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Background and Objectives:In the United States, Black, Hispanic, and Asian Americans suffer from excessively high incidence rates of hemorrhagic stroke compared to White Americans. Women suffer from higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity.Methods:We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke.Results:After reviewing 6161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control following intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life-care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care.Discussion:Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke.

Background and ObjectivesStroke in young adults constitutes 15%–18% of all ischemic stroke cases. Black individuals have an excess risk of ischemic stroke especially in young adults. Although it is known that Black patients have a higher prevalence of hypertension and diabetes, few studies have addressed the association of concurrent multiple vascular risk factors with the excess risk of early-onset stroke among Black individuals.MethodsA population-based case-control study of early-onset ischemic stroke, ages 15–49 years, was conducted in the Baltimore-Washington DC region between 1992 and 2007. Presence of the risk factors of obesity, hypertension, diabetes, and current smoking were obtained from both cases and controls by an in-person interview. Risk factor groups were defined as (1) 1 risk factor, (2) 2 risk factors, (3) 3 risk factors, and (4) 4 risk factors. Logistic regression analysis adjusting for age and sex was used to evaluate the association between each risk factor group and ischemic stroke compared with the reference group with no risk factors.ResultsThe study included 1,034 cases and 1,091 controls. Of the cases, 47% were Black, 54% were men, and the mean (±SD) age was 41.0 (±6.9) years. The odds of having a stroke increased exponentially as the number of risk factors increased, 2.1, 2.6, 7.6, 16.5, allp< 0.001, for groups 1–4, respectively. When stratified by race, Black individuals were approximately 6 times more likely to have all 4 risk factors.DiscussionThe risk of stroke in young adults increased exponentially with the number of risk factors. Young Black patients with ischemic stroke were approximately 6 times more likely to have the co-occurrence of obesity, hypertension, diabetes, and smoking compared with their White counterparts. Targeting public health interventions to identify and improve care to Black young adults with multiple stroke risk factors may have substantial impact on lowering risk of stroke.

Background:Cerebral venous sinus stenting (VSS) has emerged as a new surgical procedure for the treatment of severe IIH, and its popularity has been anecdotally on the rise. This study explores recent temporal trends of VSS and other surgical IIH treatments in the United States.Methods:Adult IIH patients were identified from the 2016-20 National Inpatient Sample databases, and surgical procedures and hospital characteristics were recorded. Temporal trends of procedure numbers for VSS, cerebrospinal fluid (CSF) shunts, and optic nerve sheath fenestrations (ONSF) were assessed and compared.Results:46,065 [95%CI: 44,710-47,420] IIH patients were identified, of whom 7,535 patients [95%CI: 6,982-8,088] received surgical IIH treatments. VSS procedures increased 80% (150 [95%CI: 55-245] to 270 [95%CI: 162-378] per year, pConclusions:Practice patterns for surgical IIH treatment in the United States are rapidly evolving, and VSS is becoming increasingly common. These findings highlight the urgency of randomized controlled trials to investigate the comparative effectiveness and safety of VSS, CSF shunts, ONSF, and standard medical treatments.

Background and ObjectiveTo test the hypothesis that age-specific, sex-specific, and race-specific and ethnicity-specific incidence of nontraumatic subarachnoid hemorrhage (SAH) increased in the United States over the last decade.MethodsIn this retrospective cohort study, validated International Classification of Diseases codes were used to identify all new cases of SAH (n = 39,475) in the State Inpatients Databases of New York and Florida (2007–2017). SAH counts were combined with Census data to calculate incidence. Joinpoint regression was used to compute the annual percentage change (APC) in incidence and to compare trends over time between demographic subgroups.ResultsAcross the study period, the average annual age-standardized/sex-standardized incidence of SAH in cases per 100,000 population was 11.4, but incidence was significantly higher in women (13.1) compared with that in men (9.6),p< 0.001. Incidence also increased with age in both sexes (men aged 20–44 years: 3.6; men aged 65 years or older: 22.0). Age-standardized and sex-standardized incidence was greater in Black patients (15.4) compared with that in non-Hispanic White (NHW) patients (9.9) and other races and ethnicities,p< 0.001. On joinpoint regression, incidence increased over time (APC 0.7%,p< 0.001), but most of this increase occurred in men aged 45–64 years (APC 1.1%,p= 0.006), men aged 65 years or older (APC 2.3%,p< 0.001), and women aged 65 years or older (APC 0.7%,p= 0.009). Incidence in women aged 20–44 years declined (APC −0.7%,p= 0.017), while those in other age/sex groups remained unchanged over time. Incidence increased in Black patients (APC 1.8%,p= 0.014), whereas that in Asian, Hispanic, and NHW patients did not change significantly over time.DiscussionNontraumatic SAH incidence in the United States increased over the last decade predominantly in middle-aged men and elderly men and women. Incidence is disproportionately higher and increasing in Black patients, whereas that in other races and ethnicities did not change significantly over time.

For many years, stroke has been recognized as a coronary risk equivalent.1 This means that patients with a previous ischemic stroke are at sufficiently high risk for cardiac ischemic events over the next decade that they warrant intensive medical management. This includes antithrombotic therapy, high-potency statins, blood pressure control, and treatment of lifestyle factors such as smoking, diet, and physical activity.2

Objective:To evaluate trends in prevalence of cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking, and drug abuse) and cardiovascular diseases (carotid stenosis, chronic renal failure [CRF], and coronary artery disease [CAD]) in acute ischemic stroke (AIS) in the United States.Methods:We used the 2004–2014 National Inpatient Sample to compute weighted prevalence of each risk factor in hospitalized patients with AIS and used joinpoint regression to evaluate change in prevalence over time.Results:Across the 2004–2014 period, 92.5% of patients with AIS had ≥1 risk factor. Overall age- and sex-adjusted prevalence of hypertension, diabetes, dyslipidemia, smoking, and drug abuse were 79%, 34%, 47%, 15%, and 2%, respectively, while those of carotid stenosis, CRF, and CAD were 13%, 12%, and 27%, respectively. Risk factor prevalence varied by age (hypertension: 44% in 18–39 years vs 82% in 60–79 years), race (diabetes: Hispanic 49% vs white 30%), and sex (drug abuse: men 3% vs women 1.4%). Using joinpoint regression, prevalence of hypertension increased annually by 1.4%, diabetes by 2%, dyslipidemia by 7%, smoking by 5%, and drug abuse by 7%. Prevalence of CRF, carotid stenosis, and CAD increased annually by 13%, 6%, and 1%, respectively. Proportion of patients with multiple risk factors also increased over time.Conclusions:Despite numerous guidelines and prevention initiatives, prevalence of hypertension, diabetes, dyslipidemia, smoking, and drug abuse in AIS increased across the 2004–2014 period. Proportion of patients with carotid stenosis, CRF, and multiple risk factors also increased. Enhanced risk factor modification strategies and implementation of evidence-based recommendations are needed for optimal stroke prevention.

ObjectiveTo test the hypothesis that race-, age-, and sex-specific incidence of cerebral venous thrombosis (CVT) has increased in the United States over the last decade.MethodsIn this retrospective cohort study, validated ICD codes were used to identify all new cases of CVT (n = 5,567) in the State Inpatients Databases (SIDs) of New York and Florida (2006–2016). A new CVT case was defined as first hospitalization for CVT in the SID without prior CVT hospitalization. CVT counts were combined with annual Census data to compute incidence. Joinpoint regression was used to evaluate trends in incidence over time.ResultsFrom 2006 to 2016, annual age- and sex-standardized incidence of CVT in cases per 1 million population ranged from 13.9 to 20.2, but incidence varied significantly by sex (women 20.3–26.9, men 6.8–16.8) and by age/sex (women 18–44 years of age 24.0–32.6, men 18–44 years of age 5.3–12.8). Incidence also differed by race (Blacks: 18.6–27.2; Whites: 14.3–18.5; Asians: 5.1–13.8). On joinpoint regression, incidence increased across 2006 to 2016, but most of this increase was driven by an increase in all age groups of men (combined annualized percentage change [APC] 9.2%, p < 0.001), women 45 to 64 years of age (APC 7.8%, p < 0.001), and women ≥65 years of age (APC 7.4%, p < 0.001). Incidence in women 18 to 44 years of age remained unchanged over time.ConclusionCVT incidence is disproportionately higher in Blacks compared to other races. New CVT hospitalizations increased significantly over the last decade mainly in men and older women. Further studies are needed to determine whether this increase represents a true increase from changing risk factors or an artifactual increase from improved detection.

To evaluate trends in atrial fibrillation (AF) prevalence in acute ischemic stroke (AIS) and TIA in the United States.We used the Nationwide Inpatient Sample to retrospectively compute weighted prevalence of AF in AIS (n = 4,355,140) and TIA (n = 1,816,459) patients admitted to US hospitals from 2004 to 2013. Multivariate-adjusted models were used to evaluate the association of AF with clinical factors, mortality, length of stay, and cost.From 2004 to 2013, AF prevalence increased by 22% in AIS (20%-24%) and by 38% in TIA (12%-17%). AF prevalence varied by age (AIS: 6% in 50-59 vs 37% in ≥80 years; TIA: 4% in 50-59 vs 24% in ≥80 years), sex (AIS: male 19% vs female 25%; TIA: male 15% vs female 14%), race (AIS: white 26% vs black 12%), and region (AIS: Northeast 25% vs South 20%). Advancing age, female sex, white race, high income, and large hospital size were associated with increased odds of AF in AIS. AF in AIS was a risk factor for in-hospital death (odds ratio 1.93, 95% confidence interval 1.89-1.98) but mortality in AIS with AF decreased from 11.6% to 8.3% (p0.001). Compared to no AF, AF was associated with increased cost of $2,310 and length of stay 1.1 days in AIS.AF prevalence in AIS and TIA has continued to increase. Disparity in AF prevalence in AIS and TIA exists by patient and hospital factors. AF is associated with increased mortality in AIS. Innovative AIS preventive strategies are needed in patients with AF, especially in the elderly.

Having more than one-third of the world's 7.6 billion population, China and India experience heavy personal, social, and financial costs of stroke and other vascular disease, in the context of having a high prevalence of background vascular risk and rapidly evolving demography (aging, urbanization), lifestyles (sedentary, diet), and economies. However, their differing health care systems and insurance schemes may influence the patterns of care and recovery from stroke, but to date, no one has directly quantified this. The article by Li et al.1 in this issue of Neurology ® is therefore a welcome contribution to defining the comparative patient profile, as well as the management and outcomes, for acute ischemic stroke (AIS) between these 2 countries.

We thank Dr. Hsieh for the interest in our study that investigated prevalence of vascular risk factors in stroke patients.1

The “Time is brain” concept should be familiar to anyone who cares for patients with acute ischemic stroke. IV tissue plasminogen activator (tPA) reduces disability after stroke when administered within 4.5 hours of symptom onset, but the benefit of IV tPA is time-dependent.1 Earlier treatment improves functional outcomes. Quantified many ways, studies provide estimates in terms of functional outcome at 90 days, neurons saved, and days of disability-free life gained.1–3 As a result, door-to-needle time, defined as the time from hospital arrival to the initiation of IV tPA, has become an important quality metric for stroke hospitals around the world.

Carotid endarterectomy (CEA) remains one of the most commonly performed vascular surgical procedures. Strong, but somewhat outdated data1 demonstrate the benefit of CEA for stroke prevention in select patients with symptomatic and asymptomatic stenosis. Prior investigation and commentary have underscored the effect of surgeon volumes and experience on CEA outcomes. But, what about patient characteristics? In addition to traditional risk stratification factors (symptomatic vs asymptomatic, time of most recent cerebrovascular event, patient sex), do clinicians need to heed other patient variables?

Objective:To compare comorbidities and use of surgery and palliative care between men and women with intracerebral hemorrhage (ICH).Methods:The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a prospective, multicenter, case-control study of ICH risk factors and outcomes. We compared comorbidities, treatments, and use of do-not-resuscitate (DNR) orders in men vs women. Multivariate analysis was used to assess the likelihood of ICH surgery and palliative care after adjustment for variables that were p < 0.1 in univariate analyses and backward elimination to retain those that were significant (p < 0.05).Results:Women were older on average (65.0 vs 59.9, p < 0.0001), and higher proportions of women had previous stroke (24.1% vs 19.3%, p = 0.002), had dementia (6.1% vs 3.4%, p = 0.0007), lived alone (23.1% vs 18.0%, p = 0.0005), and took anticoagulants (12.8% vs 10.1% p = 0.02), compared with men. Men had higher rates of alcohol and cocaine use. After adjusting for age, hematoma volume, and ICH location, there was no difference in rates of surgical treatment by sex (odds ratio [OR] 0.93 for men vs women, 95% confidence interval [CI] 0.68–1.28, p = 0.67), and there was no difference in DNR/comfort care decisions after adjustment for ICH score, prior stroke, and dementia (OR 0.96, CI 0.77–1.22, p = 0.76).Conclusions:After ICH, women do not receive less aggressive care than men after controlling for the substantial comorbidity differences. Future studies on sex bias should include the presence of comorbidities, prestroke disability, and other factors that may influence management.

Objective: To compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis. Methods: VIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant. Results: Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1–4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14–1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05). Conclusions: Stenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk. ISRCTN.com identifier: ISRCTN95212240. Classification of evidence: This study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.

For over a decade, clinicians have used multimodal pharmacologic therapy for optimal stroke prevention based in part on promising results from clinical trials demonstrating the value of blood pressure and cholesterol lowering for secondary stroke prevention. Patients are typically treated with a cocktail of medications, including antithrombotic agents, antihypertensives, and statins.1

There are limited data on the relationship between control of vascular risk factors and vascular events in patients with symptomatic intracranial arterial stenosis.We utilized the Warfarin Aspirin Symptomatic Intracranial Disease study database to analyze vascular and lifestyle risk factors at baseline and averaged over the course of the trial. Cutoff levels defining good control for each factor were prespecified based on national guidelines. Endpoints evaluated included 1) ischemic stroke, myocardial infarction, or vascular death or 2) ischemic stroke alone. Univariate associations were assessed using the log-rank test and multivariable analysis was done using Cox proportional hazards regression.From baseline until year 2 follow-up, there was not a significant improvement in blood pressure control. During the same period, there were improvements in patients with total cholesterol200 mg/dL (54.6% to 79.2%, p0.001) or low-density lipoprotein100 mg/dL (28.7% to 55.9%, p0.001). Multivariable analysis showed that systolic blood pressureor=140 mm Hg (HR = 1.79, p = 0.0009, 95% confidence limits 1.27 to 2.52), no alcohol consumption (HR 1.69, 1.21 to 2.39, p = 0.002), and cholesterolor=200 mg/dL (HR 1.44, 1.004 to 2.07, p = 0.048) were associated with an increased risk of stroke, myocardial infarction, or vascular death. The same risk factors were predictors of ischemic stroke alone in multivariable analysis.Elevated blood pressure and cholesterol levels in symptomatic patients with intracranial stenosis are associated with an increased risk of stroke and other major vascular events.

The WASID trial showed no advantage of warfarin over aspirin for preventing the primary endpoint of ischemic stroke, brain hemorrhage, or vascular death. In analyses of selected subgroups, there was no definite benefit from warfarin. Warfarin reduced the risk of the primary endpoint among patients with basilar artery stenosis, but there was no reduction in stroke in the basilar artery territory or benefit for vertebral artery stenosis or posterior circulation disease in general.

Most patients in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) did not receive lipid-lowering treatment. As vascular event rates can be lowered with statins, antihypertensive agents, and newer antiplatelet agents, the authors conducted a study to determine the usage of these medications in patients following carotid endarterectomy (CE).Claims data from Blue Cross and Blue Shield Michigan were used to study non-Medicare members who underwent CE in the years 1999 to 2001 (n = 1,049). Prescription of pharmacotherapy and sustained use (80% use of the follow-up period) were examined in the 365-day period following index CE.Overall, 1,049 individuals underwent CE during the years 1999 to 2001. For the 1-year period following CE, the statin prescription rate was 70, 66, and 73% for the 3 study years. Sustained statin use was noted, on average, in 38%. The 3-year average was lower for sustained use of angiotensin-converting enzyme inhibitor (19%) and even lower for prescription antiplatelet agents (5%).Use of statins has increased following carotid endarterectomy (CE) compared with the North American Symptomatic Carotid Endarterectomy Trial era, but sustained treatment with statins remains at40%. Recent studies have shown a decrease in vascular event rates with statins regardless of low-density lipoprotein level, suggesting that statin use should be routine following CE. Increased statin use as part of a multimodality intensive medical regimen following CE has the potential to improve long-term vascular event rates in this population.

In 2015, several published clinical trials showed that acute stroke intervention with thrombectomy devices improved outcomes for patients with acute ischemic stroke.1–5 An analysis of individual patient data from 5 trials found that the chance for reduced disability at 90 days was substantially higher for patients with large vessel occlusion treated with endovascular therapy (odds ratio 2.49).6

Severe internal carotid artery (ICA) stenosis with a recent stroke or TIA carries a high early risk of stroke. In previous population-based studies, the risk of recurrent stroke with large vessel atherosclerosis was much higher than that for other stroke subtypes, such as small vessel disease or cardioembolic stroke.1

Background: Previous studies have shown that neurologic complications following carotid endarterectomy (CE) are underestimated if patients are not examined by neurologists after surgery.Objective: To review the morbidity and mortality in a cohort of patients examined before and after CE in a neurology and stroke clinic.Methods: This was a prospective case series from an academic medical center; 44 patients were referred for CE during the period June 1995 to April 1999. Mean age was 64.3 years; 70.5% were referred for symptomatic stenosis and 29.5% were asymptomatic. Three neurosurgeons and two vascular surgeons operated on the patients.Results: The 30-day mortality rate was 4.5% and the 30-day stroke or death rate was 11.4%. One patient had a TIA due to thrombus formation at the operative site and a second patient had an asymptomatic intimal flap.Conclusions: With prospective follow-up by neurologists, the CE complication rate in an academic medical center was significantly higher than the rates reported in controlled clinical trials. The generalizability of data from CE clinical trials is limited and local audits are necessary to better establish the risk/benefit ratio for individual hospitals and surgeons.

The performance of MRI with diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) sequences in patients with acute ischemic stroke has greatly evolved over the past decade.1 The larger question remains: can these imaging techniques help to identify patients with meaningful amounts of salvageable brain tissue and will performing these imaging tests be worth it, both in terms of financial costs and the delay in institution of revascularization therapies?

We read with interest the systematic review by Munster et al.1 It is welcome news that results for carotid endarterectomy (CEA) in asymptomatic patients are improving. We agree with the authors' conclusion that modern trials are needed to compare intensive medical therapy (IMT) alone vs IMT plus CEA. We would like to alert …

Despite recent advances in medical and surgical treatments to prevent arterial stroke, the cerebrovascular burden of atherosclerosis remains high. Factors associated with a high risk for arterial stroke include stenosis >50% and ulcerated plaque. Given the important role of inflammation in atherosclerotic plaque progression and rupture, a measure of plaque inflammation may help stratify arterial stroke risk. Indeed, inflammatory markers have been associated with arterial stroke.1,2 A noninvasive imaging method to characterize atherosclerotic plaque inflammation could add to the assessment of plaque vulnerability and rupture risk.

I agree with Mehndiratta et al., who outlined concerns about stroke in India.1 India needs to invest more in stroke research and to develop adequate stroke infrastructure for its 1.2 billion citizens. Progress is being made by the Indian Stroke Association (ISA) and the recent launch of the Indian Stroke Registry. However, the authors missed the importance of emergency medical services (EMS). The American Heart Association/American Stroke Association guidelines for the management of adults with ischemic stroke include the role of EMS in the stroke chain of survival.2 Early stroke detection, EMS dispatch, and patient delivery to a designated center are critical in stroke management. Currently, India lacks an organized EMS …

Objective: To assess the efficacy of carotid endarterectomy for stroke prevention in asymptomatic and symptomatic patients with internal carotid artery stenosis. Additional clinical scenarios, such as use of endarterectomy combined with cardiac surgery, are also reviewed. Methods: The authors selected nine important clinical questions. A systematic search was performed for articles from 1990 (the year of the last statement) until 2001. Additional articles from 2002 through 2004 were included using prespecified criteria. Two reviewers also screened for other relevant articles from 2002 to 2004. Case reports, review articles, technical studies, and single surgeon case series were excluded. Results: For several questions, high quality randomized clinical trials had been completed. Carotid endarterectomy reduces the stroke risk compared to medical therapy alone for patients with 70 to 99% symptomatic stenosis (16% absolute risk reduction at 5 years). There is a smaller benefit for patients with 50 to 69% symptomatic stenosis (absolute risk reduction 4.6% at 5 years). There is a small benefit for asymptomatic patients with 60 to 99% stenosis if the perioperative complication rate is low. Aspirin in a dose of 81 to 325 mg per day is preferred vs higher doses (650 to 1,300 mg per day) in patients undergoing endarterectomy. Conclusions: Evidence supports carotid endarterectomy for severe (70 to 99%) symptomatic stenosis (Level A). Endarterectomy is moderately useful for symptomatic patients with 50 to 69% stenosis (Level B) and not indicated for symptomatic patients with

A 43-year-old woman presented with new-onset right temporal headache associated with episodes of visual loss in her right eye for 3 months. Initial MRI showed a filling defect in the left transverse sinus, and subsequent contrast-enhanced MR venography (MRV) confirmed a …

Worldwide, cerebrovascular diseases are responsible for 6.15 million deaths (10.8% of all deaths)(1) and are the second most common cause of mortality; 87% of stroke deaths occur in low or middle income countries.(2) With the world's second largest population, India is witnessing several adverse trends for the cardiovascular health of its population, including a rapid rise in the proportion of patients with diabetes and dyslipidemia, and the relative lack of exercise among the general population. India has the world's largest population of patients with diabetes, with over 62 million people with diabetes in 2011.(3) At the current time, the population in India is projected to have over 1 million strokes per year. This figure will surely rise in the coming decades due to longer life expectancy and the downstream influence of risk factors such as diabetes.

To improve medical outcomes, a large coalition of employers has organized the Leapfrog Initiative. The Leapfrog Initiative suggests that hospitals caring for their employees meet volume standards for five high-risk surgical procedures, one of which is carotid endarterectomy (CE).1 By shifting procedures to high-volume institutions, the Leapfrog coalition believes that health outcomes will improve. The Leapfrog volume standard for CE is >100 procedures per year. We assessed the potential effect of regionalizing CE in Michigan. We analyzed data from the Michigan Health and Safety Coalition Consumer Report for 65 hospitals. These data were voluntarily reported for October 2000 through September 2001. We calculated the number of hospitals that meet the 100 CEs per year threshold and a reduced 50 CEs per year threshold. A reduced 50 CE threshold was selected because some hospitals might find the 100 CE requirement overly restrictive. Teaching hospitals were defined as having a …

Objective: To investigate control of risk factors in African American patients with previous stroke. Methods: The baseline history, physical examination, and laboratory data for 1,086 subjects enrolled in the African American Antiplatelet Stroke Prevention Study from 1995 to 1999 were studied. The level of awareness, pharmacologic treatment, and control of diabetes mellitus (casual plasma glucose level ≥200 mg/dL), hypertension (blood pressure ≥140/90 mm Hg), and hypercholesterolemia (serum total cholesterol level ≥240 mg/dL) were determined. Results: Forty percent of subjects reported a history of diabetes mellitus or use of diabetic medication, and 2% of the remaining subjects had a serum glucose level of ≥200 mg/dL. Of those subjects known to be diabetic, 33% had a serum glucose level of ≥200 mg/dL. A history of hypertension or use of antihypertensive medication was reported in 87% of subjects, and 48% of the remaining subjects were found to have a blood pressure of ≥140/90 mm Hg on exam. Of those subjects known to be hypertensive by history, 73% were on antihypertensive medication, but only 30% of the treated subjects had a blood pressure under 140/90 mm Hg. A history of hypercholesterolemia or use of a lipid-lowering agent was reported in 40% of subjects, and 24% of the remaining subjects had a cholesterol level of ≥240 mg/dL. Use of a lipid-lowering agent was reported in 43% of subjects known to be hypercholesterolemic, and 38% of the hypercholesterolemic subjects had a cholesterol level of ≥240 mg/dL. Conclusion: Inadequate rates of awareness and control of cardiovascular disease and stroke risk factors are seen in a clinical trial of African American stroke patients and are comparable with those of previously published reports.

Stroke remains a common and costly problem worldwide, but substantial advances have been made in recent decades in understanding stroke mechanisms, risk factors, and therapies. Because thrombosis plays an important role in the pathogenesis of ischemic stroke, drugs that interfere with hemostasis and clot formation such as anticoagulants and platelet antiaggregants commonly are used in the management of cerebrovascular disease. Considerable evidence supports the use of certain antithrombotic drugs in stroke prevention. However, because of limited supportive data, the use of these agents in patients with acute ischemic stroke remains controversial. In this report, we examine the published evidence relevant to the effects of anticoagulants and antiplatelet agents on acute ischemic stroke mortality, morbidity, and recurrence rates as well as associated ancillary benefits and risks of those treatments on the rates of deep vein thrombosis, pulmonary embolus, and cardiovascular complications. As part of these analyses, we also sought to determine whether there was evidence supporting differential efficacy of these drugs according to ischemic stroke subtypes. To prepare this report, experienced neurologists with a special interest in stroke diagnosis and management were appointed by the Quality Standards Subcommittee (QSS) and the Therapeutics and Technology Assessment (TTA) Subcommittee of the American Academy of Neurology, and the Stroke Council and Science Advisory and Coordinating Committee (SACC) of the American Heart Association (AHA). The QSS, TTA, Stroke Council and SACC are each charged with the responsibility of preparing evidence-based reports pertaining to medical practice issues including stroke. To facilitate the process of joint guideline development, a Steering Committee, chaired by representatives of the AAN and the American Stroke Association of the AHA, was appointed to discuss potential topics of wide interest to the stroke community. Choosing the role of anticoagulants and antiplatelet agents in acute ischemic stroke as the first topic, a Joint Writing …

Intracerebral hemorrhage (ICH) can be due to diverse causes and is the least treatable form of stroke. Over a decade ago, Brott and colleagues1 noted that growth of cerebral hematoma volume occurs in 38% of patients who are initially imaged using a CT scan within 3 hours of stroke onset and then imaged again within 24 hours of stroke onset. Hematoma expansion (HE) subsequently attracted interest as a potential therapeutic target. If acute ischemic strokes can be treated with “clot busters,” then perhaps acute ICH could be treated with “clot promoters.” Trials of hemostatic agents and acute blood pressure lowering have been conducted in recent years.2,3 Although each approach has succeeded in reducing HE, neither has yet shown definite benefit on patient outcome (with fully powered studies of blood pressure lowering still in progress). An important issue from the clinical and research trial standpoint is whether HE remains a reasonable therapeutic target. One possible explanation for the failure to translate reduced HE into improved outcome is inconsistent definition of clinically important …

Neurologists frequently lament that we are about a decade behind cardiologists: therapies initially pioneered in coronary artery disease, such as use of thrombolytics and statins, eventually filter down to the treatment of stroke. However, an opportunity presents itself by taking advantage of cardiology therapeutic advances or red flags raised in the treatment of coronary artery disease. Should neurologists be concerned about potential implications for our patients with stroke or TIAs if concerns arise in the context of cardiovascular disease? One concern that has been raised is the potential for adverse vascular events following the discontinuation of clopidogrel1 in those receiving dual antiplatelet therapy with aspirin and clopidogrel for acute coronary syndrome. In these patients, dual antiplatelet therapy is frequently administered for 3 to 12 months and subsequently aspirin monotherapy is continued indefinitely. A few …

In recent years, both patients and third-party payers have become more interested in the impact of physician and hospital experience and the outcomes of technically demanding procedures. Initiatives such as the Leapfrog Group have been organized and there has been a suggestion that complex procedures should be referred to more experienced centers.1 In this issue of Neurology ®, results are presented from the NIH Wingspan Registry for patients who underwent intracranial stenting for symptomatic atherosclerosis.2 Overall, the investigators in this registry enrolled 160 recently symptomatic patients with 50%–99% angiographic stenosis. Patients were followed for a median time of 5.4 months and the primary endpoint was stroke or death within 30 days of the procedure and stroke in the territory of the treated vessel thereafter. Several factors were associated with an increased risk for postprocedure major complications, including posterior circulation stenosis, stenting at a low enrollment site (fewer than 10 patients), stenting within 10 days of the last …

Intracranial atherosclerosis is a major cause of ischemic stroke. Depending on the population studied, it accounts for 10 to 29% of brain ischemic events.1 There is now no consensus regarding optimal medical management for these patients, although most patients receive antiplatelet agents or warfarin.2 Despite its frequency, the prognosis for patients with symptomatic intracranial stenosis is not well-defined. A retrospective, nonrandomized review of 151 patients with 50 to 99% stenosis treated at several academic centers found that the stroke rate was 10.4 per 100 patient-years with aspirin and 3.6 with warfarin.3 Another retrospective study of 102 patients with symptomatic, intracranial vertebrobasilar stenosis found that 14% of the patients had another stroke over a 15-month follow-up interval, although only 57% of the strokes were in the territory of the originally symptomatic artery.4 For patients who …

Objective: To report an outcome of post cardiac catheterization stroke patients treated with endovascular intervention. Background Cardiac catheterization related stroke has an incidence of 0.03% to 0.3% for diagnostic procedures and 0.3–0.4% for percutaneous coronary intervention (PCI). Endovascular interventions have added a new option for treatment in patients with embolic occlusion of large vessel occlusion. Design/Methods: Following retrospective data was collected from 2007 to September 2011 for post cardiac catheterization stroke and endovascular intervention : demographics, risk factors, National Institute of Health Stroke Scale- NIHSS, arterial involvement, type of intervention, outcome. Results: Nine patients underwent cerebral angiogram for post cardiac catheterization stroke. Five patients (mean age- 76.3 years, 1 male and 4 female, all black) had large arterial occlusion, 2 middle cerebral, 1 carotid bifurcation, 1 anterior cerebral, 1 basilar artery. All patients had history of hypertension, hyperlipidemia and coronary atherosclerosis. Two had severe heart failure, one had left ventricular thrombus and one had descending aorta thrombus. None of them had atrial fibrillation. Median NIHSS was 17.5. All interventions were performed within 8 hours of symptoms. Three received intravenous thrombolysis. Pre TIMI score was 0 in 4 and 1 in 1 patient. Intra arterial thrombolysis was used in 3 while mechanical thrombectomy (MERCI or Penumbra) in 4. Post procedure, 3 patients had TIMI 3 recanalization and 2 had TIMI 2. None of them had hemorrhage. Two patients (Basilar, carotid bifurcation occlusion) died during hospitalization due to large stroke in spite of recanalization. At discharge, modified Rankin scale was 2 in 2 patients and 3 in 1. Conclusions: Some patients with post-cath large vessel occlusion can be salvaged with a reasonable functional outcome. Mortality/bad outcome rate remains high with endovascular intervention in spite of good recanalization rate. Further data is needed to evaluate the factors predicting the outcome in this group of patients. Disclosure: Dr. Kansara has nothing to disclose. Dr. Damani has nothing to disclose. Dr. Tiwari has nothing to disclose. Dr. Narayanan has nothing to disclose. Dr. Chaturvedi has received personal compensation for activities with Genentech, Inc., and Abbott Vascular. Dr. Xavier has received personal compensation for activities with Concentric as a consultant.

Objective: In the present study we assessed contemporary rates of perioperative complications following carotid artery stenting (CAS) and carotid endarterectomy (CEA) among women. Background Perioperative risks during carotid revascularization procedures in clinical trials are higher among women. Design/Methods: A retrospective chart review was conducted of all carotid revascularization procedures performed at four hospitals in a metropolitan region between June 2009-May2011. Gender differences in choice of revascularization procedures were explored. Rates of combined outcome of in-hospital stroke, clinically significant myocardial infarction and death were assessed. Results: Over 2 years, 483 carotid revascularizations (36.4% CEA and 63.6% CAS) were performed. Women composed 37.1% of the CAS group and 46% of CEA group. Among subjects with asymptomatic stenosis, women were less likely to get CAS (35.8% of CAS group vs. 48% of CEA group were women; p=0.03). Among subjects Conclusions: Gender influences the choice of revascularization procedure among asymptomatic patients and subjects less than 70 years. In spite of advances in contemporary revascularization methods, complication rates among women are quite high; especially in the subgroup of asymptomatic women over 70 years. Disclosure: Dr. Bhattacharya has nothing to disclose. Dr. Damani has nothing to disclose. Dr. Rayes has nothing to disclose. Dr. Chaturvedi has received personal compensation for activities with Genentech, Inc., and Abbott Vascular.

Objective: To measure brain serotonin synthesis with PET using the tracer α-[ 11 C]methyl-l-tryptophan in migraine patients. Background: Although the cause of migraine remains poorly understood, there is considerable evidence to support a role of the neurotransmitter serotonin in the pathophysiology of migraine. Methods: We studied 11 women (aged 33 ± 7.7 years) with a diagnosis of migraine according to International Headache Society criteria and 8 healthy women (aged 29 ± 9.2 years). Five patients were studied before and after chronic treatment with propranolol or nadolol. Results: Serotonin synthesis capacity (K-complex) values in migraine patients were higher than those measured in controls throughout the brain ( p = 0.016); mean K-complex for whole brain was 0.0077 + 0.0020 mL/g/min in patients with migraine and 0.0054 ± 0.0003 mL/g/min in controls. The regional pattern did not differ between the two groups. However, the K-complex for whole brain in the subgroup of migraine patients with aura (n = 3) did not differ from that of the control group ( p = 0.32). In the five patients studied twice (before and after treatment), we found a trend of increased whole-brain K-complex after drug treatment ( p = 0.06). Conclusions: Our findings indicating increased brain serotonin synthesis capacity in migraine patients are consistent with previous reports of systemic alteration of serotonin metabolism in patients without aura. Our results also suggest that the mechanism of action of beta-adrenergic antagonists for migraine prophylaxis may involve regulation of serotonin synthesis.

Background: Congenital variations in the configuration and size of the cerebral vessels may predispose to ischemic stroke. Objectives/ Methods: To illustrate that a hypoplastic basilar artery may lead to posterior circulation ischemia in adults, eight cases are reported from two university medical centers. Results: Five men and three women with a mean age of 49.8 years are reported. Four of the patients had other conventional stroke risk factors. Two patients had brainstem strokes, and six had TIA. All patients had hypoplastic basilar arteries. Seven patients had at least one hypoplastic vertebral artery (bilateral in five cases), and six patients had both posterior cerebral arteries originating from the internal carotid arteries. Conclusions: A hypoplastic basilar artery is frequently accompanied by vertebral artery hypoplasia, and this can predispose adults to posterior circulation ischemia. This entity can be suspected on the basis of MR angiogram, but conventional angiography will provide definitive diagnosis. Optimal medical and surgical treatment of this condition is unresolved.

The efficacy of carotid endarterectomy (CE) in stroke prevention has been evaluated by several randomized clinical trials.1-4 If taken at face value, one could conclude (somewhat paradoxically) that CE is beneficial for symptomatic patients with greater than 70% stenosis and asymptomatic patients with greater than 60% stenosis. The perceived efficacy of CE for both symptomatic and asymptomatic stenosis raises the question "Is it necessary to have a patient evaluated by a neurologist at any point on the road to or from the surgeon?" If both symptomatic and asymptomatic patients benefit from CE, it would seem that the only necessary elements in the equation for surgical stroke prevention are a patient, an ultrasound machine, a referring physician (who could be a family practitioner or internist), and a surgeon. Should the neurologist be included in this framework? We suggest that neurologists play a critical role in the preoperative, operative, and postoperative evaluation of the CE patient. Preoperative assessment. A central premise of the theme that neurologists can play a major role in the care of the CE patient is the difference in prognosis for patients with symptomatic and asymptomatic carotid stenosis. Considering the annual stroke risk of four commonly encountered clinical conditions (table 1), there is a substantial difference in the likelihood of stroke for symptomatic versus asymptomatic patients. This translates into a significant difference in the risk-to-benefit ratio for CE in symptomatic and asymptomatic patients. Using clinical trial data, one can conclude that six symptomatic patients are required to undergo CE to prevent one stroke at 2 years and 67 asymptomatic patients would have to undergo CE to prevent one stroke at a comparable interval. This has led some authorities to question whether CE should be undertaken at all in asymptomatic patients.9,10 The difference in the risk-to-benefit ratio leads …