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Background: Due to its lower incidence, strokes in young adults, studies have difficulty answering why there are more women than men less than 35 with incident strokes. The goal of this study is to link claims and registry data to create a new longitudinal and clinical cohort of strokes in young adults. Methods: Colorado mandates reporting of commercial and public insurance (Medicaid and Medicare) claims to the All Payer Claims Database (APCD). We identified all first-time stroke admissions using ICD-9 /10 codes between 2012 to 2018 in young adults (18-55). Get with the Guidelines (GWTG) Stroke registry has stroke cases from 41 hospitals in Colorado since 2010. Matching was based on exact birthdate, sex and +/- 1day in admission/discharge dates. Confirmation of match was based on comparing the admitting hospital between the two databases. Cardiovascular(CV) and non-CV risk factors occurring from enrollment until 1 day prior to stroke date in the APCD were included. Student’s T-test, and Z-tests were used to test differences between men and women. Results: We identified 3032 stroke cases in the APCD. Of these, 1455 (48.0%) matched to an admission in the GWTG-Stroke registry. Of these, 1303 (89.6%) also matched based on the admitting hospital (Table). The final cohort contained 51% women, 11.3% Conclusions: Clinical registries such as GWTG-Stroke can be used to supplement longitudinal administrative cohorts of young adults with stroke to get richer data on stroke etiology and severity.

Background: We examined the effect of CV and non-CV risk factors on the development of strokes in young adults 18-55 years old. Methods: This case-control study, using the Colorado All Payer Claims Database (APCD), identified young adults with index stroke admissions and assigned them(1:3) to controls matched on age/sex/insurance type(commercial or public)/enrollment duration. Controls were assigned a proxy stroke date based on their matched case. CV and non-CV risk factors occurring from enrollment until 1 day prior to stroke date were included. Pregnancy, postpartum, and oral contraceptives were separated from other non-CV risk factors in women. To assess whether there was a differential effect of the risk factors by age in each sex, conditional logistic regression models were fit separately for men and women with an interaction between age and risk factor. Results: Between 2012-2018, 2735 index stroke admissions were identified (52.3% women) and matched to 8,178 controls. In men with stroke, 53.4% and 27.7% had at least one CV and non-CV risk factor, respectively. In women with stroke, 57.6%, 41.0%, and 12.1% had at least one CV, non-CV and hormonal risk factor, respectively. The most common CV risk factors were hypertension(27.8%), hyperlipidemia(26.8%), tobacco use(20.9%) in men and hypertension(25.5%), tobacco use(22.9%), obesity(22.6%) in women. The most common non-CV risk factors were migraines (14.3%), renal failure(6.9%), thrombophilia(6.1%) in men and migraines(29.1%), malignancy(9.5%), thrombophilia(6.7%) in women. Having one or more CV or non-CV risk factors significantly contributed to the development of strokes(Figure). Controlling for CV risk factors, having at least one non-CV risk factor had the highest risk among men and women Conclusions: Non-CV risk factors play a significant role in the development of strokes among young adults and warrants further study.

Introduction: Incidence of ischemic stroke in young adults is increasing, but reasons for this change remain unclear. One potential explanation may be increased detection of stroke due to increased use of brain MRI imaging. Methods: We performed a retrospective cohort study of adults ages 18-55 who presented to a large, multicenter health system from 1/1/2012-12/31/2018 with predefined focal neurologic chief complaints. Total counts of ischemic strokes based on ICD 9/ICD 10 code and total counts of MRIs were examined. Probability of ischemic stroke conditional on MRI and probability of MRI conditional on ischemic stroke were calculated. Counts were analyzed with Poisson/negative binomial count models and probabilities were analyzed with relative risk. Results: A total of 118,486 unique encounters were identified. Of these encounters, 1,179 (0.01%) led to ischemic stroke diagnosis and 8,293 (7.0%) had MRI brain ordered. Sixty-two percent of the encounters and the same proportion of MRIs were in females, but only 50% of ischemic strokes were in females. The probability (risk) of ischemic stroke diagnosis conditional on MRI was estimated to decrease by a proportion of 4.24% per year (95% CI: (0.91%, 7.24%), p value=0.013) (Figure). Yearly percent change from 2012 to 2018 of MRIs ordered and ischemic strokes followed a similar trend. Conclusion: The decreasing proportion of ischemic strokes diagnosed when MRIs were ordered suggests that the threshold for ordering MRIs in young adults with focal neurologic symptoms has decreased. Therefore, some of the increased incidence of stroke among young adults may be explained by increased use of MRI.

Background: Emergency Medicine Service (EMS) provider compliance with American Heart Association (AHA) guidelines for acute stroke care is low. While early recognition improves in-hospital quality of care, including door-to-computed tomography (CT) time, the impact of compliance with individual recommendations on in-hospital outcomes is unknown. Methods: We identified 410 acute ischemic stroke patients who presented to a Comprehensive Stroke Center via EMS between January 1, 2018, and December 31, 2019. Guideline concordant care was defined as encounters in which EMS documented: a blood glucose, a 12-lead electrocardiogram, a stroke scale result, and time of the last known well; were enroute within less than 2 minutes from dispatch and spent less than 15 minutes on scene. We used a multivariable linear regression model to determine the effect of individual metrics, race/ethnicity, sex, and age on door-to-CT times. Results: There was low compliance with all quality-of-care metrics (37/410 encounters, 9%), but most encounters met at least 4 metrics (60.3%). Compliance with recommendations to maintain short dispatch-to-enroute times and to obtain a blood glucose were the highest (88.1% and 74.5%, respectively). Only 44.5% of encounters documented a stroke scale, but 95.9% documented a neurological exam. A linear regression model identified documentation of classic symptoms (unilateral weakness, facial droop, or speech changes) (parameter estimate -16.6, 95% CI -21.8 to -11.5) and documentation of the last known well time (parameter estimate -15.9, 95% CI -21.6 to -10.1) as significant predictors of door-to-CT times. However, documentation of a last known well occurred only in 59.9% encounters. Conclusions: Like prior studies, this study finds similarly low compliance with AHA stroke guideline and also identifies two key EMS actions that are associated with shorter door-to-CT times - documentation of last known well and recognition and documentation of classic stroke symptoms. Further education is needed to reinforce the importance of individual recommendations such as documentation of last known well and its impact on in-hospital care. Broader analysis of EMS practices is needed to fully understand the impact on additional patient outcomes.

Background: Stroke is a medical emergency. The effectiveness of stroke treatment is time dependent. Due to the urgency of treatment and the challenge of rapidly assessing stroke-like symptoms, patients with stroke mimics (non-stroke etiologies of focal neurologic symptoms) may be treated with thrombolysis. We aimed to understand characteristics of patients treated with IV tPA with a final diagnosis of stroke versus a stroke mimic. Methods: This retrospective cohort study identified patients who received tPA for stroke-like symptoms in the emergency department at a single urban Comprehensive Stroke Center over 26 months. Final diagnosis was based on ICD-10 codes. Demographic data, medical history and presenting symptoms were obtained through electronic medical record review. Characteristics of patients with strokes and mimics were compared using Chi-squared and t-tests. Results: Of 202 patients presenting with stroke-like symptoms who received tPA, final diagnosis was ischemic stroke in 166 (82%) and mimic in 36 (18%). A statistically significant difference was noted between the stroke and mimic groups in age (64 ±16.9 vs 57 ±13.8 years, p=0.015) and neared significance in sex (38% vs 56% female, p=0.052). There was no difference in initial NIHSS (7.8 ±7.2 vs 5.8 ±5.2, p=0.109), Hispanic ethnicity (13% vs 22%, p=0.170), presence of stroke risk factors (79% vs 78%, p=0.880), or race distribution (white 54% vs 61%, Black 28% vs 14%, multiple/other 18% vs 25%, p=0.199). The most common mimic symptoms included unilateral weakness (61%), unilateral numbness (53%), dysarthria (33%), ataxia (28%), vertigo (22%), and gait impairment (17%). The most common clinical diagnoses in mimics were headache, functional neurologic disorder, and toxic/metabolic disturbances (17% each). Conclusion: Of patients receiving tPA at our facility, stroke mimics comprised 18% and were significantly younger than patients with ischemic stroke. Further analysis of demographics within these two groups could identify characteristics that distinguish strokes from mimics, which may lower the rate of tPA administration to non-stroke presentations.

Background and Purpose: Cardiovascular risk factors, which are overall more prevalent in men, are considered the major risk factors for strokes among young adults. However, recent European data found the incidence of strokes to be higher in young women. Using a large US claims sample, we examined sex differences in the index stroke rate of young adults. Methods: We performed a retrospective cohort study of enrollees in a 10% random sample of PharMetrics, a nationally representative claims database of insured Americans from 2001 to 2014. Outcomes were index ischemic stroke events, based on inpatient admissions using International Classification of Diseases-Ninth Revision codes. The index stroke rate was estimated from Poisson rate models with time varying covariates for 2-year periods, stratified by sex and age groups. Results: We identified 20 554 index strokes (50.4% women; mean age 63) including 5198 in young adults ages 15 to 54. There was no difference by sex in the index stroke rate in the extremes of age groups 15 to 24 and ≥75 years old. However, in the 25 to 34 and 35 to 44 year age groups, more women had strokes than men (incidence rate ratio: men:women, 0.70 [95% CI, 0.57–0.86]; 0.87 [95% CI, 0.78–0.98], respectively). In contrast, in the 45 to 54, 55 to 64, and 65 to 74 year age groups, more men had strokes (incidence rate ratio, 1.25 [95% CI, 1.16–1.33]; 1.41 [95% CI, 1.18–1.34]; 1.18 [95% CI, 1.12–125], respectively). Conclusions: More young women than men have strokes, suggesting possible importance of sex-mediated etiologies of stroke. Understanding these drivers is critical to stroke treatment and prevention efforts in young adults.

Introduction: Young women with stroke represent a unique patient population. There are a variety of sex-specific etiologies that warrant a different approach to evaluation and secondary prevention in young women. Secondary prevention begins during the acute hospitalization, thus, certain aspects of the history and evaluations may be indicated early after stroke. We describe our center’s experience with young women presenting with stroke over a 2.5-year period. Methods: We performed a retrospective review of women between 18-45 years, identified from our stroke registry (1/2015 to 5/2018). An assessment of key variables regarding common stroke risk factors (RFs), sex-specific RFs, (pregnancy history, estrogen use, migraine, autoimmune conditions) and workup (pregnancy test, hypercoagulable states, substance use) was conducted. Results: Of 198 women with acute ischemic stroke in our study period, medical RFs of hypertension, diabetes, hyperlipidemia, and atrial fibrillation were each ascertained for more than 98% of women. Lifestyle RFs of tobacco use and alcohol use were reported for 85.9% and 87.6%, respectively and urine drug screens were performed in 67%. Obstetric history (gravida/para) was obtained in only 19.7%, pregnancy tests were conducted in 69.2%, and hypertensive disorders of pregnancy were only reported in patients who were pregnant (2%) or post-partum (5.6%). Oral contraceptive (OCP) or hormone replacement (HRT) was reported in 6.6% and migraine with or without aura in 12.6%. Among 76 patients (38.4%) with cryptogenic stroke, obstetric history was reported in only 25%, OCP/HRT use in 5.3%, and antiphospholipid antibody syndrome was assessed in 64%. Conclusion: The acute stroke hospitalization is a critical period for identification of stroke etiology and assessment of cardiovascular risk. There are known sex disparities in standard evaluation and management of stroke. In pre-menopausal women, gaps in care may be even greater if the history and assessment are not completed with sex-specific variables in mind. We suggest a standard approach to the history and assessment of young women. We plan to implement this approach in our patient population while tracking the impact on care.

Background: Stroke mimics are often difficult to distinguish from true ischemic and hemorrhagic cerebrovascular accidents, and present a challenge for appropriate delivery of rapid stroke treatment. This is particularly true in ultra-early stroke care with Mobile Stroke Units (MSU), which administer tPA in the field, within minutes of symptom onset. We sought to evaluate and characterize stroke mimics during prehospital care with an MSU at a Comprehensive Stroke Center. Methods: The study compared patient and stroke characteristics, neurologic evaluation, and treatment between confirmed strokes and stroke mimics treated during a one-year pilot period on the MSU at a large urban medical center. Variables included patient demographics, NIHSS score, tPA administration, final diagnosis, and discharge disposition. Results: Between Jan. 15, 2016 and Jan. 9, 2017, 47 patients received prehospital management on the MSU, and 44 were admitted to UC hospital and had an available final diagnosis. Of these, 12 (27%) were stroke mimics. Mimics were younger [median age 60 (IQR 54-71) years, mimics vs. 68 (IQR 60-77) years, strokes], and were more often female (58%, mimics vs. 47%, strokes). Initial NIHSS score was lower for confirmed strokes [median 3 (IQR 2-10) strokes, vs. 6 (IQR 4-12) mimics], but severe strokes with a NIHSS score >17, were more common in strokes (16%, strokes vs. 0%, mimics). Of mimics, 6 (50%) were seizures, 2 (17%) migraine, 2 (17%) conversion, 1 (8%) encephalopathy, and 1 (8%) delirium. Thirteen (30%) of all patients were treated with IV tPA on the MSU, of whom 4 (31%) were mimics. Of mimics given tPA, 2 were seizures, 1 migraine and 1 conversion. Mimics were more likely to be discharged to home (64%, mimics vs. 46%, strokes) while strokes more likely received rehabilitation (23%, strokes vs. 9%, mimics). Conclusions: One third of patients treated on the MSU were stroke mimics, and among these the most common diagnosis was seizures. These results suggest vigilance is warranted for seizure, as well as further study of rapid EEG technologies to guide appropriate treatment for presentations that appear to be stroke, including antiepileptic drugs, in ultra-early MSU care of suspected CVA.

Background: Transthoracic echocardiogram (TTE) is a “moderate” recommendation under the 2021 AHA/ASA Guidelines. We aimed to identify in which patients TTE is most likely to reveal a clinically relevant finding that helps guide workup and secondary stroke prevention. Methods: We reviewed records of patients at an academic stroke center with primary discharge diagnosis of ischemic stroke between January 1-December 31, 2019 excluding those with prior stroke. Stroke location was classified as cortical, subcortical, brainstem, multiple/multifocal. TTE findings defined as clinically significant included reduced ejection fraction, enlarged left atrial size, patent foramen ovale, vegetations, thrombus, and atrial fibrillation during the procedure. Chi-square and Fisher’s exact association tests were used for two-way tables, relative risk, and logistic regressions. Results: Of the 307 identified patients admitted for first time stroke, 181(59.0%) were male, and median age was 63.6+/-14.3 years. Stroke location was cortical in 99(32.2%), subcortical in 41(13.4%), brainstem in 39(12.7%), and multiple/multifocal in 128(41.7%). Clinically significant findings on TTE were found in 150 patients(48.9%). Age predicted clinically significant TTE (risk ratio per 10 year interval 1.11, 95% CI 1.02-1.20). Atrial fibrillation and cortical location predicted clinically significant TTE findings (table). Other locations and risk factors were not associated with clinically significant TTE. Discussion: Cortical stroke was the only location associated with clinically significant TTE findings. The lack of association with multifocal strokes was surprising as they are often presumed cardioembolic. This suggests that TTE may be most beneficial in evaluating cortical stroke, but given that nearly half of all stroke patients had TTE findings that would inform further management suggests that continuing universal TTEs.

Background and Purpose: Recent evidence suggests that young women (18–45 years) may be at higher risk of ischemic strokes than men of the same age. The goal of this systematic review is to reconcile and synthesize existing evidence of sex differences among young adults with ischemic strokes. Methods: We searched PubMed from January 2008 to July 2021 for relevant articles and reviews and consulted their references. We included original studies that (1) were population based and (2) reported stroke incidence by sex or sex-specific incidence rate ratios of young adults ≤45 years. We excluded studies that (1) omitted measurements of error for incidence rates or incidence rate ratios, (2) omitted age adjustment, and (3) were not in English. Statistical synthesis was performed to estimate sex difference by age group (≤35, 35–45, and ≤45) and stroke type. Results: We found 19 studies that reported on sex-specific stroke incidence among young adults, including 3 that reported on overlapping data. Nine studies did not find a statistically significant sex difference among young adults ≤45 years. Three studies found higher rates of ischemic stroke among men among young adults ≥30 to 35 years. Four studies found more women with ischemic strokes among young adults ≤35 years. Overall, in young adults ≤35 years, the estimated effect size favored more ischemic strokes in women (incidence rate ratio, 1.44 [1.18–1.76], I 2 =82%) and a nonsignificant sex difference in young adults 35 to 45 years (incidence rate ratio, 1.08 [0.85–1.38], I 2 =95%). Conclusions: Overall, there were 44% more women ≤35 years with ischemic strokes than men. This gap narrows in young adults, 35 to 45 years, and there is conflicting evidence whether more men or women have ischemic strokes in the 35 to 45 age group.

OBJECTIVE: Emergency Medicine Service (EMS) providers play a pivotal role in early identification and initiation of treatment for stroke. The objective of this study is to characterize nationwide EMS practices for suspected stroke and assess for gender-based differences in compliance with American Stroke Association (ASA) guidelines. METHODS: Using the 2019–2020 National Emergency Medical Services Information System (NEMSIS) Datasets, we identified encounters with an EMS designated primary impression of stroke. We characterized patient characteristics and EMS practices and assessed compliance with eight metrics for “guideline-concordant” care. Multivariable logistic regression modeled the association between gender and the primary outcome (guideline-concordant care), adjusted for age, EMS level of service, EMS geographical region, region type (i.e. urban or rural), and year. RESULTS: Of 693,177 encounters with a primary impression of stroke, overall compliance with each performance metric ranged from 18% (providing supplemental oxygen when the pulse oximetry is less than 94%) to 76% (less than 90sec from incoming call to EMS dispatch). 2,382 (0.39%) encounters were fully guideline-concordant. Women were significantly less likely than men to receive guideline-concordant care (adjusted OR 0.82, 95% CI 0.75–0.89; 0.36% women, 0.43% men with guideline-concordant care). CONCLUSIONS: A minority of patients received prehospital stroke care that was documented to be compliant with ASA guidelines. Women were less likely to receive fully guideline-compliant care compared to men, after controlling for confounders, although the difference was small and of uncertain climical importance. Further studies are needed to evaluate the underlying reasons for this disparity, its impact on patient outcomes, and to identify potential targeted interventions to improve prehospital stroke care.

Introduction: Multiple societal guidelines recommend patients with TIA be emergently imaged with brain-MRI and neurovascular screening-CTA, MRA or carotid ultrasound-to identify and treat risk factors for future stroke. Increased ED compliance with TIA imaging guidelines has previously been demonstrated, along with a substantial increase in imaging utilization over the past decade. The purpose of this study was to quantify prevalence of redundant imaging during ED work-up of TIA, and to identify imaging practices that could be targeted to reduce unnecessary expenditures. Methods: Utilizing the 2006-2017 Nationwide Emergency Department Sample, patients discharged with TIA from EDs in the US were identified using ICD-9/10 codes. Brain and neurovascular imaging obtained during the encounter was identified using CPT codes. Demographics, payor, patient income, and hospital characteristics were incorporated into a hierarchical multivariable logistic regression analysis to identify significant associations with redundant neuroimaging. Results: In 2017 there were 184,870 patients discharged from EDs with TIA. Redundant brain, brain vascular, and cervical vascular imaging was identified in 55,513(30%), 5,149(2.8%) and 1,325(0.7%) of encounters respectively. Decreased odds of obtaining redundant neuroimaging in a TIA encounter was observed in Medicaid patients(OR:0.72, 95%CI:0.64-0.81), non-trauma centers(OR:0.49, 95%CI:0.26-0.93), rural hospital locations(OR:0.18, 95%CI:0.11-0.29) and weekend encounters(OR:0.9, 95%CI:0.85-0.96). Trend analysis from 2006 to 2017 demonstrated a rise in redundant brain and neurovascular imaging from 2.3% and 0.2% of encounters respectively in 2006 to 30% and 3.5% of encounters in 2017. Using Medicare fee estimates, in 2017 redundant brain and neurovascular imaging for patients discharged from EDs with TIA resulted in additional charges of approximately 8,670,832 USD. Conclusion: Increasing utilization of imaging for workup of TIA across EDs in the US is also associated with substantial and increasing use of redundant imaging. We identify redundant brain and neurovascular imaging as areas that could be targeted to mitigate rising imaging expenditures.

Objective To determine the feasibility of using a machine learning algorithm to screen for large vessel occlusions (LVO) in the Emergency Department (ED). Materials and methods A retrospective cohort of consecutive ED stroke alerts at a large comprehensive stroke center was analyzed. The primary outcome was diagnosis of LVO at discharge. Components of the National Institutes of Health Stroke Scale (NIHSS) were used in various clinical methods and machine learning algorithms to predict LVO, and the results were compared with the baseline method (aggregate NIHSS score with threshold of 6). The Area-Under-Curve (AUC) was used to measure the overall performance of the models. Bootstrapping (n = 1000) was applied for the statistical analysis. Results Of 1133 total patients, 67 were diagnosed with LVO. A Gaussian Process (GP) algorithm significantly outperformed other methods including the baseline methods. AUC score for the GP algorithm was 0.874 ± 0.025, compared with the simple aggregate NIHSS score, which had an AUC score of 0.819 ± 0.024. A dual-stage GP algorithm is proposed, which offers flexible threshold settings for different patient populations, and achieved an overall sensitivity of 0.903 and specificity of 0.626, in which sensitivity of 0.99 was achieved for high-risk patients (defined as initial NIHSS score > 6). Conclusion Machine learning using a Gaussian Process algorithm outperformed a clinical cutoff using the aggregate NIHSS score for LVO diagnosis. Future studies would be beneficial in exploring prospective interventions developed using machine learning in screening for LVOs in the emergent setting.

Background Pneumonia, the most common post-acute ischemic stroke (AIS) infection, accounts for up to 30% of deaths after a stroke. Multiple chronic inflammatory diseases, such as rheumatoid arthritis, psoriasis, and inflammatory bowel disease, are associated with increased risk of stroke and stroke morbidity. This study assessed the relationship between chronic inflammatory diseases and stroke-associated pneumonia (SAP). Methods Using data from the 2015-2017 National Inpatient Sample, we classified hospital discharges with a diagnosis of AIS as having ulcerative colitis, Crohn's disease, rheumatoid arthritis, psoriasis, systemic lupus erythematosus, other chronic inflammatory diseases, multiple chronic inflammatory diseases, or none. With multivariable logistic regression, we assessed for associations between chronic inflammatory disease and in-hospital SAP or death. Results Among AIS discharges, there was a decreased risk of SAP among those with psoriasis or other chronic inflammatory diseases (adjusted odds ratio (aOR) 0.70, 95%CI 0.63-0.99; aOR 0.64, 95%CI, 0.46-0.89, respectively), compared to those without psoriasis and without other chronic inflammatory disease, respectively. Rheumatoid arthritis, psoriasis, and other chronic inflammatory diseases were associated with reduced in-hospital mortality (aOR 0.89, 95%CI 0.78-1.00; aOR 0.77, 95%CI 0.59-1.00; aOR 0.69, 95%CI 0.50-0.94, respectively). Conclusions The risk of SAP and in-hospital mortality varies by chronic inflammatory disease – psoriasis and other chronic inflammatory diseases are associate with reduced rates of SAP, whereas rheumatoid arthritis, psoriasis and other chronic inflammatory disease were associated with reduced in-hospital mortality. Further investigations are needed to determine a relationship between the potential role of immunomodulation and the reduction in SAP and mortality in chronic inflammatory diseases.

Background and Purpose: Multiple societal guidelines recommend urgent brain and neurovascular imaging in patients with transient ischemic attack (TIA) to identify and treat risk factors that may lead to future stroke. The purpose of this study was to evaluate whether national imaging utilization for workup of TIA complies with society guidelines. Methods: Analysis utilized the Nationwide Emergency Department Sample. Primary analysis was performed on a 2017 cohort, and secondary trend analysis was performed on cohorts from 2006 to2017. Patients diagnosed and discharged from emergency departments with TIA were identified using International Classification of Diseases, Ninth Revision and Tenth Revision codes. Brain and neurovascular imaging obtained during the encounter was identified using Current Procedural Terminology codes. Demographics, health insurance, patient income, and hospital-type covariates were analyzed using a hierarchical multivariable logistic regression analysis to identify predictors of obtaining neurovascular imaging during an emergency department encounter. Results: In 2017, there were 167 999 patients evaluated and discharged from emergency departments with TIA. The percentage of patients receiving brain and neurovascular imaging was 78.5% and 43.2%, respectively. The most common imaging workup utilized was a solitary computed tomography–brain without any neurovascular imaging (30.9% of encounters). Decreased odds of obtaining neurovascular imaging was observed in Medicaid patients (odds ratio, 0.65 [95% CI, 0.58–0.74]), rural hospitals (odds ratio, 0.26 [95% CI, 0.17–0.41]), nontrauma centers (odds ratio, 0.40 [95% CI, 0.21–0.74]), and weekend encounters (odds ratio, 0.91 [95% CI, 0.85–0.96]). Trend analysis demonstrated a steady rise in brain and neurovascular imaging in 2006 from 34.9% and 6.8% of encounters, respectively, to 78.5% and 43.2% of encounters in 2017. Conclusions: Compliance with imaging guidelines is improving; however, the majority of TIA patients discharged from the emergency department do not receive recommended neurovascular imaging during their encounter. Follow-up studies are needed to determine whether delayed or incomplete vascular screening increases the risk of future stroke.

Background and Purpose: Pregnancy is a risk factor for stroke. The mechanisms of stroke in pregnancy have not been well established. Cervical artery dissection may be one such mechanism, but it is unclear whether pregnancy is a risk factor for cervical artery dissection. Methods: We performed a cohort-crossover analysis using administrative claims data from all hospitalizations and emergency department visits involving nonfederal acute care hospitals in NY and FL between 2005-2015. We identified women ≥12 years old who were hospitalized for labor and delivery. Our outcome was cervical artery dissection, defined as carotid or vertebral artery dissection. We defined the period of risk as 6 months antepartum through 3 months postpartum. We compared each patient’s risk of dissection during this time period versus the corresponding 270-day period exactly 1 year later. Conditional Poisson models with robust standard errors were used to calculate incidence risk ratios (IRRs). Results: We identified 4,193,417 pregnancies among 3,061,413 women during our study period. There were 52 cases of cervical artery dissection during the peripartum period and 24 cases during the control period 1 year later. The incidence of cervical artery dissection was 12 (95% CI, 10-17) per million pregnancies versus 6 (95% CI, 4-9) per million patients during the control period 1 year later (IRR, 2.2; 95% CI, 1.3-3.5). Our findings were similar when we limited our outcome to cervical artery dissections complicated by ischemic stroke (IRR, 2.3; 95% CI, 1.1-5.1). Secondary analyses suggested that the heightened risk occurred in the peripartum and postpartum period (IRR,5.5; 95% CI, 2.6-11.7), not the antepartum period (IRR, 0.5; 95% CI, 0.2-1.2). Conclusions: In a large, population-based sample of women, pregnancy was associated with an increased risk of cervical artery dissection. This increased risk appeared to be limited to the peripartum and postpartum period.

Introduction: Multiple societal guidelines recommend urgent imaging in patients with transient ischemic attack (TIA) to identify and treat risk factors that may lead to future stroke. Recommended studies include brain imaging, preferably with MRI, and neurovascular imaging (cranio-cervical CTA, cranio-cervical MRA or carotid ultrasound). The purpose of this study was to evaluate whether emergency department (ED) imaging utilization practices comply with recommended guidelines. Methods: Analysis utilized the Nationwide Emergency Department Sample (NEDS), a comprehensive, nationally representative sample of ED visits. Primary analysis was performed on the 2016 cohort, and a secondary trend analysis was performed on cohorts from 2006-2016. Patients diagnosed and discharged from the emergency department with transient ischemic attack were identified using ICD-9 and ICD-10 codes. Brain and neurovascular imaging obtained during the encounter were identified using CPT codes. Demographics, health insurance, patient income, and hospital type data were analyzed and a survey weighted logistic regression analysis was performed to identify predictors of obtaining neurovascular imaging. Results: In 2016 there were 183,216 patients evaluated and discharged from emergency departments with TIA. The percentage of patients receiving brain and neurovascular imaging was 75.73% and 37.99% respectively. Of the top 5 imaging work-ups utilized, the most common (34.06% of cases) was a solitary noncontrast head CT without any neurovascular imaging. Decreased odds of obtaining neurovascular imaging was observed in Medicaid patients (OR: 0.73, 95%CI: 0.66-0.80), non-trauma centers (OR: 0.42, 95%CI: 0.38-0.45), and rural hospital locations (OR: 0.30, 95%CI: 0.27-0.33). Trend analysis demonstrated a steady rise in brain and neurovascular imaging from 34.02% and 6.51% of encounters respectively in 2006 to 75.73% and 37.99% of encounters in 2016. Conclusion: The majority of TIA patients discharged from the ED do not receive recommended neurovascular imaging during their encounter. Follow-up studies are needed to determine whether delayed or incomplete vascular screening increases the risk of future stroke.

Background Incidence of cardiovascular disease in young adults is unabated. Increased prevalence of self‐reported atherosclerotic risk factors may be driving this trend. The goal of this study was to examine whether the prevalence of atherosclerotic risk factors in young adults is increasing over time using both self‐report and standard clinical criteria. Methods and Results Data from young adults, aged 20 to 45 years, in the National Health and Nutrition Examination Survey from 1999/2000 to 2013/2014 were analyzed. Risk factor prevalence of hypertension, diabetes mellitus, and hyperlipidemia was measured using clinical criteria and self‐report. Smoking was based on self‐report only, and obesity was based clinically on body mass index and waist to height ratio. Prevalence by survey was adjusted for age, sex, and race/ethnicity. By clinical criteria, adjusted prevalence of any 3 risk factors (hypertension, diabetes mellitus, and hyperlipidemia) declined slightly from 21.8% to 18.9% ( P for trend=0.05). However, by self‐report, the adjusted prevalence of any 3 risk factors increased from 17.8% to 26.5% ( P P =0.32) but increased by self‐report ( P P =0.35 and P =0.29, respectively). Hyperlipidemia, by clinical criteria, declined over time ( P P P P P Conclusions The perception that young adult risk factors are increasing is consistent with increasing self‐reported risk factors. However, evidence does not suggest that clinical risk factor prevalence overall has increased in young adults.

Background: Recent studies suggest an increasing incidence of stroke in young populations in the last 2 decades in contrast with the declining incidence in older adults. Rising prevalence of atherosclerotic risk factors (ARF) has been proposed as an explanation for this trend. The aim of this study was to determine the odds of stroke with different ARF across the young population. Methods: In a case control study nested within a cohort of children (29 days-19 years) and young adults (20-49 years) enrolled in a Northern California integrated health care system between 2000-2014, cases of ischemic stroke were identified using ICD-9 codes as well as text string searches of the radiology database, and were confirmed by chart review and adjudicated by 2 MD review. Controls matched by age and dates of enrollment were randomly selected from the cohort. Charts for all cases and controls were reviewed for evidence of ARF prior to stroke diagnosis. Results: Strokes were identified in 141 children and 449 young adults, and 354 childhood controls and 1,014 young adult controls were randomly selected. All ARF were found at very low rates in both childhood cases and controls (figure). In the 20-29 year age group, hypertension and having more than one risk factor significantly increased the odds of stroke. In the oldest 2 groups (30-39, 40-49y), all 5 ARF significantly increased the odds of stroke, as did having more then one risk factor. Conclusions: ARF are very rare in children, including in those with strokes. Hypertension begins to increase the odds of stroke in the 3 rd decade of life, but in the 4 th and 5 th decades, each risk factor’s impact on stroke risk is significant, with more then one risk factor increasing the odds of stroke 10-fold.

Background: Readmissions after ischemic strokes are common and associated with high morbidity and cost. Whether early follow-up after stroke can reduce readmissions remains unclear. We examined the relationship between follow-up after stroke hospitalization with primary care or neurology and readmissions at 30 and 90 days. Methods: A retrospective cohort study was performed using PharMetrics claims database of US commercial insurers from 2009 to 2015. Inclusion: (1) inpatient admission with primary diagnosis of ischemic stroke, (2) discharge home, (3) age 18-89, (4) 1 year of enrollment prior to stroke and 3 months after discharge. Exclusion: (1) stroke transfers, (2) repeat admission for stroke. The primary outcome was all-cause 30-day and 90-day hospital readmission. Multivariable Cox models were used with primary care and neurology visits specified as time-dependent covariates, adjusting for patient demographics, comorbidities (calculated for one year prior to stroke) and stroke severity measures. Results: The cohort consisted of 16,965 patients (table). Readmissions at 30 days occurred in 6.56% of patients at a median (interquartile range) of 12 days (5-20). Readmissions at 90 days occurred in 13.2% of patients at a median of 31 days (12-58). By 30 days, 50.2% had a primary care visit and 17.1% had a neurology visit. Patients with a primary care visit within 30 days had a 23% lower rate of readmission than those who did not (hazard ratio [HR], 0.77; 95% confidence interval, 0.66-0.89). The association is less strong for primary care visits within 90 days and readmissions (HR 0.88; 0.80-0.98). Neurology follow-up did produce benefit but did not reach significance. Conclusion: Early outpatient follow-up with primary care is associated with a significant reduction in hospital readmission. Even though this was an insured population, almost half of all patients did not receive primary care follow-up at 30 days, which represents an opportunity for intervention.

Background: The University of Colorado Mobile Stroke Unit (UC MSU) provides ambulance-mounted CT scanning and tele-stroke neurologic assessment in the Denver, CO, metropolitan area. As one of the first U.S. medical centers to utilize a mobile stroke protocol we sought to compare operational characteristics of the MSU during its first year with standard management (SM) of pre-hospital stroke alerts at a Comprehensive Stroke Center. Methods: The study compared patient and stroke characteristics, ambulance response, neurologic evaluation, and treatment between the MSU, and SM patients for the same ambulance service area. Variables included time from stroke alert (MSU or ambulance dispatch) to tPA administration, as well as time from arrival at the door of MSU or ED to first brain CT and to IV tPA administration. Patients were dichotomized into those with time from door to needle greater or less than the American Stroke Association “Target: Stroke” study goal of 45 minutes. Results: Between Jan. 15, 2016 and Jan. 9, 2017, 47 patients received prehospital management with the UC MSU, and 73 received standard management. Median age was 66 years (IQR 57-77), and 45% were female, with no difference between MSU and SM patients. Thirteen (28%) of patients were treated with IV tPA on the MSU, compared with 16 (22%) through SM. Median time was significantly shorter from door to first CT on the MSU than SM [4 minutes (IQR 4-5) MSU vs. 9 minutes (IQR 6-15) SM, p Conclusions: Patients treated via the MSU benefited from quicker time to CT, neurologic evaluation, and, critically, significantly shorter time from dispatch to tPA administration, compared with pre-hospital stroke alerts arriving from the same service area. These results suggest prehospital management with an MSU has potential to aid the goal of earlier thrombolysis after ischemic stroke symptom onset.

Background: While there have been dramatic declines in the incidence of cardiovascular diseases in older adults, the incidence of strokes and acute myocardial infarctions (AMI) in young adults are as high as ever. The goal of this study was to better understand sex differences in the incidence of stroke and AMI in young adults. Methods: A 10% random sample of all enrollees from a commercial claims database between 2001-2014 was used. Enrollees between 15 to 45 years old with claims for first ever stroke or AMI hospitalizations identified by ICD-9 code were included. Logistic regression was used to quantify incidence over time, adjusting for age groups and sex, also allowing for sex and year interaction (so women and men can have trends in opposite directions). Results: Among 3,717,422 young adults, there were 3357 incident stroke and 2986 incident AMI hospitalizations. The average age based on first year of enrollment was 28.6 with a mean 3.6 years of follow-up. There were 52.0% women overall. Women were more likely than men to be admitted for stroke (55.2% vs. 44.8%; p=0.0003) but less likely to be admitted for AMI (30.7% vs. 69.3%; p Conclusions: In the young adult population, AMI is more common in men and stroke is more common in women. The explanation for this difference is unclear but suggests there may be different etiologies of stroke and AMI in young adults. Further research could help to better define the varying role of atherosclerotic risk factors in young adults with stroke as compared with AMI.

Background and Purpose— Percutaneous transcatheter closure of patent foramen ovale (PFO closure) plus antiplatelet therapy has been shown to reduce the risk of recurrent stroke compared with medical therapy alone in carefully selected patients after cryptogenic stroke presumed to be from paradoxical embolism. Our objective was to determine the cost-effectiveness of PFO closure after cryptogenic stroke compared with conservative medical management from a US healthcare payer perspective. Methods— A decision analytic Markov model estimated the 15-year cost and outcomes associated with the additional benefit of PFO closure compared with medical management alone. Model inputs were obtained from published literature, national databases, and a meta-analysis of 5 published randomized clinical trials on PFO closure. Health outcomes were measured in quality-adjusted life years (QALY). Cost-effectiveness used the incremental cost per QALY gained, whereas the net monetary benefit assumed a willingness to pay of $150 000/QALY. One-way and probabilistic sensitivity analyses estimated the uncertainty of model results. Results— At 15 years, PFO closure compared with medical therapy alone improved QALY by 0.33 at a cost saving of $3568, representing an incremental net monetary benefit of $52 761 (95% interval −$8284 to $158 910). When the meta-analysis hazard ratio for stroke was increased to the 95% interval’s upper bound of 0.77, one-way sensitivity analyses suggested that PFO closure’s cost-effectiveness was $458 558 per additional QALY. Probabilistic sensitivity analysis suggested cost-effectiveness in 90% of simulation runs. Conclusions— PFO closure for cryptogenic strokes in the right setting is cost-effective, producing benefit in QALYs gained and potential cost savings. However, patient selection remains vitally important as marginal declines in treatment effectiveness can dramatically affect cost-effectiveness.

Background: The aggressive management of atherosclerotic risk factors (ARF) has been accredited with the declining incidence of stroke in older adults. The goal of this study was to look at treatment patterns of ARF in young adults compared to older adults. Methods: A commercial claims database was used, containing enrollees between ages 15 to 45 for young adults and ≥ 55 for older adults from 2001 to 2014. Diagnosis for ARF including hypertension, diabetes and hyperlipidemia were established based on 2 outpatient or 1 inpatient claim. Hospitalization with the primary diagnosis of stroke were identified. Of patients with an ARF diagnosis, we looked for the presence of any medication claims including oral antihypertensive, antihyperlipidemics, and antidiabetics (including injectables) based on the Generic Product Identifier (GPI) codes. Results: Included in the analysis were 3,770,474 young adults with mean age 28 and 1,552,351 older adults with mean age 60. From 2001 to 2014, the overall prevalence of hypertension, diabetes and hyperlipidemia were 7.68%, 2.65%, and 7.85% respectively in young adults, compared to 47.8%, 18.0% and 46.6% respectively in older adults. Treatment rate of hypertension, diabetes and hyperlipidemia improved faster annually in older adults (1.9%, 1.7%, 1.8% respectively) than young adults (0.96 %, 0.99%, 0.61%, respectively, p Conclusion: Proportion of treatment for ARF in older adults improved at a faster rate than young adults. Overall treatment rates of diabetes was higher in young adults likely due to proportionally more cases of type 1 diabetes. Hyperlipidemia was treated at a much lower rate in young adults than older adults.

Background: Recent studies have suggested that arterial ischemic stroke (AIS) has increased over the last two decades in young populations, even while declining in older adults. This may be due in part to epidemic obesity in the US, since obesity can contribute to the development of atherosclerotic risk factors associated with stroke. The aim of this study was to determine the earliest age at which AIS can be linked to such risk factors. Methods: In the population of Kaiser Permanente Northern California, we retrospectively identified children and young adults (29 days-49 years) with possible AIS from 2000-2014 by searching stroke-related ICD-9 codes and text strings in radiology reports. Two stroke neurologists independently confirmed AIS by chart review using imaging and clinical criteria; medical records analysts abstracted data on atherosclerotic risk factors: hypertension, diabetes, hyperlipidemia, obesity and smoking. We calculated the prevalence of these risk factors among stroke cases stratified by age (decades). Results: We confirmed AIS in 128 children and 233 young adults. We found little documentation of atherosclerotic risk factors among stroke patients < 30 years old with the exception of smoking, which was reported in 13% of those in their twenties (Figure 1). Prevalence of risk factors increased between the ages of 30-39 and again from 40-49, by which time nearly half of those with stroke were hypertensive, 31% were reported to have hyperlipidemia, 28% and 30% were obese or smokers, respectively, and 25% had diabetes mellitus. Conclusions: These findings suggest that while atherosclerotic risk factors do not play a major role in AIS pathogenesis in the first three decades of life, their cumulative effects begin to contribute to stroke risk beyond this age. Earlier screening for poorly controlled risk factors that begin in childhood could lessen their impact on ischemic strokes in the 4 th decade of life.

Background and Purpose: It is publicly reported 2%-15% of all strokes occur in patients hospitalized for another procedure or diagnosis. The evidence suggests greater delays in the evaluation and treatment of in hospital stroke. The stroke program at University of Colorado Hospital identified these in-hospital delays as a result of an informal in-patient alert process. During the day, the stroke alert responders included the stroke attending, stroke resident and/or APP. During off hours, the stroke resident was the responder responsible for both evaluating and transporting the patient to CT scanner within the 25 minute goal window. We identified the lack of a formal process contributed to a delay in the care and treatment of stroke patients. Method: A multidisciplinary team was created to identify ways to improve the inpatient stroke alert process. This group approved the Neurosurgical ICU charge nurse to carry a stroke alert pager becoming a 24 hour responder for the acute inpatient stroke alert response team. Prior to implementation, mandatory training included the charge nurse group attending a lecture including topics of neuro assessment, stroke alert documentation and time goals. The stroke alert policy was updated to reflect this change. The stroke alert phone number was also changed to be in alignment with this hospital’s CODE response. Hospital-wide education of the new inpatient response number and our stroke alert criteria was also provided. A retrospective analysis was then performed comparing the 12 months prior to the initiation of the inpatient stroke alert process and the 12 months post implementation. Results: See image Conclusion: A consistent response team leads to a more organized stroke alert process with improved accuracy of inpatient stroke alerts diagnosis, faster CT times, an increase in treatment rates, and improved treatment times.

Background: Atherosclerotic risk factors (ARF) are known causes of stroke and acute myocardial infarction (AMI) in older adults. However, their role in young adult stroke incidence is largely unknown. Hypothesis: We hypothesized that if the trend in incidence of young adult strokes is driven by premature atherosclerosis then we would observe similar trends in young adult AMI. Methods: A 10% random sample of all enrollees, from a commercial claims database between 2001-2014, was used. Enrollees were divide into ages 15 to 45 for young adults and 55 to 75 for older adults. Individual claims for first ever stroke or AMI hospitalizations were identified using ICD-9 and ICD-10 codes. Annual incidence rate was adjusted for age in both groups. A simple linear regression model was used to plot trend lines for incidence. Results: Included in the analysis were 3,770,474 young adults with mean age 28 and 1,552,351 older adults with mean age 60. Of all young adults, there were 3,078 strokes and 3,408 AMIs compared to 38,707 strokes and 26,094 AMIs in older adults. Both older adult stroke and AMI incidence showed an annual decline with 36.8 and 21.9 less cases per 100,000 enrollees, respectively (R 2 = 0.85 and 0.81). Young adult stroke showed a slight increase in incidence overtime with overall, with 0.29 more cases a year per 100,000 enrollees (R 2 = 0.24). Meanwhile, young adult AMI incidence showed a slight decline overtime with 0.19 less cases a year per 100,000 enrollees (R 2 = 0.139). Though neither change was significantly different from 0, taken together their slopes are different from each other with p = 0.035. Conclusion: Despite the decreasing incidence of stroke and AMI in older adults, young strokes and AMI incidence remain largely unchanged. The slightly divergent trends between young adult stroke and AMI suggest that there may be more than atherosclerosis at play that is driving the increased incidence young adult strokes, which have been observed in other studies.

Background: The University of Colorado Mobile Stroke Unit (UC MSU) began clinical operation in January 2016, providing ambulance-mounted CT scanning and tele-stroke neurologic assessment in the Denver, CO, metropolitan area. As one of the first U.S. tertiary stroke centers to utilize a mobile stroke protocol we sought to evaluate characteristics of response, neurologic evaluation, and treatment of the MSU. Methods: The study assessed patient, stroke, ambulance response, neurologic evaluation, and treatment characteristics of the UC MSU for its initial year in service. Variables included time from stroke alert (MSU dispatch) to brain CT in the field, treatment decision, tPA administration, and transport to a hospital stroke center. Time intervals from last seen normal were calculated for all patients. Study variables were compared for patients treated with thrombolysis on the MSU, and those who were not; and with reported times for other MSUs, and hospitals. Results: Between Jan. 15, 2016 and Jan. 9, 2017, 47 individuals received prehospital management with the UC MSU. Median age was 67 years (IQR 58-77), and 51% were female. Median initial NIH Stroke Scale score was 5 (IQR 2-11), and 36% were moderate to severe (NIHSS ≥8). Thirteen (28%) of patients were treated with IV tPA on the MSU. Median times from stroke alert to MSU arrival on the scene and first CT were 7 minutes (IQR 5-8), and 20 minutes (IQR 18-24), respectively. Median time to tPA administration was 39 minutes (IQR 35-45) from stroke alert, and 52 minutes (IQR 48-77) from the last time the patient was seen normal. Times from stroke alert and last seen normal to arrival at a stroke hospital were a median of 51 minutes (IQR 45-54) and 71 minutes (IQR 56-118), respectively. Conclusions: In this study of the initial year of an urban MSU’s operation, time intervals from stroke alert to initial brain CT imaging, neurologic evaluation and administration of thrombolysis were found to be substantially reduced compared to conventional, hospital-based stroke protocols, and some earlier MSUs. Intervals from last seen normal to these procedure time points were similarly reduced. These results suggest prehospital management with an MSU has potential to aid the goal of earlier thrombolysis after ischemic stroke symptom onset.

Background and Purpose— Childhood arterial ischemic stroke is frequently associated with an intracranial arteriopathy that often progresses in the first 3 to 6 months post stroke. We hypothesized that children with enhancing arteriopathies on vessel wall imaging (VWI) would have a higher risk of arteriopathy progression than those without enhancement. Methods— Our institutional radiographic database was searched for cases of childhood stroke with VWI. Inclusion criteria consisted of age ranging from 1 month through 20 years, diagnosis of arterial ischemic stroke, available VWI, and follow-up magnetic resonance angiogram. Imaging was reviewed to systematically describe VWI findings, categorize arteriopathies, steroid therapy, and identify progressive arteriopathies using CACADE definitions. Results— Sixteen cases of childhood stroke at Children’s Hospital Colorado between January 1, 2010 and July 1, 2016 were reviewed. Strong vessel wall enhancement at presentation was associated with progressive arteriopathy in 83% of cases (10/12), when compared with 0% (0/4) without strong enhancement ( P =0.008). Conclusions— Our case series demonstrates the potential benefit of VWI in children with stroke because it may identify patients who will have progressive arterial disease.

Our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide and to examine regional differences and factors associated with the mode of transport to the emergency department (ED).Patients with a primary discharge diagnosis of stroke based on previously validated International Classification of Disease, 9th revision codes were abstracted from the National Hospital Ambulatory Medical Care Survey for the years 2007 to 2009. We excluded subjects18 years of age and those with missing data. Using logistic regression, we identified independent predictors of arrival by ambulance to the ED.Overall, 566 patients met the entry criteria, representing 2,153,234 patient records nationally, based on 2010 US census data. Of these, 50.4% arrived by ambulance. After adjustment for potential confounders, age was associated with use of an ambulance. In addition, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (South: odds ratio [OR] 0.45 and 95% confidence interval [CI] 0.26-0.76; West: OR 0.45 and 95% CI 0.25-0.84; Midwest: OR 0.56 and 95% CI 0.31-1.01). Compared to the Medicare population, privately insured and self-insured patients had lower odds of arriving by ambulance (OR for private insurance 0.48 and 95% CI 0.28-0.84; OR for self-payers 0.36 and 95% CI 0.14-0.93). Gender, race, urban or rural location of ED, and safety net status was not independently associated with ambulance use.Patients with stroke arrive by ambulance more frequently in the Northeast than in other regions of the United States. Identifying reasons for this difference may be useful in improving stroke care.

Dural venous sinus thrombosis (DVST) is a cause of infarction and intracranial hemorrhage (ICH) that can lead to significant morbidity. Endovascular therapy has emerged as an adjunctive therapy in select cases but has been associated with increased hemorrhagic complications. We present our experience with a large single-center cohort of DVST cases treated with current-generation thrombectomy devices.In this retrospective cohort study, a chart review was performed to compare presentations and outcomes of patients treated with anticoagulation alone with those treated with additional interventional therapy, using the modified Rankin Scale (mRS) score at discharge and at 90 days' follow-up.A total of 66 patients were included; 37 were treated with anticoagulation alone, and 29 underwent additional interventional therapy. Patients presenting with ICH or infarction had a significantly greater likelihood of disability at the time of discharge (odds ratio [OR] of 64.5 and 45.8, respectively; P .0001) and at 90 days (OR of 28.4 and 22.8, respectively; P .0001). Patients presenting with ICH or infarction were more likely to be selected for endovascular therapy (P .05). Endovascular therapy was typically performed within 24 hours of admission; 9 patients (31%) had post-treatment hemorrhage, with 2 being (6.9%) symptomatic. There were fewer patients with slight disability (mRS score ≤1) in the endovascular group compared with the anticoagulation group at discharge (P = .05), but outcomes were not significantly different at 90 days (P = .19).Despite a higher rate of ICH or infarction at presentation in the endovascular group and an increased risk of postprocedural ICH, both treatment groups had similarly good functional outcomes at 90 days.

Background and Objective Infectious complications after ischemic stroke are frequent and lead to neurological deterioration, poor functional outcomes, and higher mortality. Local and systemic inflammatory responses to brain ischemia differ between males and females, but little is known about differences in poststroke susceptibility to infection by sex. The purpose of this study was to compare sex-related differences in the risk of hospital-acquired sepsis and pneumonia after acute ischemic stroke (AIS). Materials and Methods This is a retrospective, secondary analysis of the 2010-2011 California State Inpatient Database. Previously validated International Classification of Disease, Ninth Revision (ICD-9) codes were used to identify adult hospitalizations for AIS. The primary outcome was hospital-acquired sepsis or pneumonia, also identified using ICD-9 codes. Associations between sex and hospital-acquired sepsis or pneumonia were adjusted for baseline characteristics and comorbidities using multivariable logistic regression. Results There were 91,643 hospitalizations for AIS included in this analysis, of which 1027 had hospital-acquired sepsis and 1225 had hospital-acquired pneumonia. The in-hospital mortality without infection was 4.6%; the presence of hospital-acquired infections was associated with higher mortality for sepsis (32.7%) and pneumonia (21.9%). Female (versus male) sex was associated with lower adjusted odds of hospital-acquired sepsis (odds ratio [OR] .74, 95% confidence interval [CI] .65-.84) and pneumonia (OR .69, 95% CI .62-.78). This difference was similar across age strata. Among hospitalizations with either hospital-acquired sepsis or pneumonia, sex did not influence mortality. Conclusions Female sex was associated with a lower risk of hospital-acquired sepsis and pneumonia after AIS. Further investigation is needed to determine the mechanisms underlying this clinical observation.

Atrial septal defects (ASDs) can be complicated by cardioembolic strokes, but the exact incidence is unknown. Patients with large and small shunts may present with a cardioembolic stroke. Patients with cryptogenic strokes should have cardiac ultrasound to see if an ASD is present. Cardioembolic strokes associated with ASD principally occur with 2 mechanisms. The first is paradoxic embolism involving a venous-based source of thrombus, which may subsequently pass through the ASD by right-to-left shunting, causing a cardioembolic stroke. The second is atrial fibrillation that can complicate the course of patients with ASDs, especially as they age.

Background and Purpose— There are limited data about the reliability of subtype classification in childhood arterial ischemic stroke, an issue that prompted the IPSS (International Pediatric Stroke Study) to develop the CASCADE criteria (Childhood AIS Standardized Classification and Diagnostic Evaluation). Our purpose was to determine the CASCADE criteria’s reliability in a population of children with stroke. Methods— Eight raters from the IPSS reviewed neuroimaging and clinical records of 64 cases (16 cases each) randomly selected from a prospectively collected cohort of 113 children with arterial ischemic stroke and classified them using the CASCADE criteria. Clinical data abstracted included history of present illness, risk factors, and acute imaging. Agreement among raters was measured by unweighted κ statistic. Results— The CASCADE criteria demonstrated a moderate inter-rater reliability, with an overall κ statistic of 0.53 (95% confidence interval [CI]=0.39–0.67). Cardioembolic and bilateral cerebral arteriopathy subtypes had much higher agreement (κ=0.84; 95% CI=0.70–0.99; and κ=0.90; 95% CI=0.71–1.00, respectively) than cases of aortic/cervical arteriopathy (κ=0.36; 95% CI=0.01–0.71), unilateral focal cerebral arteriopathy of childhood (FCA; κ=0.49; 95% CI=0.23–0.76), and small vessel arteriopathy of childhood (κ=−0.012; 95% CI=−0.04 to 0.01). Conclusions— The CASCADE criteria have moderate reliability when used by trained and experienced raters, which suggests that it can be used for classification in multicenter pediatric stroke studies. However, the moderate reliability of the arteriopathic subtypes suggests that further refinement is needed for defining subtypes. Such revisions may reduce the variability in the literature describing risk factors, recurrence, and outcomes associated with childhood arteriopathy.

Transient ischemic attacks (TIAs) are common neurologic events characterized by stroke-like symptoms that completely resolve. They were previously thought to be benign but research over the past decade has revealed the high risk of further neurologic and cardiac events following TIA. With the knowledge of prognosis following TIA, the need for more urgent diagnostic workup and treatment has become clear, and several tools for identifying patients at the highest risk have been developed. In this review, we discuss appropriate diagnostic testing, acute management, and long-term management for preventing stroke after TIA, current research in progress, as well as areas of need for future research.

Background and Purpose— Clinical scores help predict outcome after transient ischemic attack (TIA), and imaging studies may improve the accuracy of predictions. Intracranial large vessel occlusion (LVO) predicts poor outcome after stroke, but the natural history of symptomatic intracranial LVO in patients with TIA is unknown. Methods— We studied patients presenting with TIA in the STOP Stroke Study, a prospective imaging-based study of stroke outcomes. All patients underwent brain CTA. If an intracranial vascular occlusion was found in an appropriate territory to account for clinical findings, then it was judged to be a symptomatic LVO. Baseline characteristics, follow-up events, and outcomes were collected. Characteristics of patients with and without LVO were compared using χ 2 and t tests. Predictors of LVO were analyzed by univariate and multivariate analysis. LVO was assessed as a predictor of asymptomatic outcome (modified Rankin scale [mRS] score, 0), poor outcome (mRS score ≤3), and increase in mRS score over the study period. Results— Of 97 patients with TIA, 13 (13%) had symptomatic intracranial LVO. Patients with LVO had higher baseline NIHSS on emergency department arrival, which was an independent predictor of LVO (OR, 1.15 per point; 95% CI, 1.02–1.29; P =0.02). Patients with LVO were more likely to have an increase in mRS score during the 90-day follow-up ( P =0.03). LVO independently predicted an increase in mRS score (OR, 4.76; 95% CI, 1.23–18.43; P =0.02) and was a borderline predictor of poor outcome (mRS score ≥3; OR, 5.07; 95% CI, 0.92–28.03; P =0.06). Conclusions— LVO is found in >1 in 10 patients presenting with TIA and predicts a decline in functional status, likely attributable to new brain ischemia.

Background and Purpose— Gender differences in carotid endarterectomy (CEA) rates after transient ischemic attack are not well studied, although some reports suggest that eligible men are more likely to have CEA than women after stroke. Methods— We retrospectively identified all patients diagnosed with transient ischemic attack and ≥70% carotid stenosis on ultrasound in 2003 to 2004 from 19 emergency departments. Medical records were abstracted for clinical data; 90-day follow-up events, including stroke, cardiovascular events, or death; CEA within 6 months; and postoperative 30-day outcomes. We assessed gender as a predictor of CEA and its complications adjusting for demographic and clinical variables as well as time to CEA between groups. Results— Of 299 patients identified, 47% were women. Women were older with higher presenting systolic blood pressure and less likely to smoke or to have coronary artery disease or diabetes. Fewer women (36.4%) had CEA than men (53.8%; P =0.004). Reasons for withholding surgical treatment were similar in women and men, and there were no differences in follow-up stroke, cardiovascular event, postoperative complications, or death. Time to CEA was also significantly delayed in women. Conclusions— Women with severe carotid stenosis and recent transient ischemic attack are less likely to undergo CEA than men, and surgeries are more delayed.

Introduction: Developing accurate measurements of infarct volume is vital to studying outcomes in Perinatal Arterial Ischemic Stroke (PAS). Methods for measuring Acute Infarct Volumes (aIV) are well established in PAS. However, techniques for measuring chronic infarct volume (cIV) in order to estimate aIV have not been validated and must account for changes in Total Brain Volume (TBV) over time, as well as contraction of the infarct. We compared two methods of measuring cIV, hypothesizing that cIV extrapolated from residual uninfarcted brain tissue volume would better estimate aIV than direct measurement of cIV. Methods: Using modified manual segmentation techniques, two pediatric neuroradiologists independently measured the brain and infarct volumes of 10 PAS patients both on the acute (0-7 days old) and chronic (>3 months) MRIs. Volume measurements were averaged after high inter-rater reliability was established (ICC>0.9). We evaluated acute and chronic scans for changes in infarct anatomy, and excluded patients with bilateral infarctions. Method 1 for estimating cIV used a direct measurement of the infarct (figure). Method 2 extrapolated infarct volume from residual uninfarcted brain tissue (figure). The cIV for each method was then compared to the aIV. Results: 3 patients with bilateral infarcts were excluded. Infarct anatomy between acute and chronic scans did not change for the 7 unilateral infarcts evaluated. In these 7 cases, the ICC comparing aIV and cIV from Method 1 was 0.507 (CI -0.120, 0.891), while the ICC comparing aIV and cIV from Method 2 was 0.964 (CI 0.821, 0.994). cIV’s from Method 1 were smaller than the aIV’s in all cases, despite stability of infarct anatomy. Conclusions: In this pilot study measuring cIV in PAS, direct measurement of cIV likely underestimates volume because of contraction of infarcted tissue. In conclusion, extrapolation of cIV from measurement of residual uninfarcted tissue appears to accurately estimate aIV.

Background and Purpose— Dizziness can herald a cerebrovascular event. The ABCD 2 score predicts the risk of stroke after transient ischemic attack partly by distinguishing transient ischemic attack from mimics. We evaluated whether this score would also identify cerebrovascular events among emergency department patients with dizziness. Methods— We retrospectively identified consecutive adults presenting to a university emergency department with a primary symptom of dizziness, vertigo, or imbalance. Two neurologists independently reviewed medical records to determine whether the presenting symptom was caused by a cerebrovascular event (ischemic stroke, transient ischemic attack, or intracranial hemorrhage). ABCD 2 scores were then assigned using clinical information from the medical record. The ability of the score to discriminate between patients with cerebrovascular events and those with other diagnoses was quantified using the c statistic. Results— Among 907 dizzy patients (mean age, 59 years; 58% female), 37 (4.1%) had a cerebrovascular cause, the majority of which were ischemic strokes (n=24). The median ABCD 2 score was 3 (interquartile range, 3–4). The ABCD 2 score predicted ultimate diagnosis of a cerebrovascular event (c statistic, 0.79; 95% CI, 0.73–0.85). Only 5 of 512 (1.0%) patients with a score of ≤3 had a cerebrovascular event compared to 25 of 369 patients (6.8%) with a score of 4 or 5 and 7 of 26 patients (27.0%) with a score of 6 or 7. Conclusions— The ABCD 2 score may provide useful information on dizzy emergency department patients at low-risk for having a cerebrovascular diagnosis and may aid frontline providers in acute management if validated prospectively.

Background: Despite the high risk of stroke after transient ischemic attack (TIA), many people do not seek urgent medical attention because symptoms may be mild or have already resolved or be incorrectly attributed to a benign mimic. Since the Internet has become an increasingly important source of medical information, we sought to reach these people by developing and testing an instrument to identify cerebrovascular events among those seeking information about TIA online. Methods: We developed an instrument to evaluate possible TIA symptoms ( http://tia.ucsf.edu/ ) using items from the ABCD2 score excluding blood pressure since it may not be readily available by self-report. Using targeted Internet text advertisements for terms such as “transient ischemic attack symptoms” or “mini-stroke symptoms” we invited subjects to complete a 20-item demographic, medical history, and symptom inventory online. Neurologists that were blinded to these responses then contacted subjects by telephone to assess the likelihood that a true TIA or stroke had occurred. Logistic regression was used to assess univariate and multivariable associations and ROC curves were generated to assess model discrimination. Results: The study website received 26,602 hits over 122 days of study enrollment. A total of 289 visitors started the enrollment and eligibility screening process, 253 provided consent and recorded responses for the instrument, and 173 completed the follow-up telephone assessment. The mean age was 58.7 years (range 23-88) and 63% were women. A total of 36 (21%) subjects had had symptoms within 24 hours and 60 (37%) had not yet sought medical advice for their symptoms. The follow-up telephone assessment process determined that 43 (24.9%) had a TIA, and 67 (38.7%) had either a TIA or a stroke. The ABCD2 score (excluding blood pressure) demonstrated moderate discrimination overall (c-statistic 0.69, 95% CI 0.61-0.76), but 1 (8.3%) of 12 subjects with a score of 0 had a cerebrovascular event (isolated diplopia). Those who reported multiple prior episodes of similar symptoms in the past year were less likely to have had a cerebrovascular event (OR 0.18, 95% CI 0.10-0.37) and incorporating this predictor and the presence of diplopia into the model significantly improved discrimination (c-statistic 0.78, 95% CI 0.71-0.85, p=0.03) with no events among the 7 patients who had a score of 0. Conclusion: Patients with possible TIA symptoms turn to the Internet for medical information and prior to any attempt to seek formal medical advice. Although applying self-reported elements of the ABCD2 score was inadequate to rule-out cerebrovascular disease, a modified score with additional elements may provide an efficient, immediate, and individualized mechanism to reach patients with TIA who might not otherwise seek medical attention.

Background and Purpose— Hospital-acquired urinary tract infection (UTI) is a common complication in hospitalized patients. Recently, catheter-associated UTI has been identified by the Centers for Medicare and Medicaid Services as a preventable condition, and additional payments to hospitals for its treatment are now declined, increasing the need for prevention of this important complication. Summary of Review— This article explores in-depth the pathophysiology, risk factors for, and consequences of UTI after stroke and possible methods to reduce its incidence in the stroke population. Patients with stroke are particularly vulnerable to UTI due to increased risk from immunosuppression, bladder dysfunction, and increased Foley catheter use; and the fever and systemic inflammatory response associated with UTI may impair stroke recovery. UTI is associated with poorer neurological outcomes, longer hospital stays, and increased cost of care after stroke. Intervention strategies previously attempted in this and other populations include prophylactic antibiotics, antiseptic-impregnated catheters, and quality improvement interventions to reduce inappropriate catheterization. Conclusion— Patients with stroke have different risks for, consequences of, and barriers to reducing UTI than other hospitalized patients. Further research is needed to develop an effective approach to decreasing this important complication in the stroke population.

Background: With newly-extended treatment windows for endovascular therapy in emergent large vessel occlusions, it is increasingly important to identify thrombectomy-eligible patients without overwhelming resources dedicated to acute stroke care. We devised a simple paradigm to classify patient's presenting neurologic symptoms to screen for large vessel occlusions. Methods: We reviewed the presenting symptoms, imaging findings, and final diagnoses of consecutive emergency department stroke alert cases. Patients were classified based on their neurologic exams as focal objective, focal subjective, or nonfocal. Outcomes of final diagnoses of acute ischemic stroke and large vessel occlusions were compared across groups. Comparisons were made to other large vessel occlusion prediction scales. Results: Of 521 patients, 342 (65.6%) were categorized as focal objective, 142 (27.2%) as focal subjective, and 37 (7.1%) as nonfocal. Ischemic stroke and large vessel occlusions were diagnosed in 114 (21.9%) and 27 (5.2%) of patients, respectively. Classification as focal objective significantly predicted stroke (odds ratio 3.77; 95% confidence interval 2.17-6.55) and captured all large vessel occlusions (P = .0001). The focal objective categorization was the only tool which achieved 100% sensitivity for large vessel occlusions (with a specificity of 36%) compared to other large vessel occlusion prediction tools. Conclusions: Patients who presented as stroke alerts without focal neurologic symptoms were unlikely to have large vessel occlusions. With high sensitivity, classifying patients' neurologic exams into focal objective versus subjective or nonfocal categories may serve as a useful tool to screen for large vessel occlusions and prevent unnecessary emergent workup in patients unlikely to be endovascular candidates.