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Introduction Acute large vessel occlusion (LVO) can be secondary to thromboembolism or intracranial atherosclerotic disease (ICAD). Data on LVO management due to underlying ICAD are scarce. We hypothesized that patients with ICAD have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between January 14, 2018 and October 24, 2021. Presence of ICAD at LVO site was determined by the interventionalist. We compared in‐hospital mortality, 90‐day mortality, and 90‐day modified Rankin Scale (mRS) scores between those with and without ICAD, in unadjusted and adjusting logistic regression models. Results Among 215 patients (mean age 67.1±16.0 years; 60.5% female; 80.5% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥ 2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.054). In‐hospital and 90‐day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0–2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in‐hospital mortality (OR = 4.1, 95% CI 1.7‐9.7), 90‐day mortality (OR = 3.7, 95% CI 1.6‐8.6), and poor functional outcome at 90 days (OR = 5.5, 95% CI 1.6‐19.4). Conclusions Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT. Further research is warranted to understand factors associated with worse outcomes and investigate alternative interventional approaches and medical management in this high‐risk population.

BackgroundFamilial cerebral cavernous alformation (CCM) is an autosomal dominant disease caused by mutations inKRIT1,CCM2, orPDCD10. Cases typically present with multiple lesions, strong family history, and neurological symptoms, including seizures, headaches, or other deficits. Intracranial hemorrhage (ICH) is a severe manifestation of CCM, which can lead to death or long‐term neurological deficits. Few studies have reported ICH rates and risk factors in familial CCM. We report ICH rates and assess whether CCM lesion burden, a disease severity marker, is associated with risk of symptomatic ICH during follow‐up in a well‐characterized cohort of familial CCM cases.Methods and ResultsWe studied 386 patients with familial CCM with follow‐up data enrolled in the Brain Vascular Malformation Consortium CCM Project. We estimated symptomatic ICH rates overall and stratified by history of ICH before enrollment. CCM lesion burden (total lesion count and large lesion size) assessed at baseline enrollment was tested for association with increased risk of subsequent ICH during follow‐up using Cox regression models adjusted for history of ICH before enrollment, age, sex, and family structure and stratified on recruitment site. The symptomatic ICH rate for familial CCM cases was 2.8 per 100 patient‐years (95% CI, 1.9–4.1). Those with ICH before enrollment had a follow‐up ICH rate of 4.5 per 100 patient‐years (95% CI, 2.6–8.1) compared with 2.0 per 100 patient‐years (95% CI, 1.3–3.5) in those without (P=0.042). Total lesion count was associated with increased risk of ICH during follow‐up (hazard ratio [HR], 1.37 per doubling of total lesion count [95% CI, 1.10–1.71],P=0.006).The symptomatic ICH rate for familial CCM cases was 2.8 per 100 patient‐years (95% CI, 1.9–4.1). Those with ICH before enrollment had a follow‐up ICH rate of 4.5 per 100 patient‐years (95% CI, 2.6–8.1) compared with 2.0 per 100 patient‐years (95% CI, 1.3–3.5) in those without (P=0.042). Total lesion count was associated with increased risk of ICH during follow‐up (hazard ratio [HR], 1.37 per doubling of total lesion count [95% CI, 1.10–1.71],P=0.006).ConclusionsPatients with familial CCM with prior history of an ICH event are at higher risk for rehemorrhage during follow‐up. In addition, total CCM lesion burden is significantly associated with increased risk of subsequent symptomatic ICH; hence lesion burden may be an important predictor of patient outcome and aid patient risk stratification.

Introduction: Bayesian analyses provide meaningful interpretations of clinical trial data in terms of probabilities of treatment effect. This extends the value of results beyond that obtained from traditional binary cut offs. Such interpretations provide actionable information for conditions with high mortality and no proven treatments, such as intracerebral hemorrhage (ICH). Methods: The minimally invasive surgery with thrombolysis in ICH evacuation (MISTIE 3) trial randomized 506 adults with spontaneous, supratentorial ICH of ≥ 30mL to receive either MISTIE intervention or standard medical care. Using reference priors (minimally informative, enthusiastic, skeptical) and a MISTIE 2-derived prior, we estimated probabilities that the effect of MISTIE intervention exceeds pre-specified thresholds of relative risks (RR) for achieving a 365-day Modified Rankin Scale (mRS) score of 0-3. We also computed the effects of MISTIE intervention on 180 and 30-day mRS and 365, 180 and 30-day mortality. Results: Using a minimally informative prior, the posterior probability of MISTIE intervention having any beneficial effect (RR > 1) on 365-day mRS was 70%. The probabilities of observing RR > 1.02 and > 1.10 were 63% and 34%, respectively. The probabilities of observing RR > 1, 1.02 and 1.10, with other priors are: 87%, 82% and 55% (enthusiastic); 68%, 60% and 30% (skeptical); and 73%, 66% and 38% (MISTIE 2-derived). The probabilities that MISTIE intervention has any beneficial effect on 180 and 30-day mRS, and 365, 180, and 30-day mortality are 65%,80%, 93%, 98% and 99%, respectively. RR, 95% credible intervals across various priors are shown in Figure. Conclusions: The probability that the MISTIE intervention has a favorable functional outcome at 365-days among ICH patients is 68 to 87%. Bayesian-derived probabilities of treatment effect may facilitate shared decision making in ICH management, above and beyond p-value-based frequentist interpretation of trial results.

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 microbleeds (CMBs) are manifestations of age-related microangiopathies associated with an increased risk of hemorrhagic stroke and cognitive decline. The pathophysiology of this age-related breakdown of the neurovascular unit remain unclear. Understanding CMB cellular architecture is needed for gene, pathway, and mechanism analyses, to pave the way for biomarker and therapeutic development. Herein, we aim to systematically describe histopathological changes in the CMB lesional milieu. Methods: Eight CMBs, along with contralateral non-lesional tissue, were identified by gross appearance at autopsy by a neuropathologist. Samples were first stained with H&E, then Prussian blue for non-heme iron, to localize the lesion. This was followed by multiplex fluorescence staining of β-amyloid and individual cell types including astrocytes (GFAP + ), macrophages (CD163 + /Iba1 + ), microglia (CD163 - /Iba1 + ), B-cells (CD20 + ), T-cells (CD3 + ), and endothelium (CD31 + ). The cell types within the lesional milieu, defined as 200μm from the periphery of the CMB, were quantified using QuPath. Astrocyte and microglia morphology were assessed via fluorescence imaging. Results: One CMB contained dilated capillaries, 2 contained lipohyalinized arterioles, and 4 contained dystrophic arterioles due to amyloid angiopathy. Astrocytes and macrophages showed higher normalized cell counts in all CMB tissues compared with controls ( p and p , respectively). Astrocytes in 7 of 8 CMB milieux showed reactive morphological changes, including larger cell bodies with peripheral nuclei. Microglia had higher normalized cell counts in 4 CMB tissues, with senescence-associated amoeboid, as well as ramified, reactive morphologies. The lesional milieu also showed higher counts of B-cells in 7 CMB tissues and T-cells in 3 CMB tissues when compared with controls. Conclusions: We provide the first description of the cellular architecture of the CMB and the associated lesional milieu. Despite heterogeneity of disrupted vasculature, there are common features of glial reactive changes and inflammation in CMBs. These results offer a basis for additional study of the CMB transcriptome and individual roles of respective cell types in CMB pathology.

Introduction: Currently, the modified Rankin scale (mRS) is most commonly used to assess functional outcome in clinical trials of interventions for spontaneous intracerebral hemorrhage (ICH). Extended Glasgow Outcome Score (eGOS) is often used to assess global disability/recovery after traumatic brain injury and provides additional discrimination of vegetative state (VS) from lower severe disability (LSD). We compared primary outcomes from 2 clinical trials of minimally invasive surgery for intracerebral and intraventricular hemorrhage (ICH/IVH) at different thresholds of eGOS. Methods: Post-hoc analysis of primary outcomes (PO) from the CLEAR-III trial (intraventricular alteplase [IVtPA] vs. saline for obstructive IVH; N=500; PO: mRS 0-3 at day 180), and MISTIE-III trial (stereotactic thrombolysis [MIS+tPA] vs. conservative management; N=499; PO: mRS 0-3 at day 365). eGOS was derived from functional outcome scales obtained during the trials. Outcomes on eGOS were categorized into 5 subgroups: good outcomes: 7-8 (A), 5-6 (B), 4 (C), and poor outcomes: 3 (D), and 1-2 (E). Generalized, ordered logistic regression analysis was performed, adjusting for age, ICH location, stability ICH and IVH volumes, and randomization GCS. Results: eGOS scales were available in 481 (96%) patients at day 180 in CLEAR-III and 478 (96%) patients at day 365 in MISTIE-III. In CLEAR-III, odds of being in eGOS category D (LSD) or E (death or VS) vs. the others, were approximately 40% lower for IVtPA group compared to saline group (aOR = 0.59; 95% CI, 0.38-0.90; p=0.016), and odds of being in category E (vs. the others) were almost 50% lower (aOR = 0.51; 95% CI, 0.33-0.80; p=0.004). VS occurred in 2.49% of IVtPA and 2.07% of saline group patients. In MISTIE-III, odds of being in eGOS category D or E (vs. the others) were not significantly different for MIS+tPA vs. conservative treatment: aOR = 0.84; 95% CI, 0.55-1.28; p=0.41), as were odds for being in eGOS category E (vs. the others), aOR = 0.77; 95% CI, 0.48-1.24; p=0.29). Conclusions: The 5-category dichotomized eGOS (4-8 vs. 1-3) defines a functional outcome improvement in CLEAR-III at day 180, which was not observed using the PO with mRS. Use of eGOS did not result in a different interpretation of the MISTIE-III trial.

Introduction: Acute large vessel occlusion (LVO) can be secondary to thromboembolism or intracranial atherosclerotic disease (ICAD). Data on LVO management due to underlying ICAD are scarce. We hypothesized that patients with ICAD have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods: We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between January 14, 2018 and October 24, 2021. Presence of ICAD at LVO site was determined by the interventionalist. We compared in-hospital mortality, 90-day mortality, and 90-day modified Rankin Scale (mRS) scores between those with and without ICAD, in unadjusted and adjusting logistic regression models. Results: Among 215 patients (mean age 67.1±16.0 years; 60.5% female; 80.5% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p=0.027 and 29.0% vs. 14.7%, p=0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p=0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p=0.054). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p=0.003 and 52.6% vs. 26.6%, p=0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p=0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4). Conclusions: Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT. Further research is warranted to understand factors associated with worse outcomes and investigate alternative interventional approaches and medical management in this high-risk population.

Background: Familial cerebral cavernous malformation (FCCM) is characterized by multiple brain lesions at risk for intracranial hemorrhage (ICH) and neurological morbidity, affecting quality of life (QoL). PROMIS-29 is a QoL survey validated in some neurological diseases but has not yet been evaluated for FCCM. We aimed to assess whether PROMIS-29 health domains are associated with clinical symptoms in FCCM patients. Methods: PROMIS-29 surveys assessing seven QoL domains were completed by 198 FCCM patients >=18 years either at a baseline or follow-up visit in the Brain Vascular Malformation Consortium CCM study. Raw PROMIS-29 domain scores were converted to T scores that are standardized to a reference population with mean 50 and SD 10, and oriented so that higher scores are unfavorable. One-sample t-tests and p-values assessed whether mean T-scores were significantly different from 50 (p Results: Compared to a reference population, FCCM patients had significantly higher anxiety (52.7, 95% CI: 51.3-54.2, p3 points, p Conclusion: FCCM patients differed significantly from the reference population on anxiety, pain, physical functioning, and social participation domains. These same domains were significantly associated with history of ICH or headaches in patients. Further studies will determine whether changes in health domains are associated with changes in clinical symptoms.

Introduction: Serum neutrophil-lymphocyte ratio (NLR) is a surrogate marker for the inflammatory response after intracerebral hemorrhage (ICH), and is associated with perihematomal edema and long-term functional outcomes. Whether NLR is associated with short-term ICH complications is poorly understood. Hypothesis: NLR is associated with 30-day infection and thrombotic events after ICH. Methods: We performed a post hoc exploratory analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. The study exposure was the serum NLR obtained at baseline, and on days 3 and 5. The co-primary outcomes, ascertained at 30 days, were any infection and a thrombotic event, defined as composite of cerebral infarction, myocardial infarction, or venous thromboembolism; both infection and thrombotic event were determined via adjudicated adverse event reporting. Binary logistic regression was used to study the relationship between NLR and outcomes, after adjustment for demographics, ICH severity and location, and treatment randomization. Results: Among the 500 patients enrolled in CLEAR III, we included 228 (45.6%) with no missing data on daily NLR in the first week. There were no differences in demographics, comorbidities, or ICH severity between patients with and without data on NLR. In adjusted logistic regression models, NLR at day 3 was associated with infection (OR, 1.2; 95% CI, 1.01-1.26), but not with thrombotic events (OR, 0.96; 95% CI, 0.85-1.10). Conversely, NLR at day 5 was associated with thrombotic events (OR, 1.2, 95% CI, 1.01-1.26), but not with infections (OR, 1.03; 95% CI, 0.94-1.14). NLR at baseline was not associated with either outcome. Conclusions: Serum NLR ascertained between days 3 and 5 was associated with 30-day infection and thrombotic events after ICH, suggesting that NLR could be a potential early biomarker for ICH-related complications.

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.

[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

Cerebral cavernous malformations are acquired vascular anomalies that constitute a common cause of central nervous system hemorrhage and stroke. The past 2 decades have seen a remarkable increase in our understanding of the pathogenesis of this vascular disease. This new knowledge spans genetic causes of sporadic and familial forms of the disease, molecular signaling changes in vascular endothelial cells that underlie the disease, unexpectedly strong environmental effects on disease pathogenesis, and drivers of disease end points such as hemorrhage. These novel insights are the integrated product of human clinical studies, human genetic studies, studies in mouse and zebrafish genetic models, and basic molecular and cellular studies. This review addresses the genetic and molecular underpinnings of cerebral cavernous malformation disease, the mechanisms that lead to lesion hemorrhage, and emerging biomarkers and therapies for clinical treatment of cerebral cavernous malformation disease. It may also serve as an example for how focused basic and clinical investigation and emerging technologies can rapidly unravel a complex disease mechanism.

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 Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure was recently tested in a large phase III randomized trial showing a significant probability of functional benefit in those cases that reached the goal hematoma evacuation of ≤15 mL residual (or ≥70% removal). Benefit of thrombolysis was also identified in cases with large intraventricular hemorrhage, and achieving at least 85% volume reduction in the Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. Objective To protocolize steps in the MISTIE and CLEAR procedures in order to maximize hematoma evacuation and minimize complications. Methods We articulate data-driven lessons and expert opinions surrounding the factors of patient selection, catheter placement, and dosing, which impacted safety and surgical performance in the MISTIE and CLEAR trials. Results Modifiable factors to maximize evacuation efficiency include optimizing catheter placement and pursuing aggressive dosing to achieve treatment goals, while strictly adhering to the safety steps as articulated in the respective trials. Prognostic factors that are viewed as nonmodifiable include greater initial intracerebral hemorrhage volume with irregular shape, smaller intraventricular bleeds, and the uncommon but consequential development of new bleeding during the dosing period despite strict protocol adherence. Conclusions Surgeon education in this tutorial is aimed at maximizing the benefit of the MISTIE and CLEAR procedures by reviewing case selection, safety steps, treatment objectives, and technical nuances. Key lessons include stability imaging, etiology screening, and technical adherence to the protocol in order to achieve defined thresholds of evacuation.

Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.

Intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) clinical trials rely on manual linear and semi-quantitative (LSQ) estimators like the ABC/2, modified Graeb and IVH scores for timely volumetric estimation from CT. Deep learning (DL) volumetrics of ICH have recently approached the accuracy of gold-standard planimetry. However, DL and LSQ strategies have been limited by unquantified uncertainty, in particular when ICH and IVH estimates intersect. Bayesian deep learning methods can be used to approximate uncertainty, presenting an opportunity to improve quality assurance in clinical trials.A DL model was trained to simultaneously segment ICH and IVH using diagnostic CT data from the Minimally Invasive Surgery Plus Alteplase for ICH Evacuation (MISTIE) III and Clot Lysis: Evaluating Accelerated Resolution of IVH (CLEAR) III clinical trials. Bayesian uncertainty approximation was performed using Monte-Carlo dropout. We compared the performance of our model with estimators used in the CLEAR IVH and MISTIE II trials. The reliability of planimetry, DL, and LSQ volumetrics in the setting of high ICH and IVH intersection is quantified using consensus estimates.Our DL model produced volume correlations and median Dice scores of .994 and .946 for ICH in MISTIE II, and .980 and .863 for IVH in CLEAR IVH, respectively, outperforming LSQ estimates from the clinical trials. We found significant linear relationships between ICH uncertainty, Dice scores (r = -.849), and relative volume difference (r = .735).In our validation clinical trial dataset, DL models with Bayesian uncertainty approximation provided superior volumetric estimates to LSQ methods with real-time estimates of model uncertainty.

Introduction: Studies have shown independent associations of lower admission hemoglobin (HB) levels with larger spontaneous intracerebral hemorrhage (ICH) volumes and poor outcomes, possibly mediated by hematoma expansion (HE). Objective: We retrospectively investigated the association of HB levels over the first week post ICH with functional outcomes (FO) and neuroimaging findings in patients with spontaneous ICH (>30 mL). We explored whether comorbidities modify the effects of HB. Methods: We analyzed HB levels from subjects enrolled in the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial (MISTIE III). The exposure was admission HB and the HB nadir in the first week. The primary outcome was good FO at 180 days, defined as modified Rankin Scale of 0-3. Secondary outcomes were good FO at 365 days, 30-day mortality, admission ICH volume, and HE (>6 mL). Linear and logistic regression models were used to test the association of HB with clinical outcomes and neuroimaging findings. All models were adjusted for age, sex, race, treatment (medical Vs. MISTIE), Glasgow Coma Scale, ICH volume, presence of intraventricular hemorrhage, and ICH location (deep Vs. lobar). We investigated effect modification of comorbidities on association of HB with FO. Results: A total of 493 of 499 enrolled patients (61% males, mean age 61(SD=12) years, median ICH volume 41.8 (IQR=30.8-51.5) mL) were included. Patients with good FO at 180 days had a higher admission HB (13.2 Vs. 12.6 g/dl, p=0.001) and a higher nadir HB (11.7 Vs. 10.9 g/dl, pinteraction = 0.045). Conclusions: In patients with ICH > 30 mL, higher nadir HB in the first week was associated with better long-term FO and smaller ICH volumes, but not with HE. Early hemoglobin changes may serve as a prognostic biomarker and a potentially modifiable factor to improve FO.

Introduction: Cavernous angiomas (CAs) are common neurovascular lesions predisposing patients to seizures and hemorrhagic stroke. Recent evidence shows non-endothelial cell autonomous effects contribute to CA pathogenesis within the dysfunctional neurovascular units (NVUs), consisting of endothelial cells, pericytes, astrocytes, and microglia. Herein, we developed a single-cell isolation protocol to study the transcriptome of each of these cell populations. Method: CAs and control brain tissue were frozen in optimal cutting temperature compound immediately after surgical resection. Tissue was enzymatically digested with Collagenase Type IV and DNase I. The cell suspension was then filtered, washed, and pelleted. Cell debris and myelin were removed using 25% Percoll. A multispectral LED light was used for 30 minutes to reduce background autofluorescence. Cells were stained with a CD31, CD45, CD13, P2RY12, CD49f, GLAST, CD24 and CD90 antibody cocktail. Size, granularity, and antibody-specific gating were set to sort each cell population using the BD FACSymphony S6 Cell Sorter. After isolation, RNA was extracted for each cell population, and the quality was assessed. Cell-specific genes including VWF (endothelial cells), ACTA2 (pericytes ), AQP4 (astrocytes ) and IBA-1 (microglia ), as well as GAPDH were assessed with real-time qPCR (rt-qPCR) for validation. Results: Endothelial cells (CD31 + , CD13 - , CD45 - , CD49f - , GLAST - ), pericytes (CD13 + , CD31 - , CD45 - , CD49f - , GLAST - ), astrocytes (CD49f + , GLAST + ) and microglia (P2RY12 + , CD45 + , CD31 - , CD13 - , CD49f - , GLAST - ) were individually isolated from both 5 CA lesions and 5 control brain tissue using FACS sorting. RNA quantity ranged from 31 to 83 pg/μl, with RNA Integrity Number ranging from 1 to 8.7. Each cell population within the CA lesion was validated by showing differential expression of cell-specific genes. Conclusion: We have shown, for the first-time, feasibility of individual cell type isolation from frozen, surgically excised CA lesions. The RNA quantity and quality of each cell population was suitable for the establishment of cell-specific transcriptome libraries. These will help clarify individual cell type contributions to CA pathogenesis.

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.

ObjectiveTo evaluate the relationship between prior antiplatelet therapy (APT) and outcomes after primary intracerebral haemorrhage (ICH), and assess if it varies by haematoma location.MethodsWe pooled individual patient data from the Virtual International Stroke Trials Archive-ICH trials dataset, Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase III trial. The exposure was APT preceding ICH diagnosis. The primary outcome was haematoma expansion at 72 hours. Secondary outcomes were admission haematoma volume, all-cause mortality, death or major disability (modified Rankin Scale (mRS) score ≥4) and shift in mRS distribution. Mixed-effects models were used to assess the relationship between APT and outcomes. Secondary analyses were stratified by ICH location and study cohort.ResultsAmong 1420 patients with ICH, there were 782 (55.1%) lobar and 596 (42.0%) deep haemorrhages. APT was reported in 284 (20.0%) patients. In adjusted regression models, prior APT was not associated with haematoma expansion (OR, 0.97; 95% CI 0.60 to 1.57), major disability or death (OR, 1.05; 95% CI 0.61 to 1.63), all-cause mortality (OR, 0.89; 95% CI 0.47 to 1.85), admission haematoma volume (beta, −0.17; SE, 0.09; p=0.07) and shift in mRS (p=0.43). In secondary analyses, APT was associated with admission haematoma volume in lobar ICH (beta, 0.25; SE, 0.12; p=0.03), but there was no relationship with other ICH outcomes when stratified by haematoma location or study cohort.ConclusionsIn a large heterogeneous cohort of patients with ICH, prior APT was not associated with haematoma expansion or functional outcomes after ICH, regardless of haematoma location. APT was associated with admission haematoma volumes in lobar ICH.

Cerebral cavernous malformations (CCMs) are ectatic capillary-venous malformations that develop in approximately 0.5% of the population. Patients with CCMs may develop headaches, focal neurologic deficits, seizures, and hemorrhages. While symptomatic CCMs, depending upon the anatomic location, can be surgically removed, there is currently no pharmaceutical therapy to treat CCMs. Several mouse models have been developed to better understand CCM pathogenesis and test therapeutics. The most common mouse models induce a large CCM burden that is anatomically restricted to the cerebellum and contributes to lethality in the early days of life. These inducible models thus have a relatively short period for drug administration. We developed an inducible CCM3 mouse model that develops CCMs after weaning and provides a longer period for potential therapeutic intervention. Using this new model, three recently proposed CCM therapies, fasudil, tempol, vitamin D(3), and a combination of the three drugs, failed to substantially reduce CCM formation when treatment was administered for five weeks, from postnatal day 21 (P21) to P56. We next restricted Ccm3 deletion to the brain vasculature and provided greater time (121 days) for CCMs to develop chronic hemorrhage, recapitulating the human lesions. We also developed the first model of acute CCM hemorrhage by injecting mice harboring CCMs with lipopolysaccharide. These efficient models will enable future drug studies to more precisely target clinically relevant features of CCM disease: CCM formation, chronic hemorrhage, and acute hemorrhage.

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.

Background Intraventricular hemorrhage occurs due to intracerebral hemorrhage with intraventricular extension or without apparent parenchymal involvement, known as primary intraventricular hemorrhage. Aims We evaluated the prognosis of primary intraventricular hemorrhage patients in the CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage). Methods In patients with primary intraventricular hemorrhage versus those with secondary intraventricular hemorrhage, we compared intraventricular alteplase response and outcomes including modified Rankin Scale, Barthel Index, National Institutes of Health Stroke Scale (NIHSS), and extended Glasgow Outcome Scale (eGOS) at 30, 180, and 365 days. Outcomes were also compared in primary intraventricular hemorrhage patients who received intraventricular alteplase versus placebo (normal saline) and in matched primary and secondary intraventricular hemorrhage patients using inverse-probability-weighted regression adjustment. Results Of 500 patients enrolled in CLEAR III, 46 (9.2%) had primary intraventricular hemorrhage. Combining both treatment groups, primary intraventricular hemorrhage patients had larger intraventricular hemorrhage volumes (median: 34.2 mL vs. 20.8 mL, p Conclusions In CLEAR III, primary intraventricular hemorrhage patients who survived achieved better long-term outcomes than surviving secondary intraventricular hemorrhage patients with similar mortality. Outcomes and safety were similar between primary intraventricular hemorrhage patients receiving alteplase and those receiving saline.

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.