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Introduction: Seizures are a common complication after an ischemic stroke. Electroencephalography can assist with the diagnosis of seizures however, the diagnostic yield of its use when seizure is suspected in the setting of acute ischemic stroke is unknown. We aim to evaluate the yield and cost of EEG in the acute ischemic stroke setting. Methods: We conducted a retrospective chart review of patients admitted to a single academic tertiary care center in the United States between September 1, 2015 to November 30, 2019 with a primary diagnosis of acute ischemic stroke and who were monitored on electroencephalography (EEG) for suspected seizures (total number of 70 patients). The primary outcome was how often EEG monitoring changed clinical management defined as starting, stopping, or changing the dose of an anti-epileptic drug. Secondary analysis was estimating the cost of EEG monitoring per change in management. Results: We identified 126 patients admitted with acute ischemic stroke who underwent EEG of which 70 met all inclusion and exclusion criteria. EEG monitoring resulted in a change in management in 22 patients (31%). Predictors associated with EEG monitoring resulting in a change in management were admission to the ICU, pre-existing atrial fibrillation, and symptomatic hemorrhagic transformation. Estimated cost of EEG per change in management was $1374.96 USD. Conclusion: EEG monitoring resulted in a changed management in nearly one-third of patients admitted with acute ischemic stroke suspected of having seizures.

Background and purpose The first pass effect has been reported as a mechanical thrombectomy (MT) success metric in patients with large vessel occlusive stroke. We aimed to compare the clinical and neuroimagign outcomes of patients who had favorable recanalization (mTICI 2c or mTICI 3) achieved in one pass versus those requiring multiple passes. Methods In this "real-world" multicenter study, patients with mTICI 2c or 3 recanalization were identified from three prospectively collected stroke databases from January 2016 to December 2019. Clinical outcomes were a favorable functional outcome at 90 days (modified Rankin Scale score 0-2), and the rate of symptomatic intracranial hemorrhage (ICH) any ICH, and 90-day mortality. Results Favorable recanalization was achieved in 390/664 (59%) of consecutive patients who underwent MT (age 71.2 ± 13.2 years, 188 [48.2%] women). This was achieved after a single thrombectomy pass (n = 290) or multiple thrombectomy passes (n = 100). The rate of favorable clinical outcome was higher (41% vs. 28 %, p = .02) in the first pass group with a continued trend on multivariate analysis that did not reaching statistical significance (OR 1.68 95% confidence interval [CI] 1.0-2.95, p = .07). Similarly, the odds of any ICH were significantly lower (OR 0.56 CI 0.32-0.97, p = .03). A similar trend of favorable clinical outcomes was noticed on subgroup analysis of patients with M1 occlusion (OR 1.81 CI 1.01-3.61, p = .08). Conclusion The first-pass reperfusion was associated with a trend toward favorable clinical outcome and lower rates of ICH. These data suggest that the first-pass effect should be the mechanical thrombectomy procedure goal.

Background and purposeA subset of ischaemic stroke patients with atrial fibrillation (AF) have ischaemic stroke despite anticoagulation. We sought to determine the association between prestroke anticoagulant therapy and recurrent ischaemic events and symptomatic intracranial haemorrhage (sICH).MethodsWe included consecutive patients with acute ischaemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from eight comprehensive stroke centres in the USA. We compared recurrent ischaemic events and delayed sICH risk using adjusted Cox regression analyses between patients who were prescribed anticoagulation (ACp) versus patients who were naïve to anticoagulation therapy prior to the ischaemic stroke (anticoagulation naïve).ResultsAmong 2084 patients in IAC, 1518 had prior anticoagulation status recorded and were followed for 90 days. In adjusted Cox hazard models, ACp was associated with some evidence of a higher risk higher risk of 90-day recurrent ischaemic events only in the fully adjusted model (adjusted HR 1.50, 95% CI 0.99 to 2.28, p=0.058) but not increased risk of 90-day sICH (adjusted HR 1.08, 95% CI 0.46 to 2.51, p=0.862). In addition, switching anticoagulation class was not associated with reduced risk of recurrent ischaemic events (adjusted HR 0.41, 95% CI 0.12 to 1.33, p=0.136) nor sICH (adjusted HR 1.47, 95% CI 0.29 to 7.50, p=0.641).ConclusionAF patients with ischaemic stroke despite anticoagulation may have higher recurrent ischaemic event risk compared with anticoagulation-naïve patients. This suggests differing underlying pathomechanisms requiring different stroke prevention measures and identifying these mechanisms may improve secondary prevention strategies.

ObjectiveTo investigate the aetiology, subsequent preventive strategies and outcomes of stroke despite anticoagulation in patients with atrial fibrillation (AF).MethodsWe analysed consecutive patients with AF with an index imaging-proven ischaemic stroke despite vitamin K-antagonist (VKA) or direct oral anticoagulant (DOAC) treatment across 11 stroke centres. We classified stroke aetiology as: (i) competing stroke mechanism other than AF-related cardioembolism; (ii) insufficient anticoagulation (non-adherence or low anticoagulant activity measured with drug-specific assays); or, (iii) AF-related cardioembolism despite sufficient anticoagulation. We investigated subsequent preventive strategies with regard to the primary (composite of recurrent ischaemic stroke, intracranial haemorrhage, death) and secondary endpoint (recurrent ischaemic stroke) within 3 months after index stroke.ResultsAmong 2946 patients (median age 81 years; 48% women; 43% VKA, 57% DOAC), stroke aetiology was competing mechanism in 713 patients (24%), insufficient anticoagulation in 934 (32%) and cardioembolism despite sufficient anticoagulation in 1299 (44%). We found high rates of the primary (27% of patients; completeness 91.6%) and secondary endpoint (4.6%; completeness 88.5%). Only DOAC (vs VKA) treatment after index stroke showed lower odds for both endpoints (primary: adjusted OR (aOR) (95% CI) 0.49 (0.32 to 0.73); secondary: 0.44 (0.24 to 0.80)), but not switching between different DOAC types. Adding antiplatelets showed higher odds for both endpoints (primary: aOR (95% CI) 1.99 (1.25 to 3.15); secondary: 2.66 (1.40 to 5.04)). Only few patients (1%) received left atrial appendage occlusion as additional preventive strategy.ConclusionsStroke despite anticoagulation comprises heterogeneous aetiologies and cardioembolism despite sufficient anticoagulation is most common. While DOAC were associated with better outcomes than VKA, adding antiplatelets was linked to worse outcomes in these high-risk patients. Our findings indicate that individualised and novel preventive strategies beyond the currently available anticoagulants are needed.Trial registration numberISRCTN48292829.

IntroductionPredictors of long-term ischaemic and haemorrhagic complications in atrial fibrillation (AF) have been studied, but there are limited data on predictors of early ischaemic and haemorrhagic complications after AF-associated ischaemic stroke. We sought to determine these predictors.MethodsThe Initiation of Anticoagulation after Cardioembolic stroke study is a multicentre retrospective study across that pooled data from consecutive patients with ischaemic stroke in the setting of AF from stroke registries across eight comprehensive stroke centres in the USA. The coprimary outcomes were recurrent ischaemic event (stroke/TIA/systemic arterial embolism) and delayed symptomatic intracranial haemorrhage (d-sICH) within 90 days. We performed univariate analyses and Cox regression analyses including important predictors on univariate analyses to determine independent predictors of early ischaemic events (stroke/TIA/systemic embolism) and d-sICH.ResultsOut of 2084 patients, 1520 patients qualified; 104 patients (6.8%) had recurrent ischaemic events and 23 patients (1.5%) had d-sICH within 90 days from the index event. In Cox regression models, factors associated with a trend for recurrent ischaemic events were prior stroke or transient ischemic attack (TIA) (HR 1.42, 95% CI 0.96 to 2.10) and ipsilateral arterial stenosis with 50%–99% narrowing (HR 1.54, 95% CI 0.98 to 2.43). Those associated with sICH were male sex (HR 2.68, 95% CI 1.06 to 6.83), history of hyperlipidaemia (HR 2.91, 95% CI 1.08 to 7.84) and early haemorrhagic transformation (HR 5.35, 95% CI 2.22 to 12.92).ConclusionIn patients with ischaemic stroke and AF, predictors of d-sICH are different than those of recurrent ischaemic events; therefore, recognising these predictors may help inform early stroke versus d-sICH prevention strategies.

Background: A small randomized controlled trial suggested that dabigatran may be as effective as warfarin in the treatment of cerebral venous thrombosis (CVT). We aimed to compare direct oral anticoagulants (DOACs) to warfarin in a real-world CVT cohort. Methods: This multicenter international retrospective study (United States, Europe, New Zealand) included consecutive patients with CVT treated with oral anticoagulation from January 2015 to December 2020. We abstracted demographics and CVT risk factors, hypercoagulable labs, baseline imaging data, and clinical and radiological outcomes from medical records. We used adjusted inverse probability of treatment weighted Cox-regression models to compare recurrent cerebral or systemic venous thrombosis, death, and major hemorrhage in patients treated with warfarin versus DOACs. We performed adjusted inverse probability of treatment weighted logistic regression to compare recanalization rates on follow-up imaging across the 2 treatments groups. Results: Among 1025 CVT patients across 27 centers, 845 patients met our inclusion criteria. Mean age was 44.8 years, 64.7% were women; 33.0% received DOAC only, 51.8% received warfarin only, and 15.1% received both treatments at different times. During a median follow-up of 345 (interquartile range, 140–720) days, there were 5.68 recurrent venous thrombosis, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Among 525 patients who met recanalization analysis inclusion criteria, 36.6% had complete, 48.2% had partial, and 15.2% had no recanalization. When compared with warfarin, DOAC treatment was associated with similar risk of recurrent venous thrombosis (aHR, 0.94 [95% CI, 0.51–1.73]; P =0.84), death (aHR, 0.78 [95% CI, 0.22–2.76]; P =0.70), and rate of partial/complete recanalization (aOR, 0.92 [95% CI, 0.48–1.73]; P =0.79), but a lower risk of major hemorrhage (aHR, 0.35 [95% CI, 0.15–0.82]; P =0.02). Conclusions: In patients with CVT, treatment with DOACs was associated with similar clinical and radiographic outcomes and favorable safety profile when compared with warfarin treatment. Our findings need confirmation by large prospective or randomized studies.

We sought to determine if interhemispheric asymmetry of cortical and medullary veins evaluated on CT angiography can provide a more accurate prediction of outcome in patients with acute ischemic stroke when compared to hemispheric asymmetry of cortical or medullary vein drainage alone.We retrospectively reviewed a database of patients with anterior circulation distribution acute ischemic stroke, who were evaluated by multiphase CTA. Cortical veins were evaluated using the adopted Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) system. Medullary veins were evaluated by the presence of asymmetry determined by 5 or more medullary veins visualized in one hemisphere as compared to the contralateral. Good clinical outcome was defined as a Modified Rankin Scale of 0-2 at 90 days.64 patients were included. The adopted PRECISE score was associated with a good clinical outcome in patients with AIS (OR=3.29; 95 % CI: 1.16 - 9.30; p = 0.023) and had a stronger association with clinical outcome (AUC=0.644) as compared to the asymmetry of MV (AUC=0.609). In a multivariable logistic regression model, combined medullary and cortical vein asymmetry were independently associated with clinical outcomes (AUC=0.721).Combined cortical and medullary vein interhemispheric asymmetry is a stronger predictor of clinical outcome in acute ischemic stroke compared to cortical or medullary vein asymmetry alone.

Introduction Fellowship program websites often serve as the initial resource applicants use to learn about programs. Websites have likely become even more important due to social distancing mandates related to the on-going Covid-19 pandemic. In this study, we evaluated the websites of sleep medicine fellowship programs and analyzed the comprehensiveness of their content. Methods Sleep medicine fellowship programs in the United States (US) for the 2021 match cycle were identified using the Electronic Residency Application Service (ERAS) directory and the Fellowship and Residency Electronic Interactive database (FREIDA). Twenty-two prespecified website content criteria related to education, recruitment, and compensation were evaluated. Programs’ website comprehensiveness was compared based on geographic location (Northeast/Midwest/South/West); type of programs (Community/University); programs matching status (Complete/Partial or No matching status); core specialty (Internal medicine/Other specialties); and program size (based on number of sleep fellows). Results A total of 78 US sleep fellowship program’ websites were evaluated. Most (80.8%) had a direct functional link to ERAS or FREIDA websites. The percentage of sleep medicine fellowship program’ websites reporting each of the twenty-two-criterion was highly variable (range: 2.6%-98.7%). The percentage of overall website comprehensiveness among sleep medicine fellowship programs was 56.8%±16.5% (range:13.6%-90.9%). There was a significantly higher educational website content comprehensiveness for the Internal medicine compared to other specialties-based sleep programs (p = 0.002). There were no significant association between the overall, educational, recruitment, and compensation website content comprehensiveness of sleep programs and their US region location, type of affiliation, matching status, or program size. Conclusion Website content comprehensiveness amongst sleep fellowship programs in the US is variable with a lower educational content on website pages of non-internal medicine-based sleep programs. Improvement in website content of sleep medicine programs is a potentially easy way for programs to improve fellow recruitment, and more importantly, allow prospective sleep fellow applicants to make a more informed decision with regards to program selection. Support (If Any) This study was not funded.

Background Intravenous alteplase improves outcome after acute ischemic stroke without a benefit in 90‐day mortality. There are limited data on whether alteplase is associated with reduced mortality in patients with atrial fibrillation (AF)‐related ischemic stroke whose mortality rate is relatively high. We sought to determine the association of alteplase with hemorrhagic transformation and mortality in patients with AF. Methods and Results We retrospectively analyzed consecutive patients with acute ischemic stroke between 2015 and 2018 diagnosed with AF included in the IAC (Initiation of Anticoagulation After Cardioembolic Stroke) study, which pooled data from stroke registries at 8 comprehensive stroke centers across the United States. For our primary analysis, we included patients who did not undergo mechanical thrombectomy (MT), and secondary analyses included patients who underwent MT. We used binary logistic regression to determine whether alteplase use was associated with risk of hemorrhagic transformation and 90‐day mortality. There were 1889 patients (90.6%) who had 90‐day follow‐up data available for analyses and were included; 1367 patients (72.4%) did not receive MT, and 522 patients (27.6%) received MT. In our primary analyses we found that alteplase use was independently associated with an increased risk for hemorrhagic transformation (odds ratio [OR], 2.23; 95% CI, 1.57–3.17) but reduced risk of 90‐day mortality (OR, 0.58; 95% CI, 0.39–0.87). Among patients undergoing MT, alteplase use was not associated with a significant reduction in 90‐day mortality (OR, 0.68; 95% CI, 0.45–1.04). Conclusions Alteplase reduced 90‐day mortality of patients with acute ischemic stroke with AF not undergoing MT. Further study is required to assess the efficacy of alteplase in patients with AF undergoing MT.

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

Background: Emergent treatment with intravenous thrombolysis and mechanical thrombectomy improved outcomes in patients with acute ischemic stroke. We aim to identify differences in acute stroke treatment trends between strokes occurring in the anterior versus posterior circulation. Methods: The IAC (Initiation of Anticoagulation after Cardioembolic stroke) study represents pooled data registry of 8 comprehensive stroke centers across the United States and included patients with cardioembolic stroke in the setting of AFib. In a post hoc analysis, we identified and separated patients into posterior circulation stroke (PCS) and anterior circulation stroke (ACS) groups based on imaging. Patients without infarct locations or those with multi-circulation infarcts were excluded. We compared baseline characteristics, stroke severity and the treatment trends with alteplase (tPA) and mechanical thrombectomy (MT) in PCS vs ACS using Fisher exact test, t-test and non-parametric tests. We then performed multivariable logistic regression adjusted for baseline differences to determine the associations between PCS and tPA or MT. Results: Of the 2084 patients in IAC cohort, 1589 met inclusion criteria for this study, in which 294 (22.7%) had PCS. Mean age was 76.8 years, 29.3% received tPA and 26.9% had MT. When compared to ACS, patients with PCS were more likely to be men (55.4% vs 45.6%, p=0.003), have diabetes (42.8% vs 29.8, p< 0.001) and lower median NIHSS score on admission (4 vs 8, p Conclusion: Posterior circulation strokes are half as likely to receive thrombolytic therapy and almost a third as likely to have thrombectomy, even after adjusting for baseline stroke severity scores. This is possibly due to difficulty in timely identification and diagnostic delays. There is need for better tools incorporating posterior circulation stroke signs and symptoms to allow for early detection and treatment.

Background and purpose: A proportion of patients with ischemic stroke and atrial fibrillation (AF) have an ischemic stroke despite being prescribed anticoagulation therapy. In this study of patients with ischemic stroke in the setting of AF, we aim to determine the association between prior anticoagulant therapy and 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage (sICH). Methods: We included consecutive patients with acute ischemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from 8 comprehensive stroke centers in the United States. We compared recurrent ischemic events and delayed sICH risk using unadjusted and adjusted cox-regression analyses between patients who were prescribed anticoagulation (AC p ) vs. were naïve to anticoagulation therapy prior to the ischemic stroke (AC n ). For ischemic events, we adjusted for CHA 2 DS 2 -Vasc, anticoagulation initiation, and switching anticoagulant (DOAC to Warfarin or Warfarin to DOAC). For delayed sICH, we adjusted for age, sex, NIHSS score, and early hemorrhagic transformation. Results: 2070 patients had home anticoagulation treatment status recorded. When compared to the AC n group, the AC p group were more likely to have higher median (IQR) CHA 2 DS 2 -Vasc score [5 (4-6) vs. 5 (3-6), p = 0.001], lower NIHSS score [8 (3 - 18) vs. 10 (4 - 18), p = 0.015], severe left atrial enlargement (43.5% vs. 34.5%, p < 0.001), and less likely to receive alteplase (14.4% vs. 36.2%, p < 0.001). In the adjusted cox hazard model, AC p was associated with increased risk of 90-day recurrent ischemic events (adjusted HR 1.52 95% CI 1.01 - 2.29, p = 0.047) but not increased risk of 90-day sICH (adjusted HR 1.10 95% CI 0.46 - 2.61, p = 0.838). In a sensitivity analysis, with severe left atrial enlargement added to the model, the association between AC p and recurrent ischemic event risk did not meaningfully change (adjusted HR 1.41 95% CI 0.87 - 2.28, p = 0.162). Conclusion: Patients with AF and ischemic stroke despite being prescribed anticoagulation therapy are at higher risk of recurrent events. Studies are needed to understand mechanisms of ischemic stroke in these patients to improve stroke prevention strategies.

Objective Neurology residency program websites often serve as the initial face of a program for prospective residents early in the application process. We evaluated adult neurology residency program websites to determine their comprehensiveness to identify areas for improvement. Methods A list of adult neurology residency programs in the United States was compiled using information on the Electronic Residency Application Service (ERAS) and Fellowship and Residency Electronic Interactive Database (FREIDA) websites. A total of 24 website criteria covering educational, recruitment, and compensation content were assessed for comprehensiveness. Programs' website comprehensiveness was compared based on geographic location, program affiliation (community and/or academic), program size, and program/hospital Doximity and U.S. News & World Report rankings. Results A total of 153 US adult neurology residency program websites were evaluated. Fewer than one-half of program websites were accessible with a direct link from either FREIDA or ERAS. The number of residency program websites reporting each content criterion varied greatly. Mean percentage of overall website comprehensiveness among neurology residency programs was 65.9%. Northeast location, academic affiliation, larger programs, and top-ranked programs on Doximity were associated with greater program website comprehensiveness. Interpretation There is opportunity for all neurology residency programs to improve their websites to provide prospective applicants with a more informed and comprehensive perspective of programs during the application process. ANN NEUROL 2021;89:637-642.

Background and Purpose: In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage. Methods: We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations. Results: We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01–7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63–2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29–0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22–1.48]). Conclusions: Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.

Highlights • Throughout this process, neurology resident education and service has, and will continue to be, affected during this pandemic. • Programs is operationalizing Telemedicine and the ACGME is favorable to neurology residents using this unique tool to take care of patients. • The American Academy of Neurology has provided program directors with various tools to share to provide high-yield academic education. AAN Synapse, distance learning modules, and podcasts are a few examples. • We have an obligation to learn as much about this pandemic and how it impacts our patients with neurologic disorders. • Our training and education will only benefit from this experience teaching us lessons on adaptability, the importance of teamwork, and self-sacrifice., Throughout this pandemic, neurology resident education and service has, and will continue to be, affected during this unprecedented time. Balancing the safety of our residents as well as the anticipated inpatient service demands, we have, and continue to, make changes to meet the needs of our community. Education certainly has been affected but we have made great effort to maintain normalcy. We are leveraging web-based technologies to continue formal didactics. The American Academy of Neurology has provided program directors with various tools to share to provide high-yield academic education. AAN Synapse, distance learning modules, and podcasts are a few examples. Each residency training program will likely face different challenges depending on location and community structure. We have an obligation to help all of our colleagues in the hospital in providing quality and compassionate care during this time of need. Our training and education will only benefit from this experience teaching us lessons on adaptability, the importance of teamwork, and self-sacrifice.

Background/Aims: Guidelines suggest initiating anticoagulation after cardioembolic stroke within 4-14 days from the index event. Data supporting this suggestion did not account for important factors such as infarct burden or early hemorrhagic transformation. Methods: We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with an acute cardioembolic stroke in the setting of atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days) and the primary outcome was the composite endpoint of recurrent stroke/TIA/systemic embolism, symptomatic intracerebral hemorrhage (sICH), or major extracranial hemorrhage (ECH) within 90 days. Results: We enrolled 2090 patients from 8 comprehensive centers in the United States, 1325 met the inclusion criteria (362 were excluded due to non-composite endpoint related death within 90 days, 145 lost to follow up, and 258 were not started on oral anticoagulation or the timing was not reported). Anticoagulation (875 DOAC, 404 Warfarin) was initiated in 0-3 days in 49.7%, 4-14 days in 40.4%, and >14 days in 9.9%. The combined endpoint occurred in 10.7% (142) (98 ischemic events, 21 sICH, and 30 ECH) and did not differ between the three groups: 0-3 days (11.9%), 4-14 days (9.9%), >14 days (9.9%), p=0.525. After adjusting for confounders (such as infarct volume, bridging, CHADS2-Vasc, cardiac thrombus, and hemorrhage on 24-hr imaging), oral anticoagulation timing in the 4-14 day period (vs. >14) was not associated with a reduction in ischemic events (adjusted OR 0.74, p=0.438) and oral anticoagulation timing 4-14 days (vs. 0-3) was not associated with a reduction in sICH (OR 1.28, p=0.638). Factors associated with sICH were bridging (OR 5.36, p=0.001) and hemorrhage on 24-hr imaging (OR 7.26, p Conclusion: In this multicenter real world cohort, the recommended (4-14 days) timeframe to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required determine the optimal timing of anticoagulation initiation.

The ASA/AHA guidelines recommend a fixed dose of 90 mg of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) for acute stroke patients weighing more than 100 kg. We aimed to determine if body weight100 kg (and receiving0.9 mg/kg dose) independently influence patient clinical outcomes following IV rt-PA treatment.We pooled data from IV rt-PA treatment arms from 3 randomized controlled clinical trials; NINDS IV rt-PA study, Interventional Management of Stroke 3 and ALIAS (part 1 and 2). Baseline characteristic, hospital course and 90-day mRS were compared between patients100 kg and those ≤100 kg body weight. Multivariate logistic regression model was used to identify the independent effect of100 kg body weight on favorable 90-day outcome (defined as mRS 0-2), the rate of symptomatic intracranial hemorrhage, and poor 90-day outcome (mRS 4-6).Among 873 patients treated with IV rt-PA, a total of 105 (12%) subjects had body weight100 kg. Compared with patients having ≤100 kg body weight, the rate of favorable outcome at 90 days was not significantly different among patients with100 kg body weight (OR: 0.99; 95% CI: 0.91-1.01; p=0.91) , after adjusting for potential confounders. The ordinal analysis did not show any significant shift in the distribution of 90-day mRS score in patients with100 kg body weight (OR, 0.93; 95% CI, 0.64-1.37; P = 0.74) CONCLUSIONS: There was no reduction in the rate of favorable outcome in patients with acute ischemic stroke with body weight100 kg who received0.9 mg/kg dose of IV rt-PA. Our results support the current recommendations in the ASA/AHA guidelines.

Objective Guidelines recommend initiating anticoagulation within 4 to 14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation, such as infarct size, hemorrhagic transformation, or high-risk features on echocardiography. Methods We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days), and outcomes were recurrent stroke/transient ischemic attack/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days. Results Among 2,084 patients, 1,289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the 3 groups (0-3 days: 10.3%, 64/617; 4-14 days: 9.7%, 52/535; >14 days: 10.2%, 14/137; p = 0.933). In adjusted models, patients started on anticoagulation between 4 and 14 days did not have a lower rate of sICH (vs 0-3 days; odds ratio [OR] = 1.49, 95% confidence interval [CI] = 0.50-4.43), nor did they have a lower rate of recurrent ischemic events (vs >14 days; OR = 0.76, 95% CI = 0.36-1.62, p = 0.482). Interpretation In this multicenter real-world cohort, the recommended (4-14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation. ANN NEUROL 2020;88:807-816.

Background: First pass effect (FPE) is defined as achieving a TICI 3 recanalization with a single pass with no use of rescue therapy. We aimed to compare the clinical and radiological outcomes of patient who had FPE versus those who didn’t outside a clinical trial or registry in a community setting. Methods: Patients were identified from two prospectively collected stroke databases from Jan 2015 to March 2018. We compared clinical and radiological outcomes of all endovascular treated who had FPE to those who didn’t. Primary outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale (mRS) score of 0-3), and the rate of intracranial hemorrhage (ICH). Early neurological improvement, angiographic recanalization, time to recanalization, and mortality at 30 days were used as secondary outcomes. Results: We identified 238 patients who underwent thrombectomy [mean age 68 ± 14 years, 121 (51%) were women]. FPE was achieved in 91(38%) patients. More middle cerebral artery occlusions (59% versus 41%) were present in the FPE group. Mean time from symptoms onset to revascularization was significantly shorter in the FPE group (336 ± 288 minutes vs 438± 364 minutes; P=0.003). Since the general protocol of both institutions was to use ADAPT technique for the first thrombectomy attempt when feasible, 75% of the cases with first pass success were performed with aspiration alone. FPE was an independent predictor of good clinical outcome (mRS score ≤3 56 % in FPE versus 35 % in non-FPE cohort; P=2.601 [odds ratio 2.60 (95% confidence interval 1.25-4.99)]. Similarly lower rate of ICH was observed among FPE group (23% versus 46%; P= 0.40 [(odds ratio 0.4 (95% confidence interval 0.20 -0.79)]. Conclusion: In this analysis from a community setting outside of clinical trials or registries, FPE was associated with significantly improved functional outcomes and lower ICH rates and was more frequently achieved in MCA occlusions. More studies are required in order to determine the most efficient technique to achieve FPE.

Central nervous system (CNS) involvement occurs in up to 50% of patients with systemic lupus erythematosus (SLE). Cerebral aneurysm formation is a rare complication of CNS lupus. The majority of these patients present with subarachnoid hemorrhage. We report a patient with an active SLE flare who presented with a recurrent ischemic stroke and was found to have numerous unruptured fusiform and saccular aneurysms in multiple vascular territories. He was treated with high-dose steroid and rituximab along with aspirin and blood pressure control for stroke prevention.

BACKGROUND AND PURPOSE: Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF. METHODS: The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are both viable treatment options for carotid artery stenosis. We sought to compare perioperative outcomes after CEA and CAS for the management of carotid stenosis using a "real-world" sample.We conducted a retrospective observational study using the National Surgical Quality Improvement Program database to compare 30-day (periprocedural) outcomes in patients with carotid stenosis undergoing CEA versus CAS from 2005 to 2012. Baseline characteristics and periprocedural outcomes including stroke, myocardial infarction, mortality and combined outcome (composite of any stroke, myocardial infarction, or death) were compared.A total of 54,640 patients were identified who underwent CEA and 488 who underwent CAS. Patients undergoing CEA were more likely to be older and have symptomatic stenosis, and less likely to be white, have congestive heart failure, and have chronic obstructive pulmonary disease. There were no significant differences between CEA and CAS in periprocedural mortality (0.9% vs. 1.2%,Early outcomes after CEA and CAS for carotid artery stenosis appear to be similar in a "real-world" sample and comparable to clinical trials. Patients undergoing CAS were more likely to be younger and surgically have higher risk based on baseline characteristics likely reflecting clinical practice case selection.

Background: The AHA/ASA guideline recommends endovascular therapy for patients with acute ischemic stroke within 6 hours from symptom onset. Identification of the patients most likely to benefit (and those most likely to be harmed) from reperfusion plays a pivotal role in decision-making. We applied the MR PREDICTS tool (clinical decision making tool derived from MR CLEAN clinical trial) on a real-world sample of patients with acute ischemic stroke to assess its utility in predicting clinical benefit from endovascular therapy. Methods: We identified all patients with acute ischemic stroke with occlusion of the distal internal carotid artery, proximal M1, or M2 segment of the middle cerebral artery who underwent endovascular reperfusion procedure (thrombectomy and/or intra-arterial thrombolysis) from July 2016 to June 2017. Patients were divided into two groups; those with a good outcome (90 Day mRS 0-2) and those with a poor outcome (90 Day mRS 3-6). The MR PREDICTS tool was used to determine absolute treatment benefit for each patient. This predicted outcome was compared to actual patient outcome. Results: A total of 22 patients were identified. Eight patients had a good outcome and 14 patients had a poor outcome. The calculated absolute treatment benefit from endovascular therapy using the MR PREDICTS tool was consistently higher among patients in the good outcome group, with an average absolute treatment benefit of 12% greater among these patients compared to those in the poor outcome cohort (19% versus 7%). Of note, patients with a poor outcome had a higher rate of prior stroke, higher baseline NIHSS, longer symptom onset to groin puncture time, less favorable collaterals and lower rate of successful recanalization defined as TICI 2b or 3 (100% versus 64%). Conclusion: There is a strong correlation between predicted treatment benefit by MR PREDICTS tool and actual patient outcomes which supports broader use of this tool during the decision-making process for endovascular therapy in patients with acute ischemic stroke.

ObjectiveTo determine the relationship between neurology inpatient satisfaction and (1) number of physicians involved in the patient's care and (2) patients’ ability to identify their physicians.MethodsA 10-item questionnaire addressing patient satisfaction and identification of physicians on the care team was administered to patients admitted to an academic, tertiary care, inpatient neurology service from May 1 to October 31, 2012. We hypothesized higher satisfaction among patients having fewer physicians on the care team and among patients able to identify their physicians.ResultsA total of 652 patients were enrolled. An average of 3.9 (range 3–8) physicians were involved in each patient's care. Patients were able to correctly identify on average 2.4 (60.7%) physicians involved in their care. Patients who were very satisfied correctly identified a larger percentage of physicians involved in their care (63.8% vs 50.7%, p < 0.001), were more likely to identify a physician who knew them best (94.3% vs 43.6%, p < 0.001) and who was “in charge” of their care (94.1% vs 57.6%, p < 0.001), and were more likely to have private insurance (82.8% vs 70.5%, p < 0.001) and fewer physicians involved in their care (3.84 vs 4.06, p = 0.02).ConclusionsNeurology inpatients’ ability to identify physicians involved in their care is associated with patient satisfaction. Strategies to enhance patient satisfaction might target improving physician identification, reducing actual or perceived disparities in care based on payer status, and reducing handoffs or conducting handoffs at the bedside.

Background: Carotid Endarterectomy (CEA) and Carotid Artery Stenting (CAS) are both viable treatment options for carotid artery stenosis. Factors including surgical risk, age, and symptomatic status are often used to help guide management decisions. Methods: We conducted a retrospective observational study using the National Surgical Quality Improvement Program (NSQIP) database to compare 30-day post-procedure outcomes including mortality, stroke, and myocardial infarction in patient with carotid stenosis undergoing CEA (n=54,640) versus CAS (n=488) from 2005 to 2012. Procedure type was identified by CPT codes. Findings: Patients undergoing CEA were more likely to be older and have symptomatic stenosis, and less likely to be white, have CHF, and have COPD. There was no significant difference between CEA and CAS in 30-day mortality (0.9% vs. 1.2%, p=0.33), stroke (1.6% vs. 1.6% p=0.93), myocardial infarction (0.9% vs. 1.6%, p=0.08), or combined outcome (3.0% vs. 4.9%, p=0.09). The interaction between symptomatic status and procedure type was not significant (p=0.29), indicating the association of symptomatic status with 30-day mortality was similar in cases receiving CEA and CAS. Conclusion: Early outcomes after CEA and CAS for carotid artery stenosis appear to be similar in a ‘real-world’ sample and comparable to clinical trials. Patients undergoing CAS were more likely to be younger and surgically higher risk based on baseline characteristics likely reflecting clinical practice case selection.

Background: The ASA/AHA guidelines recommend a fixed dose of 90 mg of intravenous recombinant tissue plasminogen activator(rt-PA) for acute stroke patients weighing more than 100 kilograms(kg). Previous analyses in small studies have suggested that the magnitude of benefit with IV rt-PA is lower in patients with body weight >100 kg. We determined if body weight >100 kg(and receiving Methods: We pooled data from IV rt-PA treatment arms from 3 randomized controlled trials; NINDS IV rt-PA study, IMS-III and Albumin Treatment of Acute Ischemic Stroke(ALIAS part 1 and 2). Patients demographic, stroke severity, comorbidities, hospital outcome and 90-day modified Rankin Scale(mRS) were compared between patients >100 kg and those ≤100 kg body weight(defined by estimated weight). Multivariate logistic regression model was used to identify independent effect of >100 kg body weight on 90-day favorable outcome(defined as mRS 0-2). An ordinal analysis of the mRS was also performed. Results: Among 977 patients treated with IV rt-PA, total of 111 subjects had body weight >100 kg(11% of all patients). The mean age(±SD) for the patients with weight >100 Kg was significantly lower(60±11 versus 68±13, p100 kg had higher rates of history of hypertension, diabetes mellitus, and hyperlipidemia. Patients with body weight >100 kg had longer period(days±SD) of hospitalization(11±14 versus 8±7, p=0.04). Compared with patients with ≤100 kg body weight, the rate of favorable outcome at 90 days was not significantly different among patients with >100 kg body weight[OR; (95% CI): 0.99 (0.91-1.04)p=0.91], after adjusting for potential confounders. The ordinal analysis did not showed any significant shift in the distribution of scores on the mRS in patients with >100 kg body weight(OR, 0.93; 95% CI, 0.64 to 1.37; P = 0.74). Conclusion: Body weight >100 kg(and receiving

ImportanceTreatments for symptomatic intracerebral hemorrhage (sICH) are based on expert opinion, with limited data available on efficacy.ObjectiveTo better understand the natural history of thrombolysis-related sICH, with a focus on the efficacy of various treatments used.Design, setting, and participantsMulticenter retrospective study between January 1, 2009, and April 30, 2014, at 10 primary and comprehensive stroke centers across the United States. Participants were all patients with sICH, using the definition by the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST), which included a parenchymal hematoma type 2 and at least a 4-point increase in the National Institutes of Health Stroke Scale score.Main outcomes and measuresThe primary outcome was in-hospital mortality, and the secondary outcome was hematoma expansion, defined as a 33% increase in the hematoma volume on follow-up imaging.ResultsOf 3894 patients treated with intravenous recombinant tissue plasminogen activator (rtPA) within 4½ hours after symptom onset of ischemic stroke, 128 (3.3%) had sICH. The median time from initiation of rtPA therapy to sICH diagnosis was 470 minutes (range, 30-2572 minutes), and the median time from diagnosis to treatment of sICH was 112 minutes (range, 12-628 minutes). The in-hospital mortality rate was 52.3% (67 of 128), and 26.8% (22 of 82) had hematoma expansion. In the multivariable models, code status change to comfort measures after sICH diagnosis was the sole factor associated with increased in-hospital mortality (odds ratio, 3.6; 95% CI, 1.2-10.6). Severe hypofibrinogenemia (fibrinogen level

Objective: To describe the neurologic and neuroimaging manifestations associated with Cantu syndrome. Methods: We evaluated 10 patients with genetically confirmed Cantu syndrome. All adult patients, and pediatric patients who were able to cooperate and complete the studies, underwent neuroimaging, including vascular imaging. A salient neurologic history and examination was obtained for all patients. Results: We observed diffusely dilated and tortuous cerebral blood vessels in all patients who underwent vascular imaging. White matter changes were observed in all patients who completed an MRI brain study. Two patients had a persistent trigeminal artery. One patient had an occluded right middle cerebral artery. One patient had transient white matter changes suggestive of posterior reversible encephalopathic syndrome. Four patients had migraines with one patient having complicated migraines. Seizures were seen in early life but infrequent. The majority of patients had mild developmental delays and one patient had a diagnosis of autism. Conclusions: Cantu syndrome is associated with various neurologic manifestations, particularly cerebrovascular findings including dilated and tortuous cerebral vessels, white matter changes, and persistent fetal circulation. Involvement of the KATP SUR2/Kir6.1 subtype potentially plays an important role in the neurologic manifestations of Cantu syndrome.

Background: The most feared complication from thrombolysis is symptomatic intracerebral hemorrhage (sICH). Current treatments for sICH are based on limited data. We aim to the efficacy of treatments utilized. Methods: We conducted a collaborative study from 5 academic stroke centers (Columbia University, Massachusetts General Hospital, University of Arkansas, Washington University, and UCLA) on acute post-thrombolysis sICH treatment. The definition of sICH was based on the Safe Implementation of Thrombolysis in Stroke criteria. The primary outcome was in-hospital mortality. Analysis was performed using Fisher’s test and independent t-test, followed by multivariable regression; p Results: We identified 87 patients with sICH from 1/09 to 4/14. Mean time from rtPA infusion to sICH diagnosis was 12±10 hours and mean time to treatment after diagnosis 2.5 ± 2.3 hours. 91% were diagnosed more than 2 hours from initiation of rtPA. The median NIHSS was lower in patients diagnosed in the first 3 hours versus after 3 hours (10 vs. 18, p=0.01). We found no association between receiving any treatment versus none with in-hospital mortality (37% vs 52%, p = 0.1). Factors associated with higher mortality were code status change within 24 hours (56% vs. 13%, p Conclusion: The treatment of post-thrombolysis sICH did not reduce mortality. Possible explanations include perception of futility, prolonged time to diagnosis, and endovascular treatment. More aggressive neurological monitoring beyond two hours from rtPA and screening high risk patients, especially those with high NIHSS score may potentially reduce time to diagnosis/treatment. Innovative treatment with high efficacy and short onset of action should be studied to improve the outcome of sICH.

A 28-year-old right-handed man presented with a 3-month history of persistent right arm, chest, and shoulder burning pain. He reported a history of a 20-foot fall onto his back 5 years prior, but did not identify any temporally related events at the onset of his progressive dysesthesias. He denied any history of headaches, neck pain, back pain, or bowel and bladder dysfunction.