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Background: There is growing evidence to suggest that the direct transfer to angiography suite (DTAS) approach for patients with suspected large vessel occlusion stroke potentially requiring mechanical thrombectomy shortens treatment times and improves outcomes compared with the direct transfer to conventional imaging (DTCI) model. Therefore, we conducted this meta-analysis to compare both approaches to build more concrete evidence to support this innovative treatment concept. Methods: All potentially relevant studies published in 4 electronic databases/search engines (PubMed, Web of Science, Cochrane Library, and Scopus) from inception to November 2021 were reviewed. Eligible studies were included if they enrolled ≥10 patients in both groups, were published in English, and reported baseline and procedural characteristics and outcomes. Relevant data were then extracted and analyzed. Results: Among 4514 searched studies, 7 qualified for the analysis with 1971 patients (DTAS=675, DTCI=1296). Times from door to puncture (mean difference, −30.76 minutes [95% CI, −43.70 to −17.82]; P P P =0.03) at 90 days were higher in the DTAS versus the DTCI approach. There was no difference across the DTAS and DTCI groups in terms of the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2B–3: RR, 1.03 [95% CI, 0.95–1.12]; P =0.42), near-complete/full reperfusion (modified Thrombolysis in Cerebral Infarction 2C–3: RR, 0.89 [95% CI, 0.74–1.08]; P =0.23), symptomatic intracranial hemorrhage (RR, 0.81 [95% CI, 0.56–1.17]; P =0.26), or fair outcomes (modified Rankin Scale score, 0–3: RR, 1.14 [95% CI, 0.88–1.47]; P =0.32) or mortality (RR, 0.98 [95% CI, 0.67–1.44]; P =0.93) at 90 days. Subgroup analysis showed no significant difference in 90-day functional independence across approaches in transfer patients (RR, 1.20 [95% CI, 0.96–1.51]; P =0.11). Conclusions: Our meta-analysis showed that the DTAS approach seems to be associated with improved time metrics and functional outcomes with comparable safety to the DTCI approach. Ongoing multicenter randomized clinical trials will hopefully provide more definite data about this promising approach.

Spontaneous intracerebral hemorrhage (ICH) constitutes 10-15% of all strokes, and is a significant cause of mortality and morbidity. Survivors of ICH, especially those with atrial fibrillation (AF), are at risk for both recurrent hemorrhagic and ischemic cerebrovascular events. A conundrum in the field of vascular neurology, neurosurgery, and cardiology has been the decision to initiate or resume versus withhold anticoagulation in survivors of ICH with AF. To initiate anticoagulation would decrease the risk of ischemic stroke but may increase the risk of hemorrhage. To withhold anticoagulation maintains a lower risk of hemorrhage but does not decrease the risk of ischemic stroke. In this narrative review, we discuss the evidence for and against the use of antithrombotics in ICH survivors with AF, focusing on recently completed and ongoing clinical trials.

Background Basal ganglia infarcts are thought to carry worse clinical outcomes compared with other infarct patterns. We aimed to investigate whether pretreatment topographic infarct patterns including complete basal ganglia involvement versus other infarct patterns help predict mechanical thrombectomy outcomes. Methods This was a review of a prospectively collected database of consecutive mechanical thrombectomy patients with anterior circulation large vessel occlusion strokes between January 2014 and November 2018. Patients were categorized into the following 2 groups: (1) total basal ganglia (TBG) strokes defined as infarcts affecting both the caudate and lentiform nuclei regardless of cortical involvement and (2) other infarct patterns. Infarct location was assessed on preprocedure noncontrast computed tomography using an automated software (e‐ASPECTS). Baseline characteristics and outcome measures were compared. Results A total of 1011 patients were analyzed of which 234 (23.12%) had TBG strokes. Patients with TBG strokes were younger ( P =0.01); had higher National Institutes of Health Stroke Scale (NIHSS) ( P =0.006), lower e‐ASPECTS ( P P =0.024); and had diabetes less often ( P =0.01). Baseline characteristics were otherwise comparable between groups. Involvement of the caudate or lentiform nucleus alone was observed in 237 (30.5%) and 21 (2.7%) patients, respectively, in the other infarct patterns group. No internal capsule involvement was detected in either group. There were no differences in terms of 90‐day functional outcomes whether dichotomized (modified Rankin Scale score≤2: TBG=44.6% versus other=50.1%; P =0.14) or looking at the entire spectrum of the scale (shift analysis; P =0.74). However, TBG strokes had significantly higher rates of any parenchymal hematomas (15.4% versus 8.2%; P =0.001), an association that held true in multivariable analysis (adjusted odds ratio, 2.57 [95% CI, 1.41–4.62]; P =0.002). Conclusions Despite increased rates of hemorrhagic transformation, ganglionic infarcts carry similar functional outcomes after mechanical thrombectomy compared with other stroke patterns.

Background Carotid webs (CaWs) may explain embolic strokes particularly in young patients with cerebral embolism of otherwise undetermined cause. We aim to describe the radiological patterns of infarction in patients with symptomatic CaWs. Methods Retrospective analysis of a symptomatic CaW database (September 2014–July 2019) from 2 comprehensive stroke centers. Magnetic resonance imaging scans were reviewed independently by 2 blinded raters. Patterns of acute infarction included territorial (involving ≥2 arterial subdivisions), cortical (affecting 1 arterial subdivision), 1or multiple small cortical infarcts, borderzone infarcts (cortical or internal), striatocapsular lacunes ( Results Forty symptomatic patients with CaW who had infarction were identified. The median age of patients was 49 years (interquartile range, 41–57 years), 22% were women, and 78% were of Black race. The median National Institute of Health Stroke Scale was 13 (interquartile range, 4–17), noncontrast Alberta Stroke Program Early CT Score was 8 (interquartile range, 7–8), and 13 (33%) patients received intravenous alteplase. Thirty‐four (85%) individuals presented with large vessel occlusion strokes (9% intracranial internal carotid artery, 62% middle cerebral artery M1 segment, 29% M2 segment). Sixty‐three percent of patients had right hemispheric strokes and 85% large vessel occlusion. Most patients (98%) had cortical infarcts: 30% were territorial, 38% affected 1 subdivision, and 63% had ≥1 small cortical infarct. Ten percent of the patients had infarcts involving borderzone areas. Fifteen percent of patients had striatocapsular lacunes, all of which had a concomitant cortical infarction. Five percent of patients had imaging evidence of previous strokes (all cortical and within the CaW vascular territory) and 20% had leukoaraiosis (18% grade 1 and 2% grade 2). Conclusion Acute cerebral infarction attributed to CaW were all compatible with an embolic mechanism. CaW should be considered in the workup of patients with cryptogenic strokes as a potential source of embolism.

Background and Purpose Infarct growth rate (IGR) in acute ischemic stroke is highly variable. We sought to evaluate impact of symptom-reperfusion time on outcomes in patients undergoing mechanical thrombectomy (MT). Methods A prospectively maintained database from January,2012-August,2020 was reviewed. All patients with isolated MCA-M1 occlusion who achieved complete reperfusion(mTICI2C-3), had a witnessed symptom onset and follow-up MRI were included. IGR was calculated as final infarct volume (FIV)(ml)/symptom onset to reperfusion time(hours) and was dichotomized according to the median value into slow-(SP) versus fast-progressors (FP). The primary analysis aimed to evaluate the impact of symptom-reperfusion time on 90-day mRS in SP and FP. Secondary analysis was performed to identify predictors of IGR. Results A total of 137 patients were eligible for analysis. Mean age was 63 ± 15.4 years and median IGR was 5.13ml/hour. SP(n = 69) had higher median ASPECTS, lower median rCBFConclusions The impact of symptom-reperfusion time on outcomes significantly varies across slow-versus fast-progressors. ASPECTS, collateral score, rCBF

Background and ObjectivesSimulation bootcamps are used to onboard neurology trainees. It is not known whether these bootcamps result in competency for acute ischemic stroke (AIS).MethodsFor this prospective, single-center pre-post educational intervention study, the Angoff standard setting method was used to determine a Minimum Passing Score (MPS) and Mastery Score for 2 AIS simulations. Junior neurology residents completed precourse knowledge and confidence assessments and had traditional didactic teaching. A week later, each resident completed the first scored AIS simulation. Each resident then practiced stroke care in an unscored simulation. Two to 8 weeks later, each resident was evaluated in an unannounced AIS simulation (the post-test). Postgraduate year (PGY)-3 adult neurology senior residents also completed a knowledge and confidence assessment and were scored on just the AIS post-test case. Using independent and pairedttests, respectively, we compared the junior residents' retention test performance to their baseline assessment and to senior residents' performance.ResultsThirteen junior residents (9 PGY-2 adult neurology residents and 4 PGY-3 child neurology residents) participated in the course. Only 3 junior residents (23%) initially achieved the MPS in the first AIS simulation. After the simulation course, 9 junior residents (69%) achieved the MPS threshold. Although none achieved mastery, junior residents' mean performance score in the simulation improved (mean score preintervention [SD] = 10.3 [2.8] vs mean score postintervention [SD] = 15.7 [2.6],p< 0.001) and their confidence increased (mean score preintervention [SD] = 3.3 [1.9] vs mean score postintervention [SD] = 4.9 [1.2],p< 0.001,d= 1.7). Eight PGY-3 adult neurology residents were scored on the AIS post-test. Five reached MPS (63%), and 1 demonstrated mastery. The simulation scores of the postcourse juniors and seniors were similar (junior resident mean score [SD] = 15.7 [2.6] vs senior resident mean score [SD] = 16.0 [2.5],p= 0.793).DiscussionA brief AIS simulation course may improve junior residents' performance and confidence to a level comparable with senior residents, although not to mastery.

Background Three recent randomized clinical trials (RCTs) investigated the potential benefit of endovascular therapy (EVT) in acute ischemic stroke patients presenting with large infarcts. We aimed to confirm the safety and efficacy of EVT in patients presenting with large infarcts and provide more precise estimations of the treatment effects using study-level meta-analysis. Methods Comprehensive search of MEDLINE database through PubMed till February 2023 was performed including RCTs only. The data were then extracted from the selected studies and pooled as risk ratio (RR) with 95% confidence interval (95% CI). Results There were a total of 1005 patients across the three qualifying RCTs. Regarding the functional outcomes assessed by modified Rankin Scale (mRS) score, the analyzed data demonstrated statistically significant differences in favor of thrombectomy for both independent ambulatory status (mRS 0–3: RR = 1.78, 95% CI [1.28, 2.48], p = 0.0006) and functional independence (mRS 0–2: RR = 2.54, 95% CI [1.85, 3.48], p Conclusion This study confirms the benefit of EVT on functional outcomes of patients presenting with large ischemic infarcts without significant differences in the rates of symptomatic intracranial hemorrhage, hemicraniectomy, or 90-day mortality.

Introduction: Heart failure with reduced Ejection Fraction (HFrEF) is an important risk factor for ischemic stroke and has been shown to carry higher mortality among stroke survivors. However, data among patients with large vessel occlusion strokes (LVOS) undergoing mechanical thrombectomy (MT) is lacking. We aimed to investigate the impact of HFrEF on procedural and functional outcomes after MT. Methods: We conducted a retrospective analysis of a prospectively collected MT database of all consecutive anterior circulation LVOS (Intracranial ICA, MCA-M1, M2) patients undergoing MT at a large urban comprehensive stroke center from Jan,2015-Dec,2020. HFrEF was defined as LVEF ≤40% on transthoracic or transesophageal echocardiograms obtained during the same admission. Uni-multivariable analyses were performed to evaluate the predictors of first pass effect (FPE), mRS0-2 and mortality at 90 days. Results: Of 1466 patients included in the analysis, 293 had HFrEF. The HFrEF group had fewer females, higher median baseline NIHSS, higher rates of Atrial fibrillation (p Conclusion: Our single-center study showed that HFrEF was associated with better procedural outcomes but did not impact functional outcomes at 90-day. Large multi-center studies are warranted.

Objective: We sought to determine whether administration of Intravenous Thrombolysis (IVT) to patients with Acute Ischemic Stroke (AIS) within 60 min from hospital arrival is associated with lower 2-year mortality.Methods: This retrospective study was conducted among patients receiving IVT in hospitals participating in the Georgia Coverdell Acute Stroke Registry (GCASR) from January 1, 2008 through June 30, 2018. Two-year mortality data was obtained by linking the 2008–2018 Georgia Discharge Data System data and the 2008–2020 Georgia death records. We analyzed the study population in two groups based on the time from hospital arrival to initiation of IVT expressed as Door to Needle time (DTN) in a dichotomized (DTN ≤ 60 vs. > 60 min) fashion.Results: The median age of patients was 68 years, 49.4% were females, and the median NIHSS was 9. DTN ≤60 min was associated with lower 30-day [odds ratio (OR), 0.62; 95% CI, 0.52–0.73; P < 0.0001], 1-year (OR, 0.71; 95% CI, 0.61–0.83; P < 0.0001) and 2-year (OR, 0.76; 95% CI, 0.65–0.88; P = 0.001) mortality as well as lower rates of sICH at 36 h (OR, 0.57; 95% CI, 0.43–0.75; P = 0.0001), higher rates of ambulation at discharge (OR, 1.38; 95% CI, 1.25–1.53; P < 0.0001) and discharge to home (OR, 1.36; 95% CI, 1.23–1.52; P < 0.0001).Conclusion: Faster DTN in patients with AIS was associated with lower 2-year mortality across all age, gender and race subgroups. These findings reinforce the need for intensifying quality improvement measures to reduce DTN in AIS patients.