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Background: Carotid web is a thin shelf-like fibrointimal membrane arising from the posterior or posterolateral wall of the carotid bulb. Webs cause stroke, especially in younger adults with high risk of recurrence., Methods: To report the first case of de-novo formation of an asymptomatic carotid web and describe longitudinal clinical-angiographic follow-up., Results: A previously healthy 50-year-old White female presented with acute vestibular syndrome. Brain MRI showed no brain infarction. An arch-to-vertex CT angiogram showed normal posterior circulation, however, the left internal carotid artery bulb had a thin shelf-like projection into the lumen arising from the posterior wall of the artery - an incidental carotid web. A CT angiogram performed seven years earlier showed normal carotid arteries. The three-year angiographic follow-up showed an unchanged angiographic appearance of the carotid web. The patient preferred staying on aspirin and suffered no retinal or cerebral ischemic event during the 5-year clinic follow-up., Conclusion: Our case suggests de novo (acquired) formation of a carotid web in an adult. This challenges the prevailing theory that carotid web is a congenital/developmental lesion., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Early ischemic changes on baseline imaging are commonly evaluated for acute stroke decision-making and prognostication., Aims: We assess the association of early ischemic changes on clinical outcomes and whether it differs between intravenous tenecteplase and Alteplase., Methods: Data are from the phase 3, Alteplase compared to Tenecteplase (AcT) trial. Subjects with anterior circulation stroke were included. Early ischemic changes were assessed using the Alberta Stroke Program Early CT score (ASPECTS). Efficacy outcomes included modified Rankin scale (mRS) 0-1, mRS 0-2, and ordinal mRS at 90 days. Safety outcomes included 24-h symptomatic intracerebral hemorrhage (sICH), any hemorrhage on follow-up scan, and 90-day mortality rate. Mixed-effects logistic regression was used to assess the association of ASPECTS (continuous and categorical (0-4 vs 5-7 vs 8-10)) with outcomes and if these associations were modified by thrombolytic type after adjusting for age, sex, and baseline stroke severity., Results: Of the 1577 patients in the trial, 901 patients (56.3%; median age 75 years (IQR 65-84), 50.8% females, median National Institute of Health Stroke Scale (NIHSS) 14 (IQR 17-19)) with anterior circulation stroke were included. mRS 0-1 at 90 days was achieved in 1/14 (0.3%), 43/160 (14.7%), and 252/726 (85.1%) in the ASPECTS 0-4, 5-7, and 8-10 groups respectively. Every one-point decrease in ASPECTS was associated with 2.7% and 1.9% decrease in chances of mRS 0-1 and mRS 0-2 at 90 days, respectively, and 1.9% chances of increase in mortality at 90 days. Subgroup analysis in endovascular thrombectomy (EVT)-treated population showed similar results. Thrombolytic type did not modify this association between ASPECTS and 90-day mRS 0-1 (P-interaction 0.75). There was no significant interaction by thrombolytic type with any other outcomes., Conclusion: Similar to prior studies, we found that every one-point decrease in ASPECTS was associated with poorer clinical and safety outcomes. This effect did not differ between alteplase and tenecteplase., Data Access Statement: Data shall made available on reasonable request from the PI (BMM)., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: L.C. received payments from Servier, consulting fees from iSchemaView RAPID, Circle Neurovascular Imaging (NVI), and Canadian Medical Protective Association. T.T.S. has received consulting fees from Circle NVI. R.H.S. has stock options in FollowMD and gets salary support for research from the Heart and Stroke Foundation of Canada, the Sandra Black Center for Brain Resilience & Recovery, and Ontario Brain Institute. B.M. has stock options in Circle NVI and has consulted for Biogen and Boehringer Ingelheim. M.A. reports grants from Canadian Institute of Health Research during the conduct of the study. No other disclosures are reported. N.S. gets salary support for research from the Heart and Stroke Foundation of Canada, Research Manitoba and University of Manitoba.

Objectives: There are limited data available demonstrating the safety and efficacy of intravenous tenecteplase versus alteplase in patients with acute ischemic stroke in the posterior circulation., Materials and Methods: This is a post-hoc analysis of the Alteplase compared to Tenecteplase(AcT) pragmatic, phase 3, registry-linked randomized controlled trial. Patients with any posterior circulation vessel occlusion on baseline imaging were included. Study outcomes included 90-day modified Rankin Scale(mRS) 0-1, mRS 0-2, ordinal mRS, death within 90 days, 24h symptomatic intracerebral haemorrhage(sICH) and successful reperfusion/recanalization. Mixed effects regression adjusting for age, sex and stroke severity was used to analyze differences in outcomes between patients administered tenecteplase vs. alteplase. Further, sensitivity analysis was conducted for basilar artery occlusion(BAO) alone., Results: Of 1577 patients, 136(8.6%, 77:alteplase, 59:tenecteplase) had posterior circulation stroke. Baseline characteristics were similar[median age 71(IQR 60-81) vs. 72(IQR 65-82) years, 57.1% vs. 67.8% males, median baseline NIHSS 7(IQR 4-12) vs. 7(IQR 4-16) in alteplase vs. tenecteplase arms, respectively]. 28 patients(20.6%, 16:alteplase, 12:tenecteplase arm) underwent EVT. The median 90-120 days mRS was 2(IQR 1-4). There were no differences between alteplase and tenecteplase for 90-d mRS 0-1(adjRR 0.93;95%CI 0.63-1.36), 90-day mRS 0-2(adjRR 0.95; 95%CI 0.72-1.26), sICH(RR 0.65;95%CI 0.06-7.02) and mortality (RR 1.21;95%CI 0.61-2.38). Successful reperfusion eTICI 2b-3 and successful recanalization rAOL 2b-3 was achieved in 23/28(82%, 12:alteplase, 11:tenecteplase) and in 16/28(57%, 14:alteplase, 12:tenecteplase), respectively. Similar results were seen in 31 patients (22.8%) with BAO., Conclusion: Intravenous tenecteplase has a similar effect on outcome as alteplase, without increased safety concerns in patients with acute posterior circulation strokes., Competing Interests: Declaration of competing interest PC has received honoraria from ESMINT. LC has received payments by Servier and consulting fees from Ischaemavie RAPID, Circle NV, and Canadian Medical Protective Association. SBC is principal investigator of the TEMPO-2 trial, for which Boehringer Ingelheim provides the study drug (tenecteplase). MDH has received consulting fees from Sun Pharma and Brainsgate and has stock options in Circle NVI. AYP has received a project research grant from Stryker and honoraria from BMS-Pfizer. RHS has stock options in FollowMD and receives salary support for research from the Heart & Stroke Foundation of Canada, Sandra Black Centre for Brain Resilience & Recovery, and Ontario Brain Institute. BKM has stock options in Circle NVI and has consulted for Biogen and Boehringer Ingelheim. All other authors declare no competing interests., (Copyright © 2024. Published by Elsevier Inc.)

Background: Interhospital transfer for patients with stroke due to large vessel occlusion for endovascular thrombectomy (EVT) has been associated with treatment delays., Methods: We analyzed data from Optimizing Patient Treatment in Major Ischemic Stroke With EVT, a quality improvement registry to support EVT implementation in Canada. We assessed for unadjusted differences in baseline characteristics, time metrics, and procedural outcomes between patients with large vessel occlusion transferred for EVT and those directly admitted to an EVT-capable center., Results: Between January 1, 2018, and December 31, 2021, a total of 6803 patients received EVT at 20 participating centers (median age, 73 years; 50% women; and 50% treated with intravenous thrombolysis). Patients transferred for EVT (n=3376) had lower rates of M2 occlusion (22% versus 27%) and higher rates of basilar occlusion (9% versus 5%) compared with those patients presenting directly at an EVT-capable center (n=3373). Door-to-needle times were shorter in patients receiving intravenous thrombolysis before transfer compared with those presenting directly to an EVT center (32 versus 36 minutes). Patients transferred for EVT had shorter door-to-arterial access times (37 versus 87 minutes) but longer last seen normal-to-arterial access times (322 versus 181 minutes) compared with those presenting directly to an EVT-capable center. No differences in arterial access-to-reperfusion times, successful reperfusion rates (85% versus 86%), or adverse periprocedural events were found between the 2 groups. Patients transferred to EVT centers had a similar likelihood for good functional outcome (modified Rankin Scale score, 0-2; 41% versus 43%; risk ratio, 0.95 [95% CI, 0.88-1.01]; adjusted risk ratio, 0.98 [95% CI, 0.91-1.05]) and a higher risk for all-cause mortality at 90 days (29% versus 25%; risk ratio, 1.15 [95% CI, 1.05-1.27]; adjusted risk ratio, 1.14 [95% CI, 1.03-1.28]) compared with patients presenting directly to an EVT center., Conclusions: Patients transferred for EVT experience significant delays from the time they were last seen normal to the initiation of EVT., Competing Interests: Alexandre Poppe reports grants from the Canadian Institutes of Health Research, compensation from Roche for other services, and grants from the Fondation Brain Canada, the Heart and Stroke Foundation of Canada, and Stryker. Dr Swartz reports grants from the Heart and Stroke Foundation of Canada, compensation from the Sunnybrook Research Institute for other services, compensation from F. Hoffmann-La Roche for consultant services, stock holdings in FollowMD, Inc, and grants from the Ontario Brain Institute and the National Institutes of Health. Dr Catanese reports compensation from Hoffmann-La Roche Limited for consultant services, employment by Hamilton Health Sciences, and grants from Servier Pharmaceuticals LLC. Dr Volders reports compensation from Penumbra, Inc, for consultant services. Dr Kelly reports compensation from Johnson and Johnson, Penumbra, Inc, and Medtronic Vascular, Inc, for consultant services. Dr Kamal reports stock holdings in DESTINE Health and compensation from Medtronic for consultant services. Dr Yu reports grants from the Canadian Institutes of Health Research. Dr Hill reports grants from NoNO, Inc, and Medtronic, compensation from Brainsgate Ltd for consultant services, grants from the Canadian Institutes of Health Research; Medtronic, Boehringer Ingelheim, Medtronic, and MicroVention, Inc, and compensation from Merck for end point review committee services. Dr Sharma reports grants from Bristol Myers Squibb Company to others and compensation from Bayer and AstraZeneca for consultant services. Dr Demchuk reports compensation from Hoffmann-La Roche Limited for consultant services, compensation from Lumosa for data and safety monitoring services, a patent issued for Stroke imaging software licensed to Circle NVI, compensation from Boehringer Ingelheim for consultant services, compensation from Novo Nordisk AS for other services, compensation from Philips for data and safety monitoring services, compensation from NovaSignal for consultant services, and stock holdings in Circle NVI.

Background: Almost half of acute ischemic stroke patients present with mild symptoms and there are large practice variations in their treatment globally. Individuals with an intracranial occlusion who present with minor stroke are at an increased risk of early neurological deterioration and poor outcomes. Individual patient data meta-analysis in the subgroup of patients with minor deficits showed benefit of alteplase in improving outcomes; however, this benefit has not been seen with intravenous alteplase in published randomized trials., Design: TEMPO-2 (A Randomized Controlled Trial of Tenecteplase Versus Standard of Care for Minor Ischemic Stroke With Proven Occlusion) is a prospective, open label with blinded outcome assessment, randomized controlled trial, designed to test the superiority of intravenous tenecteplase (0.25 mg/kg) over nonthrombolytic standard of care, with an estimated sample size of 1274 patients. Adult patients presenting with acute ischemic stroke with the National Institutes of Health Stroke Scale (NIHSS) ⩽ 5 and visible arterial occlusion or perfusion deficit within 12 h of onset are randomized to receive either tenecteplase (0.25 mg/kg) or standard of care. The primary outcome is return to baseline neurological functioning, measured by the modified Rankin scale (mRS) at 90 days. Safety outcomes include death and symptomatic hemorrhage (intra or extra-cranial). Other secondary outcomes include mRS 0-1, mRS 0-2, ordinal shift analysis of the mRS, partial, and full recanalization on follow-up computed tomography angiogram., Conclusion: Results of this trial will aid in determining whether there is benefit of using tenecteplase (0.25 mg/kg) in treating patients presenting with minor stroke who are at high risk of developing poor outcomes due to presence of an intracranial occlusion., Data Access Statement: Data will be available upon reasonable request., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: T.S.F. was site PI for TEMPO-2 at my institution; payments from CIHR and HSFC went to my institution. Outside of the submitted work, he has received in-kind study medication from Bayer and honoraria for advisory board work with HLS Therapeutics, Bayer Canada, Roche, AstraZeneca, and Novartis. He has done expert witness work and is on the board of DESTINE Health. A.Y.Y. holds a National New Investigator Award from the Heart & Stroke Foundation of Canada. Others have none to declare.

Background: Individuals with minor ischaemic stroke and intracranial occlusion are at increased risk of poor outcomes. Intravenous thrombolysis with tenecteplase might improve outcomes in this population. We aimed to test the superiority of intravenous tenecteplase over non-thrombolytic standard of care in patients with minor ischaemic stroke and intracranial occlusion or focal perfusion abnormality., Methods: In this multicentre, prospective, parallel group, open label with blinded outcome assessment, randomised controlled trial, adult patients (aged ≥18 years) were included at 48 hospitals in Australia, Austria, Brazil, Canada, Finland, Ireland, New Zealand, Singapore, Spain, and the UK. Eligible patients with minor acute ischaemic stroke (National Institutes of Health Stroke Scale score 0-5) and intracranial occlusion or focal perfusion abnormality were enrolled within 12 h from stroke onset. Participants were randomly assigned (1:1), using a minimal sufficient balance algorithm to intravenous tenecteplase (0·25 mg/kg) or non-thrombolytic standard of care (control). Primary outcome was a return to baseline functioning on pre-morbid modified Rankin Scale score in the intention-to-treat (ITT) population (all patients randomly assigned to a treatment group and who did not withdraw consent to participate) assessed at 90 days. Safety outcomes were reported in the ITT population and included symptomatic intracranial haemorrhage and death. This trial is registered with ClinicalTrials.gov, NCT02398656, and is closed to accrual., Findings: The trial was stopped early for futility. Between April 27, 2015, and Jan 19, 2024, 886 patients were enrolled; 369 (42%) were female and 517 (58%) were male. 454 (51%) were assigned to control and 432 (49%) to intravenous tenecteplase. The primary outcome occurred in 338 (75%) of 452 patients in the control group and 309 (72%) of 432 in the tenecteplase group (risk ratio [RR] 0·96, 95% CI 0·88-1·04, p=0·29). More patients died in the tenecteplase group (20 deaths [5%]) than in the control group (five deaths [1%]; adjusted hazard ratio 3·8; 95% CI 1·4-10·2, p=0·0085). There were eight (2%) symptomatic intracranial haemorrhages in the tenecteplase group versus two (<1%) in the control group (RR 4·2; 95% CI 0·9-19·7, p=0·059)., Interpretation: There was no benefit and possible harm from treatment with intravenous tenecteplase. Patients with minor stroke and intracranial occlusion should not be routinely treated with intravenous thrombolysis., Funding: Heart and Stroke Foundation of Canada, Canadian Institutes of Health Research, and the British Heart Foundation., Competing Interests: Declaration of interests SBC received grant funding from the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Canada (HSFC), and the British Heart Foundation (BHF) to complete the TEMPO-2 study. Boehringer Ingelheim provided off-the-shelf study drug (tenecteplase) for the study. JFA has received public research grants from the Spanish Ministry of Science, the regional health department, the European Commission, and a private research grant from AstraZeneca. He has received consultant or speaker fees from Pfizer-BMS, Medtronic, and Amgen, and travel support from Daiichi-Sankyo. KSB reports speaker fees from Boehringer Ingelheim and AstraZeneca. LC has received consulting or speakers fees from Roche. JF reports speaker fees from AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Pfizer, Sankyo, and Daiichi. AG reports a grant from Microvention; speaker fees from Alexion, Biogen, and Servier Canada; and stock options for SnapDx and Collavidence. DG reports honoraria from Boehringer Ingelheim, Ipsen, and Eisai. MG reports grant funding from Medtronic and Cerenovus and consulting fees from Mentice, CSL Behring, MicroVention, and Medtronic. TSF participated in an advisory board for Roche. FL reports speaker fees and travel support from Boehringer Ingelheim. BKM has been paid honoraria from Boehringer Ingelheim and Roche. MM has received honoraria from Boehringer Ingelheim for participation at an advisory board on the approval of tenecteplase for treatment of acute ischaemic stroke. SOM has received speaker fees from Boehringer, Medtronic, Penumbra, Bayer, Pfizer, Novartis, Novo Nordisk, Servier, and Daiichi Sankyo. KWM reports grant funding from the BHF, and the Stroke Association; consultancy fees from Boehringer Ingelheim, Biogen, IschaemaView; lecture fees from Boehringer Ingelheim, IschaemaView, and Brainomix; and non-financial support (drug supply for ATTEST-2 trial) from Boehringer Ingelheim. MWP is on Boehringer Ingelheim Advisory Board for Metalyse in stroke. AP received speaker fees from Boehringer Ingelheim and travel support from AstraZeneca for attending a meeting. OMP-N has received speaker fees from Boehringer Ingelheim and AstraZeneca. RS is part funded by the UCLH Biomedical Research Centre. DS reports an unrestricted educational grant from Boehringer Ingelheim. MIW reports sponsorship or financial assistance to support attendance at scientific meetings from Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo UK, and Bayer; honoraria for lectures given at education meetings from Boehringer Ingelheim, Bristol Myers Squibb, and AstraZeneca; and payment for participation in advisory panels from Boehringer Ingelheim and Daiichi Sankyo UK. DJW is the Co-principal Investigator for Health Research Board of Ireland, Award–Improving Pathways for Acute Stroke and Rehabilitation. AYXY reports salary support from the HSFC. MDH reports grant funding from CIHR, HSFC, Alberta Innovates, and study drug from Boehringer Ingelheim; grants from NoNo and Medtronic; consulting fees from Sun Pharma Brainsgate; and a DSMB member role on many stroke clinical trials., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Objectives: Stroke survivors have palliative care needs in multiple domains, which are overlooked. Accurate estimation of these is pivotal in ensuring proper rehabilitation and planning interventions to improve quality of life (QoL). We aimed to assess the palliative care needs of stroke patients in various domains in a structured manner at the neurology service of a tertiary care center in South India., Materials and Methods: Seventy-five consecutive stroke patients presenting to the neurology service were recruited over six months with assessment across various domains including symptom burden, physical domain, activities of daily living (ADL), psychiatric/psychological domain, and QoL at baseline and with follow-up at one month and three months., Results: Despite improvement in the conventional stroke impairment measures among stroke survivors, there were significant unmet needs across various domains; 98% were severely or entirely dependent on ADL at three-month follow-up; and pain and insomnia were the most frequent (33% incidence) troubling symptoms encountered. There were substantial mental health related issues. The QoL measurement tools employed were the stroke impact assessment questionnaire (SIAQ), a novel tool and the World Health Organization Quality Of Life Brief Version (WHO-QOL-BREF). SIAQ scores at one month showed that 19 patients (42.22%) had their QoL severely affected, and 36 patients (80%) showed the same trend at the three-month follow-up. WHO-BREF scores showed that 27 (62%) did not report good QoL, and 32 (73%) were found not to be satisfied with their health at a one-month follow-up., Conclusion: There is a significant burden of unmet palliative care needs among stroke survivors in India across various domains., Competing Interests: There are no conflicts of interest., (© 2024 Published by Scientific Scholar on behalf of Journal of Neurosciences in Rural Practice.)

Background: Carotid tandem lesions ((TL) ⩾70% stenosis or occlusion) account for 15-20% of acute stroke with large vessel occlusion., Aims: We investigated the safety and efficacy of intravenous tenecteplase (0.25 mg/kg) versus intravenous alteplase (0.9 mg/kg) in patients with carotid TL., Methods: This is a substudy of the alteplase compared with the tenecteplase trial. Patients with ⩾70% stenosis of the extracranial internal carotid artery (ICA) and concomitant occlusion of the intracranial ICA, M1 or M2 segments of the middle cerebral artery on baseline computed tomography angiography (CTA) were included. Primary outcome was 90-day-modified Rankin Scale (mRS) 0-1. Secondary outcomes were mRS 0-2, mortality, and symptomatic ICH (sICH). Angiographic outcomes were successful recanalization (revised Arterial Occlusive Lesion (rAOL) 2b-3) on first and successful reperfusion (eTICI 2b-3) on final angiographic acquisitions. Multivariable mixed-effects logistic regression was performed., Results: Among 1577 alteplase versus tenecteplase randomized controlled trial (AcT) patients, 128 (18.8%) had carotid TL. Of these, 93 (72.7%) underwent intravenous thrombolysis plus endovascular thrombectomy (IVT + EVT), while 35 (27.3%) were treated with IVT alone. In the IVT + EVT group, tenecteplase was associated with higher odds of 90-day-mRS 0-1 (46.0% vs. 32.6%, adjusted OR (aOR) 3.21; 95% CI = 1.06-9.71) compared with alteplase. No statistically significant differences in rates of mRS 0-2 (aOR 1.53; 95% CI = 0.51-4.55), initial rAOL 2b-3 (16.3% vs. 28.6%), final eTICI 2b-3 (83.7% vs. 85.7%), and mortality (18.0% vs. 16.3%) were found. SICH only occurred in one patient. There were no differences in outcomes between thrombolytic agents in the IVT-only group., Conclusion: In patients with carotid TL treated with EVT, intravenous tenecteplase may be associated with similar or better clinical outcomes, similar angiographic reperfusion rates, and safety outcomes as compared with alteplase., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: A.Y.P. is the Principal investigator of the EASI-TOC trial of carotid stenting, partially funded by Stryker, Brain Canada, Heart and Stroke Foundation of Canada, and the Canadian Stroke Consortium and is in the advisory board of and receives speaker honoraria from Roche Canada. Other authors report no conflict of interest.

Background: Recent evidence from thrombolysis trials indicates the noninferiority of intravenous tenecteplase to intravenous alteplase with respect to good functional outcomes in patients with acute stroke. We examined whether the health-related quality of life (HRQOL) of patients with acute stroke differs by the type of thrombolysis treatment received. In addition, we examined the association between the modified Rankin Scale score 0 to 1 and HRQOL and patient-reported return to prebaseline stroke functioning at 90 days., Methods: Data were from all patients included in the AcT trial (Alteplase Compared to Tenecteplase), a pragmatic, registry-linked randomized trial comparing tenecteplase with alteplase. HRQOL at 90-day post-randomization was assessed using the 5-item EuroQOL questionnaire (EQ5D), which consists of 5 items and a visual analog scale (VAS). EQ5D index values were estimated from the EQ5D items using the time tradeoff approach based on Canadian norms. Tobit regression and quantile regression models were used to evaluate the adjusted effect of tenecteplase versus alteplase treatment on the EQ5D index values and VAS score, respectively. The association between return to prebaseline stroke functioning and the modified Rankin Scale score 0 to 1 and HRQOL was quantified using correlation coefficient ( r ) with 95% CI., Results: Of 1577 included in the intention-to-treat analysis patients, 1503 (95.3%) had complete data on the EQ5D. Of this, 769 (51.2%) were administered tenecteplase and 717 (47.7%) were female. The mean EQ5D VAS score and EQ5D index values were not significantly higher for those who received intravenous tenecteplase compared with those who received intravenous alteplase ( P =0.10). Older age ( P <0.01), more severe stroke assessed using the National Institutes of Health Stroke Scale ( P <0.01), and longer stroke onset-to-needle time ( P =0.004) were associated with lower EQ5D index and VAS scores. There was a strong association ( r , 0.85 [95% CI, 0.81-0.89]) between patient-reported return to prebaseline functioning and modified Rankin Scale score 0 to 1 Similarly, there was a moderate association between return to prebaseline functioning and EQ5D index ( r , 0.45 [95% CI, 0.40-0.49]) and EQ5D VAS scores ( r , 0.42 [95% CI, 0.37-0.46])., Conclusions: Although there is no differential effect of thrombolysis type on patient-reported global HRQOL and EQ 5D-5L index values in patients with acute stroke, sex- and age-related differences in HRQOL were noted in this study., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249., Competing Interests: Disclosures Dr Menon reports stock in Circle NVI and patents for systems of triage in acute stroke. Dr Sajobi reports consulting fees received from Circle NVI and employment at the University of Calgary. Dr Almekhlafi reports to be on the medical advisory board of Palmera Medical, Inc. Dr Deschaintre reports being part of the Association des neurologues du Québec, the Société des Sciences Vasculaires du Québec, and the Université de Montréal. Dr Coutts reports that Boehringer Ingelheim provided a study drug (tenecteplase) for the TEMPO-2 trial. Dr Catanese reports employment with Hamilton Health Sciences and McMaster University, consulting fees from Hoffmann-La Roche Ltd, and a grant/contract from Servier Pharmaceuticals LLC. Dr Field reports consulting fees from AstraZeneca Canada, Bayer, HLS Therapeutics, and Roche; stock and being a fiduciary officer (board member) in Destine Health; grants/contracts from Boehringer Ingelheim and Bayer; and being an expert witness for the Canadian Medical Protective Association. Dr Siddiqui reports a grant/contract from Allergan and other interests from Bayer and Boehringer Ingelheim. Dr Demchuk reports stock in Circle NVI and patents for stroke imaging software; consulting fees from Servier Pharmaceuticals LLC, NovaSignal, Boehringer Ingelheim, HLS Therapeutics, Inc, Hoffmann-La Roche Ltd, and Medtronic; data and safety monitoring with Philips; and other interests from AstraZeneca Canada, Novo Nordisk AS, and Pfizer Canada, Inc. Dr Hill reports employment with the University of Calgary; consulting fees from Brainsgate Ltd; grants/contracts from Biogen, Inc, Boehringer Ingelheim, the Canadian Institutes of Health Research, Medtronic, MicroVention, Inc, and NoNO, Inc; being part of the end point review committee at Merck; stock in Circle NVI; and patents for systems of triage in acute stroke. Dr Poppe reports grant funding from the Fondation Brain Canada and the Heart and Stroke Foundation of Canada and research funding from Stryker. Dr Swartz reports stock in FollowMD, Inc, and grants/contracts from the Canadian Institutes of Health Research, the Heart and Stroke Foundation of Canada, the National Institutes of Health, the Ontario Brain Institute, and the Sunnybrook Research Institute. The other authors report no conflicts.

Background: A significant portion of cryptogenic stroke is hypothesized to be secondary to cardiac embolism. However, transthoracic echocardiogram is usually delayed after stroke, and more detailed cardiac imaging is not routinely done., Aims: This study aimed to determine whether non-ECG-gated cardiac CT angiography (cCTA) during hyperacute stroke would provide diagnostic quality images and act as an adjunct modality of cardiac imaging to detect sources of emboli., Methods: In this single-center prospective cohort study, modified Code Stroke imaging was implemented with a 64-slice CT scanner, where the longitudinal axis of CT angiography was extended from the carina to the diaphragm. The primary outcomes of image quality, recruitment feasibility, impact on hyperacute time metrics, and additional radiation dose were assessed. Secondary outcomes consisted of detection of high-risk cardiac sources of embolism, mediastinal or lung pathology, and impact on etiologic classification., Results: One hundred and twenty eligible patients were enrolled, of which 105 (87.5%) had good/moderate quality images for motion artifact and 119 (99.2%) for contrast opacification. Total CT time, door-to-needle time, and door-to-groin puncture time were unchanged with the addition of cCTA. Eighty-nine patients received a final diagnosis of ischemic stroke, of which 12/89 (13.5%) had high-risk cardioembolic findings on cCTA. Incidental findings, such as pulmonary embolism (PE) (7/89, 7.9%) and malignancy (6/89, 6.7%), were observed. cCTA led to changes in management for 19/120 (15.8%) of all patients, and reclassification of stroke etiology for 8/89 (9%) of patients., Conclusions: Non-ECG-gated cCTA can be feasibly incorporated into Code Stroke and provide diagnostic quality images without delays in hyperacute time metrics. It can detect high-risk cardiac sources, and other findings impacting patient care. This may help reclassify a subset of cryptogenic stroke cases and improve secondary prevention., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Understanding sex differences in stroke care is important in reducing potential disparities. Our objective was to explore sex differences in workflow efficiency, treatment efficacy, and safety in the AcT trial (Alteplase Compared to Tenecteplase)., Methods: AcT was a multicenter, registry-linked randomized noninferiority trial comparing tenecteplase (0.25 mg/kg) with alteplase (0.9 mg/kg) in acute ischemic stroke within 4.5 hours of onset. In this post hoc analysis, baseline characteristics, workflow times, successful reperfusion (extended Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracerebral hemorrhage, 90-day functional independence (modified Rankin Scale score, 0-1), and 90-day mortality were compared by sex. Mixed-effects regression analysis was used adjusting for age, stroke severity, and occlusion site for outcomes., Results: Of 1577 patients treated with intravenous thrombolysis (2019-2022), 755 (47.9%) were women. Women were older (median, 77 [68-86] years in women versus 70 [59-79] years in men) and had a higher proportion of severe strokes (National Institutes of Health Stroke Scale score >15; 32.4% versus 24.9%) and large vessel occlusions (28.7% versus 21.5%) compared with men. All workflow times were comparable between sexes. Women were less likely to achieve functional independence (31.7% versus 39.8%; unadjusted relative risk, 0.80 [95% CI, 0.70-0.91]) and had higher mortality (17.7% versus 13.3%; unadjusted relative risk, 1.33 [95% CI, 1.06-1.69]). Adjusted analysis showed no difference in outcomes between sexes., Conclusions: Differences in prognostic factors of age, stroke severity, and occlusion site largely accounted for higher functional dependence and mortality in women. No sex disparities were apparent in workflow quality indicators. Given the integration of the AcT trial into clinical practice, these results provide reassurance that no major sex biases are apparent in acute stroke management throughout participating Canadian centers., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249., Competing Interests: Disclosures Dr Field reports compensation from AstraZeneca, Bayer, BMS-Pfizer, HLS Therapeutics, and Roche for consultant services, the Canadian Medical Protective Association as an expert witness, a grant from Bayer, and is on the board of DESTINE Health. Dr Menon reports stock options in Circle CVI and has consulted for Hoffman-Laroche and Boehringer Ingelheim. Dr Coutts is a principal investigator for the TEMPO-2 trial (A Randomized Controlled Trial of TNK-tPA Versus Standard of Care for Minor Ischemic Stroke With Proven Occlusion) with the study drug (tenecteplase) provided by Boehringer Ingelheim. Dr Hill reports compensation from BrainsGate for consultant services, grants from Boehringer Ingelheim, the Canadian Institutes of Health Research, Medtronic, MicroVention, Inc, and NoNo, Inc, end point review committee work for Merck, and employment as a professor with the University of Calgary. Dr Poppe reports grants from Stryker, Fondation Brain Canada, and the Heart and Stroke Foundation of Canada. Dr Demchuk reports compensation from Boehringer Ingelheim, HLS Therapeutics, Hoffman-Laroche, Medtronic, NovaSignal, and Servier for consultant services, others from AstraZeneca, Novo Nordisk, and Pfizer, data safety monitoring board participation with Philips, and stock and patent for stroke imaging software with Circle NVI. Dr Catanese reports compensation from Hoffman-Laroche for consultant fees and a grant from Servier. Dr Yu reports grants from the Canadian Institutes of Health Research and the Heart and Stroke Foundation of Canada. Dr Deschaintre reports other compensation from the Association des neurologues du Québec, the Société des Sciences Vasculaires du Québec, and the Université du Montréal. Dr Siddiqui reports a grant from Allergan and other compensation from Bayer and Boehringer Ingelheim. Dr Swartz reports grants from the Canadian Institutes of Health Research, the Heart and Stroke Foundation of Canada, the National Institutes of Health, and the Sunnybrook Research Institute and stock in FollowMD, Inc. The other authors report no conflicts.

Background: While virtual care services existed prior to the emergence of COVID-19, the pandemic catalyzed a rapid transition from in-person to virtual care service delivery across the Canadian health care system. Virtual care includes synchronous or asynchronous delivery of health care services through video visits, telephone visits, or secure messaging. Patient advisors are people with patient and caregiving experiences who collaborate within the health care system to share insights and experiences in order to improve health care., Objective: This study aimed to understand patient advisors' perceptions related to virtual care and potential impacts on health care quality., Methods: We adopted a phenomenological approach, whereby we interviewed 20 participants who were patient advisors across Canada using a semistructured interview protocol. The protocol was developed by content experts and medical education researchers. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Data collection stopped once thematic saturation was reached. The study was conducted at Queen's University, Kingston, Ontario. We recruited 20 participants from 5 Canadian provinces (17 female participants and 3 male participants)., Results: Six themes were identified: (1) characteristics of effective health care, (2) experiences with virtual care, (3) modality preferences, (4) involvement of others, (5) risks associated with virtual care encounters, and (6) vulnerable populations. Participants reported that high-quality health care included building relationships and treating patients holistically. In general, participants described positive experiences with virtual care during the pandemic, including greater efficiency, increased accessibility, and that virtual care was less stressful and more patient centered. Participants comparing virtual care with in-person care reported that time, scheduling, and content of interactions were similar across modalities. However, participants also shared the perception that certain modalities were more appropriate for specific clinical encounters (eg, prescription renewals and follow-up appointments). Perspectives related to the involvement of family members and medical trainees were positive. Potential risks included miscommunication, privacy concerns, and inaccurate patient assessments. All participants agreed that stakeholders should be proactive in applying strategies to support vulnerable patients. Participants also recommended education for patients and providers to improve virtual care delivery., Conclusions: Participant-reported experiences of virtual care encounters were relatively positive. Future work could focus on delivering training and resources for providers and patients. While initial experiences are positive, there is a need for ongoing stakeholder engagement and evaluation to improve patient and caregiver experiences with virtual care., (©Heather Braund, Nancy Dalgarno, Sophy Chan-Nguyen, Geneviève Digby, Faizal Haji, Anne O'Riordan, Ramana Appireddy. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 23.11.2023.)

Background: The AcT (Alteplase Compared to Tenecteplase) randomized controlled trial showed that tenecteplase is noninferior to alteplase in treating patients with acute ischemic stroke within 4.5 hours of symptom onset. The effect of time to treatment on clinical outcomes with alteplase is well known; however, the nature of this relationship is yet to be described with tenecteplase. We assessed whether the association of time to thrombolysis treatment with clinical outcomes in patients with acute ischemic stroke differs by whether they receive intravenous tenecteplase versus alteplase., Methods: Patients included were from AcT, a pragmatic, registry-linked, phase 3 randomized controlled trial comparing intravenous tenecteplase to alteplase in patients with acute ischemic stroke. Eligible patients were >18 years old, with disabling neurological deficits, presenting within 4.5 hours of symptom onset, and eligible for thrombolysis. Primary outcome was modified Rankin Scale score 0 to 1 at 90 days. Safety outcomes included 24-hour symptomatic intracerebral hemorrhage and 90-day mortality rates. Mixed-effects logistic regression was used to assess the following: (a) the association of stroke symptom onset to needle time; (b) door (hospital arrival) to needle time with outcomes; and (c) if these associations were modified by type of thrombolytic administered (tenecteplase versus alteplase), after adjusting for age, sex, baseline stroke severity, and site of intracranial occlusion., Results: Of the 1538 patients included in this analysis, 1146 (74.5%; 591 tenecteplase and 555 alteplase) presented within 3 hours versus 392 (25.5%; 196: TNK and 196 alteplase) who presented within 3 to 4.5 hours of symptom onset. Baseline patient characteristics in the 0 to 3 hours versus 3- to 4.5-hour time window were similar, except patients in the 3- to 4.5-hour window had lower median baseline National Institutes of Health Stroke Severity Scale (10 versus 7, respectively) and lower proportion of patients with large vessel occlusion on baseline CT angiography (26.9% versus 18.7%, respectively). Type of thrombolytic agent (tenecteplase versus alteplase) did not modify the association between continuous onset to needle time ( P interaction =0.161) or door-to-needle time ( P interaction =0.972) and primary clinical outcome. Irrespective of the thrombolytic agent used, each 30-minute reduction in onset to needle time was associated with a 1.8% increase while every 10 minutes reduction in door-to-needle time was associated with a 0.2% increase in the probability of achieving 90-day modified Rankin Scale score 0 to 1, respectively., Conclusions: The effect of time to tenecteplase administration on clinical outcomes is like that of alteplase, with faster administration resulting in better clinical outcomes., Registration: URL: https://classic., Clinicaltrials: gov; Unique identifier: NCT03889249., Competing Interests: Disclosures Dr Coutts is principal investigator of the TEMPO-2 trial (A Randomized Controlled Trial of TNK-tPA Versus Standard of Care for Minor Ischemic Stroke With Proven Occlusion), for which Boehringer Ingelheim provides the study drug (tenecteplase). Dr Catanese has received payments by Servier and consulting fees from Ischaemavie RAPID, Circle NV, and Canadian Medical Protective Association. Dr Shankar has a grant from Medtronic to the University of Manitoba. Dr Demchuk has received consulting fees from Medtronic and honoraria from Boehringer Ingelheim. Dr Catanese is on advisory boards for AstraZeneca and Servier and has stock options in AstraZenca. Dr Hill has received consulting fees from Sun Pharma and Brainsgate and has stock options in Circle NVI. Dr Poppe has received a project research grant from Stryker and honoraria from BMS-Pfizer. Dr Sajobi has received consulting fees from Circle NVI. Dr Swartz has stock options in FollowMD and receives salary support for research from the Heart & Stroke Foundation of Canada, Sandra Black Center for Brain Resilience & Recovery, and Ontario Brain Institute. Dr Menon has stock options in Circle CVI and has consulted for Biogen, Roche and Boehringer Ingelheim. The other authors report no conflicts.

Objective: To examine the virtual family conference as an educational, preparatory, and transition planning intervention in stroke rehabilitation., Design: Observational-cross-sectional study., Setting: Inpatient stroke rehabilitation., Subjects: Eighty-seven carers, participating in 48 conferences, were evaluated., Interventions: The virtual family conference, involving the patient, carer(s), and interdisciplinary rehabilitation team, completed prior to community transition. The conference protocol and framework, consisting of nine primary themes and additional sub-themes, are outlined. Teleconferencing was the utilized virtual modality., Main Measures: Carers were assessed via questionnaires regarding pre- and post-conference rated: (1) stroke-related knowledge, (2) satisfaction with information provision, and (3) confidence, preparedness, and stress associated with community transition; by use of the Stroke Knowledge and Community Transition Preparedness Questionnaire, Mant et al . Information Satisfaction Questionnaire, and Kingston Caregiver Stress Scale., Results: Significant improvement in post-conference carer-rating was noted for knowledge, pertaining to stroke nature/impairments, stroke management/prevention, functional status, and community services. Significant gains were demonstrated in post-conference satisfaction with information provided regarding stroke and discharge planning, across all assessed topics. There was also a significant increase in carer-reported confidence and preparedness for the community transition as well as a significant reduction in self-perceived stress for elements of the caregiving role. Organization of community follow-up care was consistently enabled within the proposed framework., Conclusions: The virtual family conference intervention demonstrated efficacy in facilitating carer education and preparation, along with discharge planning prior to community transition from stroke rehabilitation. Thus, illustrating potential benefits of family conferences and feasibility of their virtual application in stroke rehabilitative care.

Importance: It is unknown whether intravenous thrombolysis using tenecteplase is noninferior or preferable compared with alteplase for patients with acute ischemic stroke., Objective: To examine the safety and efficacy of tenecteplase compared to alteplase among patients with large vessel occlusion (LVO) stroke., Design, Setting, and Participants: This was a prespecified analysis of the Intravenous Tenecteplase Compared With Alteplase for Acute Ischaemic Stroke in Canada (ACT) randomized clinical trial that enrolled patients from 22 primary and comprehensive stroke centers across Canada between December 10, 2019, and January 25, 2022. Patients 18 years and older with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly assigned (1:1) to either intravenous tenecteplase or alteplase and were monitored for up to 120 days. Patients with baseline intracranial internal carotid artery (ICA), M1-middle cerebral artery (MCA), M2-MCA, and basilar occlusions were included in this analysis. A total of 1600 patients were enrolled, and 23 withdrew consent., Exposures: Intravenous tenecteplase (0.25 mg/kg) vs intravenous alteplase (0.9 mg/kg)., Main Outcomes and Measures: The primary outcome was the proportion of modified Rankin scale (mRS) score 0-1 at 90 days. Secondary outcomes were an mRS score from 0 to 2, mortality, and symptomatic intracerebral hemorrhage. Angiographic outcomes were successful reperfusion (extended Thrombolysis in Cerebral Infarction scale score 2b-3) on first and final angiographic acquisitions. Multivariable analyses (adjusting for age, sex, National Institute of Health Stroke Scale score, onset-to-needle time, and occlusion location) were carried out., Results: Among 1577 patients, 520 (33.0%) had LVO (median [IQR] age, 74 [64-83] years; 283 [54.4%] women): 135 (26.0%) with ICA occlusion, 237 (45.6%) with M1-MCA, 117 (22.5%) with M2-MCA, and 31 (6.0%) with basilar occlusions. The primary outcome (mRS score 0-1) was achieved in 86 participants (32.7%) in the tenecteplase group vs 76 (29.6%) in the alteplase group. Rates of mRS 0-2 (129 [49.0%] vs 131 [51.0%]), symptomatic intracerebral hemorrhage (16 [6.1%] vs 11 [4.3%]), and mortality (19.9% vs 18.1%) were similar in the tenecteplase and alteplase groups, respectively. No difference was noted in successful reperfusion rates in the first (19 [9.2%] vs 21 [10.5%]) and final angiogram (174 [84.5%] vs 177 [88.9%]) among 405 patients who underwent thrombectomy., Conclusions and Relevance: The findings in this study indicate that intravenous tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO.

COVID-19 has caused an urgent implementation of virtual care (VC). Most research has focused on patient and physician experience with virtual care. Non-physician healthcare providers have played an active role in transitioning to virtual care, yet little is known about their experiences. This study explored their lived experiences in caring for patients virtually. Forty non-physician healthcare providers from local hospitals, community, and home care settings in Kingston, ON, Canada, participated and included nurse practitioners, occupational therapists, physiotherapists, psychologists, registered dietitians, social workers, and speech-language pathologists. Data were collected using semi-structured interviews between February and July 2021 and were analyzed thematically. The study was guided by organizational change theory. Four themes were identified from the data: 1) Quality of care, 2) Resources and training, 3) Healthcare system efficiency, and 4) Health equity and access for patients. Providers suggested that VC increased patient-centredness and had clear benefits for patients. Participants had little to no training in conducting patient care, virtually stating this as a key challenge. They believed that VC increased the efficiency of the healthcare system and was more proactive. Despite concerns regarding inequities across healthcare, participants reported that VC could improve equity as long as patients had access to technology. The study highlights the urgent need to support all healthcare providers in delivering optimal patient-centred care. We should leverage some of the advantages offered by VC to improve the efficiency of healthcare delivery, reduce provider burnout, and increase capacity across organizational systems., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ramana Appireddy reports financial support was provided by 10.13039/501100010661Southeastern Ontario Academic Medical Organization (SEAMO). Ramana Appireddy reports a relationship with Physicians’ Services Inc Foundation that includes: funding grants. Ramana Appireddy reports a relationship with Canada Health Infoway that includes: funding grants. Ramana Appireddy reports a relationship with 10.13039/501100000024Canadian Institutes of Health Research that includes: funding grants., (© 2023 Published by Elsevier Ltd.)

Objective: The objective of this review is to synthesize and appraise the available research on educational strategies required to prepare medical learners for engaging in telemedicine and virtual care., Introduction: The COVID-19 pandemic has resulted in significant uptake of virtual care and telemedicine, highlighting the growing need for health care organizations and medical institutions to support physicians and learners navigating this new model of health care delivery, clinical learning, and assessment. Developing a better understanding of how best to prepare medical trainees across the continuum of undergraduate, postgraduate, and continuing professional development to engage in virtual care is critical in ensuring our continued ability to meet educational mandates and provide ambulatory care that is safe, efficient, and timely., Inclusion Criteria: Eligible studies will include medical learners who receive education on how to deliver telemedicine. The quantitative component of the review will compare learners exposed to educational interventions with learners not exposed to an intervention, or to a different intervention. Outcomes will include competencies in telemedicine delivery, knowledge, and behaviors. The qualitative component of the review will explore learners' experiences with the delivery of educational strategies that address telemedicine., Methods: Embase, MEDLINE, Evidence-Based Medicine Reviews: Cochrane Central Register of Controlled Trials, Web of Science Core Collection, Education Source, and ProQuest Dissertations and Theses Global will be searched to identify published and unpublished studies. No date or language restrictions will be applied. This systematic review will be conducted in accordance with the JBI methodology for mixed methods systematic reviews using a convergent segregated approach. Titles and abstracts of potential studies will be screened, and potentially relevant studies will undergo full-text review for eligibility and critical appraisal of the study methodology. Data will be extracted from those studies selected for inclusion. Findings will be described relating to the effectiveness of educational curricula, initiatives, and best practices in trainee engagement in telemedicine and virtual care., Systematic Review Registration Number: PROSPERO CRD42021264332., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 JBI.)

Objective: The objective of this scoping review is to review the available information on objective performance metrics used during robotic neuroendovascular intervention procedures on humans., Introduction: Robotic neuroendovascular intervention is defined as any endovascular procedure within the vasculature of the central nervous system with the assistance of a robotic system for diagnostic or therapeutic procedures. Robotic systems are described as a 2-component system consisting of a patient-side mechanical robot, and a separate operator control station. Robotic neuroendovascular intervention is a growing field and there is a need to establish objective performance metrics for furthering evidence-based reporting of the literature., Inclusion Criteria: This scoping review will consider all studies involving humans that utilize robotic neuroendovascular intervention. We will consider all types of studies, reports, and reviews as well as gray literature. Studies will be included if they describe the use of an objective performance metric during robotic neuroendovascular intervention. This review is not limited to a particular country or health care system, and will consider all study designs, regardless of their rigor or language., Methods: Utilizing a 3-step framework as a guide, we will perform a systematic search in Embase, Cochrane Library, and MEDLINE. Available literature from inception to the present will be considered. Studies will be independently screened according to the inclusion criteria by 2 reviewers based on title, abstract, and full text. Data will be extracted, sorted, and presented in both a narrative summary as well as table and diagram based on the objective of the scoping review., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 JBI.)

Background: The COVID-19 pandemic resulted in a rapid shift from in-person to virtual care delivery for many medical specialties across Canada. The purpose of this study was to explore the lived experiences of resident physicians and faculty related to teaching, learning and assessment during ambulatory virtual care encounters within the competency-based medical education model., Methods: In this qualitative phenomenological study, we recruited resident physicians (postgraduate year [PGY] 1-5 trainees) and faculty from the Departments of Surgery and Medicine at Queen's University, Ontario, via purposive sampling. Participants were not required to have exposure to virtual care. Interviews were conducted from September 2020 to March 2021 by 1 researcher, and 2 researchers conducted focus groups via Zoom to explore participants' experiences with the transition to virtual care. These were audio-recorded and transcribed verbatim; qualitative data were analyzed thematically., Results: There were 18 male and 19 female participants; 20 were resident physicians and 17 were faculty; 19 were from the Department of Surgery and 18 from the Department of Medicine. All faculty participants had participated in virtual care during ambulatory care; 2 PGY-1 residents in surgery had not actively participated in virtual care, although they had participated in clinics where faculty were using virtual care. The mean age of faculty participants was 38 (standard deviation [SD] 8.6) years, and the mean age of resident physicians was 29 (SD 5.4) years. Overall, 28 interviews and 4 focus groups (range 2-3 participants per group) were conducted, and 4 themes emerged: teaching and learning, assessment, logistical considerations, and suggestions. Barriers to teaching included the lack of direct observations and teaching time, and barriers to assessment included an absence of specific Entrustable Professional Activities (EPAs) and feedback focused on virtual care-related competencies. Logistical challenges included lack of technological infrastructure, insufficient private office space and administrative burdens. Both resident physicians and faculty did not foresee virtual care limiting resident physicians' ability to progress within competency-based medical education. Benefits of virtual care included increased accessibility to patients for follow-up visits, for disclosing patients' results and for out-of-town visits. Suggestions included faculty development, improved access to technology and space, educational guidelines for conducting virtual care encounters, and development of virtual care-specific competencies and EPAs., Interpretation: In the postgraduate program we studied, virtual care imposed substantial barriers on teaching, learning and assessment during the first year of the COVID-19 pandemic. Adapting to new circumstances such as virtual care with suggestions from resident physicians and faculty may help to ensure the continuity of postgraduate medical education throughout the COVID-19 pandemic., Competing Interests: Competing interests: Ramana Appireddy has received research funding from the PSI Foundation, Canadian Institutes of Health Research, Canada Health Infoway and Southeastern Ontario Academic Medical Organization. Boris Zevin has received an education grant from Ethicon. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Background: Intravenous thrombolysis with alteplase bolus followed by infusion is a global standard of care for patients with acute ischaemic stroke. We aimed to determine whether tenecteplase given as a single bolus might increase reperfusion compared with this standard of care., Methods: In this multicentre, open-label, parallel-group, registry-linked, randomised, controlled trial (AcT), patients were enrolled from 22 primary and comprehensive stroke centres across Canada. Patients were eligible for inclusion if they were aged 18 years or older, with a diagnosis of ischaemic stroke causing disabling neurological deficit, presenting within 4·5 h of symptom onset, and eligible for thrombolysis per Canadian guidelines. Eligible patients were randomly assigned (1:1), using a previously validated minimal sufficient balance algorithm to balance allocation by site and a secure real-time web-based server, to either intravenous tenecteplase (0·25 mg/kg to a maximum of 25 mg) or alteplase (0·9 mg/kg to a maximum of 90mg; 0·09 mg/kg as a bolus and then a 60 min infusion of the remaining 0·81 mg/kg). The primary outcome was the proportion of patients who had a modified Rankin Scale (mRS) score of 0-1 at 90-120 days after treatment, assessed via blinded review in the intention-to-treat (ITT) population (ie, all patients randomly assigned to treatment who did not withdraw consent). Non-inferiority was met if the lower 95% CI of the difference in the proportion of patients who met the primary outcome between the tenecteplase and alteplase groups was more than -5%. Safety was assessed in all patients who received any of either thrombolytic agent and who were reported as treated. The trial is registered with ClinicalTrials.gov, NCT03889249, and is closed to accrual., Findings: Between Dec 10, 2019, and Jan 25, 2022, 1600 patients were enrolled and randomly assigned to tenecteplase (n=816) or alteplase (n=784), of whom 1577 were included in the ITT population (n=806 tenecteplase; n=771 alteplase). The median age was 74 years (IQR 63-83), 755 (47·9%) of 1577 patients were female and 822 (52·1%) were male. As of data cutoff (Jan 21, 2022), 296 (36·9%) of 802 patients in the tenecteplase group and 266 (34·8%) of 765 in the alteplase group had an mRS score of 0-1 at 90-120 days (unadjusted risk difference 2·1% [95% CI - 2·6 to 6·9], meeting the prespecified non-inferiority threshold). In safety analyses, 27 (3·4%) of 800 patients in the tenecteplase group and 24 (3·2%) of 763 in the alteplase group had 24 h symptomatic intracerebral haemorrhage and 122 (15·3%) of 796 and 117 (15·4%) of 763 died within 90 days of starting treatment INTERPRETATION: Intravenous tenecteplase (0·25 mg/kg) is a reasonable alternative to alteplase for all patients presenting with acute ischaemic stroke who meet standard criteria for thrombolysis., Funding: Canadian Institutes of Health Research, Alberta Strategy for Patient Oriented Research Support Unit., Competing Interests: Declaration of interests BKM has stock options in Circle NVI and has consulted for Biogen and Boehringer Ingelheim. SBC is principal investigator of the TEMPO-2 trial, for which Boehringer Ingelheim provides the study drug (tenecteplase). LC has received payments by Servier and consulting fees from Ischaemavie RAPID, Circle NV, and Canadian Medical Protective Association. JS has a grant from Medtronic to the University of Manitoba. AMD has received consulting fees from Medtronic and honoraria from Boehringer Ingelheim. LCG is on advisory boards for AstraZeneca and Servier and has stock options in AstraZenca. ASh has received consulting fees from Bayer, Servier Canada, Daiichi Sanyko Compan, AstraZeneca, VarmX, and Takeda; honoraria from Bayer and Daiichi Sankyo; is on an advisory board for Bayer; and has stock options in Ensho. MDH has received consulting fees from Sun Pharma and Brainsgate and has stock options in Circle NVI. DJG has received consulting fees from HSL Therapeutics. APo has received a project research grant from Stryker and honoraria from BMS-Pfizer. TTS has received consulting fees from Circle NVI. RHS has stock options in FollowMD and receives salary support for research from the Heart & Stroke Foundation of Canada, Sandra Black Centre for Brain Resilience & Recovery, and Ontario Brain Institute. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Since the onset of the COVID-19 pandemic, virtual care solutions have been rapidly adopted across the country to provide safe, quality care to diverse patient populations. The objective of this qualitative case study was to understand patient and caregiver experiences of virtual care to identify barriers and gather suggestions to address them., Methods: In this patient-oriented project, we sought to understand gaps in virtual care experienced by patients and caregivers, using virtual focus groups. With the assistance of a patient research liaison, we engaged 2 patient partners as full partners; they participated in study conception, data collection, data analysis and knowledge translation. Recruitment was done through email by disseminating the study poster to 30 community organizations and health units in Ontario and British Columbia. We conducted a constructivist, qualitative study guided by grounded theory methodology. One researcher employed in-vivo coding, followed by axial coding with focus group participants, followed by selective coding with the study team. The study took place from November to December 2020., Results: We conducted 6 focus groups with 13 patients and 5 caregivers. The analysis resulted in 6 major themes and 17 minor themes. Key findings showed that barriers related to access to technology and Internet, language and cultural differences were challenges to virtual care. Participants identified special considerations surrounding caregiver and family involvement; privacy, consent and confidentiality; and the patient-physician relationship. Participants suggested that technology and the Internet be universally accessible and that virtual care modalities be integrated (e.g., consolidated patient portal) to improve virtual care., Interpretation: There are multiple patient-identified barriers to accessing virtual care in Canada; patients can provide insights into ways to address these barriers. Future research should include robust patient engagement to explore ways to address these challenges and barriers to ensure that virtual care can be equitable, accessible and safe for all users., Plain Language Summary: Although virtual care has been rapidly adopted and scaled up in health care institutions across the country, few improvements informed by patient and caregiver experiences have been made. Driven by concerns expressed by patient partners, our study team undertook a patient-partnered qualitative study to understand the barriers of virtual care from the perspectives and experiences of patients and caregivers. Our study team created the interview guide drawing from our previous patient-oriented qualitative studies and designed an orientation package to provide resources related to the focus groups and to introduce participants to the study team. Drawing from local health teams, clinics and patient advisory groups, the study team recruited 13 patients and 5 caregivers to participate in 6 focus group interviews. An analysis based on grounded theory was undertaken, with participation from both the study team and participants. Lack of access to technology or Internet and language barriers were determined to be the primary challenges in virtual care. Special considerations to caregiver and family involvement, privacy and confidentiality, as well as the patient-physician relationship were considered priorities to improving access to virtual care. Participants offered recommendations and potential solutions to address barriers and challenges in virtual care, which can serve to encourage large-scale policy and programmatic changes in patient-centred ways., Competing Interests: Competing interests: Ramana Appireddy reports support from the Canadian Institutes of Health Research (CIHR, project # 432988) and Canada Health Infoway for the present manuscript, and research grants from CIHR, PSI Foundation, Canada Health Infoway, Department of Medicine, Queen’s University, Southeastern Ontario Academic Medical Organization, and Kingston General Hospital Research Institute. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Objectives: The COVID-19 pandemic has led to the widespread uptake of virtual care in Canada; however, virtual care may also create new barriers to health care. The purpose of this paper was to explore patient perceptions and concerns around virtual care access., Methods: Between February and April 2020, we conducted semi-structured interviews with participants from four chronic disease clinics (stroke, epilepsy, amyotrophic lateral sclerosis, obstetrics medicine) in a mid-sized academic hospital in Southern Ontario, Canada. Consecutive sampling was done by including the patients receiving virtual care in those months. Caregivers were invited to participate in the event that patients were unable to participate in the interview. Thematic analysis was employed to identify overarching themes, and codes were reviewed and refined using a consensus process., Results: We interviewed 31 participants (27 patients, four caregivers) that had taken part in virtual care. Our findings suggested that the COVID-19 pandemic served to isolate participants and had negatively impacted their access to health care. However, virtual care did provide a safe avenue for patients to receive care and served as a reassuring option during the pandemic. Low technological literacy and access were identified as barriers to virtual care. Greater awareness and patient engagement is needed in future research to improve access., Conclusion: Certain populations can be disproportionately affected by differential access to virtual care. Future studies should examine how social determinants intersect to impact virtual health care access in different patient populations., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RA reports research grants from CIHR, PSI Foundation, Ontario, Canada Health Infoway, Department of Medicine, Queen's University, Southeastern Ontario Academic Medical Organization, Kingston General Hospital Research Institute, (© The Author(s) 2022.)

Background: In patients with Parkinson's disease (PD), the occurrence of motor and non-motor symptoms increases with disease progression. The range of neuropsychiatric symptoms (NPS) vary among individuals and can be burdensome for caregivers. Only a few studies have identified the contributing factors of NPS and caregiver burden in India., Objectives: We aimed to study the clinical profile, disability, and predictive factors of NPS in PD patients and associated caregiver's burden., Methods and Material: This was a cross-sectional observational study carried out in PD patients and their respective caregivers attending a movement disorder clinic in a tertiary care teaching hospital in Kerala. A total of 104 patients diagnosed with idiopathic PD receiving levodopa therapy and who had a primary caregiver were enrolled in the study. Structured questionnaires were administered to both patients and caregivers to collect data. Data analysis was done using an independent t-test, linear, and multiple regression analysis., Results: Among 104 patients recruited for the study, 61.5% of patients had shown at least one NPS and 40.44% showed multiple NPS. Results from the study showed that depression is the primary NPS occurring in IPD patients (55.8%) followed by irritability, anxiety, and apathy. On linear regression models, the prime determinant of NPS was the Everyday Abilities Scale for India (EASI). For caregiver burden, the main determinants were the presence of NPS, duration of caregiving, EASI, and RBDSQ score., Conclusions: NPS in PD are highly associated with and are determinants of caregiver burden. Detailed assessment and specific interventions aimed at NPS could alleviate caregiver burden., Competing Interests: None

Objective: The objective of this study is to assess the role of prior experience with virtual care (through e-visits) in maintaining continuity in ambulatory epilepsy care during an unprecedented pandemic situation, comparing in person versus e-visit clinic uptake., Methods: This is an observational study on virtual epilepsy care (through e-visits) over two years, during a pre-COVID period (14 months) continuing into the COVID-19 pandemic period (10 months). For a small initial section of patients seen during the study period a physician survey and a patient satisfaction survey were completed (n = 53). Outcomes of eVisits were analyzed using descriptive statistics., Results: Median numbers of epilepsy clinic visits conducted during the COVID-19 period (27.5 new and 113 follow up) remained similar to the median uptake during the pre-COVID period (28 new and 116 follow up). Prior experience with e-visits for epilepsy yielded smooth transition into the pandemic period, with several other advantages. The majority of eVisits were successful despite technical difficulties and major components of history and management were still easily implemented. Results from patient surveys supported that a significant amount of time and money were saved, which was in keeping with our health-economic analysis., Conclusion: Our study is one of the first few reports of fully integrated virtual care in a comprehensive epilepsy clinic starting much before start of the COVID-19 pandemic. The results of our study support the feasibility of using virtual care to deliver specialized outpatient care in a comprehensive epilepsy center., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: The objective of this study is to understand the perceptions of new mothers using virtual care via video conferencing to gain insight into the benefits and barriers of virtual care for obstetric patients., Methods: Semi-structured interviews were conducted with 15 patients attending the Kingston Health Sciences Centre. The interviews were 20-25 min in length and recorded through an audio recorder. Thematic analysis was conducted in order to derive the major themes explored in this study., Results: New mothers must often adopt new routines to balance their needs and their child's needs. These routines could impact compliance and motivation to attend follow-up care. In our study, participants expressed high satisfaction with virtual care, emphasizing benefits related to comfort, convenience, communication, socioeconomic factors, and the ease of technology use. Participants also perceived that they could receive emotional support and build trust with their health care providers despite the remote nature of their care. Due to its ease of use and increased accessibility, we argue that virtual care shows promise to facilitate long-term compliance to care in obstetric patients., Conclusions: Virtual care is a useful modality that could improve compliance to obstetric care. Further research and clinical endeavours should examine how social factors and determinants intersect to determine how they underpin patient perceptions of virtual and in-person care., (© 2021. The Author(s).)

Virtual care, the use of videoconferencing technology to connect with patients, has become critical in providing continuing care for patients during the current COVID-19 pandemic. Virtual care has now been adopted by health care providers across the spectrum, including physicians, residents, nurse practitioners, nurses, and allied health care professionals. Virtual care is novel and nuanced compared to in-person care. Most of the health care providers who are delivering or expected to deliver virtual care have little to no prior experience with it. The nuances of virtual care involve regulatory standards, platforms, technology and troubleshooting, patient selection, etiquette, and workflow, all of which comprise critical points in the provision of health care. It is important to consistently deliver high-quality, equitable, and professional virtual care to inspire patients with the trust they need to continue follow-up of their care in these difficult times. We have been adopting virtual care in our clinical practice for over two years. In partnership with Canada Health Infoway, we have assembled a primer for virtual care that can serve as a guide for any health care provider in Canada and globally, with the goal of providing seamless transitions between in-person and virtual care., (©Andy Wong, Rashaad Bhyat, Siddhartha Srivastava, Lysa Boissé Lomax, Ramana Appireddy. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.01.2021.)

Objective: The study sought to explore the experiences of participants affected by stroke with home video visit (HVV) for follow-up visits in order to understand the determinants, barriers, and benefits associated with HVVs., Methods: Semi-structured interviews were conducted with (n = 23) participants to gather insight and descriptive information about patients' experiences with HVV. Specifically, we sought to collect descriptions about the (1) costs and time associated with in-person visits, (2) facilitators and barriers to in-person and virtual visits, and (3) their values attached to traditional and virtual forms of patient care., Results: HVVs were perceived to be a mode of healthcare that is time-saving and convenient for both participants and physicians. However, our study also found some participants felt uncomfortable using technology to conduct medical visits while others still supported a positive view of traditional forms of in-person visits because they valued the in-person interactions and safe environment of the hospital., Conclusion: While HVVs were considered to be useful in addressing geographical barriers to health care, technological and digital health literacy may serve to impede seniors from using the service, with some of them opting to go to the hospital despite geographical barriers. Resultantly, HVVs may serve both to alleviate and exacerbate certain determinants to health care.

The COVID-19 crisis has worsened the pre-existing barriers to accessing neurological specialist care in Low and middle income countries. Telemedicine has been available for well over 2 decades but has not been widely adopted in LMIC's due to issues around cost, feasibility, infrastructure and regulation. Virtual care is an offshoot of traditional telemedicine leveraging the widely available internet enabled devices to connect patients with their healthcare providers. In this manuscript, we provide an overview of the virtual care, relevance to neurology and some guidance on implementing virtual care in an Indian context., Competing Interests: Dr. Appireddy reports grants from CIHR, Canada Health Infoway, Department of Medicine, Queen’s University, PSI Foundation, Ontario, AHSC Innovation Fund, SEAMO, KGHRI, towards virtual care research and during the conduct of the study.; Dr. Chaitanya, Dr. Shukla and Dr. Bendahan has nothing to disclose., (Copyright: © 2006 - 2020 Annals of Indian Academy of Neurology.)

Background: Timely, in-person access to health care is a challenge for people living with conditions such as stroke that result in frailty, loss of independence, restrictions in driving and mobility, and physical and cognitive decline. In Southeastern Ontario, access is further complicated by rurality and the long travel distances to visit physician clinics. There is a need to make health care more accessible and convenient. Home virtual visits (electronic visits, eVisits) can conveniently connect physicians to patients. Physicians use a secure personal videoconferencing tool to connect to patients in their homes. Patients use their device of choice (smartphone, tablet, laptop, or desktop) for the visit., Objective: This study aimed to assess the feasibility and logistics of implementing eVisits in a stroke prevention clinic for seniors., Methods: A 6-month eVisit pilot study was initiated in the Kingston Health Sciences Centre stroke prevention clinic in August 2018. eVisits were used only for follow-up patient encounters. An integrated evaluation was used to test the impact of the program on clinic workflow and patient satisfaction. Patient satisfaction was evaluated by telephone interviews, using a brief questionnaire. Access and patient satisfaction metrics were compared with concurrent standard of care (patients' prior personal experience with in-person visits). Values are presented as median (interquartile range)., Results: There were 75 subjects in the pilot. The patients were aged 65 (56-73.5) years, and 39% (29/75) resided in rural areas. There was a shorter wait for an appointment by eVisit versus in-person (mean 59.98 [SD 48.36] days vs mean 78.36 [SD 50.54] days; P<.001). The eVisit was also shorter, taking on an average of only 10 min to deliver follow-up care with a high degree of patient satisfaction versus 90 (60-112) min for in-person care. The total time saved by patients per eVisit was 80 (50-102) min, 44 (21-69) min of which was travel time. Travel distance avoided by the patients was 30.1 km (11.2-82.2). The estimated total out-of-pocket cost savings for patients per eVisit was Can $52.83 (31.26-94.53). The estimated savings (opportunity cost for in-person outpatient care) for our eVisit pilot project was Can $23,832-$28,584. The patient satisfaction with eVisits was very good compared with their prior personal experience with in-person outpatient care., Conclusions: The eVisit program was well received by patients, deemed to be safe by physicians, and avoided unnecessary patient travel and expense. It also has the potential to reduce health care costs. We plan to scale the project within the department and the institution., (©Ramana Appireddy, Sana Khan, Chad Leaver, Cally Martin, Albert Jin, Bryce A Durafourt, Stephen L Archer. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.10.2019.)

Moyamoya disease is a chronic progressive cerebrovascular occlusive disease of the terminal portion of the internal carotid arteries associated with an acquired abnormal vascular network at the base of the brain, often leading to ischemic or hemorrhagic stroke. Moyamoya disease is a relatively common cause of pediatric stroke with a specific racial and well-identified clinical and imaging phenotype. Moyamoya disease is more prevalent in East Asian countries compared with other geographic regions with a higher incidence of familial cases and clinically more aggressive form. Moyamoya disease is one of the few causes of stroke that is amenable to effective surgical revascularization treatment. There are various surgical options available for revascularization, including the direct, indirect, or combined bypass techniques, each with variable responses. However, due to the heterogeneity of the diseases, different clinical course, geographical variables associated with the disease, and availability of a wide variety of surgical revascularization procedures, optimal selection of a surgical candidate and the surgical technique becomes challenging, particularly in the pediatric population. This brief review presents pertinent literature of clinical options for the diagnosis and surgical treatment of moyamoya disease in children.

Competing Interests: None

Background: Patients undergoing endovascular therapy for acute ischemic stroke may require general anesthesia to undergo the procedure. At present, there is little clinical evidence to guide the choice of anesthetic in this acute setting. The clinical implications of experimental studies demonstrating anesthetic neuroprotection are poorly understood. Here, the authors evaluated the impact of anesthetic treatment on neurologic outcome in experimental stroke., Methods: Controlled studies of anesthetics in stroke using the filament occlusion model were identified in electronic databases up to December 15, 2015. The primary outcome measures, infarct volume, and neurologic deficit score were used to calculate the normalized mean difference for each comparison. Meta-analysis of normalized mean difference values provided estimates of neuroprotection and contributions of predefined factors: study quality, the timing of treatment, and the duration of ischemia., Results: In 80 retrieved publications anesthetic treatment reduced neurologic injury by 28% (95% CI, 24 to 32%; P < 0.0001). Internal validity was high: publication bias enhanced the effect size by 4% or less, effect size increased with study quality (P = 0.0004), and approximately 70% of studies were adequately powered. Apart from study quality, no predefined factor influenced neuroprotection. Neuroprotection failed in animals with comorbidities. Neuroprotection by anesthetics was associated with prosurvival mechanisms., Conclusions: Anesthetic neuroprotection is a robust finding in studies using the filament occlusion model of ischemic stroke and should be assumed to influence outcomes in studies using this model. Neuroprotection failed in female animals and animals with comorbidities, suggesting that the results in young male animals may not reflect human stroke.

Introduction: Stroke is the third leading cause of death and disability in Canada. In the hyperacute stroke setting, the treating physician must make a time critical decision on the treatment of each patient. Recent advances in imaging help the treating physician identify the subgroup of patients eligible for acute treatment of ischaemic stroke., Areas Covered: In this review we will discuss Non-Contrast Computed Tomography (NCCT), CT-Angiography (CTA), and CT-Perfusion (CTP) in assessment of patients with acute ischaemic stroke and intracerebral haemorrhage. Intravenous tPA was the only proven therapy for acute ischaemic stroke presenting within 4.5 hours, until the five recent trials proved the efficacy of EVT for acute ischaemic stroke with proximal arterial occlusion. Imaging played a major role in patient selection in all five trials. Expert commentary: The challenge of rapid clinical assessment, review of imaging and timely treatment will continue to be made easier as the development and understanding of imaging progresses.

After many years of clinical research, endovascular thrombectomy has been conclusively proven to be an effective treatment in acute ischemic stroke. The evidence is compelling; however, it is generated in high volume stroke centers with stroke expertise. Challenges remain ahead on translating and implementing this evidence in routine clinical care across the world. The current evidence has opened up avenues for further research and innovation in this field. In this review, we will discuss the evolution of evidence on endovascular thrombectomy followed by a discussion of challenges and future prospects in this exciting field of stroke care.

The utility of intravenous tissue plasminogen activator (IV t-PA) in improving the clinical outcomes after acute ischemic stroke has been well demonstrated in past clinical trials. Though multiple initial small series of endovascular stroke therapy had shown good outcomes as compared to IV t-PA, a similar beneficial effect had not been translated in multiple randomized clinical trials of endovascular stroke therapy. Over the same time, there have been parallel advances in imaging technology and better understanding and utility of the imaging in therapy of acute stroke. In this review, we will discuss the evolution of endovascular stroke therapy followed by a discussion of the key factors that have to be considered during endovascular stroke therapy and directions for future endovascular stroke trials.