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Fibromuscular dysplasia is a nonatherosclerotic, under-recognized disorder primarily seen in middle-aged women. It can lead to several complications, such as hypertension, headaches, dissections, aneurysms, myocardial infarctions, and cerebrovascular accidents, to name a few. This article provides a comprehensive review of current literature on epidemiology, etiology, diagnosis, treatment, and long-term surveillance and fibromuscular dysplasia management. In addition, it renders the role of education and prevention for patients living with this condition and family screening. Lastly, it emphasizes the importance of a comprehensive multidisciplinary care model and patient input, given the complexity of this disease and its systemic presence and protean manifestations.

BackgroundThe benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3.MethodsThis is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage.ResultsThe unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041).ConclusionsComplete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

A health care crisis such as the coronavirus disease 2019 (COVID-19) pandemic requires allocation of hospital staff and resources on short notice. Thus, new and sometimes less experienced team members might join the team to fill in the gaps. This scenario can be particularly challenging in endovascular stroke treatment, which is a highly specialized task that requires seamless cooperation of numerous health care workers across various specialties and professions. This document is intended for stroke teams who face the challenge of integrating new team members into endovascular stroke-treatment workflows during the COVID-19 pandemic or any other global health care emergency. It discusses the key strategies for smooth integration of new stroke-team members in a crisis situation: 1) transfer of key knowledge (simple take-home messages), 2) open communication and a nonjudgmental atmosphere, 3) strategic task assignment, and 4) graded learning and responsibility. While these 4 key principles should generally be followed in endovascular stroke treatment, they become even more important during health care emergencies such as the COVID-19 pandemic, when health care professionals have to take on new and additional roles and responsibilities in challenging working environments for which they were not specifically trained.

Facial weakness is a symptom commonly associated to lack of facial muscle control due to neurological injury. Several diseases are associated with facial weakness such as stroke and Bell's palsy. The use of digital imaging through mobile phones, tablets, personal computers and other devices could provide timely opportunity for detection, which if accurate enough can improve treatment by enabling faster patient triage and recovery progress monitoring. Most of the existing facial weakness detection approaches from static images are based on facial landmarks from which geometric features can be calculated. Landmark-based methods, however, can suffer from inaccuracies in face landmarks localization. In this study, We also experimentally evaluate the performance of several feature extraction methods for measuring facial weakness, including the landmark-based features, as well as intensity-based features on a neurologist-certified dataset that comprises 186 images of normal, 125 images of left facial weakness, and 126 images of right facial weakness. We demonstrate that, for the application of facial weakness detection from single (static) images, approaches that incorporate the Histogram of Oriented Gradients (HoG) features tend to be more accurate.

OBJECTIVEThe utility of ICP monitoring and its benefit with respect to outcomes after ICH is unknown. The aim of this study was to compare intracerebral hemorrhage (ICH) outcomes in patients who underwent intracranial pressure (ICP) monitoring to those who were managed by care-guided imaging and/or clinical examination alone.METHODSThis was a retrospective analysis of data from the Ethnic/Racial variations of Intracerebral Hemorrhage (ERICH) study between 2010 and 2015. ICH patients who underwent ICP monitoring were propensity-score matched, in a 1:1 ratio, to those who did not undergo ICP monitoring. The primary outcome was 90-day mortality. Secondary outcomes were in-hospital mortality, hyperosmolar therapy use, ICH evacuation, length of hospital stay, and 90-day modified Rankin Scale (mRS) score, excellent outcome (mRS score 0–1), good outcome (mRS score 0–2), Barthel Index, and health-related quality of life (HRQoL; measured by EQ-5D and EQ-5D visual analog scale [VAS] scores). A secondary analysis for patients without intraventricular hemorrhage was performed.RESULTSThe ICP and no ICP monitoring cohorts comprised 566 and 2434 patients, respectively. The matched cohorts comprised 420 patients each. The 90-day and in-hospital mortality rates were similar between the matched cohorts. Shift analysis of 90-day mRS favored no ICP monitoring (p < 0.001). The rates of excellent (p < 0.001) and good (p < 0.001) outcome, Barthel Index (p < 0.001), EQ-5D score (p = 0.026), and EQ-5D VAS score (p = 0.004) at 90 days were lower in the matched ICP monitoring cohort. Rates of mannitol use (p < 0.001), hypertonic saline use (p < 0.001), ICH evacuation (p < 0.001), and infection (p = 0.001) were higher, and length of hospital stay (p < 0.001) was longer in the matched ICP monitoring cohort. In the secondary analysis, the matched cohorts comprised 111 patients each. ICP monitoring had a lower rate of 90-day mortality (p = 0.041). Shift analysis of 90-day mRS, Barthel Index, and HRQoL metrics were comparable between the matched cohorts.CONCLUSIONSThe findings of this study do not support the routine utilization of ICP monitoring in patients with ICH.

Background and Purpose— Perihematomal edema (PHE) is a promising surrogate marker of secondary brain injury in patients with spontaneous intracerebral hemorrhage, but it can be challenging to accurately and rapidly quantify. The aims of this study are to derive and internally validate a fully automated segmentation algorithm for volumetric analysis of PHE. Methods— Inpatient computed tomography scans of 400 consecutive adults with spontaneous, supratentorial intracerebral hemorrhage enrolled in the Intracerebral Hemorrhage Outcomes Project (2009–2018) were separated into training (n=360) and test (n=40) datasets. A fully automated segmentation algorithm was derived from manual segmentations in the training dataset using convolutional neural networks, and its performance was compared with that of manual and semiautomated segmentation methods in the test dataset. Results— The mean volumetric dice similarity coefficients for the fully automated segmentation algorithm were 0.838±0.294 and 0.843±0.293 with manual and semiautomated segmentation methods as reference standards, respectively. PHE volumes derived from the fully automated versus manual (r=0.959; P P P P P Conclusions— The fully automated segmentation algorithm accurately quantified PHE volumes from computed tomography scans of supratentorial intracerebral hemorrhage patients with high fidelity and greater efficiency compared with manual and semiautomated segmentation methods. External validation of fully automated segmentation for assessment of PHE is warranted.

Statins, a common drug class for treatment of dyslipidemia, may be neuroprotective for spontaneous intracerebral hemorrhage (ICH) by targeting secondary brain injury pathways in the surrounding brain parenchyma. Statin-mediated neuroprotection may stem from downregulation of mevalonate and its derivatives, targeting key cell signaling pathways that control proliferation, adhesion, migration, cytokine production, and reactive oxygen species generation. Preclinical studies have consistently demonstrated the neuroprotective and recovery enhancement effects of statins, including improved neurologic function, reduced cerebral edema, increased angiogenesis and neurogenesis, accelerated hematoma clearance, and decreased inflammatory cell infiltration. Retrospective clinical studies have reported reduced perihematomal edema, lower mortality rates, and improved functional outcomes in patients who were taking statins before ICH. Several clinical studies have also observed lower mortality rates and improved functional outcomes in patients who were continued or initiated on statins after ICH. Subgroup analysis of a previous randomized trial has raised concerns of a potentially elevated risk of recurrent ICH in patients with previous hemorrhagic stroke who are administered statins. However, most statin trials failed to show an association between statin use and increased hemorrhagic stroke risk. Variable statin dosing, statin use in the pre-ICH setting, and selection biases have limited rigorous investigation of the effects of statins on post-ICH outcomes. Future prospective trials are needed to investigate the association between statin use and outcomes in ICH.

OBJECTIVE A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) suggested that medical management afforded outcomes superior to those following intervention for unruptured arteriovenous malformations (AVMs), but its findings have been controversial. Subsequent studies of AVMs that would have met the eligibility requirements of ARUBA have supported intervention for the management of some cases. The present meta-analysis was conducted with the object of summarizing interventional outcomes for ARUBA-eligible patients reported in the literature. METHODS A systematic literature search (PubMed, Web of Science, Google Scholar) for AVM intervention studies that used inclusion criteria identical to those of ARUBA (age ≥ 18 years, no history of AVM hemorrhage, no prior intervention) was performed. The primary outcome was death or symptomatic stroke. Secondary outcomes included AVM obliteration, hemorrhage, death, and poor outcome (modified Rankin Scale score ≥ 2 at final follow-up). Bias assessment was performed with the Newcastle-Ottawa Scale, and the results were synthesized as pooled proportions. RESULTS Of the 343 articles identified through database searches, 13 studies met the inclusion criteria, yielding an overall study cohort of 1909 patients. The primary outcome occurred in 11.2% of patients (pooled = 11%, 95% CI 8%–13%). The rates of AVM obliteration, hemorrhage, poor outcome, and death were 72.7% (pooled = 78%, 95% CI 70%–85%), 8.4% (pooled = 8%, 95% CI 6%–11%), 9.9% (pooled = 10%, 95% CI 7%–13%), and 3.5% (pooled = 2%, 95% CI 1%–4%), respectively. Annualized primary outcome and hemorrhage risks were 1.85 (pooled = 2.05, 95% CI 1.31–2.94) and 1.34 (pooled = 1.41, 95% CI 0.83–2.13) per 100 patient-years, respectively. CONCLUSIONS Intervention for unruptured AVMs affords acceptable outcomes for appropriately selected patients. The risk of hemorrhage following intervention compared favorably to the natural history of unruptured AVMs. The included studies were retrospective and varied in treatment and AVM characteristics, thereby limiting the generalizability of their data. Future studies from prospective registries may clarify patient, nidus, and intervention selection criteria that will refine the challenging management of patients with unruptured AVMs.

Introduction: In acute ischemic stroke (AIS), hyperglycemia promotes enhanced blood brain barrier permeability, tissue acidosis, and oxygen free radicals, and may increase risk of post-tPA symptomatic intracerebral hemorrhage (sICH). We performed a pre-planned analysis from the SHINE trial (NCT01369069) to examine the effects of blood glucose (BG) control on post-thrombolysis ICH. Hypothesis: In AIS, (1) post-tPA BG measures are associated with sICH, and (2) intensive insulin therapy can reduce the risk of sICH. Methods: Hyperglycemic AIS patients Results: Of the 1151 SHINE participants, 725 (63%) received IV tPA (median age 65, 46% women, 29% Black, 18% Hispanic). Median NIHSS was 7, baseline BG 187 (IQR 153-247) mg/dL, and onset to tPA was 2.2 hrs (1.6-2.9). Post-tPA sICH occurred in 3.6% (3% intensive vs. 4.3% standard, OR 1.10, 95% CI 0.60-2.01, p=0.697). There was a consistent association between post-tPA BG measures and sICH. In the first 12 hours, every 10 mg/dL increase in median BG increased odds of sICH by ~8% (OR 1.08, 95% CI 1.03-1.14, p=0.004), and a greater percentage of BG measures 80-130 mg/dL decreased odds of sICH by ~11% (0.89, 95% CI 0.80-0.99, p=0.030). Conclusion: In this pre-planned analysis, intensive insulin therapy was not associated with a reduced risk of post-tPA sICH. However, post-tPA hyperglycemia was associated with a higher risk of sICH overall, particularly in the early post-treatment period. These data provide class IIa, level B-R evidence that post-tPA glucose levels between 80-130 mg/dL are associated with decreased risk of sICH. Acknowledgments: NIH-NINDS U01 NS069498.

Background: Posterior circulation stroke (PCS) accounts for ~20% of ischemic strokes. Existing EMS screening tools lack accuracy in the diagnosis of PCS. We aim to develop an automated screening tool to detect abnormal eye movements in patients presenting with PCS. Methods: As an initial step, we built a portable platform called RoADIE (Rolling Apparatus to Detect Impairment of the Eyes), equipped with eye-tracking software to acquire gaze data from patients presenting with PCS, acute vestibular syndrome, and normal controls. We first performed a validation study in 19 healthy controls comparing calibration (C) vs non-calibration (NC) techniques. Eye movements were captured using a standard H-Test exam. The NC condition was performed first for each volunteer to avoid a learning effect. Correlation between C and NC tests was determined using the Spearman coefficient (r). Results: Conjugate gaze (i.e. ability of eyes to track in unison) demonstrated strong correlation along the horizontal [r = 0.976 (C), 0.922 (NC)] and vertical axes [r= 0.866 (C), 0.881(NC)]. Smooth pursuit (i.e. ability of each eye to track moving target) also showed strong correlation in the horizontal plane: right eye [r = 0.945 (C), 0.946 (NC), left eye [r=0.945 (C), 0.943 (NC)]. Vertical tracking showed moderate correlation: right eye [r=0.652 (C), 0.575 (NC), left eye [r=0.678 (C), 0.550 (NC)]. Conclusion: In this initial validation test of a portable eye tracking platform, we demonstrated strong correlation for both conjugate gaze and smooth pursuit in the horizontal axis, and moderate correlation for eye tracking in the vertical axis. Given similar performance in non-calibrated tests, a calibration procedure may not be necessary for future data capture. Next steps will include validation of the eye tracking device in prospective patients presenting with PCS and acute vestibular syndrome. Acknowledgement: Funding support through AHA Innovative Project Award 19IPLOI34760692

Automated eye tracking technology could enhance diagnosis and treatment for many neurological diseases, including posterior circulation stroke. Much of the current literature focuses on gaze estimation through a form of calibration. Unlike other fields, medicine has a clear need to better track eye symmetry during movement for better detection of abnormal conjugacy, ductions, and vestibulo-ocular function in a variety of neurological diseases. However, patients with neuro-ocular deficits may have a difficult time completing a calibration procedure due to inattention and other associated neurologic deficits. Here, we investigate the need for calibration to measure the symmetry of eye movements in healthy individuals including testing fixations, smooth pursuits, and saccades. The results of this feasibility study suggest that calibration may not be necessary to measure and track binocular eye movements in tandem. The structure or shape which the eyes draw during visual tracking remain intact even without a calibration procedure. The preliminary study suggests that this technology can be deployed without a calibration procedure within this clinical context. Further research is needed to validate these findings in populations with neuro-ophthalmologic disease, including posterior circulation stroke.

Objective: Facial weakness is a common sign of neurological diseases such as Bell's palsy and stroke. However, recognizing facial weakness still remains as a challenge, because it requires experience and neurological training. Methods: We propose a framework for facial weakness detection, which models the temporal dynamics of both shape and appearance-based features of each target frame through a bi-directional long short-term memory network (Bi-LSTM). The system is evaluated on a “in-the-wild”video dataset that is verified by three board-certified neurologists. In addition, three emergency medical services (EMS) personnel and three upper level residents rated the dataset. We compare the evaluation of the proposed algorithm with other comparison methods as well as the human raters. Results: Experimental evaluation demonstrates that: (1) the proposed algorithm achieves the accuracy, sensitivity, and specificity of 94.3%, 91.4%, and 95.7%, which outperforms other comparison methods and achieves the equal performance to paramedics; (2) the framework can provide visualizable and interpretable results that increases model transparency and interpretability; (3) a prototype is implemented as a proof-of-concept showcase to show the feasibility of an inexpensive solution for facial weakness detection. Conclusion: The experiment results suggest that the proposed framework can identify facial weakness effectively. Significance: We provide a proof-of-concept study, showing that such technology could be used by non-neurologists to more readily identify facial weakness in the field, leading to increasing coverage and earlier treatment.

Dissections and aneurysms are two of the more common nonatherosclerotic arteriopathies of the cerebrovascular system and a significant contributor to neurovascular complications, particularly in the young. Specifically, ruptured intracranial aneurysms (IA) account for nearly 500,000 cases of subarachnoid hemorrhage annually with a 30-day mortality approaching 40% and survivors suffering often permanent neurologic deficits and disability. Unruptured IAs require dedicated assessment of risk and often warrant serial radiologic monitoring. Cervical artery dissection, affecting the carotid and vertebral arteries, accounts for nearly 20% of strokes in young and middle-aged adults. While approximately 70% of cervical artery dissection (CeAD) cases present with stroke or TIA, additional neurologic complications include severe headache and neck pain, oculosympathetic defect (i.e., partial Horner's syndrome), acute vestibular syndrome, and rarely lower cranial nerve palsies. Both aneurysms and dissections of the cerebrovascular system may occur frequently in patients with syndromic connective tissue disorders; however, the majority of cases are spontaneously occurring or mildly heritable with both polygenic and environmental associations. Fibromuscular dysplasia, in particular, is commonly associated with both risk of CeAD and IA formation. Further research is needed to better understand the pathophysiology of both IA and CeAD to better understand risk, improve treatments, and prevent devastating neurologic complications.

In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.

Patients who survive the initial ictus of spontaneous intracerebral hemorrhage (ICH) remain vulnerable to subsequent injury of the perilesional parenchyma by molecular and cellular responses to the hematoma. Secondary brain injury after ICH, which contributes to long-term functional impairment and mortality, has emerged as an attractive therapeutic target. This review summarizes preclinical and clinical evidence for neuroprotective therapies targeting secondary injury pathways following ICH. A focus on therapies with pleiotropic antiinflammatory effects that target thrombin-mediated chemotaxis and inflammatory cell migration has led to studies investigating statins, anticholinergics, sphingosine-1-phosphate receptor modulators, peroxisome proliferator activated receptor gamma agonists, and magnesium. Attempts to modulate ICH-induced blood-brain barrier breakdown and perihematomal edema formation has prompted studies of nonsteroidal antiinflammatory agents, matrix metalloproteinase inhibitors, and complement inhibitors. Iron chelators, such as deferoxamine and albumin, have been used to reduce the free radical injury that ensues from erythrocyte lysis. Stem cell transplantation has been assessed for its potential to enhance subacute neurogenesis and functional recovery. Despite promising preclinical results of numerous agents, their outcomes have not yet translated into positive clinical trials in patients with ICH. Further studies are necessary to improve our understanding of the molecular events that promote damage and inflammation of the perihematomal parenchyma after ICH. Elucidating the temporal and pathophysiologic features of this secondary brain injury could enhance the clinical efficacy of neuroprotective therapies for ICH.

A 68-year-old man presented with fever and altered mental status 4 weeks following an ablation procedure for atrial fibrillation (AF). Head CT revealed multifocal embolic-appearing infarcts. Chest CT revealed air in the left atrial appendage (figure). These findings led to a diagnosis of cardioembolic stroke secondary to septic emboli from an atrioesophageal fistula (AEF). AEF may occur in up to 0.25% of AF ablations and manifests 1–6 weeks postprocedure with fever, stroke, and/or end-organ damage from septic emboli.1 Transthoracic echocardiogram and chest CT should be considered to rule out AEF in patients with neurologic decline following AF ablation.1,2

International medical graduates (IMGs), individuals who graduated from medical school outside of the United States or Canada, constitute 31.3% of active neurologists and one-third of current neurology trainees. Although three-fourths of IMG neurology trainees are not US citizens, they are an integral part of our trainee and practice workforce. IMGs play a vital role in providing greater access to health care for millions of patients, particularly in traditionally underserved regions and in the face of a current global health care crisis. With this article, we outline some of the unique challenges faced by immigrant, US-trained neurologists as they seek to provide neurologic care across the country, including preparing and applying for residency, securing authorization to remain in the United States to practice, and positioning themselves for successful careers in academic and private practice. We also call for advocacy and legislation to help reduce these barriers as a means to address the increasing physician workforce gap.

The coronavirus disease 2019 (COVID-19) pandemic has in some regions overwhelmed the capacity and staffing needs of healthcare systems, necessitating the provision of resources and staff from different disciplines to aid COVID treatment teams. Stroke centers have multidisciplinary clinical and procedural expertise to support COVID treatment teams. Staff safety and patient safety are essential, as are open lines of communication between stroke center leaders and hospital leadership in a pandemic where policies and procedures can change or evolve rapidly. Support needs to be allocated in a way that allows for the continued operation of a fully capable stroke center, with the ability to adjust if stroke center volume or staff attrition requires.

Abstract: The coronavirus disease 2019 (COVID-19) pandemic has broad implications on stroke patient triage. Emergency medical services providers have to ensure timely transfer of patients while minimizing the risk of infectious exposure for themselves, their co-workers, and other patients. This statement paper provides a conceptual framework for acute stroke patient triage and transfer during the COVID-19 pandemic and similar healthcare emergencies in the future.

A 50-year-old woman underwent embolization of an anterior communicating artery aneurysm, via the left internal carotid artery, using the penumbra SMART coil system. Follow-up CT angiography at 16 months revealed a 2-mm hyperdense lesion in the left parietal lobe (figure 1). MRI confirmed multiple punctate enhancing foci with surrounding edema favored to represent nonischemic cerebral enhancing (NICE) lesions (figure 2). NICE lesions are rare complications of coil embolization putatively associated with nickel allergy or coil emboli,1 although the SMART coil system is platinum based. The patient remained asymptomatic and further workup was withheld. Follow-up MRI at 1.5 months showed resolution.

Brain arteriovenous malformations (AVMs) are anomalous direct shunts between cerebral arteries and veins that convalesce into a vascular nidus. The treatment strategies for AVMs are challenging and variable. Intracranial hemorrhage and seizures comprise the most common presentations of AVMs. However, incidental AVMs are being diagnosed with increasing frequency due to widespread use of noninvasive neuroimaging. The balance between the estimated cumulative lifetime hemorrhage risk vs the risk of intervention is often the major determinant for treatment. Current management options include surgical resection, embolization, stereotactic radiosurgery (SRS), and observation. Complete nidal obliteration is the goal of AVM intervention. The risks and benefits of interventions vary and can be used in a combinatorial fashion. Resection of the AVM nidus affords high rates of immediate obliteration, but it is invasive and carries a moderate risk of neurologic morbidity. AVM embolization is minimally invasive, but cure can only be achieved in a minority of lesions. SRS is also minimally invasive and has little immediate morbidity, but AVM obliteration occurs in a delayed fashion, so the patient remains at risk of hemorrhage during the latency period. Whether obliteration can be achieved in unruptured AVMs with a lower risk of stroke or death compared with the natural history of AVMs remains controversial. Over the past 5 years, multicenter prospective and retrospective studies describing AVM natural history and treatment outcomes have been published. This review provides a contemporary and comprehensive discussion of the natural history, pathobiology, and interventions for brain AVMs.

Background: Perihematomal edema (PHE) is a promising marker of secondary injury in patients with spontaneous intracerebral hemorrhage (ICH). It can be challenging to accurately and rapidly quantify. The aims of this study are to derive and internally validate a fully automated segmentation algorithm for volumetric PHE analysis. Methods: Inpatient CT scans of 400 consecutive adults with spontaneous supratentorial ICH enrolled in the Intracerebral Hemorrhage Outcomes Project (2009-2018) were separated into training (n=360) and test (n=40) datasets. A fully automated algorithm was derived from manual segmentations in the training dataset using convolutional neural networks and its performance was compared to manual and semi-automated segmentation methods in the test dataset. Results: The mean volumetric Dice similarity coefficients for the fully automated algorithm were 0.838±0.294 and 0.843±0.293 with manual and semi-automated segmentations as reference standards, respectively. PHE volumes derived from fully automated vs. manual (R 2 =0.959;p2 =0.960;p2 =0.961; p Conclusions: The fully automated algorithm accurately quantified PHE from CT scans of supratentorial ICH patients with high fidelity and greater efficiency compared with manual and semi-automated segmentation methods.

Introduction: CTP and MRI are increasingly used to assess endovascular thrombectomy (EVT) candidacy in large vessel occlusion stroke. Unfortunately, availability of these advanced neuroimaging techniques is not widespread and this can lead to over-triage to EVT-capable centers. Hypothesis: ASPECTS scoring applied to computed tomography angiography source images (CTA-SI) will be predictive of final infarct volume (FIV) and functional outcome. Methods: We reviewed data from consecutive patients undergoing EVT at our institution for anterior circulation occlusion between 01/14 - 01/19. We recorded demographics, comorbidities, NIHSS, treatment time parameters, and outcomes as defined by mRS (0-2 = good outcome). Cerebrovascular images were assessed by outcome-blinded raters and collateral score, TICI score, FIV, and both CT and CTA-SI ASPECTS scores were noted. Patients were grouped by ASPECTS score into low (0-4), intermediate (5-7), and high (8-10) for some analyses. FIV was predicted using a linear regression with NIHSS, good reperfusion (TICI 2b/3), collateral score, CT to groin puncture, CT and CTA-SI ASPECTS as independent variables. After excluding those with baseline mRS≥2, a binary logistic regression was performed including covariates of age, NIHSS, good reperfusion, and diabetes (factors significant at p Results: Analysis included 137 patients for FIV and 102 for outcome analysis (35 excluded for baseline mRS≥ 2). Linear regression found CTA-SI ASPECTS (Beta -10.8, p=0.002), collateral score (Beta -42.9, p=0.001) and good reperfusion (Beta 72.605, p=0.000) were independent predictors of FIV. Relative to the low CTA-SI ASPECTS group, the high CTA-SI ASPECTS group was more likely to have good outcome (OR 3.75 [95% CI 1.05-13.3]; p=0.41). CT ASPECTS was not predictive of FIV or good outcome. Outcomes: In those undergoing EVT for anterior circulation occlusion, CTA-SI ASPECTS is predictive of both FIV and functional outcome, while CT ASPECTS predicts neither. CTA-SI ASPECTS holds promise as a lower-cost, more widely available option for triage of patients with large vessel occlusion. Further study is needed comparing CTA-SI ASPECTS to CTP parameters.

This chapter provides a comprehensive review of carotid artery fibromuscular dysplasia (FMD), an idiopathic, segmental, non-inflammatory, non-atherosclerotic vasculopathy characteristically seen in the mid- or distal segments of the internal carotid artery and often diagnosed with non-invasive vascular imaging. Although the etiological risk factors associated with carotid FMD remain largely unclear, recent genomics studies confirm shared associations with cervical artery dissection, migraine, and an inverse association with atherosclerotic disease. Despite a higher risk for carotid artery dissection and intracranial aneurysms, the overall natural history of carotid FMD is generally favorable and supports reassurance for patients in whom it is discovered incidentally. Management of migraine and pulsatile tinnitus can improve quality of life for symptomatic patients. Ongoing collaborative research and involvement in patient registries is needed to better understand the pathophysiology and optimal prevention and management of its cerebrovascular manifestations.

The aims of this single-center, retrospective cohort study are to assess the outcomes of endovascular mechanical thrombectomy (EMT) for acute ischemic stroke (AIS) and determine predictors of 30-day mortality at an academic comprehensive stroke center (CSC).We retrospectively collected data from consecutive patients who underwent EMT for AIS at our institution between April 2016 and January 2018. Primary outcome was defined as mortality within 30 days from EMT. Successful revascularization was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b-3. Statistical analyses were performed to identify predictors of 30-day mortality.The study cohort was comprised 57 patients (51% male) with mean age of 72 years. Intravenous tissue plasminogen activator was administered in 51%. The median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and National Institutes of Health Stroke Scale (NIHSS) score were 8 and 20, respectively. The 30-day mortality rate was 39%. Univariate analyses found that older age (mean 77 vs. 68 years, p = 0.022), higher baseline NIHSS score (median 23 vs. 19, p = 0.032), NIHSS score at 24 h after EMT (median 14.5 vs. 7.5, p 0.001), and lower rates of successful revascularization (59% vs. 89%, p = 0.021) were associated with 30-day mortality.We observed a moderate rate of 30-day mortality after EMT at an academic CSC. Older age, higher baseline NIHSS score, higher NIHSS score at 24 h after thrombectomy, and lower rates of successful revascularization were predictive of 30-day mortality in univariate analysis. Further efforts to identify modifiable risk factors of mortality are warranted.

Background and Purpose— The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods— Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers’ comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results— These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions— These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Background Endovascular mechanical thrombectomy (EMT) is the standard of care for eligible patients presenting with anterior circulation acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO). The aim of this systematic review and meta-analysis is to compare the outcomes between patients undergoing general anesthesia (GA) versus conscious sedation (CS) for these procedures. Methods A literature review was performed to identify studies reporting the EMT outcomes of AIS patients who underwent GA or CS for the procedure. Baseline, treatment, and outcomes data were analyzed. Good outcome was defined as a modified Rankin Scale score of 0–2 at 3 months, and successful reperfusion was defined as modified thrombolysis in cerebral infarction grade of 2b–3. Results Nine studies, comprising a total of 1379 patients treated with GA (n = 761) or CS (n = 618) for EMT, were included. Based on pooled data, GA achieved good outcome in 35% and successful reperfusion in 81%, whereas CS achieved good outcome in 41% and successful reperfusion in 75%. Meta-analyses showed no significant differences in the rates of good outcome (P = 0.51) or successful reperfusion (P = 0.39) between the GA and CS groups. The rates of pneumonia were significantly higher in the GA group (21% vs. 11%; P = 0.01). Conclusions The use of either GA or CS during EMT for patients with anterior circulation acute ELVO does not yield significantly different rates of functional independence at 3 months.

Background and Purpose: The majority of published data in cervical artery dissection (CeAD), a common cause of stroke in young adults, derive from populations of European ancestry (EA), including a recent genome-wide study identifying an association with the rs9349379 polymorphism of the PHACTR1 gene. Little is known about CeAD in individuals of African ancestry (AA) despite robust epidemiological data showing increased risk of stroke at younger ages. We hypothesize that AA patients with CeAD have different epidemiology and clinical profiles compared to those of EA, and a different genetic architecture related to rs9349379 of the PHACTR1 gene. Methods: We searched a single-center database of CeAD to identify AA and EA patients. We compared differential prevalence of CeAD versus all young stroke between AA and EA patients. We characterized clinical profiles via electronic medical record review. Data include descriptive statistics reported as medians or percentages. We also obtained publicly available allele frequencies of rs9349379 in AA and EA populations. Results: AA patients comprise 7% of CeAD cases and 27% of young stroke cases while EA patients comprise 90% of CeAD cases and 70% of young stroke cases. Prevalence of hypertension, diabetes mellitus, and hyperlipidemia were 74, 30, and 50%, respectively, in AA patients compared to 37, 6, and 25% in EA patients. Allele frequencies for the CeAD risk allele, rs9349379(A), are higher in AA populations compared to EA populations. Conclusion: AA patients represent a smaller proportion of CeAD cases compared to young stroke cases at our center. AA patients suffering CeAD have higher prevalence of both vascular risk factors and frequency of the CeAD risk allele compared to EA patients. These findings suggest a complex interplay between traditional vascular risk factors and genetic predisposition underlying CeAD pathogenesis. Further prospective research is needed to clarify these associations and disparities.

As part of a scheduled review of the Common Program Requirements, the Accreditation Council for Graduate Medical Education (ACGME) recently implemented amendments to Section VI, “Resident Duty Hours in the Learning and Working Environment,” which went into effect on July 1, 2017.1 Prior to July 1, changes to Section VI of the Common Program Requirements were last implemented by the ACGME in 2011. The purpose of this review is to discuss the recent changes to Section VI of the ACGME Common Program Requirements.

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.

Introduction The benefit of endovascular mechanical thrombectomy (EMT) for acute distal occlusions of the middle cerebral artery M2 segment is incompletely defined. The aim of this systematic review is to analyze the recent literature regarding EMT for acute M2 occlusions. Methods We reviewed the literature to identify all studies of patients with acute M2 occlusions who underwent EMT that were published after January 1, 2015. Excellent and good outcomes were defined as modified Rankin Scale score of 0–1 and 0–2, respectively, at 3 months. Successful reperfusion was defined as modified Thrombolysis In Cerebral Infarction (mTICI) score of 2b–3. Results Eight studies, comprising 630 EMT-treated patients with acute M2 occlusions, were included in the analysis. The median National Institute of Health Stroke Scale score ranged from 10 to 16, and the median Alberta Stroke Program Computed Tomography Score ranged from 9 to 10. Excellent and good outcomes at 3-month follow-up were observed in 40% and 62%, respectively, of patients with acute M2 occlusion who underwent EMT, with a mortality of 11%. Successful reperfusion was achieved in 78% of cases. Postprocedural intracerebral hemorrhage (ICH) occurred in 14% of patients, including a symptomatic ICH rate of 5%. Conclusions EMT for acute M2 occlusion affords functional independence to most patients, with a modest rate of symptomatic ICH. However, compared with the natural history of distal MCA occlusions, the benefit of M2 thrombectomy using stent retriever or direct aspiration techniques remains unclear.

Background and Purpose— von Willebrand factor (vWF) plays an important role in thrombus formation during cerebrovascular damage. We sought to investigate the potential role of circulating vWF in recurrent cerebrovascular events and identify genetic contributors to variation in vWF level in an ischemic stroke population. Methods— We analyzed the effect of circulating vWF on risk of recurrent stroke using survival models in the VISP trial (Vitamin Intervention for Stroke Prevention) and the use of vWF in reclassification over traditional factors. We conducted a genome-wide association study) with imputation, based on 1000 Genomes Project data, for circulating vWF levels and then interrogated loci previously associated with vWF levels. We performed expression quantitative trait locus analysis for vWF across different tissues. Results— Elevated vWF levels were associated with increased risk for recurrent stroke in VISP. Adding vWF to traditional clinical parameters also improved recurrent stroke risk prediction. We identified single-nucleotide polymorphisms significantly associated with circulating vWF at the ABO locus ( P −8 ) and replicated findings from previous genetic associations of vWF levels in humans. Expression quantitative trait locus analyses demonstrate that most associated ABO single-nucleotide polymorphisms were also associated with vWF gene expression. Conclusions— Elevated vWF levels are associated with recurrent stroke in VISP. In the VISP population, genetic determinants of vWF levels that impact vWF gene expression were identified. These data add to our knowledge of the pathophysiologic and genetic basis for recurrent stroke risk and may have implications for clinical care decision making.

Variation in the phosphatase and actin regulator-1 (PHACTR1) gene, a downstream regulator of the endothelin-1 (EDN1) gene, has been implicated in the pathogenesis of several related vascular phenotypes including atherosclerotic coronary artery disease, non-atherosclerotic coronary artery dissection, and carotid artery dissection, though it has not been studied in carotid atherosclerosis. We analyzed differential expression of PHACTR1 and EDN1 between atheromatous and non-atheromatous carotid artery tissue within the same individual and found lower levels of PHACTR1 expression in the atheromatous carotid tissue.

To investigate potential association between collateral arterial supply and stroke in patients with isolated internal carotid artery dissection (iCeAD). We hypothesized a lower risk of stroke in patients with more robust collateral supply. This is a single-center, retrospective review of iCeAD patients between 1994 and 2018. iCeAD patients with sufficient neuroimaging data were included. Patients were categorized based on cerebral infarction (stroke) on neuroimaging. The collaterals score, ranging from 0 to 8 with higher scores indicating more robust collaterals, was assessed based on contributions from leptomeningeal arteries (0-2 points), anterior communicating artery (0-2 points) and anterior cerebral artery A1 segment (0-2 points), and posterior communicating artery (0-2 points). The study included 62 iCeAD patients, comprising 33 and 29 patients in the stroke and no stroke groups, respectively. Neurological motor deficit (p 0.001) and internal carotid artery occlusion (p = 0.033) were independent predictors of stroke. More robust collaterals was associated with lower stroke risk (p = 0.032) in univariable analysis, but not after adjustment for baseline differences. The collaterals score performed poorly in receiver-operating characteristics (ROC) curve analysis, with area under the ROC (AUROC) curve of 0.640. A collaterals score of4 had a sensitivity and specificity of 89.7% and 36.4% for no stroke, respectively. The covariate-adjusted AUROC curve was 0.514. Collateral circulation appeared to be a poor predictor of cerebral infarction in patients with isolated iCeAD. Future studies in larger, independent cohorts are needed to better understand the interaction of collaterals with stroke in cervical artery dissection.

Background and Purpose— Although cigarette use may be a risk for intracerebral hemorrhage (ICH), animal models suggest that nicotine has a potential neuroprotective effect. The aim of this multicenter study is to determine the effect of smoking history on outcome in ICH patients. Methods— We analyzed prospectively collected data from the Ethnic/Racial Variations of Intracerebral Hemorrhage study and included patients with smoking status data in the analysis. Patients were dichotomized into nonsmokers versus ever-smokers, and the latter group was further categorized as former (>30 days before ICH) or current (≤30 days before ICH) smokers. The primary outcome was 90-day modified Rankin Scale score shift analysis. Secondary outcomes were in-hospital mortality and mortality, Barthel Index, and self-reported health status measures at 90 days. Results— The overall study cohort comprised 1509 nonsmokers and 1423 ever-smokers (841 former, 577 current, 5 unknown). No difference in primary outcome was observed between nonsmokers versus ever-smokers (adjusted odds ratio [aOR], 1.041; 95% CI, 0.904–1.199; P =0.577). No differences in primary outcome were observed between former (aOR, 0.932; 95% CI, 0.791–1.178; P =0.399) or current smokers (aOR, 1.178; 95% CI, 0.970–1.431; P =0.098) versus nonsmokers. Subgroup analyses by race/ethnicity demonstrated no differences in primary outcome when former and current smokers were compared with nonsmokers. Former, but not current, smokers had a lower in-hospital mortality rate (aOR, 0.695; 95% CI, 0.500–0.968; P =0.031), which was only observed in Hispanics (aOR, 0.533; 95% CI, 0.309–0.921; P =0.024). Differences in self-reported health status measures were only observed in whites. Conclusions— Cigarette smoking history does not seem to provide a beneficial effect on 90-day functional outcome in patients with ICH.

Despite no clear evidence from randomized trials, surgical intervention of spontaneous intracerebral hemorrhage (ICH) still occurs. We sought to describe the characteristics of patients undergoing surgical intervention in ICH.Data from the ERICH (ERICH Ethnic/Racial Variations of Intracerebral Hemorrhage) study were analyzed, and patients with ICH were categorized into surgical intervention or nonoperative management groups. Patients with primary intraventricular hemorrhage and those without data regarding the use of surgical intervention were excluded.The study cohort comprised 2947 patients, and surgical intervention was performed in 289 (10%). Younger age (odds ratio [OR], 0.967; P0.001), lower baseline modified Rankin Scale score (OR, 0.728; P0.001), higher admission Glasgow Coma Scale score (OR, 1.059; P = 0.007), larger ICH volume (OR, 1.037; P0.001), infratentorial ICH location (OR, 5.966; P0.001), lobar ICH location (OR, 1.906; P = 0.001), lack of intraventricular hemorrhage (OR, 0.567; P = 0.001), intracranial pressure (ICP) monitoring (OR, 5.022; P0.001), and mannitol use (OR, 2.389; P0.001) were independent predictors of surgical intervention. Younger age (OR, 0.953; P0.001), lower baseline modified Rankin Scale score (OR, 0.713; P = 0.002), larger ICH volume (OR, 1.033; P0.001), lobar ICH location (OR, 2.467; P0.001), ICP monitoring (OR, 3.477; P0.001), and mannitol use (OR, 2.139; P0.001) were independent predictors of surgical interventions in supratentorial ICHs. Larger ICH volume (OR, 1.078; P 0.001), ICP monitoring (OR, 6.099; P0.001), and mannitol use (OR, 2.952; P = 0.005) were independent predictors of surgical interventions in infratentorial ICHs.We identified multiple factors associated with surgical intervention for patients with ICH. Younger age, good neurologic function at baseline, large ICH volume on presentation, and lobar or infratentorial hematomas were independently associated with surgical intervention in patients with ICH .

Objective: Despite no clear evidence from randomized trials, surgical intervention of spontaneous intracerebral hemorrhage (ICH) still occurs. We sought to describe the characteristics of patients undergoing surgical intervention in ICH. Methods: Data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study were analyzed, and ICH patients were categorized into surgical intervention or nonoperative management groups. Patients with primary intraventricular hemorrhage (IVH) and those without data regarding the use of surgical intervention data were excluded. Multivariable models were developed to identify predictors of surgical intervention. Results: The study cohort comprised 2,947 patients, and surgical intervention was performed in 289 (10%). Younger age (p Conclusion: We identified multiple factors associated with surgical intervention for patients with ICH. Younger age, good neurological function at baseline, large ICH volume on presentation, and lobar or infratentorial hematomas were independently associated with surgical intervention in ICH patients. Additional studies are necessary to determine the risk to benefit profile of ICH surgery.

This article is a comprehensive document on the diagnosis and management of fibromuscular dysplasia (FMD), which was commissioned by the working group ‘Hypertension and the Kidney’ of the European Society of Hypertension (ESH) and the Society for Vascular Medicine (SVM). This document updates previous consensus documents/scientific statements on FMD published in 2014 with full harmonization of the position of European and US experts. In addition to practical consensus-based clinical recommendations, including a consensus protocol for catheter-based angiography and percutaneous angioplasty for renal FMD, the document also includes the first analysis of the European/International FMD Registry and provides updated data from the US Registry for FMD. Finally, it provides insights on ongoing research programs and proposes future research directions for understanding this multifaceted arterial disease.

Background: Prehospital stroke screening tools are essential to rapid diagnosis and treatment, but variable recognition of common stroke deficits by EMS providers limits the accuracy and reliability of these tools. An automated screening tool could yield more consistent assessments and reduce operator variability. We hypothesized that a video-based, machine learning algorithm can detect facial weakness with comparable accuracy to EMS providers. Methods: Videos with normal smile and facial weakness were collected from open access, online repositories. Two senior neurology residents independently rated videos using a 5-point scale to denote the likely presence or absence of pathological facial weakness. Only videos rated concurrently by both raters were included for training and testing of the algorithm. Facial landmarks were extracted per frame using an open-source face-detector and landmark detector followed by normalization of landmarks and intensity values. Optical-flow based features and facial landmark based configural features were calculated for each video and classified with a logistic regression model. Accuracy was calculated using a 5-fold cross validation scheme. To interpret algorithm performance, we analyzed ratings of three EMS providers against the resident ratings. Results: Of 160 videos with concordant ratings, 24 were excluded due to issues with muscle activation or head orientation, resulting in 31, 36, and 69 videos with left, right, and no facial weakness, respectively. Mean accuracy for the algorithm was 84.6% (95% Cl [74.3-94.9]) compared with 89.0% (95% Cl [86.0-92.0]) for EMS providers. More severe facial weakness compromised the performance of the landmark detector, limiting detection to optical flow analysis alone. Conclusion: Our study demonstrates that a learning algorithm can detect facial weakness in videos, however, the algorithm was not as accurate as EMS. Videos with more pronounced weakness presented a challenge for the algorithm whereas human examiners can more easily identify weakness in these cases. Future research will include refining the algorithm for severe facial weakness and expanding to detect other stroke deficits such as limb weakness and ataxia.

Objective: The role of ICP monitoring in patients with spontaneous ICH is unknown, andthe associated complications may offset its benefits. The aim of the study was to compare the outcomes of ICH patients who underwent ICP monitoring to those who were managed by care-guided imaging and/or clinical exam alone. Methods: This was aretrospective, matched cohort analysis from a multicenter, prospective study with recruitment of 3,000 multi-ethnic cases of spontaneous ICH between September 2010 and October 2015. ICH patients with ICP monitoring were propensity-score matched, in a 1:1 ratio, to those without ICP monitoring. The primary outcome was mortality at 90 days. Secondary outcomes were in-hospital mortality, use of hyperosmolar (mannitol or hypertonic saline) therapy, surgical ICH evacuation, length of hospital stay, and the following 90-day outcomes: modified Rankin Scale (mRS) excellent (0-1) and good (0-2), Barthel Index, and health-related quality of life (HRQoL) (EuroQol Group 5-Dimension [EQ-5D] and EQ-5D Visual Analog Scale [VAS] scores). Results: The ICP and no ICP monitoring cohorts comprised 566 and 2,434 patients, respectively. The matched cohorts each included 420 patients. The 90-day and in-hospital mortality rates were similar between the matched cohorts. Infection rate was higher in the ICP monitoring cohort (5.7% vs. 1.2%, aOR=5.066, p=0.001).Shift analysis 90-day mRS favored no ICP monitoring (aOR=1.628, p Conclusion: The findings of this study do not support the routine utilization of ICP monitoring in patients with ICH.

Objective: While cigarette use may be a risk for intracerebral hemorrhage (ICH), animal models suggest that nicotine has a potential neuroprotective effect. The aim of this multicenter study is to determine the effect of smoking on outcome in ICH patients. Methods: We analyzed prospectively collected data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, and included patients with smoking status data in the analysis. Patients were dichotomized into non-smokers versus ever-smokers, and the latter group was further categorized as former (>30 days before ICH) or current (≤30 days before ICH) smokers. The primary outcome was 90-day modified Rankin Scale (mRS) score shift analysis. Secondary outcomes were in-hospital mortality and mortality, Barthel Index, and self-reported health status measures at 90 days. Results: The overall study cohort comprised 1,509 non-smokers and 1,423 ever-smokers (841 former, 577 current, 5 unknown). No difference in primary outcome was observed between non-smokers versus ever-smokers (aOR=1.041 [0.904-1.199], p=0.577). No differences in primary outcome were observed between former (aOR=0.932 [0.791-1.178], p=0.399) or current smokers (aOR=1.178 [0.970-1.431], p=0.098) versus non-smokers. Subgroup analyses by race/ethnicity demonstrated no differences in primary outcome when former and current smokers were compared to non-smokers. Former, but not current, smokers had a lower in-hospital mortality rate (aOR=0.695 [0.500-0.968], p=0.031), which was only observed in Hispanics (aOR=0.533 [0.309-0.921], p=0.024). Differences in self-reported health status measures were only observed in whites. Conclusion: Cigarette smoking history does not appear to provide a beneficial effect on 90-day functional outcome in patients with ICH.

Introduction: Mechanical thrombectomy has become standard of care in acute ischemic stroke with proximal arterial occlusion. For patients 6-24 hours from last known well, computed tomography perfusion (CTP) is now frequently used for assessment of endovascular therapy (EVT) eligibility. CTP requires an increased contrast load compared to computed tomographic angiography (CTA). Hypothesis: In patient assessment for EVT, CTA/CTP is not associated with higher incidence of acute kidney injury (AKI) compared to CTA alone. Methods: We reviewed data from consecutive acute stroke alerts at our institution from January-July 2018, and recorded baseline serum creatinine and creatinine at 24, 48, and 72 hours post-alert. AKI was defined by an increase in serum creatinine of 0.3, or more than a 1.5 fold increase in baseline creatinine, according to the Acute Kidney Injury Network definition. We compared patients receiving CTA/CTP versus CTA alone using independent samples t-test, including variables of age, NIHSS, baseline creatinine, and creatinine at 24, 48, and 72 hours. Chi-square testing was performed to compare incidence of AKI between groups. A binary logistic regression model was performed including covariates of age, sex, location of alert (emergency room or inpatient), NIHSS, baseline creatinine and imaging group. Significance was defined as p < 0.05 for all tests. Results: Analysis included 285 patients: 210 receiving CTA alone, and 75 receiving CTA/CTP. Incidence of AKI was 4.7% in the CTA alone group versus 4% in the CTA/CTP group (χ2=0.74, p=0.786). The two groups did not differ with regard to age, NIHSS, or serum creatinine at any time point. In the binary logistic regression model, addition of CTP to CTA did not increase the odds ratio of developing AKI (OR 1.076 [95% CI 0.276-4.193]; p=0.916). Conclusions: In acute stroke assessment for EVT eligibility, the addition of CTP to CTA did not increase rates of AKI. While this retrospective analysis includes the possibility of selection bias, the two groups were similar in baseline characteristics including kidney function. These results provide Level II, Class B evidence supporting the safety of CTP in patient selection for EVT and may inform future AHA/ASA guidelines for management of acute ischemic stroke.

Introduction: Several related neurovascular phenotypes, including cervical artery dissection, fibromuscular dysplasia, large artery stroke, hypertension, and migraine headache are associated with a single nucleotide polymorphism (rs9349378) in the phosphatase and actin regulator-1 ( PHACTR1 ) gene recently identified as a distal regulator of the endothelin-1 ( EDN1 ) gene. Vascular endothelial cells release EDN1, a potent vasoconstrictor. We hypothesize that atheromatous and normal carotid tissue will differentially express PHACTR1 and EDN1 . Methods: We obtained gene expression data from the publically available Gene Expression Omnibus Carotid Atheroma Dataset (GSE43292). This resource contains 32 paired samples of carotid atheroma and distant macroscopically intact carotid tissue from the same individual and gene expression data from the Affymetrix Human Gene 1.0 ST Array. We compared log transformed count of signal intensity of PHACTR1 and EDN1 expression in the 32 paired samples using a two-sample t-test assuming equal variance with SPSS (IBM, Armonk, NY). Results: PHACTR1 expression was lower in atheromatous compared to normal carotid tissue (7.152 vs. 7.399, delta 0.248, 95%CI 0.180 - 0.315, p=1.9 E -8 ). EDN1 expression did not differ (6.514 and 6.339, delta 0.176, 95%CI -0.004 - 0.356, p = 0.055). with genetic data associating the rs9349378[G] allele with lower levels of expression and atherosclerotic vascular diseases. The lack of differential EDN1 expression may reflect the small sample size or may challenge the assertion that EDNI is the mediator of the PHACTR1 association. Our data support the hypothesis that this pathway may play an important and potentially variable role in neurovascular phenotypes including large artery atherosclerotic stroke and non-atherosclerotic arteriopathies.

Prehospital medicine is rapidly evolving in both scope and purpose with telemedicine providing novel opportunities to offer support and oversight to emergency medical service providers while bringing advanced care to the site of illness or injury. In this chapter, the history, development, and sustainability of prehospital telemedicine programs are discussed while highlighting past, current, and possible future applications. The challenges associated with expanding prehospital telemedicine and the need to address them with innovative funding models, stakeholder buy-in, and a thorough understanding of varying local prehospital systems and their interplay with existing regulatory frameworks are also discussed. This chapter will provide a framework for understanding the complex and evolving nature of prehospital telemedicine in a practical context. Growth in this field is rapid, so this chapter looks to encourage further expansion of programs by highlighting current successful programs. This includes mobile telestroke with the development of mobile stroke units, community paramedicine, emergency department avoidance, and specialty interfacility transport.

Importance Data on neurologic manifestations of fibromuscular dysplasia (FMD) are rare, and current knowledge remains limited. Objectives To present a comprehensive review of the epidemiologic characteristics, management, and prognosis of the neurologic manifestations associated with cerebrovascular FMD (ie, involving cervical or intracranial arteries) and to guide future research priorities. Evidence Review References were identified through searches of PubMed from inception to December 2017 using both the medical subject headings and text words. Additional sources were also identified by reviewing reference lists of relevant articles and through searches of the authors’ personal files. Selected articles described at least 1 clinical or radiologic feature and/or outcome of cerebrovascular FMD. Isolated case reports could be included if they described interesting or noteworthy manifestations of FMD. Findings A total of 84 relevant references were identified. Diagnosis of cerebrovascular FMD is based on the appearance of alternating arterial dilatation and constriction (“string of beads”) or of focal narrowing, with no sign of atherosclerotic or inflammatory lesions. Although the diagnosis is easily apparent on results of radiographic imaging, making a diagnosis can be challenging in children or individuals with atypical phenotypes, such as purely intracranial FMD and arterial diaphragm. Involvement of multiple arteries is common, and there is increased incidence of cervical artery dissection and intracranial aneurysms. A variant in thePHACTR1gene has been associated with FMD as well as cervical artery dissection and migraine, although less than 5% of cases of FMD are familial. Headaches, mainly of the migraine type, are observed in up to 70% of patients with FMD. Cerebrovascular FMD is mostly asymptomatic, but the most frequent neurologic manifestations include transient ischemic attack and ischemic stroke, notably in the presence of associated cervical artery dissection. Other conditions associated with FMD include subarachnoid hemorrhage and, rarely, intracranial hemorrhage. Management relies on observational data and expert opinion. Antiplatelet therapy is considered reasonable to prevent thromboembolic complications. Endovascular therapy is typically restricted to cases with symptomatic stenosis despite optimal medical therapy or in those with rupture of an intracranial aneurysm. Conclusions and Relevance Longitudinal cohort studies of individuals of multiple ethnicities with biosampling are needed to better understand the risk factors, pathophysiological features, and outcomes of FMD. Patient advocacy groups could assist researchers in answering patient-centered questions regarding FMD.

Objectives: In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations. Methods: We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval). Results: We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to −0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92–0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites. Conclusions: Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.