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Background Mobile stroke units (MSUs) are ambulances with staff and a computed tomographic scanner that may enable faster treatment with tissue plasminogen activator (t-PA) than standard m...

INTRODUCTION: We sought to determine the feasibility and validity of estimating post-stroke outcomes using information available in the electronic medical record (EMR) through comparison with outcomes obtained from telephone interviews. METHODS: The Greater Cincinnati Northern Kentucky Stroke Study is a retrospective population-based epidemiology study that ascertains hospitalized strokes in the study region. As a sub-study, we identified all ischemic stroke patients who presented to a system of 4 hospitals during the study period 1/1/2015–12/31/2015 and were discharged alive. Enrolled subjects (or proxies for cognitively-disabled patients) were contacted by telephone at 3 and 6 months post-stroke to determine current place of residence and two functional outcomes—the modified Rankin Score (mRS) and the EuroQol (EQ-5D). Concurrently, the lead study coordinator, blinded to the telephone assessment outcomes, reviewed all available EMRs to estimate outcome status. Agreement between outcomes estimated from the EMR with “gold-standard” data obtained from telephone interviews was analyzed using the kappa statistic or interclass correlation (ICC), as appropriate. For each outcome, EMR-determined results were evaluated for added value beyond the information readily available from the stroke hospital stay. RESULTS: Of 381 ischemic strokes identified, 294 (median [IQR] age 70 [60–79] years, 4% black, 52% female) were interviewed post-stroke. Agreement between EMR and telephone for 3-month residence was very good (kappa=0.84, 95% CI 0.74–0.94), good for mRS (weighted kappa=0.75, 95% CI 0.70–0.80), and good for EQ-5D (ICC=0.74, 95% CI 0.68–0.79). Similar results were observed at 6 months post stroke. At both 3 and 6 months post stroke, EMR-determined outcomes added value in predicting the gold standard telephone results beyond the information available from the stroke hospitalization; the added fraction of new information ranged from 0.25 to 0.59. CONCLUSIONS: Determining place of residence, mRS, and EQ-5D outcomes derived from information recorded in the EMR post-stroke, without patient contact, is feasible and has good agreement with data obtained from direct contact. However, we note that the level of agreement for mRS and EQ-5D was higher for proxy interviews and that the EMR often reflects health care providers’ judgments that tend to overestimate disability and underestimate quality of life.

ObjectiveTo test the hypothesis that thrombogenic atrial cardiopathy may be relevant to stroke-related racial disparities, we compared atrial cardiopathy phenotypes between Black vs White patients with ischemic stroke.MethodsWe assessed markers of atrial cardiopathy in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of stroke incidence in a population of 1.3 million. We obtained ECGs and reports of echocardiograms performed during evaluation of stroke during the 2010/2015 study periods. Patients with atrial fibrillation (AF) or flutter (AFL) were excluded. Investigators blinded to patients' characteristics measured P-wave terminal force in ECG lead V1 (PTFV1), a marker of left atrial fibrosis and impaired interatrial conduction, and abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and atrial cardiopathy markers after adjustment for demographics, body mass index, and vascular comorbidities.ResultsAmong 3,426 ischemic stroke cases in Black or White patients without AF/AFL, 2,391 had a left atrial diameter measurement (mean, 3.65 ± 0.70 cm). Black race was associated with smaller left atrial diameter in unadjusted (β coefficient, −0.11; 95% confidence interval [CI], −0.17 to −0.05) and adjusted (β, −0.15; 95% CI, −0.21 to −0.09) models. PTFV1 measurements were available in 3,209 patients (mean, 3,434 ± 2,525 μV*ms). Black race was associated with greater PTFV1 in unadjusted (β, 1.59; 95% CI, 1.21–1.97) and adjusted (β, 1.45; 95% CI, 1.00–1.80) models.ConclusionsWe found systematic Black–White racial differences in left atrial structure and pathophysiology in a population-based sample of patients with ischemic stroke.Classification of EvidenceThis study provides Class II evidence that atrial cardiopathy phenotypes differ in Black people with acute stroke compared to White people.

Background: Since the approval of the oral factor Xa inhibitors, there have been concerns regarding the ability to neutralize their anticoagulant effects after intracranial hemorrhage (ICH). Multiple guidelines suggest using prothrombin complex concentrates (PCCs) in these patients on the basis of research that includes a limited number of patients with ICH. Given this, we aimed to evaluate the safety and efficacy of PCCs for factor Xa inhibitor–related ICH in a large, multicenter cohort of patients. Methods: This was a multicenter, retrospective, observational cohort study of patients with apixaban- or rivaroxaban-related ICH who received PCCs between January 1, 2015, and March 1, 2019. The study had 2 primary analysis groups: safety and hemostatic efficacy. The safety analysis evaluated all patients meeting inclusion criteria for the occurrence of a thrombotic event, which were censored at hospital discharge or 30 days after PCC administration. Patients with intracerebral, subarachnoid, or subdural hemorrhages who had at least 1 follow-up image within 24 hours of PCC administration were assessed for hemostatic efficacy. The primary efficacy outcome was the percentage of patients with excellent or good hemostasis on the basis of the modified Sarode criteria. Secondary outcomes included an evaluation of in-hospital mortality, length of stay, infusion-related reactions, and thrombotic event occurrence during multiple predefined periods. Results: A total of 663 patients were included and assessed for safety outcomes. Of these, 433 patients met criteria for hemostatic efficacy evaluation. We observed excellent or good hemostasis in 354 patients (81.8% [95% CI, 77.9–85.2]). Twenty-five (3.8%) patients had a total of 26 thrombotic events, of which 22 occurred in the first 14 days after PCC administration. One patient had documentation of an infusion-related reaction. For the full cohort of patients, in-hospital mortality was 19.0%, and the median intensive care unit and hospital lengths of stay were 2.0 and 6.0 days, respectively. Conclusions: Administration of PCCs after apixaban- and rivaroxaban-related ICH provided a high rate of excellent or good hemostasis (81.8%) coupled with a 3.8% thrombosis rate. Randomized, controlled trials evaluating the clinical efficacy of PCCs in patients with factor Xa inhibitor–related ICH are needed.

Introduction: The availability of rapid tissue and vessel imaging for TIA has increased, but the utilization rates of these and other diagnostic and management strategies for TIA over time are unknown. Objective: To investigate trends in TIA diagnostic and management strategies over time in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS). Methods: The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio and Northern Kentucky. For this study, all physician-adjudicated, first-ever cases of TIA (defined clinically as sudden onset of focal symptoms lasting < 24 hours) presenting to an emergency department over five study periods (1993/4, 1999, 2005, 2010, 2015) were included. Use of AHA-recommended aspects of TIA management as well as disposition of TIA patients (admission to hospital or discharge from ED) and length of stay were compared across study periods. Rates of acute infarct on MRI were also reported. Trends were examined using the Cochran-Armitage test for trend. Results: In total, over all study periods, there were 2251 first-ever TIAs. Overall, 14% (n=311) occurred in Black individuals, and 57% (n=1275) occurred in women. Utilization of diagnostic modalities [non-contrast CT brain, vascular imaging (CTA, MRA, or carotid dopplers), tissue imaging (MRI), and echocardiogram] increased significantly over time (all p Conclusions: The management of TIA has changed significantly over time. Utilization of tissue and vessel imaging as well as echocardiogram during the hospital stay has increased; in 2015, the vast majority of patients with TIA in this population-based study received each of these testing modalities and were admitted to a hospital for TIA work-up. Further work is needed to understand the best practices for work-up of suspected TIA.

Background: Substantial practice variability exists with respect to the diagnostic workup and disposition of patients with TIA. Identifying the workup needed to prevent adverse outcomes is critical. We aimed to determine whether there is an association between specific elements of TIA management and outcomes. Methods: The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio/ Northern Kentucky. For this study, all physician adjudicated, first-ever TIAs (clinically defined as sudden onset, focal neurologic symptoms lasting < 24 hours, with or without MRI correlate) presenting to the ED during 2015 were included; those with prior stoke or TIA were excluded. Multivariable logistic regression was performed to investigate associations between specific aspects of TIA management and an adverse outcome, defined as stroke, recurrent TIA, or all-cause mortality within 30 days, adjusted for demographics, co-morbidities, and symptom type and length as classified in the ABCD2 score. Results: In 2015, there were 477 adjudicated first ever TIA events presenting to the ED. Overall, 13% (n=62) occurred in Black individuals and 51% (n=243) in women. Regarding outcomes, 3% (n=16) had a stroke within 30 days, 6% (n=30) had a recurrent TIA within 30 days, and 1% (n=4) died within 30 days (all-cause mortality). 16.4% had acute infarct on MRI. In multivariable analysis, having an MRI was associated with reduced risk of adverse outcome, while performance of vessel imaging, echocardiogram, or admission to hospital were not significantly associated with outcomes (Table). Conclusions: Among common diagnostic and management strategies for TIA, only performance of MRI was associated with a lower likelihood of having an adverse outcome within 30 days. Possible contributors include variability in care between hospitals with differing MRI performance rates and changes in management of risk factors based on MRI results, though further work is needed.

Background: Functional outcomes are improved when AIS patients receive faster treatment. The first medical contact for many AIS patients is with emergency medical services (EMS) providers. We hypothesize that AIS treatment is faster when EMS providers suspect stroke. Methods: We performed a retrospective analysis of the Greater Cincinnati/Northern Kentucky Stroke Study, a comprehensive study of stroke patients in a large geographical area with 1.3 million inhabitants whose demographics are representative of the United States. We compared AIS patients age ≥18 years transported by EMS in 2015 with an EMS impression of “stroke” or “weakness/numbness” to those with other EMS impressions. Primary outcome was thrombolysis rate, and secondary outcomes were times from EMS scene arrival to ED arrival, CT, and treatment and times from ED arrival to CT and treatment. Chi-square and Mann-Whitney U-tests were used to compare treatment rates and times, respectively. Logistic regression (for rates) and median regression (for times) adjusted for NIHSS, GCS, age, sex, race, and prior stroke history. Results: Among 2,486 confirmed AIS patients from 1/1/2015-12/31/2015, 868 were transported by EMS, including 595 (69%) with EMS suspected stroke. Compared to EMS non-suspected strokes, patients with EMS suspected stroke patients were more likely to receive thrombolysis (18% vs 8%; OR 2.67, 95% CI 1.63-4.47) and had faster prehospital transport (30 vs 32 min, p=0.02), ED arrival to CT (27 vs 46 min, p Conclusions: In a large population-based study, EMS stroke identification is associated with a higher rate of and faster thrombolysis. Efforts to increase accuracy of EMS stroke identification is likely to have significant clinical impact by shortening treatment times.

Introduction: Elevations in troponin (cTn) are common in patients with acute ischemic stroke, yet their significance remains uncertain. Hypothesis: Elevated cTn at the time of acute ischemic stroke is associated with ischemic stroke recurrence. Methods: We included all adult patients with acute ischemic stroke who were residents of the Greater Cincinnati/Northern Kentucky region and who presented to an emergency department (ED) in 2015 and who had a cTn measured within 24 hours of ED arrival. Our exposure variable was an elevated cTn, defined as a value exceeding the laboratory’s 99 th percentile. Our primary outcome was ischemic stroke recurrence, defined as a new ischemic stroke with radiographic confirmation in the 3 years following the index ischemic stroke event. Cox proportional hazards model was used to evaluate the association between elevated cTn and ischemic stroke recurrence while adjusting for demographics, vascular risk factors, and stroke severity. In a secondary analysis, we excluded patients with a concomitant adjudicated myocardial infarction (MI) at the time of the index ischemic stroke. Results: Among 2,334 patients with acute ischemic stroke, 1,992 (85%) had a cTn assay within 24 hours of ED arrival and were included in the analysis. 402 (20%) patients had an elevated cTn and 259 (13%) patients had a recurrent ischemic stroke. 66 (3%) patients had an elevated cTn and a concomitant acute MI and 336 (17%) patients had an elevated cTn without a concomitant acute MI. After adjustment for demographics, vascular risk factors, and stroke severity, we found an association between elevated cTn and recurrent ischemic stroke (hazards ratio [HR], 1.5; 95% CI, 1.1-2.0). Our results were unchanged after excluding patients with a concomitant adjudicated MI (HR 1.4; 95% CI, 1.03-2.0). Conclusions: Among patients with acute ischemic stroke, elevated cTn even in the absence of concomitant adjudicated MI, was associated with ischemic stroke recurrence. Further mechanistic studies are necessary to explore the underlying etiology of hypertroponinemia among patients with acute ischemic stroke in order to guide targeted therapies to reduce stroke recurrence.

Introduction: After WARCEF, there is limited data about the epidemiology and treatment strategies for patients after an acute ischemic stroke (AIS) with existing or new left ventricular cardiomyopathy (CM) and sinus rhythm (SR). We aim to estimate prevalence, describe treatment practice, and analyze antithrombotic strategies. Methods: We calculated the prevalence of CM (ejection fraction or EF ≤40%) and SR among AIS patients with EF measurements and the frequency of anticoagulation upon discharge at Massachusetts General Hospital (MGH), Rhode Island Hospital (RIH), Yale-New Haven Hospital (YNHH), and the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS). We collected longitudinal outcome data for patients with AIS, CM, and SR at RIH and YNHH spanning 2014-2018 and computed the hazard of a combined outcome of AIS, intracranial hemorrhage, major hemorrhage, myocardial infarction, and death up to 12 months after AIS by anticoagulation status. Results: Of 11,996 AIS patients with documented EF at the 4 sites, 693 had CM and SR (MGH N=333/5481, GCNKSS N=250/3284, RIH N=30/1549, YNHH N=80/1682). The pooled percentage of AIS patients with CM and SR was 5% (95% C.I. 3-7%, I 2 =96.5%). Mean age was 67 years (SD 14.2), 47.1% were female, 31.9% had pre-stroke CM, and mean NIHSS was 7.1 (SD 7.1). Among survivors, 241 were discharged on anticoagulation, 326 on antiplatelet, and 38 on neither. There was heterogeneity by site in the proportion discharged with an anticoagulant versus an antiplatelet only (MGH 49.8%, GCNKSS 29.6%, RIH 32.3%, YNHH 36.7%, p Conclusions: AIS patients have concomitant cardiomyopathy and post-stroke antithrombotic prescription practice varies. Further study is needed to determine the association between post-stroke anticoagulation and subsequent ischemic and hemorrhagic events.

Background: Hemorrhagic transformation (HT) of ischemic stroke can have devastating consequences, leading to longer hospitalizations, increased morbidity and mortality. We sought to identify the rate of HT in stroke patients not treated with tPA within a large, biracial population. Methods: The GCNKSS is a population-based stroke epidemiology study from five counties in the Greater Cincinnati region. During 2015, we captured all hospitalized strokes by screening ICD-9 codes 430-436 and ICD-10 codes I60-I68, and G45-46. Study nurses abstracted all potential cases and physicians adjudicated cases, including classifying the degree of HT. Patients treated with thrombolytics were excluded. Incidence rates per 100,000 and associated 95% confidence intervals (CI) were estimated for HT cases, age and sex adjusted to the 2000 US population. Multiple logistic regression was used to examine risk factors associated with HT. Results: In 2015, there were 2301 ischemic strokes included in the analysis. Of these 104 (4.5%) had HT; 23 (22.1%) symptomatic, 55 (52.9%) asymptomatic and 26 (25%) unknown. Documented reasons for not receiving tPA in these patients were: time (71, 68.3%), anticoagulant use (1, 1.0%), other (18,17.3%) and unknown (14, 13.5%), which were not significantly different compared to those without HT. Only 29/104 (18.3%) had HT classified as PH-1 or PH-2. The age, sex and race-adjusted rate of HT was 9.8 (7.9, 11.6) per 100,000. The table shows rates of potential risk factors and the adjusted odds of developing HT. 90 day all-cause case fatality for patients with HT was significantly higher, 27.9% vs. 15.7%, p Conclusion: We found that 4.5% of non-tPA treated IS patients had HT. These patients had more severe strokes, were more likely to have abnormal coagulation tests or anticoagulant use, and were more likely to die within 90 days. We also report the first population-based incidence rate of HT in non-tPA treated of 9.8/100,000, a rate similar to the incidence of SAH.

Background: Hypertension is an important risk factor in the development of acute ischemic stroke (AIS). African American (AA) race is strongly associated with both hypertension and uncontrolled hypertension despite treatment, yet little is known about racial differences in presenting blood pressure (BP) in AIS. This study sought to describe differences in presenting BP and acute antihypertensive treatment between AA and white AIS patients who received and did not receive alteplase within a population. Methods: Using the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) database for years 2005, 2010 and 2015, we selected patients with a diagnosis of AIS using ICD-9/10 codes in adults ≥ 18 yrs of age presenting to a local ED within 4.5 hrs of symptom onset. Candidates were stratified by race and alteplase use. Socio-demographics, stroke risk factors, stroke severity, BP on arrival, and acute BP treatment were compared using chi-square, t-tests or Wilcoxon rank sum test, as appropriate. Results (Table 1): Of 1838 AIS patients included in the analysis, 392 (21%) received IV alteplase. AA patients were younger in both groups who received and did not receive alteplase. On presentation, AA stroke patients had higher diastolic BP. AA patients were more likely to receive 2 or more BP lowering medications compared to white patients in the alteplase treated group and the untreated group. Conclusion: AA patients presenting within 4.5 hours of AIS symptom onset are more likely to have elevated diastolic BP and to receive multiple BP lowering medications compared to white patients. These findings were significant regardless of alteplase treatment. To our knowledge, we report the first population-based distribution of BP, and medical treatment of BP, upon presentation to an ED in AIS. Further study is needed to determine if these racial differences in elevated BP and refractoriness of BP and/or aggressive treatment contribute to outcome differences.

Introduction: Patients without prior functional deficits who suffer mild stroke (NIHSS Methods: Hospitalized strokes from the Greater Cincinnati Northern Kentucky Stroke Study were used. Included patients had an initial NIHSS Results: Of 1268 ischemic strokes, 353 (28%) were functionally dependent at discharge. Increased baseline NIHSS was associated with worse outcome on the mRS. Leg, LOC questions, and sensation NIHSS subscores were the best predictors of outcome. Multivariable analysis identified age, race, hypertension, chronic kidney disease, heart failure, and post-stroke dysphagia as independently associated with discharge mRS ≥3. Discussion: Our results agree with and complement the results of prior studies. They are not limited by inclusion/exclusion criteria or referral bias. Rather, our major limitation is the retrospective estimation of NIHSS and mRS based on physician descriptive documentation rather than direct score assessment. Our results may allow for modeling to better predict outcome which in turn can inform clinical decision making and trial design.

Introduction: A main goal for hospital admission following acute ischemic stroke (AIS) is to establish the mechanism of stroke (MoS) allowing for patient specific secondary prevention of stroke interventions. We previously reported on diagnostic testing trends and MoS determination from 1993 through 2010. We updated this analysis with 2015 data to better understand the effects of trends in diagnostic testing on MoS determination. Methods: Patients with AIS aged > 20 years from all study time periods (Table) of the population based GCNKSS were included. Charts were abstracted in a systematic way for tests performed during the hospital stay. Only first-ever ischemic stroke cases, evaluated in an emergency department were used for this analysis. Stroke experts reviewed these events and adjudicated the mechanism of stroke according to modified TOAST criteria. We looked at and compared trends for testing and MoS. Results: Our analysis included 7226 patients. Basic patient demographics, MoS categories and tests across study periods are detailed in the Table. There were significant increases in EKG (7%), TTE (35%), TEE (7%), HCT (4%), brain MRI (65%), MRA (30%) and CTA (28%). Across study periods, cardioembolic (4.1%), small vessel disease (3%), large artery disease (0.9%) and other (1.5%) MoS increased while unknown MoS decreased (-9.5%). Discussion: From 1993/1994 to 2015 there has been a significant increase of in-hospital testing in AIS and decreases in undetermined MoS. Cardioembolic and small vessel disease MoS categories increased the most. Despite a significant increase in vessel imaging, large artery disease and “other determined” MoS categories are largely unchanged. Further research is required to elucidate the occult MoS underlying the undetermined category. Based on our analysis it appears unlikely to be significantly associated with our current definition of stroke associated with large artery disease defined as ≥ 50% ipsilateral stenosis.

Introduction: About 21% of acute ischemic stroke (AIS) patients present to medical attention with an elevated cardiac troponin (cTn). Previously, we described that elevated cTn is associated with an increased case-fatality at 1 year. However, it is not clear if there is a dose-dependent relationship between cTn and case-fatality, or if this effect is related to causes of death. Methods: Within a catchment area of 1.3 million we screened local hospital admissions using ICD-9/10 codes 430-436/I60-I68, G45-46 in 2014/2015, and ascertained all physician-confirmed AIS cases by retrospective chart review. Positive cTn was defined by the standard 99th percentile. To account for by hospital variance in cTn results in machine brands and normal ranges, cTn values were log-transformed and centered. Case fatality at 1 year and cause of death was obtained from the National Death Index database. Logistic regression evaluated the impact of cTn on case fatality, and included demographic and clinical risk factors in the model. The percentage with all-cause and cardiac/non-cardiac case-fatality was computed by quartiles of centered cTn levels and compared using the chi-square test. Results: In 2014/2015, there were 2989 AIS cases ascertained, which were 53% female, 30% black, with a mean age of 70 (SD 14). 441 patients with hypertropinemia were included in the analysis. See Table for case fatality at 1 year by quartile of centered cTn levels. There was no association between cTN and non-cardiac case-fatality. After adjustment for demographic and clinical characteristics, every 0.5 point increase in the centered cTn level increased the cardiac case-fatality by OR 1.19 (1.09, 1.31), p Discussion: We found that the impact of hypertropinemia on case fatality after AIS appears to be a dose-dependent association: as cTn increases, so does the cardiac case-fatality. This suggests that the degree of cTn elevation is likely an important prognostic marker for cardiac death in AIS patients.

Introduction: Most clinical research stopped during COVID due to possible impact on data quality and personnel safety. We aimed to assess the impact of COVID on study conduct at sites that continued to enroll patients during the pandemic. Methods: BEST-MSU is an ongoing study of Mobile Stroke Units (MSU) vs standard management of tPA eligible acute stroke patients in the pre-hospital setting. MSU personnel include a vascular neurologist via telemedicine, and a nurse, CT tech, and medics on board using appropriate PPE. During COVID, consent, 90 d mRS and EQ5D could be obtained by phone instead of in person, otherwise management was the same. We compared patient demographics, study metrics, and infection of study personnel during intra- vs pre-COVID eras. Results: Four of 6 BEST-MSU sites continued to enroll during COVID. There was no difference in intra- (n= 41) vs pre- (n= 763) COVID enrolled tPA eligible patients’ age, sex, race (45% vs 41% Black), ethnicity (23% vs 19% Hispanic), or NIHSS (12 vs 12). MSU alert frequency did not change, but percent of screened patients enrolled and treated with tPA declined to 12% from 23% (p Conclusion: Clinical research in the pre-hospital setting can be carried out accurately and safely during a pandemic. Study enrollment and tPA treatment rates declined, but otherwise there was no difference in patient demographics, deterioration of study processes, or serious infection of study staff.

Background:The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).Methods:The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year’s worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year’s edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.Results:Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.Conclusions:The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Most clinical research stopped during COVID due to possible impact on data quality and personnel safety. We aimed to assess the impact of COVID on acute stroke clinical trial conduct at sites that continued to enroll patients during the pandemic. BEST-MSU is an ongoing study of Mobile Stroke Units (MSU) vs standard management of tPA-eligible acute stroke patients in the pre-hospital setting. MSU personnel include a vascular neurologist via telemedicine, and a nurse, CT technologist, paramedics and emergency medicine technicians on-board. During COVID, consent, 90-day modified Rankin Scale (mRS) and EQ5D were obtained by phone instead of in-person, but other aspects of management were similar to the pre-COVID period. We compared patient demographics, study metrics, and infection of study personnel during intra- vs pre-COVID eras. Five of 6 BEST-MSU sites continued to enroll during COVID. There were no differences in intra- (n = 57) vs pre- (n = 869) COVID enrolled tPA eligible patients’ age, sex, race (38.6% vs 38.0% Black), ethnicity (15.8% vs 18.6% Hispanic), or NIHSS (median 11 vs 9). The percent of screened patients enrolled and adjudicated tPA eligible declined from 13.6% to 6.6% (p < .001); study enrollment correlated with local stay-at-home and reopening orders. There were no differences in alert to MSU arrival or arrival to tPA times, but MSU on-scene time was 5 min longer (p = .01). There were no differences in ED door to CT, tPA treatment or thrombectomy puncture times, hospital length of stay, discharge disposition, or remote vs in-person 90-day mRS or EQ5D. One MSU nurse tested positive but did not require hospitalization. Clinical research in the pre-hospital setting can be carried out accurately and safely during a pandemic. tPA eligibility rates declined, but otherwise there were no differences in patient demographics, deterioration of study processes, or serious infection of study staff. Trial registration: NCT02190500

INTRODUCTION: Previous studies have suggested that elevated neutrophils, monocytes, and neutrophil-to-lymphocyte ratio (NLR) may be associated with poor outcomes in intracerebral hemorrhage (ICH). We sought to determine if white blood cell (WBC) types were independently associated with poor outcome in ICH in a large cohort. METHODS: We performed a retrospective study of primary ICH at two academic centers. Cases were identified via ICD-9 code and verified via physician review. We included only those patients with WBC types obtained within 24 hours of ICH onset. RESULTS: We identified 593 patients with primary ICH and WBC differentials in the first 24 hours. Independent factors (OR, 95% CI) associated with 30-day case-fatality were age >80 (2.4 (1.4, 4.2)), p=0.0023; NIHSS greater than median (3.9 (2.4, 6.3)), p

Background and Purpose— Sex differences in stroke incidence over time were previously reported from the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study). We aimed to determine whether these differences continued through 2015 and whether they were driven by particular age groups. Methods— Within the GCNKSS population of 1.3 million, incident (first ever) strokes among residents ≥20 years of age were ascertained at all local hospitals during 5 periods: July 1993 to June 1994 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100 000 were adjusted for age and race and standardized to the 2010 US Census. Trends over time by sex were compared (overall and age stratified). Sex-specific case fatality rates were also reported. Bonferroni corrections were applied for multiple comparisons. Results— Over the 5 study periods, there were 9733 incident strokes (56.3% women). For women, there were 229 (95% CI, 215–242) per 100 000 incident strokes in 1993/1994 and 174 (95% CI, 163–185) in 2015 ( P P Conclusions— Overall stroke incidence decreased from the early 1990s to 2015 for both sexes. Future studies should continue close surveillance of sex differences in the 20- to 44-year and ≥85-year age groups, and future stroke prevention strategies should target strokes in the young- and middle-age groups, as well as intracerebral hemorrhage.

Background: We previously reported an increased incidence of stroke in the population with diabetes. This was particularly pronounced in those under 65 years of age. With guidelines now including glycemic monitoring during hospitalization, we examined incidence attributable to diabetes in 2010 and 2015. Methods: Ischemic strokes in the 5-county Greater Cincinnati/Northern Kentucky region were ascertained, then physician verified, at all 15 area hospitals using ICD-9 codes 430 to 436 or ICD10 codes I60 to I68. First ever ischemic strokes in patients aged 20 years and older were included in this analysis. Population age-specific rates of diabetes were estimated using the 2009-2010 and 2015-2016 NHANES databases, then applied to local population numbers, extracted from the US Census Bureau website, to estimate the denominator for calculation of incidence rates. Incidence rates were adjusted by age race and sex, as appropriate, to the 2010 US population. Diabetes was defined as reported in the electronic medical record or glycohemoglobin A1c &gt 6.4% during hospitalization. Results: There were a total of 4141 ischemic strokes; 55% female and 22% black. Stroke rates continue to be substantially higher in those with diagnosed diabetes, than those without diabetes overall and for those less than 65 years in both time periods, as well as those 65 years and older except for the black population in 2010. Racial disparities continue in both the less than 65 and 65 years and older age groups. Stroke rates were higher for Blacks in the less than 65 year age group for those both with and without diabetes; with risk ratios ranging from 1.3 to 2.7. Of note the stroke rate has decreased between 2010 and 2015 for those with diabetes Conclusions: The population with diabetes continues to be at increased risk of stroke, especially in those less than 65 years of age and those of black race.

Introduction: Data from the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) through 2010 showed that over time, stroke incidence rates decreased to a greater extent in men than in women. We aimed to determine whether this difference continued through 2015 and whether the differences are driven by particular age groups. Methods: Within the GCNKSS population of 1.3 million, all incident strokes among residents ≥20 years old were ascertained at all local hospitals during 7/93–6/94 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100,000 were adjusted for age and race, standardized to the 2010 U.S. Census. Trends over time by sex were compared (overall and age-stratified); a Bonferroni correction was applied for multiple comparisons. Results: In total over the five study periods, there were 9721 incident strokes (ischemic, ICH, and SAH); 56.4% were women. Incidence of ischemic strokes decreased from 254 (95%CI 236,272) in 1993/4 to 177 (95%CI 164,189) in 2015 among men (p Conclusions: Stroke incidence decreased between the early 1990s and 2015 for both sexes, contrary to previous data on trends through 2010 which demonstrated a significant decrease in men but not women. Temporal changes are being driven by the 65–84 year age group in both men and women, as well as the ≥ 85 age group in men. Future prevention strategies should target young and middle age adults for both sexes as well as those over 85 for women.

Background: Cerebellar lesions reportedly account for 2-7% of acute infarct visits, but this may be an underestimate since prior studies were not population-based or from the modern imaging era. Cerebellar symptoms are also often nonspecific such that increased MRI use might lead to a higher proportion of stroke due to cerebellar lesions. Details about presenting features of cerebellar infarcts and baseline medication use are also not well known. Methods: We used the 2010 Greater Cincinnati/Northern Kentucky Stroke Study. Strokes were identified by screening ICD9 codes 430-436 and physician verification. Infarct location was categorized as isolated cerebellar, mixed cerebellar (cerebellar plus ≥1 other location), or non-cerebellar. Isolated dizziness was defined as dizziness/vertigo without other focal symptoms. Atherosclerotic cardiovascular disease (ASCVD) 10-year risk scores were calculated. Descriptive statistics and multivariable logistic regression were used to compare infarct categories. Results: Isolated cerebellar lesions occurred in 4.6% (90/1940; 95% CI, 3.7%-5.7%) of infarct events. An additional 4% (77/1940; 95%CI, 3.1%-4.9%) were mixed cerebellar infarcts. Mixed cerebellar infarcts had clinical characteristics more similar to non-cerebellar events than to cerebellar events. The multivariable model found an association of isolated cerebellar infarct with low NIHSS (odds ratio [OR] 2.3, 95% CI 1.1-4.8) and any dizziness/vertigo (OR 5.1, 95% CI, 2.4-10.6), but not with isolated dizziness/vertigo, age, or sex. Median ASCVD scores were high in all infarct categories (21, interquartile range [IQR] 9-35 for isolated cerebellar; 32, IQR 15-42 for mixed cerebellar; 31, IQR 16-52 for all others). Both cerebellar and non-cerebellar strokes had a high frequency of baseline antiplatelet or anticoagulant use (52.1% vs 56.2%), whereas baseline statin therapy was less common in isolated cerebellar infarcts (34.1% vs 43.8%). Conclusions: This population-based study during the modern imaging era found that about 5% of stroke cases have isolated cerebellar infarcts and nearly 9% have any cerebellar infarct. Both cerebellar and non-cerebellar presentations have high baseline vascular risk and antiplatelet/anticoagulant use.

Objective: We sought to assess whether the proportion of stroke patients who utilized Emergency Medical Services (EMS) has changed over time in a population-based epidemiological study. Methods: Stroke and transient ischemic attack (TIA) patients were identified in a population of 1.3 million in the Cincinnati area from data in 1999, 2005, 2010, and 2015. Patient charts and EMS records were analyzed by research nurses and reviewed by study physicians. This analysis excluded strokes/TIAs that occurred while in a hospital, out of town, during EMS transport, or at unknown location. Patients with unknown EMS utilization, stroke severity, baseline pre-stroke disability, race, stroke type, or under age 18 were excluded. Proportion of EMS utilization by stroke patients was calculated and Cochran-Armitage Trend Test was used to analyze trends in EMS utilization over time. Multivariable logistic regression was used to determine the association between age, race, sex, prior stroke, stroke type, where the stroke occurred, stroke severity, and pre-stroke disability with EMS use. Results: In 1999, 2005, 2010 and 2015, 2968 of 3860, 2900 of 3643, 3010 of 3503, and 3327 of 3767 stroke cases were included, respectively. EMS use by stroke patients did not change significantly over time (52%, 51%, 52%, 53%, p=0.12 for trend). In 1999 and 2015, age, pre-stroke disability, stroke severity, hemorrhagic stroke and stroke occurring at work were significantly associated with EMS use. Race, sex, and prior stroke were not. Slight variation in associations occurred in 2005 and 2010, with stroke at work not reaching significance in 2005 and 2010, and pre-stroke disability not reaching significance in 2005. Conclusion: EMS use by stroke patients in our population did not change from 1999 to 2015. With the recent advances in treatment options for stroke, novel and effective approaches to increase EMS use are warranted.

Background: Although biologically plausible, epidemiological evidence linking exposure to methylmercury with increased risk of ischemic stroke is limited. The effects of methylmercury may be modified by selenium, which is an anti-oxidant that often co-exists with mercury in fish. Objectives: To examine the association between serum mercury levels with the incidence of ischemic stroke and to explore the possible effect modifications by serum selenium levels and demographic and geographic factors. Methods: A case-cohort study was designed nested in the REasons for Geographic and Racial Differences in Stroke cohort, including 662 adjudicated incident cases of ischemic stroke and 2494 participants in a randomly selected sub-cohort. Serum mercury was measured using samples collected at recruitment. Multivariable-adjusted hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) were estimated using the Barlow-weighting method for the Cox proportional hazards regression model. Results: No statistically significant association was observed between serum mercury concentration and the incidence of ischemic stroke (the highest vs. lowest quintile of mercury levels: HR = 0.82; 95% CI = 0.55–1.22; P for linear trend = 0.42). Sex (P for interaction = 0.06), but not serum selenium levels, modified the association; a more evident trend toward lower incidence of ischemic stroke with higher mercury levels was observed among women. Conclusion: This study does not support an association between mercury and the incidence of ischemic stroke within a population with low-to-moderate level of exposure. Further studies are needed to explore the possibility of mercury-induced ischemic stroke toxicity in other populations at higher exposure levels. Keywords: Mercury, Selenium, Ischemic stroke, Case-cohort study, REGARDS study

ObjectivesTo examine the association between urinary cadmium levels and the incidence of ischemic stroke and to explore possible effect modifications.MethodsA case-cohort study was designed nested in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, including 680 adjudicated incident cases of ischemic stroke and 2,540 participants in a randomly selected subcohort. Urinary creatinine–corrected cadmium concentration was measured at baseline. Multivariable-adjusted hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) were estimated with the Barlow weighting method for the Cox proportional hazards regression model.ResultsThe median urinary cadmium concentration was 0.42 (interquartile range 0.27–0.68) μg/g creatinine. After adjustment for potential confounders, urinary cadmium was associated with increased incidence of ischemic stroke (quintile 5 vs quintile 1: HR 1.50, 95% CI 1.01–2.22, p for trend = 0.02). The observed association was more pronounced among participants in the lowest serum zinc tertile (tertile 3 vs tertile 1: HR 1.82, 95% CI 1.06–3.11, p for trend = 0.004, p for interaction = 0.05) but was attenuated and became nonsignificant among never smokers (tertile 3 vs tertile 1: never smokers: HR 1.27, 95% CI 0.80–2.03, p for trend = 0.29; ever smokers: HR 1.60, 95% CI 1.06–2.43, p for trend = 0.07, p for interaction = 0.51).ConclusionsFindings from this study suggest that cadmium exposure may be an independent risk factor for ischemic stroke in the US general population. Never smoking and maintaining a high serum zinc level may ameliorate the potential adverse effects of cadmium exposure.

Background: We previously developed predictive models for 3-month mortality and modified Rankin Score (mRS) after ischemic stroke. Aim: The aim was to test model validity for 3-month mortality and mRS after ischemic stroke in two independent data sets. Methods: Our derivation models used data from 451 subjects with ischemic stroke in 1999 enrolled in the Greater Cincinnati/Northern Kentucky Stroke Study (GCKNSS). We utilized two separate cohorts of ischemic strokes through GCKNSS (460 in 2005 and 504 in 2010) to assess external validity by utilizing measures of agreement between predicted and observed values, calibration, and discrimination using Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis. Results: The 3-month mortality model performed well in the validation datasets with an average prediction error (Brier score) of 0.045 for 2005 and 0.053 for 2010 and excellent discrimination with an area under the curve of 0.86 (95% CI: 0.79, 0.93) for 2005 and 0.84 (0.76, 0.92) for 2010. Predicted 3-month mRS also performed well in the validation datasets with R2 of 0.57 for 2005 and 0.50 for 2010 and a root mean square error of 0.85 for 2005 and 1.05 for 2010. Predicted mRS tended to be higher than actual in both validation datasets. Re-estimation of the model parameters for age and severe white matter hyperintensity in both 2005 and 2010, and for diabetes in 2005, improved predictive accuracy. Conclusions: Our previously developed stroke models performed well in two study periods, suggesting validity of the model predictions.

BACKGROUND AND PURPOSE: Limited information is available regarding differences in neuroimaging use for acute stroke work-up. Our objective was to assess whether race, sex, or age differences exist in neuroimaging use and whether these differences depend on the care center type in a population-based study. MATERIALS AND METHODS: Patients with stroke (ischemic and hemorrhagic) and transient ischemic attack were identified in a metropolitan, biracial population using the Greater Cincinnati/Northern Kentucky Stroke Study in 2005 and 2010. Multivariable regression was used to determine the odds of advanced imaging use (CT angiography/MR imaging/MR angiography) for race, sex, and age. RESULTS: In 2005 and 2010, there were 3471 and 3431 stroke/TIA events, respectively. If one adjusted for covariates, the odds of advanced imaging were higher for younger (55 years or younger) compared with older patients, blacks compared with whites, and patients presenting to an academic center and those seen by a stroke team or neurologist. The observed association between race and advanced imaging depended on age; in the older age group, blacks had higher odds of advanced imaging compared with whites (odds ratio, 1.34; 95% CI, 1.12–1.61; P < .01), and in the younger group, the association between race and advanced imaging was not statistically significant. Age by race interaction persisted in the academic center subgroup (P < .01), but not in the nonacademic center subgroup (P = .58). No significant association was found between sex and advanced imaging. CONCLUSIONS: Within a large, biracial stroke/TIA population, there is variation in the use of advanced neuroimaging by age and race, depending on the care center type.

Background We aimed to compare sex-specific associations between cardiovascular risk factors and diabetes mellitus (DM) among patients with acute ischemic stroke (AIS) in the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS). Methods The GCNKSS ascertained AIS cases in 2005 and 2010 among adult (age ≥20 years) residents of a biracial population of 1.3 million. Past and current stroke risk factors were compared between those with and without DM using chi-square and multiple logistic regression to examine sex-specific profiles. Results There were 3515 patients with incident AIS; 1919 (55%) were female, 697 (20%) were black, and 1146 (33%) had DM. Among both women and men with DM, significantly more were obese, and had hypertension, high cholesterol, and coronary artery disease (CAD) compared with those without DM. For women with AIS, in multivariable sex-specific adjusted analyses, older age was associated with a decreased odds of having DM (aOR=0.88, 95%CI 0.80-0.98). For women with CAD, the odds of DM were increased (aOR=1.76, 95%CI 1.33-2.32). Age and CAD were not significant factors in differentiating the profiles of men with and without DM. Conclusions Women with DM had strokes at a younger age, whereas no such age difference existed in men. As opposed to men, women with DM were also more likely to have CAD compared with those without DM, suggesting a sex difference in the association between DM and vascular disease. These findings may suggest a need for more aggressive risk factor management in diabetic women.

Background and Purpose— Computed tomographic angiography and conventional angiography provide timely vascular anatomic information in patients with stroke. However, iodinated contrast dye may cause acute kidney injury (AKI). Within a large, biracial population, we examined in-hospital incidence of new or worsening kidney disease in patients with stroke and its association with administration of intravenous dye. Methods— All adult residents of the Greater Cincinnati/Northern Kentucky region with acute ischemic stroke or intracerebral hemorrhage who presented to an emergency department in 2010 were included. Prevalence of unsuspected kidney disease at the time of emergency department presentation and the incidence of AKI after admission in 2 groups of patients—those who did and those who did not receive intravenous dye—were determined. Results— In 2010, 2299 patients met inclusion criteria (89% ischemic stroke and 11% intracerebral hemorrhage); mean age 69 years (SD 15), 22% black, and 54% women. Among these patients, 37% had kidney disease at baseline, including 22% (516/2299) in whom this was unsuspected. Two percent (2%; 15/853) of patients with baseline kidney disease developed AKI during the hospital stay. Of those with no baseline kidney disease, 1% (14/14 467) developed AKI. There was no association between dye administration and new or worsening kidney disease. Conclusions— Although 22% of patients in the Greater Cincinnati/Northern Kentucky stroke population had unsuspected kidney disease, the incidence of new or worsening kidney disease was low, and AKI was not associated with dye administration. These findings confirm single-center reports that the risk of severe renal complications after contrast dye is small.

Background and Purpose Acute ischemic stroke (AIS) patients may benefit from endovascular thrombectomy (EVT) up to 24 h since last known normal (LKN). Advanced imaging is required for patient selection. Small or rural hospitals may not have sufficient CT technician and radiology support to rapidly acquire and interpret images. We estimated transfer rates using non-contrast head CT and stroke severity to select patients to be transferred to larger centers for evaluation. Methods We identified all AIS among residents of the study region in 2010. Only cases age ≥ 18 with baseline mRS 0–2 that presented to an ED were included. Among cases that presented between 6 and 24 h from LKN, those without evidence of acute infarct on head CT and with initial NIHSS ≥6 or ≥ 10 were identified. Results Of 1359 AIS cases, 448 (33.0%) presented between 6 and 24 h, of which 383 (85.5%) showed no evidence of acute infarct on CT. Of cases with no acute infarct on CT, 89/383 (23.2%) had NIHSS ≥6, of which 66 (74.2%) initially presented to a hospital without thrombectomy capabilities; and 51/383 (13.3%) had NIHSS ≥10, of which 40 (78.4%) presented to a non-thrombectomy hospital. Conclusions In our population, 40–66 AIS patients annually (0.8–1.3/week, or 3–5 patients/100,000 persons/year) may present to non-thrombectomy hospitals and need to be transferred using non-contrast CT and stroke severity as screening tools. Such an approach may sufficiently mitigate the impact of delays in treatment on outcomes, without overburdening the referring nor accepting hospitals.

Introduction: Intracerebral hemorrhage (ICH) has a high rate of morbidity and mortality and is typically classified as “lobar“ or “deep.“ While these terms describe ICH location, a more detailed examination of the relationship between supratentorial ICH location and clinical outcomes may guide clinician treatment plans and potentially predict survival rates. Methods: In this retrospective, single-center cohort study we identified patients with primary lobar ICH from 2009-2013. ICH due to trauma and structural etiologies were excluded. For patients with multiple ICHs, symptomatic location was determined via chart review. We compared demographic data, risk factors, ICH location and volume (ABC/2), clinical outcomes, and case-fatality rates and performed Cox regression analyses stratified by lobar location. Results: We identified 294 ICH patients, of which 94 were frontal (median volume 21.2 mL; IQR 10, 45), 65 temporal (21 mL; 8, 45), 75 parietal (17.2 mL; 7.5, 49), and 60 occipital (17.2 mL; 3.8, 26.3). There were no differences among locations in age (p=0.90), sex (p=0.87), IVH (p=0.22), anticoagulant use (p=0.41), or Charlson (p=0.43). There were significant differences in NIHSS across locations (p Conclusions: We found that occipital ICH was associated with lower 1-year case-fatality rates than ICH in other lobar locations independent of volume. While occipital ICH may be less likely to cause deficits associated with potentially life-threatening complications, these data suggest it may be important to separate lobar ICH mortality analyses by location to discern other characteristics of these hemorrhages and their relationships to outcomes.

Introduction: We previously reported that the incidence of stroke was decreasing for whites but stable for blacks from 1993/94 to 2005. We sought to describe recent temporal trends and racial disparities in stroke incidence within our large, bi-racial population, by including 2010 and preliminary data from 2015. Methods: The Greater Cincinnati/Northern Kentucky region includes two southern Ohio and three Northern Kentucky counties on the Ohio River, a population of 1.3 million representative of the US population in terms of sociodemographics and percent black race. Our study ascertained all hospitalized strokes that occurred in the population between 7/1/93 and 6/30/94 and in calendar years 1999, 2005, 2010 and 2015. For 2015, nursing review of medical records is complete but physician review is not; thus 2015 rates are preliminary. The denominator for the calculation of incidence rates (in those aged ≥20 years) was estimated from the U.S. Census Bureau website (www.census.gov). The 95% confidence intervals (CI) for the incidence rates were calculated assuming a Poisson distribution. Rates are age, sex, and race adjusted, as appropriate, and standardized to the 2010 U.S. population. Results: First-ever stroke incidence rates stratified by subtype, race, and study period are presented in the Table. We project that stroke incidence did not significantly change in 2015 vs. 2010 for either blacks or whites, regardless of stroke subtype. Blacks have a substantially higher incidence of stroke compared with whites in all study periods, without significant change in disparity over time. Discussion: In contrast to the significant decline in stroke incidence among whites from 1993-94 to 2005, we did not observe a statistically significant decrease in 2010 and 2015. This may be due to true stabilization of rates over time, or less statistical power to detect smaller declines. The substantial black/white racial disparity in stroke incidence has not changed over time.

Introduction: Blacks in the U.S. face twice the risk of ischemic stroke as whites, and this disparity is not fully explained by established stroke risk factors. Although atrial fibrillation (AF) is a major risk factor for stroke, blacks are less often diagnosed with AF than whites. It is unclear whether this paradox exists because AF is less thoroughly ascertained in blacks compared to whites or because blacks have less predisposing substrate and thus a truly lower risk of AF. Hypothesis: Based on our prior work, we hypothesized that black patients with ischemic stroke less often have left atrial enlargement, a major predisposing factor for AF. Methods: We compared left atrial size in black versus white patients in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of racial disparities in stroke incidence in a nationally representative population of 1.3 million. We obtained reports of echocardiograms performed for stroke evaluation among patients in the 2010 and 2015 study periods. Patients with known AF or atrial flutter were excluded. Investigators blinded to patients’ characteristics abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and left atrial diameter after adjustment for demographics, body mass index, and comorbidities. Results: Among 2,980 cases of ischemic stroke without AF, the median age was 66 years, 52% were female, and 30% were black. The overall mean left atrial diameter was 3.65 (±0.69) cm. Despite a higher burden of vascular risk factors and comorbidities, blacks had significantly smaller left atrial diameters (mean difference, -0.10 cm; 95% CI, -0.04 to -0.17 cm). This difference persisted after adjustment for demographics, comorbidities, and body mass index (adjusted mean difference, -0.15 cm; 95% CI, -0.09 to -0.21 cm). Conclusions: In a population-based sample, we found that black patients with ischemic stroke had smaller left atrial size than white patients. Our results suggest that the paradox of greater stroke risk but lower AF risk in blacks compared with whites at least partly stems from a lesser degree of AF substrate in blacks.

Introduction: The REGARDS study previously reported a lack of racial disparity in recurrent ischemic stroke (IS) events, despite large racial differences in incident IS. We sought to evaluate recurrent stroke rates at 1 year after an index ischemic (IS) or hemorrhagic (ICH and SAH) stroke or TIA within a large, biracial population representative of the US in terms of % blacks and sociodemographics with a large number of index events Methods: The Greater Cincinnati/Northern Kentucky Stroke Study ascertained all hospitalized strokes and TIAs among residents of a 5-county population of 1.3 million in 7/1/14-12/31/14 (blacks only) and 2015 (all residents), as well as recurrent strokes (but not TIAs) in 2016. One year risk of recurrent stroke was estimated by Kaplan-Meier analysis. Association between recurrent stroke and demographics/risk factors was assessed by proportional hazards analysis. Results: Among the 2014-15 cases, there were 3883 index events (2512 IS, 374 ICH, 92 SAH, 900 TIA, 5 unknown type). Median age was 70 (IQR 59, 81); 27% were black and 54% female. Recurrent events within 12 months of the index event occurred in 319 patients (276 IS, 38 ICH, 5 SAH). Those with recurrence were more likely black than those without (34% vs 27%, p Discussion: The risk of recurrent stroke was significantly associated with index event type and stroke risk factors (hypertension, diabetes, smoking, and prior stroke). Black race was not a significant independent predictor of recurrent stroke after adjusting for other known stroke risk factors.

Introduction: Previous data have shown worse post-stroke outcomes in women than men based on non-patient centered outcomes (modified rankin score (mRS)) obtained via patient contact. Our aim was to compare sex differences in post-stroke outcomes in a population-based cohort using patient-centered outcome measures obtained from the electronic medical record (EMR). Methods: Patients with ischemic stroke (IS) who presented to a single healthcare system (4 hospitals and outpatient facilities) in Northern Kentucky during 1/2015-12/2015, a subsample of the Greater Cincinnati Northern Kentucky Stroke Study, were included. Those who died prior to study time points were excluded. Cases of IS were ascertained by trained study nurses using ICD codes and EMR review. Outcomes (mRS and quality of life (EQ5D)) were estimated from EMR, a method previously shown to have good interrater agreement with telephone follow-up. EQ5D measures health-related quality of life across 5 dimensions. Utility weighted mRS (UW-mRS) were calculated by applying validated weights to mRS. Outcomes at 3- and 6-months were compared by sex using ordinal logistic regression for mRS and linear regression for UW-mRS and EQ5D, adjusted by demographics, pre-stroke mRS, stroke severity, and co-morbidities. Results: We included 382 cases; 51% were women, 94% were white. Women were older (median (IQR) 71 (61-81) vs. 66 (57-77)) than men, but pre-stroke mRS was similar (median (IQR) 1 (0-3) vs. 1 (0-2)). NIHSS was similar by sex (median 3 IQR (1-6) vs. 2 (1-5)). After adjustment, 3- and 6-month outcomes were similar by sex. Conclusions: In our cohort, sex differences in unadjusted outcomes may be related to age, pre-stroke functional status, co-morbidities, and depression, as differences were not present in adjusted models. Relatively minor strokes in our cohort may also explain similar outcomes by sex. Future studies should strive to identify intervenable targets to improve patient-centered outcomes post-stroke.

Introduction: Previously, we reported that stroke incidence in the young (age < 55) significantly increased in both blacks and whites over four study periods between 1993 and 2010. Here we further describe this temporal trend, adding data from 2015. Methods: The Greater Cincinnati/Northern Kentucky region includes 2 southern Ohio and 3 contiguous Northern Kentucky counties (estimated population, 1.3 M). Our study determined first-ever hospital-ascertained strokes that occurred in the population from 7/1/93 to 6/30/94 and in calendar years 1999, 2005, 2010, and 2015 by screening ICD9 (and ICD10, in 2015) codes of all inpatient and emergency department visits. Cases were abstracted by study nurses and verified by study physicians. Results for 2015 are preliminary. The denominator for the calculation of incidence rates (in those aged ≥20 years) was extracted from the U.S. Census Bureau website (www.census.gov). Age- and race -specific incidence rates with 95% confidence intervals (CI) were calculated assuming a Poisson distribution. We tested for differences in age trends using Student’s t-test, X 2 , and Poisson regression as appropriate. Results: The mean± SD age of stroke was 71.3±13.6 in 1993-94, 70.9±14.4 in 1999, 68.4±15.5 in 2005, 68.5±15.6 in 2010, and 68.7±15.4 in 2015 (p Discussion: The disturbing trend of increasing stroke in the young (age < 55) has leveled off slightly since 2010 but is still of great public health significance as younger strokes carry the potential for greater lifetime burden of disability. Further study is needed to determine the reasons for these results, including examination of race-specific trends.

Introduction: Previous studies have shown biases in screening for toxicologic substances among stroke patients but have limited generalizability. Our objective was to investigate predictors of the use of drug screens among stroke patients in a large population based study. Methods: The Greater Cincinnati Northern Kentucky Stroke Study is a population-based study of stroke cases ascertained from a biracial population of 1.3 million people in a 5-county region of southern Ohio/northern Kentucky. All hospital ascertained cases of stroke (ischemic (IS), transient ischemic attack (TIA), hemorrhagic (ICH), subarachnoid hemorrhage (SAH)), occurring during calendar year 2015 were included. Trained study nurses abstracted data on whether a drug screen was ordered (between emergency department (ED) presentation and hospital discharge). Screening tests for alcohol were not included. Multivariable logistic regression was used to identify predictors of use of a drug screen. Potential predictors were patient sex, age, race, select comorbidities, smoking status, stroke severity (NIHSS), treatment location and stroke type. Results: Of 3865 stroke cases (53.8% women, 20.8% black, mean age 69.7(14.8) years), 12.0% had a drug screen performed. Adjusted, black race (aOR 1.93 95%CI 1.52-2.44), current smoking (aOR 1.97 95%CI 1.58-2.47), higher NIHSS (aOR 1.22 95%CI 1.15-1.28 per 5 unit increase) and being treated in an academic ED (aOR 2.04, 95%CI 1.62-2.55) increased the likelihood of a drug screen, while female gender (aOR 0.75 95%CI 0.60-0.93) and older age (aOR 0.61 per 10 years, 95%CI 0.56-0.66) decreased the likelihood. Conclusions: In a large population based study of stroke patients, drug screens were more likely to be ordered in men, blacks, smokers, younger patients, and those seen in academic EDs. It is unknown whether these trends are similar among hospitalized patients with other diagnoses. Additionally, current evidence suggests that such differential testing may lead to missed counselling opportunities in those not tested as well as lower likelihood of thrombolytic treatment in those who are tested. Future research should investigate the yield of such drug screens and explore whether guidelines in ordering drug tests could help to avoid testing biases.

Objective: To update trends on documented substance abuse among young adults (18-54 years old) with stroke within the Greater Cincinnati/Northern Kentucky Stroke Study population, to include preliminary results from 2015. Background: Substance abuse is associated with stroke. In our population, we previously reported increases in overall substance abuse, smoking history, and use of alcohol or drugs >Design/Methods: Using ICD-9 discharge codes 430-436, potential acute stroke events are identified among 18- to 55-year-old residents of the 5 county study region. Five one-year study periods are included (7/93-6/94, 1999, 2005, 2010, 2015). Study nurses abstract all events which then undergo physician review. We searched for trends in smoking history, illicit drug use, heavy alcohol consumption, overall substance abuse (current smoking, alcohol, and illicit drug), and urine/blood test positive for alcohol or illicit drugs at presentation. Results: There were 2220 stroke events (75 % ischemic). Sex and age distribution remained stable; however, percent black increased from 35% to 46% between 1993/94 and 2015, as did the proportion of ischemic strokes (74% to 77%). Current smoking and alcohol use remained stable while illicit drug use increased significantly overall and within the age subgroups of 18-34 years and 35-54 years (see table). Conclusions: Illicit drug use continues to increase among young adults with stroke. Even though the possibility of testing bias needs to be explored further, our reported results are likely an under estimation of true rates as there are no readily available tests for new designer drugs which have become more available since the early 2000’s. Future analysis will also focus on the relationship between our findings and the U.S. opioid epidemic.

Objective:To characterize the pattern of urine drug screening in a cohort of intracerebral hemorrhage (ICH) patients at our academic centers.Methods:We identified cases of primary ICH occurring from 2009 to 2011 in our academic centers. Demographic data, imaging characteristics, processes of care, and short-term outcomes were ascertained. We performed logistic regression to identify predictors for screening and evaluated preguideline and postguideline reiteration screening patterns.Results:We identified 610 patients with primary ICH in 2009–2011; 379 (62.1%) were initially evaluated at an outside hospital. Overall, 142/610 (23.3%) patients were screened, with 21 positive for cocaine and 3 for amphetamine. Of patients p = 0.0009). In the best multivariable model, age group (p = 0.0001), black race (p = 0.4529), first Glasgow Coma Scale score (p = 0.0492), current smoking (p < 0.0001), and age group × black race (p = 0.0097) were associated with screening. Guideline reiteration in 2010 did not improve the proportion p = 0.01).Conclusions:We found disparities in drugs of abuse (DOA) screening and suboptimal guideline adherence. Systematic efforts to improve screening for DOA are warranted. Improved identification of sympathomimetic exposure may improve etiologic classification and influence decision-making and prognosis counseling.

Background Although statin therapy is associated with reduced stroke and mortality risk, some studies report that higher lipid levels are associated with improved outcomes following ischemic stroke. Aims We examined the association of hyperlipidemia (HLD) combined with statin therapy on all-cause mortality in stroke patients. Methods All stroke patients in the Greater Cincinnati Northern Kentucky region of ∼1.3 million were identified using ICD-9 discharge codes in 2005 and 2010. Stroke patients with and without HLD were categorized based on their reported statin use at baseline or discharge into three groups: no-HLD/no-statins, HLD/no-statins, and HLD/on-statins. Cox proportional hazards model was used to estimate the risk of mortality at 30 days, 1 year, and 3 years poststroke. Results Overall, 77% (2953) of the 3813 ischemic stroke patients were diagnosed with HLD and 72% ( n = 2123) of those patients were on statin medications. The mean age was 70.0 ± 14.6 years, 56% were women, and 21% were black. In adjusted analyses, the HLD/no-statins group showed 35% (adjusted hazard ratio (aHR) = 0.65, 95% CI: 0.46–0.92), 27% (aHR = 0.73, 95% CI: 0.59–0.90), and 17% (aHR = 0.83, 95% CI: 0.70–0.97) reduced risk of mortality at 30 days, 1 year, and 3 years, respectively, poststroke, compared with no-HLD/no-statins group. The HLD/on-statins group showed an additional 17% significant survival benefit at 3 years poststroke compared with HLD/no-statins group. Conclusions A diagnosis of HLD in ischemic stroke patients is associated with reduced short- and long-term mortality, irrespective of statin use. Statin therapy is associated with significant, additional long-term survival benefit.

Automated interactive voice response (IVR) call systems can provide systematic monitoring and self-management support to depressed patients, but it is unknown if stroke patients are able and willing to engage in IVR interactions. We sought to assess the feasibility and acceptability of IVR as an adjunct to post-stroke depression follow-up care. The CarePartner program is a mobile health program designed to optimize depression self-management, facilitate social support from a caregiver, and strengthen connections between stroke survivors and primary care providers (PCPs). Ischemic stroke patients and an informal caregiver, if available, were recruited during the patient's acute stroke hospitalization or follow-up appointment. The CarePartner program was activated in patients with depressive symptoms during their stroke hospitalization or follow-up. The 3-month intervention consisted of weekly IVR calls monitoring both depressive symptoms and medication adherence along with tailored suggestions for depressive symptom self-management. After each completed IVR call, informal caregivers were automatically updated, and, if needed, the subject's PCP was notified. Of the 56 stroke patients who enrolled, depressive symptoms were identified in 13 (23 %) subjects. Subjects completed 74 % of the weekly IVR assessments. A total of six subjects did not complete the outcome assessment, including two non-study-related deaths. PCPs were notified five times, including two times for suicidal ideation and three times for medication non-adherence. Stroke patients with depressive symptoms were able to engage in an IVR call system. Future studies are needed to explore the efficacy of an IVR approach for post-stroke self-management and monitoring of stroke-related outcomes.

Each chapter listed in the Table of Contents (see next page) is a hyperlink to that chapter. The reader clicks the chapter name to access that chapter. Each chapter listed here is a hyperlink. Click on the chapter name to be taken to that chapter. Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together in a single document the most up-to-date statistics related to heart disease, stroke, and the cardiovascular risk factors listed in the AHA’s My Life Check - Life’s Simple 7 (Figure1), which include core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure [BP], and glucose control) that contribute to cardiovascular health. The Statistical Update represents …

Objective 1) To develop a machine learning approach for detecting stroke cases and subtypes from hospitalization data, 2) to assess algorithm performance and predictors on real-world data collected by a large-scale epidemiology study in the US; and 3) to identify directions for future development of high-precision stroke phenotypic signatures. Materials and methods We utilized 8,131 hospitalization events (ICD-9 codes 430–438) collected from the Greater Cincinnati/Northern Kentucky Stroke Study in 2005 and 2010. Detailed information from patients’ medical records was abstracted for each event by trained research nurses. By analyzing the broad list of demographic and clinical variables, the machine learning algorithms predicted whether an event was a stroke case and, if so, the stroke subtype. The performance was validated on gold-standard labels adjudicated by stroke physicians, and results were compared with stroke classifications based on ICD-9 discharge codes, as well as labels determined by study nurses. Results The best performing machine learning algorithm achieved a performance of 88.57%/93.81%/92.80%/93.30%/89.84%/98.01% (accuracy/precision/recall/F-measure/area under ROC curve/area under precision-recall curve) on stroke case detection. For detecting stroke subtypes, the algorithm yielded an overall accuracy of 87.39% and greater than 85% precision on individual subtypes. The machine learning algorithms significantly outperformed the ICD-9 method on all measures (P value

Background: Wake-up stroke (WUS) accounts for a quarter of all ischemic strokes. Its conspicuous occurrence during sleep suggests that WUS may be associated with obstructive sleep apnea (OSA). We investigated the potential association among WUS, OSA, and measures of sympathetic hyperactivity. Methods: This is a cross-sectional analysis of data from the Sleep Apnea in Transient Ischemic Attack and Stroke (SLEEP TIGHT) study. Ischemic stroke patients were divided into WUS and non-WUS groups. Participants underwent polysomnography and ambulatory blood pressure monitoring. Collected data included demographic, medical, stroke characteristics (including severity by National Institutes of Health Stroke Scale), cholesterol, serum catecholamines, C-reactive protein, interleukin-6, B-type natriuretic peptide, blood pressure, and polysomnographic (apnea-hypopnea index (AHI); measures of hypoxia). Because both stroke and OSA affect men and women to varying degrees, the cohort was considered as a whole and by gender stratification. Results: Among 164 participants, 30.3% had WUS. The mean age was 62.0 ± 11.3 and the mean body mass index was 30.2 ± 7.9 kg/m2. One-hundred-and-five participants (63.6%) were males and 92 participants (56.8%) were Caucasian. Neither AHI nor OSA (AHI ≥5) frequency differed between WUS and non-WUS groups. Men tended to be more likely than women to have WUS (74.0 vs. 59.6%; p = 0.08), but this was not statistically significant. In gender-stratified analyses, men with WUS compared to men with non-WUS had significantly higher rates of severe OSA (AHI >30: 45.0 vs. 17.6%; p = 0.03) and tended toward more 3% oxygen desaturation events (57.0 ± 63.9 vs. 31.8 ± 22.9; p = 0.06). These differences were not seen in women. WUS patients tended to be of the male gender (74.0 vs. 59.6%; p = 0.08). History of stroke, hypertension, diabetes, dyslipidemia, or atrial fibrillation, serum catecholamines, and inflammatory biomarkers was no different between the groups. Low-density lipoprotein (LDL) was significantly higher in WUS (114.5 ± 36.3 vs. 101.4 ± 37.6; p = 0.04). Baseline diastolic blood pressure (DBP) was significantly greater in the WUS group. There was no difference in systolic or ambulatory blood pressure (including nighttime blood pressure) between WUS and non-WUS groups. Conclusions: WUS may be associated with severe OSA with more oxygen desaturation in men but not in women. WUS may be associated with high DBP and increased LDL cholesterol.

Introduction: Hyperacute injury marker (HARM) is extrahematomal CNS barrier disruption in ICH marked by enhancement on post-gadolinium FLAIR sequences. We sought to identify factors associated with HARM development over time in a prospective ICH pilot study. Methods: We conducted a longitudinal MRI-based study of primary ICH with images at baseline and 90 days. After excluding subjects without post-gadolinium FLAIR sequences and those without usable images, we evaluated HARM formation along with other MRI markers of vasculopathy, including microbleeds, lacunes, white matter disease, cortical superficial siderosis, and enlarged perivascular spaces. HARM severity was scored as 0 (absent), 1 (1 to 3 sulci affected across fewer than 10 slices), 2 (dispersed involvement; more than 3 sulci), or 3 (widespread, confluent involvement over the hemisphere). Imaging review was blinded to clinical variables. Univariate analyses were performed at both time points. Results: Of 29 subjects with usable baseline sequences, 11 (37.9%) had HARM, compared to 12/18 (66.7%) at 90 days. Twelve subjects had usable sequences at both time points, and 4 (33%) of these had HARM at both time points. HARM was most frequently noted in the temporal and occipital lobes. At baseline, HARM severity was 1 in 7 subjects, 2 in 2 subjects, and 3 in 2 subjects. At 90 days, HARM severity was 1 in 10 subjects, 2 in 1 subject, and 3 in 1 subject. HARM was distinct from parenchymal T1 enhancement on visual inspection. We did not identify statistically significant associations between HARM formation and subject demographics, vascular risk factors, hematoma characteristics, or MRI markers of vasculopathy. Conclusions: In this pilot study we found a high prevalence of HARM at baseline and 90 days. Future studies will examine whether HARM is associated with the formation of new CNS lesions or poor outcomes. HARM appears to be a second type of CNS barrier disruption and may represent a therapeutic target.

Introduction: There is conflicting evidence on the association of antiplatelet (AP) use prior to admission with baseline ischemic stroke (IS) severity. We evaluated this association within a large, bi-racial population. Methods: We identified all hospital-ascertained cases of IS that occurred in 2010 (including ED arriving, direct admits, and in-hospital strokes) within a population of 1.3 million. Specific AP used prior to presentation for IS were aspirin, clopidogrel, dipyridamole, prasugrel, and cilostazol. We excluded those on an anticoagulant (AC) medication for this analysis. Baseline IS severity was defined as NIH stroke scale score (NIHSS) on admission. A multivariable linear regression model including demographic and clinical variables with log-transformed NIHSS as the dependent variable was used to evaluate the effect of prior AP use on stroke severity (results shown as percentage change in NIHSS). Results: In 2010, there were 2259 IS cases, of which 1982 (22% black, 55% female, median age 70 years [58, 81]) were included in the analysis, and 998 (50%) had history of prior AP use. Unadjusted, minor stroke (NIHSS ≤5) was slightly less common in those with prior AP use compared with those without (68% vs. 72%; p=0.04). In the multivariable model among patients with history of atrial fibrillation (AF) yet not on AC, a significant 23% reduction in NIHSS (average NIHSS 6.00 to 4.88, p=0.02) was seen in those with prior AP use. No such association was found in patients with no history of AF. The table displays the multivariable model of stroke severity. Conclusion: We found that prior AP use did not have significant association with baseline stroke severity in the multivariable analysis. However, a subgroup of patients with history of AF had significantly less severe strokes with prior antiplatelet use.

Introduction: Undiagnosed RF (URF) are a missed opportunity for primary stroke prevention. We sought to determine the prevalence of URF (RF newly diagnosed during inpatient evaluation) among first-ever ischemic stroke (IS) cases within a large, bi-racial population. Methods: Within the population-based Greater Cincinnati/Northern Kentucky (GCNK) stroke study catchment area of 1.3 million, we ascertained all hospitalized first-ever acute IS in 2010 among individuals ≥20 years old through screening of ICD-9 codes 430-436, with all cases verified by study physicians. We evaluated the prevalence of undiagnosed diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), and atrial fibrillation (AF) among all IS patients and those with each risk factor. We also evaluated the association between URF and insurance status (private, Medicaid/Medicare, or uninsured) for each RF using chi-square tests. Results: There were 1737 first-ever IS cases in the GCNK region in 2010 (55.8% female, 19.5% black, median age 71). Of these, 21% had at least one URF (Table), most commonly HLD (13%) or HTN (6%). Among patients with a given risk factor, 21% of those with HLD, 13% with AF, 9% with DM, and 7% with HTN were undiagnosed prior to inpatient evaluation for first-ever IS. Uninsured individuals (48%) were significantly more likely than those with private (22%) or government (20%) insurance to have at least one URF. Conclusions: One in five IS patients had at least one URF upon presentation with their first-ever stroke, and URF were more prevalent among uninsured individuals. Our data reinforce the importance of screening for URF during IS evaluation and highlight the importance of earlier detection of treatable RF. Future research should evaluate factors that may predict URF, such as insurance status, race, or sex.

Introduction: Stroke incidence may be decreasing more in men than in women over time, perhaps due to sex differences in risk factor (RF) severity. We sought to investigate potential sex differences in the severity of ischemic stroke (IS) RFs. Methods: We identified all incident IS in 2010 by screening all local hospital ICD-9 codes 430–436 among residents of the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) region, a biracial population of 1.3 million. Relevant information was extracted from the medical record, including 4 IS RFs: hypertension (HTN), hyperlipidemia (HL), diabetes (DM), and body mass index (BMI). Only hospitalized incident stroke cases were included. RF severity in women vs. men was compared using multivariable analysis adjusted for age, race, insurance status, and poverty status (whether patient lived in an area with ≥ 20% below the poverty line). Severity of respective RFs were assessed using systolic blood pressure at 24 hours and presence of left ventricular hypertrophy (LVH) on ECG or echocardiogram (for HTN), Hemoglobin A1c (HbA1c) (for DM), and total cholesterol (TC) and LDL levels (for HL). For HTN-, HL-, and DM-specific analyses of severity only IS patients with pre-existing diagnoses as determined by their medical record were included. For BMI, all IS patients were included. Results: A total of 1737 patients met eligibility; 55.8% were women, and 19.6% were black. After adjusting for age, race, insurance status, and poverty, women had TC levels and mean BMIs that were significantly higher than men (Table). LDL levels among those with HL, likelihood of having LVH in those with HTN, and mean HbA1c in those with DM were similar between sexes. Conclusions: Among adults with IS in the GCNKSS, RF severity was similar by sex apart from small differences in BMI and TC. Future directions for research include possible sex differences in RF severity in incident vs. recurrent stroke, in RF severity after adjusting for medication use, and undiagnosed RFs.

Introduction: There is a trend towards ischemic stroke (IS) occurring at younger ages. We sought to better characterize outcomes and mortality over 3 years by age at time of stroke within a large, biracial population. Methods: Incident IS were ascertained during the 2005 and 2010 study periods of our population based epidemiology study via ICD-9 codes 430-436. Research nurse coordinators performed medical record abstraction on all potential events, which were then adjudicated by study physicians as case/not a case. Abstractions included discharge or 30-day outcomes (if available) as measured by modified Rankin scale (mRS). Mortality for IS events out to 3 years was determined via all available information including the Social Security Death Index. We compared the outcomes and post-stroke mortality by 20-55 (young stroke) versus >55 years, and by decade. Descriptive statistics are reported as n (%), and mean (SD) or median (25 th and 75 th %ile) as appropriate. The primary analysis examined the effect of age, race and sex using regression, life table and proportional hazards models. Results: Results are shown in the table. IS in the young occurred more frequently among black cases. The median rNIHSS was 3 although the NIHSS distribution trended towards more severe IS in the older age group. Young strokes had lower baseline and 30-day mRS. The mortality rate was greater in the older ages, at each time point and overall. After adjusting for race, sex and stroke severity the hazard ratio for lower survival in the strokes >55 years old was 4.03 (95% CI 3.15, 5.17). Conclusion: IS patients < 55 years old are less likely to die after stroke. Young stroke occurs in demographically different populations than older strokes and this group would benefit from further study.

Introduction: Previously we reported that ischemic stroke incidence is declining over time for men but not women. We sought to describe temporal trends of sex differences in TIA incidence within a large, biracial population. Methods: Among the biracial population of 1.3 million in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS) region, all first-ever transient ischemic attacks (TIAs) among area residents (≥20 years old) were identified at all local hospitals. Out of hospital cases were ascertained using a sampling scheme. All cases were reviewed by study physicians. Sex-specific TIA incidence rates over time (during 7/93-6/94 and calendar years 1999, 2005, and 2010) were determined. Incidence rates were calculated using the age-, race-, and sex-specific number of TIAs divided by the population in that group; rates were standardized to the 2010 U.S. population. Statistical testing for differences over time was done using linear regression models adjusted for age and race. The delta method was used to estimate the ratio of female to male TIA incidence and the associated standard error (SE). Results: There were a total of 3203 patients with incident TIA; 54% were female, and 12% were black. Overall, mean age for men was 66 (SE 0.36) compared to 71 (SE 0.33) for women, p=0.01. Compared with men, women had lower rates of TIA in all 4 study periods, and TIA incidence rates were stable over time for women (p=0.19) and men (p=0.12). (See table). TIA patients were younger in 2010 than in 1993/4 and 1999 (P Conclusions: Within the GCNKSS population, women had lower TIA incidence rates than men. In contrast to what we have previously described in ischemic stroke incidence, neither the sex difference in incidence nor the sex-specific incidence rates are changing over time. Further research is needed to understand the drivers of higher TIA incidence in men and the lack of change in TIA incidence over time.