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The use of telecommunications technology to provide the healthcare services, telemedicine, has been in use since the 1860s. The use of technology has ranged from providing medical care to far-off places during wartimes to monitoring physiological measurements of astronauts in space. Since the 1990s, reports have been published on diagnoses of neurological diseases with the use of video links. Studies confirm that the neurological examinations, including the National Institutes of Health Stroke Scale, performed during teleneurology are dependable. The transfer of stroke patients in rural hospitals to bigger medical centers delays treatment while there exists current and projected shortage of neurologists. Telestroke provides the solution. Patients suspected of acute stroke need a noncontrast computerized tomography (CT) scan for tissue plasminogen activator administration. Vascular imaging such as CT angiography, magnetic resonance angiography, and digital subtraction angiography can help show large-vessel occlusion or critical stenosis responsive to endovascular therapy. A standard protocol can be followed to decide a vascular modality of choice, considering advantages and disadvantages of each imaging modality. Telestroke solves the problems of distance and of shortage of neurologists. Neuroimaging plays a vital role in the delivery of telestroke, and the telestroke doctor should be comfortable with making a decision on selecting an appropriate vascular imaging modality.

The significance of cardiac troponin I (TnI) levels in patients with acute ischemic stroke remains unclear.Data were prospectively collected on 1718 patients with acute ischemic stroke (2009-2010). Patients with positive TnI (peak TnI ≥0.1 μg/L) were assigned to the myocardial infarction (MI) group if they met diagnostic criteria. The remaining patients with positive TnI were assigned to the no-MI group. Patients were followed up for 1.4 ± 1.1 years. Primary outcome was inhospital and long-term all-cause mortality.Positive TnI was present in 309 patients (18%), 119 of whom (39%) were classified as having MI. Positive TnI was independently associated with older age, hypertension, smoking, peripheral arterial disease, heart failure, higher systolic blood pressure, higher serum creatinine, and lower heart rate (P.01). Patients with MI had the highest inpatient mortality (P.001) and the lowest survival rate by Kaplan-Meier analysis (P.0001). Peak TnI greater than or equal to 0.5 μg/L, particularly if satisfying criteria for MI, was independently associated with long-term mortality (P.0001); peak TnI less than 0.5 μg/L alone was not when adjusted for covariates.Positive TnI greater than or equal to 0.5 μg/L in patients with acute ischemic stroke was independently associated with worse outcomes. Patients with diagnosis of MI represent a particularly high-risk subgroup.

Background Although National Institutes of Health Stroke Scale (NIHSS) is a known predictor of outcome in acute ischemic stroke, there are other factors like age, ambulatory status, and ability to swallow that may be predictors of outcome but are not assessed by the traditional NIHSS. The aim of this retrospective review was to identify predictors of outcome in mild ischemic stroke. Methods Discharge outcomes from patients who presented to our large academic stroke center with acute ischemic stroke from 2005 to 2013 were retrospectively reviewed. Of 7189 patients reviewed, 2597 had initial NIHSS less than 5. Outcome measures were modified Rankin Scale (MRS) score 0-1 and discharge to home. Results In all, 65% of patients with NIHSS 0-4 were discharged directly home independent of treatment. Of those patients discharged to home, 74% were able to ambulate independently and 98% passed their dysphagia screen. Of patients not discharged directly home, 66% were unable to ambulate independently and 21% did not pass their dysphagia screen. Multivariate logistic regression analysis revealed a significant effect of dysphagia screen (P = .001), ability to ambulate independently (P = .002), age (P = .016), and NIHSS (P = .005) on discharge to home but not MRS of 0-1 (P = .564). Conclusions In patients with mild stroke scale scores defined as NIHSS 0-4, several factors including age, NIHSS, ambulatory status, and ability to swallow may be independent predictors of functional outcome and discharge home. These data support the development of a modified grading system for assessing functional outcome in mild stroke that considers these factors.

Background and Purpose— In patients identified at referring facilities with acute ischemic stroke caused by a large vessel occlusion, bypassing the emergency department (ED) with direct transport to the neuroangiography suite may safely shorten reperfusion times. Methods— We conducted a single-center retrospective review of consecutive patients transferred to our facility for consideration of endovascular therapy. Patients were identified as admitted directly to the neuroangiography suite (DAN), transferred to the ED before intra-arterial therapy (ED-IA), and transferred to the ED but did not receive IA therapy (ED-IV). Results— A retrospective review of a prospectively maintained database of transfer patients between January 2013 and October 2016 with large vessel occlusions identified 108 ED-IV patients and 261 patients who underwent mechanical thrombectomy (DAN=111 patients and ED-IA=150 patients). There were no differences in baseline characteristics among the 3 groups. The median computed tomography ASPECTS (Alberta Stroke Program Early CT Score) was lower in the ED-IV group versus the ED-IA and DAN groups (8 versus 9; P =0.001). In the DAN versus ED-IA cohort, there were comparable rates of TICI2b/3 recanalization and access to recanalization time. There was significantly faster hospital arrival to groin access time in the DAN cohort (81 minutes versus 22 minutes; P =0.001). Functional independence at 90 days was comparable in the DAN versus ED-IA cohorts but worse in the ED-IV group (43% versus 44% versus 22%; P =0.001). Conclusions— DAN is safe, feasible, and associated with faster times of hospital arrival to recanalization. The clinical benefit of this approach should be assessed in a prospective randomized trial.

Objective Previous studies have suggested that patients with wake-up stroke (WUS) may have superior outcomes compared with patients with a witnessed late time of onset after revascularization. We sought to test this hypothesis in patients with anterior circulation large vessel occlusion stroke (ACLVOS) treated with endovascular therapy beyond 8 h from time last seen well (TLSW). Methods A single center retrospective review of a prospectively acquired database of consecutive patients was performed to identify patients presenting beyond 8 h of TLSW with radiographic evidence of ACLVOS, small core, and large penumbra who subsequently underwent endovascular treatment. Results We identified 206 patients. Patients were divided into two groups: (1) patients with WUS (38%, n=78) and (2) patients with witnessed onset beyond 8 h (62%, n=128). The groups were similar in age, baseline National Institutes of Health Stroke Scale score, TLSW to reperfusion, baseline infarct volume, and rate of successful recanalization. Rates of good outcome (modified Rankin Scale score of 0–2 at 90 days, 43% vs 50%, p=0.3), parenchymal hematoma (9% vs 5.5%, p=0.3), and final infarct volume (75.2 vs 61.4 mL, p=0.6) were comparable. Multivariate analysis identified age (OR=0.95, 95% CI 0.91 to 0.99, p

Objectives Spontaneous intracerebral hemorrhage (ICH) results in high morbidity and mortality. A target for therapy might be hematoma expansion, which occurs in a significant proportion of patients, and can be exacerbated by antiplatelet medications, such as aspirin. It is not clear whether platelet transfusion neutralizes aspirin. The Aspirin Response Test (ART) is commonly ordered in this patient population, but it is not clear whether the results of this test can help select patients for transfusion of platelets. The aim of our study is to investigate whether a selected group of ICH patients, those with reduced platelet activity (“aspirin responders”), will benefit from platelet transfusion. Materials and methods This retrospective study included 63 patients who were taking aspirin but no other antithrombotic medication prior to the ICH. For each patient, we measured hematoma size by head CT on admission and compared with follow-up head CT 1 day later. Results In the general cohort, 41% of transfused patients and 29% of non-transfused patients had a hematoma expansion. In the “aspirin responders” group, 46% of transfused patients and 22% of non-transfused patients had an expansion. Conclusions Our data suggest that platelet transfusion following an ICH in “aspirin responders” does not reduce hematoma expansion rates in those patients. A larger prospective study is needed.

BACKGROUND AND PURPOSE: The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial showed a trend for reduced all-cause mortality and positive secondary safety end point outcomes. We present further analyses of the mortality and severe disability data from the Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial. MATERIALS AND METHODS: The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial was a multicenter, randomized, controlled trial that evaluated the safety and effectiveness of the NeuroFlo catheter in patients with stroke. The current analysis was performed on the as-treated population. All-cause and stroke-related mortality rates at 90 days were compared between groups, and logistic regression models were fit to obtain ORs and 95% CIs for the treated versus not-treated groups. We categorized death-associated serious adverse events as neurologic versus non-neurologic events and performed multiple logistic regression analyses. We analyzed severe disability and mortality by outcomes of the mRS. Patient allocation was gathered by use of a poststudy survey. RESULTS: All-cause mortality trended in favor of treated patients (11.5% versus 16.1%; P = .079) and stroke-related mortality was significantly reduced in treated patients (7.5% versus 14.2%; P = .009). Logistic regression analysis for freedom from stroke-related mortality favored treatment (OR, 2.41; 95% CI, 1.22, 4.77; P = .012). Treated patients had numerically fewer neurologic causes of stroke-related deaths (52.9% versus 73.0%; P = .214). Among the 90-day survivors, nominally fewer treated patients were severely disabled (mRS 5) (5.6% versus 7.5%; OR, 1.72; 95% CI, 0.72, 4.14; P = .223). Differences in allocation of care did not account for the reduced mortality rates. CONCLUSIONS: There were consistent reductions in all-cause and stroke-related mortality in the NeuroFlo-treated patients. This reduction in mortality did not result in an increase in severe disability.

Intravenous thrombolysis is the only therapy for acute ischemic stroke that is approved by the US Food and Drug Association. The use of telemedicine in stroke makes it possible to bring the expertise of academic stroke centers to underserved areas, potentially increasing the quality of stroke care.All consecutive admissions for stroke were reviewed for 1 year before telemedicine implementation and for variable periods thereafter. A retrospective review identified 2588 admissions for acute stroke between March 2005 and December 2008 at 12 hospitals participating in a telestroke network, including 919 patients before telemedicine was available and 1669 patients after telemedicine was available. The primary outcome measure was the rate of intravenous tissue plasminogen activator (IV tPA) use before and after telemedicine implementation.One hundred thirty-nine patients received IV tPA in both study phases, with 26 (2.8%) patients treated before starting telemedicine and 113 (6.8%) after starting telemedicine (P.001). Incorrect treatment decisions occurred 7 times (0.39%), with 2 (0.2%) pretelemedicine and 5 (0.3%) posttelemedicine (P = .70). Arrivals within 3 hours from symptom onset were more frequent in the posttelemedicine compared to the pretelemedicine phases (55 [6%] vs 159 [9.5%]; P = .002). Among the patients treated with IV tPA, symptomatic intracranial hemorrhage occurred in 2 patients (1 [10.7%] pretelemedicine vs 1 [1.8%] posttelemedicine; P = .34).Telestroke implementation was associated with an increased rate of thrombolytic use in remote hospitals within the telemedicine network.

Background: A major barrier to enrollment into acute stroke clinical trials is timely access to a tertiary care center conducting the study. Tertiary centers often receive the majority of their patients through broad referral networks. Remote consent via telephone, telemedicine or web-based technology are strategies that have been suggested to broaden enrollment. There is limited data on the feasibility and efficacy of those methods. Methods: There are 19 telemedicine sites and 23 non-telemedicine sites in our network. We describe our experience with screening and enrolling patients into acute stroke clinical trials via our referring network. Based on mode of presentation, we divided all patients enrolled in trials into 3 cohorts; direct presentation with no prior consultation, transfer after consultation by telephone only and transfer after full telemedicine consultation. We classified trials based on required timeframe of enrollment into urgent and non-urgent. We used two-way ANOVA to compare the differences between the three cohorts across both types of trials. Results: Between January 2013 and July 2015, 175 patients were enrolled into 13 clinical trials, 8 of which were urgent. Telephone consults resulted in the highest volume of enrollment (46.3%). Telemedicine consults resulted in higher enrollment into urgent vs non-urgent trials (18.6% vs 11%). Combined; telephone and telemedicine consults comprised the majority of enrollment volume (61.7%). The results were statistically significant (Urgency of Enrollment, p = 0.02. Type of Consult, p = 0.002). Conclusion: Tele-consultation is a feasible and efficacious resource for recruitment into acute stroke trials. Wide implementation of this method can achieve broader recruitment and more rapid completion of trials. Although no major protocol violations or delays were reported in our study, future trials can assess the reliability of the different methods.

Background: Reducing time to treatment is important for acute stroke therapy including intravenous tPA and endovascular therapy. Remote evaluation of acute stroke patients by telemedicine may help triage patients for endovascular therapy and facilitate earlier treatment. Purpose: We aimed to evaluate efficiency and clinical outcome using telemedicine as a screening tool prior to transfer of stroke patients to comprehensive stroke centers for endovascular therapy. Methods: We retrospective reviewed patients receiving endovascular therapy at the University of Pittsburgh Medical Center from January 2014 through May 2015 who were initially evaluated for acute stroke at an outside facility and transferred to our hospital. We statistically analyzed our data using unpaired T test with equal standard deviation. Results: 116 patients treated with endovascular therapy were identified. 35 (30.1%) had telemedicine (TM) evaluations prior to transfer and 81 (69.8%) were transferred without telemedicine screening (NTM). The average age was 68 years in TM group and 67 years in NTM group. 71% of TM patients received IV TPA compared to 30% of NTM patients. The average NIHSS on arrival was 17 among TM and 16 in NTM. The mean time from door to groin puncture was 54 minutes in TM patients compared to 66 minutes in NTM group (p=0.37). Good outcomes (mRS < 2) occurred in 54% of TM cases and 36% of the NTM group (p=0.12). Poor outcomes (mRS 5-6) were 21% in TM patients and 40% in the NTM group (p=0.08). TICI 2b/3 revascularization was achieved in 88.5% and 88.9% in TM and NTM groups respectively (p=0.2). Conclusion: Evaluating acute stroke patients using telemedicine prior to transfer to comprehensive stroke centers may reduce time to intervention and improve selection of patients more likely to benefit from endovascular therapy.

Background and Purpose— The rationale for recanalization therapy in acute ischemic stroke is to preserve brain through penumbral salvage and thus improve clinical outcomes. We sought to determine the relationship between recanalization, clinical outcomes, and final infarct volumes in acute ischemic stroke patients presenting with middle cerebral artery occlusion who underwent endovascular therapy and post-procedure magnetic resonance imaging. Methods— We identified 201 patients with middle cerebral artery occlusion. Patients with other occlusive lesions were excluded. Baseline clinical/radiological characteristics, procedural outcomes (including thrombolysis in cerebral infarction scores), clinical outcome scores (modified Rankin scores), and final infarct volumes on diffusion weighted imaging were retrospectively analyzed from a prospectively collected database. Favorable outcome is defined as 90-day modified Rankin score ≤2. Results— Successful recanalization (thrombolysis in cerebral infarction grade 2b or 3) was achieved in 63.2% and favorable outcomes in 46% of cases. Mean infarct volume was 50.1 mL in recanalized versus 133.9 mL in non-recanalized patients ( P P Conclusions— Successful recanalization leads to improved functional outcomes through a reduction in final infarct volumes. In our series, age and final infarct volume but not recanalization were found to be independent predictors of outcome, supporting the use of final infarct volume as surrogate marker of outcome in acute stroke trials.

Background and Purpose— Acute ischemic stroke due to tandem occlusions of the extracranial internal carotid artery and intracranial arteries has a poor natural history. We aimed to evaluate our single-center experience with endovascular treatment of this unique stroke population. Methods— Consecutive patients with tandem occlusions of the internal carotid artery origin and an intracranial artery (ie, internal carotid artery terminus, M1 middle cerebral artery, or M2 middle cerebral artery) were studied retrospectively. Treatment consisted of proximal revascularization with angioplasty and stenting followed by intracranial intervention. Endpoints were recanalization of both extracranial and intracranial vessels (Thrombolysis In Myocardial Ischemia ≥2), parenchymal hematoma, and good clinical outcome (modified Rankin Scale ≤2) at 3 months. Results— We identified 77 patients with tandem occlusions. Recanalization occurred in 58 cases (75.3%) and parenchymal hematoma occurred in 8 cases (10.4%). Distal embolization occurred in 3 cases (3.9%). In 18 of 77 patients (23.4%), distal (ie, intracranial) recanalization was observed after proximal recanalization, obviating the need for distal intervention. Good clinical outcomes were achieved in 32 patients (41.6%). In multivariate analysis, Thrombolysis In Myocardial Ischemia ≥2 recanalization, baseline National Institutes of Health Stroke Scale score, baseline Alberta Stroke Programme Early CT score, and age were significantly associated with good outcome. Conclusions— Endovascular therapy of tandem occlusions using extracranial internal carotid artery revascularization as the first step is technically feasible, has a high recanalization rate, and results in an acceptable rate of good clinical outcome. Future randomized, prospective studies should clarify the role of this approach.

Background: The frequency with which intravenous thrombolysis for acute ischemic stroke results in normal clinical and radiographic status is currently unknown. Methods: Patients who received intravenous thrombolysis at community hospitals and a stroke center were retrospectively analyzed for occurrence of normal imaging after tissue plasminogen activator (tPA) treatment. The cases were classified as nonischemic process (stroke mimic), transient ischemic attack (TIA) or ischemic stroke. The occurrence rate and predictors of each condition were sought. Results: Of 254 patients who received tPA, 9 (3.5%) had a nonischemic process, 23 (9.1%) had TIA, and 222 (87%) were diagnosed with ischemic stroke. Nonischemic process patients were younger and were more likely to have received tPA at a community hospital than those with TIA or stroke. TIA was associated with lower pretreatment serum glucose, prevalence of coronary artery disease and stroke severity but not to time to treatment. Conclusion: Over 10% of patients who receive tPA for cerebral ischemia do not develop ischemic injury. tPA use for a nonischemic process is infrequent but is associated with community hospital use.

Background: We studied the effect of partial aortic occlusion on cerebral perfusion and cardiac performance using the intra-aortic NeuroFlo™ catheter. Methods: Adult pigs were instrumented to determine cardiac parameters; unique isotope-labeled microspheres were used to determine cerebral blood flow (CBF) before, during and after sequential partial aortic occlusion. Results: Six pigs were studied; there was no relevant change in cardiac output, and the desired pressure drop of 10–15 mm Hg across the balloons was achieved. CBF increased significantly with inflation of the suprarenal balloon and remained elevated 90 min after deflation. Conclusions:Partial aortic occlusion with the NeuroFlo catheter significantly increased cerebral perfusion without adversely affecting cardiac performance.

Background and Purpose— Few data on xenon computed tomography-based quantitative cerebral blood flow (CBF) in spontaneous intracerebral hemorrhage have been reported. We correlated perihematomal CBF in a retrospective series of 42 subacute spontaneous intracerebral hemorrhage patients undergoing xenon computed tomography with in-hospital discharge status and mortality. Methods— We calculated 3 area-weighted mean CBF values: (1) within the computed tomography-visible rim of perihematomal edema, (2) within a 1-cm marginal radius around the hematoma, and (3) all cortical regions of interest immediately adjacent to the hematoma. Primary outcomes were in-hospital mortality and discharge status (ordinally as 0=home, 1=acute rehabilitation, 2=nursing home, 3=death). Discharge status was used as a surrogate for in-hospital functional outcome. Results— Median hematoma volume was 14.4 cm 3 (range, 2 to 70). Median perihematomal (low-attenuation rim) CBF was 21.9 cm 3 ·100 g −1 ·min −1 (range, 6.1 to 81.1), and the median 1-cm marginal radius CBF was 26.8 cm 3 ·100 g −1 ·min −1 (range, 10.8 to 72.8). The median regional cortical CBF was 26.7 cm 3 ·100 g −1 ·min −1 (range, 6.9 to 72.6). Eight patients had 1-cm marginal radius or regional cortical CBF values 3 ·100 g −1 ·min −1 . Hematoma volume (odds ratio [OR], 1.68 per 10-cm 3 volume; P =0.036) and intraventricular hemorrhage (OR, 1.88 per grade of intraventricular hemorrhage; P =0.036) predicted mortality. Two CBF measures, hydrocephalus, and IVH predicted poor in-hospital functional outcome in bivariate analysis. Each CBF measure (OR, 0.34 to 0.43; P P Conclusions— Most spontaneous intracerebral hemorrhage patients lack perihematomal penumbra. Perihematomal CBF independently predicts in-hospital discharge status but not in-hospital mortality. Further studies are warranted to determine whether perihematomal CBF predicts long-term functional outcomes.

An established conceptualization of visual cortical function is one in which ventral regions mediate object perception while dorsal regions support spatial information processing and visually guided action. This division has been contested by evidence showing that dorsal regions are also engaged in the representation of object shape, even when actions are not required. The critical question is whether these dorsal, object-based representations are dissociable from ventral representations, and whether they play a functional role in object recognition. We examined the neural and behavioral profile of patients with impairments in object recognition following ventral cortex damage. In a functional magnetic resonanace imaging experiment, the blood oxygen level-dependent response in the ventral, but not dorsal, cortex of the patients evinced less sensitivity to object 3D structure compared with that of healthy controls. Consistently, in psychophysics experiments, the patients exhibited significant impairments in object perception, but still revealed residual sensitivity to object-based structural information. Together, these findings suggest that, although in the intact system there is considerable crosstalk between dorsal and ventral cortices, object representations in dorsal cortex can be computed independently from those in ventral cortex. While dorsal representations alone are unable to support normal object perception, they can, nevertheless, support a coarse description of object structural information.

Background and Purpose— The use of bare metal stents to treat symptomatic intracranial stenosis may be associated with significant restenosis rates. The advent of drug-eluting stents (DESs) in the coronary circulation has resulted in a reduction of restenosis rates. We report our technical success rate and short-term restenosis rates after stenting with DESs in the intracranial and extracranial circulation. Methods— This study was a retrospective review of the period between April 1, 2004, and April 15, 2006, of 59 patients with 62 symptomatic intracranial or extracranial atherosclerotic lesions at 2 medical centers (University of Pittsburgh and Borgess Medical Center). Results— The mean age of our cohort was 61±12 years. The location of the 62 lesions was as follows: extracranial vertebral artery 31 (50%), intracranial vertebral artery or basilar artery 18 (29%), extracranial internal carotid artery (ICA) near the petrous bone 5 (8%), and intracranial ICA 8 (13%). There were 2 (3%) periprocedural complications: 1 non—flow-limiting dissection and 1 disabling stroke. Fifty vessels were available for follow-up angiography or computed tomography angiography at a median time of 4.0±2 months. A total of 2 of 36 extracranial stents (7%) and 1 of 26 intracranial stents (5%) were found to have restenosis ≥50% at follow-up. Conclusions— This report demonstrates that DES delivery in the intracranial and extracranial circulation is technically feasible. A small percentage of patients developed short-term in-stent restenosis. Longer-term follow-up is required in the setting of a prospective study to determine the late restenosis rates for DESs in comparison with bare metal stents.

Conversion disorders often present with dramatic physical presentations suggestive of severe organic disease. We present the case of a young woman who presented to the Emergency Department with a dense left hemiparesis suggestive of a severe acute stroke. Emergent referral to a regional stroke center facilitated rapid medical evaluation, exclusion of organic disease, and confirmation of conversion disorder as the etiology for the symptoms. This report highlights the dramatic clinical presentations that may result from conversion disorders as well as the benefits of rapid medical evaluation by specialty stroke centers.

Background and Purpose— Endovascular therapies using mechanical and pharmacological modalities for large vessel occlusions in acute stroke are rapidly evolving. Our aim was to determine whether one modality is associated with higher recanalization rates. Methods— We retrospectively reviewed 168 consecutive patients treated with intra-arterial (IA) therapy for acute ischemic stroke between May 1999 and November 15, 2005. Demographic, clinical, radiographic, angiographic, and procedural notes were reviewed. Recanalization was defined as achieving thrombolysis in myocardial infarction 2 or 3 flow after intervention. A logistic regression model was constructed to determine independent predictors of successful recanalization. Results— A total of 168 patients were reviewed with a mean age of 64±13 years and mean National Institutes of Health Stroke Scale score of 17±4. Recanalization was achieved in 106 (63%) patients. Independent predictors of recanalization include: the combination of IA thrombolytics and glycoprotein IIb/IIIa inhibitors (odds ratio [OR], 2.9 [95% CI, 1.04 to 6.7]; P P P P value 0.006). Conclusions— Intracranial or extracranial stenting or combination therapy with IA thrombolytics and glycoprotein IIb/IIIa inhibitors in the setting of multimodal therapy is associated with successful recanalization in patients treated with multimodal endovascular reperfusion therapy for acute ischemic stroke.

Background: Hypothermia is a promising neuroprotectant. Amelioration of reperfusion injury after recanalization is a potential benefit. Due to easy access to the femoral vein, endovenous hypothermia can be combined with intra-arterial therapy. Hypothermia and shivering control is possible without mechanical ventilation, deep sedation or paralytic agents. Methods: Consecutive patients with acute ischemic stroke and receiving intra-arterial therapy were studied. An arterial sheath and an endovenous hypothermia catheter were placed into the femoral artery and vein. Hypothermia induction was performed with cold saline infusion. Goal temperature prior to recanalization was 35° or lower. Hypothermia was continued to a goal of 32° for 24 hrs. Controlled rewarming at 0.2°/hr was carried out. Shivering was controlled with skin counter warming, magnesium, dexmedetomidine, and meperidine. The BSAS scale was used to monitor shivering. Results: A total of 10 patients were studied, five women. Two patients with brainstem infarction were intubated, eight recieved sedation. Median age was 65 (range 49 - 80), NIHSS 16 (12 - 27), time from last known well 4 hrs (1 - 10) and ASPECTS 7 (6 - 10). Median door to venous needle time was 37 minutes (26 - 67) and arterial 40 minutes (30 - 70). Median time to reach 35° was 23 minutes (13 - 45). Eight patients reached 35° prior to recanalization. Median time to reach 32° was 171 minutes (122 - 235). Median BSAS was 1 (1-2). Median dose of dexmedetomidine infusion was 0.5 mcg/kg (0.2 - 0.8) meperidine 25mg (0 - 75) and magnesium 4gr (4-6). Two patients were treated for pneumonia prior to discharge. One DVT and one PE were diagnosed. No groin complications were recorded. Three patients died, two after withdrawal of care. Five patients were discharged to a rehabilitation facility and two to a skilled nursing facility. Conclusions: Combined endovenous hypothermia and intra-arterial therapy for acute ischemic stroke is feasible. In non-intubated patients shivering is well controlled and does not necessitate deep sedation or paralytic agents. Hypothermia catheter insertion does not delay intra-arterial recanalization. These data support the planning of a phase 2 trial to assess safety and optimum temperature goals.

Background: Because acute stroke due to basilar artery occlusion (BAO) without recanalization (spontaneous or treated) carries a poor prognosis, recanalization treatment is increasingly initiated beyond conventional time windows. We report our experience with endovascular treatment for this condition when patients are selected without regards to time window considerations. Methods: A retrospective review of a prospectively acquired database comprising 667 patients treated with endovascular therapy for acute stroke due to large vessel intracranial occlusions from 2000 to date. All patients presenting with BAO were included. Selection of patients occurred at the discretion of the treating stroke neurologist not necessarily based on time but based on clinical and imaging characteristics that led to the belief in a reasonable chance of a good outcome. Successful recanalization was expressed as Thrombolysis in Myocardial Infarction (TIMI) score ≥ 2. Favorable outcomes were considered 3 month modified Rankin Score (mRS) ≤ 2. Any parenchymal hematoma (PH) was considered symptomatic. Results: We identified 85 patients. Median age: 63. Median admission NIHSS: 18 (IQR 11-29). Male sex: 57.6%. Median time from last seen well (TLSW) to groin puncture: 774 min (12.9 hrs) (IQR 324min-2262min). Median procedure duration: 105.5 min (IQR 67min-145min). 18% of patients received IV tPA. TIMI 2-3 recanalization occurred in 87% of patients treated. Favorable outcomes were noted in 34% of patients. mRS of 3 was achieved in 9.4%. Mortality was 46%. PH was noted in 8.2% of patients. Treatment modalities included IA lytics (56.4%), MERCI device (39%), Penumbra (6%), Manual Aspiratoin Thrombectomy (27%), Stenting (42%), Angioplasty (46%). In 76.4% of patients the procedure was carried out in intubated state. In multivariate analysis, age (OR 0.94, P=0.007, 95% CI 0.89-0.98), successful recanalization (OR 16, P=0.027, 95% CI 1.38-197.56) and admission glucose (OR 0.98, P=0.033, 95%CI 0.97-0.99) were found to be significantly associated with favorable outcomes. Of note TLSW to treatment initiation was not found in univariate or multivariate analyses to be significantly associated with favorable outcomes. Conclusions: This single center experience indicates that endovascular treatment in selected patients with BAO without time window considerations is associated with similar rates of symptomatic hemorrhage (SICH) and rates of favorable outcomes compared to available literature data where selection is based on strict time windows. The role of time as selection criteria for treatment of BAO should be clarified by future prospective trials.

BACKGROUND: Most stroke patients present to small community hospitals without established stroke pathways or interventional stroke treatment capability. The advent of 2 way audiovisual telestroke systems gives such patients the opportunity to be assessed rapidly by stroke neurologists. Patients who are not candidates for systemic IV tPA or have failed thrombolytic treatment can be identified and transferred to a comprehensive stroke center for potential endovascular treatment. We compared the clinical outcomes of patients undergoing endovascular stroke treatment at University of Pittsburgh Medical Center triaged either through telestroke or non-telestroke means. METHODS: Prospective data including demographics, co-morbidities, baseline Alberta Stroke Program Early CT (ASPECT) and National Institute of Health Stroke Scale (NIHSS) score, intervention modality (pharmacological, mechanical or both), time to treatment, clinical outcome, and hemorrhage and mortality rates were compared. Favorable outcome was defined as modified rankin score (mRS) of 2 or less. RESULTS: Between 3/2007 and 5/2011, thirty four patients underwent endovascular stroke treatment following telestroke evaluation versus 354 patients who were triaged through other means. Baseline characteristics were similar between the groups. Time to endovascular treatment (595 vs. 767 minutes; p = 0.5), pretreatment with systemic tPA (51.6 vs. 56.9%, p=0.6), recanalization (TIMI ≥ 2; 91.2% vs. 84.8%; p = 0.31), favorable outcome (modified rankin score ≤ 2; 50% vs. 40.4%; p = 0.29) and mortality rates (28.1% vs. 34.9%, p=0.44) were comparable. Multivariate logistic regression model identified young age (OR 0.91, CI 0.88-0.95, p CONCLUSION: The results of this study suggest that telestroke guided endovascular stroke treatment is feasible and the outcomes are similar to those patients who were triaged by traditional means. Future randomized studies which specifically compare triage via telemedicine vs. telephone or direct emergency department presentation are needed to substantiate these findings.

Background Acute treatment of ischemic stroke patients presenting more than eight-hours after symptom onset remains limited and largely unproven. Partial aortic occlusion using the NeuroFlo catheter can augment cerebral perfusion in animals. We investigated the safety and feasibility of employing this novel catheter to treat ischemic stroke patients eight-hours to 24 h following symptom onset. Methods A multicenter, single-arm trial enrolled ischemic stroke patients at nine international academic medical centers. Eligibility included age 18–85 years old, National Institutes of Health stroke scale (NIHSS) score between four and 20, within eight-hours to 24 h after symptom onset, and perfusion–diffusion mismatch confirmed by magnetic resonance imaging. The primary outcome was all adverse events occurring from baseline to 30 days posttreatment. Secondary outcomes included stroke severity on neurological indices through 90 days. This study is registered with ClinicalTrials.gov, number NCT00436592. Results A total of 26 patients were enrolled. Of these, 25 received treatment (one excluded due to aortic morphology); five (20%) died. Favorable neurological outcome at 90 days (modified Rankin score 0–2 vs. 3–6) was associated with lower baseline NIHSS ( P < 0·001) and with longer duration from symptom discovery to treatment. There were no symptomatic intracranial hemorrhages or parenchymal hematomas. Asymptomatic intracranial hemorrhage was visible on computed tomography in 32% and only on microbleed in another 20%. Conclusions Partial aortic occlusion using the NeuroFlo catheter, a novel collateral therapeutic strategy, appears safe and feasible in stroke patients eight-hours to 24 h after symptom onset.

Hypertension, diabetes, obesity, and dyslipidemia are risk factors that characterize metabolic syndrome (MetS), which increases the risk for stroke by 40%. In a preliminary study, our aim was to evaluate cerebrovascular reactivity and oxygen metabolism in subjects free of vascular disease but with one or more of these risk factors. Volunteers (n = 15) 59 ± 15 (mean ± SD) years of age clear of cerebrovascular disease by magnetic resonance angiography but with one or more risk factors were studied by quantitative positron emission tomography for measurement of cerebral blood flow, oxygen consumption, oxygen extraction fraction (OEF), and acetazolamide cerebrovascular reactivity. Eight of ten subjects with MetS risk factors had OEF >50%. None of the five without risk factors had OEF >50%. The presence of MetS risk factors was highly correlated with OEF >50% by Fisher's exact test (p

Background and purpose Basilar artery occlusion remains one of the most devastating subtypes of stroke. Intravenous and intra-arterial therapy have altered the natural history of this disease; however, clinical results remain poor. Therefore, exploring more aggressive and innovative management is warranted. Methods Six consecutive patients presenting with a basilar artery occlusion were treated with the same general algorithm of intra-arterial tissue plasminogen activator and mechanical thrombectomy with the Merci retrieval system. If complete recanalization was not achieved after two passes, manual syringe aspiration through a 4.3F catheter was employed. Results All interventions utilizing aspiration thrombectomy resulted in recanalization, with five out of six cases displaying TIMI3/TICI3 flow and one patient resulting in complete recanalization of the basilar artery with persistent thrombus in one P2 segment (TIMI2/TICI2B). All patients survived, with five out of six independent in activities of daily living at 3 months (mRS 0–2). Conclusions Our small case series indicates that aspiration thrombectomy performed manually through a 4.3F catheter can facilitate recanalization of basilar artery occlusion with acceptable clinical outcomes.

Background and Purpose— Telestroke networks offer an opportunity to increase tissue-type plasminogen activator use in community hospitals. Methods— We compared 83 patients treated with intravenous tissue-type plasminogen activator by telestroke to 59 patients treated after in-person evaluation by the same neurologists at a tertiary care stroke center. Onset and door-to-treatment times and functional outcome at 90 days were obtained prospectively. Favorable outcome was defined as modified Rankin Scale score ≤2. Results— Favorable outcome rates were comparable between the groups (42.1% versus 37.5%, P =0.7). There was no significant difference in the rate of symptomatic hemorrhage. Conclusions— Telestroke is a viable alternative to in-person evaluation when stroke expertise is not readily available.

Background and Purpose— Fewer than 5% of patients with acute ischemic stroke are currently treated, and there is need for additional treatment options. A novel catheter treatment (NeuroFlo) that increases cerebral blood flow was tested to 14 hours. Methods— The Safety and Efficacy of NeuroFlo in Acute Ischemic Stroke trial is a randomized trial of the safety and efficacy of NeuroFlo treatment in improving neurological outcome versus standard medical management. The primary safety end point was the incidence of serious adverse events through 90 days. The primary efficacy end point on a modified intent-to-treat population was a global disability end point at 90 days. Secondary end points included mortality, intracranial hemorrhage, modified Rankin scale score outcome of 0 to 2, and modified Rankin scale shift analysis. Results— Between October 2005 and January 2010, 515 patients were enrolled at 68 centers in 9 countries. The primary efficacy end point did not reach statistical significance (OR, 1.17; CI, 0.81–1.67; P =0.407). The primary safety end point did not show a difference in serious adverse events ( P =0.923). Ninety-day mortality was 11.3% (26/230) in treatment and 16.3% (42/257) in control ( P =0.087). Post hoc analyses showed that patients presenting within 5 hours (OR, 3.33; CI, 1.31–8.48), with NIHSS score 8 to 14 (OR, 1.80; CI, 0.99–3.30), or older than age 70 years (OR, 2.02; CI, 1.02–4.03) had better modified Rankin scale score outcomes of 0 to 2; additionally, there were fewer stroke-related deaths in treatment compared to control groups (7.4%=17/230; 14.4%=37/257). Conclusions— The trial met its primary safety end point but not its primary efficacy end point. Signals of treatment effect were suggested on all-cause mortality, in patients presenting early, older than age 70 years, or with moderate strokes, but these require confirmation. Clinical Trial Registration Information— URL: http://clinicaltrials.gov . Unique identifier: NCT00119717.

To what extent can human observers process visual information that is not currently the focus of attention? We evaluated the extent to which unattended visual information (i.e., that which appears on the neglected side of space in individuals with hemispatial neglect) is perceptually organized and influences the perceptual processing of information on the attended side. To examine this, patients (and matched controls) judged whether successive, complex checkerboard stimuli (targets), presented entirely to their intact side of space, were the same or different. Concurrent with this demanding task, irrelevant distractor elements appeared on the unattended side and either changed or retained their perceptual grouping on successive displays, independently of changes in the ipsilesional task-relevant target. Changes in the grouping of the unattended task-irrelevant distractor elements produced congruency effects on the attended target-change judgment to the same extent in the neglect patients as in the control participants, and this was true even in those patients with severe attentional deficits. These results suggest that some perceptual processes, such as grouping, can operate in the absence of attention.

Intravenous tissue plasminogen activator (tPA) for acute ischemic stroke must be provided in an appropriate setting. The best way to provide thrombolysis in small community hospitals remains uncertain. Medical records were reviewed of tPA treatments at a stroke center between January 2002 and October 2005. The stroke center provides phone consultation for acute stroke to smaller hospitals in the region. Subjects were classified into 3 groups: tPA started at referring hospitals before transfer (treat and transfer group), tPA started at the stroke center after transfer (transfer and treat group), and the control group of patients who presented directly to the stroke center and received tPA (stroke center group). We recorded the patient and treatment characteristics, protocol deviations, symptomatic intracranial hemorrhage (ICH), and in-hospital deaths. There were 133 patients in the treat and transfer group, 35 patients in the transfer and treat group, and 86 patients in the stroke center group. Time from onset to treatment was similar in the treat and transfer and the stroke center groups, but the door-to-needle time was shorter by 12 minutes in the latter (P=.02). Fifty-five protocol deviations occurred in 38% patients in the treat and transfer group, compared with 6% in the stroke center group (P.001). The most common deviations were related to time window violations and incorrect tPA dosing. Symptomatic ICH occurred in 8.2%, with no significant difference between the groups. Neither community hospital treatment nor protocol deviation was a predictor of symptomatic ICH or in-hospital mortality. Our findings indicate the need for improved protocol adherence for stroke thrombolysis in patients presenting to small community hospitals.

OBJECTIVE Intra-arterial therapies are being used more frequently in patients presenting with acute cerebral occlusions, but they have been limited by the potential for hemorrhage. We sought to determine whether pretreatment computed tomography perfusion parameters might help to identify patients at a higher risk of developing intracranial hemorrhage after intra-arterial stroke revascularization treatment. METHODS We retrospectively reviewed all patients at the University of Pittsburgh Medical Center and Michigan State University who underwent computed tomography perfusion imaging of the brain before intra-arterial thrombolysis between January 2006 and June 2007. Demographic information, angiographic variables, and types of endovascular interventions were recorded. The mean transit time and cerebral blood volumes were recorded for the ipsilateral and contralateral middle cerebral artery territories. A binary logistic regression model was constructed to determine the independent predictors of developing intracranial hemorrhage. RESULTS A total of 57 patients (33 from the University of Pittsburgh and 24 from Michigan State University) with a mean age of 66 +/- 13 years and mean National Institutes of Health Stroke Scale scores of 16 +/- 5 were studied. The overall recanalization (Thrombolysis in Myocardial Infarction Trial scale 2 or 3 flow) was 72% for the cohort, and the overall rate of parenchymal hemorrhage was 5 of 57 (9%) patients. The overall hemorrhage rate was 19 of 57 (33%) patients. The only variable found to be predictive of the development of hemorrhage after intervention was reduced pretreatment cerebral blood volume (odds ratio, 0.49; 95% confidence interval, 0.35-0.91; P < 0.022). CONCLUSION A reduced pretreatment ipsilateral cerebral blood volume value before endovascular revascularization of an acute middle cerebral artery or internal carotid artery occlusion significantly increases the risk of an intracranial hemorrhage.

The authors provide an overview of current clinical neuroimaging techniques for acute ischemic stroke. The pathophysiology of ischemic stroke is briefly reviewed, especially as it pertains to cerebral blood flow. There are three important goals that must be met in the imaging of an acute ischemic stroke: (1) to quantitate the extent of infarction already present; (2) to quantitate the amount of salvageable brain remaining; and (3) to identify the presence of arterial stenosis or occlusion that is both responsible for the stroke and potentially amenable to treatment. Methods of quantifying the degree of infarction, by magnetic resonance imaging or computed tomography, are compared. Techniques for measuring cerebral blood flow, to quantify tissue at risk, are detailed and compared. The quantification of cerebral blood flow is discussed in detail. Methods of visualizing the cerebral circulation are illustrated.

BACKGROUND AND PURPOSE: We sought to find predictors for hemorrhagic complications in patients with acute ischemic stroke treated with multimodal endovascular therapy. MATERIALS AND METHODS: We retrospectively reviewed patients with acute ischemic stroke treated with multimodal endovascular therapy from May 1999 to March 2006. We reviewed clinical and angiographic data, admission CT Alberta Stroke Programme Early CT Score (ASPECTS), and the therapeutic endovascular interventions used. Posttreatment CT scans were reviewed for the presence of a parenchymal hematoma or hemorrhagic infarction based on defined criteria. Predictors for these types of hemorrhages were determined by logistic regression analysis. RESULTS: We identified 185 patients with a mean age of 65 ± 13 years and mean National Institutes of Health Stroke Scale score of 17 ± 4. Sixty-nine patients (37%) developed postprocedural hemorrhages: 24 (13%) parenchymal hematomas and 45 (24%) hemorrhagic infarctions. Patients with tandem occlusions (odds ratio [OR] 4.6 [1.4–6.5], P < .016), hyperglycemia (OR 2.8 [1.1–7.7], P < .043), or treated concomitantly with intravenous (IV) tissue plasminogen activator (tPA) and intra-arterial (IA) urokinase (OR 5.1 [1.1–25.0], P < .041) were at a significant risk for a parenchymal hematoma. Hemorrhagic infarction occurred significantly more in patients presenting with an ASPECTS ≤7 (OR 1.9 [1.3–2.7], P < .01). CONCLUSIONS: Hemorrhagic infarctions are related to the extent of infarct based on presentation CT, whereas parenchymal hematomas are associated with the presence of tandem occlusions, hyperglycemia, and treatment with both IV tPA and IA urokinase in patients with acute stroke treated with multimodal endovascular therapy.

The definition of death has evolved to include the concept of brain death. The brainstem is an indispensable central integrative unit for all vital functions. The clinical criteria for brain death consist of the demonstration of the absence of function of the brainstem. Confirmatory testing, which mostly evaluates higher clinical function, is usually not required for the diagnosis of brain death.

Background and Purpose— Intracerebral hemorrhage (ICH) can be a devastating complication associated with thrombolytic therapy for acute ischemic stroke. We hypothesized that patients with lower prethrombolysis cerebral blood flow (CBF) were at a higher risk of symptomatic ICH (sICH). Methods— Twenty-three patients who underwent quantitative CBF assessment with Xenon CT studies for acute stroke before intra-arterial (IA) thrombolysis for a middle cerebral artery (MCA) or internal carotid artery terminus occlusion within 6 hours of symptom onset were studied. Univariate and multivariate analysis were carried out to determine predictors of sICH post-IA thrombolysis. Receiver operating characteristic curves were generated to determine the association between mean ipsilateral CBF and the occurrence of sICH. Results— The mean age of our cohort was 68±12 years and a mean National Institutes of Health Stroke Scale (NIHSS) score of 18±3. In univariate analysis, patients with higher percent of core infarct, hyperglycemia, and reduced mean ipsilateral CBF were at risk of sICH. In multivariate analysis only mean ipsilateral CBF was associated with higher rates of sICH (odds ratio 1.58; 95% CI, 1.01 to 2.51; P P Conclusions— Patients with lower pre-IA thrombolysis mean ipsilateral MCA CBF are at significantly higher risk for sICH in the setting of a MCA or carotid terminus occlusion. The threshold identified in this study may be useful for selection of patients with acute MCA occlusions for acute stroke thrombolysis.

Identification of increased stroke risk in a population of symptomatic patients with occlusive vascular disease (OVD) is presently accomplished by measurement of oxygen extraction fraction (OEF) or cerebrovascular reserve (CVR). However, many regions identified by compromised CVR are not identified by OEF. Our aim was to determine whether the response of OEF to acetazolamide, namely, oxygen extraction fraction response (OEFR) would identify those hemispheres in hemodynamic compromise with normal OEF. Nine patients symptomatic with transient ischemic attacks and strokes, and with occlusive vascular disease were studied. Anatomical MRI scans and T2-weighted images were used to identify and grade subcortical white matter infarcts. PET cerebral blood flow (CBF) and OEF were measured after acetazolamide. The relationship between CVR and oxygen extraction fraction response (OEFR) showed that positive OEFR occurred after acetazolamide despite normal baseline OEF values. The two hemispheres with positive OEFR were also associated with severe (> 3 cm) subcortical white matter infarcts. We found that the OEFR was highly correlated with CVR and identified hemispheres that were hemodynamically compromised despite normal baseline OEF.

Background and Purpose— A systematic audit of intravenous tissue-type plasminogen activator (tPA) use and stroke outcomes in Cleveland, Ohio, during 1997–1998 demonstrated higher rates of symptomatic intracranial hemorrhage (ICH) than reported in the National Institute of Neurological Disorders and Stroke (NINDS) trial. We now report updated results of intravenous tPA use in the Cleveland Clinic Health System (CCHS). Methods— A stroke quality improvement program was initiated in the 9-hospital CCHS in 1999. A retrospective chart review for all stroke patients with primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 434 and 436 admitted to the 9 hospitals from June 1999 to June 2000 was used to determine outcomes of patients treated with intravenous tPA. Results— Intravenous tPA was given to 18.8% of patients arriving within 3 hours of symptom onset. Protocol deviations occurred in 19.1% of patients given intravenous tPA. The symptomatic ICH rate was 6.4%. Conclusions— Since 1997, intravenous tPA use has increased, while the rates of symptomatic ICH and protocol deviations have decreased in the CCHS. The CCHS symptomatic ICH rate is now similar to that reported in the NINDS trial. These improvements occurred after initiation of a stroke quality improvement program.

Preliminary clinical trials suggest that therapeutic hypothermia might improve the outcomes of patients with acute stroke. Definitive trials are under way.

Acute ischemic strokes are often accompanied by cardiac events. The prevalence, associated factors, and implications of elevated troponin I (TnI) in acute ischemic stroke merit further study. We reviewed our prospective registry of hospitalized patients with acute ischemic stroke from 2009 to 2010

Acute ischemic stroke is a cause of troponin elevation which is often attributed to demand, type 2 myocardial infarction (MI). The incidence of spontaneous, type 1 MI is unknown. We reviewed our prospective hospital registry of acute ischemic stroke (2009–2010). All patients had ≥3 troponin I (

Cardiomyopathy (CM) in patients admitted with acute ischemic stroke has not been investigated previously. A prospective registry of 1,761 patients admitted with diagnosis of acute ischemic stroke from 2009-2010 was used to identify patients with systolic CM. Echocardiography was performed on 1,594