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Evaluation of stroke etiology is an important aspect of stroke care affecting secondary prevention measures. Despite recent advances in diagnostic testing, determining the stroke etiology can remain a challenging task particularly for less common causes of stroke such as mitral annular calcification. This case will review the benefit of histopathological clot evaluation after thrombectomy to identify uncommon causes of embolic stroke which may change management.

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.

Background: Neurologic complications of Coronavirus Disease 2019 (COVID-19) may be associated with neurotropism of the virus or secondary brain injury from systemic inflammation. Acute respiratory distress syndrome (ARDS) is associated with cerebrovascular injury, including both ischemia and hemorrhage. We aimed to compare brain MRI findings of COVID-19 associated ARDS with non-COVID-19 ARDS. Methods: A registry of patients with COVID-19 from March 2020 through July 2021 from a hospital network was reviewed. Patients who met criteria for ARDS by Berlin definition and underwent MRI during their hospitalization were included. These patients were matched 1:1 by age and sex with patients who underwent MRI from another registry of patients of ARDS in the same hospital between 2010 and 2018. Cerebrovascular injury was classified as either acute cerebral ischemia (ischemic infarct or hypoxic ischemic brain injury) or intracranial hemorrhage (ICH) including intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hematoma, and cerebral microbleeds (CMBs). Results: Of 13,319 patients with COVID-19 infection, 26 patients had ARDS and MRI. Sixty-six of 678 non-COVID-19 ARDS patients had an MRI and were matched 1:1 by age and sex resulting in 23 matched pairs. The median age was 66 and 59% of patients were male. Patients with COVID-19 ARDS were more likely to have hypertension and chronic kidney disease but otherwise baseline medical characteristics were similar. ARDS severity as determined by PaO2/FiO2 ratio at ICU admission was similar between both groups. No difference was seen in the prevalence of cerebrovascular injury (52% vs 61%, p=0.8), cerebral ischemia (35% vs 43%, p=0.8), ICH (43% vs 48%, p=1.0), or CMBs (43% vs 39% p=1.0) on MRI between the COVID-19 and non-COVID-19 cohorts. However, two unique patterns of injury were seen only among COVID-19 patients: hemorrhagic leukoencephalitis (3 patients, 12%) and bilateral cerebral peduncular ischemia with microhemorrhage (2 patients, 8%). Conclusion: Cerebrovascular injury was common in both COVID-19 and non-COVID-19 ARDS without significant frequency difference. However, COVID-19 ARDS had unique neuroimaging patterns that may indicate distinct patterns of brain injury of COVID-19.

Background: Acute Respiratory Distress Syndrome (ARDS) is an acute inflammatory respiratory failure condition that may be associated with secondary cerebrovascular injury. We aimed to describe the prevalence and types of cerebrovascular injuries detected by brain MRI among ARDS patients. Methods: We reviewed a single-center ARDS registry data from a tertiary medical center from January 2010 to October 2018. Patients who underwent brain MRI during their index hospitalization were identified. MRIs were reviewed by two independent reviewers. Acute cerebrovascular injuries were classified as acute cerebral ischemia (ischemic infarct and hypoxic ischemic brain injury [HIBI]) or intracranial hemorrhage (ICH) including intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hematoma, and cerebral microbleeds (CMBs). Descriptive statistics were conducted. Results: Of the 678 ARDS patients, 66 (9.7%) underwent brain MRI during their ARDS illness. The median time from hospital admission to MRI was 10 days (interquartile range 4-17). Of 66, 31 (47%) had MRI evidence of acute cerebrovascular injuries including acute cerebral ischemia in 33% (22/66) and ICH in 21% (14/66). Among those with cerebral ischemia, common findings were bilateral globus pallidus infarcts (n=7), multifocal ischemic infarcts (n=5), and HIBI (n=3). Twelve (86%) with CMBs constituted the most common type of ICH, followed by intraparenchymal hemorrhage (14%). Patient demographics, Charlson Comorbidity Index, or disease severity as measured by the presence of sepsis/sepsis shock, cardiac arrest, extracorporeal membrane oxygenation use, admission Acute Physiology and Chronic Health Evaluation III Score, Sequential Organ Failure Assessment Score, or admission PaO 2 /FiO 2 ratio did not differ among patients with and without cerebrovascular injury including cerebral ischemia or ICH. In-hospital mortality was significantly greater in ARDS patients with acute cerebral ischemia compared to those without ischemia (55% vs 27%, p=0.03). Conclusion: Among selected patients with ARDS who underwent brain MRI, a half had secondary cerebrovascular injury including acute cerebral ischemia and CMBs.

Bloodstream infection is the leading cause of mortality in left ventricular assist device. Bloodstream infection is a risk factor for intracranial hemorrhage. We report three left ventricular assist device recipients who presented with bloodstream infection and developed subarachnoid hemorrhage. Case 1, a 37-year-old male with non-ischemic cardiomyopathy with HeartMate II, presented with confusion and found to have serratia bloodstream infection and left frontal lobe subarachnoid hemorrhage. Cerebral angiogram showed a right M3/M4 branch infectious intracranial aneurysm. He was treated with coil embolization and underwent device exchange. Case 2, a 41-year-old male with non-ischemic cardiomyopathy with HeartMate II presented with confusion and found to have methicillin-resistant staphylococcus aureus bloodstream infection and bilateral frontal convexity subarachnoid hemorrhage. Cerebral angiogram showed left M3 and left A3 infectious intracranial aneurysms, which were treated with antibiotics alone. Case 3, a 58-year-old female with ischemic cardiomyopathy with HeartMate II presented with fever, found to have candida albicans bloodstream infection and a parieto-occipital enhancing lesion concerning for cerebral abscess. Repeat computed tomography brain a week later showed a new right frontal subarachnoid hemorrhage. Cerebral angiogram showed a M4/M5 junction infectious intracranial aneurysm; patient was not a surgical candidate and was transitioned to hospice. This case series emphasizes that left ventricular assist device–associated subarachnoid hemorrhage may be caused by infectious intracranial aneurysms when acute bloodstream infections are present.

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.

Noncontact sports are associated with a variety of neurologic injuries. Concussion, vascular injury (arterial dissection), and spinal cord trauma may be less common in noncontact sports, but require special attention from the sports neurologist. Complex regional pain disorders, muscle injury from repetitive use, dystonia, heat exposure, and vascular disorders (patent foramen ovale), occur with similar frequency in noncontact and contact sports. Management of athletes with these conditions requires an understanding of the neurologic consequences of these disorders, the risk of injury with return to play, and consideration for the benefits of exercise in health restoration and disease prevention.

Background: Infectious intracranial aneurysm (IIA) can complicate infective endocarditis (IE). We aimed to describe the magnetic resonance imaging (MRI) characteristics of IIA. Methods: We reviewed IIAs among 116 consecutive patients with active IE by conducting a neurological evaluation at a single tertiary referral center from January 2015 to July 2016. MRIs and digital cerebral angiograms (DSA) were reviewed to identify MRI characteristics of IIAs. MRI susceptibility weighted imaging (SWI) was performed to collect data on cerebral microbleeds (CMBs) and sulcal SWI lesions. Results: Out of 116 persons, 74 (63.8%) underwent DSA. IIAs were identified in 13 (17.6% of DSA, 11.2% of entire cohort) and 10 patients with aneurysms underwent MRI with SWI sequence. Nine (90%) out of 10 persons with IIAs had CMB >5 mm or sulcal lesions in SWI (9 in sulci, 6 in parenchyma, and 5 in both). Five out of 8 persons who underwent MRI brain with contrast had enhancement within the SWI lesions. In a multivariate logistic regression analysis, both sulcal SWI lesions (p < 0.001, OR 69, 95% CI 7.8-610) and contrast enhancement (p = 0.007, OR 16.5, 95% CI 2.3-121) were found to be significant predictors of the presence of IIAs. Conclusions: In the individuals with IE who underwent DSA and MRI, we found that neuroimaging characteristics, such as sulcal SWI lesion with or without contrast enhancement, are associated with the presence of IIA

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.

Background: MRI features such as cerebral microbleeds and sulcal susceptibility weighted imaging (SWI) or gradient-echo T2* (GRE-T2*) lesions have been reported to be associated with the presence of infectious intracranial aneurysm (IIA) in infective endocarditis (IE). We aimed to describe the MRI imaging features that predict the presence of IIA. Methods: The derivation cohort comprised 116 IE patients with neurological evaluation at a single tertiary referral center from January 2015 to July 2016. The MRI predictors associated with IIA was evaluated, and we developed the MRI imaging predictors and assessed sensitivity and specificity. External validation was performed in a cohort of 129 IE patients who underwent digital subtraction angiogram (DSA) at the same center from 2010-2014. We assessed the validity using a receiver operating characteristic curve (ROC). Results: Of 116 IE patients in the derivation cohort, 10 (9%) had IIAs. Of 129 in the validation cohort, 19 (15%) IIAs were identified. The MRI imaging predictors for IIA consist of 1) contrast enhancement with SWI lesions, 2) cerebral microbleeds > 5mm plus sulcal SWI lesions, and 3) any MRI hemorrhages. The sensitivity for the presence of IIA in each group of the derivation cohort was: 90%, 80%, and 100%, respectively. The sensitivity in the validation cohort was: 47%, 68%, and 94% respectively. The specificity in the derivation cohort was: 87%, 85%, and 18%. In the validation cohort, the specificity was similar (87%, 75%, and 27%). Conclusions: The suggested MRI imaging predictors can be used as a sensitive and specific tool to support clinical decision-making, especially when invasive DSA is considered for assessment for presence of IIA. The absence of MRI hemorrhages may not necessitate the need for DSA.

ObjectiveTo determine the incidence and predictors of acute cerebral ischemia and neurologic deterioration in intracerebral hemorrhage (ICH) patients after an institutional protocol change in systolic blood pressure (SBP) target from MethodsWe retrospectively compared persons admitted with primary ICH before and after a protocol change in SBP target from ResultsOf 286 persons with primary ICH, 119 underwent MRI and met inclusion criteria. Sixty-two had a target SBP p < 0.001) and lower minimum SBP over 72 hours (106 vs 112 mm Hg, p = 0.02). Acute cerebral ischemia was more frequent in group 2 than in group 1 (32% vs 16%; p = 0.047) as was acute neurologic deterioration (19% vs 5%; p = 0.022). A minimum SBP ≤120 mm Hg over 72 hours was associated with cerebral ischemia, while no patient with a minimum SBP ≥130 mm Hg had cerebral ischemia. Acute cerebral ischemia was significantly associated with worse discharge NIH Stroke Scale score, while SBP target was not.ConclusionsIntensive lowering of SBP

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.

Intro: Recent clinical trials suggest that intensive blood pressure lowering in acute intracerebral hemorrhage (ICH) does not result in a lower rate of death or disability. We aimed to compare the incidence of restricted diffusion and acute neurological deterioration in patients after an institutional protocol change in systolic blood pressure (SBP) target from Hypothesis: Intensive blood pressure lowering in acute ICH increases chance of silent and symptomatic acute cerebral ischemia. Methods: We retrospectively compared persons with acute, primary ICH from 2013 to 2014 before and after a protocol change in SBP target from Results: Of 286 primary ICH patients in the study period, 119 underwent MRI and met the study criteria (median age 72, interquartile range (IQR) 59-83, median ICH volume 5.7 cc, IQR 1.3-17.6), 62 patients with target SBP Conclusions: Intensive lowering of SBP in acute ICH patients can result in increased cerebral ischemia on MRI and higher rates of neurological deterioration.

Intro: There have been case reports of ischemic infarcts after treatment with prothrombotics for anticoagulation reversal following spontaneous intracerebral hemorrhage (ICH), though there have been no systematic studies evaluating MRI infarction following prothrombin complex concentrate (PCC) or factor eight inhibitor bypassing activity (FEIBA) administration. We evaluated the prevalence of ischemic infarcts on diffusion-weighted imaging (DWI) in ICH patients who received prothrombotics compared to those who did not. Methods: We performed a retrospective review of patients admitted with ICH between January 2013 and April 2016 in whom MRI brain with DWI imaging was performed within 2 weeks of admission and prior to digital subtraction angiography. PCC (4-factor Kcentra, weight, and INR based dosing) was administered to patients on warfarin at the time of ictus with a INR≥1.4 and FEIBA (50 u/kg) was given to patients exposed to an oral Factor Xa inhibitor or direct thrombin inhibitor if ICH occurred within 3-5 half lives of the last dose. Acute ischemia was defined as DWI hyperintensity with corresponding apparent diffusion coefficient hypointensity. Perihematoma lesions, and procedure-related infarctions were excluded from analysis. Groups were compared using chi-square and Wilcoxon Rank Sum tests. Results: A total of 254 patients were enrolled. Of these, 41 (16%) received either 4-factor PCC (n=33) or FEIBA (n=8). Comparing those who received prothrombotics to those who did not, there was no difference in age (median 68 with prothrombotics and without; p=0.724), sex (44% female in both groups; p=0.977), initial NIH Stroke Scale (median 6 versus 8, p=0.838), or hematoma volume (median 15ml versus 10ml; p=0.207). Patients who received prothrombotics were more likely to have lobar ICH than deep ICH (71% versus 47%; p=0.005). DWI infarctions were found in 16% of patients who receive PCC or FEIBA compared with 22% who did not (p=0.404). Conclusions: Our data suggests prothrombotics do not increase the risk of acute ischemic infarcts within two weeks of administration.

Introduction: Despite studies of aggressive blood pressure reduction in primary intracerebral hemorrhage (ICH), the potential for inducing ischemia remains a concern. The primary objective of this study is to determine the relationship between blood pressure and acute cerebral ischemia following ICH. Methods: We performed a retrospective chart review of patients with primary ICH admitted between January 2013 and December 2014 in whom MRI brain with diffusion-weighted imaging (DWI) was performed within 2 weeks of admission. Acute ischemia was defined as DWI hyperintensity with corresponding apparent diffusion coefficient hypointensity. Lesions adjacent to the ICH or after an invasive procedure were excluded and all MRIs were performed prior to digital subtraction angiography. Serial blood pressure measurements were collected from admission to 72h post ictus. Clinical deterioration was defined as any acute exam change not explained by seizure, hematoma expansion or other medical causes. Results: Among 119 patients with primary ICH (mean age 69.3 years, 58% males, 65% Caucasians), 28 (23.5%) had acute ischemia. Acute ischemia was associated with lower mean 24-hour SBP (132 mmHg in DWI+ versus 141 mmHg in DWI-, p Conclusions: Aggressive SBP reduction, particularly SBP

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.

A 36-year-old woman with Loeys-Dietz syndrome presented with left eye ptosis, anisocoria, and shoulder pain. The diagnosis of left-sided Horner syndrome was made (figure 1). The patient had a known left subclavian artery aneurysm with percutaneous stent graft placement. CT angiography revealed a large left subclavian aneurysm sac, consistent with endoleak type I (figure 2). Horner syndrome and shoulder pain improved following common carotid to axillary artery bypass in addition to thoracic endovascular aortic repair surgery.

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.

We are describing a case of 55-year-old obese female with significant history of uncontrolled rheumatoid arthritis, who recently had decreased her immune-suppression medications. She presented with extensive acral gangrene involving multiple fingers and toes. Clinical picture and laboratory findings were suggestive of vasculitis; however, skin biopsy established diagnosis of calciphylaxis, in settings of normal kidney function. Patient was treated with sodium thiosulfate with gradual improvement in her skin lesions.

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.