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Background: Understanding clot composition may allow for better technical planning and improved outcomes in mechanical thrombectomy (MT). We sought to correlate clot composition with reperfusion outcomes in MT. Methods: Clinical, imaging, and clot data from patients enrolled in the STRIP Registry from September 2016 to September 2020 were analyzed. Samples were fixed in 10% phosphate-buffered formalin and stained with hematoxylin and eosin and Martius Scarlett Blue. Percent composition, richness, and gross appearance were evaluated. Outcome measures included the rate of First-Pass Effect (mTICI2c/3, FPE) and the number of device passes. Results: A total of 1430 patients (mean age, 68.4±13.5years; median [IQR] baseline NIHSS,17.2 [10.5-23]; IV-tPA use, 36%; Stent-Retrievers [SR], 27%; Contact Aspiration [CA], 27%; Combined SR + CA, 43%) were included. The median [IQR] number of passes was 1 [1-2]. FPE was achieved in 39.3% of the cases. There was no association between percent histological composition or clot richness and FPE in the overall population. However, the combined technique resulted in lower FPE rates for RBC-rich (P Conclusion: Despite the lack of correlation between clot histology and FPE in the overall population, our study adds to the growing body of evidence supporting the notion that clot composition influences reperfusion treatment strategy outcomes. Additional studies are needed.

Background: Plasma protein biomarkers measured in the hyperacute setting that are associated with stroke diagnosis or with clinical neurological severity, can be diagnostically and prognostically meaningful in patient care. We hypothesized that high-throughput proteomics can identify panels of plasma proteins that can differentiate stroke mimics from ischemic and hemorrhagic stroke, and are associated with neurological severity. Methods: From a clinically-characterized biorepository of 320 plasma samples collected at time of patient presentation to the Emergency Room at Grady Memorial Hospital (Atlanta), 40 samples (10 stroke mimics, 10 intracerebral hemorrhage [ICH], 20 acute ischemic stroke [AIS]) were included (Fig A). 7,000 proteins were measured per sample using aptamer-based proteomics (SomaLogic). A combination of differential-expression and variance partitioning analyses (VPA) identified proteins associated with diagnosis (mimic vs ICH vs AIS), neurological severity (NIHSS), age and sex. Results: Cohort characteristics are shown (Fig B). VPA identified top proteins that accounted for majority of variance in several traits (Fig C). One-way ANOVA identified >400 proteins showing group-wise differences, of which a panel of 56 proteins collectively distinguished mimics from both AIS and ICH, ICH from both mimics and AIS, as well as distinguished between AIS based on NIHSS (Fig D). The pattern of expression of these 56 plasma proteins across diagnostic groups is shown in Fig E. We also identified plasma biomarkers associated with increasing age, indicative of age-related vascular dysfunction. Conclusions: This pilot study of AIS, ICH and stroke mimics demonstrates the applicability of aptamer-based proteomics as a promising approach for plasma protein biomarker discovery in stroke. We identified acute plasma protein biomarkers of neurological severity, diagnostic group and age-related vascular dysfunction that need further validation.

Introduction: Over 10% of stroke survivors have a recurrent stroke, and studies indicate that Black people have a higher risk of stroke recurrence. Social Determinants of Health (SDoH) are associated with a high incidence of stroke, and there is emerging data on recurrence. Grady Memorial Hospital serves this vulnerable urban population at high risk of first and recurrent stroke. We sought to determine the prevalence of SDoH in our clinic population and address these unmet needs to reduce disparities. Methods: We implemented SDoH screening in the stroke clinic by training two medical assistants to fill out the SDoH questionnaire during patient check-in. Screening results were checked by the fellows/attending during the clinic visit. Social worker consultation was sought for unmet social needs. Data was collected in a prospectively maintained stroke clinic registry. Results: There were 131 patients seen between October 2021 and February 2022 in the stroke clinic. Of those, 108 patients (82%) were screened for unmet SDoH needs (financial, transportation, and food insecurity). Of the screened, 81% were black, the mean age was 55 years, 51% were male, and 59% were from economically at-risk or distressed communities. The mean duration from stroke onset to clinic visit was 12 months. Fifty-eight of the screened patients had at least one unmet need (54%), 30 had none (28%), and 20 were unknown (19%). Eighty-one percent (47/58) of patients with unmet needs had BP ≥130/80 (Odds ratio 2.47 CI 0.91-6.66, p =0.07). Most patients had financial insecurity (74%), followed by transportation needs (55%) and food insecurity (50%). Of the patients with unmet needs, 59% (n=34/58) reside in economically at-risk or distressed communities. 55% (32/58) of patients received resources to address these needs during the clinic visit. Conclusions: We found a high prevalence of unmet social needs in our stroke population, and the needs persisted for at least a year post-stroke. Screening and addressing unmet social needs should be incorporated as a routine follow-up post-stroke care. Systematic ways of assessing SDoH to address their effects on stroke recurrence and recovery should be done in larger studies.

Introduction: Over 10% of stroke survivors have a recurrent stroke, and studies indicate that Black people have a higher risk of stroke recurrence. Social Determinants of Health (SDoH) are associated with a high incidence of stroke, and there is emerging data on recurrence. Grady Memorial Hospital serves this vulnerable urban population at high risk of first and recurrent stroke. We sought to determine the prevalence of SDoH in our clinic population and address these unmet needs to reduce disparities. Methods: We implemented SDoH screening in the stroke clinic by training two medical assistants to fill out the SDoH questionnaire during patient check-in. Screening results were checked by the fellows/attending during the clinic visit. Social worker consultation was sought for unmet social needs. Data was collected in a prospectively maintained stroke clinic registry. Results: There were 131 patients seen between October 2021 and February 2022 in the stroke clinic. Of those, 108 patients (82%) were screened for unmet SDoH needs (financial, transportation, and food insecurity). Of the screened, 81% were black, mean age was 55 years, 51% were male, and 59% were from economically at-risk or distressed communities. The mean duration from stroke onset to clinic visit was 12 months. Fifty-eight of the screened patients had at least one unmet need (54%), 30 had none (28%), and 20 were unknown (19%). Eighty-one percent (47/58) of patients with unmet needs had BP ≥130/80 (Odds ratio 2.47 CI 0.91-6.66, p =0.07). Most patients had financial insecurity (74%), followed by transportation needs (55%) and food insecurity (50%). Of the patients with unmet needs, 59% (n=34/58) reside in economically at-risk or distressed communities. 55% (32/58) of patients received resources to address these needs during the clinic visit. Conclusions: We found a high prevalence of unmet social needs in our stroke population, and the needs persisted for at least a year post-stroke. Screening and addressing unmet social needs should be incorporated as a routine follow-up post-stroke care. Systematic ways of assessing SDoH to address their effects on stroke recurrence and recovery should be done in larger studies.

BackgroundProper identification of infarct extent is crucial for thrombectomy and prognostication. We sought to study the frequency and topographic aspects of those cases in which CT perfusion (CTP) misses a core lesion that is present on initial non-contrast CT (NCCT).MethodsA review was carried out of a prospectively collected database of endovascular patients with anterior circulation large vessel occlusion strokes from January 2014 to November 2018. Patients with an e-ASPECTS ResultsIn total, 629 patients were analyzed of which 161 (25.6%) had a TMC. On univariate analysis, TMC was associated with isolated deep middle cerebral artery (MCA) strokes (77.6% vs 56.6%, pConclusionsCTP may completely fail to detect ischemic core in as many as 25% of cases, especially in isolated deep MCA strokes. Technical refinements of the post-processing algorithms are therefore warranted. TMC infarcts may have a lower risk of reperfusion hemorrhage, potentially due to greater preservation of the neurovascular unit structure in face of delayed recovery of cerebral blood flow.

Background Basal ganglia infarcts are thought to carry worse clinical outcomes compared with other infarct patterns. We aimed to investigate whether pretreatment topographic infarct patterns including complete basal ganglia involvement versus other infarct patterns help predict mechanical thrombectomy outcomes. Methods This was a review of a prospectively collected database of consecutive mechanical thrombectomy patients with anterior circulation large vessel occlusion strokes between January 2014 and November 2018. Patients were categorized into the following 2 groups: (1) total basal ganglia (TBG) strokes defined as infarcts affecting both the caudate and lentiform nuclei regardless of cortical involvement and (2) other infarct patterns. Infarct location was assessed on preprocedure noncontrast computed tomography using an automated software (e‐ASPECTS). Baseline characteristics and outcome measures were compared. Results A total of 1011 patients were analyzed of which 234 (23.12%) had TBG strokes. Patients with TBG strokes were younger ( P =0.01); had higher National Institutes of Health Stroke Scale (NIHSS) ( P =0.006), lower e‐ASPECTS ( P P =0.024); and had diabetes less often ( P =0.01). Baseline characteristics were otherwise comparable between groups. Involvement of the caudate or lentiform nucleus alone was observed in 237 (30.5%) and 21 (2.7%) patients, respectively, in the other infarct patterns group. No internal capsule involvement was detected in either group. There were no differences in terms of 90‐day functional outcomes whether dichotomized (modified Rankin Scale score≤2: TBG=44.6% versus other=50.1%; P =0.14) or looking at the entire spectrum of the scale (shift analysis; P =0.74). However, TBG strokes had significantly higher rates of any parenchymal hematomas (15.4% versus 8.2%; P =0.001), an association that held true in multivariable analysis (adjusted odds ratio, 2.57 [95% CI, 1.41–4.62]; P =0.002). Conclusions Despite increased rates of hemorrhagic transformation, ganglionic infarcts carry similar functional outcomes after mechanical thrombectomy compared with other stroke patterns.

Background and Purpose Infarct growth rate (IGR) in acute ischemic stroke is highly variable. We sought to evaluate impact of symptom-reperfusion time on outcomes in patients undergoing mechanical thrombectomy (MT). Methods A prospectively maintained database from January,2012-August,2020 was reviewed. All patients with isolated MCA-M1 occlusion who achieved complete reperfusion(mTICI2C-3), had a witnessed symptom onset and follow-up MRI were included. IGR was calculated as final infarct volume (FIV)(ml)/symptom onset to reperfusion time(hours) and was dichotomized according to the median value into slow-(SP) versus fast-progressors (FP). The primary analysis aimed to evaluate the impact of symptom-reperfusion time on 90-day mRS in SP and FP. Secondary analysis was performed to identify predictors of IGR. Results A total of 137 patients were eligible for analysis. Mean age was 63 ± 15.4 years and median IGR was 5.13ml/hour. SP(n = 69) had higher median ASPECTS, lower median rCBFConclusions The impact of symptom-reperfusion time on outcomes significantly varies across slow-versus fast-progressors. ASPECTS, collateral score, rCBF

Introduction: Heart failure with reduced Ejection Fraction (HFrEF) is an important risk factor for ischemic stroke and has been shown to carry higher mortality among stroke survivors. However, data among patients with large vessel occlusion strokes (LVOS) undergoing mechanical thrombectomy (MT) is lacking. We aimed to investigate the impact of HFrEF on procedural and functional outcomes after MT. Methods: We conducted a retrospective analysis of a prospectively collected MT database of all consecutive anterior circulation LVOS (Intracranial ICA, MCA-M1, M2) patients undergoing MT at a large urban comprehensive stroke center from Jan,2015-Dec,2020. HFrEF was defined as LVEF ≤40% on transthoracic or transesophageal echocardiograms obtained during the same admission. Uni-multivariable analyses were performed to evaluate the predictors of first pass effect (FPE), mRS0-2 and mortality at 90 days. Results: Of 1466 patients included in the analysis, 293 had HFrEF. The HFrEF group had fewer females, higher median baseline NIHSS, higher rates of Atrial fibrillation (p Conclusion: Our single-center study showed that HFrEF was associated with better procedural outcomes but did not impact functional outcomes at 90-day. Large multi-center studies are warranted.