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Atrial fibrillation (AF) is an important risk factor for ischemic stroke resulting in a fivefold increased stroke risk and a twofold increased mortality. Our understanding of stroke mechanisms in AF has evolved since the concept of atrial cardiopathy was introduced as an underlying pathological change, with both AF and thromboembolism being common manifestations and outcomes. Despite the strong association with stroke, there is no evidence that screening for AF in asymptomatic patients improves clinical outcomes; however, there is strong evidence that patients with embolic stroke of undetermined source may require long-term monitoring to detect silent or paroxysmal AF. Stroke prevention in patients at risk, assessed by the CHA2DS2-VASc score, was traditionally achieved with warfarin; however, direct oral anticoagulants have solidified their role as safe and effective alternatives. Additionally, left atrial appendage exclusion has emerged as a viable option in patients intolerant of anticoagulation. When patients with AF have an acute stroke, the timing of initiation or resumption of anticoagulation for secondary stroke prevention has to be balanced against the risk of hemorrhagic conversion. Multiple randomized clinical trials are currently underway to determine the best timing for administration of anticoagulants following acute ischemic stroke.

AIMS Cannabis use has been reported as a risk factor for stroke. We systematically review the prevalence and outcomes of stroke in people with cannabis use. METHODS We searched MEDLINE and 6 other databases from inception to January 2020 for studies on the relationship between cannabis use and stroke. We followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) recommendations. Two independent reviewers extracted the data. Study quality was assessed by the Newcastle-Ottawa Scale for cohort and case-control studies. RESULTS Seventeen studies involving 3,185,560 people with cannabis use were included. Descriptive statistics demonstrated 18,676 (median 1.1%, interquartile range [IQR] 0.3%-1.3%) experienced stroke compared with 0.8% of those without use (Odds Ratio 1.17, 95% CI 1.10-1.25). Among people with cannabis use, median age was 26.2 years (IQR 25.2-34.3 years) and mostly male (median 57.8%). Of stroke subtypes, ischemic stroke was most prevalent (median 1.2%, IQR 0.4%-1.9%), followed by undefined stroke subtype (median 1.2%, IQR 1.1%-1.2%) and hemorrhagic stroke (median 0.3%, IQR 0.1%-0.6%). The majority of people with cannabis use who experienced stroke survived (median: 85.1%, IQR 83%-87.5%) and 64.0% of people experienced a good neurologic outcome, defined as modified Rankin Scale of 0 to 3. Few studies included outcomes of vasospasm or seizure. CONCLUSIONS In people with cannabis use, the prevalence of ischemic stroke and hemorrhagic stroke was 1.2% and 0.3%, respectively, higher than the prevalence of people without use (0.8% and 0.2%). There is insufficient information on timing, exposure, duration, and dose-responsive relationship.

Background: Decline in presentations of acute stroke during the early period of COVID-19 pandemic have been reported. We aimed to investigate the stroke presentations during the subsequent months as the pandemic evolved into a second wave. Methods: Data was obtained from a health system with 19 emergency departments (EDs) in northeast Ohio in the United States. Baseline period from January 1 to February 29, 2020, was compared with the individual months during COVID-19 period from March through July. Variables included were numbers of daily stroke alerts across the EDs, thrombolysis, thrombectomy, time to presentation, stroke severity, time from door-to-needle in thrombolysis, and door-to puncture in thrombectomy. The time periods were compared using nonparametric statistics and Poisson regression with month, weekend, and daily COVID cases as independent variables. Results: A total of 2264 stroke alerts from EDs were analyzed between January 1 to July 31, 2020. Total daily stroke alerts decreased from a median of 10 (interquartile range [IQR]:10-13) in January and February to 9 (IQR:6-11, p=0.001) in March, 8(IQR:7-10, p=0.0001) in April, 10 (IQR:8-11, p=0.04) in May, and returned similar to baseline in June (12, IQR:10-13, p=0.5) and July (13, IQR:11-14,p=0.1). In Poisson regression, stroke alert numbers showed no significant association with daily COVID-19 counts, but significant association with months, with rate ratios of 0.74 (95%CI 0.64-0.85) for March, 0.71 (95%CI 0.61-0.82) for April, and 0.86 (95%CI 0.75-0.98) for May, but not with June and July. Time to presentation and stroke severity were unchanged throughout the study period. Thrombolysis volume decreased in March and May but thrombectomy volume was unchanged. Conclusion: We observed a decrease in stroke presentations across emergency departments by about 30% during the early period of COVID-19 pandemic, followed by return to baseline frequency despite a second wave of COVID-19 cases.

BACKGROUND AND PURPOSE Ischaemic and hemorrhagic strokes are dreaded complications of infective endocarditis (IE). The timing of valve surgery for IE patients with stroke remains uncertain. The aim was to study perioperative neurological complications in relation to surgical timing. METHODS The study cohort consisted of patients diagnosed with acute IE from January 2010 to December 2016. Early surgery was defined as valve surgery within 14 days of IE diagnosis, and late surgery as after 14 days. Neurological complications that occurred within 14 days post-surgery were considered perioperative and classified as new ischaemic stroke or hemorrhagic stroke, expansion of an existing intracranial hemorrhage and new-onset seizures. Perioperative neurological complications were compared by surgical timing and other variables, including pre-surgical imaging. RESULTS Overall, 183 patients underwent valve surgery: 92 had early surgery at a median of 8 days (interquartile range 6-11); 91 had late surgery at a median of 28 days (interquartile range 19-50). Twenty patients (10.9%) had 24 complications: 11 ischaemic, six intraparenchymal hemorrhages, three subarachnoid hemorrhages (SAHs) and four new-onset seizures. Rates of neurological complications were similar for early and late surgery groups (10.9% vs. 11%). Enterococcal IE was more common amongst patients with perioperative neurological complications (35% vs. 12.3%, P

Background Early thrombolysis for acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) is associated with better clinical outcome. This is thought to be due to greater tissue salvage with earlier recanalization. We explored whether ultra-early administration of intravenous tissue plasminogen activator (IV tPA) within 60 min (Golden Hour) of symptom onset for AIS due to ELVO is associated with a higher rate of recanalization. Methods We performed a retrospective analysis of recanalization rates and clinical outcomes in patients with AIS due to ELVO treated with IV tPA, comparing patients who received IV tPA within 60 min of stroke symptom onset with those treated beyond 60 min. Results Between January 2013 and December 2016, 158 patients with AIS due to ELVO were treated with IV tPA. Of these, 25 (15.8%) patients received IV tPA within 60 min of stroke symptom onset, while the remaining 133 (84.2%) patients received IV tPA beyond 60 min. The ultra-early treatment group was found to have a higher rate of complete recanalization (28.0% vs 6.8%, 95% CI 1.78–16.63), better chance of early neurological improvement (76.0% vs 50.4%, 95% CI 1.16–8.65), favorable clinical outcomes (mRS ≤ 2 or return to premorbid mRS) (65.0% vs 36.8%, 95% CI 1.42–9.34), and lower mortality (5% vs 31.1%, 95% CI 0.01–0.74) at 90-day follow-up compared to the later treatment group. Conclusion Our data suggest that ultra-early administration of IV tPA significantly improves recanalization rates and clinical outcomes in patients with AIS due to ELVO.

Mobile stroke units (MSUs) are a major advancement in prehospital stroke treatment. Compared to standard care, current evidence shows MSUs are able to deliver intravenous alteplase faster, have higher rates of intravenous alteplase administration, and transport patients more often to appropriate levels of care. Though still in its early stages, prehospital stroke assessment with a MSU is becoming more widely recognized as an efficient, feasible, and integral component of acute advanced stroke systems of care. This chapter covers important concepts in the advent and growth of MSUs including time-based treatment benefit, clinical process efficiency, application of telemedicine, imaging capabilities, transport destination and triage, cost effectiveness, and clinical outcomes.

INTRODUCTION Favorable outcomes in intraarterial therapy (IAT) for acute ischemic stroke (AIS) are related to early vessel recanalization. The mobile stroke treatment unit (MSTU) is an on-site, prehospital, treatment team, laboratory, and CT scanner that reduces time to treatment for intravenous thrombolysis and may also shorten time to IAT. METHODS Using our MSTU database, we identified patients that underwent IAT for AIS. We compared the key time metrics to historical controls, which included patients that underwent IAT at our institution six months prior to implementation of the MSTU. We further divided the controls into two groups: (1) transferred to our institution for IAT and (2) directly presented to our emergency room and underwent IAT. RESULTS After 164 days of service, the MSTU transported 155 patients of which 5 underwent IAT. We identified 5 historical controls that were transferred to our center for IAT. Substantial reduction in times including median door to initial CT (12 minute vs. 32 minute), CT to IAT (82 minute vs. 165 minute), and door to MSTU/primary stroke center departure (37 minute vs. 106 minute) were noted among the two groups. Compared to the 6 patients who presented to our institution directly, the MSTU process times were also shorter. CONCLUSION Our initial experience shows that MSTU may help in early triage and shorten the time to IAT for AIS.

Introduction: Prehospital evaluation and response is vital to effective and early delivery of acute stroke treatment. We aimed to compare the times across various prehospital times among stroke patients arriving by municipal EMS and MSTU. Methods: We performed a retrospective study of 107 patients with a final diagnosis of ischemic stroke within our hospital system from June 2014 to July 2015. We compared on scene arrival, hospital arrival, and time of physician assessment of patients evaluated on MSTU to traditional municipal EMS. Times are reported as medians and groups were compared by Rank-Sum Test. Results: Of 107 patients, 49 patients were evaluated by traditional EMS and 58 evaluated by MSTU. Time from dispatch to scene arrival was median 9 min (IQR 5.5 - 12min) in EMS group and median 12 min (IQR 8-16 min) n MSTU (p&lt0.01). Time on scene was 17 min (IQR 14 - 24min) in EMS group and median 42 min (IQR 36-48 min) in MSTU. There was no difference within the MSTU group in time on-scene among those treated with IV tpA (43 min) and those without (41 min, p=.08 ). After dispatch, patients arrived in hospital by EMS earlier (median 40 min, IQR 33-49min) than by MSTU (median 72 min, IQR 58-81min, p&lt.01), but patients on MSTU were evaluated by a physician at median 28 (IQR 21.5-34.5) min after dispatch. Conclusion: Early evaluation of ischemic stroke patients with MSTU, doubles the time on scene compared to municipal EMS.

Introduction: The Mobile Stroke Treatment Unit (MSTU) is a novel onsite pre-hospital treatment team with all basic infra-structure to diagnose, emergently treat and hence timely triage acute ischemic and hemorrhagic stroke patients to either the primary stroke center (PSCs) or comprehensive stroke centers (CSCs). Recent evidence supports outcome benefits in favor of intra-arterial therapy (IAT) in large vessel strokes and transfers to neuro-critical care units for managing large strokes. This has resulted in a surge in transfers to CSCs summing additional transfer costs for patients not initially presenting to a CSC. This is the first ever study in the United States that utilizes a basic cost generation model to measure the economic benefits of MSTU triage directly to the CSCs by-passing PSCs, for the those patients requiring higher-level care. Method: Mobile Stroke Treatment Unit database was used to identify patients that stroke neurologists triaged to CSCs. These included all acute ICH, IAT candidates and severe strokes with ICU needs. We calculated the average costs of a typical primary stroke center emergency room visit and the cost of a critical care transport, generating a cost savings model. Result: Fifty two patients who were evaluated by stroke neurologists in the mobile stroke unit from July 2014 to October 2015 were adjudged candidates for comprehensive stroke centers. Twenty four (46%) of these were intra-cerebral hemorrhage (ICH) confirmed on portable head CT while the other 28 (54%) presented with major strokes with possible IA thrombectomy candidacy or anticipated Neuro ICU needs due to stroke severity. Eleven ICH and 13 ischemic stroke patients (46%) of the 52 patients by-passed PSC to be taken directly to comprehensive stroke centers with a potential of saving millions of dollars in costs and critical time. Conclusion: Even in a city with dense presence of comprehensive stroke centers, a large cohort of patients by-passed primary stroke centers with a potential of saving millions of dollars in costs and critical time. Future goals include evaluating for difference in outcome in this group of patients that by-passed PSC courtesy MSTU. Additionally, this needs to be replicated in other counties and cities before policy changes are proposed.

Objective:To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance.Methods:We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014–November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges.Results:Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset.Conclusion:Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.

Favorable outcomes in intraarterial therapy (IAT) for acute ischemic stroke (AIS) are related to early vessel recanalization. The mobile stroke treatment unit (MSTU) is an on-site, prehospital, treatment team, laboratory, and CT scanner that reduces time to treatment for intravenous thrombolysis and may also shorten time to IAT.Using our MSTU database, we identified patients that underwent IAT for AIS. We compared the key time metrics to historical controls, which included patients that underwent IAT at our institution six months prior to implementation of the MSTU. We further divided the controls into two groups: (1) transferred to our institution for IAT and (2) directly presented to our emergency room and underwent IAT.After 164 days of service, the MSTU transported 155 patients of which 5 underwent IAT. We identified 5 historical controls that were transferred to our center for IAT. Substantial reduction in times including median door to initial CT (12 minute vs. 32 minute), CT to IAT (82 minute vs. 165 minute), and door to MSTU/primary stroke center departure (37 minute vs. 106 minute) were noted among the two groups. Compared to the 6 patients who presented to our institution directly, the MSTU process times were also shorter.Our initial experience shows that MSTU may help in early triage and shorten the time to IAT for AIS.

Background: A Mobile stroke treatment unit (MSTU) with on-site treatment team can provide thrombolysis successfully in a pre-hospital setting more quickly than traditional treatment in the hospital. We compared our experience of patients treated with the mobile stroke unit to treatment of patients brought to emergency department via a traditional ambulance Methods: We implemented a MSTU at our institution starting July 18, 2014. The unit includes a registered nurse, paramedic, emergency medical personnel, and CT technologist. A stroke physician evaluated each patient via telemedicine and a neuroradioloigst and stroke physician remotely assessed images obtained by CereTom mobile CT (Neurologica, Danvers, USA). Data were entered in medical records and a prospective registry. The evaluation and treatment in the first 3 weeks of implementation of MSTU was compared to a control group of patients brought to the emergency department via a traditional ambulance in the preceding 3 months. The time of alarm was the dispatch time by the city emergency medical service. Results: 23 patients were treated in the MSTU group and 34 in the control group. There were no significant differences in age or gender between the groups. The median time for alarm-to-MSTU-arrival-at-scene was 13 minutes (Interquartile range 9-17). There was a significant reduction of median alarm-to-CT scan completion times (41 min in MSTU vs 62 min in controls, p Conclusion: Compared with traditional ambulance model, ambulance-based thrombolysis resulted in decreased time to imaging and treatment.

Introduction Recent intra-arterial therapy (IAT) trials for emergent large vessel occlusion (ELVO) strokes have shown positive outcomes with early treatment. Mobile Stroke Treatment Unit (MSTU), with a portable CT scanner, point-of-care laboratory testing and on-site treatment team reduces time to treatment for intravenous (IV) thrombolysis. We present our initial experience with the MSTU and its utility in the triage of ELVO strokes. Methods Retrospective review of the MSTU database identified patients that received IAT. Clinical characteristic, imaging data and time metrics were collected. Door time for MSTU was defined as the time the patient entered the MSTU for evaluation. We compared this data to patients within the same catchment area as the MSTU, which were transferred to our center and underwent IAT during the 6 months prior to initiation of MSTU. Results Out of 155 patient evaluated in the MSTU during the first 164 days of service, 5 patients underwent IAT. On initial assessment of these patients in the MSTU, due to suspicion of ELMO they were transported to IAT ready centers. Comparing the median time metrics to 5 patients in the historical control period, significant reduction in dispatch to door (19 min vs. 31 min, p = 0.03), door to initial CT (12 min vs. 32 min, p = 0.01), and CT to IAT (82 min vs. 165 min, p = 0.01) was observed. Also the time spent in the MSTU and transfer times were reduced [door to MSTU/primary stroke center (PSC) departure (37 min vs. 106 min, p = 0.01) and transfer between MSTU/PSC to IAT ready centers (14 min vs. 26 min, p = 0.05)]. Conclusions MSTU can significantly reduce time to IAT by triaging patients with suspected ELVO to appropriate hospitals. This may translate into better outcomes for ELVO strokes. Disclosures R. Cerejo: None. A. Buletko: None. S. John: None. A. Taqui: None. A. Itrat: None. G. Toth: None. K. Uchino: None. P. Rasmussen: None. M. Hussain: None.