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Background and Purpose: Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). Methods: Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. Results: Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1–4.3], P P P Conclusions: In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

Background and Purpose: There is interest in what happens over time to the thrombus after intravenous alteplase. We study the effect of alteplase on thrombus structure and its impact on clinical outcome in patients with acute stroke. Methods: Intravenous alteplase treated stroke patients with intracranial internal carotid artery or middle cerebral artery occlusion identified on baseline computed tomography angiography and with follow-up vascular imaging (computed tomography angiography or first run of angiography before endovascular therapy) were enrolled from INTERRSeCT study (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography). Thrombus movement after intravenous alteplase was classified into complete recanalization, thrombus migration, thrombus fragmentation, and no change. Thrombus migration was diagnosed when occlusion site moved distally and graded according to degrees of thrombus movement (grade 0–3). Thrombus fragmentation was diagnosed when a new distal occlusion in addition to the primary occlusion was identified on follow-up imaging. The association between thrombus movement and clinical outcome was also evaluated. Results: Among 427 patients in this study, thrombus movement was seen in 54% with a median time of 123 minutes from alteplase administration to follow-up imaging, and sub-classified as marked (thrombus migration grade 2–3 + complete recanalization; 27%) and mild to moderate thrombus movement (thrombus fragmentation + thrombus migration grade 0–1; 27%). In patients with proximal M1/internal carotid artery occlusion, marked thrombus movement was associated with a higher rate of good outcome (90-day modified Rankin Scale, 0–2) compared with mild to moderate movement (52% versus 27%; adjusted odds ratio, 5.64 [95% CI, 1.72–20.10]). No difference was seen in outcomes between mild to moderate thrombus movement and no change. In M1 distal/M2 occlusion, marked thrombus movement was associated with improved 90-day good outcome compared with no change (70% versus 56%; adjusted odds ratio, 2.54 [95% CI, 1.21–5.51]). Conclusions: Early thrombus movement is common after intravenous alteplase. Marked thrombus migration leads to good clinical outcomes. Thrombus dynamics over time should be further evaluated in clinical trials of acute reperfusion therapy.

OBJECTIVES Carotid plaque ulcers confer an increased risk for stroke/ transient ischemic attacks in both symptomatic and asymptomatic carotid artery stenosis. Little is known about the healing rates of ulcers or the development of new ulcers. Carotid Duplex studies are noninvasive and easily repeatable tests to monitor progression of carotid stenosis and plaque morphology. Our aim was to determine the prevalence and healing rates of ultrasound-detected carotid plaque ulcers. METHODS We retrospectively reviewed 5837 carotid Duplex studies performed in an outpatient ultrasound laboratory affiliated with the neurological department of an academic center. A total of 3215 patients underwent a first carotid ultrasound Duplex study, and 2622 follow-up studies were done. Carotid ulcer was defined as a 2 mm deep surface indentation in a carotid plaque with a well-defined back wall, as determined by multimodal ultrasound imaging techniques. RESULTS The prevalence of carotid plaque ulcers among the 3215 patients with a first ultrasound study was 3% (82/3215). The mean follow-up was 42 ± 30 months, and the median number of follow-up studies was 6. Among patients with ulcers, follow-up studies were available in 65/82 patients. During the follow-up period, 28/65 (43%) ulcers healed. Among all 2622 follow-up studies, 45 patients developed a new ulcer. CONCLUSIONS Duplex-detected carotid plaque ulcer prevalence is low. The carotid ulcers healed in approximately half of patients during follow-up. Factors associated with ulcer healing and development remain poorly understood.

Background and Purpose: Early neurological deterioration occurs in one-third of mild strokes primarily due to the presence of a relevant intracranial occlusion. We studied vascular occlusive patterns, thrombus characteristics, and recanalization rates in these patients. Methods: Among patients enrolled in INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography), a multicenter prospective study of acute ischemic strokes with a visible intracranial occlusion, we compared characteristics of mild (National Institutes of Health Stroke Scale score, ≤5) to moderate/severe strokes. Results: Among 575 patients, 12.9% had a National Institutes of Health Stroke Scale score ≤5 (median age, 70.5 [63–79]; 58% male; median National Institutes of Health Stroke Scale score, 4 [2–4]). Demographics and vascular risk factors were similar between the two groups. As compared with those with a National Institutes of Health Stroke Scale score >5, mild patients had longer symptom onset to assessment times (onset to computed tomography [240 versus 167 minutes] and computed tomography angiography [246 versus 172 minutes]), more distal occlusions (M3, anterior cerebral artery and posterior cerebral artery; 22% versus 6%), higher clot burden score (median, 9 [6–9] versus 6 [4–9]), similar favorable thrombus permeability (residual flow grades I–II, 21% versus 19%), higher collateral flow (9.1 versus 7.6), and lower intravenous alteplase treatment rates (55% versus 85%). Mild patients were more likely to recanalize (revised arterial occlusion scale score 2b/3, 45%; 49% with alteplase) compared with moderate/severe strokes (26%; 29% with alteplase). In an adjusted model for sex, alteplase, residual flow, and time between the two vessel imagings, intravenous alteplase use (odds ratio, 3.80 [95% CI, 1.11–13.00]) and residual flow grade (odds ratio, 8.70 [95% CI, 1.26–60.13]) were associated with successful recanalization among mild patients. Conclusions: Mild strokes with visible intracranial occlusions have different vascular occlusive patterns but similar thrombus permeability compared with moderate/severe strokes. Higher thrombus permeability and alteplase use were associated with successful recanalization, although the majority do not recanalize. Randomized controlled trials are needed to assess the efficacy of new thrombolytics and endovascular therapy in this population.

Susac syndrome is a rare, immune-mediated disease characterized by encephalopathy, branch retinal artery occlusion, and hearing loss. Herein, we describe the electron microscopic findings of three brain biopsies and two brain autopsies performed on five patients whose working clinical diagnosis was Susac syndrome. In all five cases, the key findings were basement membrane thickening and collagen deposition in the perivascular space involving small vessels and leading to thickening of vessel walls, narrowing, and vascular occlusion. These findings indicate that Susac syndrome is a microvascular disease. Mononuclear cells were present in the perivascular space, underlining the inflammatory nature of the pathology. Though nonspecific, the changes can be distinguished from genetic and acquired small vessel diseases. The encephalopathy of Susac syndrome overlaps clinically with degenerative and infectious conditions, and brain biopsy may be used for its diagnosis. Its vascular etiology may not be obvious on light microscopy, and electron microscopy is important for its confirmation.

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

Background and Purpose: Mild ischemic stroke patients enrolled in randomized controlled trials of thrombolysis may have a different symptom severity distribution than those treated in routine clinical practice. Methods: We compared the distribution of the National Institutes of Health Stroke Scale (NIHSS) scores, neurological symptoms/severity among patients enrolled in the PRISMS (Potential of r-tPA for Ischemic Strokes With Mild Symptoms) randomized controlled trial to those with NIHSS score ≤5 enrolled in the prospective MaRISS (Mild and Rapidly Improving Stroke Study) registry using global P values from χ 2 analyses. Results: Among 1736 participants in MaRISS, 972 (56%) were treated with alteplase and 764 (44%) were not. These participants were compared with 313 patients randomized in PRISMS. The median NIHSS scores were 3 (2–4) in MaRISS alteplase-treated, 1 (1–3) in MaRISS non–alteplase-treated, and 2 (1–3) in PRISMS. The percentage with an NIHSS score of 0 to 2 was 36.3%, 73.3%, and 65.2% in the 3 groups, respectively ( P P Conclusions: Patients randomized in PRISMS had comparable deficit and syndromic severity to patients not treated with alteplase in the MaRISS registry and lesser severity than patients treated with alteplase in MaRISS. The PRISMS trial cohort is representative of mild patients who do not receive alteplase in current broad clinical practice.

Introduction: Characterizing the population of ischemic stroke (IS) patients presenting in the delayed reperfusion window is important to ensure equitable implementation of recently updated acute IS treatment guidelines. Methods: Florida Stroke Registry (FSR) data from Jan 2010 - Jan 2020, provided a complete dataset of 98,372 IS cases presenting within 24 hrs of symptom onset. Generalized linear regression analysis was used to identify differences between delayed IS cases (>4.5 hours) versus those presenting within the early time window (≤ 4.5 hr). Results: A total of 60,311 presented with 4.5 hr (median age 74 (interquartile range (IQR) 62-83), 49% women, 67% white, 15% Black, 18% Hispanic), and 38,061 presented in the delayed window (median age 72 (IQR 61- 82), 49% women, 63% white, 18% Black, 19% Hispanic). As compared to early presenters, delayed window patients were younger (OR 1.23, 95% confidence interval (CI) 1.17-1.29); more Black vs. White (OR 1.12, 95% CI 1.06-1.18), have higher NIHSS (OR 1.05, 95% 1.01-1.10), insured (OR 1.18, 95% 1.11-1.25), presenting to an academic hospital (OR 1.24, 95% CI 1.09-1.40) in South Florida (OR 1.23, 95% CI (1.08, 1.41)); less likely to arrive by EMS (OR 0.59, 95% CI 0.56-0.62) and less likely to receive reperfusion therapies (OR 0.86, 95% CI 0.79-0.94). In multivariable analysis adjusting for age, race, NIHSS, EMS, reperfusion therapies, hospital academic status and region, delayed window presentation was negatively associated with discharge home (OR 0.82, 95% CI 0.76-0.89), and ambulatory status at discharge (OR 0.89, 95% CI 0.84-0.93). Conclusion: We found significant race, ethnic, socioeconomic and geographical disparities amongst those presenting in the delayed vs early reperfusion time windows with consequential effects on patient outcomes. Stroke education to younger minorities and adaptation of regional stroke systems of care are urgently needed.

Background: Impaired level of consciousness (LOC) on presentation after intracerebral hemorrhage (ICH) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and trends after ICH by the LOC status on presentation. Methods: We studied 37,613 cases with ICH in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, ICH severity, hospital size and teaching status. Results: At stroke presentation, 12,272 (33%) cases had impaired LOC (mean age 72, 49% women, 61 white%, 20% Black, 14% Hispanic). Compared to cases with preserved LOC, LOC case were older (72 vs. 70 years old), more women (49% vs. 45%), more likely to have aphasia (38% vs. 16%), had lower GCS score (9 vs. 15), had greater ICH score (3 vs. 1), greater WLST rates (41% vs. 18%), and had greater in-hospital mortality rates (32% vs. 12%). In our adjusted model, no association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.4, 95%CI 0.2-0.9, p=0.03) and more likely to ambulate independently (OR 1.6, 95%CI 1.1-2.4, p=0.02). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all, regardless of the LOC status. Conclusion: In this large multi-center registry, a third of ICH cases presents with impaired LOC. Although LOC was not associated with significantly more in-hospital morality, LOC was associated with had higher rates of WLST and more disability at discharge. Future efforts should focus on biomarkers of LOC that detect early recovery and reduced disability in ICH patients with impaired LOC.

Background Less than 40% of acute stroke patients have computed tomography (CT) imaging performed within 25 minutes of hospital arrival. We aimed to examine the race‐ethnic and sex differences in door‐to‐CT (DTCT) ≤25 minutes in the FSR (Florida Stroke Registry). Methods and Results Data were collected from 2010 to 2018 for 63 265 patients with acute ischemic stroke from the FSR and secondary analysis was performed on 15 877 patients with intravenous tissue plasminogen activator‐treated ischemic stroke. Generalized estimating equation models were used to determine predictors of DTCT ≤25. DTCT ≤25 was achieved in 56% of cases of suspected acute stroke, improving from 36% in 2010 to 72% in 2018. Women (odds ratio [OR], 0.90; 95% CI, 0.87–0.93) and Black (OR, 0.88; CI, 0.84–0.94) patients who had strokes were less likely, and Hispanic patients more likely (OR, 1.07; CI, 1.01–1.14), to achieve DTCT ≤25. In a secondary analysis among intravenous tissue plasminogen activator‐treated patients, 81% of patients achieved DTCT ≤25. In this subgroup, women were less likely to receive DTCT ≤25 (0.85, 0.77–0.94) whereas no significant differences were observed by race or ethnicity. Conclusions In the FSR, there was considerable improvement in acute stroke care metric DTCT ≤25 in 2018 in comparison to 2010. However, sex and race‐ethnic disparities persist and require further efforts to improve performance and reduce these disparities.

Background: Access to endovascular therapy (EVT) should be equitable to all eligible ischemic stroke patients presenting within the treatment time window. In the Florida Stroke Registry (FSR) we sought to determine sex, race/ethnic, hospital and regional disparities in the delivery of EVT. Methods: From January 2010 to January 2020, a total of 99,088 ischemic stroke cases within 24 hours of symptom onset were enrolled. Multivariable logistic regression with generalized estimating equations evaluated independent predictors of EVT utilization. Results: A total of 7,812 patients received EVT (51.2% female, mean age 71.3 ± SD 14.6 years, 61.4% white, 17.4% black, 21.2% Hispanic). Compared to those not treated, EVT treated patients were more likely Hispanic (21.2% vs. 14.6%), arrived earlier to the hospital (median 120 min (IQR 292) vs. 170 min (IQR 446)), via EMS (94% vs. 66%), with more severe strokes (median NIHSS 15 (IQR11) vs. 5 (IQR 9)), to large hospitals (≥ 680 beds) (73.4% vs. 47.7%), in South Florida (50.8% vs. 38.2%). In multivariable analysis, female sex (OR 1.05, 95% CI 1-1.11), atrial fibrillation (OR 1.57, 95% CI 1.45-1.7), higher NIHSS (> 6) (OR 6.19, 95% CI 5.11-7.51) and presenting to a high-volume hospital (OR 3.47, 95% CI 2.25-5.36) positively predicted EVT utilization, whereas older age (>80 years) (OR 0.88, 95% CI 0.80-0.96), and black race (vs. white OR 0.87, 95% CI 0.76-1), were independently associated with lower use of EVT. Conclusions: In this large state-wide registry study, we found significant race-ethic and geographical disparities in delivery of EVT. Systems of care should address disparities in stroke treatment to improve access to EVT for all eligible stroke patients.

Background: Impaired level of consciousness (LOC) on presentation after acute ischemic stroke (AIS) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and their trends after AISby the LOC on stroke presentation. Methods: We studied 238,989 cases with AIS in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, stroke severity, location, hospital size and teaching status. Results: At stroke presentation, 32,861 (14%) cases had impaired LOC (mean age 77, 54% women, 60 white%, 19% Black, 16% Hispanic). Compared to cases with preserved LOC, impaired cases were older (77 vs. 72 years old), more women (54% vs. 48%), had more comorbidities, greater stroke severity on NIHSS ≥ 5 (49% vs. 27%), higher WLST rates (3% vs. 0.6%), and greater in-hospital mortality rates (9% vs. 3%). In our adjusted model however, no significant association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.7, 95%CI 0.6-0.8, p Conclusion: In this large multicenter registry, AIS cases presenting with impaired LOC had more severe strokes at presentation. Although LOC was not associated with significantly worse in-hospital morality, it was associated with higher rates of WLST and more disability among survivors. Future efforts should focus on biomarkers of LOC that discriminates the potential for early recovery and reduced disability in acute stroke patients with impaired LOC.

Introduction: SSRIs, the most commonly prescribed antidepressants (AD) in the US, are linked to an increased intracerebral hemorrhage (ICH) risk possibly related to impaired platelet function. In the Florida Stroke Registry (FSR), we studied the proportion of cases presenting with ICH amongst AD users and the rate of SSRI prescription amongst stroke patients discharged on AD. Methods: From Jan 2010 to Dec 2019 we included 127,915 cases from FSR in whom information on AD use was available. Multivariable logistic regression was used to evaluate ICH proportions amongst AD and non-AD users and rates of prescribed SSRIs at discharge. Results: The rate of ICH amongst prior AD users (n=17,009, median age 74, IQR=19) and non-AD users (n=110,906, median age 72, IQR=21) were 11% and 14% respectively. Prior AD users were more likely to be female (17% vs. 10% male), non-Hispanic White (16% vs. 8% non-Hispanic Black vs. 12% Florida Hispanic vs. 6% Puerto Rican Hispanic), have hypertension (HTN) (14.% vs. 10%), diabetes mellitus (DM) (16% vs.12%), use oral anticoagulants (OAC) (17 % vs. 13%), antiplatelets (AP; 17% vs. 11%), and statins (17% vs. 10%) prior to hospital presentation. In multivariable analysis adjusting for age, race, prior history of HTN, DM, prior OAC, AP and statin use, AD users just as likely to present with spontaneous ICH as compared to non-AD users (OR=0.92, 95% CI 0.85, 1.01). A total of 3.4% of all ICH patients and 9% of those in whom AD information was available were discharged home on an AD (74 % SSRI, 24% other AD). Conclusion: In this large population-based study, we did not find an association between prior AD use and an increased rate of ICH. Importantly AD (mostly SSRIs) are commonly prescribed to patients with ICH in routine clinical practice. The association between types, duration, and safety of antidepressant use in ICH patients deserves further studies.

Introduction: Prior literature has reported differences in outcomes following stroke by race/ethnicity. While more attention has been focused on ischemic stroke, we sought to identify race/ethnic disparities in hospital outcomes at discharge following intracerebral hemorrhage (ICH). Methods: Data were obtained from the Florida Stroke Registry (FSR) consisting of stroke centers utilizing the Get With the Guidelines-Stroke (GWTG-S) tool. Pearson Chi-square and Kruskall-Wallis tests were used to compare descriptive statistics by race/ethnicity on 26,113 Florida cases with ICH discharged 2010-2018. Outcomes at discharge included in-hospital mortality, disposition, ambulation, modified Rankin Scale score & timing of initiation of comfort measures only (CMO). Generalized estimating equations logistic models accounted for age, sex, insurance, smoking, hypertension, diabetes, dyslipidemia, prior anti-coagulant/platelet use, history of stroke/TIA, admission NIHSS, ICH score, arrival mode, hospital size, teaching status & years in GWTG-S. Results: 65% were non-Hispanic White (NHW), 20% non-Hispanic Black (NHB) and 15% Hispanic. NHB were younger at ICH onset (median 60, IQR 52-71; NHW: 71, 58-81; Hispanic: 69, 52-80; p < 0.0001), had higher risk of hypertension (HTN; 74%; NHW: 66%; Hispanic: 64%; p < 0.0001), diabetes (29%; NHW: 20%; Hispanic: 27%; p < 0.0001), smoking (14%; NHW: 12%; Hispanic: 9%; p < 0.0001) and chronic renal insufficiency (8%; NHW: 4%; Hispanic: 4% ; p < 0.0001). NHW had higher risk of dyslipidemia (35%; NHB: 21%; Hispanic: 27%; p < 0.0001), atrial fibrillation/flutter (20%; NHB: 6%; Hispanic: 10%; p < 0.0001) and a higher use of prior anticoagulants (13%; NHB: 6%, Hispanic: 8%, p < 0.0001). NHB had lower odds of in-hospital mortality (adjusted OR=0.77, 95% CI=[0.61-0.96]) and CMO on days 0/1 (0.63, 0.45-0.87) compared to NHW. Conclusions: Differences in risk factor profiles, such as higher rates of HTN in NHB and greater use of anticoagulants among NHW, raises the possibility of tailoring preventive and acute care responses to ICH by race/ethnicity. Moreover, despite observing persistently lower odds of mortality and CMO among NHB after adjustment, more data are needed to identify the unobserved effects leading to these disparities.

Objectives How race/ethnic disparities in acute stroke care contribute to disparities in outcomes is not well-understood. We examined the relationship between acute stroke care measures with mortality within the first year and 30-day hospital readmission by race/ethnicity. Materials and methods The study included fee-for-service Medicare beneficiaries age ≥65 with ischemic stroke in 2010–2013 treated at 66 hospitals in the Florida Stroke Registry. Stroke care metrics included intravenous Alteplase treatment, in-hospital antithrombotic therapy, DVT prophylaxis, discharge antithrombotic therapy, anticoagulation therapy, statin use, and smoking cessation counseling. We used mixed logistic models to assess the associations between stroke care and mortality (in-hospital, 30-day, 6-month, 1-year post-stroke) and hospital readmission by race/ethnicity, adjusting for demographics, stroke severity, and vascular risk factors. Results Among 14,100 ischemic stroke patients in the full study population (73% white, 11% Black, 15% Hispanic), mortality was 3% in-hospital, 12% at 30d, 21% at 6m, 26% at 1y, and 15% had a hospital readmission within 30 days. Patients who received antithrombotics early and at discharge had lower mortality at all time points, and the protective association for early antithrombotic use was strongest among whites. Eligible patients who received statin therapy at discharge had decreased 6m and 1y mortality, but specifically among minority groups. Statin therapy was associated with lower 30-day hospital readmission. Conclusions Acute stroke care measures, particularly antithrombotic use and statin therapy, were associated with reduced odds of long-term mortality. The benefits of these acute care measures were less likely among Hispanic patients. Results underscore the importance of optimizing acute stroke care for all patients.

To compare the association of different measures of intracranial thrombus permeability on non-contrast computerized tomography (NCCT) and computed tomography angiography (CTA) with recanalization with or without intravenous alteplase.Patients with anterior circulation occlusion from the INTERRSeCT study were included. Thrombus permeability was measured on non-contrast CT and CTA using the following methods: [1] automated method, mean attenuation increase on co-registered thin (2.5 mm) CTA/NCCT; [2] semi-automated method, maximum attenuation increase on non-registered CTA/NCCT (ΔHUmax); [3] manual method, maximum attenuation on CTA (HUmax); and [4] visual method, residual flow grade. Primary outcome was recanalization with intravenous alteplase on the revised AOL scale (2b/3). Regression models were compared using C-statistic, Akaike (AIC), and Bayesian information criterion (BIC).Four hundred eighty patients were included in this analysis. Statistical models using methods 2, 3, and 4 were similar in their ability to discriminate recanalizers from non-recanalizers (C-statistic 0.667, 0.683, and 0.634, respectively); method 3 had the least information loss (AIC = 483.8; BIC = 492.2). A HUSimple methods that measure thrombus permeability are as reliable as complex image processing methods in discriminating recanalizers from non-recanalizers.

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.

Objective:The study was conducted to test the hypothesis that nitroglycerin (NTG) increases cerebral perfusion focally and globally in acute ischemic stroke patients, using serial perfusion-weighted imaging (PWI) magnetic resonance imaging measurements.Patients and methods:Thirty-five patients underwent PWI immediately before and 72 h after administration of a transdermal NTG patch or no treatment. Patients with baseline mean arterial pressure (MAP) > 100 mmHg (NTG group, n = 20) were treated with transdermal NTG (0.2 mg/h) for 72 h, without a nitrate-free interval. Patients with MAP ≤ 100 mmHg (untreated group, n = 15) were not treated. The primary outcome measure was absolute cerebral blood flow (CBF) in the hypoperfused region at 72 h.Results:The mean baseline absolute CBF in the hypoperfused region was similar in the NTG group (33.3 ± 10.2 ml/100 g/min) and untreated (32.7 ± 8.4 ml/100 g/min, p = 0.4) groups. The median (IQR) baseline infarct volume was 10.4 (2.5–49.3) ml in the NTG group and 32.6 (8.6–96.7) ml in the untreated group (p = 0.09). MAP change in the NTG group was 1.2 ± 12.6 and 8 ± 20.7 mmHg at 2 h and 72 h, respectively. Mean absolute CBF in the hypoperfused region at 72 h was similar in the NTG (29.9 ± 12 ml/100 g/min) and untreated groups (24.1 ± 10 ml/100 g/min, p = 0.8). The median infarct volume increased in untreated (11.8 (5.7–44.2) ml) than the NTG group (3.2 (0.5–16.5) ml; p = 0.033) on univariate analysis, however, there was no difference on regression analysis.Conclusion:NTG was not associated with improvement in cerebral perfusion in acute ischemic stroke patients.

An 80-year-old man with medical history of hypertension developed a sudden loss of vision in the left eye without any associated pain, flashes, or floaters. The review of systems was negative for any headaches, jaw claudication, scalp or temporal tenderness, or other symptoms suggestive of polymyalgia rheumatica (PMR). The patient's medications were benazepril and amlodipine for the treatment of hypertension. Clinical examination showed normal vital signs. Visual acuity testing revealed 20/20 vision on the right and hand movement perception only in the temporal field of the left eye, with no light perception on the nasal field of the same eye. Pupils were 3 mm bilaterally, round, and reactive with a relative afferent pupillary defect on the left. Dilated funduscopic examination was unremarkable on the right side and revealed macular whitening and retinal blanching with cherry-red spot on the left. Temporal artery pulses were present. The remainder of the neurologic examination was unremarkable. Laboratory investigations including erythrocyte sedimentation rate, C-reactive protein, lipid profile, and glycosylated hemoglobin were normal.

The effect of blood pressure (BP) reduction on cerebral blood flow (CBF) in acute ischemic stroke is unknown. We measured regional CBF with perfusion-weighted MRI before and after BP treatment in a three-armed non-randomized prospective controlled trial. Treatment arm assignment was based on acute mean arterial pressure (MAP). Patients with (MAP) >120 mmHg ( n = 14) were treated with intravenous labetalol and sublingual (SL) nitroglycerin (labetalol group). Those with MAP 100–120 mmHg ( n = 17) were treated with SL nitroglycerin (0.3 mg) (‘NTG Group’) and those with baseline MAP

Background and Purpose— Mild stroke is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable among different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD registry (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). Methods— Among 73 712 prospectively enrolled patients with a final diagnosis of ischemic stroke or TIA from January 2010 to April 2015, we identified 7746 cases with persistent neurological symptoms and National Institutes of Health Stroke Scale ≤5 who arrived within 4 hours of symptom onset. Multilevel logistic regression analysis with generalized estimating equations was used to identify independent predictors of thrombolytic administration in the subgroup of patients without contraindications to thrombolysis. Results— We included 6826 cases (final diagnosis mild stroke, 74.6% and TIA, 25.4%). Median age was 72 (interquartile range, 21); 52.7% men, 70.3% white, 12.9% black, 16.8% Hispanic; and median National Institutes of Health Stroke Scale, 2 (interquartile range, 3). Patients who received thrombolysis (n=1281, 18.7%) were younger (68 versus 72 years), had less vascular risk factors (hypertension, diabetes mellitus, and dyslipidemia), had lower risk of prior vascular disease (myocardial infarction, peripheral vascular disease, and previous stroke), and had a higher presenting median National Institutes of Health Stroke Scale (4 versus 2). In the multilevel multivariable model, early hospital arrival (arrive by 0–2 hours versus ≥3.5 hours; odds ratio [OR], 8.16; 95% confidence interval [CI], 4.76–13.98), higher National Institutes of Health Stroke Scale (OR, 1.87; 95% CI, 1.77–1.98), aphasia at presentation (OR, 1.35; 95% CI, 1.12–1.62), faster door-to-computed tomography time (OR, 1.81; 95% CI, 1.53–2.15), and presenting to an academic hospital (OR, 2.02; 95% CI, 1.39–2.95) were independent predictors of thrombolysis administration. Conclusions— Mild acutely presenting stroke patients are more likely to receive thrombolysis if they are young, white, or Hispanic and arrive early to the hospital with more severe neurological presentation. Identification of predictors of thrombolysis is important in design of future studies to assess the use of thrombolysis for mild stroke.

Susac syndrome is an immune-mediated, pauci-inflammatory, ischemia-producing, occlusive microvascular endotheliopathy/basement membranopathy that affects the brain, retina, and inner ear. Treatment of Susac syndrome is particularly challenging. The organs involved can easily become irreversibly damaged, and the window of opportunity to protect them is often short. Optimal outcome requires rapid and complete disease suppression. Adding to the challenge is the absence of objective biomarkers of disease activity and the great variability in presentation, timing and extent of peak severity, duration of peak severity, and natural disease course. There have been no randomized controlled trials or prospective treatment studies. We offer treatment guidelines based on cumulative clinical experience and a large cohort of patients followed longitudinally in a comprehensive database project. These guidelines state our preferences but do allow flexibility and discuss other options. The guidelines also serve as an initial step in the planning of prospective treatment studies, future consensus-based recommendations, and future randomized controlled trials.

Background: Early neurological deterioration occurs in one third of mild ischemic strokes primarily due to the presence of a visible intracranial vessel occlusion. We studied the clinical and vascular occlusive patterns, thrombus characteristics and recanalization rates in patients with mild ischemic stroke and a visible intracranial vessel occlusion. Methods: We studied patients enrolled in the INTERRSeCT multi-center prospective study of acute ischemic strokes with visible intracranial occlusions. We compared the clinical, thrombus characteristics and recanalization rates between two groups, 1) mild ischemic NIHSS≤5 and 2) moderate/severe strokes NIHSS >5, with or without IV alteplase treatment. Vessel imaging with CT angiography (CTA) was initiated within 12 hrs of symptom onset followed by repeat imaging with CTA or cerebral angiogram (before endovascular therapy; EVT) within 4 +/- 2 hrs. Results: Among 575 patients with a visible intracranial occlusion, 12.9% had mild strokes with similar patient characteristics compared to the moderate/severe stroke group. Residual flow grades were similar between the two groups (residual flow grades I-II, 21% vs 19%). The mild stroke group had longer symptom-onset-to -CT (240 vs 167 min, p=0.02) and -CTA (246 vs 172 min, p=0.02) times, longer CT to needle time (35 vs 26 min, p Conclusion: Some thrombus characteristics that predict recanalization in more severe strokes do not predict recanalization in mild strokes, such as residual blood flow through intracranial occlusions, though they have similar cardiovascular risk factors. Less than half of patients with mild strokes recanalized with IV alteplase which was associated with longer decision-making times suggesting that more aggressive use of thrombolytics and/or EVT may be viable treatment options in this population.

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

Background: Endovascular therapy (EVT ) is the only available reperfusion treatment in acute ischemic patients on prior oral anticoagulants (OACs). We evaluated the practice patterns, safety, and outcomes of EVT in patients on OAC therapy. Methods: From 2010 to 2019, 84,346 ischemic stroke patients presenting within 24 hours of symptoms across 107hospitals were enrolled in the Florida Stroke Registry, of which 5,702 received EVT. We collected data on demographics, past history, medications, NIHSS, symptomatic intracranial hemorrhage (sICH), discharge destination and hospital characteristics and used multivariable-adjusted logistic regression models to identify differences in outcome based on anticoagulation status. Results: Among all EVT patients (mean age 71±15 years, 48% women), 969 (17%) were treated with OAC. Compared to those not on OACs, anticoagulated patients were older (mean age 75.5±12.8 vs 70.0 ±14.9 years), more women (56% vs 50%), Hispanics (25% vs 20%), Medicare patients (44% vs 34%) and more likely to have atrial fibrillation (78.5% vs 27%), present earlier to the hospital (101 min vs 122 min) with similar clinical severity (median NIHSS 16 vs 15). There was no significant difference in length of stay 0-6 days (OAC 45.7% vs 46.8%), mRS 0-2 (OAC 23.9% vs 30.9%), independent ambulation (OAC 31.1% vs 38.3%), sICH (OAC 6.1% vs 5.4%), life-threatening or serious hemorrhage (OAC 0.4% vs 0.8%) or mortality (OAC 9.8% vs 9.8%) between the two groups. After multivariate adjustment, EVT patients on OACs were less likely to be discharged home compared to patients not on OACs (OR 0.18, 95% CI 0.05-0.31). Conclusion: In this large, multi-center study, EVT for patients with acute ischemic stroke on oral anticoagulation therapy did not result in higher rates of sICH, life threatening hemorrhage or death, though these patients are less likely to be discharged directly home.

Introduction: There is no definitive evidence currently to guide the choice between general anesthesia (GA) over conscious sedation (CS) for patients undergoing mechanical thrombectomy (MT). As MT outcomes are highly time-sensitive especially in the early time window, we aim to evaluate work-flow metrics and outcome differences between the two approaches in routine clinical practice at a Comprehensive Stroke Center (CSC). Methods: From 2/2015-9/2018, 329 consecutive MT patients were included from a large retrospective CSC database. In late 2017, we implemented a first-choice GA protocol at our CSC from a first choice CS for MT. Baseline characteristics, work-flow metrics and outcomes measures: mRS at discharge, mRS last follow-up (median, IQR 184 days, 37.25-202.5), radiological hemorrhagic conversion (rHT) and symptomatic intracranial hemorrhage (sICH) defined as rHT with post-MT (4-24 hours) NIHSS worsening ≥4, were examined. Multivariate logistic regression model was used to compare workflow and outcomes in GA vs. CS patients. Results: 82 (25.2%) patients received GA and 246 (74.8%) received CS. Baseline characteristics show significantly higher baseline HTN (p .043) and posterior circulation strokes (p .02) in GA patients. Compared to CS, patients undergoing GA had significantly longer procedure times 54±35 vs. 37±22min (OR .98, 95%CI .97-.996) but no difference in onset- or door-to-puncture times. Both had similar first pass success ~57% vs. 53% (p .59), number of attempts 1(1-2) vs. 1(1-2) (p .94) and rate of TICI 2b-3 ~87% vs. 84% (p .85). On multivariate regression, there was no significant difference in outcome measures between GA and CS: rHT (OR 1.1, 95%CI .64-1.9), sICH (OR 1.15, 95%CI .41-3.2), mRS at discharge (OR .75, 95%CI .176-3.22) and mRS at last follow-up (OR 1.05, 95%CI .53-2.08). Conclusion: In routine clinical practice, compared to CS, patients who underwent GA for MT had no difference in clinical outcomes, despite longer procedure times.

Introduction: Identification of race/ethnic disparities in stroke outcomes is essential in achieving equity of patient care across demographic subgroups. We sought to identify disparities by race/ethnicity in patient outcomes following subarachnoid hemorrhage (SAH). Methods: Records obtained from the Florida Stroke Registry (FSR), a multi-hospital Get With the Guidelines (GWTG)-Stroke data collaborative, were used to compare descriptive statistics and outcomes by race/ethnicity. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics by race/ethnicity. Outcomes included in-hospital mortality, discharge location, ambulation at discharge, modified Rankin Scale (mRS) score at discharge, and receiving comfort measures only. Logistic regression models with generalized estimating equations accounted for age, insurance, smoking, hypertension, diabetes, dyslipidemia, atrial fibrillation/flutter, coronary artery disease, peripheral vascular disease, prior stroke/TIA, carotid stenosis, prior anticoagulation or antiplatelet use, prior ambulatory status, arrival mode, admission NIHSS, Florida region, number of beds, years in GWTG, and teaching hospital status. Results: The sample consisted of 10, 559 records with SAH discharged between 2010-2018; 63% were non-Hispanic White (NHW), 19.4% non-Hispanic Black (NHB), and 17.6% Hispanic. NHB were younger at onset (median age=54, IQR=45-65; NHW: 62, 53-73; Hispanic: 58, 48-71; p < 0.0001) and had the highest rate of hypertension (62%; NHW: 50%, Hispanic: 51%; p < 0.001), while NHW had the highest rate of smoking (24%; NHB: 20%; Hispanic: 17%; p < 0.0001). NHB had lower odds of in-hospital mortality compared to NHW (adjusted OR 0.8, 95% CI 0.68-0.94), but were less likely to have been discharged home/rehab (0.83, 0.73-0.94), to ambulate independently at discharge (0.71, 0.60-0.84), and to have a discharge mRS score of 0-2 (0.67, 0.49-0.92). Conclusions: While NHB have lowered odds of dying in-hospital from SAH, survivors have worse functional outcomes. These race/ethnic disparities highlight the need for further research into the causes of these differences and to refine approaches to improve acute care of SAH.

Background: The Florida Stroke Act set criteria for comprehensive stroke centers (CSC). Hospitals could be certified by a national agency (The Joint Commission (TJC), Det Norske Veritas (DNV), Healthcare Facilities Accreditation Program (HFAP)) or could self-attest as fulfilling CSC criteria. This study aimed to evaluate whether nationally certified (NC) and self-attested hospitals (SA) have similar quality of care in acute ischemic stroke (AIS). Methods: The study population included AIS cases from 37 CSCs (74% of FL CSCs) in the FL-Stroke Registry, a multi-hospital registry using Get With the Guidelines-Stroke data from Jan 2013-Dec 2018. Hospital and patient level characteristics and stroke metrics were evaluated using unadjusted and adjusted (age, sex, race and NIH) analyses. Results: 13 NC-CSCs with 32,061 AIS cases and 24 SA-CSCs with 46,363 AIS cases were included. NCs were larger, with younger patients (71 (60-81) vs 72 (61-82)) and more severe strokes (median NIH; 5 vs 4, NIH ≥ 16; 15.4 vs 11.9% p p p p p p =.01). Conclusion: Among FL-Stroke Registry CSCs, AIS performance and treatment measures are superior in NC CSC when compared to SA CSCs. These findings have crucial implications for stroke systems of care in Florida and supported recent change in legislation regarding CSC center certification.

Introduction: Previous studies have yielded inconsistent results on whether weekend admission impacts the utilization of EVT and IV-rtPA. There is limited data available of whether age groups difference affects on use of IV-rtPA and EVT admitted during the off-hours. Our study aimed to investigate whether admission during the off-hours has any effect on the EVT & IV-rtPA utilization and is distributed uniformly across all age groups? Method: All adults admitted to US hospitals from 2005-2015 with a primary diagnosis AIS (n=4,520,516) were identified from the Nationwide Inpatient Sample using ICD-9 CM codes. Discharge weights were used to generate national estimates. On-hours vs. off-hours were defined using the weekend variable. Age groups were divided into 18-39, 40-59, 60-79 and ≥80 years. An age groupwise multivariable logistic regression models were used to compare odds of EVT and IV-rtPA use between on-hours vs. off-hours. Result: Total 4.5 million AIS population comprised 2.1% of 18-39 years, 20.0% of 40-59 years, 44.1% of 60-79 years and 34.0% of ≥80 years. Off-hours admissions comprised 25.7% of total AIS. Univariate analysis of off-hours vs. on-hours effects showed EVT utilization was 2.2% vs. 2.3% (P=0.50) and IV-tPA use was 7.9% vs. 7.3% (P=0.18) in 18-39 years. In 40-59 years age group, EVT 1.19% vs. 1.17% (P=0.74) and IV-tPA 6.2% vs. 5.7% (P Conclusion: Our study concludes that there is a lower rate of EVT performed during off-hours in the age groups of 60-79 and ≥ 80 years old. However, There was no difference reported in the use of EVT in the younger population. It’s also interesting to note that there is a higher use of IV-rtPA during the off-hours in all age groups except age group 18-39 years.

Background: Approximately 1 in 7 patients with mild ischemic stroke (NIHSS ≤5) have large vessel occlusion (LVO). These patients were excluded from randomized trials of endovascular therapies (EVT). We conducted a survey to evaluate global practice patterns of EVT in mild stroke with LVO. Methods: International vascular stroke clinicians and interventionalists were invited to participate through professional stroke listservs. The survey consisted of 6 clinical vignettes of mild stroke patients with LVO (Table). Cases varied by NIHSS, neurological symptoms and LVO site. All had same risk factors, time from symptom onset (5h) and unremarkable head CT (high ASPECTS). Advanced imaging data was available upon request. We explored independent case and responder specific factors associated with advanced imaging request and EVT decision. Results: Of 492 responders, 482 had analyzable data ([median age 44 (IQR 11.25)], 78% male, 77% attending, 22% interventionalist). Participants were from USA (45%), Europe (32%), Australia (12%), Canada (6%), and Latin America (5%). EVT was offered to 48% (84% M1, 29% M2 and 19% A2). Treatment decision made without advanced imaging in 66%. In multivariable analysis, proximal occlusion (M1 vs M2 or A2, p Conclusions: Treatment patterns of EVT in mild stroke vary widely. More proximal occlusion, higher NIHSS, younger physician, fellow level training, and area of residence (Europe and Latin America) were key factors associated with offering EVT. These data suggest that wide equipoise exists in the current approach to this important subset of LVO stroke.

Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion and has recently revolutionized stroke care. Oftentimes, ischemic core extent on baseline imaging is used to determine endovascular treatment-eligibility. There are, however, 3 fundamental issues with the core concept: First, computed tomography and magnetic resonance imaging, which are mostly used in the acute stroke setting, are not able to precisely determine whether and to what extent brain tissue is infarcted (core) or still viable, due to variability in tissue vulnerability, the phenomenon of selective neuronal loss and lack of a reliable gold standard. Second, treatment decision-making in acute stroke is multifactorial, and as such, the relative importance of single variables, including imaging factors, is reduced. Third, there are often discrepancies between core volume and clinical outcome. This review will address the uncertainty in terminology and proposes a direction towards more clarity. This theoretical exercise needs empirical data that clarify the definitions further and prove its value.

Background The Alberta Stroke Program Early CT Score (ASPECTS) is a systematic method of assessing the extent of early ischemic change on non-contrast computed tomography in patients with acute ischemic stroke. Our objective was to validate an automated ASPECTS scoring method we recently developed on a large data set. Materials and methods We retrospectively collected 602 acute ischemic stroke patients’ non-contrast computed tomography scans. Expert ASPECTS readings on non-contrast computed tomography were compared to automated ASPECTS. Statistical analyses on the total ASPECTS, region level ASPECTS, and dichotomized ASPECTS (≤4 vs. >4) score were conducted. Results In total, 602 scans were evaluated and 6020 (602 × 10) ASPECTS regions were scored. Median time from stroke onset to computed tomography was 114 min (interquartile range: 73–183 min). Total ASPECTS for the 602 patients generated by the automated method agreed well with expert readings (intraclass correlation coefficient): 0.65 (95% confidence interval (CI): 0.60–0.69). Region level analysis showed that the automated method yielded accuracy of 81.25%, sensitivity of 61.13% (95% CI: 58.4%–63.8%), specificity of 86.56% (95% CI: 85.6%–87.5%), and area under curve of 0.74 (95% CI: 0.73–0.75). For dichotomized ASPECTS (≤4 vs. >4), the automated method demonstrated sensitivity 97.21% (95% CI: 95.4%–98.4%), specificity 57.81% (95% CI: 44.8%–70.1%), accuracy 93.02%, and area under the curve of 0.78 (95% CI: 0.74–0.81). For each individual region (M1–6, lentiform, insula, and caudate), the automated method demonstrated acceptable performance. Conclusion The automated system we developed approached the stroke expert in performance when scoring ASPECTS on non-contrast computed tomography scans of acute ischemic stroke patients.

Endovascular therapy (EVT) for patients with mild ischemic stroke (NIHSS ≤5) and visible intracranial occlusion remains controversial, including within 6 hours of symptom onset. We conducted a survey to evaluate global practice patterns of EVT in this population.Vascular stroke clinicians and neurointerventionalists were invited to participate through professional stroke listservs. The survey consisted of six clinical vignettes of mild stroke patients with intracranial occlusion. Cases varied by NIHSS, neurological symptoms and occlusion site. All had the same risk factors, time from symptom onset (5h) and unremarkable head CT. Advanced imaging data was available upon request. We explored independent case and responder specific factors associated with advanced imaging request and EVT decision.A total of 482/492 responders had analyzable data ([median age 44 (IQR 11.25)], 22.7% women, 77% attending, 22% interventionalist). Participants were from USA (45%), Europe (32%), Australia (12%), Canada (6%), and Latin America (5%). EVT was offered in 48% (84% M1, 29% M2 and 19% A2) and decision was made without advanced imaging in 66% of cases. In multivariable analysis, proximal occlusion (M1 vs. M2 or A2, p0.001), higher NIHSS (p0.001) and fellow level training (vs. attending; p=0.001) were positive predictors of EVT. Distal occlusions (M2 and A2) and higher age of responders were independently associated with increased advanced imaging requests. Compared to US and Australian responders, Canadians were less likely to offer EVT, while those in Europe and Latin America were more likely (p0.05).Treatment patterns of EVT in mild stroke vary globally. Our data suggest wide equipoise exists in current treatment of this important subset of mild stroke.

Introduction: There is interest in understanding thrombus dynamics from IV TPA prior to endovascular thrombectomy (EVT) given the possible dichotomy amongst sites of occlusion for IV TPA benefit/harm. Kaesmacher et al reported beneficial 5+% rates of early TICI > 2a reperfusion in distal M1 or M2 MCA occlusions with IV TPA. However in more proximal occlusions this was rare; and potentially harmful worsening of perfusion seen with change of occlusion site. We aimed to examine IV TPA related thrombus dynamics including migration further across both proximal and distal occlusions in a multicenter prospective cohort study INTERRSeCT. Methods: Acute ischemic stroke patients with intracranial occlusion who had baseline CTA and follow-up CTA or initial run angio in INTERRSeCT and IV TPA were reviewed. We evaluated change of occlusion site (COS) and classified patients into 4 categories: Complete Recanalization (CR) of primary occlusive lesion with no remaining thrombus; definite Thrombus Migration (dTM) with primary occlusion site moved to a distal artery and occlusion site patent on baseline CTA; probable Thrombus Migration (pTM) with COS evident but initial occlusion extent not visualized; or No Change of occlusion site (NC). Results: A total of 462 IV TPA patients were enrolled, 41% received EVT. Median time from TPA to follow-up imaging was 133 minutes. COS was seen in 50% of cases with CR in 15% and TM in 35% (dTM 12%, pTM 23%). Distal artery occlusion and longer interval of TPA to imaging were independent predictors for COS. In 62 proximal occlusion (ICA and proximal-mid M1 MCA) patients with follow-up imaging within 60 mins after TPA (receiving EVT in 94%), any TM showed a lower rate of 90-day mRS≤2 than NC (47% vs 78%, adjusted OR 0.21, 95%CI 0.04-0.87). No CR was seen in this early group. Conclusions: Thrombus migration is common after IV TPA. Thrombus instability from IV TPA may worsen clinical outcome in proximal occlusions despite early EVT initiation, possibly due to migration of thrombus to distal arteries accelerating infarction or more challenging thrombectomy due to thrombus dispersion. The benefit of IV TPA prior to EVT at comprehensive stroke centers for ICA or prox-mid M1 occlusions require more study in randomized clinical trials.

The therapeutic window for acute ischemic stroke with intravenous recombinant tissue plasminogen activator (IV rt-PA) is brief and crucial. The American Heart Association/American Stroke Association Target: Stroke Best Practice Strategies (TSBPS) aim to improve intravenous thrombolysis door-to-needle (DTN) time. We assessed the efficacy of implementation of selected TSBPS to reduce DTN time in a large tertiary care hospital. A multidisciplinary DTN committee assessed causes of delayed DTN time and implemented focused TSBPS in our urban academic medical center. We analyzed door-to-CT time, DTN time, and CT to IV rt-PA time in consecutive patients treated with IV rt-PA over 27 months preimplementation and 13 months postimplementation. One hundred forty-eight patients were included in the preimplementation and 126 in the postimplementation group. We found no significant difference between the groups in demographics, comorbidities, anticoagulation status, prethrombolysis hypertension treatment, arrival by EMS, after-hours arrival, or in stroke etiology. After implementation, median DTN time improved from 59 (interquartile range [IQR]: 52-80) to 29 (IQR: 20-41) minutes (P < .001). Door-to-CT time decreased from 17 (14-21) to 16 (12-19) minutes (P = .016), and CT-to-IV rt-PA time improved from 43 (IQR: 31-59) to 13 (IQR: 6-23) minutes (P < .001). Rates of symptomatic intracranial hemorrhage (2.7% vs 3.2%, P = .82) and treatment of stroke mimics (9% vs 13%, P = .31) were similar in both the groups. Individualized hospital gap analysis identifies targeted interventions that lead to rapid and sustained improvement in treatment times.

BACKGROUND AND PURPOSE: Intracranial hemorrhage is a known complication following endovascular thrombectomy. The radiologic characteristics of a CT scan may assist with hemorrhage risk stratification. We assessed the radiologic predictors of intracranial hemorrhage following endovascular therapy using data from the INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) study. MATERIALS AND METHODS: Patients undergoing endovascular therapy underwent baseline imaging, postprocedural angiography, and 24-hour follow-up imaging. The primary outcome was any intracranial hemorrhage observed on follow-up imaging. The secondary outcome was symptomatic hemorrhage. We assessed the relationship between hemorrhage occurrence and baseline patient characteristics, clinical course, and imaging factors: baseline ASPECTS, thrombus location, residual flow grade, collateralization, and clot burden score. Multivariable logistic regression with backward selection was used to adjust for relevant covariates. RESULTS: Of the 199 enrolled patients who met the inclusion criteria, 46 (23%) had an intracranial hemorrhage at 24 hours. On multivariable analysis, postprocedural hemorrhage was associated with pretreatment ASPECTS (OR, 1.56 per point lost; 95% CI, 1.12–2.15), clot burden score (OR, 1.19 per point lost; 95% CI, 1.03–1.38), and ICA thrombus location (OR, 3.10; 95% CI, 1.07–8.91). In post hoc analysis, clot burden scores of ≤3 (sensitivity, 41%; specificity, 82%; OR, 3.12; 95% CI, 1.36–7.15) and pretreatment ASPECTS ≤ 7 (sensitivity, 48%; specificity, 82%; OR, 3.17; 95% CI, 1.35–7.45) robustly predicted hemorrhage. Residual flow grade and collateralization were not associated with hemorrhage occurrence. Symptomatic hemorrhage was observed in 4 patients. CONCLUSIONS: Radiologic factors, early ischemia on CT, and increased CTA clot burden are associated with an increased risk of intracranial hemorrhage in patients undergoing endovascular therapy.

Importance Recanalization of intracranial thrombus is associated with improved clinical outcome in patients with acute ischemic stroke. The association of intravenous alteplase treatment and thrombus characteristics with recanalization over time is important for stroke triage and future trial design. Objective To examine recanalization over time across a range of intracranial thrombus occlusion sites and clinical and imaging characteristics in patients with ischemic stroke treated with intravenous alteplase or not treated with alteplase. Design, Setting, and Participants Multicenter prospective cohort study of 575 patients from 12 centers (in Canada, Spain, South Korea, the Czech Republic, and Turkey) with acute ischemic stroke and intracranial arterial occlusion demonstrated on computed tomographic angiography (CTA). Exposures Demographics, clinical characteristics, time from alteplase to recanalization, and intracranial thrombus characteristics (location and permeability) defined on CTA. Main Outcomes and Measures Recanalization on repeat CTA or on first angiographic acquisition of affected intracranial circulation obtained within 6 hours of baseline CTA, defined using the revised arterial occlusion scale (rAOL) (scores from 0 [primary occlusive lesion remains the same] to 3 [complete revascularization of primary occlusion]). Results Among 575 patients (median age, 72 years [IQR, 63-80]; 51.5% men; median time from patient last known well to baseline CTA of 114 minutes [IQR, 74-180]), 275 patients (47.8%) received intravenous alteplase only, 195 (33.9%) received intravenous alteplase plus endovascular thrombectomy, 48 (8.3%) received endovascular thrombectomy alone, and 57 (9.9%) received conservative treatment. Median time from baseline CTA to recanalization assessment was 158 minutes (IQR, 79-268); median time from intravenous alteplase start to recanalization assessment was 132.5 minutes (IQR, 62-238). Successful recanalization occurred at an unadjusted rate of 27.3% (157/575) overall, including in 30.4% (143/470) of patients who received intravenous alteplase and 13.3% (14/105) who did not (difference, 17.1% [95% CI, 10.2%-25.8%]). Among patients receiving alteplase, the following factors were associated with recanalization: time from treatment start to recanalization assessment (OR, 1.28 for every 30-minute increase in time [95% CI, 1.18-1.38]), more distal thrombus location, eg, distal M1 middle cerebral artery (39/84 [46.4%]) vs internal carotid artery (10/92 [10.9%]) (OR, 5.61 [95% CI, 2.38-13.26]), and higher residual flow (thrombus permeability) grade, eg, hairline streak (30/45 [66.7%]) vs none (91/377 [24.1%]) (OR, 7.03 [95% CI, 3.32-14.87]). Conclusions and Relevance In patients with acute ischemic stroke, more distal thrombus location, greater thrombus permeability, and longer time to recanalization assessment were associated with recanalization of arterial occlusion after administration of intravenous alteplase; among patients who did not receive alteplase, rates of arterial recanalization were low. These findings may help inform treatment and triage decisions in patients with acute ischemic stroke.

Background Patients with proximal arterial M2-segment of the Middle Cerebral Artery (M2-MCA) occlusions were largely excluded from endovascular stroke trials. Current American Stroke guidelines are conservative in recommending thrombectomy for such patients. We sought to assess the natural history of medically- treated M2-MCA occlusion patients. Methods This is a prospective multi-central international cohort study of all acute ischemic stroke patients with intracranial occlusions on baseline imaging. Patients with M2-MCA occlusions were identified on baseline CT angiography and non-endovascular-treated patients were included. The M2-MCA segment was defined as the first-order branch of the proximal MCA, excluding the anterior temporal artery. The M2-MCA was further classified according to its visually-assessed diameter relative to the M1-MCA into: M1-equivalent (>90% of the diameter of the M1-MCA), Major (50%–90%), Minor ( Results Out of 575 patients in the entire study, there were a total of 184 M2-MCA occlusions seen. Of those, 104 patients were NOT treated with endovascular therapy: 90 patients (86.5%) received IV TPA and 14 (23.5%) patients conservative management. Among those, 23.1% (24/104) M1-equivalent, 66.4% (69/104) major, and 9.6% (10/104) minor M2-MCA. The median age was 76 years (interquartile range 19 years). The median (IQR) baseline NIHSS score of the cohort was 9 (9): M1-equivalent 12(10), major 9 (9), minor 7 (8). The median baseline ASPECTS was 9 overall and in all M2 groups. Successful recanalization was observed in 44.2% (46/104) of the medical M2 occlusion cohort overall. TPA group was 47.8% (43/90) and conservative group 21.4% (3/14). With IV TPA successful recanalization occurred in 30% (6/20) of M1-equivalent, 50% (31/62) of major, and 75% (6/8) of minor M2-MCA occlusions. In conservative management group successful recanalization occurred in 25% (1/4) of M1-equivalent, 14.3% (1/7) of major, and 50% (1/2) of minor M2-MCA occlusions. Good functional outcome (mRS 0–2) at 90 day was observed in 62.1% (64/104) of the cohort overall. Among those with successful recanalization, 76.1% (35/46) achieved good outcome. With IV TPA, the proportion of patients achieving independent functional outcome was 45% (9/20) with M1-equivalent, 70.5% (43/61) of major, and 62.5% (5/8) of minor M2-MCA occlusions. In the conservative management group, the proportion of patients achieving independent functional outcome at 90 day was 25% (1/4) with M1-equivalent, 71.4% (5/7) of major, and 50% (1/2) of minor M2-MCA occlusions. In logistic regression analyses, successful recanalization predicted independent functional outcome (OR 2.9, 95% CI 1.02 to 8.1, p 0.046). Age (OR 0.89, 95% CI 0.84 to 0.94, p Conclusion While over one half of medically-treated patients with M2-MCA segment occlusions achieve independent outcome, a subset of patients suffers poor functional outcomes at 90 days. Successful recanalization are associated with higher odds of independent functional outcome. Disclosures B. Menon: None. M. Najm: None. F. Al-Ajlan: None. M. Almekhlafi: None. J. Puig: None. M. Castellanos: None. D. Dowlatshahi: None. A. Calleja: None. S. Sohn: None. S. Ahn: None. A. Poppe: None. R. Mikulik: None. N. Asdaghi: None. T. Field: None. A. Jin: None. T. Asil:None. J. Boulanger: None. E. Smith: None. S. Coutts: None. P. Barber: None. S. Bal: None. S. Subramanian: None. S. Mishra: None. A. Trivedi: None. S. Dey: None. M. Eesa: None. T. Sajobi: None. M. Goyal: None. M. Hill: None. A. Demchuk: None.

Background and Purpose— Few studies have examined predictors of cognitive impairment after minor ischemic stroke and transient ischemic attack (TIA). We examined clinical and imaging features associated with worse cognitive performance at 90 days. Methods— TIA or patients with minor stroke underwent neuropsychological testing 90 days post event. Z scores were calculated for cognitive tests, and then grouped into domains of executive function (EF), psychomotor processing speed (PS), and memory. White matter hyperintensity and diffusion-weighted imaging volumes were measured on baseline magnetic resonance imaging. Ninety-day outcomes included modified Rankin Scale (mRS) and Centre for Epidemiological Studies Depression Scale (CES-D) score. Results— Ninety-two patients were included, 76% male, 54% TIA, and mean age 65.1±12.0. Sixty-four percent were diffusion-weighted imaging positive. Median domain z scores were not significantly different from published norms ( P >0.05): memory −0.03, EF −0.12, and PS −0.05. Patient performance ≥1 SD below normal was 20% on memory, 16% on PS, and 17% on EF. Cognitive scores did not differ by diagnosis (stroke versus TIA), stroke pathogenesis, presence of obstructive sleep apnea, and diffusion-weighted imaging or white matter hyperintensity volumes. In multivariable analyses, lower EF was associated with previous cortical infarct on magnetic resonance imaging ( P =0.03), mRS score of >1; P =0.0003 and depressive symptoms (CES-D ≥16; P =0.03). Lower PS scores were associated with previous cortical infarct ( P =0.02), acute bilateral positive diffusion-weighted imaging ( P =0.02), mRS score of >1 ( P =0.003), and CES-D ≥16 ( P =0.03). Conclusions— Despite average-range cognitive performance in this TIA and population with minor stroke, we found associations of EF and PS with evidence of previous stroke, postevent disability, and depression.

Background and Purpose— There are limited data on the extent of blood–brain barrier (BBB) compromise in acute intracerebral hemorrhage patients. We tested the hypotheses that BBB compromise measured with permeability-surface area product (PS) is increased in the perihematoma region and predicts perihematoma edema growth in acute intracerebral hemorrhage patients. Methods— Patients were randomized within 24 hours of symptom onset to a systolic blood pressure (SBP) treatment of Results— Patients were randomized at a median (interquartile range) time of 9.3 hours (14.1) from symptom onset. Treatment groups were balanced with respect to baseline SBP and hematoma volume. Perihematoma PS (5.1±2.4 mL/100 mL per minute) was higher than PS in contralateral regions (3.6±1.7 mL/100 mL per minute; P P P =0.51). Conclusions— BBB permeability is focally increased in the hematoma and perihematoma regions of acute intracerebral hemorrhage patients. BBB compromise does not predict acute perihematoma edema volume or edema growth. SBP reduction does not affect BBB permeability. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00963976.

Purpose To report a case of acute macular neuroretinopathy in a patient with Susac syndrome. Methods Case report. Results A 39-year-old male patient presented with severe headache, photopsias, and a sudden onset of hearing loss in the right ear. Fluorescein angiography of the right eye revealed multiple branch retinal artery occlusions. Clinical presentation of encephalopathy, hearing loss, and branch retinal artery occlusions, along with characteristic magnetic resonance imaging findings, led to a diagnosis of Susac syndrome. Despite aggressive immunosuppression for four months, the patient later presented with acute macular neuroretinopathy in the left eye. Conclusion Acute macular neuroretinopathy and Susac is a new association of two well-defined disorders. The concurrence of both disorders supports retinal ischemia as the proximate cause of acute macular neuroretinopathy and inflammation as a potential etiology.

Isolated cortical vein thrombosis (ICVT) is a rare entity and diagnosis requires high clinical suspicion and select imaging modalities.

Background: After endovascular therapy (EVT) became standard of care for acute ischemic stroke (AIS) in 2015, emergency medical services (EMS) in 3 urban southeast Florida counties modified their transport protocols for suspected AIS. In 2015, Broward (BC) and Palm Beach counties (PBC) phased in EMS transport of all stroke alerts to state-attested comprehensive stroke centers (CSC). Miami-Dade (MDC) adopted a severity-based protocol. Methods: The impact of EMS policy changes was assessed using the AHA Get with the Guidelines-Stroke data prospectively collected for the Florida-Puerto Rico Stroke Registry involving 35,794 AIS cases in the 3 counties with 27 CSC between 2010 and 2016. Results: The percent of patients transported directly by EMS from scene to CSCs in BC and PBC rose from 34% and 13% during 2010, to 97% and 86%, respectively, in 2016 (p=0.002). In MDC, it increased from 62% to 77%. In 2016, the percentage of AIS patients that presented to CSC as transfers from primary stroke centers (PSC) was 5% in BC, 8% in PBC, and 12% in MDC. Of all patients receiving IV tPA in 2016, 81% were transported by EMS and 87 % of IV tPA treatment was administered in a CSC. From 2010 to 2016, IV tPA treatment increased from 8% to 18% in CSC vs. 8% to 12% in PSC (p=0.41). By 2016 the mean door to needle time was 13 min shorter in CSCs (p Conclusion: Modifying EMS policies to transport most suspected AIS patients directly to CSCs was associated with higher rates of IV tPA treatment, shorter intervals to IV tPA after symptom onset, faster arrival times for EVT evaluation and higher rates of EVT compared to patients triaged to PSCs. Based on these findings, directly transporting suspected AIS patients to CSC may be a successful strategy to expedite stroke care interventions in urban centers with high CSC density.

Introduction: Multiple studies have correlated larger final infarct volume (FIV) with worse clinical outcomes. In INTERRSeCT , an international multicenter prospective cohort study, we sought to determine the favorable intracranial clot characteristics predicting smaller infarct volumes. Methods: FIV was measured (24 ±12 hours after baseline imaging) in 605 patients from INTERRSeCT study by blinded readers using Quantomo (Cybertrial Inc, Calgary). Clot Burden Score (CBS) is a 10-point scale with 10 referring to a completely patent ipsilateral anterior circulation from ICA to both M2 arteries, whereas 0 refers to a completely occluded ipsilateral anterior circulation. Residual Flow Grade (RFG) assesses the radiological permeability of the clot to contrast, with grade 0, 1, and 2 defined as no contrast, diffuse ghosting, and hairline lumen, respectively. Both of these scores were assessed by a blinded reader to the FIV. Using ordinal logistic regression, FIV was divided into deciles as the outcome. CBS and RFG were analyzed from 0 to 10, and 0 to 2, respectively. Two models were used, the first has no recanalization status, while the second included it. Results: The median FIVs with and without recanalization were 12.34 ml (IQR: 32.3 ml) and 22.15 ml (IQR: 60.12ml), respectively. CBS and RFG were independently predictive of FIV (p-value= Conclusions: Residual flow grade and clot burden score are fast and practical techniques for practitioners treating acute ischemic stroke patients. Favorable RFG and CBS independently, predict lower infarct volumes regardless of whether recanalization achieved.

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

Background: While recent endovascular therapy trials have had a minimal number of adverse events, intracerebral hemorrhage (ICH) still occurs. The predictors of ICH with endovascular therapy remain unclear. We assessed predictors of hemorrhage following endovascular thrombectomy using data from the prospectively collected, multicenter INTERRSeCT study. Methods: Patients undergoing endovascular therapy +/- intravenous alteplase (tPA) were enrolled and received baseline CT/CTA, follow-up CTA/Angiogram and 24-hr CT or MRI images. Primary outcome was any ICH as per the ECASS classification of hemorrhage. Secondary outcome was PH1/PH2 hemorrhages. We assessed the relations between ICH and baseline ASPECTS scoring, thrombus location, residual flow, collateralization, tPA use, and final recanalization state. Multivariable regression with stepwise selection was used to adjust for relevant covariates. Results: Of 242 patients who met inclusion criteria, 58 (24%) had an ICH at 24 hours (HI1 53%, HI2 19%, PH1 7%, PH2 21%). Post-procedure hemorrhage was associated with lower ASPECTS scores (p Conclusion: Early ischemia defined by imaging, mid-M1 thrombus location, and increased serum glucose are associated with increased risk of hemorrhage in patients undergoing combination tPA and endovascular therapy.

Background and Aims: TIA and minor stroke offer a massive opportunity for stroke prevention. Patients with motor or speech symptoms have a higher risk of early recurrent stroke. Many patients with transient or mild neurological deficits do not have high-risk features (eg sensory symptoms). The aim of the DOUBT study was to assess what proportion of these lower risk patients have true brain ischemia and secondarily to establish whether clinically we can predict what clinical factors predict a higher risk of brain ischemia. Method: DOUBT was a multicentre, international, prospective, observational, cohort study assessing the diagnosis and prognosis of patients with lower risk focal neurological symptoms. Patients aged ≥ 40, with no previous stroke, with either very brief ( Results: 1047 patients in Canada, Europe and Australia were prospectively enrolled in the study. All patients had a detailed neurological assessment prior to undergoing MRI brain. Preliminary analysis shows 13% true brain schema rate (DWI positive). Patients were less likely to have a DWI lesion if their symptoms were fully resolved at assessment (RR 0.57, 95%CI: 0.38-0.79, p Conclusion: We found a low but real risk of true brain ischemia in these lower risk patients. Further analysis is needed to explain why woman are more likely to have DWI lesions with low risk symptoms. Detailed neurological assessment may help us stratify these patients further.

Background and Purpose— The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial (ICH ADAPT) demonstrated blood pressure (BP) reduction does not affect mean perihematoma or hemispheric cerebral blood flow. Nonetheless, portions of the perihematoma and borderzones may reach ischemic thresholds after BP reduction. We tested the hypothesis that BP reduction after intracerebral hemorrhage results in increased critically hypoperfused tissue volumes. Methods— Patients with Intracerebral hemorrhage were randomized to a target systolic BP (SBP) of Results— Seventy-five patients with intracerebral hemorrhage were randomized a median (interquartile range) of 7.8 (13.3) hours from onset. Acute hematoma volume was 17.8 (27.1) mL and mean SBP was 183±22 mm Hg. At the time of computed tomographic perfusion (2.3 [1.0] hours after randomization), SBP was lower in the P P =0.78) or P =0.62). Similar results were found in the perihematoma region. Low SBP load (fraction of time with SBP Conclusions— BP reduction does not increase the volume of critically hypoperfused borderzone or perihematoma tissue. These data support the safety of early BP reduction in intracerebral hemorrhage. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00963976.

Importance Early treatment of patients with transient ischemic attack (TIA) reduces the risk of stroke. However, many patients present with symptoms that have an uncertain diagnosis. Patients with motor, speech, or prolonged symptoms are at the highest risk for recurrent stroke and the most likely to undergo comprehensive investigations. Lower-risk patients are much more likely to be cursorily investigated. Objective To establish the frequency of acute infarct defined by diffusion restriction detected on diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI) scan (DWI positive). Design, Setting, and Participants The Diagnosis of Uncertain-Origin Benign Transient Neurological Symptoms (DOUBT) study was a prospective, observational, international, multicenter cohort study of 1028 patients with low-risk transient or minor symptoms referred to neurology within 8 days of symptom onset. Patients were enrolled between June 1, 2010, and October 31, 2016. Included patients were 40 years or older and had experienced nonmotor or nonspeech minor focal neurologic events of any duration or motor or speech symptoms of short duration (≤5 minutes), with no previous stroke. Exposures Patients underwent a detailed neurologic assessment prior to undergoing a brain MRI within 8 days of symptom onset. Main Outcomes and Measures The primary outcome was restricted diffusion on a brain MRI scan (acute stroke). Results A total of 1028 patients (522 women and 506 men; mean [SD] age, 63.0 [11.6] years) were enrolled. A total of 139 patients (13.5%) had an acute stroke as defined by diffusion restriction detected on MRI scans (DWI positive). The final diagnosis was revised in 308 patients (30.0%) after undergoing brain MRI. There were 7 (0.7%) recurrent strokes at 1 year. A DWI-positive brain MRI scan was associated with an increased risk of recurrent stroke (relative risk, 6.4; 95% CI, 2.4-16.8) at 1 year. Absence of a DWI-positive lesion on a brain MRI scan had a 99.8% negative predictive value for recurrent stroke. Factors associated with MRI evidence of stroke in multivariable modeling were older age (odds ratio [OR], 1.02; 95% CI, 1.00-1.04), male sex (OR, 2.03; 95% CI, 1.39-2.96), motor or speech symptoms (OR, 2.12; 95% CI, 1.37-3.29), ongoing symptoms at assessment (OR, 1.97; 95% CI, 1.29-3.02), no prior identical symptomatic event (OR, 1.87; 95% CI, 1.12-3.11), and abnormal results of initial neurologic examination (OR, 1.71; 95% CI, 1.11-2.65). Conclusions and Relevance This study suggested that patients with transient ischemic attack and symptoms traditionally considered low risk carry a substantive risk of acute stroke as defined by diffusion restriction (DWI positive) on a brain MRI scan. Early MRI is required to make a definitive diagnosis.

Background: Magnetic resonance imaging (MRI) is proposed as the preferred imaging modality to investigate patients with transient ischemic attack (TIA). This is mainly based on a higher yield of small acute ischemic lesions; however, direct prospective comparisons are lacking. In this study, we aimed to directly compare the yield of acute ischemic lesions on MRI and computed tomography (CT) in the emergency diagnosis of suspected TIA or minor stroke. Methods: Consecutive patients aged 18 years or older presenting with minor stroke (NIHSS Results: A total of 347 patients were included, 168 with TIAs, 147 with minor strokes and 32 with a final diagnosis of a mimic. Acute ischemic lesions were detected in 39% of TIAs by using MRI versus 8% by using CT (p < 0.0001) and in 86% of minor strokes by using MRI versus 18% by using CT (p < 0.0001). Compared to MRI, CT had a sensitivity of 20% and a specificity of 98% in identifying an acute ischemic lesion. The infarct volume on diffusion-weighted MRI was larger in cases where the CT also showed an acute ischemic lesion (median 5.07 ml, IQR 10) as compared to lesions seen only on MRI (median 0.68 ml, IQR 1.31, p < 0.0001). Conclusion: MRI is superior to CT in detecting the small ischemic lesions occurring after TIA and minor stroke. Since these lesions are clinically relevant, MRI should be the preferred imaging modality in this setting.