Harahsheh, Ehab

Background: Although no tests are currently available to predict post-stroke depression (PSD), a risk factor for diminished quality of life and stroke-related death, emerging evidence suggests that ischemic stroke (IS) may induce behavioral changes by damaging connections throughout the brain rather than via localized injury. Hypothesis: We sought to determine if active (surveys) and passive (accelerometer, GPS, and other sensors) smartphone data could quantify exploratory behavioral proxies of PSD. Methods: Thirty-four adults with a recent IS (n = 12) or transient ischemic attack (TIA) (n = 22) diagnosis were followed for 3 months. Participants used the Beiwe app to complete a weekly Patient Health Questionnaire-8 (PHQ-8) survey and were evaluated every 30 days with the Montgomery-Asberg Depression Rating Scale (MADRS). Results: Preliminary analysis of app survey compliance was adequate (86%), and the quantity of data collected was greater for Android than iOS phones. PHQ-8 indicated depression (moderate or severe) in 20% of participants. MADRS highly correlated with the most recent PHQ-8 ( r = 0.92, 95% CI (0.19, 0.99), P = 0.028). Several exploratory passive physical activity and social measures showed statistically significant change over time and/or associations with PHQ-8 and MADRS. Conclusion: Low-burden smartphone data holds promise for developing novel IS and TIA outcome measures as well as identifying patients most at risk of PSD.

Background Patients with atrial fibrillation (AF) are at increased risk of ischemic cerebrovascular events despite anticoagulants (AC). We aim to evaluate whether changing AC or adding antiplatelet therapy to anticoagulants (AP + AC) in patients with AF presenting with acute ischemic stroke (AIS) or transient ischemic attack (TIA) despite AC, decreases the risk of recurrent AIS/TIA compared to patients continued on same AC regimen. Methods Patients with AF on AC presenting with AIS or TIA at our center between 2011- 2021 were included. Data on Demographics, index event, antithrombotic therapy before and after index event, recurrent AIS/TIA, or major bleeding events (MBE) were extracted. Cox proportional hazards models were used to compare outcomes between AC unchange vs AC change, and AP + AC vs AC only groups. Results One hundred eighty-five patients were included (mean age 78.3 years; 62% males, median follow-up 9 months (IQR 1-34)). Seventeen patients (9%) had AC change, 100 (54%) received AP + AC, 39 (21%) had recurrent AIS/TIA, and 27 (15%) had MBE following index event. No difference was observed between AC unchange vs AC change and AP + AC vs AC only groups regarding recurrent AIS/TIA (HR 1.72 [.65-4.57], P = .27 and HR 1.02 [.53- 1.98], P = .95, respectively) or MBE (HR .85 [.19-3.67], P = .83 and HR 1.49 [.67-3.33)], P = .33, respectively). Fourteen vascular neurologists treated this cohort and 9(64%) implemented AC changes. Conclusion In this single center retrospective study of 185 patients with AF and AIS/TIA despite AC, changing AC or adding AP agents did not decrease the risk of ischemic cerebrovascular events.

Objective: To assess whether diffusion restriction (DR) of the retina and optic nerve (ON) can be accurately and reliably identified on standard stroke protocol brain magnetic resonance diffusion-weighted imaging (DWI-MRI) in patients presenting with acute non-arteritic central retinal artery occlusion (CRAO). Background: Retinal DR (RDR) and ONDR in patients with acute non-arteritic CRAO have been described with various diagnostic accuracies and often identified by experienced neuroradiologists with fair inter-rater agreement. Methods: This retrospective case-control study included patients that presented to our academic center from 2013-2021 with acute non-arteritic CRAO or acute cerebral ischemia (controls, age and gender-matched) and had brain MRI performed within 14 days from symptom onset. Two neuroradiologists, blinded to the site of CRAO and diagnosis, independently reviewed MRI of CRAO cases and controls to assess for the presence of RDR and ONDR. Their inter-rater agreement was calculated (prevalence and bias- adjusted kappa coefficient) and their final consensus was used to perform sensitivity and specificity analyses. Results: We included 128 patients with CRAO (mean age 69 years; 50% males; median time from CRAO to MRI 2 days (IQR 1-5)) and 128 matched controls with acute cerebral ischemia (mean age 68 years; 51% males). After neuroradiologists’ consensus, DR was correctly identified in the retina or ON in 51/128 (39.8%), retina alone 35/128 (27.3%), ON alone 31/128 (24.2%), both retina and ON 15/128 (11.7%), with excellent inter-rater agreement for retina (K=0.91) and ON (K=0.83). There were no cases of RDR or ONDR in the control group. After neuroradiologists’ consensus, sensitivity, specificity, PPV and NPV were 28.1%, 100%, 100%, and 58.2% for RDR and 27.3%, 100%, 100%, and 57.9% for ONDR. Conclusion: Though RDR and ONDR can be identified with excellent interrater reliability, they are infrequent findings and their role in diagnosing acute CRAO is unclear. Observational prospective studies with large cohort of patients, optimization of dedicated and standardized orbit DWI-MRI protocols, and education of neurology and neuroradiology providers are needed to facilitate more accurate identification of RDR and ONDR in hyperacute CRAO.

This case report describes a patient with status epilepticus and neuroimaging features of fleeting T2 fluid-attenuated inversion recovery hyperintense lesions on magnetic resonance imaging.

Introduction: Embolic stroke of undetermined source (ESUS) is a clinical paradigm that helps to classify and lead investigations into cryptogenic stroke. Diagnostic evaluation of ESUS involves investigating several potential etiologies of stroke. One such etiology includes antiphospholipid syndrome (APLS), a syndrome known to cause hypercoagulability. Clinical characteristics of primary APLS in ESUS have not been described. Methods: This is an IRB approved, retrospective study including patients from 2015-2020 who were seen at Mayo Clinic, were diagnosed with ESUS, and had APLS testing (anti-cardiolipin, beta-2 glycoprotein, or lupus anticoagulant). Baseline characteristics and radiographic features were collected and compared between patients who were and were not diagnosed with APLS, as well as between patients who were and were not APLS antibody positive. Results: Our study included 206 patients. Positive APLS antibody testing was seen in 21 (10%) patients. Of those patients, 8 (4%) received a formal diagnosis of APLS. Compared to controls, patients with positive APLS antibodies as well as those diagnosed with APLS were more likely to have a history of cancer (20 [11%] APLS antibody negative vs 7 [33%] APLS antibody positive p=0.004) (23 [12%] APLS diagnosis negative vs 4 [50%] APLS diagnosis p=0.002). Mean age in primary APLS was greater, 57 years old APLS antibody negative vs 69 years old APLS antibody positive (p<0.001) and 58 years old APLS diagnosis negative vs 75 years old APLS diagnosis (p=0.001) (Table 1). Regressions analyses examining infarct topography and rate of hemorrhagic transformation were non-significant between groups (p>0.1) Conclusion: APLS presenting as ESUS is associated with older age and history of malignancy. We speculate this finding may underscore the need to consider hypercoagulable conditions more broadly in stroke evaluations of older populations. Larger cohorts and longer follow up will be required to validate this observation.

Abstract Background Despite the increasing incidence of neuroinvasive West Nile virus (NiWNV) infection in the US, the spectrum of disease characteristics and neuroimaging findings in immunosuppressed (IS) individuals are not adequately described. We aimed to compare the clinical characteristics and outcomes of NiWNV infection in IS and immunocompetent (IC) patients. Methods We extracted relevant data from all NiWNV patients hospitalized 7/2003-10/2021 at Mayo Clinic hospitals. Cohort was inclusive of patients from the recent historic WNV outbreak in Arizona in 2021. Chi-Square or Kruskal-Wallis and logistic regression were used to compare relevant variables and determine predictors of mortality respectively. Results We included 115 patients (72 IC and 43 IS), mean age 63.5 years; neurologic syndromes included meningoencephalitis (85.2%), encephalomyelitis (8.7%) and myeloradiculitis (6.1%). Presenting symptoms were malaise (72%), fever (66%), altered mentation (64%), gastrointestinal (47%) and myalgia (35.7%). MRI brain was abnormal in 62.8% (49/78), demonstrating T2/FLAIR hyperintensities in 47.4% (brainstem, thalamus, temporal lobes), leptomeningeal enhancement (16.7%) and diffusion restriction (20.5%). Altered mental status (76.7% vs 56.9%), myalgia (44.4% vs. 20.9%), myoclonus (18.6% vs. 4.2%) and thalamic MRI T2 FLAIR abnormalities (11.4% vs 0%) were more common in IS patients. Higher CSF WBC counts were observed in IC vs IS patients (P&lt; 0.05). Immunosuppressed patients were more likely to be treated with intravenous immunoglobulin (44.2% vs 8.3% p=&lt; 0.001) and/or interferon therapy (32.6% vs 6.9%, p=0.0003) and had increased odds of 90-day mortality on multivariable analysis (Adjusted Odds Ratio, AOR 2.22; 95% CI 1.065-4.627, p=0.0334). In the IS subgroup, ICU admission, mechanical ventilation, and Glasgow coma scale of &lt; 8 were associated with reduced overall survival/increased 90-day mortality (p&lt; 0.005). Conclusion Individuals presenting in summer/fall months with the aforementioned symptoms and/or MRI abnormalities should be evaluated for NiWNV infection. Compared to the immunocompetent, immunosuppressed patients with NiWNV are at a significantly greater mortality risk. Novel and effective antiviral therapies aimed at improving outcomes are warranted. Disclosures All Authors: No reported disclosures.

Introduction: Central retinal artery occlusion (CRAO) is a neurovascular emergency and acute monocular visual loss should trigger a stroke code activation. As thrombolytic therapy is considered for non-arteritic CRAO in the stroke therapeutic window, we aimed to review all telestroke encounters for acute visual loss in Mayo Clinic national telestroke network, focusing on the ocular diagnosis and the management recommendations. Hypothesis: patients evaluated via telestroke for acute visual loss are less likely to receive thrombolysis Methods: We conducted a retrospective review of the Mayo Clinic Arizona Telestroke/Teleneurology (2010-2017, 6364 encounters) and Mayo Clinic Enterprise Telestroke databases (2018-2020, 3147 encounters), searching for visits requested for acute visual loss. We recorded the subjects’ demographics, time from last seen normal to telestroke evaluation, preliminary diagnosis, and therapeutic/diagnostic recommendation. Results: From a total of 9511 audio-video telestroke encounters, 49 (0.51%) had an ocular diagnosis. Out of those, 6 patients (12.2%) had a provisional diagnosis of CRAO. 4/6 (66.6%) CRAO patients presented within 4.5h from symptom onset (median 2 hours) and none received thrombolytic therapy. All telestroke physicians recommended antiplatelet, ophthalmology consultation for diagnostic evaluation and comprehensive stroke work-up. Conclusions: Telestroke evaluations for CRAO, in routine practice, are less common than the disease prevalence would predict, suggesting that education is urgently mandated to increase the index of awareness. Even when CRAO subjects are evaluated via telestroke within 4.5 hours from symptom onset, they do not receive thrombolytic therapy nor timely ophthalmologic evaluation. Telestroke visits may benefit from the inclusion of tele-ophthalmologic consults to help with establishing the diagnosis in the narrow time-window of intravenous thrombolysis.

Introduction: Reversible cerebral vasonstriction syndrome (RCVS) is an increasingly recognized clinical and radiologic syndrome. However, it has been rarely reported in the setting of the novel coronavirus disease-2019 (COVID-19) infection or sarcomatous tumors. RCVS might be the initial manifestations of COVID-19 infection or noncatecholamine producing masses including sarcoma. Case Report: A 44-year-old male who developed COVID-19–related symptoms followed by rapid onset of severe headaches in the setting of persistently elevated blood pressure (BP). Brain imaging showed multifocal arterial narrowing in the anterior and posterior circulation consistent with RCVS. Serial imaging demonstrated resolution of the arterial narrowing after BP control was achieved with improvement in the patient’s headaches. Further investigation for secondary causes of the patient’s elevated BP revealed a right renal mass, and the patient underwent right nephrectomy, and the biopsy results confirmed the diagnosis of pleomorphic sarcoma. Conclusion: Our case suggests a possible association between severe acute respiratory syndrome coronavirus 2 with development of RCVS, but further studies are needed to validate this observation, establish a causal relationship and define a pathophysiological mechanism. Considering tumors other than catecholamine-producing masses as a potential risk factor for developing RCVS might lead to earlier detection and treatment of any underlying malignancy in patients whom the main and sole presentation could be RCVS.