Unilateral absence of internal carotid artery: A rare case report

Unilateral absence of internal carotid artery (ICA) is a rare congenital anomaly. We present the case of a 35-year-old man with episodes of recurrent strokes in the past and now presenting with right-sided upper limb weakness. Radiological diagnostic workup revealed a thin left ICA in the neck with non-visualization beyond petrous bone in the intracranial course. The ipsilateral brain parenchyma is supplied by vessels from the contralateral side of the Circle of Willis. As the patient had no evidence of a cerebrovascular accident on radiological evaluation and no neurological signs and symptoms, he was discharged with anticoagulant medications with the advice of follow-up. This is the first report to describe a case of ICA agenesis with a pattern of collateral circulation that doesn’t fit any of the six types described by Lie.

Early-onset vascular leukoencephalopathy caused by bi-allelic NOTCH3 variants

Objective Heterozygous NOTCH3 variants are known to cause cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), with patients typically presenting in adulthood. We describe three patients presenting at an early age with a vascular leukoencephalopathy. Genome sequencing revealed bi-allelic variants in the NOTCH3 gene. Methods Clinical records and available MRI and CT scans of three patients from two unrelated families were retrospectively reviewed. Results The patients presented at 9-14 months of age with developmental delay, seizures, or both. The disease course was characterized by cognitive impairment and variably recurrent strokes, migraine attacks, and seizures. MRI findings pointed at a small vessel disease, with extensive cerebral white matter abnormalities, atrophy, lacunes in the basal ganglia, microbleeds and microcalcifications. The anterior temporal lobes were spared. Bi-allelic cysteine-sparing NOTCH3 variants in exons 1, 32 and 33 were found. Interpretation This study indicates that bi-allelic loss-of-function NOTCH3 variants may cause a vascular leukoencephalopathy, distinct from CADASIL.

Recurrent Stroke Prediction using Machine Learning Algorithms with Clinical Public Datasets: An Empirical Performance Evaluation

Recurrent strokes can be devastating, often resulting in severe disability or death. However, nearly 90% of the causes of recurrent stroke are modifiable, which means recurrent strokes can be averted by controlling risk factors, which are mainly behavioral and metabolic in nature. Thus, it shows that from the previous works that recurrent stroke prediction model could help in minimizing the possibility of getting recurrent stroke. Previous works have shown promising results in predicting first-time stroke cases with machine learning approaches. However, there are limited works on recurrent stroke prediction using machine learning methods. Hence, this work is proposed to perform an empirical analysis and to investigate machine learning algorithms implementation in the recurrent stroke prediction models. This research aims to investigate and compare the performance of machine learning algorithms using recurrent stroke clinical public datasets. In this study, Artificial Neural Network (ANN), Support Vector Machine (SVM) and Bayesian Rule List (BRL) are used and compared their performance in the domain of recurrent stroke prediction model. The result of the empirical experiments shows that ANN scores the highest accuracy at 80.00%, follows by BRL with 75.91% and SVM with 60.45%.

Recurrent Strokes as the First Presentation of Occult Pancreatic Cancer; Trousseau Syndrome: A Case Report

Cerebrovascular disorders (CVDs) are widespread in cancer patients, exacerbating their condition and lowering their prognosis. Approximately 15% of cancer patients have a coexisting CVD. Stroke may occur after the initial cancer diagnosis or before the diagnosis of malignant disease. The underlying causes of stroke in cancer patients are distinct from those in noncancer patients and are related to both cancer itself and the type of treatment. Cardio-embolism, large vessel atherosclerosis, and small vessel occlusion have all been identified as important causes of ischemic stroke, but nonbacterial thrombotic endocarditis has been documented only infrequently. We present a case of a 64-year-old female with recurrent ischemic stroke of unknown cause and involving different arterial territories, who was discovered to have metastatic pancreatic cancer. The initial workup with brain imaging revealed multiple acute/subacute ischemic strokes and a negative cardiac assessment. Accordingly, she underwent a whole-body positron emission tomography-computed tomography which revealed a hypermetabolic mass lesion in the pancreaticoduodenal area. Our case indicates that cancer-associated stroke should be seriously evaluated. It demonstrates the critical nature of contemplating hidden cancer in survivors of ischemic stroke and identifies factors that may necessitate further investigation as part of a comprehensive approach to ischemic stroke, especially embolic stroke of unknown sources.

Memory Trajectories Before and After First and Recurrent Strokes

Background and objectivesThe evidence on timing of memory change after first and recurrent strokes is limited and inconsistent. We investigated memory trajectories before and after first and recurrent strokes in eighteen European countries, and tested whether the country-level acute stroke care was associated with memory change after stroke.MethodsData were from the Survey of Health, Ageing and Retirement in Europe (2004–2019). Incident first and recurrent strokes were identified among baseline stroke-free individuals. Within each country, each participant with incident stroke (case group) was matched with a stroke-free individual (control group) using the Propensity Score Matching. We applied multilevel segmented linear regression to quantify acute and accelerated memory changes (measured by the sum score of immediate and delayed word recall tests; 0–20 words) before and after first and recurrent strokes in both groups. Associations between stroke and memory were compared between countries with different levels of acute stroke care indicators.ResultsThe final analytical sample included 35,164 participants who were stroke-free at baseline (≥50 years). 2,362 incident first and 341 recurrent strokes between 2004 and 2019 were identified. In case group, mean acute decreases in memory scores were 0.48 (95% confidence interval: 0.31, 0.65) and 1.14 (95% confidence interval: 0.80, 1.48) words after first and recurrent stroke, respectively, independent of a range of confounders. No such acute decreases were observed in control group after a hypothetical non-stroke onset date. In both groups, memory declined over time but decline rates were similar (-0.07 [95% confidence interval: -0.10, -0.05] versus -0.06 [95% confidence interval: -0.08, -0.05] words per year). The mean acute decreases in memory scores after first and recurrent strokes were smaller in countries with better access to endovascular treatment.DiscussionWe found acute decreases but not accelerated declines in memory after first and recurrent strokes. Improved endovascular therapy might be associated with smaller memory loss after stroke but more evidence based on individual-level data is needed. More effort should be made in early assessment and intensive prevention of stroke among the ageing population, and promoting access to and delivery of acute stroke care among patients with stroke.

Ischemic Stroke in a Patient with Stable CADASIL during COVID-19: A Case Report

Background: SARS-CoV-2 infection has been associated with different neurological conditions such as Guillain-Barré, encephalitis and stroke. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an inherited small-vessel disease characterized by recurrent ischemic stroke, cognitive decline, migraine and mood disturbances. One of the mechanisms involved in CADASIL pathogenesis is endothelial dysfunction, which causes an increased risk of recurrent strokes. Since COVID-19 infection is also associated with coagulopathy and endothelial dysfunction, the risk of ischemic stroke might be even higher in this population. We describe the case of a CADASIL patient who developed an acute ischemic stroke after SARS-CoV-2 infection. In patients with diseases causing endothelial dysregulation, such as CADASIL, the hypercoagulability related to COVID-19 may contribute to the risk of stroke recurrence.

P.067 A worldwide survey of physician approaches to patients with acutely symptomatic carotid stenosis (“hot carotid”)

Background: Patients with acutely symptomatic carotid stenosis (“hot carotid”) have high up-front risk of recurrent strokes. Uncertainties remain regarding optimal anti-thrombotic management, particularly while awaiting revascularization with endarterectomy or stenting (CEA/CAS). Methods: We administered a worldwide electronic survey through Neurology: Clinical Practice. Respondents chose their preferred antithrombotic regimen (1) in a general case of acutely symptomatic carotid stenosis, (2) if the patient was already on aspirin, or (3) had associated intraluminal thrombus(ILT). Responses among different groups were compared using multivariable logistic regression. Results: We received 668 responses from 71 countries. Most respondents favoured CEA(69.1%) over CAS, an aspirin-containing regimen(88.5%), and a clopidogrel-containing regimen(64.4%) if already on aspirin. Monotherapy was favoured by 54.4-70.6% across scenarios. The preferred dual therapy was low-dose aspirin(75-100mg) plus clopidogrel(22.2%), or high-dose aspirin(160-325mg) plus clopidogrel if already on aspirin(12.2%). Respondents favouring CAS more often chose ≥2 agents (adjusted odds-ratio[aOR] vs CEA: 2.00, 95%CI 1.36-2.95,p=0.001) or clopidogrel-containing regimens (aOR:1.77,1.16-2.70,p=0.008). Respondents from Europe less commonly chose multiple agents (aOR vs United States/Canada: 0.57,0.35–0.93,p=0.023) while those from Asia more often favored multi-agent regimens (aOR:1.95,1.11–3.43,p=0.020). Conclusions: Our results highlight the heterogeneous anti-thrombotic management of hot carotids. Future trials should likely include high-dose aspirin monotherapy or low-dose aspirin/clopidogrel dual-therapy as a comparator arm to stimulate enrolment.

Abstract 1122‐000190: Persistent DWI Signal for 18 Months in Ischemic Stroke Patient with Carotid Web

Introduction : Diagnostic tools for acute ischemic infarcts include the use of DWI sequence on MRI to identify acute infarcts is especially useful since lesions can become hyperintense on this sequence very rapidly (Albers 1998). Over the next 15 days, DWI hyperintensity slowly decreases back to isointense. In some patients, however, there is persistent DWI hyperintensity past 1 month. There are theories that these persistent areas exhibit delayed onset infarct, prolonged ischemia, or perhaps different repair processes (Rivers, et al 2006). To this day, all DWI signals have been known to resolve within a few months even for persistent hyperintensities (Rivers, et al 2006). Carotid webs are a rare form of fibromuscular dysplasia that protrudes from the intimal tissues of carotid arteries. They are shelf‐like projections that grow into the lumen and disrupt normal blood flow (Zhang, et al 2018). These outgrowths are theorized to lead to ischemic strokes due to flow stasis and subsequent embolization of clots that form (Zhang, et al 2018). There is no consensus on the best management of carotid webs, and secondary prevention of recurrent strokes range from medical management to carotid stenting. Methods : This is a case report, and information for the patient was gathered through review of medical records on the EMR. Results : We present a case of ischemic stroke in the right basal ganglia/corona radiata, who presented with left sided weakness. The patient was found to have prediabetes, HTN, and HLD. However, she had recurrence of her symptoms over the next 18 months (figure 1). Repeat MRIs showed persistent DWI hyperintensity that slowly decreased in size and signal intensity over this period but in the same area as the initial infarct. The rest of the work up was only significant for a carotid web in the right internal carotid artery identified on conventional angiography. Ultimately she was managed with medical therapy including aspirin, statin, and antihypertensives. Conclusions : It is unclear whether the carotid web is associated with persistent DWI for such an extended time frame. There is very little research that explores the pathophysiology of ischemic strokes from carotid webs. In addition, there is even less information about the physiology of an evolving infarct that shows persistent DWI signals for such an extended time frame. Further studies that look into carotid webs may help us understand the best long term management in such patients. Future studies that explore the physiology of ischemic strokes that show such persistent DWI signals may elucidate and perhaps expand upon current management options and possibly identify new areas for intervention.