Management of Childhood Migraine by Headache Specialist versus Non-Headache Specialists

This study aims to compare the management practices of a headache specialist with non-headache specialists in the treatment of pediatric migraine. The use of appropriate rescue medications and prophylactic agents, application of neuro-imaging, and short-term outcomes are compared in children treated by the two groups of physicians. A retrospective cohort study was conducted utilizing the electronic medical records of children 3-18 years of age with migraine, who were evaluated at a tertiary care children’s hospital from 2016-2018. Of the 849 patients that met the study criteria, 469 were classified as having chronic migraine or high-frequency episodic migraine and were followed up on at least one occasion. Imaging was obtained in 66.5% of children. The headache specialist used 5-HT agonists (“triptans”) for migraine management in 56.7% of cases compared to non-headache specialists who prescribed them in 28.7% of cases (p \u3c0.001). Of the children with chronic migraine, the headache specialist evaluated 135 patients while the non-headache specialists treated 334 children. Non-headache specialists prescribed prophylaxis in the form of natural supplements more frequently (63.8% of cases) compared to the headache specialist (38.5% of children) (p\u3c0.001). Contrarily, prophylaxis with prescription drugs was utilized more often by the headache specialist (66.7%) than non-headache specialists (37.4%) (p\u3c0.001). Imaging appears to be commonly recommended by both headache specialists and non-headache specialists in children with migraine. The headache specialist was more likely to use triptans as rescue medications. Short-term outcomes were not statistically different whether children were being managed by the headache specialist or the non-headache specialists

Abstract 112: When Cell Blood Count Matter, Hypereosinophilic Syndrome a Rare Cause of Ischemic Strokes

Introduction Hypereosinophilic syndrome (HES) is a rare hematological disorder defined by persistently elevated blood eosinophil count (>1500/μL), associated with evidence of organ damage. It can occasionally present primarily with neurological conditions such as ischemic strokes, encephalopathy, or sensory neuropathy. Driving hypothesized mechanisms are hypercoagulability owing to eosinophil‐related endothelial damage or cardioembolism. We present an unusual case of ischemic strokes due to HES in the setting of Fip1‐like 1‐platelet‐derived growth factor receptor alpha (FIP1L1‐PDGFRA) mutation. Methods The patient was identified in routine clinical practice. Results 38 year‐old‐male with no significant medical history who was transferred to our institution for blurred vision, and dizziness. His initial National Institutes of Health Stroke Scale was 3 for bilateral leg weakness. The neurological exam was pertinent for paresis in his left arm and legs. Magnetic resonance imaging (MRI) of the brain demonstrated multiple acute infarcts in bilateral cortical and subcortical structures as shown in Figure 1. Computed tomography angiography (CTA) of the brain and neck did not show significant stenosis or occlusion. During admission, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) did not reveal any source for cardioembolism. Subsequently, he developed hyperactive delirium requiring anti‐psychotics. He was worked up for any infectious etiology because he continued to have a leukocytosis with an eosinophil count as high as 49%. Doppler of lower extremities showed deep vein thrombosis in the left femoral vein. Hematology evaluated the patient and, after performing a bone marrow biopsy, he was diagnosed with primary Hypereosinophilic syndrome (HES) in the setting of FIP1L1‐PDGFRA mutation. He was started on high‐dose methylprednisolone, hydroxyurea and later switched to Imatinib. A cardiac MRI was performed which was negative for eosinophilic myocarditis. The patient's mental status improved significantly after starting Imatinib and his anti‐psychotics were discontinued. In regards to secondary prevention, vascular neurology wanted antiplatelet monotherapy, however, the patient was started on Apixaban to treat his DVT. He was followed up in the stroke clinic 2 months after discharge, his modified Rankin score (mRS) was 1. Aspirin was recommended for secondary stroke prevention once hematology considers it safe to discontinue apixaban. Conclusion This case encourages the consideration of HES in patients with low cardiovascular risk factors who have infarcts following a cardioembolic or watershed pattern in brain imaging. Going back to the basics and reviewing simple laboratory tests like cell blood count can be the initial clue for diagnosis. Early recognition is crucial as immunosuppression is the most important treatment in the acute phase. While imatinib is the treatment of choice for FIP1L1‐PDGFRA mutation HES, patients continued to be at risk of stroke recurrence despite having normal eosinophil count as described by Rohmer et al

Abstract 093: Carotid Stump Syndrome: an Insidious Source of Recurrent Ischemic Strokes

Introduction Carotid stump syndrome (CSS) is a paradoxical phenomenon that occurs when there are repeated ischemic events in the carotid vascular territory despite demonstrated occlusion of the ipsilateral internal carotid artery (ICA). It is thought to be caused by turbulent blood flow in the patent stump of the occluded ICA creating microemboli which reach the brain through anastomotic channels and retrograde flow. We present a case of recurrent infarctions in setting of known ipsilateral ICA occlusion, who was diagnosed with carotid stump syndrome. Methods A male veteran in his 60s with a medical history of DVTs on apixaban, PVD, and ischemic stroke with residual right‐sided weakness, presented with worsening right‐sided weakness and difficulty with ambulation. Two months prior to the presentation he was diagnosed with acute infarcts in left frontal, parietal, and temporal lobes due to thromboembolism from left ICA occlusion. On presentation his neurological exam revealed right‐sided hemiparesis. MRI brain showed multiple acute and chronic cortical and subcortical infarcts in the left frontotemporoparietal lobes and lack of flow void in the left distal ICA. To further evaluate the dynamics of blood flow patient underwent a cerebral angiogram which confirmed the diagnosis of complete occlusion of left ICA and demonstrated reconstitution of the intracranial ICA through retrograde filling via the ophthalmic artery and anastomotic branches with the internal maxillary artery (IMax). For secondary prevention he was started on statin and aspirin while his home Apixaban was continued. Surgical and endovascular treatment approaches were discussed but the patient declined any intervention. In his four months follow up clinic visit he had no further concerns of recurrent strokes or new symptoms. Results Carotid stump syndrome is a rare cause of cerebral and retinal ischemia; however, it must be considered in patients with recurrent ischemic strokes and chronic ipsilateral ICA occlusion. Due to the patent proximal, or perhaps in some cases distal, carotid stump, there’s turbulent flow and hence the thrombus formation can occur. Hemodynamic and embolic factors attribute towards the microembolization from the proximal carotid stump through the external carotid artery (ECA), into the facial artery and IMax and their distal branches which anastomose with the ophthalmic artery, causing the emboli to end up in the major branches of the carotid terminus. If a distal stump is symptomatic, then the microemboli can readily end up in the distal ICA branches. In addition to medical management with DAPT or anticoagulation and high intensity statin, our literature review supports endovascular or surgical interventions due to reportedly good outcomes. Interventional approaches may include ECA‐ICA stenting with a covered stent or stent‐assisted coil embolization of the proximal stump. Surgical procedures include an endarterectomy on the ipsilateral ECA or contralateral ICA to increase collateral circulation. ECA‐ICA bypass is another option. Conclusion Carotid stump syndrome is a rare and underrecognized cause of recurrent ischemic strokes, though it is a potentially treatable entity. The therapeutic goals include medical management along with endovascular or surgical treatment whenever possible

Abstract 094: Sudden Onset Dysphagia: A Symptom To Be Aware of During Code Strokes

Introduction Lateral medullary infarction (LMI) can present with dysphagia, dysphonia, dysarthria, vertigo, nausea, skew deviation, and ipsipulsion. Patients may also exhibit sensory loss and ipsilateral Horner’s syndrome. LMS often develops because of an acute infarct from the vertebral arteries or posterior inferior cerebellar arteries (PICA). The most common mechanism of stroke usually is atherothrombosis, followed by cardioembolic, dissection and embolic source of undetermined source (ESUS). While dysphagia often accompanies the constellation of LMS symptoms, it is rarely the first symptom and has only been reported in a few cases in the literature. In this report we describe the case of a man in his 40s with acute onset dysphagia as the presenting finding ahead of an LMS diagnosis. Methods The patient was identified in routine clinical practice. Results A man in his 40s with medical history of HTN, type 2 DM and polycystic kidney disease, presented with sudden‐onset dysphagia which started while he was drinking alcohol. Later he noticed that he was unable to keep his balance. His National Health Institute Stroke Scale was 4. Neurologic exam was pertinent for left‐sided miosis, ptosis, and dysmetria. Pinprick and temperature sensation were decreased on the right arm and leg. Facial sensation to light touch was diminished on the left. Brain MRI showed an acute infarct in the left lateral medulla (Figure A). CTA showed calcified atherosclerosis of the V4 segment of left vertebral artery (Figure B). Mechanism of ischemic stroke was artery to artery thromboembolism from the left V4 segment of vertebral artery. For secondary prevention, dual antiplatelet therapy, high intensity statin, and optimization of his risk factors were initiated. Conclusion This case report demonstrates that dysphagia can be the initial symptom of an acute ischemic stroke. Diagnosis and recognition of an atypical presentation of lateral medullary syndrome can pose a particular challenge especially in this era of “time is brain” but is of the utmost importance to facilitate good outcomes. Patients presenting with dysphagia who have risk factors for stroke and no other obvious etiology for their symptoms should be worked up for possible cerebrovascular etiology

Abstract 161: Repeated administration of thrombolytic therapy in the setting of stuttering lacunar infarct

Introduction Tissue plasminogen activator (tPA) is the standard of care for the treatment of acute ischemic stroke with symptom onset within 4.5 hours. One exclusion criterion for tPA administration is stroke within 3 months due to the presumed increased risk of hemorrhage. While the rate of early recurrent stroke (ERS) within 3 months is as high as 14.5‐18.3%, the safety and effectiveness of repeated tPA administration remain unclear. An increasing number of studies pose a challenge to this recommendation. One study identified 19 patients who received tPA for ERS and found no symptomatic intracranial hemorrhage. Fifteen other studies with a cohort of 57 patients (including one patient receiving repeated tPA within 90 minutes) reached the same conclusion that repeated tPA is safe in ERS. We present a patient with stuttering motor weakness who received intravenous (IV) tPA twice, 3 days apart with discharged modified Rankin scale (mRS) of 3. Methods The patient was identified in routine clinical practice. Results Our patient is a 61‐year‐old right‐handed Caucasian woman with a medical history of untreated hypertension presented with sudden onset of left arm and leg weakness. IV tPA was given at the local emergency department (ED) and she was then transferred to our comprehensive stroke center. Upon arrival, her National Institutes of Health Stroke Scale (NIHSS) was 0. Her symptoms were completely resolved. Computed tomography (CT) head was unremarkable and CT angiography (CTA) did not show significant stenosis or occlusion. Magnetic resonance imaging (MRI) of the brain was negative for an acute infarct. She was diagnosed with a transient ischemic attack and was discharged home with aspirin and a high‐intensity statin for secondary stroke prevention. She presented to the ED the next day with identical left‐sided weakness again. Her NIHSS was 5 this time and IV tPA was given again. MRI showed an acute infarct in the right posterior limb of the internal capsule. Transthoracic echo did not reveal an intracardiac shunting or thrombus. The stroke mechanism was small vessel disease, and anti‐hypertensive medications were added to the treatment. She was discharged to an acute rehabilitation center with an mRS of 3 and her 90‐day mRS was 1 on follow up. Conclusion Management of ERS is a challenging issue in stroke care. Our case adds value to the current limited literature demonstrating the safety and effectiveness of repeated tPA in ERS, especially in patients with MR negative stuttering lacunar infarct and subsequent improvement following tPA. Further research with larger registries is needed to identify appropriate selection criteria for repeated tPA use in this patient population

Abstract 272: Effect of Level of Education on Outcomes of Mechanical Thrombectomy

Introduction Multiple epidemiological studies have investigated the association between stroke clinical outcomes and education level. However, the relationship between the level of education in patients who underwent mechanical thrombectomy (MT) is limited. We aim to assess if the level of education is associated with poor functional outcome, defined as a modified Rankin Scale (mRS) score of ≥3, in patients following MT. Methods We reviewed 257 patients with large vessel occlusion (LVO) who underwent MT between 2018 and June 2023, education levels were available on 106 patients. Education level was defined as “less than high school” (n=15, 14.2%), “high school” (n=54, 50.9%), and “college or higher” (n=36, 34%), 1 of these with “other” education level was excluded from the analysis. Chi‐square and Kruskal Wallis tests were used to examine potential differences in education level and outcomes. All analyses were conducted in IBM SPSS Statistics version 29. Results Compared to those with a college or higher education, those with a less than high school education were more likely to have a poor functional outcome (mRS ≥3) at 90 days. (p=0.03). Black patients were more likely to have a less than high school education than white patients (30.0% vs 4.8%) p<0.001. There were no significant differences in mortality, length of hospitalization, comorbid conditions, Alberta stroke program early CT score (ASPECTS), or initial National Institutes of Health Stroke Scale (NIHSS). Conclusion In our cohort, patients with less than a high school education are more likely to have poorer functional outcomes 90 days post‐MT compared with patients with a college education or higher. Interestingly, there was no significant statistical difference noted in initial NIHSS, ASPECTS, and length of hospitalization between these cohorts. Larger post‐thrombectomy cohorts should be used to further investigate these initial results. In addition, it is important to note that education and race are intertwined in this study, though our relatively small sample of post‐thrombectomy patients limited our analyses. Future research should evaluate this relationship further

A Cross-Country Network Analysis of Adolescent Resilience

Purpose: In situations of adversity, young people draw on individual, relational, and contextual (community and cultural) resources to foster their resilience. Recent literature defines resilience as a capacity that is underpinned by a network of interrelated resources. Although empirical studies show evidence of the value of a network approach, little is known regarding how different country contexts influence which resources are most critical within a resource network and how resources interact for adolescent resilience. Methods: Network analysis was conducted with data from studies that had used the Child and Youth Resilience Measure. Regularized partial correlation networks of 17 resources were estimated for 14 countries (Botswana, Canada, China, Colombia, Equatorial Guinea, India, Indonesia, Italy, Jordan, New Zealand, the Philippines, Romania, South Africa, and Syrian refugees living in Jordan). The sample size was 18,914 (mean age = 15.70 years, 48.8% female). Results: We observed mostly positive associations between the resources of interest. The salience and strength of associations between resources varied by country. The most central resource across countries was having supportive caregivers during stressful times because this resource had the most and strongest positive associations with other resources. Conclusions: This study gives first empirical evidence from multiple countries that an interplay of social–ecological resources (such as individual skills, peer, caregiver and community support, and educational aspirations and opportunities) matter for adolescent resilience. Across countries, caregiver support appears to be most central for adolescent resilience. Future resilience interventions might apply this network approach to identify important, contextually relevant resources that likely foster additional resources