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Cervical artery dissection (CAD) is rare, yet it is a common cause of stroke in young and middle-aged adults. Historically, some senior clinicians favored anticoagulation in the prevention of stroke due to CAD. Choosing the optimal antithrombotic treatment with either antiplatelet (AP) or anticoagulant (AC) medications remains a challenge. This paper will review the clinical features and imaging of CAD, and the acute treatment and prevention of stroke due to CAD. Until 2015, there were no prospective randomized trials in the optimal antithrombotic management of CAD. The Cervical Artery Dissection in Stroke Study (CADISS) trial found that treatment with AC did not lower the risk of subsequent stroke or death at 3 months when compared to AP agents. This led to a paradigm shift in national guidelines. In 2021, The Biomarkers and Antithrombotic Treatment in of Cervical Artery Dissection (TREAT-CAD) trial however did not confirm the non-inferiority of AP therapy in stroke prevention due to CAD. The optimal antithrombotic management for stroke prevention in CAD remains uncertain, while the superiority of anticoagulation has not been established, nor has the non-inferiority of AP agents. The future direction of research should consider early preventative treatment, dual treatment with AP agents, direct oral AC medications, and aggregation of data from existing randomized trials.

BackgroundThere is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19.MethodsThis multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes.ResultsA total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054).ConclusionIV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.

Purpose of Review: Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global health challenge. This review aims to summarize the incidence, risk factors, possible pathophysiology, and proposed management of neurological manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC) or neuro-PASC based on the published literature. Recent Findings: The National Institutes of Health has noted that PASC is a multi-organ disorder ranging from mild symptoms to an incapacitating state that can last for weeks or longer following recovery from initial infection with SARS-CoV-2. Various pathophysiological mechanisms have been proposed as the culprit for the development of PASC. These include, but are not limited to, direct or indirect invasion of the virus into the brain, immune dysregulation, hormonal disturbances, elevated cytokine levels due to immune reaction leading to chronic inflammation, direct tissue damage to other organs, and persistent low-grade infection. A multidisciplinary approach for the treatment of neuro-PASC will be required to diagnose and address these symptoms. Tailored rehabilitation and novel cognitive therapy protocols are as important as pharmacological treatments to treat neuro-PASC effectively. Summary: With recognizing the growing numbers of COVID-19 patients suffering from neuro-PASC, there is an urgent need to identify affected individuals early to provide the most appropriate and efficient treatments. Awareness among the general population and health care professionals about PASC is rising, and more efforts are needed to understand and treat this new emerging challenge. In this review, we summarize the relevant scientific literature about neuro-PASC.

Background: To provide an overview of the worldwide association between hospital beds, the burden of non-communicable diseases (NCDs), and COVID-19 mortality. Methods: We extracted data regarding COVID-19 deaths and cases from the Our World in Data as of November 21, 2020. We also obtained the following data:1) NCDs disability-adjusted life years (DALYs), health-adjusted life expectancy, and the health access and quality index from the Global Burden of Disease study; 2) the number of hospital beds, physicians, nurses and midwives per population, and out-of-pocket payments from the WHO website; 3) income levels and population density from the World Bank database. Using the principal component approach and a multilevel generalised linear model, we examined these variables’ independent associations with COVID-19 mortality rate ratio (MRR). Findings: During the study period, 17.62 COVID-19 deaths per 100,000 population were reported globally (1.20 in low-, 13.43 in lower-middle-, 14.14 in upper-middle-, and 46.72 in high-income countries). Median age increased COVID-19 mortality. Hospital beds were associated with reduced COVID-19 mortality (MRR=0.62; 95% CI: 0.59, 0.64) globally. During COVID-19 peak periods, despite a decreasing trend in COVID-19 MRR with increasing beds in high-income countries, the odds of mortality remained high even within the highest percentile of hospital beds (MRR=2.99 for 20th - 40th and 1.51 for >60 th bed percentile, respectively). On the contrary, in middle-income countries, we observed an inverse association between the number of hospital beds and COVID-19 mortality in both periods. NCD DALYs were associated with increased COVID-19 deaths, particularly during peak mortality periods in high-income countries. Death-to-case ratio increased by approximately two times during the peak vs non-peak mortality periods. Interpretations: COVID-19 is a syndemic interacting with non-communicable diseases and not only a pandemic. A comprehensive national healthcare plan against COVID-19 spread should include adequate measures to protect vulnerable patients with pre-existing chronic conditions. Funding: None. Declaration of Interests: The authors declare no conflicts of interest to disclose.

Background: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. We describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease, and investigate the role of sex on outcome. Methods: This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers from Chicago metropolitan area. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. Results: The study included 83 patients. Median age was 64 years and the majority were Blacks (47%) followed by Hispanics (28%) and whites (16%). Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Higher proportions of male experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p=0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared to female, males had higher mortality (38% vs. 13%; p=0.02) and were less likely to be discharged home (12% vs. 33%; p=0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR=1.47, 95% CI=1.03-2.09) Conclusion: In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.

Coronavirus disease 2019 (COVID-19) has become a global health crisis of our time. The disease arises from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that binds to angiotensin-converting enzyme 2 (ACE2) receptors on host cells for its internalization. COVID-19 has a wide range of respiratory symptoms from mild to severe and affects several other organs, increasing the complexity of the treatment. There is accumulating evidence to suggest that SARS-CoV-2 can target the nervous system. In this review, we provide an account of the COVID-19 central nervous system (CNS) manifestations. A broad spectrum of the CNS manifestations including headache, impaired consciousness, delirium, loss of smell and taste, encephalitis, seizures, strokes, myelitis, acute disseminated encephalomyelitis, neurogenic respiratory failure, encephalopathy, silent hypoxemia, generalized myoclonus, neuroleptic malignant syndrome and Kawasaki syndrome has been reported in patients with COVID-19. CNS manifestations associated with COVID-19 should be considered in clinical practice. There is a need for modification of current protocols and standing orders to provide better care for COVID-19 patients presenting with neurological symptoms.

Idiopathic extracranial internal carotid artery (ICA) vasospasm is a rare pathological phenomenon that may lead to stroke in young patients. We report a case of an 18 year-old female with recurrent extracranial ICA vasospasm since age thirteen. We summarize published data related to this condition including all twenty-three reported cases of extracranial ICA vasospasm. We describe the various proposed pathophysiological mechanisms underlying this disorder. Various treatment modalities have been attempted but there is no known long-term effective treatment., Highlights • Reversible extracranial ICA vasospasm can cause stroke in the young. • We present an 18 year-old female with recurrent extracranial ICA vasospasm. • Twenty-three cases of extracranial ICA vasospasm are reported in the literature. • An underlying genetic predisposition likely plays a role. • Various treatment modalities have not been effective long-term.

BackgroundThe emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran.MethodsThis study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model.ResultsDuring the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p&nbsp

Background and PurposeThe novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic.MethodsThis is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center.ConclusionThe proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.

Introduction Current evidence on the association between COVID-19 and dementia is sparse. This study aims to investigate the associations between COVID-19 caseload and the burden of dementia. Methods We gathered data regarding burden of dementia (disability-adjusted life years [DALYs] per 100,000), life expectancy, and healthy life expectancy (HALE) from the Global Burden of Disease (GBD) 2017 study. We obtained COVID-19 data from Our World in Data database. We analyzed the association of COVID-19 cases and deaths with the burden and mortality of dementia using Spearman's rank correlation coefficient. Results Globally, we found significant positive (p, Highlights • We assessed the burden of dementia on COVID-19 caseload and mortality worldwide. • Global burden of dementia correlates with COVID-19 caseloads. • Global burden of dementia correlates with COVID-19 mortality. • Healthy life expectancy correlates with COVID-19 cases and mortality. • We recommend a targeted approach to reduce the burden of COVID-19 in dementia.

Highlights • Globally, there was a significant correlation between healthy life expectancy (HALE), non-communicable disease DALYs and mortality, with COVID-19 caseload and deaths. • There was a positive independent association between HALE and COVID-19 cases. • The number of tourists was also associated with COVID-19 mortality. • Our integrated model of global data is valuable for health policymakers, allowing for the implementation of optimal preventative measures at national and global scales., Background The interaction between coronavirus disease 2019 (COVID-19) and non-communicable diseases may increase the global burden of disease. We assessed the association of COVID-19 with ageing and non-communicable diseases. Methods We extracted data regarding non-communicable disease, particularly cardiovascular disease, deaths, disability-adjusted life years (DALYs), and healthy life expectancy (HALE) from the Global Burden of Disease Study (GBD) 2017. We obtained data of confirmed COVID-19 cases, deaths, and tests from the Our World in Data database as of May 28, 2020. Potential confounders of pandemic outcomes analyzed include institutional lockdown delay, hemispheric geographical location, and number of tourists. We compared all countries according to GBD classification and World Bank income level. We assessed the correlation between independent variables associated with COVID-19 caseload and mortality using Spearman's rank correlation and adjusted mixed model analysis. Findings High-income had the highest, and the Southeast Asia, East Asia, and Oceania region had the least cases per million population (3050.60 vs. 63.86). Sub-saharan region has reported the lowest number of COVID-19 mortality (1.9). Median delay to lockdown initiation varied from one day following the first case in Latin America and Caribbean region, to 34 days in Southeast Asia, East Asia, and Oceania. Globally, non-communicable disease DALYs were correlated with COVID-19 cases (r = 0.32, p

Highlights • COVID-19 disease is associated with stroke • All strokes subtypes are seen in association with COVID-19, with ischemic stroke being most prevalent • The most common etiology for ischemic stroke in SARS-CoV2 infection is cryptogenic • Sex plays an important role in stroke outcomes in patients with COVID-19 disease • Males have higher rates of ICU admission, in-hospital complications and more likely to have worse outcome at hospital discharge compare with females, Background and Purpose Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. To objective of this paper is to describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease and determine the role of sex on outcome. Methods This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage or median and interquartile range. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. Results The study included 83 patients, 47% of which were Black, 28% Hispanics/Latinos, and 16% whites. Median age was 64 years. Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Compared with females, a higher proportion of males experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p = 0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared with females, males had higher mortality (38% vs. 13%; p = 0.02) and were less likely to be discharged home (12% vs. 33%; p = 0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR = 1.47, 95% CI = 1.03–2.09). Conclusion In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.

Tenecteplase offers pharmacological advantages over alteplase, and growing evidence supports its consideration for the treatment of patients with acute ischemic stroke. Its ease of administration as a single bolus makes it a preferable agent for patients who need to be urgently transported to a comprehensive stroke center for endovascular therapy (drip and ship) and for patients first evaluated at comprehensive stroke centers who are eligible for endovascular intervention (combined intravenous and endovascular approach). Recent randomized controlled trials indicated that the efficacy of tenecteplase may be similar to that of alteplase in patients with mild strokes and that it is superior to alteplase for patients with more severe strokes from a large vessel occlusion. Cumulative evidence currently favors the use of the 0.25 mg/kg dose. While tenecteplase has not been approved by regulatory agencies in the USA or the EU for the treatment of acute ischemic stroke, ongoing trials and additional clinical experience from countries where it is already being used in practice will likely clarify the role of tenecteplase for the acute management of ischemic stroke in the near future.

Highlights • Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) • Some COVID-19 patients have exhibited widespread neurological manifestations including stroke. • Acute ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis have been reported in patients with COVID-19. • COVID-19-associated coagulopathy is likely caused by inflammation. • Resultant ACE2 down-regulation causes RAS imbalance, which may lead to stroke., Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global health threat. Some COVID-19 patients have exhibited widespread neurological manifestations including stroke. Acute ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis have been reported in patients with COVID-19. COVID-19-associated coagulopathy is increasingly recognized as a result of acute infection and is likely caused by inflammation, including inflammatory cytokine storm. Recent studies suggest axonal transport of SARS-CoV-2 to the brain can occur via the cribriform plate adjacent to the olfactory bulb that may lead to symptomatic anosmia. The internalization of SARS-CoV-2 is mediated by the binding of the spike glycoprotein of the virus to the angiotensin-converting enzyme 2 (ACE2) on cellular membranes. ACE2 is expressed in several tissues including lung alveolar cells, gastrointestinal tissue, and brain. The aim of this review is to provide insights into the pathophysiological stroke mechanisms in COVID-19 patients. SARS-CoV-2 can down-regulate ACE2 and, in turn, over-activate the classical renin-angiotensin system (RAS) axis and decrease the activation of the alternative RAS pathway in the brain. The consequent imbalance in vasodilation, neuroinflammation, oxidative stress, and thrombotic response may contribute to the pathophysiology of stroke during SARS-CoV-2 infection.

Coronavirus disease 2019 (COVID-19) is a pandemic respiratory disease with serious public health risk and has taken the world off-guard with its rapid spread. As the COVID-19 pandemic intensifies, overwhelming the healthcare system and the medical community, current practice for the management of acute ischemic stroke (AIS) will require modification, and guidelines should be relaxed while maintaining high standard quality of care. The aim of these suggestions is to avoid contributing to the rapid spread of COVID-19 as well as to conserve what are likely to be very limited resources (including personnel, intensive care/hospital beds as well as physicians) while maintaining high quality care for patients with AIS. We present our recommendations for the management of acute stroke during the COVID-19 pandemics.

Non-stroke conditions may present in ways suggestive of ischemic stroke (ie, stroke mimic). Alternatively, the clinical presentation of ischemic stroke can vary considerably and may appear similar to another condition (ie, stroke chameleon). Common and uncommon mimics and chameleons are presented with discussion of key considerations to improve diagnostic accuracy.

Patients with stage 5 chronic kidney disease (CKD5D) have a higher risk of developing neurocognitive deficits. Stroke, cervical carotid artery disease (CCAD), and intracranial atherosclerotic disease (ICAD) are causes of such deficits in CKD5D. Chronic inflammation from renal failure elevates risk for these diseases through oxidative stress and vascular dysfunction. The adverse impact on the carotid and intracranial vasculatures contributes to the multifactorial pathophysiology of stroke. Eleven plasma biomarker levels in patients with CKD5D (n = 97) and healthy controls (n = 17-50) were measured using sandwich enzyme-linked immunosorbent assay (ELISA) method. Of the 97 patients with CKD5D, 24 had CCAD, 19 had ICAD, and 23 had acute stroke. Elevations in NACHT, LRR, and PYD domains-containing protein 3 (NALP3) levels in patients with CKD5D (+)CCAD (1.80 ± 0.11 ng/mL) compared to patients with (−)CCAD (1.55 ± 0.08 ng/mL) were statistically significant ( P = .0299). Differences in D-dimer levels were also found to be statistically significant ( P = .0258) between CKD5D (+)stroke (1.83 ± 0.42 μg/mL) and (−)stroke (0.89 ± 0.13 μg/mL) groups. The ages of the (+) neurovascular disease groups were found to be significantly elevated compared to the (−) neurovascular disease groups ( P = .0002 carotid AD; P < .0001 ICAD; P = .0157 stroke). D-dimer levels were positively correlated with age in CKD5D ( P = .0375). With the possible exception of NALP3 for CCAD, profiling levels of specific biomarkers for risk stratification of neurovascular diseases in the CKD5D population warrants further investigation.

Remarkable advances have occurred in the management of acute ischemic stroke, especially in regards to reperfusion treatments. With advances in reperfusion treatments come the risk of complications associated with these treatments. Areas covered: The article focuses on three acute complications that can occur in the setting of acute ischemic stroke: cerebral edema, hemorrhagic transformation, and orolingual angioedema following administration of alteplase, a recombinant tissue plasminogen activator. Predictors of the development of these complications are reviewed. The management of cerebral edema and hemorrhagic transformation is also reviewed in depth including potential new treatments targeting the blood-brain barrier. The article also reviews the management of the rare but potentially fatal complication of orolingual angioedema secondary to alteplase. Expert commentary: An understanding of the pathophysiology leading to the development of malignant cerebral edema and hemorrhagic transformation allows the clinician to anticipate and properly manage these acute complications. Regardless of a patient's age or comorbidities, the decision to pursue decompressive hemicraniectomy in patients with malignant cerebral edema should be based on an honest assessment of expected outcome and guided by the patient's prior wishes regarding an acceptable quality of life.

The StrokeVascular Neurology Section of the American Academy of Neurology was charged to identify challenges to the recruitment and retention of stroke neurologists and to make recommendations to address any identified problems. The Section initiated this effort by determining the impact of stroke on-call requirements as a barrier to the recruitment and retention of vascular neurologists.This is a cross-sectional survey of a sample of US Neurologists providing acute stroke care.Of the 900 neurologists who were sent surveys, 313 (35%) responded. Of respondents from institutions providing stroke coverage, 71% indicated that general neurologists and 45% indicated that vascular neurologists provided that service. Of those taking stroke call, 36% agreed with the statement, "I spent too much time on stroke call," a perception that was less common among those who took less than 12-hour shifts (P .0001); 21% who participated in stroke call were dissatisfied with their current job. Forty-six percent indicated that their stroke call duties contributed to their personal feeling of "burnout."Although the reasons are likely multifactorial, our survey of neurologists providing stroke care suggests that over-burdensome on-call responsibilities may be contributing to the vascular neurology workforce burnout and could be affecting recruitment and retention of vascular neurologists. Strategies to reduce the lifestyle impact of stroke call may help address this problem.

Background and Purpose— Stroke preparedness interventions are limited by the lack of psychometrically sound intermediate end points. We sought to develop and assess the reliability and validity of the video-Stroke Action Test (video-STAT) an English and a Spanish video-based test to assess people’s ability to recognize and react to stroke signs. Methods— Video-STAT development and testing was divided into 4 phases: (1) video development and community-generated response options, (2) pilot testing in community health centers, (3) administration in a national sample, bilingual sample, and neurologist sample, and (4) administration before and after a stroke preparedness intervention. Results— The final version of the video-STAT included 8 videos: 4 acute stroke/emergency, 2 prior stroke/nonemergency, 1 nonstroke/emergency, and 1 nonstroke/nonemergency. Acute stroke recognition and action response were queried after each vignette. Video-STAT scoring was based on the acute stroke vignettes only (score range 0–12 best). The national sample consisted of 598 participants, 438 who took the video-STAT in English and 160 who took the video-STAT in Spanish. There was adequate internal consistency (Cronbach α=0.72). The average video-STAT score was 5.6 (SD=3.6), whereas the average neurologist score was 11.4 (SD=1.3). There was no difference in video-STAT scores between the 116 bilingual video-STAT participants who took the video-STAT in English or Spanish. Compared with baseline scores, the video-STAT scores increased after a stroke preparedness intervention (6.2 versus 8.9, P Conclusions— The video-STAT yields reliable scores that seem to be valid measures of stroke preparedness.

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.

Encephalopathy can range from the acute confusional state to frank coma, and is broadly defined as a constellation of symptoms and signs reflecting diffuse cerebral dysfunction. The potential causes of encephalopathy are vast requiring a thorough initial assessment and systematic diagnostic approach. Obtaining a comprehensive history may be challenging and ancillary sources of information are often helpful in narrowing the differential diagnosis. The general examination may provide hints as to the cause of encephalopathy and the neurologic examination can guide both acute management and focus the diagnostic investigations on specific etiologies which fit the clinical presentation. The systemic manifestations of infection and toxic exposures are common causes of encephalopathy. In sepsis, not only is brain perfusion compromised, multi system dysfunction is common and additional factors related to the specific infection such as hypoxia in pneumonia or secondary CNS involvement can complicate management. An understanding of the common physical examination findings of toxic exposures can aid in the diagnosis and rapid treatment of reversible toxic encephalopathies such as narcotics, benzodiazepines or environmental toxins. Cardiopulmonary dysfunction can lead to hypoxic-ischemic encephalopathy and advances in critical care, and particularly targeted temperature management following cardiac arrest, have improved the neurologic outcome in these patients. This review contains 2 figures, 3 tables, and 25 references. Key words: encephalopathy, delirium, ascending reticular activating system, acute confusional state, subclinical seizures, Glasgow Coma Scale, Full Outline of Unresponsiveness (FOUR) Score , hypoxic-ischemic encephalopathy, neuroleptic malignant syndrome, serum neuron-specific enolase

Basilar artery occlusion can present with both positive and negative neurologic signs. A thorough neurologic examination is crucial for timely recognition and urgent intervention when applicable.

The present manuscript examines the significance of blood pressure elevation in patients with acute ischemic stroke, the physiologic principles worthy of consideration during its treatment, and the recent empirical evidence that should guide management protocols. It also provides a sound and practical approach to treatment along the time continuum, with particular relevance to reperfusion strategies. The existing evidence shows that both insufficient and excessive blood pressures are detrimental to the outcome of patients with acute ischemic stroke. This “U-shaped” relation, however, relates to measurements at the time of presentation, and clinical studies lack detail and specificity relative to differential measurements along the time continuum, particularly prior to and following reperfusion. Extrapolating from recent series, it is possible to construct treatment protocols balanced for effectiveness and safety. The management of blood pressure after acute ischemic stroke is an important, complex, and challenging aspect of care, requiring a thorough understanding of cerebrovascular physiology. Along the time continuum, the therapeutic priorities start with the preservation of penumbral tissue prior to reperfusion and then follow with the limitation of the damaging effects of excessive blood pressure readings after reperfusion, optimizing the chances of improved outcomes.

Intracerebral hemorrhage (ICH) is a stroke subtype associated with significant morbidity and mortality. The purpose of this review is to provide an update on important research on ICH over the past three years. Topics covered include risk factors, imaging predictors of hematoma expansion, scoring schema to predict hematoma expansion, hemostatic therapies, acute blood pressure lowering, intraventricular administration of alteplase for intraventricular hemorrhage, and the current status of surgical therapies.

Spontaneous primary intracerebral hemorrhage (ICH) is a stroke subtype associated with the highest mortality rate. High blood pressure (BP) is the most common cause of non-lobar ICH. Recent clinical trials have been inconclusive regarding the efficacy of aggressive BP lowering to improve ICH outcome. The association between high BP and ICH prognosis is rather complex and parameters other than absolute BP levels may be involved. In this regard, there is accruing evidence that BP variability (BPV) plays a major role in ICH outcome. Different BPV indices have been used to predict hematoma growth, neurological deterioration, and functional recovery. This review highlights the available evidence about the relationship between BPV and clinical outcomes among patients. We identified standard deviation (SD), residual SD, coefficient of variation, mean absolute change, average real variability, successive variation, spectral analysis using Fourier analysis, and functional successive variation (FSV) as indices to assess BPV. Most studies have demonstrated the association of BPV with ICH outcome, suggesting a need to monitor and control BP fluctuations in the routine clinical care of ICH patients. When large inter-subject variability exists, FSV is a viable alternative quantification of BPV as its computation is less sensitive to differences in the patient-specific observation schedules for BP than that of traditional indices.

Introduction: Acute ischemic stroke (AIS) treatment is time sensitive and every 15 minutes saved in treatment results in 1 additional month of disability-free life in patients treated with thrombolysis. Pre-notification by Emergency Medical Services (EMS) has shown to reduce door to CT scan time, door to needle time for thrombolysis and increase the number of patients treated with thrombolysis. Determining which factors contribute to recognition and emergent treatment of stroke in the emergency department (ED) which are not recognized in the field can help improve models of pre-hospital notification. Objective: To determine which factors predict pre-hospital notification by EMS in patients with AIS treated with emergent therapy. Methods: We retrospectively reviewed our institutional database for all patients arriving through the ED by EMS who underwent acute stroke treatment from 2007-2018. All patient's arriving by EMS were dichotomized by the presence or absence of pre-hospital notification. We assessed the impact of demographic, clinical [NIHSS, FAST scores ((Face, Arm, Speech, Time) dichotomized into 0-1 or 2-3)], and diagnostic (vascular territory) factors on the likelihood of pre-hospital notification by EMS. A multivariate logarithmic regression analysis with assessment for confounding factors was applied. Results: A total of 183 patients were identified. The presence of 2 or 3 FAST criteria increased the odds of pre-hospital notification by EMS by 3.07 (p = 0.022, 95% CI 1.17-8.05) when adjusted for age. The vascular territory involved did not independently predict the likelihood of pre-hospital notification. We did not identify any significant confounders in the multivariate analysis. Conclusions: Patients with AIS receiving emergent treatment are over three times more likely to benefit from pre-hospital notification by EMS when presenting with 2 or 3 FAST criteria. Pre-hospital notification of AIS has established itself as a means to expedited clinical and radiographic evaluation and faster and more frequent treatment on hospital arrival. Improving EMS triage of AIS patients presenting with symptoms not well represented in the FAST criteria represents a stroke systems of care performance and quality improvement opportunity.

The prevalence of neurocognitive deficits remains high in patients with stage 5 chronic kidney disease (CKD5D). Major contributors to such deficits include stroke, cervical carotid artery disease (CCAD), and intracranial atherosclerotic disease (ICAD). The risk of developing these dysfunctional vascular processes is facilitated by the chronic inflammation associated with renal failure. Plasma levels of 10 circulating biomarkers in patients with CKD5D (n = 78-90) were quantified using the sandwich enzyme linked immune sorbent assay method. Biomarkers for this study included kidney injury molecule-1, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), neutrophil gelatinase-associated lipocalin, interleukin-18, endothelin 1, calcifediol, parathyroid hormone, platelet-derived growth factor, microparticles-expressing tissue factor, and lipoprotein(a) (Lp(a)). Of the 90 patients with CKD5D, 30 had CCAD, 24 had ICAD, and 22 had stroke. Lp(a) level was significantly elevated in patients with CKD5D with comorbid ICAD compared to those without (125.70 ± 10.03 ng/mL vs 97.16 ± 5.97 ng/mL; P = .0065). NT-proBNP level was also significantly elevated in patients with CKD5D with comorbid stroke diagnosis compared to those without stroke history, once patients with a diagnosis of heart failure (HF) were excluded (14.84 ± 2.80 ng/mL vs 9.06 ± 1.27 ng/mL; P = .0283). Profiling levels of Lp(a) and NT-ProBNP could thus be useful in the risk stratification of ICAD and stroke, respectively, in the CKD5D population.

In the past for patients undergoing craniotomies and craniectomies, headache was not identified as a significant complication of their procedure. However, there are a myriad of headache- and pain-related issues that arise in the post-craniotomy period. This pain can be acute pain or chronic pain. Acute pain arises in the postoperative period up to 2 months postsurgical intervention. Chronic pain occurs or persists 2 months after intervention and beyond. These headaches and pain syndromes are further subdivided by phenotype, type of surgery, and surgical approach. Focused management of acute postsurgical headaches can improve short-term outcomes and decrease analgesic-related ICU complications. Tailored therapy in chronic headache cases can improve quality of life. Chronic postsurgical headaches appear to mirror their nonsurgical counterparts in terms of therapy. It is important to recognize that these syndromes can arise in the postoperative period. There are a number of postsurgical syndromes associated with headaches that should be identified to facilitate treatment.

The cerebellar ataxia syndromes are a heterogeneous group of disorders clinically characterized by the presence of cerebellar dysfunction. Initial assessment of patients with progressive cerebellar ataxia is complex because of an extensive list of potential diagnoses. A detailed history and comprehensive examination are required for an accurate diagnosis and hierarchical diagnostic investigations. Although no cure exists for most of these conditions, a small group of metabolic, hereditary, inflammatory, and immune-mediated etiologies of cerebellar ataxia are amenable to disease-modifying, targeted therapies. Over the past years, disease-specific treatments have emerged. Thus, clinicians must become familiar with these disorders because maximal therapeutic benefit is only possible when done early. In this article, we review disorders in which cerebellar ataxia is a prominent clinical feature requiring targeted treatments along with specific management recommendations.

Introduction: Patients with stage 5 chronic kidney disease (CKD5D) have a higher risk for developing neurocognitive deficits. Stroke, cervical carotid artery disease (CCAD), and intracranial atherosclerosis (ICAD), are causes of such deficits in CKD5D. Chronic inflammation from renal failure elevates risk for these diseases through oxidative stress and vascular dysfunction. The adverse impact on the carotid and intracranial vasculatures contributes to the multifactorial pathophysiology of stroke. Objective: Profile levels of inflammatory and hemostatic biomarkers in CKD5D plasma, and relate measurements to neurovascular diagnoses. Methods: Eleven plasma biomarker levels in CKD5D patients (n=97) and healthy controls (n=17-50) were measured using sandwich ELISA method. Of the 97 CKD5D patients, 24 had CCAD, 19 had ICAD, and 23 had acute stroke. Data were collected in Microsoft Excel, and analyzed using GraphPad Prism. Statistics were performed with Mann-Whitney t-tests, Kruskal-Wallis non-parametric ANOVA, and non-parametric Spearman correlations. Results: Every biomarker was elevated in CKD5D plasma, except for plasminogen activator inhibitor-1 (PAI-1; p=0.9764), compared to controls. Statistical significance was only found between CKD5D (+) and (-)CCAD inflammasomes (NALP3; p=0.0299), and between (+) and (-)stroke D-dimer (p=0.0258). Ages between each (+) and (-) disease groups were also significant (p=0.0002 CCAD; p Discussion: Lack of difference in PAI-1 levels between CKD5D and controls could be due to anticoagulants. Elevated D-dimer levels in CKD5D stroke patients could be due to increased age instead of stroke. NALP3 is known to be connected to the stability of atherosclerotic plaques in CCAD. NALP3 elevates IL-1β and IL-18, which subsequently increases risk of CCAD and stroke. Lack of more significant differences in biomarker levels between (+) and (-) disease groups could due to the BBB, which might filter out the biomarkers of our study. Conclusion: Profiling biomarker levels of this study may not be useful in the risk stratification of neurovascular diseases in the CKD5D population, with the possible exception of NALP3 for CCAD.

Introduction: Stroke is reported among the top 10 causes of death in children in the US. In the Kids’ Inpatient Database, older age and Hispanic ethnicity were risk factors for mortality after pediatric ICH. Limited data is available regarding risk factors for death after pediatric arterial ischemic stroke (AIS). Objective: To identify predictors of in-hospital mortality in pediatric patients hospitalized with AIS. Methods: Neonates (0-28 days) and children (29 days- Results: Fourteen of 915 neonates (1.5%) and 74/2,285 children (3.2%) died during hospitalization. Of 54 cases with reported causes of death, 32 (59%) were related to AIS (herniation 2, brain death 10, ICH/hemorrhagic transformation 5, care withdrawal due to stroke severity 15), with the remaining deaths attributed to underlying medical disease. Of 356 children with Pediatric NIH Stroke Scale (PedNIHSS) scores, median PedNIHSS was 19 (IQR 14-27) among the 13 children who died and 7 (IQR 3-12) among the 343 children who did not die. In multivariable analysis, congenital heart disease (OR 4.1, 95%CI 1.3-13, p=0.018) and posterior plus anterior circulation stroke (OR 4.3, 95%CI 1.3-14, p=0.017) were associated with in-hospital mortality for neonates, while higher PedNIHSS [OR 1.11 (per 1 point PedNIHSS increase), 95%CI 1.03-1.19, p=0.004], Hispanic ethnicity (OR 7.6, 95%CI 1.8-32.3, p=0.006), and cardiac disease (OR 7.5, 95%CI 1.5-38.6, p=0.015) were associated with in-hospital mortality for children. Conclusions: In-hospital mortality occurred in about 2% of pediatric AIS cases with nearly 60% attributable to stroke. Risk factors for in-hospital mortality included cardiac disease and stroke severity, factors also associated with mortality in adults. Hispanic ethnicity, a factor associated with mortality in childhood ICH, was also associated with mortality after childhood AIS; the underlying reasons are unclear. Additional information is needed on stroke-related deaths after hospitalization.

A 48-year-old woman with recent diagnosis of nonischemic cardiomyopathy and longstanding history of asthma and allergic rhinitis without additional vascular risk factors had intermittent chest pain and dyspnea for 6 weeks, treated with antibiotics and oral steroids without benefit. Subsequently, she developed bilateral leg edema, orthopnea, and chest pain, and was hospitalized twice at another institution. Transthoracic echocardiogram (TTE) demonstrated an ejection fraction (EF) of 30%. Cardiac catheterization was normal. CT of the chest showed a large pericardial effusion (∼300 mL) and bilateral pleural effusions. She had urgent pericardiocentesis and right thoracentesis, and was transferred to our institution for further evaluation and care.

An increased diameter (ectasis) and/or long and tortuous course (dolichosis) of at least one cerebral artery define intracranial arterial dolichoectasia (IADE). IADE could be detected incidentally or may give rise to an array of neurological complications including ischemic stroke, intracranial hemorrhage, or compression of surrounding neural structures. The basilar artery is preferentially affected and has been studied in more detail, mainly due to the presence of accepted diagnostic criteria proposed by Smoker and colleagues in 1986. Criteria for the diagnoses of dolichoectasia in other cerebral arteries have been suggested. However, they lack validation across studies. The prevalence of IADE is approximately 0.08–6.5% in the general population, while in patients with stroke, the prevalence ranges from 3% and 17%. Variations among case series depend on the characteristics of the studied population, diagnostic tests used, and diagnostic criteria applied. In rare instances, an underlying hereditary condition, connective tissue disorder, or infection predispose to the development of IADE. However, most cases are sporadic and associated with traditional vascular risk factors including advanced age, male gender, and arterial hypertension. The link between this dilative arteriopathy and other vascular abnormalities such as abdominal aortic aneurysm, coronary artery ectasia and cerebral small vessel disease suggest and underlying diffuse vascular process. Further understanding is needed on the physiopathology of IADE and how to prevent its progression and clinical complications.

Certain early neuroimaging findings are independent predictors of clinical outcome in acute basilar artery occlusion. These imaging findings may serve as important baseline imaging characteristics as well as subgroups in future randomized controlled trials. The purpose of this review is to review and compare early neuroimaging findings seen on non-invasive cranial imaging that predict clinical outcome in acute basilar artery occlusion.

Although the literature offers a number of clinical and radiologic approaches to the investigation of reversible cerebral vasoconstriction syndrome (RCVS), clinicians faced with new presentations of intracranial arteriopathy have no validated approach to assist them.1,2 The diagnostic criteria in the International Classification of Headache Disorders, 3rd edition (ICHD-3), provides a predominantly descriptive classification of RCVS categorizing definite and probable cases3 that provides little guidance in the setting of a new acute presentation. Distinguishing between RCVS and non-RCVS arteriopathies has important management implications particularly because steroids, often used in the management of non-RCVS arteriopathies, worsen the course and outcome of RCVS.4

In 2003, the American Board of Psychiatry and Neurology (ABPN) received approval from the American Board of Medical Specialties (ABMS) to recognize the expertise of those board-certified neurologists who were providing specialized care of patients with a broad spectrum of cerebrovascular diseases (vascular neurology.) This designation reflected the growth in knowledge about stroke as reflected by dedicated meetings and focused journals. The expansion in knowledge in vascular diseases of the brain and spinal cord, which was the result of advances in experimental, epidemiological, and clinical research, also served as an impetus. In 2005, the ABPN started the process of awarding 10-year time-limited certificates in vascular neurology. Now, ≈10 years later, it is reasonable to review the progress in the field of vascular neurology and to look at the future of the subspecialty. Because of their demonstrated special expertise and experience in the diagnosis and treatment of patients with a broad spectrum of vascular diseases of the central nervous system, vascular neurologists are and will continue to be at the forefront of stroke management. Patients, third-party payers, and colleagues will continue to seek the advice and care of vascular neurologists. With the advent of specialized training and resultant certification, many general neurologists now refer their problematic cases to vascular neurologists. This trend likely will continue and probably will accelerate. In addition, vascular neurologists are well-suited for leadership positions within hospital quality improvement programs and clinical initiatives. As of January 2013, the Centers for Medicare and Medicaid Services began mandatory hospital reporting of 7 stroke quality metrics known as core measures. Performance on these measures may become incorporated in determining reimbursement incentives and penalties in the future. The Joint Commission also is certifying primary and comprehensive stroke centers based on the recommendations of the Brain Attack Coalition. Certification standards include a well-defined …

Purpose— Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional. Methods— Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific Statements Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. Results— Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery–artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard. Conclusions— CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

Background and Purpose— Hemicraniectomy and Durotomy Upon Deterioration From Infarction-Related Swelling Trial (HeADDFIRST) was a randomized pilot study to obtain information necessary to design a Phase III trial to evaluate the benefit of surgical decompression for brain swelling from large supratentorial cerebral hemispheric infarction. Methods— All patients with stroke were screened for eligibility (age 18–75 years, National Institutes of Health Stroke Scale ≥18 with Item 1a Results— Among 4909 screened patients, only 66 (1.3%) patients were eligible for HeADDFIRST. Forty patients were enrolled, and 26 patients developed the requisite brain swelling for randomization. All who failed to meet randomization criteria were alive at 21 days. Mortality at 21 and 180 days was 40% (4/10) in the medical treatment only and 21% (3/14) and 36% (5/14) in the medical treatment plus surgery arms, respectively. Conclusions— HeADDFIRST randomization criteria effectively distinguished low from high risk of death from large supratentorial cerebral hemispheric infarction. Lower mortality in the medical treatment only group than in other published trials suggests a possible benefit to standardizing medical management. These results can inform the interpretation of recently completed European trials concerning patient selection and medical management. Clinical Trial Registration— This trial was not registered because enrollment began before July 1, 2005.

Background To report 2 patients with Susac syndrome presenting with acute confusion and abnormal neuroimaging and cerebrospinal fluid (CSF) findings, both of whom were initially misdiagnosed. Susac syndrome is a rare, though likely underdiagnosed, endotheliopathy defined clinically by the triad of encephalopathy, branch retinal artery occlusions (BRAOs), and sensorineural hearing loss (SNHL). Its pathogenesis remains poorly understood. The classic clinical triad may not be fully developed at initial presentation, even at the time magnetic resonance imaging (MRI) demonstrates characteristic central corpus callosum lesions. Methods We describe the patient's clinical course, investigations, management, and follow-up. Results A 57-year-old woman had acute onset of confusion and was initially thought to have multiple strokes. MRI demonstrated restricted diffusion involving the splenium of the corpus callosum and CSF showed elevated protein levels. Audiometry showed asymmetric bilateral SNHL. Fluorescein angiography showed multiple bilateral BRAOs. Patient received corticosteroids and intravenous immunoglobulin (IVIG). At 1-month follow-up, patient's confusion had resolved. The second patient was a 32-year-old man who had acute onset of confusion. CSF demonstrated pleocytosis and elevated protein. MRI demonstrated restricted diffusion involving the corpus callosum. Patient was discharged and rehospitalized 20 days later where he was diagnosed with acute disseminated encephalomyelitis. Patient presented a third time with vision loss. Fluorescein angiography demonstrated bilateral BRAOs. Audiometry noted bilateral SNHL. He received IVIG and discharged on a prednisone taper and mycophenolate mofetil. At 1-month follow-up, patient's confusion had resolved. Conclusions We report 2 patients evaluated within 1 month of each other who presented with acute confusion and were eventually diagnosed with Susac syndrome. Susac syndrome should be considered in young patients with otherwise unexplained acute onset of confusion with MRI and CSF changes as described previously.

Strokes are a major public health problem. In the United States, someone has a stroke every 40 seconds, and someone dies from a stroke every 4 minutes. This article discusses the diagnosis and management of stroke by posing 11 commonly asked questions about this disease.

Intracerebral hemorrhage (ICH) represents a potentially lethal form of stroke. ICH in a patient taking anticoagulant therapy presents unique diagnostic and therapeutic challenges. Specific clinical circumstances, outcomes, and evidence-based or rationally derived treatments (when the evidence is incomplete) are reviewed.

Central post-stroke pain syndrome (CPSP) is a debilitating sequel that can follow thalamic sensory stroke. Less well recognized, CPSP follows lateral medullary stroke and parietal cortical stroke and may develop anywhere along the spinothalamic or trigemino-thalamic pathways. Patients describe sharp, stabbing, or burning pain and experience hyperpathia and especially allodynia. Although CPSP was first described over 100 years ago, CPSP is too frequently under-recognized. It is treatable disorder. Pharmacological therapy, magnetic stimulation, and invasive electrical stimulation are reviewed and recommendations made.

To review the acute and chronic systemic complications of spinal cord injury and discuss treatment recommendations.The psychological, social, economic, and permanent neurologic effects associated with spinal cord injury (SCI) have universally persisted over time. Treating acute complications and preventing secondary injury can influence outcome, highlighting the importance of proper management of this patient population. Spinal cord injury (SCI) is due to traumatic or non-traumatic causes. Outcome depends on the level of injury and degree of sensorimotor deficits. After the primary injury occurs, it is crucial to detect and treat secondary mechanisms of injury. Correct method of intubation, preventing avoidable complications, and treating cardiovascular, pulmonary, renal, and infectious systemic complications are crucial as they all impact morbidity and mortality in SCI patients.

Age constitutes one of the most important nonmodifiable risk factors for cerebral infarction. About 15% of all the ischemic strokes occur in young adults. Since stroke predominately affects the elderly, most of the data gathered in pivotal clinical trials and population-based studies were obtained using cohorts of older patients with coexisting cardiac disease and atherosclerosis. In comparison to older individuals, however, patients aged 15–50 years have a lower prevalence of traditional vascular risk factors and a higher representation of uncommon causes of stroke; these differences necessitate a particularized, thoughtful approach and cause-specific treatments. This chapter hence focuses on the epidemiology, pathogenesis, and diagnostic investigations of ischemic stroke in the young.

A dissection is a hematoma within the arterial wall, that can be spontaneous or the result of trauma. Cervicocephalic arterial dissections are a common cause of cerebrovascular disease, particularly in younger patients in whom atherosclerosis is less prevalent. The clinical presentation of dissections is variable. The pain fibers within the arterial wall are compressed by dissection causing ipsilateral headaches or neck pain, sometimes as the only symptom. Dissections of the cervicocephalic arteries can also result in an ischemic stroke or a subarachnoid hemorrhage. The arterial hematoma can result in a flow-limited lesion or an intramural thrombus, either of which can lead to brain ischemia. Dissection in intracranial vessels can also result in a “pseudoaneurysm” (dissecting aneurysm) that can cause a subarachnoid hemorrhage if it ruptures. Prevention of further ischemic events is typically done with antithrombotic agents, and endovascular procedures in complicated cases. Brain ischemia secondary to cervicocephalic arterial dissections has generally a better prognosis than ischemia due to atherosclerotic cerebrovascular disease.