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Background and Purpose— We aimed to evaluate the current practice patterns, safety and outcomes of patients who receive endovascular therapy (EVT) having mild neurological symptoms. Methods— From Jan 2010 to Jan 2018, 127,794 ischemic stroke patients were enrolled in the Florida-Puerto Rico Stroke Registry. Patients presenting within 24 hours of symptoms who received EVT were classified into mild (National Institutes of Health Stroke Scale [NIHSS] ≤5) or moderate/severe (NIHSS>5) categories. Differences in clinical characteristics and outcomes were evaluated using multivariable logistic regression. Results— Among 4110 EVT patients (median age, 73 [interquartile range=20] years; 50% women), 446 (11%) had NIHSS ≤5. Compared with NIHSS >5, those with NIHSS ≤5 arrived later to the hospital (median, 138 versus 101 minutes), were less likely to receive intravenous alteplase (30% versus 43%), had a longer door-to-puncture time (median, 167 versus 115 minutes) and more likely treated in South Florida (64% versus 53%). In multivariable analysis younger age, private insurance (versus Medicare), history of hypertension, prior independent ambulation and hospital size were independent characteristics associated with NIHSS ≤5. Among EVT patients with NIHSS ≤5, 76% were discharged home/rehabilitation and 64% were able to ambulate independently at discharge as compared with 53% and 32% of patients with NIHSS >5. Symptomatic intracerebral hemorrhage occurred in 4% of mild stroke EVT patients and 6.4% in those with NIHSS >5. Conclusions— Despite lack of evidence-based recommendations, 11% of patients receiving EVT in clinical practice have mild neurological presentations. Individual, hospital and geographic disparities are observed among endovascularly treated patients based on the severity of clinical symptoms. Our data suggest safety and overall favorable outcomes for EVT patients with mild stroke.

BACKGROUND AND PURPOSE: Atrial Fibrillation (AF) is the most common cardiac cause of ischemic stroke. However, the relation between AF and stroke care outcomes in diverse populations is understudied. We aimed to evaluate sex and race-ethnic disparities associated with AF in hospital stroke outcomes utilizing data from the FLorida PuErto Rico Atrial Fibrillation (FLiPER–AF) Stroke Study. METHODS: The study included 104,308 ischemic stroke cases with available information on AF status enrolled in a state-wide stroke registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the association between AF and stroke outcomes and the modification effects on the associations by sex and by race-ethnicity, adjusted for socio-demographic status, vascular risk factors and stroke severity. RESULTS: AF was present in 23% of ischemic stroke cases. AF was associated with worse disability at discharge (OR=1.11, 95% CI, 1.04–1.18), less discharge to home (OR=0.89, 0.85–0.92), and longer length of hospital stay (LOS>6 days, OR=1.53, 1.46–1.60). Interaction analyses showed that the association between AF and less discharge to home was stronger in women than men (p for interaction

OBJECTIVES Although disparities in stroke care and outcomes have been well documented nationally, state-based registries to monitor acute stroke care in Florida (FL) and Puerto Rico (PR) have not been established. The FL-PR Collaboration to Reduce Stroke Disparities (CReSD) was developed to evaluate race-ethnicity and regional disparities in stroke care performance. The objective of this study was to assess and compare hospital characteristics within a large quality improvement registry to identify characteristics associated with better outcomes for acute ischemic stroke care. METHODS Trained personnel from 78 FL-PR CReSD hospitals (69 FL, 9 PR) completed a 50-item survey assessing institutional characteristics across seven domains: acute stroke care resource availability, emergency medical services integration, stroke center certification, data collection and use, quality improvement processes, FL-PR CReSD recruitment incentives, and hospital infrastructure. RESULTS The rate of survey completion was 100%. Differences were observed both within FL and between FL and PR. Years participating in Get With The Guidelines-Stroke (8.9 ± 2.6 years FL vs 4.8 ± 2.4 years PR, P < 0.0001) and proportion of hospitals with any stroke center certification (94.2% FL vs 11.1% PR, P < 0.0001) showed the largest variations. Smaller hospital size, fewer years in Get With The Guidelines-Stroke, and lack of stroke center designation and acute stroke care practice implementation may contribute to poorer outcomes. CONCLUSIONS Results from our survey indicated variability in hospital- and system-level characteristics in stroke care across hospitals in Florida and Puerto Rico. Identification of these variations, which may explain potential disparities, can help clinicians understand gaps in stroke care and outcomes and targeted interventions to reduce identified disparities can be implemented.

Introduction: It is unclear whether the outcomes of late presenting patients (6-24 hrs from symptom onset) receiving endovascular thrombectomy (EVT) in routine clinical practice parallels the favorable results of recently completed randomized trials. We evaluated characteristics and outcomes of EVT utilization, over the past decade, for late and early presenting (≤ 6 hrs from onset) patients. Methods: From Jan 2010 to Jan 2019, 84,346 ischemic stroke patients presenting within 24 hrs of symptoms were enrolled in the Florida Stroke Registry. Differences in clinical characteristics, utilization trends and outcomes at discharge were compared between late vs. early presenting EVT patients using multivariable regression analysis. Results: Among 5,702 EVT patients (mean age 71±15, 48% women), 1,580 (28%) were late presenting. Late presenting EVT patients had higher rates of private insurance (39% vs 35%), dyslipidemia (39% vs 35%) and smoking (16% vs.13% ) but lower rates of Hispanic patients (19% vs 24%) and atrial fibrillation (34% vs 37%.). Late presenting patients had lower National Institute of Health Stroke Scores [median 14 (IQR=12) vs 17 (IQR=11)] and rates of thrombolysis (6% vs 58%). Short term discharge outcomes and treatment complications are shown in Table. In multivariable analysis adjusting for age, sex, stroke severity and intravenous thrombolysis, late presenting EVT patients had similar symptomatic intracerebral hemorrhage rates [OR 1.02 (0.72-1.45)] and outcomes but were less likely to ambulate independently at discharge (OR 0.80, 95% CI 0.70-0.92) compared to early presenting EVT patients. Discussion: Over the past decade, nearly a third of EVT patients were treated after 6 hours from onset. In clinical practice late EVT carries comparable safety and favorable outcome profiles to early EVT.

Background: Patients with minor ischemic stroke were largely excluded from the randomized trials of endovascular therapy (EVT) in stroke. In the Florida-Puerto Rico Registry we sought to determine the utilization of EVT in this population. Methods: From January 2010 to March 2017, 57,750 acute ischemic stroke patients within 24 hours of symptom onset were prospectively included from 88 sites in four Florida regions (south, west central, north and panhandle, east central) and Puerto Rico. Differences between minor (NIHSS ≤ 5) and moderate/severe (NIHSS>5) stroke patients who received EVT were evaluated using multivariable logistic regression with generalized estimating equations. Results: Among 2,845 EVT patients (50% women, mean age ±SD 71±14 years), 347 (12%) had NIHSS ≤ 5. As compared to NIHSS>5, minor stroke patients were younger (mean age 67 vs. 71, p5. Majority of minor stroke patients who received EVT were discharged home or to rehab (75%) while 53% of those with NIHSS>5. Conclusions: More than 1 in 10 cases that received EVT had mild neurological symptoms. Many factors including hospital expertise and time of presentation affect the use of this treatment. Further study of EVT in minor stroke is warranted.

Introduction: Primary stroke center (PSC) and comprehensive stroke center (CSC) designation in Florida aims to improve delivery of care and outcomes for stroke patients. In line with the goals of the NINDS funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study, we sought to compare ischemic stroke performance metrics by stroke center designation in participating Florida hospitals. Methods: We analyzed 74,623 cases with acute ischemic stroke from 26 CSC and 40 PSC from January 2010-April 2016. We described patient demographics, comorbidities and Get With The Guidelines-Stroke performance metrics of defect free care (compliance with 7 pre-defined performance core measures), door to CT time (DTCT) ≤25 mins and door to needle time (DTN) ≤60 mins. Results: Compared with PSC patients, CSC patients were younger (70 ± 15 vs. 71 ± 14 years, p; < 25 mins 33% vs. 31%, p Conclusion: Patients treated in CSC, compared with those treated in PSC, received better defect-free care and had lower DTCT and DTN times. Race-ethnic disparities in performance metrics are still evident in both CSC and PSC. Identification of these disparities is important to design interventions to reduce disparities and improve stroke quality of care for all.

Background: Sex is a contributing factor to inequalities in stroke care. In line with the aims of the FL-PR CReSD Study to assess Get With The Guidelines-Stroke (GWTG-S) quality improvement data, we sought to compare stroke performance metrics by sex among 9 GWTG-S participating Puerto Rico hospitals from 2010-2014. Methods: Age and NIHSS-adjusted hierarchical generalized linear models, stratified by sex, were evaluated for the following GWTG-S performance metrics: IV tPA treatment, early antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy for atrial fibrillation (AF) at discharge, statin medication at discharge, smoking cessation counseling, defect-free care (compliance with all performance measures), in addition to CT scan ≤25 minutes and door-to-IV tPA administration ≤60 minutes of hospital arrival. Results: Among 3,277 acute ischemic stroke cases, 48% were women. As compared to men, women were older (72±14 vs. 68±13 years, P Conclusions: Overall, stroke care remains lower for Puerto Rican women than men. Continued adoption of the GWTG-S quality improvement program may help reduce sex disparities in quality of care across the island.

The diagnosis of Creutzfeldt-Jakob disease (CJD) is often a challenge for most physicians given its extremely low incidence and different clinico-pathological presentations. We report the case of a 56-year old patient native to Puerto Rico suspected of sporadic Creutzfeldt-Jakob disease (sCD). The symptoms at onset were notorious for bilateral cortical blindness followed by rapidly progressive cognitive decline, visual deficit, increased levels of CSF 14-3-3 and tau along with positive brain MRI and EEG, are highly indicative of CJD. The definite diagnosis was confirmed by the National Prion Disease Pathology Surveillance Center (NPDPSC), in Cleveland, Ohio, USA. Lack of genetic mutations in the prion protein (PrP) gene, widespread histopathological changes and the accumulation of scrapie PrP (PrPSc) in the brain confirmed the diagnosis of sCJD. The patient, admitted to our institution in 2011, represents the first detailed report of sCJD in a native Puerto Rican patient living in Puerto Rico.

Background: Stroke mortality varies considerably according to race/ethnicity and place of residence. However, limited information is available about contemporary in-hospital death rates and one-year mortality in Hispanics hospitalized with acute stroke. We sought to examine the clinical characteristics, in-hospital, and one-year mortality death rates of Puerto Rican Hispanic patients hospitalized with an acute stroke. Design/Methods: Observational study using data from the Puerto Rico Stroke Registry. The study population consisted of patients hospitalized with an initial (first) acute stroke in 11 medical centers of Puerto Rico in 2007. In-hospital mortality was calculated as the percentage of patients hospitalized with an initial acute stroke who died during the index hospitalization, one-year all-cause mortality was determined through the review of death records in the Puerto Rico Department of Health Vital Statistics Records. Results: Of the 1528 consecutive patients hospitalized with an acute stroke, 1299 (85%) had an ischemic stroke. The mean age was 70 (+/- 28) years, and 53% were women. Patients hospitalized with an acute stroke had a considerable prevalence of comorbidities: 86% had hypertension, 52% had diabetes, 26% had hyperlipidemia, and 9% were current smokers. The overall in-hospital mortality rate was 11% and the one-year all-cause mortality rate was 26%. In comparison with men, women were older (71 years vs. 68 years), more likely to be hypertensive (89% vs. 83%, p=0.001), had similar odds of dying during hospitalization (OR=1.1 [95%CI= 0.8-1.6]), and more likely to die one year after hospital discharge (OR=1.3 [95%CI= 1.1-1.5]). Discussion: Our findings indicate a high in-hospital and one year mortality rates after an initial acute stroke in Hispanic Puerto Ricans. Given the high, short and long-term, death rates associated with acute stroke, monitoring the clinical characteristics, death rates and factors associated with an increased risk of dying remains warranted.