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Background and Purpose: The aim of this study was to examine whether sphingosine-1-phosphate (S1P) levels in patients with acute stroke are associated with stroke severity and outcome. Methods: In a prospective stroke cohort (MARK-STROKE), 374 patients with acute ischemic stroke or transient ischemic attack were enrolled (mean age: 67.9±13.0 years, sex: 64.7% male), and serum-S1P at admission was analyzed with tandem mass spectrometry. In addition to cross-sectional analyses, 79 adverse events (death, stroke, myocardial infarction, rehospitalization) were recorded in 270 patients during follow-up. Regression analyses were adjusted for age, sex, low-density lipoprotein cholesterol, and vascular risk factors. Results were validated in an independent stroke cohort with 219 patients with acute ischemic stroke (CIRCULAS). Results: Low serum-S1P was associated with higher National Institutes of Health Stroke Scale score at admission and with anterior circulation nonlacunar infarcts determined by multivariate regression analyses. During a follow-up of 294±170 days, patients with S1P in the lowest tertile (P =0.048 for trend). In adjusted Cox regression analysis, the lowest S1P tertile was associated with a worse outcome after stroke (hazard ratio, HR 0.51 [95% confidence interval 0.28–0.92]). Results were confirmed in an independent cohort, ie, low S1P levels were associated with higher National Institutes of Health Stroke Scale, larger infarct volumes and worse outcome after 90 days (β-coefficient: –0.03, P =0.026; β-coefficient: −0.099, P =0.009 and odds ratio 0.52 [0.28–0.96], respectively). Conclusions: Our findings imply a detrimental role of low S1P levels in acute stroke and therefore underpin the therapeutic potential of S1P-mimics.

Background and Purpose: The AFFINITY trial (Assessment of Fluoxetine in Stroke Recovery) reported that oral fluoxetine 20 mg daily for 6 months after acute stroke did not improve functional outcome and increased the risk of falls, bone fractures, and seizures. After trial medication was ceased at 6 months, survivors were followed to 12 months post-randomization. This preplanned secondary analysis aimed to determine any sustained or delayed effects of fluoxetine at 12 months post-randomization. Methods: AFFINITY was a randomized, parallel-group, double-blind, placebo-controlled trial in adults (n=1280) with a clinical diagnosis of stroke in the previous 2 to 15 days and persisting neurological deficit who were recruited at 43 hospital stroke units in Australia (n=29), New Zealand (4), and Vietnam (10) between 2013 and 2019. Participants were randomized to oral fluoxetine 20 mg once daily (n=642) or matching placebo (n=638) for 6 months and followed until 12 months after randomization. The primary outcome was function, measured by the modified Rankin Scale, at 6 months. Secondary outcomes for these analyses included measures of the modified Rankin Scale, mood, cognition, overall health status, fatigue, health-related quality of life, and safety at 12 months. Results: Adherence to trial medication was for a mean 167 (SD 48) days and similar between randomized groups. At 12 months, the distribution of modified Rankin Scale categories was similar in the fluoxetine and placebo groups (adjusted common odds ratio, 0.93 [95% CI, 0.76–1.14]; P =0.46). Compared with placebo, patients allocated fluoxetine had fewer recurrent ischemic strokes (14 [2.18%] versus 29 [4.55%]; P =0.02), and no longer had significantly more falls (27 [4.21%] versus 15 [2.35%]; P =0.08), bone fractures (23 [3.58%] versus 11 [1.72%]; P =0.05), or seizures (11 [1.71%] versus 8 [1.25%]; P =0.64) at 12 months. Conclusions: Fluoxetine 20 mg daily for 6 months after acute stroke had no delayed or sustained effect on functional outcome, falls, bone fractures, or seizures at 12 months poststroke. The lower rate of recurrent ischemic stroke in the fluoxetine group is most likely a chance finding. Registration: URL: http://www.anzctr.org.au/ ; Unique identifier: ACTRN12611000774921.

Background and Purpose: Fever is a common observation after ischemic or hemorrhagic stroke and is associated with a worse clinical outcome. Infections, stroke severity, preexisting medical conditions, insertion of catheters, and dysphagia have been implicated in causing poststroke fever. Given that dysphagia has not been evaluated in detail yet, the aim of this study was to investigate if the severity of dysphagia assessed by a detailed swallowing assessment predicts poststroke fever. Methods: In this retrospective monocentric cohort study, all patients admitted for ischemic or hemorrhagic stroke within 12 months were included. Patients underwent a detailed standardized swallowing assessment including a clinical exam by a speech therapist and fiberoptic endoscopic evaluation in a subset of patients. Patients who developed fever within 5 days were compared with patients without fever regarding swallowing parameters and other clinical characteristics relevant for the prediction of poststroke fever. Results: Nine hundred twenty-three patients with acute ischemic or hemorrhagic stroke were included. One hundred twenty-seven (13.8%) patients developed fever. In multivariable analyses, fever was independently predicted by moderate-to-severe dysphagia in clinical assessments (odds ratio [95% CI], 3.05 [1.65–5.66]) and also by dysphagia with proven risk of aspiration as a combined end point of clinical and instrumental assessments (1.79 [1.07–3.00]). Other independent predictors were stroke severity (odds ratio, 1.06 per point on the National Institutes of Health Stroke Scale score [1.01–1.11]) and the presence of an urinary catheter (odds ratio, 2.03 [1.13–3.65]). Conclusions: Severe dysphagia evaluated by a detailed clinical assessment complemented by instrumental testing predicts the development of poststroke fever. Early identification of patients with severe dysphagia after stroke followed by consequent monitoring and treatment might be effective in reducing poststroke fever.

Background and Purpose: A recent randomized controlled trial DIRECT-MT (Direct Intra-Arterial Thrombectomy to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals) compared the safety and efficacy of mechanical thrombectomy (MT) versus combined intravenous thrombolysis (IVT) and MT for acute large vessel occlusion. The current study utilized a prospective, nationwide registry to validate the results of the DIRECT-MT trial in a real-world practice setting. Methods: Subjects were selected from a prospective cohort of acute large vessel occlusion patients undergoing endovascular treatment at 111 hospitals from 26 provinces in China (ANGEL-ACT registry [Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke]) between November 2017 and March 2019. All patients eligible for IVT and receiving MT were reviewed and then grouped according to whether prior IVT or not (MT and combined IVT+MT). After a 1:1 propensity score matching, the outcome measures including the 90-day modified Rankin Scale, successful recanalization, door-to-puncture time, symptomatic intracranial hemorrhage, and intraprocedural embolization were compared. Results: A total of 1026 patients, 600 in the MT group and 426 in the combined group, were included. Among 788 patients identified after matching, there were no significant differences in the 90-day modified Rankin Scale (median, 3 versus 3 points; P =0.82) and successful recanalization (86.6% versus 89.3%; P =0.23) between the two groups; however, patients of the MT group had a shorter door-to-puncture time (median, 112 versus 136 minutes; β=−45.02 [95% CI, −68.31 to −21.74]), lower rates of symptomatic intracranial hemorrhage (5.5% versus 10.1%; odds ratio, 0.52 [95% CI, 0.30–0.91]), and embolization (4.6% versus 8.1%; odds ratio, 0.54 [95% CI, 0.30–0.98]) than those of the combined group. Conclusions: This matched-control study largely confirmed the findings of the DIRECT-MT trial in a real-world practice setting, suggesting that MT may carry similar effectiveness to combined IVT+MT for acute large vessel occlusion patients, despite MT alone seems to be associated with a shorter in-hospital delay until procedure, lower risks of symptomatic intracranial hemorrhage, and embolization. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03370939.

Background and Purpose: Endovascular treatment (EVT) in acute ischemic stroke is effective in the late time window in selected patients. However, the frequency and clinical impact of procedural complications in the early versus late time window has received little attention. Methods: We retrospectively studied all acute ischemic strokes from 2015 to 2019 receiving EVT in the Acute Stroke Registry and Analysis of Lausanne. We compared the procedural EVT complications in the early ( Results: Among 695 acute ischemic strokes receiving EVT (of which 202 were in the late window), 113 (16.3%) had at least one procedural complication. The frequency of each single, and for overall procedural complications was similar for early versus late EVT (16.2% versus 16.3%, P adj =0.90). Procedural complications lead to a significantly less favorable short-term outcome, reflected by the absence of National Institutes of Health Stroke Scale improvement in late EVT (delta-National Institutes of Health Stroke Scale-24 hours, −2.5 versus 2, P adj =0.01). Conclusions: In this retrospective analysis of consecutive EVT, the frequency of procedural complications was similar for early and late EVT patients but very short-term outcome seemed less favorable in late EVT patients with complications.

Physicians often base their decisions to offer acute stroke therapies to patients around the question of whether the patient will benefit from treatment. This has led to a plethora of attempts at accurate outcome prediction for acute ischemic stroke treatment, which have evolved in complexity over the years. In theory, physicians could eventually use such models to make a prediction about the treatment outcome for a given patient by plugging in a combination of demographic, clinical, laboratory, and imaging variables. In this article, we highlight the importance of considering the limits and nuances of outcome prediction models and their applicability in the clinical setting. From the clinical perspective of decision-making about acute treatment, we argue that it is important to consider 4 main questions about a given prediction model: (1) what outcome is being predicted, (2) what patients contributed to the model, (3) what variables are in the model (considering their quantifiability, knowability at the time of decision-making, and modifiability), and (4) what is the intended purpose of the model? We discuss relevant aspects of these questions, accompanied by clinically relevant examples. By acknowledging the limits of outcome prediction for acute stroke therapies, we can incorporate them into our decision-making more meaningfully, critically examining their contents, outcomes, and intentions before heeding their predictions. By rigorously identifying and optimizing modifiable variables in such models, we can be empowered rather than paralyzed by them.

The efficacy of intravenous thrombolysis and endovascular thrombectomy (EVT) for acute ischemic stroke is highly time dependent. Optimal organization of acute stroke care is therefore important to reduce treatment delays but has become more complex after the introduction of EVT as regular treatment for large vessel occlusions. There is no singular optimal organizational model that can be generalized to different geographic regions worldwide. Current dominant organizational models for EVT include the drip-and-ship- and mothership model. Guidelines recommend routing of suspected patients with stroke to the nearest intravenous thrombolysis capable facility; however, the choice of routing to a certain model should depend on regional stroke service organization and individual patient characteristics. In general, design approaches for organizing stroke care are required, in which 2 key strategies could be considered. The first entails the identification of interventions within existing organizational models for optimizing timely delivery of intravenous thrombolysis and/or EVT. This includes adaptive patient routing toward a comprehensive stroke center, which focuses particularly on prehospital triage tools; bringing intravenous thrombolysis or EVT to the location of the patient; and expediting services and processes along the stroke pathway. The second strategy is to develop analytical or simulation model-based approaches enabling the design and evaluation of organizational models before their implementation. Organizational models for acute stroke care need to take regional and patient characteristics into account and can most efficiently be assessed and optimized through the application of model-based approaches.

Supplemental Digital Content is available in the text., Background and Purpose: Evaluation of the lung apices using computed tomography angiography of the head and neck during acute ischemic stroke (AIS) can provide the first objective opportunity to screen for coronavirus disease 2019 (COVID-19). Methods: We performed an analysis assessing the utility of apical lung exam on computed tomography angiography for COVID-19–specific lung findings in 57 patients presenting with AIS. We measured the diagnostic accuracy of apical lung assessment alone and in combination with patient-reported symptoms and incorporate both to propose a COVID-19 era AIS algorithm. Results: Apical lung assessment when used in isolation, yielded a sensitivity of 0.67, specificity of 0.93, positive predictive value of 0.19, negative predictive value of 0.99, and accuracy of 0.92 for the diagnosis of COVID-19, in patients presenting to the hospital for AIS. When combined with self-reported clinical symptoms of cough or shortness of breath, sensitivity of apical lung assessment improved to 0.83. Conclusions: Apical lung assessment on computed tomography angiography is an accurate screening tool for COVID-19 and can serve as part of a combined screening approach in AIS.

Background and Purpose:The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata.Methods:Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme.Results:There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51–0.59],PPPP=0.086; large towns, 1.05 [1.01–1.09],P=0.009; small towns, 1.10 [1.06–1.15],PPPPPConclusions:Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.

Background and Purpose: This study aims to assess the number of patients with acute ischemic cerebrovascular events seeking in-patient medical emergency care since the implementation of social distancing measures in the coronavirus disease 2019 (COVID-19) pandemic. Methods: In this retrospective multicenter study, data on the number of hospital admissions due to acute ischemic stroke or transient ischemic attack and numbers of reperfusion therapies performed in weeks 1 to 15 of 2020 and 2019 were collected in 4 German academic stroke centers. Poisson regression was used to test for a change in admission rates before and after the implementation of extensive social distancing measures in week 12 of 2020. The analysis of anonymized regional mobility data allowed for correlations between changes in public mobility as measured by the number and length of trips taken and hospital admission for stroke/transient ischemic attack. Results: Only little variation of admission rates was observed before and after week 11 in 2019 and between the weeks 1 and 11 of 2019 and 2020. However, reflecting the impact of the COVID-19 pandemic, a significant decrease in the number of admissions for transient ischemic attack was observed (−85%, −46%, −42%) in 3 of 4 centers, while in 2 of 4 centers, stroke admission rates decreased significantly by 40% and 46% after week 12 in 2020. A relevant effect on reperfusion therapies was found for 1 center only (thrombolysis, −60%; thrombectomy, −61%). Positive correlations between number of ischemic events and mobility measures in the corresponding cities were identified for 3 of 4 centers. Conclusions: These data demonstrate and quantify decreasing hospital admissions due to ischemic cerebrovascular events and suggest that this may be a consequence of social distancing measures, in particular because hospital resources for acute stroke care were not limited during this period. Hence, raising public awareness is necessary to avoid serious healthcare and economic consequences of undiagnosed and untreated strokes and transient ischemic attacks.

Background and Purpose— Despite recanalization, almost 50% of patients undergoing endovascular treatment (EVT) experience poor outcome. We aim to evaluate the value of computed tomography perfusion as immediate outcome predictor postendovascular treatment. Methods— Consecutive patients receiving endovascular treatment who achieved recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI] 2a-3) underwent computed tomography perfusion within 30 minutes from recanalization (CTPpost). Hypoperfusion was defined as the Tmax>6 second volume; hyperperfusion as visually increased cerebral blood flow/cerebral blood volume with reduced Tmax compared with unaffected hemisphere. Dramatic clinical recovery (DCR) was defined as 24-hour National Institutes of Health Stroke Scale score ≤2 or ≥8 points drop. Delayed recovery was defined as no-DCR with favorable outcome (modified Rankin Scale score 0–2) at 3 months. Results— We included 151 patients: median National Institutes of Health Stroke Scale score 16 (interquartile range, 10–21), median admission ASPECTS 9 (interquartile range, 8–10). Final recanalization was the following: mTICI2a 11 (7.3%), mTICI2b 46 (30.5%), and mTICI3 94 (62.3%). On CTPpost, 80 (52.9%) patients showed hypoperfusion (median Tmax>6 seconds: 4 cc [0–25]) and 32 (21.2%) hyperperfusion. There was an association between final TICI and CTPpost hypoperfusion(median Tmax>6: 91 [56–117], 15 [0–37.5], and 0 [0–7] cc, for mTICI 2a, 2b, and 3, respectively, P P P P P Conclusions— Hypoperfusion on CTPpost constitutes an immediate accurate surrogate marker of success after endovascular treatment and identifies those patients with delayed recovery and favorable outcome.

Background and Purpose— The risk of arterial ischemic events after intracerebral hemorrhage (ICH) is poorly understood given the lack of a control group in prior studies. This study aimed to evaluate the risk of acute ischemic stroke and myocardial infarction (MI) among patients with and without ICH. Methods— We performed a retrospective cohort study using claims data from Medicare beneficiaries from 2008 to 2014. Our exposure was acute ICH, identified using validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Our primary outcome was a composite of acute ischemic stroke and MI, whereas secondary outcomes were ischemic stroke alone and MI alone. We used Cox regression analysis to compute hazard ratios during 1-month intervals after ICH. Sensitivity analyses entailed exclusion of patients with atrial fibrillation and valvular heart disease. Results— Among 1 760 439 Medicare beneficiaries, 5924 had ICH. The 1-year cumulative incidence of an arterial ischemic event was 5.7% (95% CI, 4.8–6.8) in patients with ICH and 1.8% (95% CI, 1.7–1.9) in patients without ICH. After adjusting for potential confounders, the risk of an arterial ischemic event remained significantly increased for the first 6 months after ICH and was especially high in the first month (hazard ratio, 6.7 [95% CI, 5.0–8.6]). In secondary analysis, the risk of ischemic stroke was increased in the first 6 months after ICH (hazard ratio, 6.1 [95% CI, 3.5–9.3]) but the risk of MI was not (hazard ratio, 1.6 [95% CI, 0.3–2.9]). In sensitivity analyses excluding patients with atrial fibrillation and valvular heart disease, the association between ICH and arterial ischemic events was similar to that of the primary analysis. Conclusions— In a large population-based cohort, we found that elderly patients with ICH had a substantially increased risk of ischemic stroke in the first 6 months after diagnosis. Further exploration of this risk is needed to determine optimal secondary prevention strategies for these patients.

Background and Purpose— Health systems are faced with the challenge of ensuring fast access to appropriate therapy for patients with acute stroke. The paradigms primarily discussed are mothership and drip and ship. Less attention has been focused on the drip-and-drive (DD) paradigm. Our aim was to analyze whether and under what conditions DD would predict the greatest probability of good outcome for patients with suspected ischemic stroke in Northwestern Germany. Methods— Conditional probability models based on the decay curves for endovascular therapy and intravenous thrombolysis were created to determine the best transport paradigm, and results were displayed using map visualizations. Our study area consisted of the federal states of Lower Saxony, Hamburg, and Schleswig-Holstein in Northwestern Germany covering an area of 64 065 km 2 with a population of 12 703 561 in 2017 (198 persons per km 2 ). In several scenarios, the catchment area, that is, the region that would result in the greatest probability of good outcomes, was calculated for each of the mothership, drip-and-ship, and the DD paradigms. Several different treatment time parameters were varied including onset-to-first-medical-response time, ambulance-on-scene time, door-to-needle time at primary stroke center, needle-to-door time, door-to-needle time at comprehensive stroke center, door-to-groin-puncture time, needle-to-interventionalist-leave time, and interventionalist-arrival-to-groin-puncture time. Results— The mothership paradigm had the largest catchment area; however, the DD catchment area was larger than the drip-and-ship catchment area so long as the needle-to-interventionalist-leave time and the interventionalist-arrival-to-groin-puncture time remain 2 (2%). Conclusions— Our study suggests the largest catchment area for the mothership paradigm and a larger catchment area of DD paradigm compared with the drip-and-ship paradigm in Northwestern Germany in most scenarios. The existence of different paradigms allows the spread of capacities, shares the cost and hospital income, and gives primary stroke centers the possibility to provide endovascular therapy services 24/7.

Facilitating successful care transitions across settings is a key nursing competency. Although we have achieved improvements in acute stroke care, similar advances in stroke care transitions in the postacute and return to community phases have lagged far behind. In the current delivery system, care transitions are often ineffective and inefficient resulting in unmet needs and high rates of unnecessary complications and avoidable hospital readmissions. Nurses must use evidence-based approaches to prepare stroke survivors and their family caregivers for postdischarge self-management, rehabilitation, and recovery. The purpose of this article is to provide evidence on the important nursing roles in stroke care and transition management across the care continuum, discuss cross-setting issues in stroke care, and provide recommendations to leverage nursing’s impact in optimizing outcomes for stroke survivors and their family unit across the continuum. To optimize nursing’s influence in facilitating safe, effective, and efficient care transitions for stroke survivors and their family caregivers across the continuum we have the following recommendations (1) establish a system of coordinated and seamless comprehensive stroke care across the continuum and into the community; (2) implement a stroke nurse liaison role that provides consultant case management for the episode of care across all settings/services for improved consistency, communication and follow-up care; (3) implement a validated caregiver assessment tool to systematically assess gaps in caregiver preparedness and develop a tailored caregiver/family care plan that can be implemented to improve caregiver preparedness; (4) use evidence-based teaching and communication methods to optimize stroke survivor/caregiver learning; and (5) use technology to advance stroke nursing care. Nurses must leverage their substantial influence over the health care delivery system to achieve these improvements in stroke care delivery to improve the health and lives of stroke survivors and their families.

Background and Purpose: When reporting primary results from randomized controlled trials, recommendations include reporting results by sex. We reviewed the reporting of results by sex in contemporary acute stroke randomized controlled trials. Methods: We searched MEDLINE for articles reporting the primary results of phase 2 or 3 stroke randomized controlled trials published between 2010 and June 2020 in one of nine major clinical journals. Eligible trials were restricted to those with a therapeutic intervention initiated within one month of stroke onset. Of primary interest was the reporting of results by sex for the primary outcome. We performed bivariate analyses using Fisher exact tests to identify study-level factors associated with reporting by sex and investigated temporal trends using an exact test for trend. Results: Of the 115 studies identified, primary results were reported by sex in 37% (n=42). Reporting varied significantly by journal, with the New England Journal of Medicine (61%) and Lancet journals (40%) having the highest rates ( P =0.03). Reporting also differed significantly by geographic region (21% Europe versus 48% Americas, P =0.03), trial phase (13% phase 2 versus 40% phase 3, P =0.05), and sample size (24% 750 participants, P P =0.11), there was a temporal trend in favor of greater reporting among later publications (25% 2010–2012 versus 48% 2019–2020). Conclusions: Although reporting of primary trial results by sex improved from 2010 to 2020, the prevalence of reporting in major journals is still low. Further efforts are required to encourage journals and authors to comply with current reporting recommendations.

Background and Purpose: The influence of prior antiplatelet therapy (APT) uses on the outcomes of patients with acute ischemic stroke treated with endovascular therapy is unclear. We compared procedural and clinical outcomes of endovascular therapy in patients on APT or not before stroke onset. Methods: We analyzed 2 groups from the ongoing prospective multicenter Endovascular Treatment in Ischemic Stroke registry in France: patients on prior APT (APT+) and patients without prior APT (APT−) treated by endovascular therapy, with and without intravenous thrombolysis. Multilevel mixed-effects logistic models including center as random effect were used to compare angiographic (rates of reperfusion at the end of procedure, procedural complications) and clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) outcomes according to APT subgroups. Comparisons were adjusted for prespecified confounders (age, admission National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, intravenous thrombolysis, and time from onset to puncture), as well as for meaningful baseline between-group differences. Results: A total of 2939 patients were analyzed, of whom 877 (29.8%) were on prior APT. Patients with prior APT were older, had more frequent vascular risk factors, cardioembolic stroke mechanism, and prestroke disability. Rates of complete reperfusion (37.9% in the APT− group versus 42.7 % in the APT+ group; aOR, 1.09 [95% CI, 0.88–1.34]; P =0.41) and periprocedural complication (16.9% versus 13.3%; aOR, 0.90 [95% CI, 0.7–1.2]; P =0.66) did not differ between the two groups. Symptomatic intracerebral hemorrhage (aOR, 0.93 [95% CI, 0.63–1.37]; P =0.73), 3 months favorable clinical outcome (modified Rankin Scale score of 0–2; aOR, 0.98 [95% CI, 0.77–1.25]; P =0.89), and mortality (aOR, 0.95 [95% CI, 0.72–1.26]; P =0.76) at 90 days did not differ between the groups. Conclusions: Prior APT does not influence angiographic and functional outcomes following endovascular therapy and should not be taken into account for acute revascularization strategies.

[Figure: see text].

Background and Purpose: Mechanical thrombectomy has dramatically increased patient volumes transferred to comprehensive stroke centers (CSCs), resulting in transfer denials for patients who need higher level of care only available at a CSC. We hypothesized that a distributive stroke network (DSN), triaging low severity acute stroke patients to a primary stroke center (PSC) upon initial telestroke consultation, would safely reduce transfer denials, thereby providing additional volume to treat severe strokes at a CSC. Methods: In 2017, a DSN was implemented, in which mild stroke patients were centrally triaged, via telestroke consultation, to a PSC based upon a simple clinical severity algorithm, while higher acuity/severity strokes were triaged to the CSC. In an observational cohort study, data on acute ischemic stroke patients presenting to regional community hospitals were collected pre- versus post-DSN implementation. Safety outcomes and rate of CSC transfer denials were compared pre-DSN versus post-DSN. Results: The pre-DSN cohort (n=150), triaged to the CSC, had a similar rate of symptomatic intracerebral hemorrhage and discharge location compared with the post-DSN cohort (n=150), triaged to the PSC. Time to stroke unit admission was faster post-DSN (2 hours 40 minutes) versus pre-DSN (3 hours 29 minutes; P P =0.02), despite an increase in telestroke consultation volume over the same period (median, 3 calls per day pre-DSN versus 5 calls per day post-DSN; P =0.001). No patients who were triaged to the PSC required subsequent transfer to the CSC. Conclusions: A DSN, triaging mild ischemic stroke patients from community hospitals to a PSC, safely reduced transfer denials to the CSC, allowing greater capacity at the CSC to treat higher acuity stroke patients.

Supplemental Digital Content is available in the text., Background and Purpose: Mechanical properties of thromboemboli play an important role in the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke. However, very limited data on mechanical properties of human stroke thrombi are available. We aimed to mechanically characterize thrombi retrieved with EVT, and to assess the relationship between thrombus composition and thrombus stiffness. Methods: Forty-one thrombi from 19 patients with acute stroke who underwent EVT between July and October 2019 were mechanically analyzed, directly after EVT. We performed unconfined compression experiments and determined tangent modulus at 75% strain (Et75) as a measure for thrombus stiffness. Thrombi were histologically analyzed for fibrin/platelets, erythrocytes, leukocytes, and platelets, and we assessed the relationship between histological components and Et75 with univariable and multivariable linear mixed regression. Results: Median Et75 was 560 (interquartile range, 393–1161) kPa. In the multivariable analysis, fibrin/platelets were associated with increased Et75 (aβ, 9 [95% CI, 5 to 13]) kPa, erythrocytes were associated with decreased Et75% (aβ, −9 [95% CI, −5 to −13]) kPa. We found no association between leukocytes and Et75. High platelet values were strongly associated with increased Et75 (aβ, 56 [95% CI, 38–73]). Conclusions: Fibrin/platelet content of thrombi retrieved with EVT for acute ischemic stroke is strongly associated with increased thrombus stiffness. For thrombi with high platelet values, there was a very strong relationship with thrombus stiffness. Our data provide a basis for future research on the development of next-generation EVT devices tailored to thrombus composition.

Background and Purpose— It is unknown whether the benefit of thrombectomy in late presenting acute stroke patients with imaging evidence of clinical-infarct mismatch is different in patients presenting with wake-up stroke compared with those presenting with witnessed onset or unwitnessed onset. Methods— Prespecified secondary analysis was performed from DAWN (Diffusion Weighted Imaging [DWI] or Computerized Tomography Perfusion [CTP] Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention), a multicenter, prospective, randomized clinical trial with blinded end point assessment comparing thrombectomy with the Trevo device against standard medical therapy in patients with acute stroke and clinical-infarct mismatch presenting 6 to 24 hour after the time last seen well. For the purposes of this study, the primary outcome was the proportion of modified Rankin Scale score 0 to 2 at 90 days. Univariable analysis and multivariable logistic regression was used to assess the relationship between outcome and mode of onset. Results— All 206 enrolled patients were included in the study. Mode of onset was: wake-up stroke (55.3%, n=114), witnessed onset (12.1%, n=25), and unwitnessed onset (32.5%, n=67) with median time last seen well to randomization (13.4±3.7, 10.0±3.7, 14.1±4.9 hours) respectively. Rates of 90-day modified Rankin Scale score of 0 to 2 and symptomatic intracerebral hemorrhage in the thrombectomy arm were not statistically different across patient onset subtypes ( P =0.79 and P =0.40, respectively). The benefit of thrombectomy compared with best medical therapy was maintained across all 3 onset modes (rates of 90-day modified Rankin Scale score of 0 to 2 in patients allocated to thrombectomy versus control: wake-up stroke—49.3% versus 10.6%, witnessed onset—63.6% versus 21.4%, UW—41.4% versus 13.2%; P ×interaction=0.79). In univariable and multivariable analyses, mode of onset was not identified as a significant predictor of modified Rankin Scale score 0 to 2 at 90 days. Conclusions— In patients with acute ischemic stroke presenting between 6 and 24 hours from time last seen well and harboring clinical-infarct mismatch, the benefit of thrombectomy was similar regardless of the wake-up, unwitnessed, or witnessed mode of onset.

Background and Purpose— The emergency management of stroke is complex and highly time-sensitive. Recent landmark trials demonstrating the strong benefit of thrombectomy have led to rapid change in stroke management. This article reviews a large number of medical malpractice lawsuits related to the emergency management of stroke to characterize factors involved in these lawsuits. Methods— Three large legal databases were used to search for jury verdicts and settlements in cases related to the acute care of stroke patients in the United States. Search terms included “stroke” and “medical malpractice.” Cases were screened to include only cases in which the allegation involved negligence in the acute care of a patient suffering a stroke. Results— We found 246 medical malpractice cases related to the acute management of ischemic stroke and 26 related to intracranial hemorrhage. Seventy-one cases specifically alleged a failure to treat with tPA (tissue-type plasminogen activator) and 7 cases alleged a failure to treat, or to timely treat, with thrombectomy. Overall there were 151 cases (56%) which ended with no payout, 74 cases (27%) were settled out of court, and 47 cases (17%) went to court and resulted in a verdict for the plaintiff. The average payout in settlements was $1 802 693, and the average payout in plaintiff verdicts was $9 705 099. Conclusions— Malpractice litigation is a risk in acute stroke care and can lead to significant financial consequences. The majority of malpractice lawsuits related to the emergency management of stroke allege a failure to diagnose and failure to treat. Allegations of a failure to treat acute ischemic stroke with tPA were frequently found and are common in lawsuits. Allegations of a failure to treat a large vessel occlusion with thrombectomy were less frequently found. Given recent changes in practice guidelines and the demonstrated strong treatment effect of thrombectomy, it is likely that such litigation will increase in the coming years.

Background and Purpose— Brain electrical stimulation, widely studied to facilitate recovery from stroke, has also been reported to confer direct neuroprotection in preclinical models of acute cerebral ischemia. Systematic review of controlled preclinical acute cerebral ischemia studies would aid in planning for initial human clinical trials. Methods— A systematic Medline search identified controlled, preclinical studies of central nervous system electrical stimulation in acute cerebral ischemia. Studies were categorized among 6 stimulation strategies. Three strategies applied different stimulation types to tissues within the ischemic zone (cathodal hemispheric stimulation [CHS], anodal hemispheric stimulation, and pulsed hemispheric stimulation), and 3 strategies applied deep brain stimulation to different neuronal targets remote from the ischemic zone (fastigial nucleus stimulation, subthalamic vasodilator area stimulation, and dorsal periaqueductal gray stimulation). Random-effects meta-analysis assessed electrical stimulation modification of final infarct volume. Study-level risk of bias and intervention-level readiness-for-translation were assessed using formal rating scales. Results— Systematic search identified 28 experiments in 21 studies, including a total of 350 animals, of electrical stimulation in preclinical acute cerebral ischemia. Overall, in animals undergoing electrical stimulation, final infarct volumes were reduced by 37% (95% CI, 34%–40%; P I 2 =93.1%, P heterogeneity P Conclusions— Electrical stimulation reduces final infarct volume across preclinical studies. CHS shows the most robust evidence and is potentially appropriate for progression to early-stage human clinical trial testing as a promising neuroprotective intervention.

Background and Purpose— Racial and ethnic disparities in the access to mechanical thrombectomy (MT) for treatment of acute ischemic stroke (AIS) secondary to large vessel occlusion have been previously described. The effect of recent randomized trials validating MT as an effective therapy for AIS secondary to large vessel occlusion on such disparities has not been investigated. Methods— Information on admissions for AIS to endovascular centers occurring between January 2016 and September 2018 was obtained from a national database. The number of patients receiving IV-tPA (intravenous tissue-type plasminogen activator) and MT at each institution was determined, and patient demographics were characterized according to age, sex, race/ethnicity, and insurance status. Comparisons of patients who did and did not undergo MT and between patients of different racial and ethnic backgrounds were performed. Demographic variables independently associated with the utilization of MT were identified using multivariate linear regression analysis. Results— There were 206 853 admissions to 173 endovascular centers during the time period of interest. The overall utilization of MT was 8.4%. The utilization of MT for black/Hispanic patients was lower than that among white/non-Hispanic patients (7.0% versus 9.8%; P P P P P =0.029), and black/Hispanic race/ethnicity (β=−0.062; P =0.046) were independently associated with lower institutional utilization of MT. Conclusions— Despite the mainstream acceptance of MT for the treatment of AIS secondary to large vessel occlusion, racial and ethnic disparities in the utilization of MT persist.

Background and Purpose— Perioperative stroke is associated with significant morbidity and mortality. Conventional cardiovascular risk scores have not been compared to predict acute stroke after noncardiac surgery. Methods— Patients undergoing noncardiac surgery between 2009 and 2010 were identified from the US National Surgical Quality Improvement Program (n=540 717). Patients were prospectively followed for 30 days postoperatively for the primary outcome of stroke. Established cardiovascular and perioperative risk scores (CHADS 2 , CHA 2 DS 2 -VASc, Revised Cardiac Risk Index, Mashour et al risk score, Myocardial Infarction or Cardiac Arrest risk score, and National Quality Improvement Project American College of Surgeons surgical risk calculator) were assessed to predict perioperative stroke. Results— Stroke occurred in the perioperative period of 1474 noncardiac surgeries (0.27%). Patients with perioperative stroke were older, more frequently male, had lower body mass index, and were more likely to have undergone vascular surgery or neurosurgery than patients without stroke ( P 2 , CHA 2 DS 2 -VASc, and Mashour risk scores ( P for comparison, Conclusions— The Myocardial Infarction or Cardiac Arrest risk score and American College of Surgeons surgical risk calculator surgical risk scores provide excellent risk discrimination for perioperative stroke in most patients undergoing noncardiac surgery. Stroke prediction was less optimal in patients undergoing vascular surgery.

Background and Purpose— The optimal antithrombotic strategy to balance thromboembolic and bleeding events, especially acute stroke, for patients with atrial fibrillation following coronary stenting remains a matter of debate. We conducted a network meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in atrial fibrillation after coronary stenting. Methods— PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials and observational studies of patients with atrial fibrillation after coronary stenting. The outcomes of interest were stroke, myocardial infarction, major adverse cardiac events, mortality, and major bleeding. A network meta-analysis was performed comparing the available antithrombotic regimens in the literature. Results— Three randomized and 15 observational studies were included, with a total of 23 478 participants. Median follow-up was 2 years. Network meta-analysis demonstrated that vitamin K antagonist plus single antiplatelet therapy or direct-acting oral anticoagulant plus single antiplatelet therapy were the most effective regimens in preventing stroke. Direct-acting oral anticoagulant regimens were associated with lower major bleeding rates than vitamin K antagonist regimens. Regimens with dual antiplatelet therapy were associated with lower rates of myocardial infarction. Vitamin K antagonist plus dual antiplatelet therapy was associated with a lower mortality and low-dose direct-acting oral anticoagulants with decreased major cardiovascular adverse events. Conclusions— Direct-acting oral anticoagulant regimens were associated with less major bleeding and major cardiovascular adverse events, but vitamin K antagonists were associated with decreased mortality and stroke. These results suggest that the decision of antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention needs to be individualized.

Background and Purpose— Predicting safe extubation represents a clinical challenge in acute stroke patients. Classical respiratory weaning criteria have not proven reliable. Concerning the paramount relevance of postextubation dysphagia in this population, criteria related to airway safety seem to perform better, but diagnostic standards are lacking. We compare clinical and instrumental swallowing examination tools to assess extubation readiness and propose a simple Determine Extubation Failure in Severe Stroke score for decision making. Methods— Data of 133 orally intubated acute stroke patients were prospectively collected in this observational study. Classical extubation criteria, a modified semiquantitative airway score, and an oral motor function score were assessed before extubation. A 3-ounce water swallow test and validated 6-point fiberoptic endoscopic dysphagia severity scoring were performed thereafter. Association of demographic and clinical parameters with extubation failure (EF) was investigated. Independent predictors of EF were translated into a point scoring system. Ideal cutoff values were determined by receiver operator characteristics analyses. Results— Patients with EF (24.1% after 24±43 hours) performed worse in all swallowing assessments ( P P 2 =0.54) with an ideal cutoff ≥4 (sensitivity: 81.3% and specificity: 78.2%). Conclusions— Risk of EF is strongly correlated with postextubation dysphagia severity in stroke. Fiberoptic endoscopic examination of swallowing best predicts necessity of reintubation but requires a trial of extubation. The Determine Extubation Failure In Severe Stroke score is based on easy to collect clinical data and may guide extubation decision making in critically ill stroke patients.

Background and Purpose— The ESCAPE trial (The Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times) was a multicentre, randomized controlled trial of endovascular thrombectomy versus standard care for patients with acute ischemic stroke that allowed patients to be enrolled with deferred consent. We investigated the knowledge and opinions of these patients or their authorized third parties about the consent process. Methods— All patients (or their authorized third parties) enrolled with deferral of consent in ESCAPE were invited to complete a 12-question survey within the first 4 days of enrollment and again at 90 days. Questions investigated knowledge of the ESCAPE trial and opinions on deferral of consent. Results— Of 56 patients enrolled with deferred consent, 33 (59%) completed the initial survey, and of these, 27 (81%) completed the 90-day follow-up. Enrollment with deferred consent was not associated with a significant difference in door-to-randomization times (50.5 versus 57 minutes; P =0.29) but allowed these 56 patients to participate in the trial. Only 52% of respondents understood that patients could be randomized to thrombectomy or standard care, although most understood the other basic principles of the trial. At baseline and at 90 days, respondents disagreed or strongly disagreed with deferred consent in acute stroke trials generally (82% and 78%) and in the ESCAPE trial specifically (93% and 91%). Conclusions— Respondents generally disagreed with the use of deferred consent for enrollment in the ESCAPE trial and in stroke trials more generally.

Introduction: The COVID-19 pandemic has strained the healthcare systems across the world but its impact on acute stroke care is just being elucidated. We hypothesized a major global impact of COVID-19 not only on stroke volumes but also on thrombectomy practice. Methods: A 19-item questionnaire survey aimed to identify the changes in stroke volumes and treatment practices seen during COVID-19 pandemic was designed using Qualtrics software. It was sent to stroke and neuro-interventional physicians around the world who are part of the executive committee of a global coalition, Mission Thrombectomy 2020 (MT2020) between April 5 th to May 15 th , 2020. Results: There were 113 responses across 25 countries. Globally there was a median 33% decrease in stroke admissions and a 25% decrease in mechanical thrombectomy (MT) procedures during COVID-19 pandemic compared to immediately preceding months (Figure 1A-B). This overall median decrease was despite a median increase in stroke volume in 4 European countries which diverted all stroke patients to only a few selected centers during the pandemic. The intubation policy during the pandemic for patients undergoing MT was highly variable across participating centers: 44% preferred intubating all patients, including 25% centers that changed their policy to preferred-intubation (PI) vs 27% centers that switched to preferred-conscious-sedation (PCS). There was no significant difference in rate of COVID-19 infection between PI vs PCS (p=0.6) or if intubation policy was changed in either direction (p=1). Low-volume (20 strokes/month) are less likely to have neurointerventional suite specific written personal protective equipment protocols (74% vs 88%) and if present, these centers are more likely to report them to be inadequate (58% vs 92%). Conclusion: Our data provides a comprehensive snapshot of the impact on acute stroke care observed worldwide during the pandemic.

Background: Telestroke is an integral part of acute stroke systems of care. To further grow telestroke and maintain quality, we surveyed telestroke stakeholders’ experience. Methods: We conducted open-ended, semi-structured interviews with stroke program managers, hub neurologists, emergency department physicians and nurses in a telestroke network in an academic medical center. The goal of the interviews was to understand stakeholders’ experience with telestroke including their perceptions of telestroke values, barriers, and solutions. The data analysis was performed using qualitative methods guided by a grounded theory approach. Results: Face-to-face interviews with 44 stakeholders, including 8 hub neurologists, 7 stroke program managers, 15 emergency physicians, and 14 emergency department nurses were completed. The values provided by telestroke were consistent: empowering emergency physicians in treatment decisions, increasing access to a comprehensive stroke care, and improving health outcomes. The stakeholders also agreed that the main utilization barriers were unmatched role expectations, technical issues, and patient-provider detachment. Other barriers were specific to certain stakeholder groups. Stroke program managers emphasized the importance of the unified criteria for telestroke activation. Hub neurologists highlighted the lack of interoperability of the electronic health records system and the variation in nurse training. Nurses reported inadequate dissemination of the telestroke updates during night-shifts. Emergency physicians were concerned about the lack of emergency department representation at telestroke meetings. The stakeholders were actively managing arising issues through developing their own strategies and reporting the problems to the telestroke program. Conclusion: Stakeholders perceive telestroke as a necessary tool that assure high quality care. However, addressing the barriers to optimal telestroke use might improve provider and patient experience.

Background: Any clinical feature that may improve the early recognition of, or increase pretest probability of, acute stroke could shorten treatment times. We evaluated the sensitivity and specificity of the "Arm and Leg Positioning and self-Help Assessment” (ALPHA) sign in a predominantly stroke population. This sign was developed from the observation that some stroke patients guard the affected limb. Even mild deficits seem to have minimally supportive micro-gestures of one hand touching or lightly supporting the affected limb. Methods: IRB approval was obtained to review available videos of 63 stroke and non-stroke patients. Observers were instructed to only watch the initial 30 seconds of each video and focus on the limbs. The remaining video, and all the audio, were withheld. Videos were independently scored for the ALPHA sign. A composite score, defined as positive if >/= 50% of examiners reported its presence, was assigned. Scores were compared to true diagnosis (stroke/ CNS lesion was positive if there was a scorable deficit and imaging positive CNS lesion). Sensitivity analyses were performed. Results: Of the original 69 videos, 37 were from the outpatient setting (21 with stroke or other CNS lesions; 16 neurologically intact) and 26 were from the inpatient setting (20 with stroke or other CNS lesions; 6 neurologically intact). The ALPHA sign had a specificity of 86.4% and positive predictive value of 89.7%. Sensitivity was 63.4% and negative predictive value was 55.9%. Conclusions: High specificity and positive predictive value of the ALPHA sign were found suggesting that the recognition of subtle supportive gestures may help in early identification of CNS lesions during a stroke code. As expected, the sign had a lower sensitivity as the cohort was not limited to motor-only deficits. Further assessments in other stroke types, assessing a larger cohort and more examiners of various training level, are planned.

Background: Acute stroke care is constantly evolving and often necessitates rapid change. When COVID-19 struck our community, our team determined that we needed to change our approach to emergent stroke cases without sacrificing efficiency and safety. Our goals with the changes in our hyperacute stroke response pathway (called Code Brain) in our ED was to minimize COVID-19 exposure to our team, reduce PPE usage, and maintain an environment of safety and readiness, all while providing the same high-quality stroke care. Purpose: The purpose of this study was to determine if the changes we made to our Code Brain pathway in the ED effected our door-to-needle time for tissue plasminogen activator (t-PA) administration our door-to-groin puncture (DTG) times, or our CT scan turn-around times (CT TAT) under 45 minutes percentage. Implementation: It was decided that the stroke team RNs would respond to the bedside and a neurology resident or fellow would respond via telemedicine robot at bedside. The stroke team nurse is the safety monitor who ensures proper PPE use. The patient is moved through the Code Brain pathway with the telemedicine robot in tow, assuring constant contact with the patient by the stroke physician and stroke nurse. We implemented our revised Code Brain pathway on March 17, 2020. We retrospectively collected data from November 2019 to July 2020 and extracted our DTN, DTG and CT TAT times for a 4 ½ month comparison. Results: From November 2019 through March 17, 2020, our DTN median time was 39 minutes, DTG median time was 101 minutes, and CT TAT under 45 minutes was 97%. From March 18, 2020 to July 2020, our DTN median time was 54 minutes, DTG median time was 101 minutes, and CT TAT under 45 minutes was 95%. Variables to consider are the length of time it takes to apply the appropriate PPE for the stroke nurse, obtaining the telemedicine robot from our ED storage area and connectivity issues. Conclusion: Although we radically changed the way we approach our Code Brain patients, our response and treatment times changed only slightly. We will continue to streamline this process for optimal outcomes.

Background: The first surge of COVID-19 cases in Louisiana began in late March 2020 in the Greater New Orleans Area and quickly spread throughout the state. We sought to determine if LVO screening and door in-door out (DIDO) among patients who screened positive for large vessel occlusions (LVO) deteriorated. Methods: Our statewide stroke registry, mandatory for hospitals attesting to Acute Stroke Ready Hospital status, was queried. We compared LVO screening and transfer efficiency during Q1 and Q2 2020 with Q3 and Q4 2019. Results: Patients presenting within 24hr of last seen normal declined by 11%. The proportion arriving by ambulance increased (50.6% vs 40.7%, p Discussion: Louisiana experienced a reduction in acute stroke presentation during COVID-19. Screening for LVO actually improved during this time, but DIDO was compromised due to problems securing transfer acceptance and secondary ambulance service. Earlier identification and initiation of secondary transfer for patients screening positive for LVO should help improve efficiency in delivering acute stroke therapy.

Tenecteplase (TNK) is more fibrin specific and has longer activity duration than Alteplase (ALT). Compared to ALT, recent acute stroke treatment studies have found TNK at doses up to 0.4mg/kg to have equivalent safety and efficacy. A major advantage of TNK is that it is given as a five second bolus without the need for a 60 minutes infusion. The 2018 AHA/ASA guidelines suggest that TNK may be considered as an alternative to ALT. In January 2019 we switched to TNK for our first line acute stroke treatment at our institution. Methods: Following AHA/ASA plus ECAS3 < 4.5 hour stroke thrombolytic treatment guidelines, we treated consecutive patients with TNK 0.25mg/kg max 25mg at our main “hub” hospital in 2019. We compared these results to patients we treated with ALT in 2019 using telestroke at our 10 “satellite” hospitals. Safety was assessed by SICH on CT at 24 hours. For LVO patients early vessel opening was accessed by angiogram, and clinical success was determined by three month Modified Rankin Score (MR 0-1). Results: We have successfully treated 22 patients with TNK: Baseline median NIH was 9 (2-20); with a mean treatment time of 148±58 minutes. There were no systemic bleeding or mortality events and 0% SICH occurred. 19/22 patients had initial LVO on presentation with 9/19 (47%) having early vessel opening post TNK prior to thrombectomy. 14/22 (64%) of patients had excellent recovery (MR 0-1) at three months. During the same time we also treated 76 patients with Alteplase: Median BL NIHSS of 14 (2-27) (P = 0.001) with 0% SICH, 5% mortality and 30% MR 0-1 (P = 0.02 worse compared to TNK). Conclusion: We successfully changed to TNK as our preferred stroke thrombolytic and our initial experience with it has been very favorable. We are currently in the process of switching to TNK at several of our spoke hospital sites. TNK should be considered as an alternative to Altepase especially at sites that need to transfer patients for thrombectomy.

Objective: Our Stroke Program regularly provides community outreach and stroke education. The stroke team educates on signs and symptoms of stroke, risks factors, and 911 activation. Within a few days of discharge, Neuroscience nurses call stroke patients to ensure patients have obtained their prescription medications, have follow-up appointments, inquire about their satisfaction with our services, and reinforce stroke education. As part of these calls, our team asked why patients/families did not call 911. The purpose of this study was to determine if the COVID-19 crisis influenced the reasons why 911 was not called for possible stroke to better plan for targeted stroke education. Method: Discharge phone survey data from our stroke network was collected from Feb-Jul 2019 and compared to Feb-Jul 2020. Our stroke network includes 1 comprehensive stroke center and 2 primary stroke centers. Emergency Department (ED) stroke activation data was gathered for the same time periods. Discharge phone calls data was based on discharge date, whereas ED stroke alert data was based on admission date. Results: There was a notable decline in stroke volume between 2019 to 2020 with the largest decline occurring during the first peak (Apr 2020) in COVID-19 cases within our state. This decline was driven by a 16% decline in walk-in ED stroke arrivals as compared to a 1% decline in EMS stroke arrivals. Of those who did not call 911 in 2020, there was a 7% increase in failing to recognize stroke symptoms as an emergency, a 6% increase in concern about EMS cost, and 6% decrease in hospital preference. Conclusion: The COVID-19 crisis negatively influenced stroke volumes within our system stroke program. Reductions in stroke walk-ins accounted for this decline. COVID-19 affected the reasons why 911 was not called. The largest increase was in not recognizing stroke symptoms as an emergency and increased concern about EMS associated costs. Surprisingly, COVID-19 was not listed as a reasons for avoiding 911. Targeted community educational efforts on these concerns may lead to improved 911 usage for suspected stroke during the COVID-19 pandemic. Limitations: Further research is needed to investigate why those with a stroke who would have been walk-ins decided not to seek urgent medical attention.

Introduction: Patient selection for acute stroke revascularisation therapies is commonly based on clinical-imaging mismatch paradigms. Anatomical scores or total volumes of brain affected are assumed to correlate with clinical deficit without reference to the functional eloquence of the regions involved. In this study we used the relationship between presenting hypoperfusion abnormality and the corresponding NIHSS to generate functionally weighted atlases from patients with acute ischaemic stroke. Methods: Patients with acute large vessel occlusion (LVO) of the anterior circulation and with CTP at the time of presentation were included in this study. CTP was analysed with e-CTP (Brainomix Ltd., Oxford, UK) and hypoperfusion maps defined (Tmax >6s). Voxelwise lesion to symptom mapping was used to generate probability maps associating regions of hypoperfusion with clinical deficit at presentation. Results: 58 patients with itemised NIHSS and CTP were included. Discrete patterns of deficit were associated with each NIHSS domain. Total NIHSS correlated most strongly with left MCA involvement, consistent with the weighting towards language in this clinical scale. Regions associated with upper and lower limb deficits identified the respective motor cortex regions and descending motor tracts. Example mapping is presented in the Figure (A: total NIHSS, B: left arm paresis, C: left leg paresis). Data from a larger cohort will be presented at the meeting. Conclusions: Functional mapping using associations between presenting NIHSS and hypoperfusion lesion can be used to create eloquence-weighted atlases. Such atlases from stroke patients may be helpful to develop tools to predict clinical deficit associated with a presenting ischemic core lesion defined on non-contrast CT or CTP. This approach could refine clinical-imaging mismatch concepts, expanding endovascular treatment to a wider group of patients who would not currently be treated.

Background: The University of Cincinnati Stroke Team provides acute stroke care to the southwest Ohio, northern Kentucky, and southeast Indiana catchment area of ~2 million people and 30 healthcare facilities. We previously published a significant decline in stroke activations and reperfusion treatment (IV thrombolysis and EVT) rates following state announcements of COVID-19 mitigation measures. Here, we update these trends after state reopening guidelines. Methods: We compared Stroke Team activations and reperfusion treatments logged in a prospectively collected database, comparing the same period in 2020 versus 2019. Kentucky and Ohio announced school and restaurant closures on March 12 and 13, respectively, followed by Indiana. A stepwise reopening of our tristate area started on May 1, 2020. We also compared trends in activations and treatment rates before (Weeks 1-10), during (Weeks 11-17), and after (Weeks 18-26) the lifting of COVID-19 mitigation efforts using the Poisson test, and graphically with segmented regression analysis. Results: Compared to 2019, stroke team activations declined by 12% in 2020 (95% CI 7 - 16%; p Conclusion: The initial decline in stroke team activations during COVID-19 mitigation efforts was followed by an increase in activations after reopening. Hospital capacity and 911 services remained fully intact, suggesting that the reduction in activations were related to reduced presentation by patients for emergent stroke care.

Introduction/Objective: Sleep-wake disturbances (SWDs) are common amongst stroke patients; however, little work has been done on the effect of stroke location on sleep architecture. The aim of this study was to investigate the impact of stroke topography on prevalence and severity of SWDs in the post-acute phase of ischemic stroke recovery. Methods: Ischemic stroke patients (n=55) were assessed for SWDs via overnight attended polysomnography in a post-acute rehabilitation setting. The mean age was 55 ± 1.4 years and mean latency from injury was 106 ± 11 days. Sleep measures included total sleep time (TST), sleep and REM latency, sleep efficiency, percent time in sleep stages, apnea/hypopnea index (AHI), wake after sleep onset (WASO), and arousal index. Patients who did not have at least four hours of TST were excluded. Stroke patients were identified as having supratentorial or infratentorial injuries. Results: Results showed a significant difference between supratentorial and infratentorial stroke in regards to sleep efficiency, REM sleep, and sleep apnea. Patients with infratentorial stroke (n=15) displayed significantly poorer sleep efficiency (F(1,53)=12.386, p.05). Conclusion: Infratentorial ischemic stroke patients display significant disruptions in sleep and may require close monitoring for sleep-wake disturbances in the post-acute period. REM sleep is particularly effected when compared to supratentorial ischemic stroke.

Introduction: Safety of emergent carotid artery stenting (CAS) during endovascular thrombectomy (EVT) for acute strokes with intracranial large vessel and cervical internal carotid artery tandem occlusion is still unclear. Given the potential risk of symptomatic intracranial hemorrhage (ICH) with anti-thrombotic medications required in the setting of CAS, the decision between CAS versus carotid artery angioplasty (CAA) alone remains controversial. In this study, we aimed to identify the optimal endovascular carotid revascularization approach in this patient population, using a large, nationally representative dataset. Methods: We utilized the Nationwide Readmissions Database 2016-2017 to identify patients admitted due to acute ischemic stroke who underwent anterior circulation EVT as well as CAS or CAA on the same day. Survey design methods were used to generate national estimates. Logistic regression analysis was used to compare the in-hospital outcomes between patients who underwent CAS versus CAA. Survival analysis was used to estimate the 30-day readmissions. Results: We identified 2,042 hospitalizations meeting the study inclusion criteria (mean±SD age: 66.0±12.5 years, female 31.3%). Of these, 1,391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar except patients with CAS were more likely to be on anti-thrombotics and were less likely to have received intravenous thrombolysis (tPA) as compared to those with CAA. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, and hospital charges between the two groups in unadjusted analysis and after adjustment for the demographics and tPA use. All-cause 30-day readmission rate was similar between the two groups [hazards ratio (HR) 0.98, 95% confidence interval (CI) 0.64-1.51, p-value 0.924]. Patients with CAS had more readmissions due to ICH (HR 2.72, 95% CI 0.30-24.74) and less readmissions due to ischemic events (HR 0.78, 95% CI 0.12-5.08), although the difference was not statistically significant. Conclusion: Emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.

Introduction: Predictors of changes in depression in the early transitional period following an acute stroke are not well understood. We conducted a secondary analysis of patients enrolled in the Michigan Stroke Transitions Trial (MISTT) to characterize factors associated with changes in depressive symptoms from 7 to 90 days after returning home. Methods: MISTT was an open, parallel, randomized clinical trial testing the efficacy of social worker case management alone or in conjunction with a website to improve outcomes following acute stroke. Patient-reported outcomes including PHQ-9 were collected via telephone interviews conducted 7 and 90 days after patients returned home. PHQ-9 score ranges from 0-27 with higher scores indicating more severe symptoms. Key demographic variables were extracted from medical records. Multivariable linear regression was used to identify independent predictors of change in PHQ-9 score from 7 to 90 days using the GLM procedure in SAS. All analyses were adjusted for baseline (7-day) PHQ-9 score and pre-specified confounders (Table). We accounted for missing data using inverse probability weighting. Results: Of 265 patients enrolled in MISTT, 164 had PHQ-9 scores available at both 7 and 90 days and were included in the analysis. The mean PHQ-9 score was 5.4 at 7 days and 4.9 at 90 days. The mean within person change from 7 to 90 days was -0.5. In the final model, being unmarried (versus married), and moderate or severe stroke severity (versus mild) were associated with an increase in depressive symptoms (Table). As expected, 7-day PHQ-9 score was a strong predictor of 90-day score. Accounting for missing data did not meaningfully change model results. Conclusions: Increases in PHQ-9 scores following stroke hospitalization were seen in unmarried patients and those with greater stroke severity. Identifying factors associated with worsening symptoms over time may help guide clinical management during the early transition period.

Background and Issues: Acute strokes are medical emergencies that require rapid assessment and treatment. Following treatments, focused and frequent monitoring is essential to quickly identify and mitigate any physiological deterioration. However, hospital capacity and decreased availability of monitored beds often causes delay in admission and prolonged stays in the emergency department and the potential increase in morbidity and mortality. Purpose: The purpose of this quality improvement initiative is to reduce the length of time from a patient presenting to the emergency department with acute stroke symptoms and treated with alteplase, to the time that the patient is being monitored utilizing “comprehensive specialized stroke care” level monitoring. This level of monitoring allows for the patient to be assessed closely and frequently to ensure the absence of physiological or neurological deterioration as well as for any adverse thrombolytic reaction. Methods: To improve the process of patient progression within the hospital, the care team utilized the ADKAR® Change Management Model. This model focuses on sponsoring awareness, promoting desire, providing knowledge, ensuring ability, and reinforcing changes. Each of these five components is critical to implement the proposed changes and ensure the longevity of the process changes. Results: Since the implementation of the process change, the Primary Stroke Center has experienced twenty-four months of mean “door-to-monitored bed” times below the 180 minute benchmark. In addition, the mean “door to monitored bed” time has decreased from 210 minutes in the three months preceding the process change (n=20), to 113 minutes during the twenty-four months following the change (n=150). Conclusions: During this process change, the Stroke Center successfully reduced the time between patient arrival and being in a monitored bed. The use of the ADKAR® Change Management Model is particularly advantageous in implementing a process change that is expected to be sustained into the future.