scholar2 Perry da Camara C, Nogueira RG, Al‐Bayati AR, Pisani L, Mohammaden M, Allen JW, Nahab F, Olive Gadea M, Frankel MR, Haussen DC. Comparative analysis between 1‐D, 2‐D and 3‐D carotid web quantification. J Neurointerv Surg. 2022;neurintsurg‐2021‐018192.Google Scholar3 North American Symptomatic Carotid Endarterectomy Trial Collaborators , Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, Ferguson GG, Fox AJ, Rankin RN, Hachinski VC, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high‐grade carotid stenosis. N Engl J Med. 1991; 325:445‐453.CrossrefMedlineGoogle Scholar4 Spence JD, Eliasziw M, DiCicco M, Hackam DG, Galil R, Lohmann T. Carotid plaque area: a tool for targeting and evaluating vascular preventive therapy. Stroke. 2002; 33:2916‐2922.LinkGoogle Scholar5 Spence JD, Hackam DG. Treating arteries instead of risk factors: a paradigm change in management of atherosclerosis. Stroke. 2010; 41:1193‐1199.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails Article InformationMetrics © 2022 The Authors. Published on behalf of the American Heart Association, Inc., and the Society of Vascular and Interventional Neurology by Wiley Periodicals LLC.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/SVIN.122.000559 Manuscript receivedJune 22, 2022Manuscript acceptedAugust 29, 2022Originally publishedOctober 21, 2022 PDF download

To present a case of contrast-induced encephalopathy (CIE) after IV thrombolysis (IVT) for acute ischemic stroke (AIS).