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Introduction: The objective of this study was to evaluate left atrial (LA) echocardiographic parameters and a novel panel of serum biomarkers to identify ESUS patients who may benefit from early anticoagulation. Methods: We prospectively identified ESUS patients seen in the Emory Clinic from January 1, 2015 to June 30, 2017 who underwent prolonged cardiac monitoring with mobile cardiac outpatient telemetry (MCOT) and/or implantable loop recorder (ILR). In a subset of consecutive patients, 4 measures of coagulation and hemostatic activation (MOCHA) including d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer were obtained ≥ 2 weeks after the index stroke and repeated if abnormal. We evaluated the ability of LA structural parameters to identify patients with atrial fibrillation (AF) on monitoring and the ability of abnormal MOCHA levels to identify patients who had the composite outcome of newly diagnosed AF, malignancy, or recurrent stroke. Results: During the study period, 92 ESUS patients (mean age 64 +/- 15 years, 54% female, 62% non-white, mean follow-up 1.4 +/- 0.8 years) underwent prolonged cardiac monitoring (65% MCOT, 62% ILR, 38% MCOT+ILR); 16 (17%) were found to have AF. Severe LA enlargement (vs normal) was associated with subsequent detection of AF (p=0.09) however LA diameter and LA volume index were not. Baseline characteristics of ESUS patients who underwent MOCHA testing (n=44) were similar to patients who did not except that those tested were younger (60 vs 67 years, p=0.04); over mean follow-up of 1.2 +/- 0.8 years, 18 (41%) patients had newly diagnosed AF, malignancy or recurrent stroke. ESUS patients with persistently abnormal (vs normal) MOCHA levels were significantly more likely to have newly diagnosed AF, malignancy or recurrent stroke (OR 11.3, 95% CI 2.5-50.1, p=0.001); elevated levels of ≥ 3 MOCHA markers had a 67% sensitivity and 81% specificity for identifying patients with the composite outcome. Conclusion: Abnormal MOCHA levels identified ESUS patients who were more likely to have newly diagnosed AF, malignancy or recurrent stroke over follow-up and may be more effective than LA structural abnormalities in identifying patients who could benefit from early anticoagulation.

BackgroundThe use of periprocedural heparin has previously been reported to be safe and potentially beneficial during thrombectomy with older generation devices. We aimed to evaluate the safety and clinical outcomes of heparin use in the stent retriever era.MethodsA post hoc analysis of the TREVO 2 trial was performed comparing baseline characteristics and clinical outcomes between patients who received (HEP+) and those who did not receive periprocedural heparin (HEP−) while undergoing MERCI or TREVO clot retrieval.ResultsOf 173 patients, 58 (34%) received periprocedural heparin including 40 who received one preprocedural bolus (median 3000 units). Baseline characteristics among HEP+ and HEP− patients were similar except HEP+ patients had a lower NIH Stroke Scale (NIHSS) score (17 vs 19; p=0.04), lower IV tissue plasminogen activator use (38% vs 64%; pConclusionsThe use of periprocedural heparin in stent retriever thrombectomy is associated with a good clinical outcome at 90 days and similar rates of symptomatic intracranial hemorrhage. Further studies are warranted.Clinical trial registrationURL:http://www.clinicaltrials.gov. Unique identifier: NCT01270867; Post-results.

Introduction: Periodic limb movements (PLMs) and obstructive sleep apnea (OSA) have been associated with an increased risk of cardiovascular disease. There are limited data on the frequency of PLMs and OSA among a diverse cohort of stroke patients and their association with resistant hypertension and atrial fibrillation (AF). Hypothesis: Stroke and TIA patients with PLMs or moderate-severe OSA are more likely to have resistant hypertension and AF than patients without these findings on diagnostic polysomnography (PSG). Methods: Consecutive stroke and TIA patients referred by a vascular neurologist for PSG from October 1, 2012 to September 30, 2015 were included in this analysis. Baseline clinical characteristics and PSG results were collected retrospectively. The frequency of PLMs (mild ≥5/hour, severe ≥15/hour), arousals due to PLMs (≥5/hour), and moderate-severe OSA (Apnea-Hypopnea Index≥15) was evaluated by PSG to determine their association with AF and resistant hypertension, defined as patients whose blood pressure was not at goal with 3 antihypertensive agents of different classes or controlled with 4 or more medications. Results: Of 103 patients (mean age 60±15 years, 50% female, 61% non-white, 76% ischemic stroke, 23% resistant hypertension) who underwent PSG (median time from cerebrovascular event to PSG 5 months), 48% had mild PLMs, 28% had severe PLMs, 14% had frequent PLM arousals and 22% had moderate-severe OSA. In multivariable analyses, non-white race was associated with lower likelihood of mild (OR 0.32, 95% CI 0.13 to 0.80) and severe PLMs (OR 0.29, 95% 0.10 to 0.79) and female sex was associated with lower likelihood of frequent PLM arousals (OR 0.38, 95% CI 0.14 to 1.00). Factors associated with moderate-severe OSA included older age (OR 1.06, 95% CI 1.016 to 1.106) and the presence of AF (OR 4.26, 95% CI 1.17 to 15.44). There was no significant association between PLMs, PLM arousals or moderate-severe OSA with resistant hypertension. Conclusions: A significant number of stroke and TIA patients have PLMs and moderate-severe OSA. Stroke and TIA patients with AF are more likely to have moderate-severe OSA and should be referred for PSG. The presence of resistant hypertension was not associated with PLMs or moderate-severe OSA in our study.

Introduction: Endovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes (LVOS). Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied. Methods: We retrospectively reviewed a prospectively collected endovascular database (September 2010-December 2015, n=898) for all patients with distal intracranial occlusions treated with endovascular therapy. Distal occlusions were defined as any occlusion of the anterior cerebral artery (ACA), any occlusion of the posterior cerebral artery (PCA), or any occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment. Results: Distal occlusions were treated in 70 patients. The mean age was 66+/-14 and 57% of the patients were male. Thirty-one (44%) of the patients received IV-tPA. The median pre-procedure NIHSS was 19 (IQR, 13-23). The distal occlusion was the primary treatment location in 54 patients and in 16 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal LVOS. The locations of the primary cases were MCA-M3 (n=21), ACA with a concomitant MCA-M1 or MCA-M2 (n=16), ACA alone (n=9), PCA (n=6), and ACA with a concomitant MCA-M3 (n=2). The locations of the rescue cases were MCA-M3 (n=8), ACA (n=7), and both MCA-M3 and ACA (n=1). The most common treatment modalities employed were intra-arterial tPA (n=37, 52%), small (3mm) stent-retrievers (n=24, 33%), and thromboaspiration (n=30, 42%). Near or complete reperfusion (mTICI 2b-3) was achieved in 56 cases (80%). Overall, there were 5 (7%) cases of any parenchymal hematoma (PH). However, two of the PHs were in patients with both a MCA-M1 and an ACA occlusion, and both of these hemorrhages were in the MCA territory. Thus only 3 PHs (4.3%) occurred in the territory of the treated distal occlusion with two of these patients also receiving IV tPA. At 90 days, 24 patients (40%) had a mRS of 0-2 and 13 (21%) had died. Conclusions: Distal intracranial occlusions can be treated safely and successfully with endovascular therapy. Although promising our results need to be corroborated by larger prospective controlled studies.

Background: The role of anticoagulation in patients with embolic strokes of unknown source (ESUS) remains controversial. Left atrial (LA) structural and functional parameters on transthoracic echocardiography (TTE) may predict ESUS patients who are likely to develop subsequent paroxysmal atrial fibrillation (PAF). Hypothesis: LA parameters in ESUS patients will be similar to cardioembolic (CE) stroke patients and different from patients with strokes due to other determined cause (ODC). Methods: Patients admitted to a stroke center from June 1 to November 30, 2015 with acute ischemic stroke were included in this analysis. Baseline characteristics and results of inpatient diagnostic workup including neuroimaging, echocardiography, and cardiac telemetry were reviewed retrospectively to classify patients into three subtypes: CE, ODC or ESUS. LA diameter, LA volume index (LAVI), mitral valve early (MV E) and late filling peak (MV Peak A) velocities were compared between the 3 subtypes. Results: Of 131 patients (mean age 67 ± 16, 47% female, 45% white), 35 (27%) were classified as CE, 62 (47%) ODC and 34 (26%) ESUS. Baseline characteristics were similar between groups except that ODC patients were less likely to be female than CE and ESUS patients (p=0.05). LAVI, MV E and MV Peak A were all significantly different in CE compared with ODC and ESUS patients (p Conclusions: LA structural and functional parameters among CE patients in our cohort were significantly different from those of ESUS and ODC patients, suggesting that ESUS patients may have lower risk of AF (and therefore lower likelihood of benefit from preemptive anticoagulation). Our study suggests that ESUS patients may benefit from long-term cardiac monitoring prior to initiation of anticoagulation therapy.

Background The objective of this study was to determine whether clinical outcomes differed in acute ischemic stroke (AIS) patients who underwent thrombectomy on weekends versus weekdays. Methods Patients with a primary diagnosis of AIS who underwent thrombectomy were identified from the Nationwide Inpatient Sample from 2005 to 2011 and stratified according to weekend or weekday admission. Logistic regression analysis was performed to identify factors associated with moderate-to-severe disability at hospital discharge in teaching and nonteaching hospitals. Results Of 12,055 patients with AIS who underwent thrombectomy during the study period, 2862 (23.7%) were admitted on a weekend. In a multivariate logistic regression analysis, factors associated with moderate or severe disability at discharge in nonteaching hospitals were weekend admission (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.0-2.8; P = .04), diagnosis of hypertension (OR, 1.9; 95% CI, 1.0-3.6; P = .05), and Medicare or Medicaid insurance status (OR, 2.1; 95% CI 1.1-4.3; P = .02); factors associated with moderate or severe disability at discharge in teaching hospitals were age >70 years (OR, 1.5; 95% CI, 1.1-2.2; P = .02), pneumonia (OR, 4.7; 95% CI, 2.2-10.2; P P = .03), intracranial hemorrhage (OR, 3.3; 95% CI, 1.8-6.1; P = .0001), and treatment in a Northwest hospital region (OR, 1.7; 95% CI, 1.2-2.4; P = .03). Conclusions AIS patients undergoing thrombectomy who were admitted to nonteaching hospitals on weekends were more likely to be discharged with moderate-to-severe disability than those admitted on weekdays. No weekend effect on discharge clinical outcome was seen in teaching hospitals.

We evaluated the utility of left atrial volume index (LAVI) and markers of coagulation and hemostatic activation (MOCHA) in cryptogenic stroke (CS) patients to identify those more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent stroke during follow-up

Background and Purpose: There are limited data on the optimal duration of dual antiplatelet therapy for secondary stroke prevention in patients with symptomatic intracranial atherosclerotic disease. Methods: Consecutive patients presenting with high-grade (70-99%) symptomatic intracranial stenosis from January 1, 2011, to December 31, 2013, and evaluated within 30 days of the index event were eligible for this analysis. All patients underwent treatment with aspirin plus clopidogrel for a target duration of 12 months along with aggressive medical management based on the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) protocol; all patients were given gastrointestinal prophylaxis for the duration of their aspirin and clopidogrel treatment. Clinical and safety outcomes of our cohort were compared with the medical arm of the SAMMPRIS trial cohort (n = 227). Results: Our cohort included 25 patients that met the inclusion criteria. Achievement of blood pressure and LDL cholesterol targets were similar between our cohort and the SAMMPRIS cohort. At 1 year, the rates of stroke, myocardial infarction or vascular death were 0% in our cohort and 16% in the SAMMPRIS cohort (p = 0.03). At 1 year, major bleeding rates were similar between our cohort and the SAMMPRIS cohort (4 vs. 2.2%, p = 1.0). Conclusion: A prolonged course of dual antiplatelet therapy for symptomatic intracranial atherosclerotic disease may be associated with less vascular events with no increase in hemorrhagic complications.

BACKGROUND: There is limited data on the optimal duration of dual antiplatelet therapy in combination with aggressive optimization of risk factors for secondary stroke prevention in patients with symptomatic intracranial stenosis. METHODS: Consecutive patients presenting to Emory University Hospital with high-grade (70-99%) symptomatic intracranial stenosis from January 1, 2011 to December 31, 2013 and evaluated within 30 days of the index event (stroke or TIA) were eligible for this analysis. All patients underwent treatment with aspirin plus clopidogrel for a target duration of 12 months along with aggressive medical management based on the SAMMPRIS protocol; all patients were given an H2 blocker as gastrointestinal prophylaxis for the duration of their aspirin and clopidogrel treatment. Clinical and safety outcomes of our cohort were compared with the medical arm of the SAMMPRIS trial cohort (n=227). RESULTS: Of 25 patients who met inclusion criteria, mean age was 65 +/- 14 years, 77% male, 58% white, 92% with hypertension, 100% with dyslipidemia, 15% with coronary artery disease, and 73% had stroke as their symptomatic event; baseline characteristics were similar between the Emory cohort and the SAMMPRIS cohort except for active smoking at the time of symptomatic event (Cohort 8%, SAMMPRIS 30%) and basilar site of symptomatic stenosis (Cohort 44%, SAMMPRIS 22%). Achievement of blood pressure and LDL cholesterol targets were similar between our cohort and SAMMPRIS cohort. At 1 year, rates of stroke, myocardial infarction or vascular death were 0% in our cohort vs 16% in the SAMMPRIS cohort (p = 0.03). At 1 year, major bleeding occurred in only 1 (4%) patient who had gastrointestinal bleeding requiring transfusion while taking concomitant non-steroidal anti-inflammatory medication. CONCLUSIONS: A prolonged course of dual antiplatelet therapy with aspirin and clopidogrel for at least 12 months in combination with aggressive medical management based on the SAMMPRIS protocol may be associated with reduced rates of stroke, myocardial infarction, and vascular death compared to dual antiplatelet therapy for 3 months.