Global urban environmental change drives adaptation in white clover.

Urbanization transforms environments in ways that alter biological evolution. We examined whether urban environmental change drives parallel evolution by sampling 110,019 white clover plants from 6169 populations in 160 cities globally. Plants were assayed for a Mendelian antiherbivore defense that also affects tolerance to abiotic stressors. Urban-rural gradients were associated with the evolution of clines in defense in 47% of cities throughout the world. Variation in the strength of clines was explained by environmental changes in drought stress and vegetation cover that varied among cities. Sequencing 2074 genomes from 26 cities revealed that the evolution of urban-rural clines was best explained by adaptive evolution, but the degree of parallel adaptation varied among cities. Our results demonstrate that urbanization leads to adaptation at a global scale

Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in the Early and Extended Window

Importance: Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. Objective: To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. Design, setting, and participants: This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score. Exposure: All patients underwent MT in one of the included centers. Main outcomes and measures: A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset). Results: A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64). Conclusions and relevance: In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window

ICAR: endoscopic skull‐base surgery

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Global urban environmental change drives adaptation in white clover

Urbanization transforms environments in ways that alter biological evolution. We examined whether urban environmental change drives parallel evolution by sampling 110,019 white clover plants from 6169 populations in 160 cities globally. Plants were assayed for a Mendelian antiherbivore defense that also affects tolerance to abiotic stressors. Urban-rural gradients were associated with the evolution of clines in defense in 47% of cities throughout the world. Variation in the strength of clines was explained by environmental changes in drought stress and vegetation cover that varied among cities. Sequencing 2074 genomes from 26 cities revealed that the evolution of urban-rural clines was best explained by adaptive evolution, but the degree of parallel adaptation varied among cities. Our results demonstrate that urbanization leads to adaptation at a global scale

E-212 Pulserider in the treatment of wide-neck bifurcation aneurysms: interim results of the NAPA trial

IntroductionThe NAPA study was a prospective, multicenter, single-arm IDE trial of the PulseRider device as an adjunctive treatment in conjunction with coil embolization of unruptured wide-neck bifurcation aneurysms which was electively discontinued for reasons not related to the safety or performance of the device. We report on the available enrollments in NAPA and their available follow up.MethodsThe PulseRider device was implanted in 18/21 enrollments. Available core-lab adjudicated data from the first 18 implants is presented. Of those, 5 have one year follow up data available. Of the 3 device implantation failures, the locations included basilar (1), carotid terminus (1), and ACOMM (1).ResultsFor the 18 patients with PulseRider implanted as a coil-adjunct device, the mean age was 60.7± 8.9 yrs and 16 were female. The mean aneurysm diameter was 6.6± 2.2 mm, height 5.3±1.7 mm and neck 4.8 ±1.5 mm. Locations included the basilar apex (11), MCA bifurcation (4) and ACOMM (3). Thirteen of 18 were de novo aneurysms while the remainder (5) were treated in the setting of aneurysmal recurrence. The most common PulseRider placement was extra-aneurysmal (12/18), followed by intra-aneurysmal (4/18) and hybrid (2/18). Immediate angiographic occlusions were 66.6% RR-I, 16.7% RR-II, 16.7% RR-III. There were no device related adverse events. There were 3 (16.7%) procedure-related adverse events which did not result in neurological changes. Seven enrollments have 6 month follow up and all are RRI-II. Only 1 has one year angiographic follow up (RRI) adjudicated by the core lab, and 4 have clinical follow up (4/4 mRS 0–2). None of the target aneurysms have required retreatment.ConclusionsThe results of the discontinued NAPA provide high quality data on the occlusion rates and safety profile for the PulseRider device. Further one year angiographic and clinical follow up will be reported when available.Disclosures A. Spiotta: 1; C; Microvention. 2; C; Minnetronix, Penumbra, Cerenovus. 6; C; Cerenovus, Penumbra, Pulsar Vascular, Stryker, Microvention. K. Ebersole: None. J. Lena: None. R. Starke: 2; C; Medtronic Neurovascular, Penumbra, Cerenovus, Abbott. R. De Leacy: 6; C; Penumbra, Cerenovus, Siemens. A. Puri: 1; C; Stryker Neurovascular, Medtronic Neurovascular. 2; C; Stryker Neurovascular, Medtronic Neurovascular. D. Yavagal: 2; C; Medtronic Neurovascular, Rapid Medical, Steering Committee, Neuralanalytics. 6; C; Medtronic, Cerenovus/Johnson & Johnson, Rapid Medical, Neuralanalytics. B. Bohnstedt: 2; C; Penumbra, Stryker, Medtronic. L. Rangel-Castilla: None. A. Cheema: None. J. Davies: 1; C; National Center for Advancing Translational Sciences of the National Institutes of Health under award number KL2TR001413 to the University of Buffalo. 2; C; Medtronic, Neurotrauma Science, LLC. 4; C; RIST Neurovascular. K. de Macedo Rodrigues: None. J. Grossberg: None. B. Howard: None. C. Kellner: 1; C; Penumbra, Siemens Corp. G. Lanzino: None. S. Tateshima: 2; C; Cerenovus, Medtronic, Neurovasc, Stryker. 4; C; Neurovasc

O-065 Multicenter investigation into presentation, management and outcome of infectious intracranial aneurysms

Introduction Infectious intracranial aneurysms (IIAs) are rare complications of infective endocarditis or systemic infection. To date, data are limited regarding management as well as long-term outcomes of patients with ruptured or unruptured IIAs. We explored, at multicenter level, the presentation, technical and clinical outcomes of patients with IIAs management by conservative or surgical intervention. Methods This is a multicenter retrospective study of patients presenting with IIAs between January 2016 and December 2022 at seven tertiary care centers in the United States. Medical record, procedure notes, and imaging findings were reviewed for demographics, aneurysm features, management and clinical and technical outcomes. Patients were managed either via sole medical management (MM) which included antibiotics and serial imaging, endovascular embolization and antibiotics, or open microsurgery and antibiotics. Technical outcome include aneurysm obliteration at follow-up vascular imaging, and primary clinical outcome was the modified Rankin Score (mRS) at 90 days dichotomized into good outcome (mRS 0-2) and poor outcome (mRS 3-6). Results A total of 66 patients with 116 IIAs (Age: 42+/-17, 67% Males) were treated at all sites during the study period. Comorbid IE was present in 67%, and 12% had a Left Ventricular Assist Device. IIAs presented with rupture in 73% of cases, were discovered during stroke workup in 9%, or were incidentally discovered in 18%. Most IIAs (64%) were diagnosed with a cerebral angiogram, 30% with MR angiography, and 6% with CT angiography. Multiple aneurysms were detected in 36% of subjects. Aneurysms predominantly involved the M3/4 segment (62%), followed by M2 (9%), and A2/3 (8%) while 11% involved the posterior circulation (7% in P2/3). The average size of aneurysms was 4.2 mm +/- 3.5; 73% were less than 5mm in size while 7% were above 10 mm. Primary medical management was used in 63% of IIAs, of which 43% failed medical management with progression of aneurysm or rupture/re-rupture with average time to fail of 24+/- 23 days (42% within 2 weeks). Endovascular treatment was used in 22% of cases as primary treatment (36% as both primary and rescue of failed medical management), whereas open microsurgery was used as primary treatment in 14% of cases (21% as both primary and rescue of failed medical management). Recurrence or progression was noted in 12% of the endovascular group, and 4% of microsurgery group with average follow-up of 200 days. The overall 1-year mortality rate was 21%, and 48% had a mRS 0-2 at 90 days. Multivariate model for prediction of failure of MM, aneurysms with larger size (aOR=1.5,p=0.002) and posterior circulation aneurysms (aOR=6.9,p=0.001) were independent predictor of antibiotic failure. On multivariate logistic regression controlling for demographics, comorbidities, aneurysm size, location and morphology, and treatment group, predictors of 1-year mortality included failed medical management (aOR=6.1,p=.005), age (aOR=1.07,p<0.001), and black race (aOR=3.95,p=0.03). Conclusion Patients with IIAs are at high risk of aneurysm rupture or re-hemorrhage despite treatment with antibiotics. Antibiotic failure occurred in 43% of medically treated patients, and failure was associated with 6 times higher odds of mortality in 1 year. Disclosures A. Alawieh: None. L. Dimisko: None. Y. Zohdy: None. H. Saad: None. S. Newman: None. J. Grossberg: None. C. Cawley: None. G. Pradilla: None. C. Fox: None. C. Perez-Vaga: None. J. Burkhardt: None. M. Salem: None. P. Jabbour: None. K. El Naamani: None. R. Schmidt: None. M. Gooch: None. R. Starke: None. A. Abdelsalam: None. V. Lu: None. M. Levitt: None. A. Spiotta: None. V. Hertzberg: None. D. Barrow: None. B. Howard: None

E-111 Repeat thrombectomy after large vessel occlusion stroke: incidence, clinical and technical outcomes

Introduction Endovascular thrombectomy (EVT) remains the standard of care for acute large vessel occlusion stroke. In a subset of patients, the target vessel could re-occlude following successful recanalization requiring consideration of repeat EVT. In this study, we use a large real-world patient cohort to study the incidence of repeat thrombectomy as well as clinical and technical outcomes in this subset. Methods This is an international multicenter study including retrospectively reviewed cohort of patients undergoing EVT for ischemic stroke at 21 centers in the United States and globally as part of multicenter registry between 01/2013 and 03/2022. Patients undergoing single or repeat thrombectomy were included irrespective of whether thrombolysis was administered, location of thrombus, onset to groin time or thrombectomy technique. Patients undergoing another thrombectomy after 30 days of index thrombectomy or for a different vascular territory were excluded. Propensity score matching was used to compare patients undergoing single versus repeat thrombectomy. The primary outcome was the modified Rankin score (mRS) at 90 days, and secondary outcomes were successful recanalization defined as Thrombolysis in Cerebral Ischemia (TICI) score of 2B or above, incidence of postprocedural hemorrhage and mortality. Results A total of 7387 patients met inclusion criteria of which 1.8% (N=90) underwent repeat thrombectomy for the same vascular territory within 30 days and were included in this study. Of this subset, the average time to re-occlusion was 5.3±7.3 days, and 41 (45.6%) required re-EVT within 24hrs. Using propensity score matching for age, baseline comorbidities, admission NIHSS, and IV-tPA use, patients undergoing repeat thrombectomy had comparable rate of good outcome defined as mRS 0-2 at 90 days compare to patients undergoing single procedure (27% versus 31%, p=0.57), similar mortality (17% versus 20%, p=0.58) but higher rate of symptomatic intracranial hemorrhage (11% versus 5%, p=0.025). When comparing the change in NIHSS before and after the second thrombectomy, there was a significant reduction in NIHSS between pre-procedure and discharge (ΔNIHSS = (-)5±11, one sample t-test, p=0.006). The rate of successful recanalization was similar in patients undergoing single or repeat thrombectomy (78% versus 80%, p= 0.78) and between index thrombectomy and repeat thrombectomy for the same patient (79% versus 80%, p = 0.78). The rate of hemorrhagic conversion was similar regardless if intracranial stenting was performed. Conclusions Repeat EVT for patients with re-occlusion within 30 days of thrombectomy is associated with favorable improvement in NIHSS, similar functional outcomes to patients undergoing single EVT, but has significantly higher risk of hemorrhagic conversion. Disclosures Y. Zohdy: None. H. Saad: None. B. Howard: None. C. Cawley: None. A. Pabaney: None. T. Garzon-Muvdi: None. I. Maier: None. A. Spiotta: None. P. Jabbour: None. S. Wolfe: None. A. Rai: None. J. Kim: None. J. Mascitelli: None. R. Starke: None. A. Shaban: None. S. Yoshimura: None. R. De Leacy: None. P. Kan: None. I. Fragata: None. A. Polifka: None. A. Arthur: None. M. Park: None. C. Matouk: None. M. Levitt: None. S. Tjoumakaris: None. J. Liman: None. K. Fargen: None. A. Alawieh: None. J. Grossberg: None