Search

[Image: see text] Cerebral cavernous malformations (CCMs) are hemorrhagic neurovascular lesions that affect more than 1 million people in the United States. Rapamycin inhibits CCM development and bleeding in murine models. The appropriate dosage to modify disease phenotype remains unknown. Current approved indications by the U.S. Food and Drug Administration and clinicaltrials.gov were queried for rapamycin human dosing for various indications. A systematic literature search was conducted on PubMed to investigate mouse dosimetry of rapamycin. In humans, low daily doses of

Introduction: Cavernous Angiomas (CAs) are vascular malformations characterized by clusters of blood-filled capillary spaces lined by “leaky” endothelium. While mutations in endothelial cells have long been recognized as necessary for lesion genesis, there is evidence of inflammation, response to hypoxia, and non-endothelial autonomous cell effects driving pathogenesis. Disrupted gene expression in the CA neurovascular unit (NVU) has been described but the contribution of each cell type has not been previously investigated. Methods: Six CA and four control brain samples were collected and frozen during surgical resection. The endothelial cells, pericytes, and neuroglia (astrocytes and neurons) were sorted, and the RNA was extracted and sequenced. The differentially expressed genes (DEGs) were identified ( p p p p Results: In endothelial cells, 362 DEGs were identified contributing to 54 enriched IPA pathways. In addition, 484 DEGs were found in pericytes and 50 IPA pathways were identified. The common functions between these two cell types were related to angiogenesis, extracellular matrix organization, cell adhesion, and platelet activation, while the function related to response to hypoxia was only shown in pericytes. Finally, 242 DEGs and 52 IPA pathways were identified in neuroglia cells. The associated pathway functions were related to inflammatory response and cell adhesion. The IPA results were further confirmed by the GO term and KEGG pathway analyses. Conclusion: We confirm that disrupted genes related to angiogenesis, blood-brain barrier integrity, cell adhesion and platelet activation in the CA lesion involve endothelial cells and pericytes primarily. Pericytes are particularly associated with disrupted genes related to response to hypoxia, while neuroglia is associated with greater gene disruptions related to inflammation. These results motivate novel mechanistic hypotheses regarding non-endothelial cell contributions to lesion pathobiology.

Background: Cerebral cavernous malformation is a common lesion affecting more than a million Americans, with potential severe sequelae. It is unclear how socioeconomic status (SES) and race influence access to specialized care, and the enrollment and adherence in clinical trials aimed at novel therapies for CCM. Methods: We analyzed a cohort of patients harboring CCM lesions screened for IRB approved research studies between 01/2010 -12/2021 at an accredited center of excellence for CCM, leading NIH funded clinical studies. Demographics, lesion location, history of hemorrhage, insurance type and area of deprivation index (ADI) were collected. Insurance type was categorized as commercial, Medicare/Medicaid, or out-of-pocket. The ADI ranking score was analyzed per decile with 1 (least disadvantaged) through 10 (most disadvantaged). Primary outcomes were clinical follow-up within a year from the 1 st visit for all CCM patients (excluding pregnancy), and enrollment/adherence among eligible subjects for first in disease NIH funded clinical trial [clinicaltrials.gov NCT02603328]. Statistical analysis (Chi 2 test; t-test) was applied to determine whether these differed in ADI groups, races or insurance type categories. Results: Despite the institution’s location in an area with majority African American population and lower SES, only 11.5% of subjects were African American, and the majority (52.8%) had a high SES (ADI 1-3). As expected, patients who had a symptomatic bleed were more likely to follow-up (p=0.01), and those with brainstem lesion were more likely to enroll and adhere in clinical trial (p=0.02). Correcting for these confounders, there was no difference in rates of clinical follow-up or enrollment/adherence among different ADI groups, races or insurance coverage. Conclusion: Access of disadvantaged patients and races to a center of excellence care and research remains limited despite geographic proximity to their community. Contrary to common belief, patients with poor SES and African Americans are as likely to follow-up and enroll/adhere in clinical trials, if provided access to specialized care. Mitigation efforts should target systemic causes of low access to specialized care among poor and African American patients.

Background: Quantitative susceptibility mapping (QSM) is a measure of iron content, and ≥6% increase in QSM has been correlated with new hemorrhage in previously stable cavernous angiomas. Longitudinal changes in QSM are not known in cavernous angiomas with symptomatic hemorrhage (CASH) with high rates of rebleeding and are the targets of novel pharmacotherapies. In a prospective multisite Trial Readiness project (clinicaltrials.gov NCT03652181), QSM is longitudinally assessed. Methods: Trial eligible subjects with CASH in the prior year and not undergoing lesion resection or radiation, were enrolled. Mean QSM of CASH lesion was acquired at baseline and at 1 and 2 year planned follow-ups. Relative change in mean lesional QSM during each follow-up year was assessed, and any symptomatic hemorrhage (SH), asymptomatic changes (AC; defined as subclinical bleed or growth) in the lesion during the same epoch. Results: Paired QSM assessments were completed to date in 99 CASH lesions (67 year 1, and 32 year 2) and are reported herein. Four SH and 6 ACs occurred during 1 st follow-up year, and 3 SH during 2 nd year. QSM increased in 54 lesion-years, decreased in 44, and remained stable in 1. The % lesional QSM change in year 1 was significantly higher than that observed in year 2 (mean +9.33, SD 37.52 vs. +5.20; SD= 24.86; p=0.05; Spearman correlation ρ -0.36). CAs with clinical SH or AC had a significantly higher % QSM change than lesions without (mean +28.03, SD 17.77 vs. +4.97, SD= 34.75; p=0.0014). All 13 lesions with SH/AC demonstrated a QSM increase ≥6% while 31 of 86 (36%) lesions with no clinical events had a ≥6% QSM increase. Conclusion: QSM change of ≥6% is present in every CASH lesion manifesting a new SH or AC (100% specificity), and is more common than clinical events (3.4X higher sensitivity). The biomarker can hence be used as a more sensitive categorical outcome than SH or AC in clinical trials of novel therapies aimed at bleeding in CASH lesions. Effect of an intervention on % QSM change may also be proposed as a time-averaged difference between 2 arms using a repeated measures analysis implemented as an unadjusted linear mixed model. These results are the basis of application for certification by the U.S F.D.A. of QSM as a monitoring biomarker of drug effect in CASH.

Background: Cerebral cavernous angiomas with symptomatic hemorrhage (CASH) carry highest rebleed rates and are targeted for novel interventions. A multisite clinical trial readiness project (clinicaltrials.gov NCT03652181) aims to identify clinical and functional changes over time in trial eligible CASH patients. Methods: Adult patients from 5 high volume centers with a CASH in the prior year and no planned surgical intervention were enrolled. In addition to demographic, clinical, and imaging review, patients underwent baseline, 1 year and 2 year NIH-stroke scale (NIHSS), modified Rankin scale (mRS), Euro-QOL 5D-3L (EQ-5D-3L) and EQ VAS (visual analog score), and PROMIS 29 assessments. Recurrent symptomatic hemorrhages (SH) were verified. We assessed the hemorrhage rate, change in scores/scales over time, and determined which scales/scores were most affected in patients with SH. Results: 123 patients completed baseline assessments and were prospectively followed (60.9% female; mean age 44.1 years; 39.1% familial; 41.5% brainstem location). As of reporting date, 89 of 104 (86%) and 58 of 76 (76%) cases have completed assessments. There were 16 SHs during 147 patient-years of follow up (10.9% per patient year). At baseline, 111 (90.2%) of patients had NIHSS 0-2 and 77 (62.6%) patients had mRS baseline 0-1 which improved to 40 (95.2 %) and 43 (75.4%) at 2 years. At baseline, 54 (43.9%) of patients had at least one moderate to severely abnormal PROMIS-29 domain compared to 13 (26.5%) at 2 years. EQ-5D-3L baseline demonstrated a moderate proportion of patients reporting some difficulty with pain (48.8%), anxiety (41.5%), and activity (41.5%) which improved to 28%, 30%, and 34% respectively at 2 years. Patients with a prospective SH were more likely than those without recurrent SH at 2 years to display mild functional decline (0.5 SD) of most PROMIS-29 domains, a mRS of 2 or higher and an abnormal EQ- self-care (P Conclusion: We report SH rate and functional outcome at baseline and rates of changes during 2 years in trial eligible CASH patients. The PROMIS-29, mRS, and EQ-self-care domains were most discriminative in patients with recurrent SH. No test was 100% specific.

Introduction: Age-related cerebral microbleeds (CMBs) are vascular changes associated with an increased risk of intracerebral hemorrhage (ICH) and neurocognitive decline. CMBs share a strikingly similar appearance on MRI to cerebral cavernous malformations (CCMs), which are leaky capillary lesions predisposing patients to brain bleeding. Our team had previously shown increased vascular permeability in CCM and in the brain of older subjects, with common circulating biomarkers of angiogenesis and inflammation. We examine here whether vascular permeability is greater in the aging brain harboring CBMs. Methods: Dynamic Contrast-Enhanced Quantitative Perfusion (DCEQP) MRI, which assesses vascular permeability, was acquired for 7 patients with CMBs (>50 years old), 10 old (>50 years old), and 9 young (18-30 years old) healthy subjects without CMBs. Cases with active brain disease, stroke or seizure in the prior year were excluded. DCEQP scans were co-registered onto their respective T1-weighted images, normalized using the Desikan-Killiany atlas, and finally segmented into white and gray matter within frontal, temporal, parietal, and occipital lobes. The mean permeability was calculated within each segmented area, and values were compared between the 3 groups of interest. Results: Increased permeability was observed within the frontal white and gray matter as well as the parietal gray matter of patients with CMBs compared to age matched old healthy controls (both: p Conclusion: We confirm that the human brain exhibits increased vascular permeability with aging, and this is more pronounced in brains harboring CMBs. This may provide insight into the pathogenesis of CMBs, potentially reflecting end stage age-related failure of the blood brain barrier, associated with frank bleeding. These results offer a starting point for the development of diagnostic and prognostic imaging biomarkers of CMBs, which can help stratify patients at higher risk of future ICH and cognitive decline.

Background: Increases in mean lesional iron content (≥6%) measurement by QSM and vascular permeability (≥40%) assessed by DCEQP MRI have been associated with new bleeding, and are used as monitoring biomarkers in NINDS funded 1st clinical trial of pharmacotherapy (clinicaltrials.gov NCT02603328) in cavernous angiomas with symptomatic hemorrhage (CASH). Plasma protein levels previously associated with CASH in diagnostic and prognostic contexts have never been compared to lesional QSM and DCEQP in the same subjects. Methods: Plasma samples and MRI sequences were simultaneously acquired during 1 year-epochs of prospective follow-up of CASH patients. Plasma levels of 16 proteins were assayed by ELISA and correlated with lesional QSM and DCEQP during the same epochs. Univariate correlations were followed by multivariate analyses combining multiple protein levels to minimize Akaike Information Criterion (AIC) and increase R 2 . Accuracy (AUC on receiver operating curves) and sum of squared error (SSE) are reported for associations achieving statistical significance with FDR correction. Results: None of the proteins individually correlated with QSM/DCEQP (continuous or categorical). Relative change of angiopoietin2, and absolute change of the combination (endoglin+IL1B+IL16) had the highest accuracy (AUC 78.7%, SD 0.062 and 98.4%, SD 0.013 respectively) for lesional QSM increase ≥6%. Relative change of endoglin+IL1B, and absolute change of angiopoetin2+endoglin+thromobomodulin+VEGF, had the highest accuracy (AUC 64.6%, SD 0.057 and 93.2%, SD 0.040 respectively) for lesional DCEQP increase ≥40%. Relative change in angiopoetin1 had the lowest SSE (8.87) with QSM change as a continuous variable, and relative change in lipopolysaccharide binding protein had the lowest SSE (469.06) with DCEQP change as continuous variable. Conclusion: Circulating proteins reflect changes in lesional iron content and permeability in CASH during prospective follow-up. Results are a proof of concept that blood tests could replace more complex and costly imaging biomarkers in the monitoring of hemorrhage in cavernous angiomas. Additional mechanistic plasma molecules (miRNAs and metabolites) may further enhance the accuracy of these monitoring biomarkers.

Patients with familial cerebral cavernous malformation (CCM) inherit germline loss of function mutations and are susceptible to progressive development of brain lesions and neurological sequelae during their lifetime. To date, no homologous circulating molecules have been identified that can reflect the presence of germ line pathogenetic CCM mutations, either in animal models or patients. We hypothesize that homologous differentially expressed (DE) plasma miRNAs can reflect the CCM germline mutation in preclinical murine models and patients. Herein, homologous DE plasma miRNAs with mechanistic putative gene targets within the transcriptome of preclinical and human CCM lesions were identified. Several of these gene targets were additionally found to be associated with CCM-enriched pathways identified using the Kyoto Encyclopedia of Genes and Genomes. DE miRNAs were also identified in familial-CCM patients who developed new brain lesions within the year following blood sample collection. The miRNome results were then validated in an independent cohort of human subjects with real-time-qPCR quantification, a technique facilitating plasma assays. Finally, a Bayesian-informed machine learning approach showed that a combination of plasma levels of miRNAs and circulating proteins improves the association with familial-CCM disease in human subjects to 95% accuracy. These findings act as an important proof of concept for the future development of translatable circulating biomarkers to be tested in preclinical studies and human trials aimed at monitoring and restoring gene function in CCM and other diseases.

Background Cavernous angiomas (CAs) are vascular malformations that may result in stroke. Case Description Herein, we evaluate a CA patient with chronic migraine who experienced 2 documented symptomatic hemorrhages after receiving respective high doses of botulinum toxin (Btx). Conclusions Recently, bacterial lipopolysaccharide has been reported to contribute to CA development through Toll-like receptor signaling, causing hemorrhagic angiogenic proliferation. Lipopolysaccharide and Btx share a common intracellular signaling pathway driving CA development and hemorrhage. Significance of these observations is demonstrated by previous works on plasma molecules showing prognostic associations with symptomatic hemorrhages in human CA, related to the same canonical pathways. Authors suggest careful tracking of the association of Btx and hemorrhage in CA patients.

Introduction: Cavernous Angioma (CA) is a hemorrhagic neurovascular disease characterized by either a familial form with autosomal dominant germline mutations in one of three CCM genes or a sporadic form with somatic mutations of the same genes. Circulating proteins have been previously investigated as possible diagnostic and prognostic biomarkers of disease activity, with up to 86% and 88% sensitivity and specificity, respectively. We hypothesize that differentially expressed (DE) plasma microRNAs and metabolites in CA patients can be integrated with plasma proteins to increase the sensitivity and specificity of circulating CA biomarkers. Methods: Mechanistically relevant homologous DE miRNAs were identified between familial CA patients and preclinical murine models and validated in an independent cohort of patients using real time qPCR. In conjunction, DE metabolites were determined in CA patients using liquid-chromatography mass spectrometry. The interactions of these metabolites with the previously established CA transcriptome, proteome, and microbiome were queried to assess for mechanistic relevance. Optimal diagnostic models of proteins, DE miRNAs, and DE metabolites alone were next established. Plasma metabolites and miRNAs were then separately integrated with protein, using a machine learning-implemented, Bayesian approach to develop diagnostic CA biomarkers. Results: The optimal diagnostic biomarker model with only DE miRNAs performed at up to 68%, while proteins and metabolites achieved up to 68%, and 82% accuracy respectively. The optimal combination for proteins with miRNAs improved the diagnostic association of familial-CA disease to up to 94.7% sensitivity and 100% specificity. Integrating metabolites and proteins improved the diagnosis of CA disease and its clinical manifestations to 100% sensitivity and 100% specificity. Conclusion: Combining plasma proteins with miRNAs or metabolites can improve diagnostic accuracy of CA disease and its disease characteristics above any single molecular modality alone. Future studies should incorporate proteins, miRNAs, and metabolites to further increase diagnostic accuracy, and validate these in a larger cohort with control for demographic and disease features.

Introduction: Hemorrhagic microangiopathies (HMAs) are age-related cerebral microbleeds associated with an increased risk of cognitive decline and intracerebral hemorrhage (ICH). HMAs share a strikingly similar appearance on MRI to cerebral cavernous malformations (CCMs), which are clusters of leaky capillaries predisposing patients to brain bleeding. We hypothesize that HMAs and CCMs share common dysregulated genes and pathways reflecting hemorrhagic failure of the neurovascular unit. Thus, biomarkers developed in CCM may be applicable to HMA. Methods: Extracted mRNA from 5 HMA lesions collected at autopsy along with 3 non-lesional brain sections from the same patients was sequenced, and differentially expressed genes (DEGs) were identified. Enrichment analyses were performed using the Reactome database. Pathways related to postulated mechanisms of HMA were identified, as well as those overlapping pathways with a previously published CCM transcriptome. Dynamic Contrast-Enhanced Quantitative Perfusion (DCEQP) and Quantitative Susceptibility Mapping (QSM) MRIs were performed on 11 HMA patients, 12 age-matched, and 22 young healthy subjects assessing vascular permeability and iron content, as previously done in CCM. Mean permeability and QSM values were calculated for white and gray matter in the frontal, temporal, parietal, and occipital lobes. Results: Differential analyses of the HMA transcriptome identified 376 DEGs ( p p Conclusion: Transcriptomic commonalities suggest that similar pipelines for plasma and imaging biomarkers developed in CCM research may be adapted for risk assessment and monitoring of HMA. These will help improve the understanding of HMA pathogenesis and assist in patient management, offering a large public health impact.

Background and Purpose: Brain cavernous angiomas with symptomatic hemorrhage (CASH) have a high risk of neurological disability from recurrent bleeding. Systematic assessment of baseline features and multisite validation of novel magnetic resonance imaging biomarkers are needed to optimize clinical trial design aimed at novel pharmacotherapies in CASH. Methods: This prospective, multicenter, observational cohort study included adults with unresected, adjudicated brain CASH within the prior year. Six US sites screened and enrolled patients starting August 2018. Baseline demographics, clinical and imaging features, functional status (modified Rankin Scale and National Institutes of Health Stroke Scale), and patient quality of life outcomes (Patient-Reported Outcomes Measurement Information System-29 and EuroQol-5D) were summarized using descriptive statistics. Patient-Reported Outcomes Measurement Information System-29 scores were standardized against a reference population (mean 50, SD 10), and one-sample t test was performed for each domain. A subgroup underwent harmonized magnetic resonance imaging assessment of lesional iron content with quantitative susceptibility mapping and vascular permeability with dynamic contrast-enhanced quantitative perfusion. Results: As of May 2020, 849 patients were screened and 110 CASH cases enrolled (13% prevalence of trial eligible cases). The average age at consent was 46±16 years, 53% were female, 41% were familial, and 43% were brainstem lesions. At enrollment, ≥90% of the cohort had independent functional outcome (modified Rankin Scale score ≤2 and National Institutes of Health Stroke Scale score 30% of patients (EuroQol-5D). Patients had significantly worse Patient-Reported Outcomes Measurement Information System-29 scores for anxiety ( P =0.007), but better depression ( P =0.002) and social satisfaction scores ( P =0.012) compared with the general reference population. Mean baseline quantitative susceptibility mapping and permeability of CASH lesion were 0.45±0.17 ppm and 0.39±0.31 mL/100 g per minute, respectively, which were similar to historical CASH cases and consistent across sites. Conclusions: These baseline features will aid investigators in patient stratification and determining the most appropriate outcome measures for clinical trials of emerging pharmacotherapies in CASH.

BACKGROUND Cerebral cavernous angioma (CA) is a capillary vasculopathy affecting more than a million Americans with a small fraction of cases demonstrating lesional bleed or growth with major clinical sequelae. Perfusion and permeability are fundamental features of CA pathophysiology, but their role as prognostic biomarkers is unclear. PURPOSE To investigate whether perfusion or permeability lesional descriptors derived from dynamic contrast-enhanced quantitative perfusion (DCEQP) magnetic resonance imaging (MRI) can predict subsequent lesional bleed/growth in the year following imaging. STUDY TYPE Single-site case-controlled study. SUBJECTS Two hundred and five consecutively enrolled patients (63.4% female). FIELD STRENGTH/SEQUENCE Three-Tesla/T1 -mapping with contrast-enhanced dynamic two-dimensional (2D) spoiled gradient recalled acquisition (SPGR) sequences. ASSESSMENT Prognostic associations with bleed/growth (present or absent) in the following year were assessed in 745 CA lesions evaluated by DCEQP in the 205 patients in relation to lesional descriptors calculated from permeability and perfusion maps. A subgroup of 30 cases also underwent peripheral blood collection at the time of DCEQP scans and assays of plasma levels of soluble CD14, IL-1β, VEGF, and soluble ROBO4 proteins, whose weighted combination had been previously reported in association with future CA bleeding. STATISTICAL TESTS Mann-Whitney U-test for univariate analyses. Logistic regression models minimizing the Bayesian information criterion (BIC), testing sensitivity and specificity (receiver operating characteristic curves) of weighted combinations of parameters. RESULTS The best prognostic biomarker for lesional bleed or growth included brainstem lesion location, mean lesional permeability, and low-value perfusion cluster mean (BIC = 201.5, sensitivity = 77%, specificity = 72%, P

Background Minimally invasive surgery procedures, including stereotactic catheter aspiration and clearance of intracerebral hemorrhage (ICH) with recombinant tissue plasminogen activator hold a promise to improve outcome of supratentorial brain hemorrhage, a morbid and disabling type of stroke. A recently completed Phase III randomized trial showed improved mortality but was neutral on the primary outcome (modified Rankin scale score 0 to 3 at 1 yr). Objective To assess surgical performance and its impact on the extent of ICH evacuation and functional outcomes. Methods Univariate and multivariate models were used to assess the extent of hematoma evacuation efficacy in relation to mRS 0 to 3 outcome and postulated factors related to patient, disease, and protocol adherence in the surgical arm (n = 242) of the MISTIE trial. Results Greater ICH reduction has a higher likelihood of achieving mRS of 0 to 3 with a minimum evacuation threshold of ≤15 mL end of treatment ICH volume or ≥70% volume reduction when controlling for disease severity factors. Mortality benefit was achieved at ≤30 mL end of treatment ICH volume, or >53% volume reduction. Initial hematoma volume, history of hypertension, irregular-shaped hematoma, number of alteplase doses given, surgical protocol deviations, and catheter manipulation problems were significant factors in failing to achieve ≤15 mL goal evacuation. Greater surgeon/site experiences were associated with avoiding poor hematoma evacuation. Conclusion This is the first surgical trial reporting thresholds for reduction of ICH volume correlating with improved mortality and functional outcomes. To realize the benefit of surgery, protocol objectives, surgeon education, technical enhancements, and case selection should be focused on this goal.

Cavernous angiomas with symptomatic hemorrhage (CASH) have a high risk of rebleeding, and hence an accurate diagnosis is needed. With blood flow and vascular leak as established mechanisms, we analyzed perfusion and permeability derivations of dynamic contrast-enhanced quantitative perfusion (DCEQP) MRI in 745 lesions of 205 consecutive patients. Thirteen respective derivations of lesional perfusion and permeability were compared between lesions that bled within a year prior to imaging (N = 86), versus non-CASH (N = 659) using machine learning and univariate analyses. Based on logistic regression and minimizing the Bayesian information criterion (BIC), the best diagnostic biomarker of CASH within the prior year included brainstem lesion location, sporadic genotype, perfusion skewness, and high-perfusion cluster area (BIC = 414.9, sensitivity = 74%, specificity = 87%). Adding a diagnostic plasma protein biomarker enhanced sensitivity to 100% and specificity to 85%. A slightly modified derivation achieved similar accuracy (BIC = 321.6, sensitivity = 80%, specificity = 82%) in the cohort where CASH occurred 3–12 months prior to imaging after signs of hemorrhage would have disappeared on conventional MRI sequences. Adding the same plasma biomarker enhanced sensitivity to 100% and specificity to 87%. Lesional blood flow on DCEQP may distinguish CASH after hemorrhagic signs on conventional MRI have disappeared and are enhanced in combination with a plasma biomarker.

Objectives To determine factors associated with post-stroke depression (PSD) and relationship between PSD and functional outcomes in spontaneous intracerebral hemorrhage (ICH) using prospective data from a large clinical trial. Materials and Methods MISTIE III, a randomized, multicenter, placebo-controlled trial, was conducted to determine if minimally invasive surgery with thrombolysis improves outcome compared to standard medical care. Our primary outcome was post-stroke depression at 180 days. Secondary outcomes were change in blinded assessment of modified Rankin Scale (mRS) from 30 to 180 days, and from 180 to 365 days. Logistic regression models were used to assess the relationship between PSD and outcomes. Results Among 379 survivors at day 180, 308 completed Center for Epidemiologic Studies Depression Scale, of which 111 (36%) were depressed. In the multivariable analysis, female sex (Adjusted Odds Ratio [AOR], 95% Confidence Interval [CI]: 1.93 [1.07-3.48]), Hispanic ethnicity (3.05 [1.19-7.85]), intraventricular hemorrhage (1.88 [1.02-3.45]), right-sided lesions (3.00 [1.43-6.29]), impaired mini mental state examination at day 30 (2.50 [1.13-5.54]), and not being at home at day 30 (3.17 [1.05-9.57]) were significantly associated with higher odds of PSD. Patients with PSD were significantly more likely to have unchanged or worsening mRS from day 30 to 180 (42.3% vs. 25.9%; p=0.004), but not from day 180 to 365. Conclusions We report high burden of PSD in patients with large volume ICH. Impaired cognition and not living at home may be more important than physical limitations in predicting PSD. Increased screening of high-risk post-stroke patients for depression, especially females and Hispanics may be warranted.

Background: Patients with cerebral cavernous angiomas with symptomatic hemorrhage (CASH) have high risk of disability from recurrent bleeding. Candidate medications to prevent rebleeding in CASH lesions will require multisite clinical trials with standardized data collection. Objective: To report the prevalence and baseline cohort features in CASH patients and establish a research network infrastructure for trials. Methods: This prospective observational cohort study includes adults with radiologically verified CASH lesion within 1-year of consent. Exclusions include prior or planned surgical intervention, spinal location, or prior brain irradiation. Six sites enrolled patients into the screening and clinical assessment portion of the study starting July 2018. Patients also had the option to participate in the follow up biomarker validation at 4 sites. Baseline demographics, clinical and imaging information, and outcomes (mRS, PROMIS-29, NIHSS, and EuroQol-5D) were collected. Biomarker imaging included dynamic contrast enhanced quantitative perfusion (DCEQP) and quantitative susceptibility mapping (QSM) that correlated with symptomatic bleeding. Descriptive statistics were performed and one-sample t-test was used to compare whether mean T-scores for PROMIS-29 domains differed significantly from a reference population. Results: As of May 2020, 849 CASH patients were screened of whom 110 (13%) were eligible and enrolled; 73 also enrolled into the biomarker validation study. Average age at enrollment was 46±16 years at a mean of 4.4 months after symptom onset; 53% were female, 41% were familial, and 43% of CASH lesions were brainstem location. At enrollment, 90% of the cohort had independent functional outcome (mRS ≤ 2 and NIHSS 30% (EuroQol-5D). CASH cases had significantly worse anxiety but better depression and social satisfaction scores compared to a general population (all P Conclusion: We demonstrate feasibility of multisite recruitment of CASH patients and report prevalence of baseline features that will aid in design of clinical trials and inclusion of appropriate outcome measures.

Introduction: Diagnosis of cavernous angioma with symptomatic hemorrhage (CASH) requires MRI evidence of lesional bleeding associated directly with attributable symptoms. However, hemorrhagic signs of CASH may become clinically silent on conventional MRI after 3 months. As CASH is likely to rebleed for several years, accurate diagnosis of CASH that bled more than 3 months prior is needed. Hypothesis: Perfusion and permeability derivations of dynamic contrast-enhanced quantitative perfusion (DCEQP) MRI can diagnose CASH and predict bleeding/growth in CAs. Methods: CAs of 205 consecutively enrolled patients scanned with DCEQP during clinical visits were classified as CASH that bled 3 - 12 months prior (N = 55) versus non-CASH (N = 658) or CA with (N = 23) versus without (N = 721) bleeding/growth within a year after MRI. Demographics and 13 perfusion and 13 permeability derivations of DCEQP were assessed via machine learning and univariate analyses. Logistic regression models ln ( P / 1 - P ) = Σ (β i x i ) + β 0 were selected as the best diagnostic and prognostic biomarkers by minimizing the Bayesian information criterion (BIC). Results: The best diagnostic biomarker of CASH that bled 3 - 12 months prior (BIC = 321.6, Figure A) showed 80% sensitivity and 82% specificity. Permeability derivations did not add diagnostic efficacy when combined with perfusion. The best prognostic biomarker of bleeding/growth (BIC = 201.5, Figure B) showed 77% sensitivity and 72% specificity. Conclusion: Perfusion imaging may diagnose CASH even after hemorrhagic signs disappear on conventional MRI. A combination of permeability and perfusion derivations may help predict bleeding/growth in CAs.

Introduction: There is a current need for sensitive and specific biomarkers of Cerebral Cavernous Malformation (CCM) that can be readily translated from preclinical to human models to accurately diagnose and monitor disease states and response to novel therapeutics. MiRNAs are small non-coding RNAs that influence gene expression and whose levels can be affected by disease states. We hypothesize that there are human homologs of differentially expressed (DE) miRNA in the plasma of CCM murine models that can be identified in CCM patients. We further hypothesize that these miRNAs have gene targets within previously published CCM transcriptomes, mechanistically linking them to CCM disease. Methods: Plasma miRNAs from homozygous and heterozygous Ccm1 and Ccm3 mice, as well as their respective wild type controls were sequenced and analyzed. Putative gene targets of DE miRNAs [pCcm1 and Ccm3 mouse models were identified and assessed in the plasma of healthy controls (n=13), CCM1 (n=11), and CCM3 (n=11) patients using RT-qPCR. Results: 5 miRNAs in homozygous and 10 in heterozygous for Ccm1 , while 45 in homozygous and 2 in heterozygous for Ccm3 were DE in the plasma of mouse models (pmmu-miR-375-3p as DE in both Ccm1 +/- and Ccm3 -/- mice. RT-qPCR assays show that plasma relative quantification values of the human homolog hsa-miR-375-3p were higher in CCM3 than in CCM1 patients ( p p Conclusion: DE plasma miRNAs identified in mouse models with human homologs and putative gene targets mechanistically implicated in CCM disease may be used as candidate biomarkers for specific clinical contexts.

Background The extent of intracerebral hemorrhage (ICH) removal conferred survival and functional benefits in the minimally invasive surgery with thrombolysis in intracerebral hemorrhage evacuation (MISTIE) III trial. It is unclear whether this similarly impacts outcome with craniotomy (open surgery) or whether timing from ictus to intervention influences outcome with either procedure. Objective To compare volume evacuation and timing of surgery in relation to outcomes in the MISTIE III and STICH (Surgical Trial in Intracerebral Hemorrhage) trials. Methods Postoperative scans were performed in STICH II, but not in STICH I; therefore, surgical MISTIE III cases with lobar hemorrhages (n = 84) were compared to STICH II all lobar cases (n = 259) for volumetric analyses. All MISTIE III surgical patients (n = 240) were compared to both STICH I and II (n = 722) surgical patients for timing analyses. These were investigated using cubic spline modeling and multivariate risk adjustment. Results End-of-treatment ICH volume ≤28.8 mL in MISTIE III and ≤30.0 mL in STICH II had increased probability of modified Rankin Scale (mRS) 0 to 3 at 180 d (P = .01 and P = .003, respectively). The effect in the MISTIE cohort remained significant after multivariate risk adjustments. Earlier surgery within 62 h of ictus had a lower probability of achieving an mRS 0 to 3 at 180 d with STICH I and II (P = .0004), but not with MISTIE III. This remained significant with multivariate risk adjustments. There was no impact of timing until intervention on mortality up to 47 h with either procedure. Conclusion Thresholds of ICH removal influenced outcome with both procedures to a similar extent. There was a similar likelihood of achieving a good outcome with both procedures within a broad therapeutic time window.

Cavernous angiomas (CA) are common vascular anomalies causing brain hemorrhage. Based on mouse studies, roles of gram-negative bacteria and altered intestinal homeostasis have been implicated in CA pathogenesis, and pilot study had suggested potential microbiome differences between non-CA and CA individuals based on 16S rRNA gene sequencing. We here assess microbiome differences in a larger cohort of human subjects with and without CA, and among subjects with different clinical features, and conduct more definitive microbial analyses using metagenomic shotgun sequencing. Relative abundance of distinct bacterial species in CA patients is shown, consistent with postulated permissive microbiome driving CA lesion genesis via lipopolysaccharide signaling, in humans as in mice. Other microbiome differences are related to CA clinical behavior. Weighted combinations of microbiome signatures and plasma inflammatory biomarkers enhance associations with disease severity and hemorrhage. This is the first demonstration of a sensitive and specific diagnostic microbiome in a human neurovascular disease., Gut microbiome has been linked to cavernous angioma (CA), a common vascular disease, but the role in humans remains unclear. Here, the authors combine 16S rRNA sequencing and shotgun metagenomics to profile the microbiome in a large cohort of human subjects with and without CA, and among subjects with different CA clinical features.

Brain senescence is associated with impaired endothelial barrier function, angiogenic and inflammatory activity, and propensity to brain hemorrhage. The same pathological changes occur in cerebral cavernous malformations (CCM), a genetic neurovascular anomaly. We hypothesized common transcriptomic and plasma cytokine signatures in the aging brain and CCM. We identified 320 genes [fold change ≥1.5; p

Introduction: Studies on the natural clinical course of Cavernous Angioma (CA) have reported a Methods: Patients with CA diagnosis were prospectively enrolled in IRB approved database from 09/2009 to 02/2019 (N=327). Imaging and clinical follow-up were recommended annually, or sooner with new symptoms. Patients with 1 or more CA with maximum diameter >4 mm on T2 MRI, not excised or irradiated, and 1 or more clinical/imaging follow-up were included (N=192). New AH and SH were assessed per prospectively articulated criteria, and rates were estimated per lesion-year and patient-year, and NLF in familial cases. Results: There were no demographic or disease confounders among cases included and excluded from the study cohort, except for higher rates of prior SH and greater prevalence of cases with solitary lesion excluded because of surgical treatment. Total follow-up was 410 patient-years (2539 lesion-years). During prospective follow-up, the rate of AH was higher than the rate of SH (12.9% vs. 7.5% per patient-year and 2.1% vs. 1.2% per lesion -year, p=0.02 and p=0.01 respectively). Patients presenting with SH in the prior year had higher rate of AH than those presenting incidentally or with seizures (19.83% and 8.2% per patient-year respectively; p=0.003). A higher rate of NLF on T2 (p=0.0002) and SWI (p=0.0004) was also observed in patients with prior SH compared to stable patients. After an AH, 3 of 6 sporadic patients with solitary lesion and only 2 of 28 familial cases with multiple lesions underwent surgical resection of the lesion with AH. Conclusions: Subclinical imaging changes are more common than SH during prospective follow-up of CAs. They are more common in patients presenting with prior SH, and likely reflect a more sensitive biomarker of CA instability. AH more likely provokes a surgical decision in cases with solitary lesion than in familial cases with multiple lesions.

Introduction: The Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation Phase III trial (MISTIE III) concluded that the extent of hematoma reduction confers a mortality and functional benefit. It is unclear if a minimum extent of evacuation is needed for mortality and functional outcome benefit in lobar cases with MISTIE and with open surgical interventions. Objective: We analyzed the effect of extent of lobar ICH evacuation on clinical outcome at 180 days after undergoing the MISTIE procedure and open craniotomy, in the context of the MISTIE III and STICH II clinical trials, respectively. Methods: Patients randomized to the surgical arm with lobar ICH, who underwent the procedure in the MISTIE III trial (n=84) and the STICH II trial (n=266) were analyzed, excluding cases crossing over to surgery. We assessed end of treatment ICH volume on post procedure CT scans and % hematoma evacuation, in relation to survival and likelihood of mRS 0-3. Cubic spline modeling with dichotomized outcome was used to compare the extent of hematoma evacuation on clinical outcome. Results: End of treatment volume of < 28 mL in lobar ICH MISTIE III patients and < 30 mL in STICH II trial patients showed a significantly increased probability of achieving an mRS of 0-3 at 180 days (p Conclusion: This analysis confirms that extent of hematoma evacuation is important in attaining the benefits of both minimally invasive and open surgical interventions in non-herniating lobar ICH patients randomized in clinical trials. Extent of ICH evacuation must be considered in the analysis of comparative effectiveness of various techniques and in the design of future trials.

Introduction: Completion of the MISTIE procedure requires a period of hematoma stability before and during hematoma removal and, if necessary, dosing of rtPA which can take days to complete. Early surgery was intended in the STICH I and II trials, yet was performed after varying delays. No previous analysis has evaluated the timing for hematoma removal on outcomes in these trials. Objective: Determine if time from ictus to completion of hematoma removal may have affected patient outcome in three large surgical clinical trials of ICH evacuation. Methods: Patients randomized to surgery in the MISTIE III (n=242), STICH I (n=464) and STICH II (n=266) trials who received the procedure were analyzed, excluding cases crossing over to surgery. Time from ictus to end of treatment, defined as 24 hours after last dose in (MISTIE III) or time to craniotomy (STICH I and II), was analyzed in relation to likelihood of survival and functional outcome at 180 days. Cubic spline models with dichotomized outcomes were used. Results: The probability of achieving an mRS 0-3 increased significantly with longer time until completion of the procedure, up to 83 hours post-ictus, and worsened with longer delays thereafter (p=0.05). Better mRS was also achieved in STICH I patients with longer time until surgical removal, up to 60 hours post-ictus (p=0.0002), but not with longer delays (p=0.49). In STICH II (lobar cases), there was greater likelihood of mRS 0-3 with longer delay after 22 hours post-ictus (p=0.004), but not with earlier surgery (p=0.19). There was no significant benefit in survival, with earlier intervention across modalities and trials. Adjustment by initial hematoma volume further validated that early procedures do not favor survival or achieving a mRS 0-3. Conclusion: Early hematoma evacuation up to 60-80 hours post-ictus does not increase the probability of survival nor a good functional outcome in non-herniating ICH patients included in clinical trials, likely in view of bleeding instability. This was true in minimally invasive intervention as well as open surgeries.

Background: Cellular senescence is associated with gene expression dysregulation affecting endothelial barrier function as well as angiogenic and inflammatory processes. These pathological changes occur in cerebral cavernous malformations (CCMs), a neurovascular anomaly predisposing patients to hemorrhagic stroke. We hypothesize common transcriptomic and biomarker signatures between the aging brain and CCMs. Method: Brain specific genes dysregulate in Younger (age < 30) and Older (age > 50) human brain parenchyma were identified using the Genotype-Tissue Expression database, and compared with differential transcriptome in microdissected neurovascular units of human CCM lesions. Brain white matter vascular permeability in areas devoid of lesions was measured in non-CCM (23 Younger, 27 Older), Sporadic-CCM (S-CCM) (26 Younger, 37 Older) and Familial-CCM (F-CCM) (41 Younger, 17 Older) using dynamic contrast-enhanced quantitative perfusion MRI. Plasma levels of 6 proteins with reported roles in CCMs were quantified, including VEGF, angiopoietin (ANG 1 & 2), CRP, thrombospondin 2 (THBS 2), and endoglin (ENG). All reported correlations were significant at P< 0.05, FDR corrected. Result: We identified 320 genes (absolute fold change≥1.5) commonly dysregulated in aging brain and CCM, related to inflammation and extracellular matrix organization pathways. Brain permeability was greater in Older non-CCM and S-CCM compared to Younger subjects. Brain permeability was higher in Younger F-CCM harboring germ line CCM mutations, than in both Younger non-CCM (p Conclusion: There are common transcriptomic, and brain permeability and plasma biomarker signatures in the aging brain and CCM, suggesting common dysregulated pathways. Biomarkers and potential therapies identified in a well characterized Mendelian neurovascular disease may be applicable to mitigate the same mechanistic aberrations in the aging brain.

Background More than a million Americans harbor a cerebral cavernous angioma (CA), and those who suffer a prior symptomatic hemorrhage have an exceptionally high rebleeding risk. Preclinical studies show that atorvastatin blunts CA lesion development and hemorrhage through inhibiting RhoA kinase (ROCK), suggesting it may confer a therapeutic benefit. Objective To evaluate whether atorvastatin produces a difference compared to placebo in lesional iron deposition as assessed by quantitative susceptibility mapping (QSM) on magnetic resonance imaging in CAs that have demonstrated a symptomatic hemorrhage in the prior year. Secondary aims shall assess effects on vascular permeability, ROCK activity in peripheral leukocytes, signal effects on clinical outcomes, adverse events, and prespecified subgroups. Methods The phase I/IIa placebo-controlled, double-blinded, single-site clinical trial aims to enroll 80 subjects randomized 1-1 to atorvastatin (starting dose 80 mg PO daily) or placebo. Dosing shall continue for 24-mo or until reaching a safety endpoint. Expected outcomes The trial is powered to detect an absolute difference of 20% in the mean percent change in lesional QSM per year (2-tailed, power 0.9, alpha 0.05). A decrease in QSM change would be a signal of potential benefit, and an increase would signal a safety concern with the drug. Discussion With firm mechanistic rationale, rigorous preclinical discoveries, and biomarker validations, the trial shall explore a proof of concept effect of a widely used repurposed drug in stabilizing CAs after a symptomatic hemorrhage. This will be the first clinical trial of a drug aimed at altering rebleeding in CA.

Incidence of catheter tract hemorrhage (CTH) after initial ventriculostomy placement ranges from 10 to 34%. We investigated CTH incidence in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III trial. Prospective observational analysis of 1000 computer tomography (CT) scans from all 500 patients enrolled in the trial. All catheters were evaluated on first CT post-placement and on last CT prior to randomization for placement location and CTH size, location, and severity. Clinical variables were assessed for association with CTH with multivariable logistic regression. Of 563 catheters, CTH was detected in 14 and 21% of patients on first and last CT (median 3.7 and 43.4 h after catheter placement, respectively). All, but one were asymptomatic. Majority of CTH (86%) occurred within 24 h after placement, were located within 1 cm of the skull, and had at least one diameter > 5 mm. Most catheters (71%) terminated in the third or lateral ventricle ipsilateral to insertion site. Factors significantly associated with CTH were pre-admission use of antiplatelet drugs, accuracy of catheter placement, non-operating room catheter placement, Asian race, and intraventricular hemorrhage expansion. CTH incidence on initial catheter placement and during stabilization was relatively low, despite emergent placement in a high-risk population. Catheter placement accuracy was similar or better than convenience samples from the published literature. Decreasing risk of CTH may be achieved with attention to catheter placement accuracy and placement in the operating room. Antiplatelet agent use was an independent risk factor for CTH.

Background As intraventricular thrombolysis for intraventricular hemorrhage (IVH) has developed over the last 2 decades, hemorrhagic complications have remained a concern despite general validation of its safety in controlled trials in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-IVH) program. Objective To analyze factors associated with symptomatic bleeding following IVH with and without thrombolysis in conjunction with the recently completed CLEAR III trial. Methods We reviewed safety reports on symptomatic bleeding events reported during the first year after randomization among subjects enrolled in the CLEAR III trial. Clinical and imaging data were retrieved through the trial database as part of ongoing quality and safety monitoring. A posthoc root-cause analysis was performed to identify potential factors predisposing to rebleeding in each case. Cases were classified according to onset of rebleeding (during dosing, early after dosing and delayed), the pattern of bleeding, and treatment rendered (alteplase vs saline). Results Twenty subjects developed a secondary symptomatic intracranial hemorrhage constituting 4% of subjects. Symptomatic rebleeding events occurred during the dosing protocol (n = 9, 67% alteplase), early after the protocol (n = 5, 40% alteplase), and late (n = 6, 0% alteplase). Catheter-related hemorrhages were the most common (n = 7, 35%) followed by expansion or new intraventricular (n = 6, 30%) and intracerebral (n = 5, 25%) hemorrhages. Symptomatic hemorrhages during therapy resulted from a combination of treatment- and patient-related factors and were at most partially attributable to alteplase. Rebleeding after the dosing protocol primarily reflected patients' risk factors. Conclusion Intraventricular thrombolysis marginally increases the overall risk of symptomatic hemorrhagic complications after IVH, and only during the treatment phase.

Background Cerebral cavernous angioma (CA) is a capillary microangiopathy predisposing more than a million Americans to premature risk of brain hemorrhage. CA with recent symptomatic hemorrhage (SH), most likely to re-bleed with serious clinical sequelae, is the primary focus of therapeutic development. Signaling aberrations in CA include proliferative dysangiogenesis, blood-brain barrier hyperpermeability, inflammatory/immune processes, and anticoagulant vascular domain. Plasma levels of molecules reflecting these mechanisms and measures of vascular permeability and iron deposition on magnetic resonance imaging are biomarkers that have been correlated with CA hemorrhage. Objective To optimize these biomarkers to accurately diagnose cavernous angioma with symptomatic hemorrhage (CASH), prognosticate the risk of future SH, and monitor cases after a bleed and in response to therapy. Methods Additional candidate biomarkers, emerging from ongoing mechanistic and differential transcriptome studies, would further enhance the sensitivity and specificity of diagnosis and prediction of CASH. Integrative combinations of levels of plasma proteins and characteristic micro-ribonucleic acids may further strengthen biomarker associations. We will deploy advanced statistical and machine learning approaches for the integration of novel candidate biomarkers, rejecting noncorrelated candidates, and determining the best clustering and weighing of combined biomarker contributions. Expected outcomes With the expertise of leading CA researchers, this project anticipates the development of future blood tests for the diagnosis and prediction of CASH to clinically advance towards precision medicine. Discussion The project tests a novel integrational approach of biomarker development in a mechanistically defined cerebrovascular disease with a relevant context of use, with an approach applicable to other neurological diseases with similar pathobiologic features.

Objective We hypothesize that procedure deployment rates and technical performance with minimally invasive surgery and thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE) can be enhanced in post-trial clinical practice, per Phase III trial results and lessons learned. Materials and Methods We identified ICH patients and those who underwent MISTIE procedure between 2017–2021 at a single site, after completed enrollments in the Phase III trial. Deployment rates, complications and technical outcomes were compared to those observed in the trial. Initial and final hematoma volume were compared between site measurements using ABC/2, MISTIE trial reading center utilizing manual segmentation, and a novel Artificial Intelligence (AI) based volume assessment. Results Nineteen of 286 patients were eligible for MISTIE. All 19 received the procedure (6.6% enrollment to screening rate 6.6% compared to 1.6% at our center in the trial; p=0.0018). Sixteen patients (84%) achieved evaculation target 70% removal, compared to 59.7% in the trial surgical cohort (p=0.034). No poor catheter placement occurred and no surgical protocol deviations. Limitations of ICH volume assessments using the ABC/2 method were shown, while AI based methodology of ICH volume assessments had excellent correlation with manual segmentation by experienced reading centers. Conclusions Greater procedure deployment and higher technical success rates can be achieved in post-trial clinical practice than in the MISTIE III trial. AI based measurements can be deployed to enhance clinician estimated ICH volume. Clinical outcome implications of this enhanced technical performance cannot be surmised, and will need assessment in future trials.

BACKGROUND Minimally invasive thrombolytic evacuation of intracerebral hematoma is being investigated in the ongoing phase III clinical trial of Minimally Invasive Surgery plus recombinant Tissue plasminogen activator for Intracerebral hemorrhage Evacuation (MISTIE III). OBJECTIVE To assess the accuracy of catheter placement and efficacy of hematoma evacuation in relation to surgical approach and surgeon experience. METHODS We performed a trial midpoint interim assessment of 123 cases that underwent the surgical procedure. Accuracy of catheter placement was prospectively assessed by the trial Surgical Center based on prearticulated criteria. Hematoma evacuation efficacy was evaluated based on absolute volume reduction, percentage hematoma evacuation, and reaching the target end-of-treatment volume of

Background Quantitative susceptibility mapping (QSM) and dynamic contrast-enhanced quantitative permeability (DCEQP) on magnetic resonance (MR) have been shown to correlate with neurovascular disease progression as markers of vascular leakage and hemosiderin deposition. Applying these techniques as monitoring biomarkers in clinical trials will be necessary; however, their validation across multiple MR platforms and institutions has not been rigorously verified. Purpose To validate quantitative measurement of MR biomarkers on multiple instruments at different institutions. Study type Phantom validation between platforms and institutions. Phantom model T1 /susceptibility phantom, two-compartment dynamic flow phantom. Field strength/sequence 3T/QSM, T1 mapping, dynamic 2D SPGR. Assessment Philips Ingenia, Siemens Prisma, and Siemens Skyra at three different institutions were assessed. A QSM phantom with concentrations of gadolinium, corresponding to magnetic susceptibilities of 0, 0.1, 0.2, 0.4, and 0.8 ppm was assayed. DCEQP was assessed by measuring a MultiHance bolus as the consistency of the width ratio of the curves at the input and outputs over a range of flow ratios between outputs. Statistical tests Each biomarker was assessed by measures of accuracy (Pearson correlation), precision (paired t-test between repeated measurements), and reproducibility (analysis of covariance [ANCOVA] between instruments). Results QSM accuracy of r2 > 0.997 on all three platforms was measured. Precision (P = 0.66 Achieva, P = 0.76 Prisma, P = 0.69 Skyra) and reproducibility (P = 0.89) were good. T1 mapping of accuracy was r2 > 0.98. No significant difference between width ratio regression slopes at site 2 (P = 0.669) or site 3 (P = 0.305), and no significant difference between width ratio regression slopes between sites was detected by ANCOVA (P = 0.48). Data conclusion The phantom performed as expected and determined that MR measures of QSM and DCEQP are accurate and consistent across repeated measurements and between platforms. Level of evidence 1 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2020;51:1192-1199.

Background Brain cavernous angiomas with symptomatic hemorrhage (CASH) are uncommon but exact a heavy burden of neurological disability from recurrent bleeding, for which there is no proven therapy. Candidate drugs to stabilize the CASH lesion and prevent rebleeding will ultimately require testing of safety and efficacy in multisite clinical trials. Much progress has been made in understanding the epidemiology of CASH, and novel biomarkers have been linked to the biological mechanisms and clinical activity in lesions. Yet, the ability to enroll and risk-stratify CASH subjects has never been assessed prospectively at multiple sites. Biomarkers and other outcomes have not been evaluated for their sensitivity and reliability, nor have they been harmonized across sites. Objective To address knowledge gaps and establish a research network as infrastructure for future clinical trials, through the Trial Readiness grant mechanism, funded by National Institute of Neurological Disorders and Stroke/National Institutes of Health. Methods This project includes an observational cohort study to assess (1) the feasibility of screening, enrollment rates, baseline disease categorization, and follow-up of CASH using common data elements at multiple sites, (2) the reliability of imaging biomarkers including quantitative susceptibility mapping and permeability measures that have been shown to correlate with lesion activity, and (3) the rates of recurrent hemorrhage and change in functional status and biomarker measurements during prospective follow-up. Expected outcomes We propose a harmonized multisite assessment of enrollment rates of CASH, baseline features relevant to stratification in clinical trials, and follow-up assessments of functional outcomes in relation to clinical bleeds. We introduce novel biomarkers of vascular leak and hemorrhage, with firm mechanistic foundations, which have been linked to clinical disease activity. We shall test their reliability and validity at multiple sites, and assess their changes over time, with and without clinical rebleeds, hence their fitness as outcome instruments in clinical trials. Discussion The timing cannot be more opportune, with therapeutic targets identified, exceptional collaboration among researchers and the patient community, along with several drugs ready to benefit from development of a path to clinical testing using this network in the next 5 years.

Acute stroke due to supratentorial intracerebral haemorrhage is associated with high morbidity and mortality. Open craniotomy haematoma evacuation has not been found to have any benefit in large randomised trials. We assessed whether minimally invasive catheter evacuation followed by thrombolysis (MISTIE), with the aim of decreasing clot size to 15 mL or less, would improve functional outcome in patients with intracerebral haemorrhage. MISTIE III was an open-label, blinded endpoint, phase 3 trial done at 78 hospitals in the USA, Canada, Europe, Australia, and Asia. We enrolled patients aged 18 years or older with spontaneous, non-traumatic, supratentorial intracerebral haemorrhage of 30 mL or more. We used a computer-generated number sequence with a block size of four or six to centrally randomise patients to image-guided MISTIE treatment (1·0 mg alteplase every 8 h for up to nine doses) or standard medical care. Primary outcome was good functional outcome, defined as the proportion of patients who achieved a modified Rankin Scale (mRS) score of 0-3 at 365 days, adjusted for group differences in prespecified baseline covariates (stability intracerebral haemorrhage size, age, Glasgow Coma Scale, stability intraventricular haemorrhage size, and clot location). Analysis of the primary efficacy outcome was done in the modified intention-to-treat (mITT) population, which included all eligible, randomly assigned patients who were exposed to treatment. All randomly assigned patients were included in the safety analysis. This study is registered with ClinicalTrials.gov, number NCT01827046. Between Dec 30, 2013, and Aug 15, 2017, 506 patients were randomly allocated: 255 (50%) to the MISTIE group and 251 (50%) to standard medical care. 499 patients (n=250 in the MISTIE group; n=249 in the standard medical care group) received treatment and were included in the mITT analysis set. The mITT primary adjusted efficacy analysis estimated that 45% of patients in the MISTIE group and 41% patients in the standard medical care group had achieved an mRS score of 0-3 at 365 days (adjusted risk difference 4% [95% CI -4 to 12]; p=0·33). Sensitivity analyses of 365-day mRS using generalised ordered logistic regression models adjusted for baseline variables showed that the estimated odds ratios comparing MISTIE with standard medical care for mRS scores higher than 5 versus 5 or less, higher than 4 versus 4 or less, higher than 3 versus 3 or less, and higher than 2 versus 2 or less were 0·60 (p=0·03), 0·84 (p=0·42), 0·87 (p=0·49), and 0·82 (p=0·44), respectively. At 7 days, two (1%) of 255 patients in the MISTIE group and ten (4%) of 251 patients in the standard medical care group had died (p=0·02) and at 30 days, 24 (9%) patients in the MISTIE group and 37 (15%) patients in the standard medical care group had died (p=0·07). The number of patients with symptomatic bleeding and brain bacterial infections was similar between the MISTIE and standard medical care groups (six [2%] of 255 patients vs three [1%] of 251 patients; p=0·33 for symptomatic bleeding; two [1%] of 255 patients vs 0 [0%] of 251 patients; p=0·16 for brain bacterial infections). At 30 days, 76 (30%) of 255 patients in the MISTIE group and 84 (33%) of 251 patients in the standard medical care group had one or more serious adverse event, and the difference in number of serious adverse events between the groups was statistically significant (p=0·012). For moderate to large intracerebral haemorrhage, MISTIE did not improve the proportion of patients who achieved a good response 365 days after intracerebral haemorrhage. The procedure was safely adopted by our sample of surgeons. National Institute of Neurological Disorders and Stroke and Genentech. [Abstract copyright: Copyright © 2019 Elsevier Ltd. All rights reserved.]

Background: Cerebral cavernous malformation is a genetic neurovascular disorder causing aberrant angiogenesis and lesion development within capillary beds. Lesions exhibit impaired endothelial barrier function, causing blood-brain barrier leakage and hemorrhage. Quantitative MRI biomarkers (dynamic contrast-enhanced quantitative permeability (DCEQP) and quantitative susceptibility mapping (QSM)) have been shown to correlate with CCM disease progression as measures of barrier leakage and hemorrhagic iron deposition, and there is interest in utilizing these biomarkers as endpoints in clinical trials. However, their consistencies across multiple platforms and institutions has not yet been rigorously verified. Materials and Methods: Instruments used were a 3T Philips Ingenia at University of Chicago and a 3T Siemens Prisma at Northwestern University. QSM was assessed by five balloons filled with varying concentrations of MultiHance, corresponding to magnetic susceptibilities of 0, 0.1, 0.2, 0.4, and 0.8, surrounded by an agarose gel. Permeability was assessed by the injection of a bolus of MultiHance through a coiled hose inside a water-filled shell, and the consistency of the peak-to-peak ratio of the curves at the input and output was measured. Each biomarker was assessed by accuracy (to expected values, Pearson correlation), precision (between repeated measurements, paired t-test), and reproducibility (between instruments, paired t-test). Results: QSM measured with an accuracy of r 2 = 0.997 on the Philips Achieva and r 2 = 0.999 on the Siemens Prisma. Each scanner had adequate precision between measurements, showing no significant difference by a paired t-test (p = 0.66 Achieva, p = 0.45 Prisma), and the reproducibility between scanners also showed no significant difference (p = 0.89). The peak-to-peak ratio on DCEQP scans was accurate (r 2 = 0.998), precise between measurements (p = 0.54), and repeatable between instruments (p = 0.49). Conclusion: Quantitative imaging biomarkers DCEQP and QSM are accurate, consistent across multiple measurements, and between platforms and will be useful for future clinical trials in CCM.

Background: Cerebral cavernous malformation (CCM) patients have lesions comprised of dilated capillaries in the brain. Despite the knowledge that mutations of three CCM genes can cause this disease, other genetic and environmental factors that contribute to lesion formation are likely given the highly variable disease expression. Genome-wide association studies in CCM cohorts and mouse models of CCM, both point to a role of lipopolysaccharide. Mouse studies have shown that the microbiome, particularly Gram-negative bacteria, drive CCM lesion development. These data point to a possibility that CCM disease is affected by the gut microbiome. In this study, we investigated if human CCM disease could be linked to the gut microbiome. Methods: Fecal samples from 88 CCM patients, from four sites, were assayed using 16S rRNA gene sequencing. Following taxonomic classification by exact sequence variant analysis (ESV) using DeBlur, microbiome composition was compared with those of a reference non-CCM population (n=348), or between subgroups of CCM patients based on clinical data elements. Results: Analyses of microbiome composition statistics identified bacterial ESVs belonging to Clostridiales , Lachnospiraceae, Ruminococcaceae , and the genus Bacteroides that were significantly enriched in CCM patients compared to healthy controls. Within our CCM cohort, patients with germline CCM mutations had stool-associated enrichment of ESVs annotated to Clostridiales, and the genera Bacteroides and Prevotella , when compared to sporadic CCM patients, while patients with CCM1 and CCM2 mutations had different proportions of Clostridiales, Lachnospiraceae, and the genus Ruminococcus . Furthermore, Lachnospiraceae and Bacteroides proportions differentiated disease aggressiveness (All p Conclusions: These data are the first to show that CCM patients have a distinct microbiome signature. Germline mutation and disease aggressiveness can correlate with further unique microbiome composition. This study supports further investigation into the mechanistic link between CCM disease and the microbiome. This will enhance our understanding of the brain-gut axis in CCM disease and the use of microbiome as a therapeutic target.

Introduction: Cerebral cavernous angiomas with a documented symptomatic hemorrhage (CASH) are associated with an exceptionally high risk of recurrent hemorrhage and serious morbidity. It is unclear if peripheral blood plasma biomarkers implicated in disease biology can differentiate CASH, and whether the same or different biomarkers can distinguish cases who would rebleed. Methods: Eighteen plasma molecules with postulated mechanistic roles in this disease were quantified in 114 patients and 12 healthy subjects. The best biomarker combination differentiating CASH in the prior year (+/- 30 days) was derived by minimizing the Akaike Information Criterion (AIC), and was validated using statistical and machine-learning simulations. This was compared to the biomarker predicting bleeding in the subsequent year (+/- 30 days), and both explanatory and predictive biomarkers were followed longitudinally in a subset of cases. Results: Nine plasma molecules had significantly different levels expressed in CASH patients (p Conclusions: Our results suggest shared and unique biomarkers of recent symptomatic hemorrhage and of future bleeding in cavernous angiomas. This may be applied for risk stratification in clinical trials, and potentially developed as a tool in clinical practice.

Rationale: The clinical course of cerebral cavernous malformations is highly unpredictable, with few cross-sectional studies correlating proinflammatory genotypes and plasma biomarkers with prior disease severity. Objective: We hypothesize that a panel of 24 candidate plasma biomarkers, with a reported role in the physiopathology of cerebral cavernous malformations, may predict subsequent clinically relevant disease activity. Methods and Results: Plasma biomarkers were assessed in nonfasting peripheral venous blood collected from consecutive cerebral cavernous malformation subjects followed for 1 year after initial sample collection. A first cohort (N=49) was used to define the best model of biomarker level combinations to predict a subsequent symptomatic lesional hemorrhagic expansion within a year after the blood sample. We generated the receiver operating characteristic curves and area under the curve for each biomarker individually and each weighted linear combination of relevant biomarkers. The best model to predict lesional activity was selected as that minimizing the Akaike information criterion. In this cohort, 11 subjects experienced symptomatic lesional hemorrhagic expansion (5 bleeds and 10 lesional growths) within a year after the blood draw. Subjects had lower soluble CD14 (cluster of differentiation 14; P =0.05), IL (interleukin)-6 ( P =0.04), and VEGF (vascular endothelial growth factor; P =0.0003) levels along with higher plasma levels of IL-1β ( P =0.008) and soluble ROBO4 (roundabout guidance receptor 4; P =0.03). Among the 31 weighted linear combinations of these 5 biomarkers, the best model (with the lowest Akaike information criterion value, 25.3) was the weighted linear combination including soluble CD14, IL-1β, VEGF, and soluble ROBO4, predicting a symptomatic hemorrhagic expansion with a sensitivity of 86% and specificity of 88% (area under the curve, 0.90; P Conclusions: This is the first study reporting a predictive association between plasma biomarkers and subsequent cerebral cavernous malformation disease clinical activity. This may be applied in clinical prognostication and stratification of cases in clinical trials.

Introduction: The clinical course of cerebral cavernous malformations (CCMs) is highly unpredictable, with a limited number of cross sectional studies correlating pro-inflammatory genotypes and plasma biomarkers with prior disease severity. We hereby hypothesize that a panel of plasma biomarkers, with reported role in the physiopathology of CCM, may predict subsequent clinically relevant disease activity. Methods: This was a single-site prospective observational cohort study, without planned intervention. Non-fasting peripheral venous blood samples from 55 patients (25 with sporadic and 30 with familial CCM) were collected. Twenty-four plasma biomarkers were quantified and analyzed regarding their predictive association with the occurrence of a symptomatic hemorrhage or lesional growth within a year following the blood sample. We generated the receiver operating characteristic (ROC) curves and area under curves (AUC) for each biomarker individually and for each weighted linear combination of relevant biomarkers. The best model to predict lesional activity was selected as that minimizing the Akaike Information Criterion (AIC), representing parsimonious model offering the best fit to the data with the fewest number of predictors. Results: Eleven patients experienced lesional activity events (5 symptomatic bleeds and 10 lesional growths) within a year after the blood draw. These patients had lower levels of CD14 (p=0.05), IL6 (p=0.04), ROBO4 (p=0.03) and VEGF (p=0.0003), along with higher IL1β (p=0.008) plasma levels. Among the 35 weighted linear combinations of these 5 biomarkers, the best model (with the lowest AIC value=25.3), was the combination including CD14, IL1β, VEGF and ROBO4, predicting a symptomatic bleed or lesional growth with a sensitivity of 86% and specificity of 88% (AUC=0.90, p Conclusion: This is the first study reporting a predictive association between plasma biomarkers and subsequent CCM disease clinical activity. This may be applied in clinical prognostication, and in the stratification of cases in clinical trials.

Retrospective series report varied rates of bleeding and infection with external ventricular drainage (EVD). There have been no prospective studies of these risks with systematic surveillance, threshold definitions, or independent adjudication.To analyze the rate of complications in the ongoing Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) trial, providing a comparison with a systematic review of complications of EVD in the literature.Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software.Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis.Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to60 trial sites.

Objective:To investigate the temporal pattern and relevant associations of CSF inflammatory measures after intraventricular hemorrhage (IVH).Methods:We analyzed prospectively collected CSF cell counts and protein and glucose levels from participants in the Clot Lysis Evaluation of Accelerated Resolution of IVH phase III (CLEAR III) trial. Corrected leukocyte count and cell index were calculated to adjust for CSF leukocytes attributable to circulating blood. Data were chronologically plotted. CSF inflammatory measures (daily, mean, median, maximum, and cases with highest quartile response) were correlated with initial IVH volume, IVH clearance rate, thrombolytic treatment, bacterial infection, and adjudicated clinical outcome at 30 and 180 days.Results:A total of 11,376 data points of CSF results from 464 trial participants were analyzed. Measures of CSF inflammatory response evolved during the resolution of IVH. This was significantly more pronounced with initial IVH volume exceeding 20 mL. Intraventricular alteplase was associated with a significantly augmented inflammatory response compared to saline, even after correcting for initial IVH volume. There was an association but nonpredictive correlation of CSF inflammation measures with culture-positive CSF bacterial infection. None of the CSF inflammatory measures, including cases with upper quartile inflammatory response, was associated with a significant detrimental effect on 30 or 180 days functional outcome or mortality after multivariate adjustment for measures of disease severity.Conclusions:Aseptic CSF inflammation after IVH is primarily dependent on the volume of initial bleed. Thrombolysis intensifies the inflammatory response, with no apparent detrimental effect on clinical outcome.Clinicaltrials.gov identifier:NCT00784134.

BACKGROUND: Quantitative Susceptibility Mapping (QSM) MRI allows accurate assessment of iron content in cerebral cavernous malformations (CCM), and a threshold increase by ≥6% in QSM has been shown to reflect new symptomatic hemorrhage (SH) in previously stable lesions. PURPOSE/HYPOTHESIS: It is unclear how lesional QSM evolves in CCMs after recent SH, and whether this could serve as a monitoring biomarker in clinical trials aimed at preventing rebleeding in these lesions. STUDY TYPE: This is a prospective observational cohort study. POPULATION: 16 CCM patients who experienced a SH within the past year, whose lesion was not resected or irradiated. FIELD STRENGTH/SEQUENCE: The data acquisition was performed using QSM sequence implemented on a 3T MRI system. ASSESSMENT: The lesional QSM assessments at baseline and yearly during 22 patient-years of follow-up were performed by a trained research staff including imaging scientists. STATISTICAL TESTS: Biomarker changes were assessed in relation to clinical events. Clinical trial modeling was performed using two-tailed tests of time-averaged difference (assuming within-patient correlation of 0.8, power = 0.9 and alpha = 0.1) to detect 20%, 30% or 50% effects of intervention on clinical and biomarkers event rates during two years of follow-up. RESULTS: The change in mean lesional QSM of index hemorrhagic lesions was +7.93% per patient-year in the whole cohort. There were 5 cases (31%) of recurrent SH or lesional growth, and twice as many instances (62%) with a threshold (≥6%) increase in QSM. There were no instances of SH hemorrhage or lesional growth without an associated threshold increase in QSM during the same epoch. DATA CONCLUSION: We report novel biomarker changes which are sensitive to and twice as common as recurrent SH or lesional growth during follow-up of CCMs after recent bleed. The frequency of threshold QSM increase, or mean lesional QSM change per epoch may serve as monitoring biomarkers of CCM hemorrhage, reducing sample size requirements for proof of effect of novel therapies and enhancing the efficiency of clinical trials.